Supporting Rural Hospitals to Report Indicators of Quality

The Medicare Beneficiary Quality Improvement Project

Project Summary

Vermont has eight small rural hospitals, classified as as Critical Access hospitals (CAHs).These CAHs are located in rural areas, have fewer than 25 inpatient beds, maintain a low annual average length of stay for acute inpatient care, and offer 24/7 emergency care. CAHs can be challenged in reporting certain quality indicators due to their small number of visiting patients, limited number of procedures offered, and/ or challenges with internal technological systems.

The MBQIP is a quality improvement activity under the Medicare Rural Hospital Flexibility (Flex) grant program of the Health Resources and Services Administration’s Federal Office of Rural Health Policy. Program measures are “rural relevant”, designed to be collected and reported by CAHs across the country. The goal of MBQIP is to improve the quality of care provided in CAHs by increasing quality data reporting and driving quality improvement activities based on the data.[1] Measures are organized into four categories, currently including the following:

  • Patient Safety measures, which include influenza vaccination coverage among healthcare personnel and influenza immunizations provided to applicable patients.
  • Patient Engagement measures, collected through the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey, which assess patient perspectives of care received.
  • Care Transitions measures, which assess the transfer of patient information when patients have been discharged from the hospital to their next point of care.
  • Outpatient measures, which encompass a range of services provided in the Emergency Department (ED). [2]

Recommendations and Next Steps

As we enter our second year of the Medicare Beneficiary Quality Improvement Project, VPQHC will continue to support hospitals develop the infrastructure and capacity to report MBQIP measures. For hospitals that are already reporting measures, we will begin
working with quality improvement leaders to improve systems and processes identified
through MBQIP reporting.


[1] https://www.ruralcenter.org/tasc/mbqip
[2] Includes fibrinolysis/fibrinolytic therapy, time to patient transfer for acute coronary,
patients receiving aspirin at arrival, time to ECG, time to diagnostic evaluation, time to
departure for discharged patients, time to pain management for long bone fracture, and captures those patients who left the ED without being seen.