# Presentation: 288959

## Your Quality Improvement Organization (QIO): Unlocking the Mystery

- Heart Disease and Stroke Meeting
- September 19, 2007
- Sharon Donnelly

**Notes:**
Objective:

Introduce the QIO program  
	our CMS work
	other types of contracts
	staff make-up/expertise
(ask here how many know and/or have worked with their QIO)

Elaborate on QI approach – introduce some “human factors” perspective

Explore partnering opportunities with your programs and QIOs

## QIOs: America’s Quality Measurement and Improvement Infrastructure

- National network of 40 state-based, private organizations dedicated to health care quality improvement
- Three-year contracts with Medicare

## QIOs: America’s Quality Measurement and Improvement Infrastructure

- QIO Program represents largest coordinated federal investment in quality improvement
- Less than 0.1% of annual Medicare spending
- QIOs have other federal, state and private contracts

**Notes:**
Early advise from my mentor at HealthInsight

If we don’t do a good job – the absolute best we can we are “taking money from old people”

How do we design effective programs that will improve care?
How do we know?

How will you?

## History of the QIO Program

- Peer Review Organization (PRO) program created by Congress in 1982 shortly after Medicare started
- 1984-92: primary work was case review to control utilization, react to poor quality = quality assurance (QA)

**Notes:**
The program started by performing extensive medical case review to control PPS utilization – and basically randomly identify individual instances of “bad” care in the system. This may have corrected the actions of a few but it didn’t yield much overall improvement in care.

## History of the QIO Program

- 1993-present: primary work is facilitating proactive quality improvement (QI) in clinical systems
- 2002: New name “QIO” better reflects the work

**Notes:**
In 1993 – CMS adopted the system-based quality improvement principles that other industries have been using for years.  Based on the principle that quality improvement at its core is improving entire systems – by examining the processes used in providing the care and  identifying best practices – and implementing them as system-wide improvements – not punishing individuals for system-level mistakes.

Earlier this month, Yale researchers released a study that surveyed hospital quality managers’ opinions of their QIO and found that QIOs have come a long way from the PRO old days. Positive relationship between QIOs and nursing homes, home health agencies and physicians offices is also strong evidence of that shift.

One thing you’ll find is consistent about QIO’s is that they have existing relationships with all kinds of providers in the states they serve.

## Quality Assurance vs Quality Improvement

- How do you frame the question?
- Identify and fix bad performers
- Identify and fix bad systems
- Analyze root cause and barriers

**Notes:**
STOP –  discuss QA vs QI

When you think about what you are tasked with how do you frame it?

How can we get _____ to do (or stop doing ) _______?
How do we make them do it right?
How can we identify those not doing it right and educate them?

Why are they not able to do _____?
   what are their barriers
   what results does the current system yield 
        AND how can we change the system to get a different outcome?
What are each of the player incentives?

## Non-Medicare Work of the QIOs

- 70% of QIOs also serve Medicaid:
- Focused Quality Review
-     (e.g., pediatric immunization rates, prevention, asthma)
- External Quality Review (EQRO) of MCOs
- Administration of CAHPS surveys
- 30% of QIOs have private customers:
- Data management/analysis, record abstraction
- HEDIS audits
- Independent medical review of insurance claims
- 20% have other federal and state contracts: VA, IHS, CDC, Rural Flex and TRICARE

## Expertise in a Wide Variety of Areas

- Clinical
- Statistical/Analytical
- Project management
- Change management
*Systems change: *the whole health care system and how parts interact
*Organizational change: *create ripe ground for application of quality improvement
*Process change: *study and then improve on current processes of care (work flow analyze and redesign)
- Root cause analysis/Human error
- Extensive provider relationships

**Notes:**
Expertise in a wide variety of areas needed to apply QI to healthcare:

## Managing Failures - Patient Safety

**Planning Errors **
- 	actions may conform exactly to the plan, but the *plan is inadequate to achieve its intended outcome* = mistakes.
**Execution Errors **
- 	plan is adequate, but *actions fail to go as planned* = slips or lapses
**Violations **
- 	*intentional deviations* from safe operating procedures, standards or rules - actions are intended but the possible *bad consequences or outcomes are not*.

**Notes:**
Created in the Patient Safety context but widely applicable (and you’ll find more and more has been thrown into patient safety over time)

Planning Errors 
A planning error is an error in which the actions may conform exactly to the plan, but the plan is inadequate to achieve its intended outcome. These are unintended failures and are commonly called mistakes. 
Execution Errors 
An execution error is an error in which a person’s plan is adequate, but his or her actions fail to go as planned. These are unintended failures of execution and are commonly termed slips, lapses, trips, or fumbles. 
Violations 
Violations are intentional deviations from safe operating procedures, standards or rules. We are primarily interested in deliberate violations in which the actions are intended but the possible bad consequences or outcomes are not.

Stop here and discuss specific examples
Ask them to relate to H/S Program.

## 7th Statement of Work (SOW) 2002 - 2005

- Assist nursing homes, home health agencies, hospitals and physicians to improve on a set of national measures
- Work focused on providing intensive assistance to a subset of providers (called “identified participants”), in addition to statewide improvement efforts
- ESRD, Pharmacy Plans, HIE/RHIOs

**Notes:**
The IP group has really given us a lot more information about what kind of impact the QIOs have on quality by comparing the identified participants against the state or national trends—example is nursing homes where the identified participants outperformed the national trends.

