If you work in a health system today, healthcare quality reporting can feel like a second job. Core measures. Readmissions. HCAHPS. Value-based purchasing. Clinical registries. Then you add in reporting for stroke, sepsis, heart failure, PCI, and you start to wonder: how did we get here?

The short answer is that we built this world on purpose. The long answer is a 100-plus year story about how the U.S. went from “trust us, we are professionals” to a system where hospital quality metrics drive public rankings, contract negotiations, and even reimbursement.

But we didn’t arrive here by accident. The current landscape of public scores, value based programs, cardiovascular registries, readmission penalties, and a growing push toward automation came from more than 100 years of change.

Here is a brief account of how health systems went from “trust us” to “show us the data,” how cardiology showed everyone else what is possible when you combine data, guidelines, and transparency, and how we’re primed for AI to be the next phase of quality reporting.

1910s to 1950: The Foundations of Standardized Care

The earliest quality efforts focused on professional standards, not spreadsheets.

• In 1910, the Flexner Report reshaped U.S. medical education and shut down many low-quality schools. That was about raising the floor for physician training, not tracking outcomes.

• In 1918, the American College of Surgeons launched the Hospital Standardization Program. Hospitals had to have an organized medical staff, adequate facilities, and complete medical records to be recognized.

• In 1951, the Joint Commission on Accreditation of Hospitals was formed. It looked at structures and policies to decide if a hospital was “good enough,” but it did not publish performance scores or talk about heart attack care quality.

Quality in this era was binary. You were either accredited or you weren’t. No one was publishing hospital quality metrics on mortality or complications.

1950s-1960s: Building the Framework

In 1951, the Joint Commission on Accreditation of Healthcare Organizations (now The Joint Commission) was founded, building on the earlier work of the ACS. For the first time, hospitals could earn accreditation based on meeting quality and safety criteria. However, these early standards still focused primarily on structure and policies rather than measuring actual patient outcomes.

The conceptual breakthrough came in 1966, when researcher Avedis Donabedian introduced his now-famous framework for evaluating medical care quality. Donabedian proposed that quality could be assessed through three components:

1. Structure: Hospital resources and staff qualifications

2. Process: Whether providers followed recommended treatments

3. Outcome: Patient survival, recovery, and complications

This framework is still foundational to healthcare quality measurement today. It established that you couldn't just look at results. You also needed to examine whether the right care was being delivered and whether healthcare organizations had the proper systems in place.

1960s to 1980s: Medicare Changes the Stakes

When Medicare and Medicaid arrived in 1965, the government became one of the largest healthcare payers overnight. That brought a new concern. Not just “is the hospital competent,” but “are we paying for care that is necessary and appropriate.”

In the 1970s and early 1980s, Congress created the first formal Medicare quality programs:

• Professional Standards Review Organizations (PSROs) in 1972. Physician-led local bodies that reviewed the necessity and quality of services for Medicare and Medicaid beneficiaries.

• Peer Review Organizations (PROs) in 1982, which replaced PSROs as Medicare moved to DRG-based payment. PROs were supposed to ensure that cost control did not become under-treatment.
  
  

These programs were important, but they were mostly about utilization review and retrospective chart audits. The public could not see the results. Clinicians did not have real-time feedback on processes or patient safety and outcomes.

Then HCFA (now CMS) tested something new.

1980s to 1990s: The First Public Outcomes and the Start of Cardiovascular Reporting

In 1987, HCFA released “Medicare Hospital Mortality Information, 1986” with hospital-specific mortality rates based on Medicare claims. It was one of the first national attempts to report outcome data at the hospital level, and it sparked intense debate about risk adjustment and fairness. This was controversial, but it signaled that accreditation alone was no longer enough.

The lesson was clear: if you want meaningful healthcare quality reporting, you need better clinical data than claims alone.

While the federal government was experimenting with mortality reports, New York State pushed much further and faster for cardiology.

In the late 1980s and early 1990s, New York:

• Built a state cardiac surgery registry.

• Began publicly reporting risk-adjusted mortality rates for coronary artery bypass graft (CABG) surgery by hospital and then by surgeon.

CABG mortality in New York dropped significantly over the early years of public reporting. One analysis found that mortality for Medicare patients fell faster in New York than in the rest of the country.

At the same time, researchers documented a downside. Some surgeons appeared to avoid very high-risk patients out of concern for their published scores.

Those two truths still shape the design of cardiovascular quality reporting today:

• Transparency can save lives.

• Poorly designed metrics can create incentives to avoid the sickest patients.

If your team is currently debating report cards, risk adjustment, or tiered networks, you’re having a conversation that New York surgeons started more than 30 years ago.

1990s to 2000s: Cardiovascular Registries Expand and National Reporting Begins

The American College of Cardiology launched the first NCDR registry, CathPCI, in 1997 to track cardiac catheterization and PCI care.

Over time, NCDR grew into a full portfolio of clinical registries for STEMI, NSTEMI, device implants, heart failure, AFib, and structural heart disease. These registries:

• Help hospitals benchmark against peers.

• Identify gaps in heart attack care quality.

• Support research that feeds back into guidelines and performance measures. 

The American Heart Association piloted and scaled Get With The Guidelines (GWTG) in the early 2000s to improve adherence to evidence-based therapies for coronary disease, heart failure, and stroke. Early studies found that GWTG hospitals increased use of medications like aspirin, beta blockers, and ACE inhibitors and improved discharge care for heart failure.

