The Medicare Beneficiary Quality Improvement Project (MBQIP) data submitted by the CAHs gauges quality improvement. The four core domains in MBQIP are patient safety, patient engagement, care transitions, and outpatient measures. The Federal Office of Rural Health Policy (FORHP) continues to evaluate the MBQIP core measures for relevance in measuring the quality of care provided by rural hospitals. The goal for program is to increase the number of CAHs consistently reporting quality data and improving the quality of care.
Care Transitions
Care Transitions are measured in the Emergency Department Transfer Communications (EDTC).
– Home Medications
– Allergies and/or Reactions
– Medications Administered in Emergency Department
– Emergency Department Provider Note
– Mental Status/Orientation Assessment
– Reason For Transfer and/or Plan Of Care
– Tests and/or Procedures Performed
– Tests and/or Procedures Results
Patient Engagement
Patient engagement is measured in the Hospital Consumer Assessment of Health Care Providers and Systems (HCAHPS).
• HCAHPS Composite 1: Q1 to Q3, Communication with Nurses
• HCAHPS Composite 2: Q5 to Q7, Communication with Doctors
• HCAHPS Composite 3: Q4 & Q11, Responsiveness of Hospital Staff
• HCAHPS Composite 5: Q13 & Q14, Communication about Medicines
• HCAHPS Composite 6: Q16 & Q17, Discharge Information
• HCAHPS Composite 7: Q20 to Q22, Care Transition
• HCAHPS Q-8: Cleanliness of Hospital Environment
• HCAHPS Q-9: Quietness of Hospital Environment
• HCAHPS Q-18: Overall Rating of Hospital
• HCAHPS Q-19: Willingness to Recommend This Hospital
Patient Safety and Inpatient
Patient safety (PS) and inpatient (IP) measures are:
• HCP/IMM-3: Influenza Vaccination Coverage Among Health Care Personnel (annual measure, updated in quarter 4 only)
• Antibiotic Stewardship (annual measure, updated in quarters 3 & 4 only)
– Number of Elements Met
– Element 1: Leadership
– Element 2: Accountability
– Element 3: Drug Expertise
– Element 4: Action
– Element 5: Tracking
– Element 6: Reporting
– Element 7: Education
Outpatient
Outpatient (OP) measures are:
• OP-2: Fibrinolytic Therapy Received Within 30 Minutes of ED Arrival
• OP-3b: Median Time to Transfer to Another Facility for Acute Coronary Intervention
• OP-18b: Median Time from ED Arrival to ED Departure for Discharged ED Patients
• OP-22: Patient Left Without Being Seen (annual measure, updated in quarter 4 only
Patient Safety and Inpatient additional core measures.
• Healthcare-Associated Infections (HAI) measures
– Central-Line Associated Bloodstream Infections (CLABSI)
– Catheter-Associated Urinary Tract Infections (CAUTI)
– Clostridiodes difficile (C.diff ) Intestinal Infections (CDI)
– Methicillin-Resistant Staphylococcus aureus Blood Infections (MRSA)
– Surgical Site Infections From Colon Surgery (SSI:C)
– Surgical Site Infections From Abdominal Hysterectomy (SSI:H)