CMS quality reporting programs collect standardized information about healthcare services. The program determines who reports, which measures apply and how the data are submitted and used.
For hospitals, two examples are the Hospital Inpatient Quality Reporting program, or IQR, and Hospital Outpatient Quality Reporting program, or OQR. Both are described by CMS as pay-for-reporting programs. They have different participating settings and requirements. Hospital IQR; Hospital OQR
Separate reporting from performance
Meeting a reporting requirement is not the same claim as achieving a strong result on every measure. Reporting concerns whether the organization supplies the required information appropriately. Performance concerns what a defined measure shows about care or outcomes.
CMS explains that selected IQR measures also inform separate programs that adjust payment based on quality. A measure can therefore appear in more than one context without those programs becoming interchangeable.
When a dashboard says “compliant,” ask whether it refers to data submission, documentation completeness or a clinical result. The word alone is insufficient.
Identify the setting and measurement period
Check the exact program and population before comparing figures. CMS's IQR overview concerns specified acute care hospitals paid under the inpatient prospective payment system. OQR concerns qualifying hospital outpatient departments. Program scopes; OQR overview
Next, record the dates: when care occurred, when data were submitted, when results were published and which payment period is involved. These may describe different stages of the reporting process.
Avoid labeling an older performance period as “current care” solely because the webpage was recently updated.
Follow the information back to its source
CMS describes OQR data drawn from sources such as medical records, claims, web submissions and surveys. The source affects what a measure can capture and what staff can verify.
For a local review, identify the measure definition, inclusion criteria, exclusions and source fields. Ask how missing information is handled and which team resolves discrepancies.
In a fictional example, two unit reports show different totals because one counts eligible discharges and the other counts all encounters. Reconcile the definitions before treating the difference as a performance change. Neither number should be silently substituted for the other.
Make nursing participation meaningful
Nurses can bring practical knowledge to a data review: whether documentation reflects the workflow, where information is lost and whether a proposed change adds an avoidable burden.
Ask the quality team to explain how a nursing action connects to the specified measure. Do not invent new documentation requirements from a measure title alone.
Use current program instructions for operational reporting.
Before comparing two scores, review how to specify a quality measure.
Related pages cover value-based purchasing, readmission measures and hospital quality star ratings.
Sources
- Hospital Inpatient Quality Reporting Program (accessed 2026-09-17) — CMS.
- Hospital Outpatient Quality Reporting Program (accessed 2026-09-17) — CMS, updated January 9, 2026.