MEDICARE’S QUALITY IMPROVEMENT ORGANIZATION PROGRAM pptx

Committee on Redesigning Health Insurance Performance Measures,
Payment, and Performance Improvement Programs
Board on Health Care Services
MEDICARE’S QUALITY
IMPROVEMENT
ORGANIZATION PROGRAM
Maximizing Potential
Pathways to Quality Health Care
THE NATIONAL ACADEMIES PRESS 500 Fifth Street, N.W. Washington, DC 20001
NOTICE: The project that is the subject of this report was approved by the Governing Board
of the National Research Council, whose members are drawn from the councils of the Na-
tional Academy of Sciences, the National Academy of Engineering, and the Institute of Medi-
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competences and with regard for appropriate balance.
This study was supported by Contract No. HHSM-500-2004-00010C between the National
Academy of Sciences and the United States Department of Health and Human Services through
the Centers for Medicare and Medicaid Services. Any opinions, findings, conclusions, or rec-
ommendations expressed in this publication are those of the author(s) and do not necessarily
reflect the view of the organizations or agencies that provided support for this project.
Library of Congress Cataloging-in-Publication Data
Medicare’s quality improvement organization program : maximizing potential / Committee
on Redesigning Health Insurance Performance Measures, Payment, and Performance
Improvement Programs, Board on Health Care Services.
p. ; cm. — (Pathways to quality health care)
“This study was supported by Contract No. HHSM-500-2004-00010C between the
National Academy of Sciences and the United States Department of Health and Human
Services through the Centers for Medicare and Medicaid Services”—T.p. verso.
Includes bibliographical references and index.
ISBN 0-309-10108-5 (hardback)
1. Medicare—Quality control. 2. Medical care—United States—Quality control. 3. Health

care reform—United States. I. Institute of Medicine (U.S.). Committee on Redesigning
Health Insurance Performance Measures, Payment, and Performance Improvement Pro-
grams.
II. Series.
[DNLM: 1. Medicare—organization & administration. 2. Quality Assurance, Health Care
—organization & administration—United States. 3. Health Care Reform—organization &
administration—United States. 4. Quality of Health Care—organization & administration—
United States. WT 31 M4898 2006]
RA412.3.M449 2006
368.4′260068—dc22
2006014099
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COMMITTEE ON REDESIGNING HEALTH INSURANCE

PERFORMANCE MEASURES, PAYMENT, AND PERFORMANCE
IMPROVEMENT PROGRAMS
STEVEN A. SCHROEDER (Chair), Distinguished Professor of Health and
Health Care, University of California, San Francisco
BOBBIE BERKOWITZ, Alumni Endowed Professor of Nursing,
Psychosocial and Community Health, University of Washington, Seattle
DONALD M. BERWICK, President and Chief Executive Officer, Institute
for Healthcare Improvement, Cambridge, MA
BRUCE E. BRADLEY, Director, Health Care Strategy and Public Policy,
Health Care Initiatives, General Motors Corporation, Pontiac, MI
JANET M. CORRIGAN,
1
President and Chief Executive Officer, National
Committee for Quality Health Care, Washington, DC
KAREN DAVIS, President, The Commonwealth Fund, New York
NANCY-ANN MIN DEPARLE, Senior Advisor, JPMorgan Partners, LLC,
Washington, DC
ELLIOTT S. FISHER, Professor of Medicine and Community Family
Medicine, Dartmouth Medical School, Hanover, NH
RICHARD G. FRANK, Margaret T. Morris Professor of Health
Economics, Harvard Medical School, Boston, MA
ROBERT S. GALVIN, Director, Global Health Care, General Electric
Company, Fairfield, CT
DAVID H. GUSTAFSON, Research Professor of Industrial Engineering,
University of Wisconsin, Madison
MARY ANNE KODA-KIMBLE, Professor and Dean, School of Pharmacy,
University of California, San Francisco
ALAN R. NELSON, Special Advisor to the Executive Vice President,
American College of Physicians, Fairfax, VA
NORMAN C. PAYSON, President, NCP, Inc., Concord, NH

