Medicare Beneficiary Quality Improvement Program (MBQIP)

The MBQIP for Critical Access Hospitals (CAHs) is a quality improvement activity under the Medicare Rural Hospital Flexibility (Flex) Program of the Health Resources and Services Administration’s (HRSA) Federal Office of Rural Health Policy (FORHP). MCRH facilitates this program for the State of MI.

The goal of MBQIP is to improve the quality of care provided in CAHs, by increasing quality data reporting by CAHs and then driving quality improvement activities based on the data. This project provides an opportunity for individual hospitals to look at their own data, measure their outcomes against other CAHs, and partner with other hospitals in the state around quality improvement initiatives to improve outcomes and provide the highest quality care to each and every one of their patients.

All MI CAHs participate in the MBQIP program. MBQIP's Core Improvement Initiatives fall under four domains:

Patient Safety
Patient Engagement
Care Transitions
Outpatient

Additional domains are recommended but not required. Details on the current domains are available here.

MICAH QN and MBQIP Alignment

The MICAH QN supports and recommends full participation in the MBQIP program. As part of this support, the MBQIP data is reported out at the MICAH QN quarterly meetings and Strategy Group #2 provides peer sharing and best practices around the data.

Why should CAHs participate in the MBQIP program?

CAHs are affected directly and indirectly by the rapidly changing health care payment and delivery environment.
- This includes an increased focus on moving beyond models that have financial incentives for quality and value, to models that include a component of downside financial risk. CMS has outlined a goal to have 50 percent of traditional Medicare and Medicare Advantage payments in models with downside risk by 2022, and 100 percent by 2025. Medicaid and other payers are expected to follow in this direction as well.
- Although CMS does not currently mandate quality reporting by CAHs, it cannot be considered optional for CAHs to keep pace in an environment that has rapidly shifted to focus on value
Although the Centers for Medicare & Medicaid Services (CMS) has not mandated CAH quality reporting, other programs are driving measurement and reporting.
- In September 2019, CMS published a final rule that included updates to the CAH Conditions of Participation. One aspect of the proposed rule refines the language related to the implementation of a Quality Assessment and Performance Improvement (QAPI) program. In the final rule, CMS actively encourages CAHs to “utilize the technical assistance and services for CAHS that are available through the State Flex Programs, including MBQIP.”
CAHs are increasingly in the spotlight of federal policymakers, and there is recognition that quality measurement is necessary, but can be challenging in a rural environment.

Alignment with the MI Medicare Rural Hospital Flexibility Grant Program

The MI Flex Program provides a wide variety of resources to MI CAHs including but not limited to the following:

Swing Bed Quality and Utilization Technical Assistance
Lean and Service Line Projects/Assessments
Financial Benchmarking
Quality Benchmarking
Quality Improvement Training via the Institute for Healthcare Improvement
Mileage and Lodging support for CAH-specific meetings
Board of Directors Training
Population Health Resources

In 2019, HRSA developed a phased approach in which thresholds of MBQIP participation would allow for CAHs to be eligible for Flex Funded resources, such as those described above. To learn more about this, please reach out to Crystal Barter.

MBQIP Quality Measure Resources

(MBQIP) Data Submission Deadlines
Data Submission Guides - These guides provide detailed instructions for submitting MQBIP measure data. They include measure details, linked trainings and step-by-step data submission instructions for the measure.
MBQIP Navigator is a powerful guide designed to streamline the MBQIP reporting process for hospitals. The MBQIP Navigator provides the support you need to ensure accurate and timely measure reporting
MBQIP 2025 Measure Guide - Updated October 2025
MBQIP Measures - Updated table that incorporates the new MBQIP 2025 measures and includes the table of suggested additional.
This entire webpage is a good resource to review
Specific Resources related to the EDTC measure within MBQIP
- Webpage that houses the tool that CAHs need to use to abstract the data
How to upload a Population and Sampling File– Video link on how to Upload a Population and Sampling File to HQR
How to submit Hybrid Measures and View Outcomes - Video link on how to submit Hybrid Measures and View Outcomes to HQR
CAH eCQM Resource List outlines the inpatient eCQM reporting requirements and the alignment between two Centers for Medicare & Medicaid Services (CMS) programs: the Promoting Interoperability (PI) Program and the Hospital Inpatient Quality Reporting Program