Improving Patient Safety and Quality of Care for Seniors

A National Network of Quality Improvement Experts : How QIOs Work
Major Medicare QIO Efforts 2002-2005 : Background

• Medicare QIOs help hospitals, physicians, nursing homes, and home health professionals improve clinical care by measuring quality and encouraging adoption of proven “best” clinical practices.
• QIOs work with beneficiaries to increase awareness of quality of care data in major clinical areas.
• About 2/3 of the Medicare QIOs perform independent quality oversight/utilization review for state Medicaid programs. Many QIOs also perform independent external reviews for private health plans.

How QIOs Work

QIOs measure health care quality using clinical indicators – like the number of minutes it takes to administer certain drugs to heart attack patients or the percentage of people with diabetes who get regular retinal eye exams. QIOs measure how often care is delivered in accordance with these quality indicators. When an indicator shows that care falls short, QIOs collaborate with doctors, hospital personnel, and other health professionals to examine their practices and improve systems of providing care. QIOs provide suggestions based on successful improvement projects in other hospitals and clinics consistent with the medical literature. Whenever possible, they re-measure the indicators to find out if the quality improvement intervention succeeded.

Major Medicare QIO Efforts 2002-2005

Under the current contract with CMS, QIOs work across a range of health care settings and are focused on:

• Improving Hospital Care
  QIOs continue to work with hospitals to improve clinical care for heart attack, congestive heart failure, and pneumonia—all major threats to the health of the Medicare population. These projects assist hospitals in establishing or refining clinical systems to more consistently provide the best care.
  
• Preventing Surgical Infections
  QIOs are implementing projects to reduce the incidence of post-surgical infections. These efforts will improve timely and appropriate use of prophylactic antibiotics before, during, and after surgery.
  
• Improving Care for Breast Cancer, Diabetes, Flu & Pneumonia
  QIOs continue to help physicians increase screening for breast cancer, improve care for diabetes, and prevent influenza and pneumonia through immunizations.
  
• Offering Assistance to Nursing Homes
  QIOs provide technical assistance to help nursing homes implement better systems of care – with a focus on pain management, prevention of pressure ulcers, prevention of infections, management of delirium, and improvement in walking. QIOs also help the public interpret and use data published by CMS on the quality of care in individual nursing homes.
  
• Working With Home Health Agencies
  QIOs offer home health agencies education and training to speed their adoption of Outcomes Based Quality Improvement (OBQI) methodology and techniques. QIOs will help the public understand and use CMS-published data on quality of care offered by individual home health agencies.
  
• Reducing Racial, Ethnic, and Rural Health Disparities
  In addition to continuing projects that help eliminate disparities in care received by ethnic and racial minorities, some QIOs have launched projects to improve care in rural areas.
  
• Protecting and Informing Patients
  QIOs establish Consumer Advisory Councils to increase communication with Medicare beneficiaries and consumer awareness about quality of care. In addition, QIOs review and respond to written complaints alleging inadequate quality of care, appeals of non-coverage notices from a number of care settings, and Emergency Medical Treatment And Labor Act (anti-patient dumping law) cases.
  
• Supporting Hospital Reporting on Quality
  QIOs are helping hospitals collect and submit the quality data required to qualify for the full hospital payment update under the Medicare Modernization Act of 2003.
  
• Assisting Physician Offices in Adopting Health Information Technology
  Under a 2 year special study for CMS, four QIOs are helping physicians adopt and use Health Information Technology (HIT) to improve care. Lead by the California QIO, Lumetra, the other participating QIOs are HealthInsight in Utah , the Arkansas Foundation for Medical Care and MassPRO in Massachusetts. 
  
• Developing New Methods to Advance Quality of Care
  QIOs continue to conduct special projects to find new ways to speed improvement in care systems. For example, a four-state special QIO study in the mid-1990s led to the successful ongoing national QIO effort to improve heart attack care. One study now being planned will spur measurement and improvement of care provided in doctors’ offices to patients with chronic diseases.

Background

Medicare QIOs are the successors to the Peer Review Organization (PRO) program created in 1982 by Congress to monitor beneficiaries’ quality of care and safeguard the integrity of Medicare. In the early years, PROs primarily conducted utilization review work to make sure Medicare was paying for medically necessary care. Early quality efforts were limited largely to reviewing individual patients’ care, a process known as case review. In the mid-1990s, Medicare shifted the main focus of the program to proactive community-based quality improvement and beneficiary education. QIOs now work in partnership throughout the health care system with physicians, hospitals, nursing homes and beneficiaries to help ensure the routine delivery of high-quality medical care.