MBQIP MOU

Memorandum of Understanding Between the <State Flex Program>
and <Critical Access Hospital>

To print the MBQIP MOU, click here.

Background

The Medicare Beneficiary Quality Improvement Project goal is for CAHs to implement quality improvement initiatives to improve their patient care and operations. Through MBQIP, the <State Flex Program> will support Critical Access Hospitals (CAHs) with technical assistance to improve health care outcomes on Hospital Compare and other national benchmarks. CAHs opting to participate will report on a specific set of annual measures and engage in quality improvement projects to benefit patient care.

The passage of meaningful use requirements and the Affordable Care Act heightened national attention on quality activities and reporting. In the environment of meaningful use, pay for performance, bundled payments, and accountable care organizations (ACO), CAHs may increasingly be compared with their urban counterparts to ensure public confidence in the quality of their health services. This initiative takes a proactive and visionary approach to ensure CAHs are well-equipped and prepared to meet future quality requirements. Additionally, MBQIP fulfills the Flex grant Quality Improvement (QI) objectives regarding Hospital Compare reporting, and supporting participation in various multi-hospital QI initiatives. This project emphasizes putting patients first by focusing on improving health care services, processes and administration.

Measures

Phase 1 Measures

  • Pneumonia: Hospital Compare CMS Core Measure (participate in all sub-measures); AND
  • Congestive Heart Failure: Hospital Compare CMS Core Measure (participate in all sub-measures)

Phase 2 Measures

  • Outpatient 1-7: Hospital Compare CMS Measure (all sub-measures that apply); AND
  • Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS)

Phase 3 Measures

  • Pharmacist CPOE/Verification of Medication Orders Within 24 Hours; AND
  • Outpatient Emergency Department Transfer Communication

Role of State Flex Program

  • Assist <CAH> in accessing needed technical assistance around data collection and reporting
  • Assist <CAH> in analyzing their own and comparative data via Hospital Compare
  • Determine appropriate partners to execute quality improvement activities
  • Provide technical assistance around quality improvement activities

Role of CAH

  • Collect and submit the measures to Hospital Compare
  • Determine appropriate staff to coordinate the project
  • Engage in quality improvement trainings
  • Implement quality improvement activities

Timeline

 

Project Period Years

(September – August)

Measures

Activities

Year 1: 2010-2011

 

Planning for the project (work with hospitals, determine technical assistance needs for data collection)

Year 2: 2011-2012

By September 1, hospitals have begun reporting on Phase 1 measures

Plan for QI activities and assist with TA around data collection and analysis.

Year 3: 2012-2013

By September 1, hospitals have added Phase 2 measures to their reporting

In 2013, annual benchmarking data will be available from Phase 1. Plan QI activities and TA for Phases 1 and 2.

Year 4: 2013-2014

By September 1, hospitals have added Phase 3 measures to their reporting

In 2014, annual benchmarking data will be available from Phases 1 and 2. Plan QI activities and TA for Phases 1 (if necessary), 2 and 3.

Year 5: 2014-2015

Hospitals continue reporting on all Phases.

In 2015, annual benchmarking data will be available from Phases 1, 2 and 3. Plan QI activities and TA for Phases 1 (if necessary), 2 and 3.

 Project Period

This MOU is effective on the date the agreement is signed by both parties.

Review

The parties agree to review jointly the terms and conditions at least annually to determine if expectations are met and the hospital will begin the collection on the next phase of measures.

Data Use

­­__ By checking here, the provider hereby confirms its written consent as required by 42 CFR section 480.140(d) to the release of the confidential Quality Review Study information for purposes as outlined below:

  • The data from measures for Phase 1 and 2 project submitted by the hospital into Hospital Compare will be provided to the Federal Office of Rural Health Policy, or designated entity, who will analyze the data.
  • Beneficiary level data will not be accessed.
  • Hospital level data will be analyzed and reported to the <State Flex Program> for comparison among hospitals within the state.

Duration of Agreement

The project period for this agreement is effective from the date signed and terminates on August 31, 2015. Activities may be added to this agreement through modifications. Affected parties must agree to any modification or amendment of the agreement in writing. Any party may terminate their participation in this agreement for a cause by giving the other party 30 days written notice.

Contact Information

Flex Coordinator
Hospital Quality Improvement Coordinator (or main POC for MBQIP).

Signatures

__________________________________________

Appropriate Official at the State (Flex Coordinator?)


__________________________________________

Hospital CEO or designate               

 

Appendix: Measure Definitions

Phase One Measures

  • Pneumonia: CMS Hospital Compare Core Measure (participate in all sub-measures);

PN-2: Pneumococcal Vaccination

PN-3b: Blood Cultures Performed in the Emergency Department Prior to Initial Antibiotic Received in Hospital

PN-4: Adult Smoking Cessation Advice/Counseling

PN-5c: Initial Antibiotic Received Within 6 Hours of Hospital Arrival

PN-62: Initial Antibiotic Selection for CAP in Immunocompetent Patient

PN-7:Influenza Vaccination

  • Congestive Heart Failure: CMS Hospital Compare Core Measure (participate in all sub-measures)

HF-1: Discharge Instructions

HF-2: Evaluation of LVS Function

HF-3: ACEI or ARB for LVSD

HF-4: Adult Smoking Cessation Advice/Counseling

Phase 2 Measures

  • Outpatient 1-7: Hospital Compare CMS Measure (all sub-measures that apply);

OP-1: Median Time to Fibrinolysis in the Emergency Department

OP-2: Fibrinolytic Therapy Received Within 30 Minutes of ED Arrival in the Emergency Department

OP-3: Median Time to Transfer to another Facility for Acute Coronary Intervention in the Emergency Department

OP-4: Aspirin at Arrival in the Emergency Department

OP-5: Median Time to ECG in the Emergency Department

OP-6: Timing of Antibiotic Prophylaxis (Prophylactic Antibiotic Initiated Within One Hour Prior to Surgical Incision) in Surgery

OP-7: Prophylactic Antibiotic Selection for Surgical Patients in Surgery

  • Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS)

Phase 3 Measures

  • Pharmacist CPOE/Verification of Medication Orders Within 24 Hours

Numerator:  Number of patients whose medication orders are directly entered (CPOE) or verified by a pharmacist within 24 hours.

Denominator:  Number of patients with at least one medication in their medication list (entered using CPOE) admitted to a CAH’s inpatient or emergency department during the reporting period.

  • Outpatient Emergency Department Transfer Communication (Seven Elements)
    • Pre-Transfer Communication Information                                                            
    • Patient Identification                                                                                                  
    • Vital Signs                                                                                                                                    
    • Medication-related Information
    • Practitioner generated information                                                                         
    • Nurse generated information                                                                                  
    • Procedures and tests

Link for Measure:

http://www.qualityforum.org/Publications/2009/09/National_Voluntary_Consensus_Standards_for_Emergency_Care.aspx