Part of the Medicare Beneficiary Quality Improvement Project (MBQIP), within the Outpatient domain, CAHs must report on the percentage of patients who left the emergency department before being seen. Reducing patient wait time in the ED helps improve access to care, increase capability to provide treatment, reduce ambulance refusals/diversions, reduce rushed treatment environments, reduce delays in medication administration, and reduce patient suffering.

Part of the Medicare Beneficiary Quality Improvement Project (MBQIP), within the Outpatient domain, CAHs must report on the average time patients spent in the emergency department before being sent home. Reducing the time patients remain in the emergency department (ED) can
improve access to treatment and increase quality of care, potentially improves access to care specific to the patient condition and increases the capability to provide additional treatment.

Part of the Medicare Beneficiary Quality Improvement Project (MBQIP), within the Outpatient domain, CAHs must report on the median number of minutes before outpatients with chest pain or possible heart attack who needed specialized care were transferred to another hospital. The early use of primary angioplasty in patients with STEMI results in a significant reduction in mortality and morbidity. The earlier primary coronary intervention is provided, the more effective it is. Times to treatment in transfer patients undergoing primary PCI may influence the use of PCI as an intervention. Current recommendations support a door-to-balloon time of 90 minutes or less.

Part of the Medicare Beneficiary Quality Improvement Project (MBQIP), within the Outpatient domain, CAHs must report on time-to-fibrinolytic therapy, which is a strong predictor of outcome in patients with AMI.

Part of the Medicare Beneficiary Quality Improvement Project (MBQIP), within the Patient Safety/Inpatient domain, the Antibiotic Stewardship measure assesses the core elements of hospital antibiotic stewardship programs: leadership, accountability, drug expertise, action, tracking, reporting, and education.

Part of the Medicare Beneficiary Quality Improvement Project (MBQIP), the intent of the HCAHPS initiative is to provide a standardized survey instrument and data collection methodology for measuring patients’ perspectives on hospital care. While many hospitals have collected information on patient satisfaction, prior to HCAHPS there was no national standard for collecting or publicly reporting patients’ perspectives of care information that would enable valid comparisons to be made across all hospitals. The HCAHPS Survey is composed of 29 items: 19 items that encompass critical aspects of the hospital experience (communication with nurses, communication with doctors, responsiveness of hospital staff, communication about medicines, discharge information, care transition, cleanliness of the hospital environment, quietness of the hospital environment, overall rating of hospital, and recommendation of hospital); three items to skip patients to appropriate questions; five items to adjust for the mix of patients across hospitals; and two items to support congressionally-mandated reports.

(Note: Formerly OP-27) Part of the Medicare Beneficiary Quality Improvement Project (MBQIP), within the Patient Safety/Inpatient domain, CAHs must report on the influenza vaccination data for HCP physically working in the inpatient and outpatient hospital units for at least one working day between October 1 through March 31, regardless of clinical responsibility or patient contact. This includes all influenza vaccinations administered during the influenza season at the facility or elsewhere, influenza vaccine declinations, and determinations of a medical contraindication to influenza vaccination. Data should be reported separately for employees, licensed independent practitioners, and adult students/trainees and volunteers.

Part of the Medicare Beneficiary Quality Improvement Project (MBQIP), the Emergency Department Transfer Communication (EDTC) quality measure is National Quality Forum (NQF) endorsed (NQF #291), and relevant to small rural hospitals. This measure is being implemented by critical access hospitals (CAHs) in the Medicare Beneficiary Quality Improvement Project (MBQIP) because small rural hospitals frequently transfer a higher proportion of emergency department (ED) patients than larger urban facilities. It is an important goal of MBQIP to help hospitals improve care transitions, including ED transfers, in order to reduce preventable hospital readmissions and adverse events in hospitals.