Iowa Medicare Beneficiary Quality Improvement Project (MBQIP) Rural Hospital Flexibility (Flex) Quality Improvement Program

MBQIP is a quality improvement activity under the Flex program of the Health Resources and Services Administration’s (HRSA) Federal Office of Rural Health Policy (FORHP). The goal of MBQIP is to improve the quality of care provided in critical access hospitals (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 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.

Flex Program Components

Quality Improvement

The quality improvement area includes MBQIP data. Submitting MBQIP data is the only requirement for CAHs to participate in the Flex Program. If CAHs meet the MBQIP reporting requirements they are automatically able to participate in Flex Program activities. Compass sends MBQIP reports to hospitals and provides technical assistance, webinars, calls and live events related to quality improvement.

Core Measure Focus Areas

• Patient Safety/Inpatient
• Patient Engagement
• Care Transitions
• Outpatient

Financial Improvement

HomeTown Health provides financial improvement webinars, triage resources, live meetings, comparative dashboards, in-depth assessments and action planning and peer assistance.

Operational Improvement

HomeTown Health provides operational improvement webinars, live meetings, comparative dashboards, in-depth assessments and action planning and peer assistance.

Population Health

 

Population Health activities are aimed at providing technical assistance with Community Health Needs Assessments (CHNAs)/Implementation Plans, encouraging collaboration with local public health and other community partners, and assisting with population health projects that impact Social Drivers of Health (SDOH), mental and behavioral health and age-friendly health system designation. 

 

To learn more about how these various organizations work together to support hospitals through the Flex program refer to the Flex Program Crosswalk.

Data Reporting

Enrolled hospitals submit Emergency Department Transfer Communication (EDTC) data to Compass via the Compass Portal. Compass provides participating hospital with quarterly hospital level performance reports to assist them in monitoring performance across measures.

Other Data Reporting Platforms

Measure	Encounter Period Due Date	Submission Portal
Core Elements of Antibiotic Stewardship via the CDC NHSN Annual Facility Survey	Annually by March 1st using the previous CY data*	National Healthcare Safety Network (NHSN)
Critical Access Hospital Quality Inventory and Assessment (Global Measure)	Annually September-November	Flex Monitoring Team via Qualtrics
ED Throughput - Patient left without being seen (OP-22)	Annually by May 15th using the previous CY data*	Hospital Quality Reporting (HQR) – Outpatient Web Based
Emergency Department Throughput (OP-18)	Quarterly on the first of the month in February, May, August and November*	HQR
Emergency Department Transfer Communication (EDTC)	Quarterly on the last day of the month (February, April, July, October) following the end of the previous quarter*	Compass Data Portal
Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS)	Quarterly in January, April, July and October	HQR-HCAHPS (via your HCAHPS vendor)
Hybrid Hospital-Wide Readmission  (Hybrid HWR)	Annually by October 1st using Q3 of previous CY through Q2 of current CY data	HQR
Influenza vaccination coverage among healthcare personnel (HCP/IMM-3)	Annually by May 15th using Q4 of previous CY through Q1 of current CY data	NHSN
Safe Use of Opioids - Concurrent Prescribing	Exact due date changes annually (February/March)	HQR - eCQM File Upload

*If the date falls on a weekend, the due date is the following business day

 

Resources

Participating hospitals have access to resources, education and trainings such as:

• Rural Quality Improvement Technical Assistance (RQITA) Resource Center
• National Rural Health Resource Center
  • MBQIP Key Resources
  • MBQIP Quality Reporting Guide
  • MBQIP Measures Fact Sheets
  • MBQIP Data Abstraction Training Series
• Iowa HHS
• iCompass - Communication Platform
• iCompass Academy - Educational Platform

Questions?

Connect with Compass Healthcare Collaborative's director of hospital quality initiatives, Charisse Coulombe at coulombec@compasshcc.org.