Medicare Beneficiary Quality
Improvement Project (MBQIP) Resources

The Medicare Beneficiary Quality Improvement Project (MBQIP) was developed via the Medicare Rural Hospital Flexibility (Flex) grant program under the Health Resources and Services Administration’s Federal Office of Rural Health Policy (FORHP) to improve the quality of care delivered by Critical Access Hospitals (CAHs). Enhanced data collection enables quality improvement activities to be developed and implemented. CAHs are able to examine their own data, measure outcomes versus other CAHs, and partner with other Pennsylvania hospitals to develop quality improvement initiatives to improve patient outcomes and quality of care. The following MBQIP resources are provided for your usage:

MBQIP New Required Measure (2018): Antibiotic Stewardship

The Federal Office of Rural Health Policy (FORHP) is adding an antibiotic stewardship program (AMS) requirement to the Medicare Beneficiary Quality Improvement Project (MBQIP). Critical Access Hospitals (CAHs) will be given four (4) years to fully implement an antibiotic stewardship program by the end of FY 2021 (September 1, 2021 – August 31, 2022).

MBQIP New Required Measures (2018): ED-1 and ED-2

The Federal Office of Rural Health Policy (FORHP) is adding two CMS Hospital Compare Measures as core measure requirements for the Medicare Beneficiary Quality Improvement Project (MBQIP):

ED-1 – Median Time from ED Arrival to ED Departure for Admitted ED Patients
ED-2 – Admit Decision Time to ED Departure Time for Admitted Patients

MBQIP Removed OP Measures (2018) : OP-1, OP-4, OP-20 & OP-21

CMS has announced that four of the Outpatient Measures that are currently required for MBQIP will be removed following Q1 2018 data submission:

OP-1: Median Time to Fibrinolysis
OP-4: Aspirin at Arrival
OP-20: Door to Diagnosis Evaluation by a Qualified Medical Professional
OP-21: Median Time to Pain Management for Long Bone Fracture

HCAHPS Vendor Directory


Please direct all Quality Improvement questions to Lannette Johnson:

Lannette Johnston
Quality Improvement Coordinator

Pennsylvania Office of Rural Health
118 Keller Building
University Park, Pennsylvania 16801
kmj29@psu.edu