WILLIAM A. PECK, Director, Center for Health Policy, Washington
University School of Medicine, St. Louis, MO
NEIL R. POWE, Professor of Medicine, Epidemiology and Health Policy,
The Johns Hopkins University School of Medicine and Johns Hopkins
Bloomberg School of Public Health, Baltimore, MD
CHRISTOPHER QUERAM, President and Chief Executive Officer,
Wisconsin Collaborative for Healthcare Quality, Madison
ROBERT D. REISCHAUER, President, The Urban Institute,
Washington, DC
v
1
Appointed to the committee beginning June 1, 2005.
WILLIAM C. RICHARDSON, President Emeritus, The Johns Hopkins
University and W.K. Kellogg Foundation, Hickory Corners, MI
CHERYL M. SCOTT, President Emerita, Group Health Cooperative,
Seattle, WA
STEPHEN M. SHORTELL, Blue Cross of California Distinguished
Professor of Health Policy and Management and Dean, School of Public
Health, University of California, Berkeley
SAMUEL O. THIER, Professor of Medicine and Professor of Health Care
Policy, Harvard Medical School, Massachusetts General Hospital,
Boston
GAIL R. WILENSKY, Senior Fellow, Project HOPE, Bethesda, MD
Study Staff
JANET CORRIGAN,
2
Project Director
ROSEMARY A. CHALK,
3
Project Director

KAREN ADAMS,
4
Senior Program Officer, Lead Staff for the
Subcommittee on Performance Measurement Evaluation
DIANNE MILLER WOLMAN, Senior Program Officer, Lead Staff on
Quality Improvement Organization Program Evaluation
CONTESSA FINCHER,
5
Program Officer
TRACY A. HARRIS, Program Officer
SAMANTHA M. CHAO, Senior Health Policy Associate
DANITZA VALDIVIA, Program Associate
MICHELLE BAZEMORE, Senior Program Assistant
2
Served through May 2005.
3
Served beginning May 2005.
4
Served through February 2006.
5
Served through July 2005.
vi
vii
Reviewers
This report has been reviewed in draft form by individuals chosen for
their diverse perspectives and technical expertise, in accordance with proce-
dures approved by the National Research Council’s Report Review Com-
mittee. The purpose of this independent review is to provide candid and
critical comments that will assist the institution in making its published
report as sound as possible and to ensure that the report meets institutional

standards for objectivity, evidence, and responsiveness to the study charge.
The review comments and draft manuscript remain confidential to protect
the integrity of the deliberative process. We wish to thank the following
individuals for their review of this report:
BRUCE BAGLEY, Medical Director for Quality Impr
ovement,
American Academy of Family Physicians, Leawood, KS
LAWRENCE P. CASALINO, Assistant Professor, University of
Chicago, Department of Health Studies, Chicago, IL
BARBARA B. FLEMING, Chief, Office of Quality and Performance,
Veterans Health Administration, Washington, DC
MARY ANNE KEHOE, Chief Operating Officer, Lincoln Lutheran
Home, Racine, WI
PETER V. LEE, President and Chief Executive Officer, Pacific Business
Group on Health, San Francisco, CA
RICARDO MARTINEZ, Executive Vice President of Medical Affairs,
The Schumacher Group, Kennesaw, GA
MYLES MAXFIELD, Associate Director of Health Research,
Mathematica Policy Research, Inc., Washington, DC
vii
viii REVIEWERS
ELIZABETH A. MCGLYNN, Associate Director, Center for Research
on Quality Health Care, RAND Corporation, Santa Monica, CA
DON NIELSEN, Senior Vice President for Quality Leadership,
American Hospital Association, Washington, DC
L. GREGORY PAWLSON, Executive Vice President, National
Committee for Quality Assurance, Washington, DC
MICHAEL ROBBINS-ROTHMAN, Senior Consultant, Clinical
Systems Improvement, University of Mississippi Medical Center,
Jackson

