Clinical Quality

Physician Quality Reporting System (PQRS)

The Physician Quality Reporting System (PQRS) ended in 2016 and has since transitioned to the Merit-based Incentive Program (MIPS). Previously, PQRS was the program used for eligible individual providers and group practices to report quality care data to Medicare.

Merit-based Incentive Payment System (MIPS)

The Merit-based Incentive Payment System is one of two payment tracks offered by the Centers for Medicare and Medicaid Services. Currently, it is the largest value-based care payment program, and a consolidation of three previous programs – Medicare Electronic Health Records (EHR) Incentive Program for Eligible Clinicians, Physician Quality Reporting System (PQRS) and Value-Based Payment Modifier (VBM).

Clinicians are required to report MIPS data in four categories – quality, improvement activities, promoting interoperability and cost. Each category carries its own weight and maximum allowable point values. The unified scoring system accounts for exceptional performance, exemptions, evaluation at the individual or group level, special circumstances and non-patient-facing MIPS eligible physicians.

The MIPS performance threshold and payment adjustments have increased since the start of the program and are only expected to continue to increase. In 2018, providers could receive a negative or positive adjustment in 2020 of five percent depending on performance. This adjustment follows the provider, wherever they are in practice, two years after the performance year.

National Database of Nursing Quality Indicators (NDNQI)

The National Database of Nursing Quality Indicators (NDNQI) is the only national nursing database that provides quarterly and annual reporting of structure, process and outcome indicators to evaluate nursing care at the most granular level.

Hospitals and health systems nationwide use these indicators to accurately link nurse staffing levels and patient outcomes using this database.

Agency for Healthcare Research and Quality (AHRQ)

The Agency for Healthcare Research and Quality (AHRQ) is a federal agency under the Department of Health and Human Resources committed to improving the safety and quality of the Nation’s healthcare system, created in 1989.

The agency’s main focus is investing in research on the Nation’s health delivery system that goes beyond the “what” of health care to understand “how” to make health care safer and improve quality. AHRQ develops and provides information to teach and train healthcare systems and professionals and generates measures and data used by providers and policymakers.

Qualified Registry (QR)

A Qualified Registry (QR), similar to a QCDR, is a Centers for Medicare and Medicaid Services (CMS) entity that collects data from an individual MIPS-eligible clinician, group and/or virtual group and submits the data to CMS on the individual’s behalf for the purposes of MIPS. QRs provide many of the same benefits as a QCDR except a QR can only report on specific MIPS measures supplied by CMS. Also, a QR does not have the ability to create new measures to be used for reporting.

Qualified Clinical Data Registry (QCDR)

The Centers for Medicare and Medicaid Services (CMS) define a Qualified Clinical Data Registry (QCDR) as a CMS-approved entity that collects data from an individual MIPS-eligible clinician, group and/or virtual group and submits the data to CMS on their behalf. QCDR data is used in evaluating incentive-based payment programs such as MIPS (Merit-Based Incentives Payment System).

Although CMS allows a variety of participation methods, the QCDR offers several important benefits:

  • All-in-One Reporting: The ability to report on all three incentive-based payment system categories including: quality, promoting interoperability and improvement activities.
  • Regular Feedback: Participants receive at least four feedback reports per year, which include physician-level data. Physicians can review their performance scores at all levels.
  • Individual and Group Reporting: The MIPS Portal supports both individual reporting and group reporting for clinicians.
  • Control: The ability to review and manage which measures to assess and to preview results before submitting them to CMS.
  • Wider range of patients:  The ability to report on all patients instead of only just Medicare Part B patients.
  • Create QCDR Measures:  The ability to create QCDR measures in addition to the MIPS measures.


The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) is a survey for measuring hospital patients’ perspectives on the care received. Though individual hospitals may have their own methods for measuring patient satisfaction and feedback, the HCAHPS is the first standardized and publicly-reported survey in the U.S.

The survey contains 27 questions about the patient’s hospital stay, with 18 questions dedicated to the most critical aspects of patients’ hospital experiences. These include nurse and doctor communication, hospital staff responsiveness, the hospital’s cleanliness and quietness, pain management, communication about medicines, discharge information, overall rating of the hospital and if they would recommend the hospital to others.

Benefits of receiving high HCAHPS scores include an improved reputation for the hospital, patients feeling like their voices are heard and financial incentives provided by the U.S. government for good performance.