Quality Initiatives and Tools

AJRR has been designated as a Qualified Clinical Data Registry (QCDR) by the Centers for Medicare & Medicaid Services (CMS) every year since 2014. We are dedicated to helping you participate in quality improvement initiatives and adopt tools that may enhance clinical practice.

Participation in the AJRR has many benefits including assistance with several federal quality initiatives, insurer’s distinction programs, and state collaboratives. These programs provide reimbursements and other incentives for displaying improvement in the quality of patient care, prompting medical institutions to use clinical data registries like AJRR to compare outcomes success. Learn more about these programs below.

Quality Initiatives

Comprehensive Care for Joint Replacement (CJR)

Top 12 Things to Know About CJR as it Relates to Clinical Data Registries
Top 12 List for CJR

The Centers for Medicare & Medicaid’s (CMS) Comprehensive Care for Joint Replacement (CJR) model final ruling was released in November 2015 and the orthopaedic community is addressing the issues and figuring out how the ruling impacts them – especially when it comes to Clinical Data Registry participation. Utilizing the data from your participation with AJRR can be considered a quality initiative that can earn hospitals credit towards this CMS program.

What Exactly is the CJR?

The CJR is a five-year model with the goal of improving quality of care and cost efficiency in hip and knee procedures through bundled payments and quality measurement. It started on April 1, 2016, and is set to run through 2020. As of November 2015, about 800 hospitals in 67 geographical areas, or metropolitan statistical areas (MSAs), were required to participate. MSAs were selected because they are counties that have a central urban area that has a population of at least 50,000 people.

CJR participants receive target prices for their episodes of care from Medicare, and are paid under the usual payment system rules throughout the year. At the end of the CJR performance year, participants’ actual spending is compared to the target episode price, and based on their composite quality score and spending performance, Medicare will either provide additional payment to a hospital or request repayment.

How Can AJRR Help?

Although AJRR is unable to help hospitals with their target episode spending, the Registry can assist with CJR participants’ composite quality scores. The scores are determined by a hospital’s performance on a Total Hip Arthroplasty/Total Knee Arthroplasty Complications measure, a Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) Survey measure, and submission of patient-reported outcomes and risk variable data. The composite quality score is out of 20 points, and participating hospitals receive their scores in the second quarter of each following performance year.

The Registry is able to collect PROs and limited risk variable data for CJR participants, and even has a “CJR template” that allows for easy submission to CMS. PROs and limited risk variables are currently only voluntary for CJR, but can provide participants with up to 2 points for their quality score, so they’re a great way to pad your score. As you can see in the chart below, the required PRO measures for CJR include the Veterans Rand 12 Item Health Survey (VR-12) or the Patient-reported Outcomes Measurement Information System (PROMIS) 10-Global, and the Hip disability and Osteoarthritis Outcome Score (HOOS), JR./Knee injury and Osteoarthritis Outcome Score (KOOS), JR. or their subscales.

 Required PROMs for the CJR

The deadline for PRO submission in 2018 is August 31, 2018, and post-operative data on Performance Year 2 Patients and Pre-Operative Data on Performance Year 3 Patients are required. The minimum case requirement for successful PRO collection increases each year of the program; in Performance Year 3, the minimum is 70% of eligible procedures or at least 100 cases, whichever is lower. The chart below displays the minimum case requirements for subsequent performance years.

CJR Minimum Case Requirement for Successful PRO Collection

Have There Been Any Changes to the CJR Rule?

In December 2016, CMS finalized changes to the CJR rule, in addition to creating the Episode Payment Models (EPMs) and the Cardiac Rehabilitation (CR) Incentive Payment Model. The major takeaway from this CJR change is that the CJR is now considered an Advanced Alternative Payment Model (APM), giving clinicians more opportunities to qualify for a 5% incentive payment through the Medicare Access and CHIP Reauthorization Act (MACRA).

You may have heard about how in August 2017, CMS proposed to make additional changes to the CJR. As of December 1, 2017, the number of mandatory CJR participants was reduced from 67 to 34, and the 33 remaining MSAs were allowed to voluntarily participate. All low volume and rural hospitals in CJR MSAs had voluntary participation as well. CMS held a one-time participation election period for the voluntary MSAs and low volume and rural hospitals that lasted from January 1, 2018 until January 31, 2018. 86 providers opted to continue with CJR.

If you are in one of the remaining MSAs or are voluntarily participating in CJR, reach out to your region’s AJRR Registry Engagement Associate if you are not already using our template to collect PROMs. We would be happy to help set you up so that you can qualify for the 2 quality points next year.

Additional Resources

We've put together this Top 12 list of things to know about CJR and Clinical Data Registries.

Download the PRO and Risk Variable Data Elements list here.