Together, these programs gave providers tools to track heart failure quality measures and acute coronary syndrome care with far more precision than administrative data alone.

They also provided a model. Other specialties followed cardiology’s lead and built their own registries and quality collaboratives.

1999-2001: A National Wake-Up Call

Two Institute of Medicine reports jolted healthcare into recognizing quality and safety as urgent priorities. "To Err is Human" (1999) revealed that tens of thousands of Americans died annually from preventable medical errors. "Crossing the Quality Chasm" (2001) called for fundamental healthcare system transformation to achieve six aims: safety, effectiveness, patient-centeredness, timeliness, efficiency, and equity.

These reports catalyzed unprecedented federal investment in quality infrastructure. In 1999, Congress established the Agency for Healthcare Research and Quality (AHRQ) as the lead federal agency for healthcare quality and safety research. That same year, the National Quality Forum (NQF) was founded as a public-private partnership to endorse standardized performance measures. This ensured that hospitals and clinicians nationwide measured the same things in the same ways.

National public reporting: Hospital Compare and hospital quality metrics

As registries were evolving, Medicare moved from internal oversight to full public transparency.

Key milestones:

• The Hospital Quality Alliance (HQA) formed in 2002 to align CMS, the Joint Commission, AHA, and others on a starter set of measures.

• In 2005, CMS launched Hospital Compare, a public website with standardized hospital quality metrics. The initial “starter set” included ten process measures for heart attack, heart failure, pneumonia, and surgical infection prevention.

By the late 2000s, Hospital Compare expanded to include:

• Outcomes such as 30-day mortality and readmission for AMI and heart failure.

• The HCAHPS patient experience survey.

• More conditions and safety measures.

For most health systems, this was the moment when quality reporting truly became public. Boards, marketers, and clinicians could all see the same data. Local media could contrast hospitals on AMI mortality or readmission. Payers could reference national metrics in contracting.

This is also when the volume of Medicare quality programs and measures really began to climb.

2010 to 2015: The Value-Based Care Era Begins

Initially, hospitals were simply required to report data to avoid a financial penalty. With the introduction of the Affordable Care Act (ACA), the focus shifted from reporting to performance.

Several programs defined the value-based care era:

• Hospital Value-Based Purchasing (HVBP): started in FY 2013, ties a portion of DRG payment to performance on clinical care, patient experience, and safety. Cardiac process and outcome measures are core inputs.

• Hospital Readmissions Reduction Program (HRRP): penalizes hospitals with higher than expected 30-day readmission rates for conditions like heart failure and acute myocardial infarction.

• MACRA (passed in 2015) and MIPS (2017): extend quality reporting and value-based payment into the physician space, with a variety of cardiovascular measures relating to blood pressure control, cholesterol management, and outcomes.

During this period, national studies documented improvements in patient safety and outcomes for conditions such as AMI and heart failure. One large analysis found that adverse event rates for AMI and heart failure patients declined substantially from 2005 through 2011, coinciding with greater national focus on quality metrics and public reporting.

From the front lines, of course, this also felt like a rising tide of reporting requirements, audits, and dashboards.

2016 to Present: Digital Measures and AI Reshape the Landscape

We are now in the middle of another big shift. The industry is trying to solve two problems at once:

1. We want better measures that matter to patients and clinicians.

2. We want far less manual work to get them.

Several trends are worth keeping on your radar:

• Interoperability and FHIR APIs under laws like the 21st Century Cures Act make it easier to pull structured data directly from EHRs.

• CMS is planning a transition to digital quality measures that can be calculated from standard data feeds rather than manual abstraction.

• Early research shows that large language models (LLMs) can support AI in healthcare quality by automating complex chart abstraction.
  
  
  

For example, a 2024 study in NEJM tested an LLM system that used FHIR data to complete a sepsis quality measure abstraction (the SEP-1 bundle). The system matched manual abstractors 90 percent of the time and even caught some errors in the human review.

Other work is exploring how LLMs can extract key data elements for registries, such as those used in pulmonary embolism and other cardiovascular conditions, to reduce the abstraction burden while maintaining accuracy.

This is the next logical step in the history of quality reporting:

• Early era: “Are you a real hospital with basic standards?”

• Medicare era: “Are we paying for necessary care?”

• Transparency era: “Show us your hospital quality metrics for heart attack and heart failure.”

• Value era: “We will pay more or less depending on your patient safety and outcomes.”

• Digital/AI era: “Can we measure quality in real time, accurately, and without burning out your staff?”
  
  

  
  

Cardiology, with its deep clinical registries and long history in public reporting, is again a proving ground. It is easy to imagine a near future where registries like NCDR and STS draw more heavily from AI-enabled digital abstractions than from manual chart review.

Why History Matters for Health Systems’ Futures

If you work in a health system, this history is not just trivia. Understanding how we got here helps health systems make smarter decisions about what to measure, how to measure it, and how technology can finally lighten the load.

A few takeaways you can reference with your team:

• Quality reporting is moving toward more outcomes, less manual abstraction.

• Cardiology has led the way (and still does).

• Technology (especially AI) is becoming capable of handling the rote work so clinicians can focus on care.

• The pressure to improve quality is not slowing down. If anything, it’s accelerating.

When you talk with clinicians who are tired of reporting or executives who are trying to prioritize resources, you can ground the conversation in this simple narrative:

We built this system over a century to protect patients and reward better care. Cardiology showed what was possible. Now the challenge is to keep what works, fix what doesn’t, and use the next generation of tools to make quality measurement lighter, faster, and more meaningful for everyone involved.