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The Medicare Beneficiary Quality Improvement Project (MBQIP) is a quality improvement activity under the Medicare Rural Hospital Flexibility (Flex) grant program of the Health Resources and Services Administration’s Federal Office of Rural Health Policy.
The goal of MBQIP is to improve the quality of care provided in critical access hospitals by increasing quality data reporting by critical access hospitals (CAHs) and then planning quality improvement activities based on the data. In Minnesota and nationally, CAHs are required to report MBQIP measures to participate in Flex Program activities. Stratis Health supports the Flex Program to assist Minnesota CAHs with the MBQIP measures.
Critical access hospital core measure reporting in Minnesota
The following chart shows the reporting channels for MBQIP core measures. Stratis Health developed the MBQIP Minnesota Quality Reporting Guide to help CAH staff understand the core MBQIP measure reporting process. For each reporting channel, information is included on registering for the sites, which measures are reported to which site, and how to submit those measures.
MBQIP measure abbreviations to know:
- ABX: Antibiotic Stewardship
- CART: CMS Abstraction and Reporting Tool
- EDTC: Emergency Department Transfer Communication
- FMT: Flex Monitoring Team
- HCAHPS: Hospital Consumer Assessment of Healthcare Providers and Systems
- HCP: Vaccination Coverage Among Healthcare Personnel
- NHSN: National Healthcare Safety Network
MBQIP data reports
Every CAH in Minnesota can securely access quarterly reports with its data on all MBQIP core measures to drive and support its quality improvement efforts. Login access is provided to individuals identified as designated report contacts at each Minnesota CAH.
If you want to know the designated report contacts for your CAH, please contact Jodi Winters.
Login instructions
- Go to Stratis Health Sharefile.
- Enter your email address and password.
- Click Sign in.
Note: First-time users click on “Forgot Password” to set up their password.
MBQIP support
Abstraction and Data Submission of MBQIP Measures Recorded Training
Stratis Health presents three one-hour Zoom sessions on abstraction and data submission of MBQIP measures.
Session One – EDTC Abstraction and Submission. The Minnesota Hospital Association demonstrates how the EDTC data is submitted to their portal, and we review the EDTC Specifications Manual.
Session Two – Outpatient Measure Abstraction. We discuss where to find the Hospital Outpatient Quality Reporting Manuals, how to determine your measure population and abstraction for the AMI and ED-Throughput Measure Sets.
Session Three – CART and Data Submission. Demonstration of where to find and how to enter data using CART (the CMS Abstraction and Reporting Tool) and how to submit data to HQR (Hospital Quality Reporting).
Minnesota MBQIP Open Calls
Stratis Health hosts open discussion calls for Minnesota CAHs to support CAHs to submit data for core MBQIP measures, share promising practices with other CAHs, and have a chance to ask questions of Stratis Health staff and each other. CAHs are encouraged to review their MBQIP reports ahead of the calls and come with questions.
- Wednesday, July 10, 2024, 1-2 p.m. CT
Register > - Wednesday, August 14, 2024, 11 a.m.-Noon CT
Register >
EDTC QI Open Calls
Stratis Health hosts open discussion calls for Minnesota CAHs to improve ED Transfer Communication (EDTC) composite core MBQIP measure scores. The main objectives of these calls are to support CAHs in sharing promising practices on EDTC documentation to improve scores on the EDTC composite measure and to have a chance to ask questions of Stratis Health staff and each other. CAHs are encouraged to review their EDTC MBQIP data reports and scatterplots ahead of the calls and come with questions.
Past Recorded Open Calls
- May 15, 2024, EDTC QI Open Call
Slide handout. - April 10, 2024, MN MBQIP Open Call
Slide handout. - March 13, 2024, EDTC QI Open Call
Slide handout. - January 10, 2024, MN MBQIP Open Call
Slide handout. - November 15, 2023, EDTC QI Open Call
Slide handout. - November 9, 2023, CAH Quality Assessment Call
Slide handout. - October 5, 2023, MN MBQIP Open Call
Slide handout.
EDTC Measure Ongoing Lessons and Best Practices.
During our ongoing work to help CAHs improve their EDTC measure scores, this resource will share what we have learned to date on issues affecting the EDTC documentation and some of the CAH’s solutions and best practices to address those issues. This a work in progress that will be updated as Minnesota CAHs continue finding ways to improve this measure.