100-10 Quality Improvement Organization Manual: Chapter 16 - Health Care Quality Improvement Program

Quality Improvement Organization Manual
Chapter 16 - Health Care Quality Improvement
Program
Table Of Contents
(Rev. 30, 04-21-17)
Transmittals for Chapter 16
16000 - Introduction
16005 - Quality Improvement Interventions
16025 - Developing and Spreading Successful Interventions
16035 - Documenting and Disseminating Results

16000 - Introduction
(Rev. 30, Issued: 04-21-17, Effective: 04-21-17, Implementation: 04-21-17)
The Quality Improvement Organization (QIO) Program is based on broad statutory and
regulatory authorities.
• 	QIOs perform one or more of the functions listed in Section 1154(a) of the Social
Security Act, and Section 1154(a)(18) of Act authorizes that: “The organization
shall perform, subject to the terms of the contract, such other activities as the
Secretary determines may be necessary for the purposes of improving the quality
of care furnished to individuals with respect to items and services for which
payment may be made under title XVIII.”
• 	42 CFR 480.101 Definitions states “Quality review study means an assessment,
conducted by or for a QIO, of a patient care problem for the purpose of
improving patient care through peer analysis, intervention, resolution of the
problem and follow-up. Quality review study information means all
documentation related to the quality review study process.”
• 	42 CFR 476.1 Definitions states “Quality improvement initiative means any
formal activity designed to serve as a catalyst and support for quality
improvement that uses proven methodologies to achieve these improvements. The
improvements may relate to safety, health care, health and value and involve
providers, practitioners, beneficiaries, and/or communities.”
The objectives of CMS’s healthcare quality improvement program are: (1)improve
quality of care for beneficiaries; (2) protect the integrity of the Medicare Trust Fund by
ensuring that Medicare pays only for services and goods that are reasonable and
necessary and are provided in the most appropriate setting; and (3) protect beneficiaries
by expeditiously addressing: individual complaints; provider-based notice appeals;
alleged violations of the EMTALA; and other related responsibilities in QIO law.
QIOs also assist healthcare providers, practitioners, beneficiaries and communities by
identifying and analyzing data from various sources to change and improve the patterns
of care and behaviors of Medicare beneficiaries in targeted areas. CMS chooses these
areas based on the data obtained and on the feasibility of measuring and improving the
quality of care to beneficiaries.
16005 - Quality Improvement Interventions
(Rev. 30, Issued: 04-21-17, Effective: 04-21-17, Implementation: 04-21-17)
QIOs perform quality improvement functions in accordance with the terms that CMS
defines in its QIO contracts. QIOs may assist with implementing quality improvement
functions through a set of related intervention activities designed to achieve measurable
improvement in processes and outcomes of care. QIOs assist healthcare providers,
practitioners, plans and/or beneficiaries with achieving better healthcare and quality
improvements through interventions that target Medicare beneficiaries.

QIOs are encouraged to be innovative in the development of strategies and build on
activities that other QIOs or other interested parties have developed and tested. QIOs are
accountable for demonstrating success in achieving the objectives in as efficient and
effective a manner as feasible. QIOs must continually evaluate progress against the
original objectives, and document how quality improvement experiences can contribute to
a growing understanding of what works and what does not work to improve care. QIOs
are charged with identifying and assisting healthcare providers, practitioners, plans
and/or beneficiaries with implementing intervention strategies designed to affect
identified quality of care measures (or quality measures) to improve performance in the
desired manner compared to a measure baseline as well as document and disseminate the
results of the intervention.
Quality improvement interventions should be based on and developed from scientific
evidence from clinical research reported in the peer-reviewed literature, consensus that
has already been developed, and, where possible, guidelines that have already been
written. Carrying out improvement projects may involve applying the results of research
studies and may utilize many of the tools and terminology of epidemiological, clinical, or
health services research. However, quality improvement interventions should not involve:
• 	Efforts to prove that a process of care is effective or ineffective
• 	Development of practice guidelines
16025 - Developing and Spreading Successful Interventions
(Rev. 30, Issued: 04-21-17, Effective: 04-21-17, Implementation: 04-21-17)
The QIO is responsible for developing and/or spreading successful quality improvement
interventions. The interventions should serve to change the processes or situations that
serve as obstacles to optimal care or health status (e.g., obstacles that discourage
implementation of best practice guidelines). The success of an intervention is judged by
its effect; that is, a good intervention is one that results in a positive change in the
outcome, process, situation, or behavior. Interventions must be designed to affect the
practices or behaviors of those institutions or individuals directly involved in the
provision and/or acceptance of healthcare.
Interventions are best when they are evidence-based, proven, appropriate, and supported
by a QIO proposing methods that facilitate improvement. For example, if a QIO can
statistically demonstrate to representatives of a particular hospital that its median time
from emergency department (ED) arrival to ED departure for admitted patients is
significantly higher than that of the State, and at the same time, suggest changes in
hospital practices that are designed to reduce that time, the QIO (and the intervention
itself) will have a greater likelihood of success. QIOs may use written communications,
discussions with individual providers, presentations at conferences or special meetings,
media releases, Web page presentations, or any of the modes of communication available.
QIOs should direct intervention efforts toward convincing the target audience to make the
appropriate change(s). In some instances, the intervention may directly target the

individual or institution whose behavior a QIO wishes to change (e.g., a direct contact
with beneficiaries designed to increase the influenza immunization rate) while in other
cases the intervention will be less direct (e.g., encouraging hospitals to institute
procedures that promote influenza immunization for all patients).
16035 - Documenting and Disseminating Results
(Rev. 30, Issued: 04-21-17, Effective: 04-21-17, Implementation: 04-21-17)
In addition to satisfying the reporting requirements specified in your contract, there are a
number of activities QIOs may undertake to document and disseminate the results of
quality improvement interventions. For example:
• 	Quantify the effect of the project on improving care by addressing:
o 	The number of beneficiaries and proportion of the universe of eligible
beneficiaries in the State(s) directly affected
o 	Expected cost savings (if applicable)
o 	The benefit(s) attributable to this project
• 	Evaluate the project process by:
o 	What worked and what did not work
o 	What factors were associated with success or failure
o 	Lessons learned
• 	Assess the effect of the project on the capacity to affect improvement:
o 	What factors led to capacity building
o 	What obstacles were overcome or proved insurmountable
• 	Share information concerning the QIO’s improvement projects with individual
partners, the medical and beneficiary community, and other QIOs, as appropriate
in accordance with the QIO confidentiality requirements (See Chapter 10),
communications requirements (See Chapter 12) and as specified in the QIO
contract.

Transmittals Issued for this Chapter
Rev # 	Issue Date 	Subject 	Impl Date CR#
R30QIO 	04/21/2017 	QIO Manual Chapter 16 – “Healthcare
Quality Improvement Program”
04/21/2017 N/A
R3QIO 	07/11/2003 	Initial Issuance of Chapter 16 	N/A 	N/A
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