More info about CJR can be found here

CMS-supplied Frequently Asked Questions can be found here

Maintenance of Certification (MOC)

The American Board of Orthopaedic Surgery (ABOS) recognizes registry involvement by surgeons counting as credit towards their Maintenance of Certification (MOC) process. Registries that are part of the AAOS Registry Program, including AJRR, have been approved to receive MOC Part II Self-Assessment Examination credits.

ABOS is the certifying board that sets the standards for ensuring that orthopaedic surgeons stay current in their profession. The ABOS MOC Program is focused on assessing the surgical knowledge, skill set, and professionalism of ABOS physicians on behalf of patients, families, and communities. In order to meet the goal of improving the relevance of MOC while minimizing burden, a wide menu of existing educational and improvement activities have been recognized by the ABOS and will remain an important part of this process.

What is MOC?

Maintenance of Certification (MOC) is the process through which surgeons of the American Board of Orthopaedic Surgery (ABOS) can maintain their primary certificate in orthopaedic surgery. The American Board of Medical Specialties (ABMS), of which the ABOS is one of 24 medical specialty certifying boards, has developed the MOC process as a robust continuous professional development program. The ABOS has created a MOC program that is specific for orthopaedic surgeons who are initially ABOS certified.

More information about registries in ABOS’ MOC Program can be found here.

The Alliance Cooperative (Midwest States)

Registry Participation Helps with Quality Designation for the Midwest

The Alliance QualityPath

The Alliance is a not-for profit cooperative based in Wisconsin that exists to help their members manage their health care dollars while positively impacting their employees’ health. They contract with several hospitals, professional service providers, and insurance trusts in Illinois, Wisconsin, and Iowa. The Alliance has a program called QualityPath which covers 100% of medical costs for patients for certain procedures, including knee and total hip replacements. These patients are directed specifically to QualityPath-designated hospitals and surgeons who are known for quality care.

To receive this designation for knee and total hip replacement from The Alliance, hospitals and surgeons are required to be AJRR participants. There are three registry-related criteria that hospitals and surgeons must meet in order to submit a QualityPath application:

  • Facility must participate in the AJRR
  • Facility must use data from registry to support quality improvement efforts
  • Surgeon must participate in the AJRR

Hospitals must have a signed contract with the AJRR at the time of their QualityPath application. They also must have proof that they have submitted data. This can be in the form of an email from AJRR confirming submission success, or reports from the Registry showing organizational data. Hospitals also need to demonstrate their use of AJRR data for quality improvement and show surgeon involvement. To support this criterion, hospitals must provide a brief description of how their facility and surgeons use registry data to improve quality. The third criterion is that surgeons must participate in the AJRR by submitting data or having the data submitted on their behalf, to the full extent allowed by the Registry. A dashboard report must be presented as proof. 

Below you'll see the service areas where hospitals and surgeons are eligible to become Quality-Path designated.

The Alliance QualityPath Service Areas

For more information on QualityPath, please visit The Alliance website.

The Bree Collaborative (Washington State)

AJRR and the Bree Collaborative TKR/TJR Bundle for Hospitals in WA

The Bree Collaborative in Washington State

The Bree Collaborative is a partnership established to provide a mechanism through which public and private health care stakeholders can work together to improve quality, health outcomes, and cost effectiveness of care in Washington State. Workgroups made up of Bree members and community experts send quality improvement recommendations to health care purchasers. Our mission aligns with the goals of the Bree Collaborative, and the "Repair of the Osteoarthritic Joint" section of the Bree Collaborative TKR/THR Bundle requires all implants to be registered using the AJRR.

A majority of Bree Collaborative members are currently participating in the AJRR. If you are a Washington institution that is not yet participating in the National Registry but would like to qualify for the TKR/THR Bundle, contact AAOS Manager of Registry Engagement Phil Dwyer at This email address is being protected from spambots. You need JavaScript enabled to view it. for information on how to enroll.

The Joint Commission's Advanced Certification for Total Hip and Knee Replacement (THKR)

The Joint Commission Logo

The American Academy of Orthopaedic Surgeons (AAOS) has announced collaboration with The Joint Commission to incorporate AAOS clinical expertise into standards development and performance measurement requirements for Total Hip and Knee Replacement (THKR) Certification. The Joint Commission established the voluntary advanced certification in 2016 for accredited hospitals, critical access hospitals and ambulatory surgery centers (ASCs) seeking to elevate the quality, consistency and safety of their services and patient care.

Through the new collaboration, the AAOS and The Joint Commission will jointly oversee scientific issues, performance measurement, quality improvement activities, education, data sharing and research related to the certification—with continued commitment to constantly assessing and evaluating quality for the safety and benefit of orthopaedic patients. This includes, as of January 1, 2019, implementation of a new THKR certification requirement for hospitals and ASCs to participate in a national registry, like the American Joint Replacement Registry (AJRR), to further help standardize care and quality improvement in hip and knee replacements. Effective July 1, 2019, the AJRR will become the sole pathway for meeting The Joint Commission’s THKR certification registry requirement.

