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￾cine. The members of the committee responsible for the report were chosen for their special

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

Additional copies of this report are available from the National Academies Press, 500 Fifth

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Advising the Nation. Improving Health.

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National Research Council.

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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

1Appointed 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

2Served through May 2005.

3Served beginning May 2005.

4Served through February 2006.

5Served 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 Improvement,

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