Oregon Office of Rural Health

Quality and the Medicare Beneficiary Quality Improvement Program (MBQIP)

Crooked River

The Medicare Beneficiary Quality Improvement Project (MBQIP) for Critical Access Hospitals (CAHs) is a quality improvement activity under the Medicare Rural Hospital Flexibility (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 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 own 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. 

Although MBQIP reporting is optional to CAHs, it is required for CAHs who wish to participate in any Flex-funded opportunity in the areas of quality, finance and operations, EMS and/or population health.  MBQIP's Core Improvement Initiatives fall under four domains:

  • Patient Safety
  • Patient Engagement
  • Care Transitions
  • Outpatient

Additional domains are recommended but not required. Details on the current domains are available here.

2022 Presentations

CAH Quality Program Review (by Susan Runyan)

Changing Landscape of Quality Measurement (by Karla Weng)

Emergency Department Efficiencies (by Susan Runyan)

Introduction to Project Firstline  (by Dr. Judy Guzman-Cotrell)

Leveraging TeleMentoring & TeleEducation During COVID 19  (by Zahra Kassamalli-Excobar & Natalie Martinez-Paz)

OHA Lessons Learned During COVID-19 (by Roza Tammer)

Reducing Readmission by Optimizing Transition of Care in Rural Settings (by Seema Rathor & Alena Acklin)

Medicare Beneficiary Quality Improvement Project (MBQIP) & Quality Improvement Webinar Series

Webinar 1: MBQIP Overview and Current State | March 14, 2023

Presenters: Sarah Brinkman & Janelle Shearer, RQITA


  • Articulate the purpose of the Medicare Beneficiary Quality Improvement Program (MBQIP) program and its position in the national quality reporting landscape.
  • Understand requirements of MBQIP, how data is reported, and current national performance trends.
  • Identify ways to utilize MBQIP data and suggested strategies to drive improvement.

Presentation video | Slides

Webinar 2: Abstraction Data + CART Overview | April 23, 2023 | 10 a.m. - 11 a.m. PST 

Presenter: Robyn Carlson, RQITA


  • Identify resources to support abstracting, submitting and confirming data submission to the Centers for Medicare & Medicaid Services (CMS) Hospital Quality Reporting (HQR) secure platform.
  • Describe how to use the CMS Hospital Outpatient Quality Reporting Specifications Manuals for abstraction guidance and technical specifications to submit the core MBQIP measures.
  • Discuss how to use CART, the CMS Abstraction & Reporting Tool, for the collection and submission of the core MBQIP measures.

Presentation video | Slides

Webinar 3: Embedding Quality Improvement into Organizational Culture | May 9, 2023 | 10 a.m. - 11:30 a.m. PST 

Presenters: Sarah Brinkman & Janelle Shearer, RQITA


  • Identify characteristics of a culture of quality.
  • Assess current state of organizational culture as it relates to quality and identify short- and long-term opportunities for improvement.
  • Describe strategies for embedding quality improvement into organizational culture.

Presentation video | Slides

Webinar 4: Changing Landscape of Quality Reporting | June 20, 2023 | 11:30 a.m. - 1:00 p.m. PST | Register here

Presenters: Sarah Brinkman & Janelle Shearer, RQITA


  • Identify trends in quality measure reporting and discuss implications for critical access hospitals.
  • Review the recent MBQIP Measures Under Consideration request for information and related updates.
  • Explore topics such as the CMS Overall Quality Hospital Star Ratings and electronic Clinical Quality Measures (eCQM) and how the impact critical access hospitals.
  • CAH Quality 101
    The CAH Quality 101 Training Series, led by Susan Runyan of Runyan Health Care Quality Consulting is aimed to teach best practices in quality improvement, data abstracting, data reporting and process improvement within the CAH setting.  This series is targeted toward new quality professionals and acts as a refresher course for seasoned quality professionals.
    o    Session One Recording
    o    Session One Slides

        o    Session Two Recording
        o    Session Two Slides

  • Critical Access Hospital Quality Reporting Overview Guide to assist new and experienced Quality Officers with reporting requirements at their CAH.
  • Oregon’s CAH Quality Network encourages CAH quality professionals collaborate and learn together. All CAHs are encouraged to join monthly calls and participate in regional networking activities.  For more information about the Oregon CAH Quality Network, contact Stacie Rothwell at rothwels@ohsu.edu.
  • Additional MBQIP resources from the National Rural Health Resource Center are available at the MBQIP Resource Page or FAQs.
  • MBQIP Monthly is a monthly e-newsletter that provides Critical Access Hospitals (CAHs) with information and support for quality reporting and improvement and highlights current information about the Medicare Beneficiary Quality Improvement Project (MBQIP). To view current, or past issues of MBQIP Monthly, click here.


Stacie Rothwell | 971-235-3978