Patient Safety / Inpatient

These resources focus on quality improvement related to patient safety and inpatient care. The current required and additional Medicare Beneficiary Quality Improvement Project (MBQIP) measures that fall under this domain include: HCP/IMM-3 (OP-27): Influenza Vaccination Coverage among Healthcare Personnel, IMM-2: Influenza Immunization, Antibiotic Stewardship, ED-1 and ED-2: Emergency Department (ED) Care for Admitted Patients, Hospital Acquired Infections (HAI), Central Line-Associated Bloodstream Infection (CLABSI), Catheter-Associated Urinary Tract Infection (CAUTI), Clostridioides difficile infection, Methicillin-Resistant Staphylococcus aureus (MRSA), Perinatal Care (PC-01), Falls, Adverse Drug Events, and Patient Safety Culture Survey.

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Take advantage of these resources designed to help you better understand MBQIP measures and protocols, as well as ways to make the process go a lot smoother.


The Art Dept

Many hospitals and healthcare organizations do not have marketing departments or budgets for quality agency materials that can be customized. Our goal is to provide you the ability to use free of charge campaigns that will help your organization.

Use our customization tool and choose the various options you would like to use. Each theme will have different deliverables. Choose just one, or a couple to create a well-rounded campaign. If you need them printed, we offer that service as well.

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Please use these resources to help expand the knowledge of your staff on the various MBQIP measures that are essential for state Flex programs.


The MBQIP Patient Safety and Inpatient Care Quality Reports include data from CMS Hospital Compare measures that are relevant for CAHs under the MBQIP domains of patient safety/inpatient care. The reports include data from all CAHs that have signed a MBQIP Memorandum of Understanding (MOU) and have submitted data. Thus, the reports include data from CAHs that have not agreed to publicly report on Hospital Compare, in addition to data from CAHs that don’t have enough cases to be publically reported on Hospital Compare, providing a more complete picture of performance across CAHs nationally.

Using Compairson Data for Patient Safety and Inpatient/Outpatient Measures

MBQIP Patient Safety and Inpatient/Outpatient Care Quality Reports summarize process-based quality measures that evaluate implementation of clinically proven best practices of care. Hospitals should strive to provide these best practices in clinical care to every patient, 100 percent of the time. Each measure includes the following comparison groups:

  • all reporting CAHs by state, under the column header CAH State Current Quarter
  • all reporting CAHs nationally, under the column header CAH National Current Quarter
  • all reporting hospitals nationally (both Prospective Payment System hospitals and CAHs), under the column header All National Current Quarter (unavailable for Antibiotic Stewardship)

Although it can be helpful to understand performance in comparison to those norms, averages represent the middle ground for performance and everyone should strive to achieve at least the 90th percentile for each measure. For quality improvement purposes, such data benchmarks are more useful than average comparison data.

View the quality report of your hospital by entering its CCN below.

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