The Hospital IQR Program is a quality data reporting program for inpatient hospital services implemented by CMS. Through its hospital quality improvement initiatives, the Centers for Medicare & Medicaid Services (CMS) strives to improve the care provided by the nation's hospitals and publicly display (on Care Compare) quality information to consumers and others. Acute care hospitals paid under the Inpatient Prospective Payment System are required to report Inpatient Quality Reporting Data (IQR).
Critical Access hospitals are not included in the Hospital IQR Program but are encouraged to participate in voluntary reporting and have their data publicly reported on the public reporting website. To participate in voluntary reporting, critical access hospitals must let CMS know by submitting an Optional Public Reporting Notice of Participation, which may be submitted at any time. Critical access hospitals are required to participate in the Medicare Promoting Interoperability Program, which is a separate, but related program to the Hospital IQR Program.
To submit Hospital IQR eCQM data that is timely, complete and accurate, follow these steps.
- If unregistered with HARP, please complete HARP Registration to obtain access. HARP is a secure identity management portal provided by the Centers for Medicare and Medicaid Services (CMS). Creating a HARP account provides a user ID and password that can be used to sign in to many CMS applications, including Hospital Quality Reporting.
- Create HCQIS Access Roles and Profile (HARP) account. Hospitals must register staff and at least one staff as Security Official regardless of the method used for submitting data within the Hospital Quality Reporting (HQR) Secure Portal. The HQR Secure Portal is the only CMS-approved website for secure healthcare quality data exchange.
- If key personnel changes occur after registration, use the Hospital Contact Change Form (https://qualitynet.cms.gov/inpatient/iqr/resources) to update the Inpatient VIQR Support Contractor for the Hospital IQR Program.
- Hospitals need to complete a Hospital IQR Program Notice of Participation (NOP) through the Hospital Quality Reporting Secure Portal online tool. During this process, hospitals identify two contacts to receive notification of pledge changes. The Hospital Inpatient Quality Reporting Program NOP may be completed at https://qualitynet.cms.gov/inpatient/iqr/participation#tab2.
The attached, “2024 Important Dates and Deadlines” provide data submission deadlines and mandatory data reporting quarters for payment determination. Hospitals utilizing a vendor to submit data on their behalf must first complete the online authorization process, accessible from the HQR Secure Portal. Please contact Quality Net Help Desk at 1-866-288-8212 for further assistance.
Hospitals participating in the Hospital Inpatient Quality Reporting Program (IQR) may request Extraordinary Circumstances Exception, also referred to as an ECE. eCQM ECE forms are due by April 1, 2024, for the 2023 calendar year reporting period. To learn more about the ECE policy or to access the request form, please visit the QualityNet website at https://qualitynet.cms.gov
For additional information on registering for HARP, please review the following resources at https://qualitynet.cms.gov/getting-started. To receive email notifications on eCQM reporting for Hospital IQR and Medicare Promoting Interoperability Programs, join the Listserv group at https://qualitynet.cms.gov/listserv-signup