MBQIP Monthly: July 2024

• I am reporting the Hybrid Hospital-Wide Readmission measure for the first time. How do I upload the data into the Hospital Quality Reporting System (HQR) for submission? Is there a way to verify I have submitted data correctly?

• Our healthcare system is increasing vigilance on cyber security and preventing cyber disruptions. What support is available for critical access hospitals in preventing healthcare-related cyber attacks?  

• The Screening for Social Drivers of Health measure specifications do not specify a screening tool that needs to be used by hospitals. While the flexibility of choosing our own tool is nice, we are overwhelmed at the amount of screening tools that exist. What screening tools are used by other critical access hospitals?

MBQIP Monthly: June 2024

• My hospital is working to achieve Domain 1: Equity is a Strategic Priority of the Hospital Commitment to Health Equity measure. What kind of information needs to be included in the strategic plan?

• We are integrating screening for health-related social needs (HRSN) to be able to report the Screening for Social Drivers of Health measure (SDOH-1) and the Screen Positive Rate for Social Drivers of Health measure (SDOH-2). What resources are available to help our team? 

• I subscribe to the Outpatient Quality Reporting (OQR) Newsletter by the Quality Reporting Center. I saw the Sex data element will be replaced by the Sex Assigned at Birth data element. What does that mean for data abstraction for OP-18?

MBQIP Monthly: March 2024

• I hear there are new core measures for MBQIP. Where can I find more information? 

• I’m new to using CMS Abstraction and Reporting Tool (CART), is there training available to help me get orientated to the tool?

• I’m familiar with the Social Drivers of Health measures (SDOH-1, SDOH-2) and the Hospital Commitment to Health Equity measure (HCHE). How are these measures submitted? 

• I am interested in reporting the new Antimicrobial Use and Resistance (AUR) Surveillance Reporting Measure which is now a required measure for the Medicare Promoting Interoperability Program participants. What eligibility or exclusion criteria are there for reporting?

MBQIP Monthly: December 2023

• My hospital will be reporting the Hybrid Hospital-Wide Readmission (HWR) Measure. What does “hybrid” mean and how does that impact reporting?

• My hospital is becoming increasingly interested in health equity due to the new CMS measure Hospital Commitment to Health Equity. Where can I find more information on the importance of this measure to help get others in my hospital involved? 

• My hospital uses the CMS Abstraction & Reporting tool (CART) for data reporting. What version should I be using?

MBQIP Monthly: September 2023

• CAHs Can! QI Mentor Stories – Improving Swing Bed Quality

• CAHs Measure Up: Collaborative Impact

• Tips: Robyn Quips – Antibiotic Use and Resistance Module Submissions

• Tools and Resources – MBQIP and Rural Health Improvement Resources

MBQIP Monthly: June 2023

• Apply Now for One Year of Virtual and On-site Technical Assistance

• Deadline: August 15, 2023

• Meet the RHPTP Technical Assistance Consultants

• RHPTP Informational Webinar Registration

• HELP Webinars Registration

• Rural Health Value Community Engagement Resource Guide

MBQIP Monthly: March 2023

Includes:

• CAHs Can! How Critical Access Hospitals Improved Patient Experience During the Pandemic

• Data: CAHs Measure Up – HCAHPS Performance in 2021

• Tips: Robyn Quips – CART Tool

• Tools and Resources – Helping CAHs Succeed in Quality Reporting & Improvement

MBQIP Monthly: December 2022

Includes:

• CAHs Can! National Rural Virtual Quality Improvement Mentor Profile Series: Tammy Suchy

• Data: CAHs Measure Up – Antibiotic Stewardship Program Education Implementation Update

• Tips: Robyn Quips – Abstraction and Reporting Resources

• Tools and Resources – Helping Critical Access Hospitals Succeed in Quality Reporting & Improvement

MBQIP Monthly: September 2022

Includes:

• CAHs Can! National Rural Virtual Quality Improvement Mentor Profile Series: Jenifer Monzo

• Data: CAHs Measure Up – Antibiotic Stewardship Program Core Elements Met by Critical Access Hospitals (CAHs)

• Tips: Robyn Quips – Outpatient Measure Abstraction Quiz Answers

• Tools and Resources – Helping CAHs Succeed in Quality Reporting & Improvement

MBQIP Monthly: May 2024

• I subscribe to the Outpatient Quality Reporting (OQR) Newsletter by the Quality Reporting Center. I saw the Sex data element will be replaced by the Sex Assigned at Birth data element. What does that mean for data abstraction for OP-18?

• I’m a new employee in my hospital and am being tasked with submitting data into HQR. How can I get access to the HQR portal?  

• Our hospital is working on reporting the Hybrid-Hospital Wide Readmission Measure which is a part of the MBQIP 2025 Core Measure Set. We are having issues with our data getting rejected. Can the RQITA team help?

MBQIP Monthly: February 2024

• After reviewing my hospital’s MBQIP data reports provided by our state Flex program, I noticed we are performing lower than other critical access hospitals (CAHs) in our state for the measure Median Time from emergency department (ED) Arrival to ED Departure for Discharged ED Patients (OP-18). What are some strategies we can implement in our hospital to make improvements? 

