The Centers for Medicare & Medicaid Services (CMS) appreciates the Institute of Medicine ’s (IOM) review of the Medicare Quality Improvement Organization (QIO) Program. Quality improvement is a very high priority across the Agency, and the QIOs play an important role in supporting the Agency’s work in this area. CMS is pleased that the IOM has confirmed significant quality improvements in Medicare and strongly supports an effective QIO Program to achieve greater improvements. As the IOM noted, more can be done to increase the Program’s impact on quality improvement. The IOM’s report and recommendations complement the Agency’s ongoing review of the QIO Program and will be carefully considered as CMS works to shape the future of this important program.
This is not the first time the IOM has reviewed the nation’s QIO Program, which has led to dramatic changes in the role of these local peer review organizations. In 1990, a congressionally mandated IOM study of the QIO program was a catalyst for shifting to a quality improvement-focused archetype, which strengthened the program and redefined the QIO mission. In the 15-plus years since the release of that report, the quality improvement landscape in the nation’s health care system has changed dramatically. During this time, the IOM issued additional landmark studies, including “To Err is Human” and “Crossing the Quality Chasm,” which point to system-wide process change – not individual provider sanctions – as the most effective way to improve healthcare quality. CMS and the organizations making up the QIO program have paid close attention to the IOM reports, and have made changes to the program that reflect their findings and recommendations.
In concluding that the quality of health care received by Medicare beneficiaries has improved, the IOM noted the difficulties of directly linking QIO contributions to that success. There is some recent evidence that the QIO Program is contributing to the improvements. For example, by creating an environment and infrastructure that fosters quality and quality improvement, QIO leadership in the areas of nursing home and home health quality measurement and improvement, and hospital surgical infection prevention,
is helping to make such improvement possible. To provide much clearer evidence on how QIOs can have the maximum impact, the QIO’s current work plan (“8th Scope of Work”) includes a more rigorous and controlled evaluation of the impact of QIO activities.
In reaffirming the continued need for the QIO Program, the IOM also recommends a number of significant changes to the Program, including reforms to strengthen the beneficiary complaint and appeals process. We take our responsibilities for beneficiary appeals seriously and we are committed to taking all the steps we can under the law to make sure that beneficiaries are well informed about the complaint and appeals process, and that they are able to use it effectively when they need it. The IOM’s recommendation to consolidate the review functions into a few regional or national competitive contracts is a promising approach that the Agency will evaluate promptly as part of its ongoing review of the Program.
QIOs are key resources to CMS, working to refine care delivery systems; investigate beneficiary complaints; safeguard the integrity of the Medicare Trust Funds; and build national partnerships with key provider organizations. QIOs also play an important role in developing quality measures that can be used to measure provider performance and spur quality improvement activities. QIOs also assist in the validation process for quality data that has been submitted and develop information about best practices and tools which support them. All of these activities contribute to the goal of creating an environment for quality improvement.
In short, the QIO program is doing important work and we are pleased that the IOM recognizes that QIOs are “a potentially valuable nationwide infrastructure dedicated to promoting quality health care.” Today’s report is a central point in the national conversation about the future of American healthcare quality and CMS’ quality improvement efforts. We look forward to working with Congress, the IOM, the Administration and stakeholders to continue to build on the success of QIO initiatives and shape the future of this important program.