Ultimate Guide to the Hospital Inpatient Quality Reporting Program

Fiscal Year 2025 ushered in several notable changes to the Hospital Inpatient Quality Reporting Program, including a new mandatory Patient Reported Outcome-Based Performance Measure (PRO-PM), structural measures, and additional electronic clinical quality measures (eCQMs). Healthcare leaders must fully understand the CMS Hospital Inpatient Quality Reporting Program to meet compliance obligations and protect revenue.

What Is the Hospital IQR Program?

The Hospital Inpatient Quality Reporting (IQR) Program is a pay-for-reporting initiative for acute care hospitals established through the Medicare Prescription Drug, Improvement, and Modernization Act (MMA) of 2003. Initially, the MMA penalized hospitals with a 0.4% reduction in their annual market basket update for failing to report on required performance metrics. This penalty was increased to 25% under the Affordable Care Act (ACA) of 2010 for noncompliance with hospital IQR program requirements.

FY 2027 Hospital IQR Program Requirements

Because the Hospital IQR Program applies a two-year delay between data collection and payment impact, changes implemented during FY 2025 will influence reimbursement in FY 2027. Hospital administrators should be well-versed in both quarterly and annual hospital inpatient quality reporting program measures.

The FY 2025 Program updates include the following updates, some of which are mandatory for reporting:

Mandatory Outcomes Measure

• Hospital-Level Total Hip Arthroplasty (THA) and/or Total Knee Arthroplasty (TKA) Patient Reported Outcome-Based Performance Measure (PRO-PM)

Mandatory Structural Measures

• Patient Safety Structural Measure
• Age Friendly Hospital Structural Measure

New Claims Measure

• Thirty-day Risk-Standardized Death Rate among Surgical Inpatients with Complications (FTR) Measure

Additional eCQMs Added

• Hospital Harm – Pressure Injury (PI)
• Hospital Harm – Acute Kidney Injury (AKI)
• Excessive Radiation Dose or Inadequate Image Quality for Diagnostic Computed EHR Tomography in Adults

Understand Quarterly and Annual Reporting Requirements

Due Quarterly

Hospitals must submit the following data each quarter for the CMS hospital IQR program measures:

• HCAHPS survey data
• Population and sampling for the SEP-1 measure (Severe Sepsis and Septic Shock Management Bundle)
• Clinical process of care measure (SEP-1)
• COVID-19 Vaccination Coverage Among Health Care Personnel measure

If selected, hospitals also are required to produce validation of medical records on a quarterly basis.

Hospital IQR Program FY 2027: Quarterly Dates and Deadlines

Due Annually: Hospital IQR Requirements

• Data Accuracy and Completeness Acknowledgment (DACA)
• eCQMs (3 mandatory, 3 self-selected)
• Structural Measures (6 mandatory)
• Hybrid Measures (claims data only; voluntary for 2025 reporting period)
• Influenza Vaccination Coverage Among Healthcare Personnel administrative measure

Mandatory Structural Measures for the Hospital IQR Program

Hospitals must report the following six CMS hospital IQR program measures in 2025:

• Maternal Morbidity Structural Measure
• Hospital Commitment to Health Equity (HCHE)
• Screening for Social Drivers of Health (SDOH)
• Screen Positive Rate for Social Drivers of Health
• Age Friendly Hospital
• Patient Safety

Reporting period: Jan 1 – Dec 31, 2025
Submission window: Apr 1 – May 18, 2026

Hospitals are required to submit responses once annually. Responses for the Maternal Morbidity, HCHE, two SDOH measures and Age Friendly measure should go through a CMS-approved web-based tool within the HQR Secure Portal. Hospitals should submit the Patient Safety Structural Measure through the CDC’s National Healthcare Safety Network.

Hospitals that do not provide labor or delivery care must still submit a response, indicating “N/A.”

Incorporate Best Practices for Measures Reporting

• Hospitals are required to have a certified QualityNet Security Officials (SO). CMS administrators recommend that hospitals designate at least two QualityNet SOs to streamline Hospital IQR Program reporting.
• Note that blank fields do not fulfill a reporting requirement for population and sampling-based measures. Hospitals must submit a zero (0) even when there are no relevant discharges for a measure set.
• For hospitals that have five or fewer discharges per quarter related to a particular measure set, including both Medicare and non-Medicare patients), they are not required to report patient-level data for that quarter.
• CMS encourages hospitals to submit data at least 15 calendar days prior to the reporting deadline so there’s time to amend any discrepancies based on feedback reports.

CMS Hospital Inpatient Quality Reporting (IQR) Program Measures for the Fiscal Year (FY) 2027 Payment Update

Table Footnotes:
1 Hospital Quality Reporting (HQR)
2 Electronic Health Record (EHR)
3 National Healthcare Safety Network (NHSN)
* Requirement includes claims-only data portion of the measure for the FY 2026 and 2027 payment determinations.

Mandatory eCQM Reporting Requirements for the Hospital IQR Program

Hospitals must submit six eCQMs annually—three CMS-mandated and three self-selected—from a menu of 15. All must be submitted using a certified EHR.

CMS-mandated eCQMs:

• Safe Use of Opioids – Concurrent Prescribing
• Cesarean Birth
• Severe Obstetric Complications

In total, the 2025 reporting period offers 15 possible eCQMs, leaving 12 additional measures that hospitals can choose to report. Of the 12 remaining, hospitals must elect to report three measures. Hospitals are required to use an EHR certified to report on all eCQMs in the measure set. Each quarterly reporting period must contain the same six eCQMs, remaining consistent throughout the course of the reporting year.

Hospitals can find additional resources about available eCQMs and measure specifications, including tools such as flow diagrams, at the Electronic Clinical Quality Improvement’s Hospital – Inpatient eCQMs page. To find current-year measure, the selected period should be 2025. Hospitals also can find full submission overview for eCQMs at the Hospital IQR Program eCQM page.

Reporting Deadline: March 2, 2026.

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