Consider when you create your programs
How will you be able to determine your impact vs the impact of overall efforts (including QIOs) in these areas?

## 7th Statement of Work Results

- Improvement shown on measures across settings, with identified participants demonstrating greater progress
- Hospitals  - Combined average improvement of 21%.
- Nationally, nursing homes reduced prevalence of chronic pain by 38% from 2002-2004.  Identified participant nursing homes improved 49%.

## CMS Goals

- CMS expects transformational change on multiple topics in multiple settings
- QIOs lead the change process by:
- 	-	Working intensively with a subset of 	providers
- 	-	Engaging in improvement for quality 	measures statewide - PARTNERS

## 8th SOW Strategies Applied 2005 - 2008

- Clinical Performance Measurement and Public Reporting
- Transparency of quality
- Process Improvement
- Applied quality improvement efforts
- Systems Improvement
- Health care system redesign - incentives
- Organizational Culture Change
- Senior leadership engagement

**Notes:**
Discuss public reporting in all setting:
Limitations in physician office setting – tie in later to p4p

## Setting Specific Goals(Mostly Appropriate Care)

- Hospital – Care, Health Information Technology (HIT) adoption, Senior leaders
- Nursing Homes – Care, Satisfaction, Staff retention
- Home Health Agencies – Care, Culture, Telehealth
- Physicians Offices – Care, HIT, Disparities, Pharmacy benefit

**Notes:**
Hospital:
Heart attack, heart failure, pneumonia, surgical infections
Some adoption of HIT
Engage senior leader

Nursing Homes:
Pressure ulcers, physical  restraints, depression management, chronic pain
Resident AND staff satisfaction, staff retention

Home Health:
Reduce acute care hospitalization and immunization screening
organizational culture and use telehealth technology
Improve publicly reported OASIS measure

Physicians Offices:
Diabetes, mammo, flu/PPV
HIT – and begin building reporting system
Culturally sensitive care – Ethnic underserved 
Use of new pharmacy benefit

## Heart Disease and Stroke Prevention

- Educational, policy and systems change with emphasis on the six program priority areas:
- 1. control of high blood pressure
- 2. control of high blood cholesterol
- 3. knowledge of signs/symptoms for heart disease and stroke - calling 9-1-1
- 4. emergency response
- 5. quality of heart disease and stroke care
- 6. disparities
- Focus on the health care and worksite settings.

## Hospitals: Improving Heart Disease Care

- Heart attack:
- Aspirin at arrival and discharge
- Beta blocker at arrival and discharge
- ACE or ARB for LVSD
- Fibrinolytic therapy within 30 min. of hospital arrival
- Percutaneous coronary intervention (PCI) within 90 min. of hospital arrival
- Adult smoking cessation counseling

## Hospitals: Improving Heart Disease Care

- Heart failure:
- Evaluation of LVS function
- ACE or ARB for LVSD
- Discharge instructions
- Activity
- Diet
- Medications
- Weight monitoring
- Worsening symptoms
- Follow up care
- Adult smoking cessation counseling

## Hospitals: Transfer Measures

- Acute MI
- Aspirin at arrival
- Fibrinolytic therapy within 30 min. of hospital arrival
- Median time to Fibrinolytic therapy
- Median time to ECG
- Rural FLEX projects – Acute stroke care

**Notes:**
Emergency department transfer measures (applicable mostly to rural facilities)
Currently in comment period
After comments considered, will be endorsed by the National Quality forum (NQF) and reported like the other hospital quality measures

ED Communication
The transferring hospital will provide the receiving hospital with: 
Administrative information, e.g., insurance
Patient demographics, contact information for family, significant others
Vital signs
Provider-to-provider communication
Nurse-to-nurse communication
Rural FLEX
Acute stroke care
Participation in benchmarking quality measures

## Physician Office:Few overlapping measures

- 8th SOW
- Diabetes, Mammography, Immunizations
- DOQ-IT – date submission on a wider group of health indicators
- Primarily treatment and not prevention
- Disparities
- Pay for performance pilots include even more indicators
- 9th SOW		??

## Pay for performance/reporting

- Medicare Care Management Performance (MCMP) Demonstration
- Utah, Arkansas, California, Massachusetts
- Physician Voluntary Reporting Program (PVRP)
- Report clinical quality indicators through billing claims
- Goal to have measures for all specialists

## The QIO 8th SoWBeing effective and efficient

- Physician practices, hospitals, nursing homes and home health agencies
- Fewer financial resources = even more cost efficient and effective methods
- Partnerships (especially committed providers) helped to get the job done

## 9th SOW Draft Proposed Strategies  2008 – 2011?

- Patient Safety
- Right care - every time
- Patient Pathways
- Care across the continuum
- Beneficiary Protection
- Responsive to patients and providers
- Prevention
- Maybe health promotion in future?

## Who is the QIO for my state?

- Use the QIO locator on American Health Quality Association’s website: www.ahqa.org
- Call AHQA at 202-331-5790

## www.ahqa.org

## Select letter or scroll down to state

## Questions? Thank you!

- Sharon Donnelly, MS
*HealthInsight* 801-892-6668sdonnelly@healthinsight.org
**Pub# is 8SOW-OM-TR-79**
**This material was prepared by HealthInsight under a contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services (DHHS).  The contents presented do not necessarily reflect CMS policy.**