• I was not able to submit data for the measure Median Time from ED Arrival to ED Departure for Discharged ED Patients (OP-18) last quarter. How can I make sure I am able to submit Q4 data by the May 1, 2024 deadline? 

• Many of the measures I report continually release new measure specifications, how do I confirm that I am always using the correct measure specifications for reporting? 

• I saw a new outpatient version of CART was released. What version of CART should I be using?

MBQIP Monthly: November 2023

• I heard Outpatient Measure Patient Left Without Being Seen (OP-22) was proposed by CMS to be removed for reporting as a CMS quality measure. Does that mean this measure is being removed from reporting? 

• When will the new CART version be released for inpatient reporting?

• What is the most recent outpatient CART tool released?

MBQIP Monthly: August 2023

• CAHs Can! QI Mentor Stories – Reducing Avoidable Hospital Readmissions

• CAHs Measure Up: Influenza Vaccination Coverage

• Tips: Robyn Quips – CMS Reporting Structures

• Tools and Resources – MBQIP and Rural Health Improvement Resources

MBQIP Monthly: May 2023

Includes:

• CAHs Can! QI Mentor Series – Improving Durable Medical Equipment Process

• Data: CAHs Measure Up – OP-18 Performance

• Tips: Robyn Quips – Abstraction Tidbits

• Tools and Resources – Helping CAHs Succeed in Quality Reporting & Improvement

MBQIP Monthly: February 2023

Includes:

• CAHs Can! National Rural Virtual Quality Improvement Mentor Profile Series: Linda Webb

• Data: CAHs Measure Up – EDTC Measure Reporting Trends

• Tips: Robyn Quips – MBQIP Measure Updates

• Tools and Resources – Helping Critical Access Hospitals Succeed in Quality Reporting & Improvement

MBQIP Monthly: November 2022

Includes:

• CAHs Can! National Rural Virtual Quality Improvement Mentor Profile Series: Katrina Strowbridge

• Data: CAHs Measure Up – Antibiotic Stewardship Program Reporting Implementation Update

• Tips: Robyn Quips – Influenza Vaccination Coverage Among Healthcare Personnel

• Tools and Resources – Helping Critical Access Hospitals Succeed in Quality Reporting & Improvement

MBQIP Monthly: August 2022

Includes:

• CAHs Can! National Rural Virtual Quality Improvement Mentor Profile Series: Stacey Karvoski

• Data: CAHs Measure Up – Top 10 States with Outstanding Quality Performance

• Tips: Robyn Quips – Outpatient Measure Abstraction Quiz

• Tools and Resources – Helping CAHs Succeed in Quality Reporting & Improvement

MBQIP Monthly: April 2024

• My hospital is working to build capacity for reporting the new measures in the MBQIP 2025 Measure Core Set. Where can I learn more about reporting the measures?

• I was not able to submit data for Median Time from ED Arrival to ED Departure for Discharged ED Patients (OP-18) last quarter. How can I make sure I am able to submit Q4 data by the May 1, 2024 deadline?  

• We started screening for social drivers of health in my hospital. We would like to offer resources for patients when they indicate an area of need for assistance but I don’t know what is available in my community. Where can I go for help?

MBQIP Monthly: January 2024

• I am trying to submit data with the CMS Abstraction and Reporting Tool (CART)-Outpatient tool for measure OP-18: Median time from ED arrival to ED departure for discharged ED patients. I am running into error messages, what should I do? 

• My hospital would like to begin reporting the Hospital Commitment to Health Equity measure. What key information do I need to know before reporting this measure?

MBQIP Monthly: October 2023

• What happened to measures OP-2 and OP-3?

• Is there an updated version of the MBQIP Eligibility Criteria Document? 

MBQIP Monthly: July 2023

• CAHs Can! QI Mentor Stories – QI Mentor Stories Implementing Successful Fall Prevention Strategies

• CAHs Measure Up: Centers for Disease Control and Prevention (CDC) Core Elements of Hospital Antibiotic Stewardship Programs

• Tips: Robyn Quips – Data Submission Reminders

• Tools and Resources – Helping CAHs Succeed in Quality Reporting & Improvement

MBQIP Monthly: April 2023

Includes:

• CAHs Can! Engaging Hospital Boards in Quality

• Data: CAHs Measure Up – New Birthing-Friendly Hospital Designation

• Tips: Robyn Quips – Annual Measures OP 22 and HCP

• Tools and Resources – Helping CAHs Succeed in Quality Reporting & Improvement

MBQIP Monthly: January 2023

Includes:

• CAHs Can! National Rural Virtual Quality Improvement Mentor Profile Series: Tammy Sudtelgte

• Data: CAHs Measure Up – MBQIP Annual Reports: What Are They, and What Do They Tell Us?

• Tips: Robyn Quips – Year-end and New Year Abstraction Reminders

• Tools and Resources – Helping Critical Access Hospitals Succeed in Quality Reporting & Improvement

MBQIP Monthly: October 2022

Includes:

• CAHs Can! Use Healthcare Quality Week To Show That Quality Matters Every Day

• Data: CAHs Measure Up – Influenza Vaccination Coverage Among Healthcare Personnel

• Tips: Robyn Quips – Centers for Medicare and Medicaid (CMS) Quality Program Emails

• Tools and Resources – Helping Critical Access Hospitals Succeed in Quality Reporting & Improvement