Quality Improvement Organizations (QIOs) in Medicare

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CMS’ Quality Improvement Organization Program[edit]

The Centers for Medicare & Medicaid Services’ (CMS) Quality Improvement Organization (QIO) Program is one of the largest federal programs dedicated to improving health quality at the community level. It serves as the engine that drives greater connectivity and coordination across all care settings to transform health care delivery for Medicare beneficiaries.

The QIO Program aligns with the CMS Quality Strategy, as well as with the U.S. Department of Health and Human Services’ National Quality Strategy. It contributes to CMS’ goal of achieving the Three-Part Aim for better care, better health and lower costs. The Program – which is known for its data-driven and results-oriented focus – collaborates with other national organizations and initiatives dedicated to improving patient safety and population health, including Advancing Excellence in America’s Nursing Homes, the Centers for Disease Control and Prevention (CDC), the Home Health Quality Initiative, and Million Hearts®.

In 2014, CMS redesigned the QIO Program to further enhance the quality of services for Medicare beneficiaries. The new program structure maximizes learning and collaboration in improving care, enhances flexibility, supports the spread of effective new practices and models of care, helps achieve the priorities of the National Quality Strategy and the goals of the CMS Quality Strategy, and delivers program value to beneficiaries, patients, and taxpayers. The QIO Program changes include separating case review from quality improvement, extending the contract period of performance from three (3) to five (5) years, removing requirements to restrict QIO activity to a single entity in each state/ territory, and opening contractor consideration to a broad range of entities to perform the work.

Types of Quality Improvement Organizations[edit]

The QIO Program operates through a national network of QIOs, which are independent, mostly non-profit, private organizations staffed by health care professionals and quality improvement experts working to improve the quality and efficiency of health care across all care settings.

There are two kinds of QIOs: Quality Innovation Network-QIOs (QIN-QIOs) and Beneficiary and Family Centered Care-QIOs (BFCC-QIOs). Fourteen QIN-QIOs and two BFCC-QIOs serve the entire United States and its territories.

BFCC-QIOs aim to help Medicare beneficiaries exercise their right to high-quality health care. They provide patients an avenue for submitting complaints about the quality of care they received, and for disputing decisions related to payment, coverage, or a patient’s discharge from the hospital or services. BFCC-QIOs manage all beneficiary complaints, reviews, appeals and other cases to ensure consistency in the review process while considering local factors relevant to beneficiaries and their families. Each state or territory is serviced by one of the two BFCC-QIOs.

The Program’s 14 QIN-QIOs work with providers and other community-based partners on data-driven quality initiatives to improve patient safety, reduce harm, engage patients and families, and improve clinical care at the local level. They work to improve the quality of care for targeted health conditions and priority populations while also aiming to reduce healthcare-acquired conditions and preventable hospital readmissions. Heavily focused on collaboration, QIN-QIOs are meant to serve as conveners of local stakeholders who share a common goal related to improving health care in their community. They also support change initiatives enforced by hospitals, nursing homes, and other providers with the aim of making care more patient-centered, safer, affordable and coordinated. Each QIN-QIO services a region of two to six states or territories.

The combined work of BFCC-QIOs and QIN-QIOs is designed to drive swift, wide-spread advances in care quality with a focus on the patient perspective. Their objective is to achieve better patient care, improved population health and lower costs through ongoing improvements to processes and procedures.

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