Learn more here.

Download FAQs here.

The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA)


The Centers for Medicare & Medicaid Services' (CMS) Quality Payment Program (QPP) ended the Sustainable Growth Rate formula with the creation of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). MACRA has two tracks that clinicians can choose from: the Advanced Alternative Payment Models (APMs), or the Merit-based Incentive Payment System (MIPS). If you provide care for more than 200 Medicare patients a year and bill more than $90,000 in Medicare Part B allowed charges a year or submit data for an APM, then you are in the MACRA program. The AJRR can help its participants meet the requirements for the MIPS track. 

The Merit-based Incentive Payment System (MIPS)

The MIPS track can be very helpful to clinicians, as it will adjust Medicare payments based on the quality and completeness of data submitted to CMS.

Occupations eligible for MIPS include:

  • clinical nurse specialists
  • nurse practitioners
  • certified registered nurse anesthetists
  • physician assistants
  • physicians
For those who participated in MIPS in 2018, quality data needs to be submitted to CMS by April 2, 2019 at 8 p.m. EDT. Medicare will then provide feedback on your performance, and will give you either a negative, neutral, or positive payment adjustment in 2020.

When participants choose not to submit any data, they will receive a negative 5% payment adjustment. They can also choose to submit a mix of measures and categories to earn 15 points, which will give them a neutral payment adjustment. The third option is for participants to submit all four categories of data and earn 16-69 performance points. These participants will recieve a small positive payment adjustment in 2020. The final option is to submit all categories and recieve 70+ performance points. This will earn your practice a moderate positive payment adjustment. The positive and negative adjustments increase each year of the program, as you can see in the diagram below.

MIPS Payment Adjustment Timeline








Now we’ll quickly go over the quality data and technology information categories that are required for MIPS. They are:

  • Quality
  • Advancing Care Information
  • Improvement Activities
  • Cost

You may recognize aspects of these MIPS categories, as most of them replace previous CMS initiatives. The Quality category replaces the Physician Quality Reporting System (PQRS). The Advancing Care Information category replaces the Medicare Electronic Health Record (EHR) Incentive Program, also known as Meaningful Use (MU). The Cost category replaces the Value-Based Modifier (VBM). The Improvement Activities category is new.

How Can AJRR Help?

AAOS QCDR Splash Page

The American Academy of Orthopaedic Surgeons (AAOS) Orthopaedic Quality Resource Center is a collaboration between AJRR, the American Orthopaedic Association's (AOA) Own the Bone program, the American Association of Hip and Knee Surgeons (AAHKS), the Orthopaedic Trauma Association (OTA), and Premier Healthcare Solutions, Inc. It's approved by CMS as a Qualified Clinical Data Registry (QCDR). The QCDR provides a standard to complete Merit-based Incentive Payment System (MIPS) requirements based on satisfactory participation. A QCDR is a CMS-approved entity that collects medical and/or clinical data for the purpose of patient and disease tracking to foster improvement in the quality of care furnished to patients. 

The AAOS Orthopaedic Quality Resource Center is comprised of 38 measures, including three AAHKS-sponsored hip and knee measures and the Academy's own 2017 Orthopaedic Preferred Speciality (OPS) List. The AOA’s Own the Bone program has also provided measures that will remain as part of the platform. The AAOS Orthopaedic Quality Resource Center has been a QCDR since 2014.

The AAOS QCDR can assist Eligible Professionals (EPs) and organizations participating in the Group Practice Reporting Option (GPRO) across all orthopaedic specialties. The Resource Center’s MIPS reporting can satisfy the full MIPS program and prevent institutions from receiving up to a 5% negative payment adjustment. Besides for MIPS reporting, AAOS' QCDR can also automate EHR data, track performance against benchmarks, and help manage your patient population.

Register here to get started.

Download a brochure about the AAOS Orthopaedic Quality Resource Center here.

The Advanced Alternative Payment Models (APMs)

The AJRR can partially help meet one APM, the Comprehensive Care for Joint Replacement (CJR) model. Although AJRR cannot completely help meet the requirements for an APM, it is helpful for Registry participants to know that those who participate in APMs will receive a 5% incentive payment in 2020.

Additional Resources

Below are a few additional resources that you can use to become more familiar with MACRA:


Collaborations, Affiliations, and Other Registries

Collaborating with and supporting other registries and related organizations is an important strategic goal of ours. The descriptions below discuss our involvement with some of these organizations.

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Physician Clinical Registry Coalition
National Quality Registry Network (NQRN)
Michigan Arthroplasty Registry Collaborative Quality Initiative (MARCQI)
International Society of Arthroplasty Registries (ISAR)
International Consortium of Orthopaedic Registers (ICOR)

The Register

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