MBQIP Hospital Compare Consent Form

Consent Form for the Federal Office of Rural Health Policy’s Medicare Rural Hospital Flexibility Program Medicare Beneficiary Quality Improvement Project

To print the MBQIP Hospital Consent Form, click here.

Background

The Medicare Beneficiary Quality Improvement Project (MBQIP) goal is for CAHs to implement quality improvement initiatives to improve their patient care and operations. Through MBQIP, the state Flex programs 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. To facilitate the use of Hospital Compare reporting to improve quality, the Federal Office of Rural Health Policy (ORHP) will be analyzing the data in each of the phases for reporting back to the State Flex programs and CAHs. By providing consent, CAHs allow ORHP access to all the non-beneficiary level data that is submitted to Hospital Compare and will ensure thorough and timely analysis and feedback of the results.  

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. 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)

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.

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 each state Flex program for comparison among hospitals within the state.

Contact Information

Hospital Contact

Address

Phone

Email

 

Signature

__________________________________________

Hospital CEO or designate