TIMOTHY SIZE, Executive Director, Rural Wisconsin Health
Cooperative, Sauk City
ANDREW WEBBER, President and Chief Executive Officer, National
Business Coalition on Health, Washington, DC
ALAN ZASLAVSKY, Professor of Statistics, Department of Health
Care Policy, Harvard Medical School, Boston, MA
Although the reviewers listed above provided many constructive com-
ments and suggestions, they were not asked to endorse the report’s conclu-
sions or recommendations, nor did they see the final draft of the report
before its release. The review of this report was overseen by coordinator
DONALD M. STEINWACHS, Professor and Chair, Johns Hopkins Bloom-
berg School of Public Health, Baltimore, Maryland, and monitor HAROLD
C. SOX, Editor, Annals of Internal Medicine, Philadelphia, Pennsylvania.
Appointed by the National Research Council and the Institute of Medicine,
they were responsible for making certain that an independent examination
of this report was carried out in accordance with institutional procedures
and that all review comments were carefully considered. Responsibility for
the final content of this report rests entirely with the authoring committee
and the institution.
ix
Foreword
Transformation of the U.S. health care system will not come easily. It
will require concerted action by many public- and private-sector partici-
pants working toward the goals of safety, effectiveness, efficiency, patient-
centered care, timeliness, and equity, which the Institute of Medicine (IOM)
has previously identified as the critical aims of health care quality.
This report is part of a new IOM series titled Pathways to Quality
Health Care. The series of reports explores how to transition between the
existing health care system and the system we should create if we are to
reduce waste and unnecessary procedures while fostering value and perfor-

mance. The present report aims to help individual and institutional provid-
ers improve their clinical performance and achieve higher levels of quality
as assessed by purchasers and consumers. The report highlights the impor-
tant roles that a national program with private organizations in each state
can play in supporting higher-quality care, especially for those providers
who serve Medicare beneficiaries.
As discussed in the first report in the Pathways series, Performance
Measurement: Accelerating Improvement, more visible and consistent
measures of quality must be associated with specific providers and health
care settings to support better decisions and investments in health care. In
this second report, the committee looks closely at the sources of technical
assistance that encourage providers to improve their performance. In the
early history of quality improvement, Congress thought it best to review
individual case records of beneficiaries in seeking to improve care in the
Medicare system. More recent experience in other sectors of the economy
suggests that such retrospective record reviews are only one dimension of
x FOREWORD
what is needed to achieve higher levels of performance from a complex
enterprise. Broader system-level interventions frequently offer better ways
to nurture behavioral and organizational change that can improve
performance.
Many health care providers and organizations have made great strides
in improving their quality of care. But the pace of progress is uneven. Some
providers want and deserve technical assistance in eliminating key barriers
that impede their progress. All providers and their patients can benefit from
opportunities to learn from one another and to share lessons learned from
experience in implementing higher standards of care.
In this report, the IOM Committee on Redesigning Health Insurance
Performance Measures, Payment, and Performance Improvement Programs
carefully examines the Quality Improvement Organizations that serve every

state, as well as the national program that guides and supports them. The
committee’s recommendations deserve careful consideration as our elected
leaders and health care purchasers seek to reward high-performing provid-
ers. The committee recommends focusing public resources for technical as-
sistance to achieve better quality on those providers that demonstrate the
potential for change, with priority given to those in greatest need. The re-
port suggests public- and private-sector collaborations that can strengthen
the foundation for this valuable technical assistance. It is important to note
that, consistent with IOM policy and procedures, one member of the study
committee who currently serves on the board of a Quality Improvement
Organization did not participate in the committee deliberations that led to
the development of this report.
This report is a further step from the “what” of quality improvement to
the “how.” By providing an in-depth assessment of the federal experience
with quality improvement, the report helps point the way for those who
strive to create higher quality and better value in health care.
Harvey V. Fineberg, M.D., Ph.D.
President, Institute of Medicine
February 2006
xi
Preface
This report, Medicare’s Quality Improvement Organization Program:
Maximizing Potential, is the second in the Institute of Medicine’s (IOM)
Pathways to Quality Health Care series and was authored by the IOM’s
Committee on Redesigning Health Insurance Performance Measures, Pay-
ment, and Performance Improvement Programs. The committee concludes
that the changing environment of health care, with the increased public
reporting of performance measures and payment incentives for providers
who meet certain quality standards, will create a growing demand from
providers for technical assistance with the reporting of performance mea-

