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EDTC-Abstraction Training Offered October 24, 2017

Through its hospital quality improvement initiatives, the Centers for Medicare & Medicaid Services strives to improve the care provided by the nation’s hospitals and provide quality information to consumers and others. Data collection is an integral part of CMS’ hospital quality improvement initiatives. CMS focuses on reporting measure data that have high impact and support national priorities for improved quality and efficiency of care.

The current measure sets include measures that assess processes of care, imaging efficiency patterns, care transitions, ED throughput efficiency, population health, the use of health information technology, care coordination, patient safety, and volume. These measures are included in the Medicare Beneficiary Quality Improvement Project.

The EDTC-Abstraction Training is designed to instruct new and seasoned quality data personnel from Small Hospital Improvement Program grant eligible facilities. Join us at the Holiday Inn, 3145 S 9th St., Salina, Kansas on Tuesday, October 24, 2017.

Click Here to View the Agenda

Click Here to Register Online


CAHs are affected directly and indirectly by the rapidly changing health care payment and delivery environment

Significant efforts are underway to fundamentally change the way health care is provided and paid for in the United States. The U.S. Department of Health and Human Services (HHS) launched a delivery system reform initiative to accelerate improvements to our health care delivery system, with specific goals in adopting value-based care and payments announced in January 2015.

  • A critical component of the changing health care environment is to accelerate adoption of reimbursement models that reward value, with an emphasis on quality and care coordination. Alternative payment models, such as accountable care organizations, are one key component, with HHS setting targets of 50 percent of Medicare fee-for-service payments through these new models by 2018. However, incentives linked to quality of care metrics also are growing exponentially, with an HHS goal of 90 percent of Medicare FFS payments linked to quality by 2018.
  • Paid under a cost-based reimbursement model aimed at stabilizing financing for safety net care, CAHs are excluded from most quality reporting and incentive programs and care coordination payments linked to current fee-for-service payment structures (i.e. prospective payment system – PPS).
  • Although some CAH leaders may breathe a sigh of relief that they have been excluded from many of these changes, they are not immune to the impacts. Value-based reimbursement models nearly all include incentives related to performance on quality metrics as well as reducing overall costs by improving care coordination and reducing hospitalizations and emergency department utilization. Even if the CAH isn’t directly participating in value based reimbursement, it is likely that affiliated providers and partners have reimbursement tied to quality and cost goals.
  • Providing evidence of high-quality care delivery necessitates participation in quality reporting programs, as partners, payers and consumers will – and should – demand evidence that the quality of care provided in a small, rural hospital is equivalent to, if not better than, those same services in an urban setting.
  • One of the first steps in the transition to value-based reimbursement models is often related to quality reporting and the ability to demonstrate quality, efficiency, and strong patient experience.
  • Despite the challenges, many rural communities are stepping up to the opportunities of delivery system reform. Although considered voluntary by CMS, nearly 90% of CAHs nationwide participate in public reporting of at least some quality metrics. 95% of Kansas CAHs have participated in public reporting of quality metrics.  
  • CMS is leading the way in implementation of many value based payment methods, but a growing number of state Medicaid programs and commercial payers are implementing quality incentive programs and and alternative payment models which provide opportunities and/or requirements for CAH participation.
  • Although CMS does not currently mandate quality reporting by CAHs, it cannot be considered optional for CAHs in order to keep pace in an environment that is rapidly shifting to focus on value.

The Medicare Beneficiary Quality Improvement Project (MBQIP) is a nation-wide initiative of the Federal Office of Rural Health Policy and the Rural Medicare Flexibility program (FLEX to support critical access hospitals in reporting rural – relevant quality data measures and adopting proven clinical delivery models to drive quality and performance.

The Federal Office will aggregate this quality data reporting by the critical access hospitals to build a national database to be used to demonstrate the effectiveness of rural health quality improvement initiatives.

MBQIP Data Submission Deadlines – 2017-2018 SHIP


Available Help Desks:

Quality Health Indicators (QHi), Stuart Moore,, (785) 233-7436

National Healthcare Safety Network (NHSN),, (877) 681-2901

QualityNet,, (866) 288-8912


Additional Resources:

Paul Moore’s Video – Confused about MBQIP?

MBQIP Data Abstraction Training Series

  • Locating CMS Specifications Manuals (13-minute video)
  • Locating CART (CMS Abstraction Reporting Tool) (9-minute video)
  • Outpatient AMI Measures (OP1 – OP5) (23-minute video)
  • Outpatient Chest Pain Measures (OP4 – OP5) (20-minute video)
  • ED Throughput Measures (OP18, OP20, OP22) (19-minute video)
  • Outpatient Pain Management Measure (OP21) (12-minute video)
  • Inpatient Influenza Vaccination Measure (IMM-2) (18-minute video)