MBQIP Data Report Flowchart: questions to determine where improvement in the MBQIP process
may be needed
Has the CAH agreed to
participate in MBQIP?
No
Did you receive a data
report for the CAH?
No
Work with the CAH and encourage
participation (see additional
resource on encouraging MBQIP
participation)
Yes
Follow up with your
ORHP project officer
Yes
(As identified by “N/A” in all fields of the
report)
Did the CAH report
data for the quarter?
(1) Follow up with the CAH and
determine reasons as to why; (2)
encourage future reporting; (3) work
with partners (such as the QIO) to
provide necessary TA to CAH
No
Yes
Does the data provided on the report
look reasonable? E.g. does it look like an
appropriate number of cases were reported
for each measure given your knowledge of
the patient population for that CAH? You
may need to engage your CAHs and quality
partners in this discussion.
Yes
Begin review of data/quality
outcomes and determine
potential QI interventions
for your CAHs and/or your
state.
No
Work with the CAH and
your quality partners to
determine why the reported
numbers do not appear
reasonable and then
provide the appropriate TA.
Some potential reasons could
include:
• Under-reporting of cases at
the CAH level? (the goal is to
have all cases reported for
all measures, not just those
that meet the CMS 25-case
threshold for public
reporting)
• Did the CAH submit data for
more cases than are included
in the report? Explore the
potential reasons for this.
December 2012