sures and analysis, as well as with process and systems improvements.
The Pathways to Quality Health Care series builds on earlier IOM
studies, known collectively as the Quality Chasm series, which highlight the
importance of strengthening key elements of the health care infrastructure
to dramatically improve the quality of care delivered to patients across all
health care settings. The Pathways to Quality Health Care series addresses
the critical role of performance measurement and reporting, quality im-
provement, and payment incentives in reducing the fragmentation of the
health care delivery system and improving care. In 2005, the IOM released
the first report in the Pathways to Quality Health Care series, Performance
Measurement: Accelerating Improvement, which recommends adoption of
leading performance measures, identifies gaps in performance measures and
areas for further development, and calls for a coherent national system to
support robust performance measurement and public reporting. The con-
gressional request for a comprehensive evaluation of the Medicare Quality
Improvement Organization (QIO) program provided a timely opportunity
xii PREFACE
to examine how the QIO program fits within the evolving performance
improvement efforts in the nation’s health care system. The third report of
the series, to be released in 2006, will examine payment strategies that the
Centers for Medicare and Medicaid Services (CMS) could use to stimulate
higher levels of performance within the health care system and improve the
quality of services offered to Medicare beneficiaries.
The committee’s study of the QIO program shows that the program
has the potential to play an important role in this new environment, but
that a major restructuring is essential to enhance the program’s ability to
promote quality improvement. Recognizing the critical need for quality
improvements in health care, the committee presents recommendations to
strengthen the QIO program for the future.
The committee concludes that the quality of health care for Medicare

beneficiaries has been improving slowly but that gaps in quality persist. The
QIO program could become an important national resource to accelerate
the improvement of quality on the basis of its presence in each state,
programwide support centers, and national support services for perfor-
mance measurement. The current program, however, needs updating and a
major restructuring. The U.S. Congress, the U.S. Department of Health and
Human Services, and CMS should create an improved structure for the
QIOs and a program environment that promotes QIO assistance to more
providers more effectively.
A strong, focused QIO network is essential to the effective implementa-
tion of performance measurement and reporting. The QIO program should
help the national board proposed in the first report in the Pathways to
Quality series implement the system for performance measurement and re-
porting, and assist providers with the development of their own capacity to
measure and improve their performance. CMS should encourage and ex-
pect continuous performance improvement among all Medicare providers,
and the QIOs should aid those providers requesting assistance.
To realize their potential in the emerging health care environment, QIOs
should focus on technical assistance for performance measurement and im-
provement; their effectiveness is currently diluted by competing interests
and activities. Therefore, CMS should develop separate contracts with other
capable organizations to conduct reviews of beneficiary complaints, ap-
peals, and other cases. This devolution of functions will ensure that benefi-
ciaries and the Medicare Trust Funds receive primary attention and that
case reviews are conducted more efficiently.
The committee trusts that its recommendations will provide guidance
to both the U.S. Congress and the U.S. Department of Health and Human
Services on how to restructure the QIO program so that it will be better
positioned to serve as Medicare’s main program for quality improvement.
The report includes as well both a broad and detailed overview of the cur-

PREFACE xiii
rent QIO program that should be useful to members of Congress and the
federal executive branch, as well as the QIO community, seeking to under-
stand this complex program. The report should also serve as a useful foun-
dation upon which future studies can build.
All Americans deserve what CMS has set as its vision: the right care for
every person every time. We do not yet benefit from that level of quality,
and it is clear that science-based guidelines are not followed consistently.
To the extent that the QIO program can assist health care facilities and
practitioners with measurement and improvement of the quality of the
health care they provide, we will all benefit.
As chairman of the committee, I thank all committee members, IOM
staff, and the Subcommittee for Quality Improvement Organization Pro-
gram Evaluation for their contributions of expertise and insight. They all
voluntarily spent considerable time and effort on the study and on shaping
the report. I particularly would like to recognize the contributions of the
chair of the subcommittee, Steve Shortell, and IOM senior program officer
Dianne Miller Wolman, who directed this study.
Steven A. Schroeder, M.D.
Chairman
February 2006

xv
Acknowledgments
Medicare’s Quality Improvement Organization Program: Maximizing
Potential benefited from the contributions of many people. The committee
takes this opportunity to recognize those who helped develop the data and
analyses on which the report is based.
The committee acknowledges the members of the Subcommittee on
Quality Improvement Organization Program Evaluation, who contributed

so much to this report: Stephen M. Shortell, Chair, University of California,
Berkeley; Anne-Marie J. Audet, The Commonwealth Fund; Jack L. Cox,
consultant; David H. Gustafson, University of Wisconsin; Jeff Kang, CIGNA
HealthCare; Alan R. Nelson, American College of Physicians; Gregg Pane,
District of Columbia Department of Health; Barbara R. Paul, BEI; William
A. Peck, Washington University School of Medicine; Eric D. Peterson, Duke
University School of Medicine; and Shoshanna Sofaer, Baruch College. All
members of the subcommittee gave much time and advice in designing the
original data collection tools and procedures, in performing the critical lit-
erature review that supports this report’s findings and conclusions, and in
reviewing and critiquing primary research articles. John Ring and Clyde
Behney also contributed as directors of the Board on Health Care Services
of the Institute of Medicine.
The committee benefited from presentations made by a number of ex-
perts. The following individuals shared their research, experience, and per-
spectives with the committee: Marc M. Boutin, National Health Council;
Elizabeth Bradley, Yale School of Public Health; David Brailer, U.S. De-
partment of Health and Human Services; Donald W. Fisher, American
Medical Group Association, Inc.; Nancy Foster, American Hospital Asso-
xvi ACKNOWLEDGMENTS
ciation; Larry A. Green, American Academy of Family Physicians; Maulik
Joshi, Delmarva Foundation; Barbara B. Manard, American Association of
Homes and Services for the Aging; Mark McClellan, Centers for Medicare
and Medicaid Services; Gordon Mosser, Institute for Clinical Systems Im-
provement; Peter Pronovost, The Johns Hopkins University School of Medi-
cine; and Andrew Webber, National Business Coalition on Health.
The American Health Quality Association was an important source of
information and support. Many staff and members, especially the following
individuals, generously gave their time and knowledge and made presenta-
tions to further the committee’s aims: David Adler, Dale Bratzler, Todd

Ketch, David Schulke, and Jonathan Sugarman.
The committee acknowledges the particular contributions of Allyson
Ross Davies, consultant, in the development and implementation of a web-
based data collection tool, and Cheryl Ulmer, consultant, in the conduct
and analysis of 20 telephone interviews. Timothy Jost, professor, Washing-
ton and Lee University School of Law, provided valuable legal advice. Eric
Lawrence, Assistant Professor of Political Science, The George Washington
University, offered guidance on research methodologies and statistics. Rona
Briere, Alisa Decatur, and Michael K. Hayes provided editorial assistance
and assistance with the preparation of the manuscript for publication.
The committee extends special thanks to all 53 Quality Improvement
Organizations for their willing and active participation in multiple inter-
views, site visits, and data collection efforts.
Funding for the project came from the Centers for Medicare and Med-
icaid Services (CMS). The committee appreciates the assistance and infor-
mation received from CMS staff around the country and particularly recog-
nizes Gary Christopherson, Steve Jencks, Joyce Kelly, and Bill Rollow for
their extra support throughout the project.
xvii
Contents
SUMMARY 1
Background, 2
Key Findings and Conclusions, 4
Recommendations, 11
INTRODUCTION 19
Background, 20
Audiences for This Report, 27
Study Approach, 27
Organization of This Report, 29
References, 30

INTRODUCTION TO PART I 33
1A HISTORICAL PERSPECTIVE AND THE CURRENT
QIO PROGRAM 35
History of the QIO Program, 36
Evolution of Medicare’s Quality Improvement Program, 39
Summary, 52
References, 53
2 ASSESSMENT OF THE QIO PROGRAM:
FINDINGS AND CONCLUSIONS 55
Evidence of Quality Improvement in Medicare, 56
Alternatives to the Current QIO Program, 61
xviii CONTENTS
Program Infrastructure, 63
Functions of the QIOs, 66
Structural Issues, 69
Oversight of the QIO Program, 74
Summary, 79
References, 79
3 PERFORMANCE MEASUREMENT, QUALITY
IMPROVEMENT, AND OTHER ENTITIES 82
The Need for an Organized Performance Measurement and
Reporting System, 83
Functions of the National Quality Coordination Board and
Implications for QIOs, 90
References, 101
4 IMPROVING QUALITY AND PERFORMANCE
MEASUREMENT BY THE QIO PROGRAM 102
Technical Assistance Functions, 105
QIO Support for Quality Improvement Efforts, 109
QIO Board and Organizational Structure, 110

Responsibility for Complaints, Appeals, and Case Reviews, 112
References, 118
5 CMS OVERSIGHT OF THE OPERATIONS AND
MANAGEMENT OF THE QIO PROGRAM 120
Data Processing, 121
QIO Program Management, 126
QIO Program Evaluations, 134
QIO Program Funding, 138
References, 141
INTRODUCTION TO PART II 143
6 STUDY APPROACH 145
Data Sources, 146
Focused Literature Review, 148
Web-Based Data Collection, 149
Quantitative Analyses of QIO Performance, 150
Visits to QIOs, 151
Telephone Interviews, 151
Three-Day Briefing by CMS, 154
Access to QIONet, 154
Face-to-Face Interviews, 155
CONTENTS xix
Focus Group, 155
Specific Data Requests to CMS Staff, 156
Formal and Informal Discussions with AHQA, 156
Informal Discussions with Consumer Organizations and
Providers, 156
National Conferences and Meetings, 157
Suggestions of “Other Entities,” 157
Research Challenges, 157
Strength of Research Conclusions, 158

References, 159
7 STRUCTURE AND FINANCES 160
Structure of QIOs, 160
QIO Support Centers, 173
Finances of QIOs, 179
Summary, 188
References, 190
8 TECHNICAL ASSISTANCE FOR QUALITY
IMPROVEMENT 192
Defining Technical Assistance, 193
Recruitment of Identified Participants, 193
Interaction with Providers, 197
Technical Assistance During the 7th and 8th SOWs, 199
Nursing Homes, 201
Home Health, 205
Hospitals, 208
Physicians’ Offices and Practices, 213
Underserved and Rural Beneficiaries, 218
Managed Care, 221
QIO Support Centers, 223
Summary, 227
References, 228
9 IMPACT OF TECHNICAL ASSISTANCE FOR QUALITY
IMPROVEMENT AND KNOWLEDGE TRANSFER 230
Quality Improvement, 230
Approaches to Quality Improvement, 239
Knowledge Transfer, 243
Summary, 252
References, 252
xx CONTENTS

10 EVALUATION OF QUALITY IMPROVEMENT
ACHIEVED BY THE QIO PROGRAM 257
CMS Evaluation of QIO Performance on Technical
Assistance Tasks, 257
IOM Analysis of Task 1 Performance by QIOs, 262
Impact of Intense QIO Assistance, 272
Provider Satisfaction, 273
Programwide Evaluation of Impact, 276
Summary, 277
References, 278
11 BENEFICIARY EDUCATION AND COMMUNICATIONS 279
Task 2a: Promoting the Use of Performance Data, 279
Task 2b: Transitioning to Hospital-Generated Data, 285
Task 2c: Other Mandated Communications Activities, 287
Role of QIOs in Beneficiary Education: Telephone Interviews, 288
QIO Support Centers in the 7th and 8th SOWs, 293
Summary, 295
References, 295
12 PROTECTION OF MEDICARE BENEFICIARIES AND
PROGRAM INTEGRITY 297
Case Review Activities in the 7th SOW, 298
Mediation in the 7th SOW, 307
Medicare Beneficiary Protection QIOSC, 308
QIO Performance Evaluation in the 7th SOW, 310
Case Review Activities in the 8th SOW, 310
Hospital Payment Monitoring Program in the 7th SOW, 311
HPMP in the 8th SOW, 315
Impact of Protective Activities in the 7th SOW, 318
Summary, 322
References, 323

13 CMS OVERSIGHT 325
Organizational Structure of QIO Program in CMS, 325
Communications and Information Technology Services, 333
Data Flow, 341
Data Lag Issues, 343
QIO Contracts, 345
Overall Program Guidance, 351
Summary, 358
References, 359
CONTENTS xxi
APPENDIXES
A SUPPORTING TABLES 363
B PRIVATE-SECTOR ORGANIZATIONS OFFERING
SERVICES RELATED TO QUALITY IMPROVEMENT 435
C APPROACHES TO EVALUATION DESIGN 466
D GLOSSARY AND ACRONYMS 473
E COMMITTEE BIOGRAPHIES 481
INDEX 501

MEDICARE’S QUALITY
IMPROVEMENT
ORGANIZATION PROGRAM