Reporting And Data

MBQIP - OP-3: Median Time to Transfer to Another Facility for Acute Coronary Intervention

Latest Update: September 11, 2020

Reporting Information

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.

Responsible Party

Who Must Report?

Critical Access Hospitals (CAHs)


When Do I Report?

Quarterly - May 1, August 1, November 1, February 1


How Do I Report?

Hospitals report to CMS by entering data into the CART software and then uploading to the QualityNet Secure Portal.

*NRHP members may have their CART software hosted on a "CART server" at NRHP. NRHP staff is then responsible for managing patches and upgrades to new versions.

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.

Publicly Displayed

Link to the website/ranking/grading/etc. where the data is published

Results displayed on Hospital Compare and affect the overall star rating for those facilities with large enough volume.


The legal mandate requiring reporting

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


Any other pertinent information

Find the Specifications Manual here: https://www.qualitynet.org/outpatient

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.