1. Medicare Beneficiary Quality Improvement Project (MBQIP)
Began in September 2011
Key quality improvement activity within the Medicare Rural Hospital Flexibility grant program
Goal of MBQIP: to improve quality of care in small rural hospitals
Voluntary program

2. Science of MBQIP Improved Patient Outcomes Quality Measurement
Quality Improvement

3. How Quality Reporting to MBQIP Can Help Your Facility
Identify opportunities for improvement
Track progress of improvements
Gauge how your performance stacks up against other providers
Demonstrates to your community that your are dedicated to patient safety, transparency and providing the best possible care
Positively affect your bottom line – what gets measured, gets managed

4. Drop the Denominator Collecting data has a human impact
Therefore, it’s best to measure missed opportunities – Not percentages
Each missed opportunity should be evaluated as to how a new or current process is performing

5. Small Hospital Improvement Program (SHIP)
To support hospital activities related to patient quality improvement, attaining equipment and/or training to comply with meaningful use of health information technology, ICD-10 standards, and payment bundling.
Hospitals utilize funds to:
pay for costs related to maintaining accurate prospective payment system billing and coding such as updating and or implementing ICD-10 hardware/software
2) pay for the costs related to delivery system changes as outlined in the ACA such as value-based purchasing (VBP), accountable care organizations (ACO), and payment bundling.

6. Participation SHIP Grant Program
SHIP program is very menu driven and hierarchical
Signed MBQIP agreement and actively reporting quality measures
2. Working toward ICD-10 implementation and/or Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS)
3. Other menu items once 1 and 2 above are met

7. Medicare Rural Hospital Flexibility Grant Program (Flex)
Three Main Areas:
Quality Improvement
Financial and Operational Improvement
Community Health Needs Assessments

8. Flex Program
Strongly recommended MBQIP participation in grant
MBQIP would become intricately involved with Flex
Quality Improvement Organization – Mountain Pacific (Shanelle and Ericka) actively recruited and provided TA for MBQIP reporting
MBQIP participation mandatory for Flex participation in
Critical Access Hospitals not reporting MBQIP must implement program
All Critical Access Hospitals must be reporting required MBQIP measures by August 31, 2015

9. Reporting MBQIP Measures
Measures reported to QualityNet (CMS Hospital Compare website)
CART tool may be used for extraction and reporting
Measures were implemented in 3 phases:
Phase 1 – Inpatient Measures
Phase 2 – Outpatient Measures
Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS)
Phase 3 – Emergency Department Transfer Communication
Pharmacy Review

10. MBQIP Reporting Measures
Phase 1 Measures
Pneumonia: CMS Hospital Compare Core Measure (participate in all sub-measures);
PN-3b: Blood Cultures Performed in the Emergency Department Prior to Initial Antibiotic Received in Hospital
PN-62: Initial Antibiotic Selection for CAP in Immunocompetent Patient
Congestive Heart Failure: CMS Hospital Compare Core Measure (participate in all sub-measures)
HF-1: Discharge Instructions
HF-2: Evaluation of LVS Function
HF-3: ACEI or ARB for LVSD

11. MBQIP Reporting Measures
Phase 2 Measures
Outpatient 1-7: Hospital Compare CMS Measure (all sub- measures that apply);
OP-1: Median Time to Fibrinolysis in the Emergency Department
OP-2: Fibrinolytic Therapy Received Within 30 Minutes of ED Arrival in the Emergency Department
OP-3: Median Time to Transfer to another Facility for Acute Coronary Intervention in the Emergency Department
OP-4: Aspirin at Arrival in the Emergency Department
OP-5: Median Time to ECG in the Emergency Department
OP-6: Timing of Antibiotic Prophylaxis (Prophylactic Antibiotic Initiated Within One Hour Prior to Surgical Incision) in Surgery
OP-7: Prophylactic Antibiotic Selection for Surgical Patients in Surgery
Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS)

12. MBQIP Reporting Measures
Phase 3 Measures
• Pharmacist CPOE/Verification of Medication Orders Within 24 Hours
Numerator: Number of patients whose medication orders are directly entered (CPOE) or verified by a pharmacist within 24 hours.
Denominator: Number of patients with at least one medication in their medication list (entered using CPOE) admitted to a CAH’s inpatient or emergency department during the reporting period.
• Outpatient Emergency Department Transfer Communication (Seven Elements)
o Pre-Transfer Communication Information
o Patient Identification
o Vital Signs
o Medication-related Information
o Practitioner generated information
o Nurse generated information
o Procedures and tests

14. Reporting format for Pharmacy Verification Measure

19. CMS Retired Measures – Still MBQIP Active

21. CMS Names VIQR National Support Contractor
The Centers for Medicare & Medicaid Services (CMS) has announced that FMQAI/HSAG has been named the Hospital Inpatient Value, Incentives, and Quality Reporting (VIQR) Outreach and Education National Support Contractor.
Submit all questions regarding the Hospital IQR Program to the contractor via the Hospital Inpatient Quality Reporting Questions and Answers tool or by phone, toll-free, at (844) or (866) weekdays from 8 a.m. to 8 p.m. Eastern Time (5 a.m. to 5 p.m. Pacific Time).
The Centers for Medicare & Medicaid Services (CMS) has designated HSAG as the Hospital OQR Program Support Contractor. HSAG provides technical support and feedback to assist hospitals with quality data reporting.
Submit all questions about the Hospital OQR Program to HSAG at Hospital Outpatient — Questions/Answers or by calling, toll-free, (866) weekdays from 7 a.m. to 6 p.m. Eastern Time.

22. MBQIP Program is Changing for 2015

23. Changes to MBQIP

24. Questions ?
Contact Information
Shellie Smith
State of Alaska
Phone: