CAH MBQIP Resources

Medicare Flexibility Program & Quality Reporting Resources

The Medicare Flexibility Program has additional programmatic resources to support quality improvement activities through provision of hospital reports and technical assistance offerings through the Federal Office of Rural Health.  Please find below helpful resource links that further explain the reporting structure and resources for quality reporting.  There are three reporting platforms utilized to compile the reports for the MBQIP data including, CMS Quality Net.


FLEX Monitoring Team

The Flex Monitoring Team (FMT) is a consortium of researchers from the Universities of Minnesota, North Carolina at Chapel Hill, and Southern Maine. Funded by the Federal Office of Rural Health Policy (grant number U27RH01080), the FMT evaluates the Medicare Rural Hospital Flexibility Grant Program (Flex Program).

There are over 1,300 CAHs working to improve access to health care services and population health for rural residents across the United States.  To help track the impact of the Flex Program, the Flex Monitoring Team examines data and conducts research on CAHs to assess quality, financial, and community measures at the national, state, and hospital level. The FMT produces a variety of different publications each year on their findings to help State Flex Programs and CAHs optimize their performance.

Stratis Health (EDTC Data Support)

The Emergency Department Transfer Communication (EDTC) measure for hospitals to evaluate communication for transitions of care during emergency department (ED) transfers is particularly relevant for critical access hospitals (CAHs) and is included in the Medicare Beneficiary Quality Improvement Project (MBQIP) as a core care transition measure.

While emergency care is important in all hospitals, the emergency department is particularly important in rural hospitals where the distance to urban tertiary care centers makes the effective triage, stabilization, and transfer of patients with the necessary and appropriate information of life-or-death importance. The emergency department transfer communication (EDTC) measure allows the acute care safety net facilities to show how well they carry out their important stabilize-and-transfer role for rural residents.  Here you can find helpful data specifications resources, data collection resources, and information on the technical expert panel who review this particular measure.

MBQIP Fundamentals Guide. This guide explains the fundamental program reporting elements and platforms for data submission. This guide will be used by Shakeerah McCoy, Director of Rural Health Innovation, during site visits for hospital coaching for quality improvement, but makes for a great reference tool to have handy during these visits.

CMS QualityNet Homepage

National Healthcare Safety Network (NHSN)

EDTC Data Submission Tool for NCHA Submission

We can add reminders for remaining of year here for EDTC

November 15, 2020
CMS Inpatient Measures**:

  • Patients seen Q2 2020 (April, May, June)
  • CMS Hospital Inpatient Reporting Specifications Manual version 5.7
  • Submitted to the QualityNet warehouse via CART or by vendor
  • CART version – 4.25.3

January 15, 2021
Emergency Department Transfer Communication (EDTC)

  • Patients seen Q4 2020 (October, November, December)
  • Submission to NCHA program contacts: Elizabeth Mizelle, Director of Measurement at and Shakeerah McCoy, Director of Rural Health Innovation,


February 1, 2021
CMS Population and Sampling (optional)*

  • Patients seen Q3 2020 (July, August, September)
  • Inpatient** and outpatient
  • Entered via Hospital Quality Reporting HARP account


 February 1, 2021
 CMS Outpatient Measures:

  • Patients seen Q3 2020 (July, August, September)
  • CMS Hospital Outpatient Reporting Specifications Manual version 13.0b
  • Submitted to the QualityNet warehouse via CART or by vendor
  • CART version – 1.18.2

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