Reporting And Data

MBQIP - Antibiotic Stewardship

Latest Update: September 11, 2020

Reporting Information

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.

Responsible Party

Who Must Report?

Critical Access Hospitals (CAHs)


When Do I Report?

Annually - March 1


How Do I Report?

Hospital tracks information and reports to CMS by answering questions on the Patient Safety Component Annual Hospital Survey on the CDC's National Healthcare Safety Network (NHSN) website.

Contact Information

Becky Bayley, MBA
Director of Strategic Initiatives

Nevada Rural Hospital Partners
4600 Kietzke Lane, Suite I-209
Reno, NV 89502

Phone: (775) 827-4770


Laima Etchegoyhen, MPH
Outreach and Technical Assistance Coordinator
Nevada Flex Program Coordinator

Office of Statewide Initiatives
University of Nevada, Reno School of Medicine
604 West Moana Lane, MS 3150
Reno, Nevada 89509

work-phone: 775-682-8471
cell-phone: 775-338-9841

website: https://med.unr.edu/statewide


Why Should I Report?

Potential loss of grant funding for not meeting eligibility requirements.


The legal mandate requiring reporting

Health Resources and Services Administration’s (HRSA) Medicare Beneficiary Quality Improvement Program (MBQIP) Memorandum of Understanding (MOU)

Although many of these requirements apply to individual medical professionals and other types of hospitals and health care facilities, the information is presented solely to support Critical Access Hospitals. The reporting requirements and legal mandates on this site are not an exhaustive list and Nevada Rural Hospital Partners, Inc. bears no responsibility or liability for any hospitals' or providers' failure to comply with Federal or State laws or regulations.