Department of Health and Human Services 
OFFICE OF 
 
INSPECTOR GENERAL 
   
   
 
 
Q I
UALITY  MPROVEMENT 
 
O P
R  GANIZATIONS  ROVIDE 
 
S M T
U  PPORT TO  ORE  HAN 
 
H H
ALF OF  OSPITAL BUT 
 
 
O W O
VERLAP  ITH  THER 
 
P  
ROGRAMS 
 
 
Daniel R. Levinson   
Inspector General  
 
January 2015 
OEI-01-12-00650   
   
EXECUTIVE SUMMARY:  QUALITY IMPROVEMENT ORGANIZATIONS 
PROVIDE SUPPORT TO MORE THAN HALF OF HOSPITALS BUT OVERLAP 
WITH OTHER PROGRAMS  
OEI-01-12-00650 
 
WHY WE DID THIS STUDY 
 
Past work by the Office of Inspector General and others raised concerns about Quality 
Improvement Organizations (QIOs), including duplication with other quality 
improvement efforts.  Between 2011 and 2014, the Centers for Medicare & Medicaid 
Services (CMS) paid QIOs about $1.6 billion to improve health care for Medicare 
beneficiaries.  During this time, CMS also spent nearly $500 million on two new quality 
improvement efforts, Hospital Engagement Networks (HENs) and the Community-Based 
Care Transitions Program (CCTP).  Given QIOs new 5-year, $4 billion contract and the 
importance of CMSs quality improvement objectives, it is crucial that CMS coordinate 
its resources to avoid duplication among its quality improvement efforts. 
 
HOW WE DID THIS STUDY  
 
We sent a questionnaire to a random sample of 410 Medicare hospitals asking whether 
they worked with QIOs or other quality improvement entities in 2013.  We received a 
weighted response rate of 93 percent.  We analyzed CMSs lists of hospitals that worked 
with QIOs, HENs, and the CCTP. Finally, we conducted site visits at three hospitals in 
two States and QIOs representing four States.   
 
WHAT WE FOUND 
 
In 2013, over half of hospitals participated with QIOs on quality improvement projects.  
All participating hospitals in our sample reported receiving benefits by working with 
QIOs. Eight out of ten participating hospitals also worked with other federally funded 
entities on the same topics as QIOs.  Most participating hospitals also worked with non-
Federal entities on the same topics as QIOs.  Data problems and timing of other CMS 
quality improvement efforts hampered QIOs ability to target eligible hospitals and avoid 
duplicating those efforts. QIOs reported problems in key CMS data for recruiting 
hospitals for infection and readmissions projects.  QIOs were already recruiting hospitals 
when CMS awarded HEN contracts and the CCTP agreements. 
 
WHAT WE RECOMMEND 
 
The overlap among CMSs quality improvement efforts raises concerns about duplication 
of efforts and makes it difficult to attribute quality improvements to any one 
effort. Therefore, we recommend that CMS take additional steps to coordinate, and 
reduce overlap between, the QIO program  and CMSs other quality improvement 
efforts.  We also recommend that CMS determine the relative contribution of each of its 
quality improvement efforts.  CMS concurred with our recommendations.   
   
   
TABLE OF CONTENTS 
 
Objectives ....................................................................................................1 

Background..................................................................................................1 

Methodology................................................................................................7 

Findings........................................................................................................9 

In 2013, over half of hospitals participated with QIOs on quality 
improvement projects.......................................................................9 

Eight out of ten participating hospitals also worked with other 

federally funded efforts on the same topics as QIOs .....................12 

Most participating hospitals also worked with non-Federal entities 
on the same topics as QIOs ............................................................14 

Data problems and timing of other CMS quality improvement 

efforts hampered QIOs ability to target eligible hospitals and 

avoid duplicating those efforts .......................................................15 

Conclusion and Recommendations ............................................................17 

Agency Comments and Office of Inspector General Response .................19 

Appendixes ................................................................................................20 

A: Sampling Methodology ............................................................20 

B: Point Estimates and Confidence Intervals................................21 

C: Agency Comments  ...................................................................22 

Acknowledgments......................................................................................26 

 
 
 
 
 
 
 
 
 
 
   
   
OBJECTIVES 
1. 	  To determine the extent to which and the ways in which hospitals 
participated in Quality Improvement Organizations (QIO) projects 
during 2013. 
2. 	  To determine the extent to which QIOs projects in hospitals 
overlapped with projects offered by other entities.  
BACKGROUND 
Quality Improvement Organizations 
The Centers for Medicare & Medicaid Services (CMS) contracts with 
QIOs to oversee and improve quality of care within the Medicare program.  
QIOs sign contracts, called scopes of work, to operate in the 50 States, the 
District of Columbia, Puerto Rico, and the U.S. Virgin Islands.1    
QIOs work with institutional health care providers, individual 
practitioners, and beneficiaries on quality improvement projects.  CMS, 
through its Center for Clinical Standards and Quality, develops new 
projects to improve specific clinical measures in each scope of work.  To  
improve these measures, QIOs make quality measure data available to 
providers, offer technical assistance tailored to individual providers, and 
facilitate meetings at which providers and stakeholders share best 
practices. QIOs also oversee quality of care by conducting case reviews 
of individual instances of care provided to Medicare beneficiaries.   
QIO Quality Improvement Projects  
QIOs work on projects with different providers.  In the 10th scope of work, 
these projects included, but were not limited to, reducing the use of 
physical restraints in nursing homes, increasing the use of electronic 
health records in physician offices, and reducing adverse drug events 
experienced by Medicare beneficiaries.2 Of the $1.6 billion budgeted for 
the QIOs 10th scope of work, which lasted from  August 2011 to August 
2014, QIOs spent about $450 million on quality improvement projects.3  
 ____________________________________________________________ 
1 Social Security Act (SSA),   1153(a), (b),  and (c)(3), 42  U.S.C.  1320c-2(a), (b), and 

(c)(3).  Title II, Subtitle C, Part II, section 261, of the Trade Adjustment  Assistance 

Extension Act  of 2011, Pub. L. No. 112-40, required certain changes to  QIO contracts,
  
such as increasing the contract term from 3 to  5 years and allowing QIO contracts at the 
 
local, State, regional, national, or  other geographic level  (i.e., versus being limited to
  
States or territories).  These changes are effective for contracts entered into or renewed 
 
on or after January 1, 2012. 

2  CMS, QIO 10th  Scope of Work,   C.7.2.B., C.9., and C.7.3. 

3 Department of Health and Human Services, Fiscal Year  2014 Budget in Brief. 

Accessed at http://www.hhs.gov/budget/fy2014 on May 15, 2014. 

QIOs Provide Support to More Than Half of Hospitals but Overlap With Other Quality Improvement Programs  
(OEI-01-12-00650)    1   
   
QIOs also spent $405 million on infrastructure and staffing, a portion of 
which supports these projects.4    
QIOs work with hospitals in the 10th scope of work addressed two types 
of quality improvement projects:  reducing certain health care-associated  
infection rates (infection projects) and reducing hospital readmissions 
through improved transitions between care settings (readmissions 
projects). QIOs also provided technical assistance to hospitals related to 
Medicare quality reporting programs.5  
In infection projects, QIOs focused on four topics:  central line-associated 
bloodstream infections, catheter-associated urinary tract infections, 
clostridium difficile (c-diff) infections, and surgical site infections.  In 
readmissions projects, QIOs worked with groups of providers, called 
communities, to improve transitions between care settings and reduce 
hospital readmissions.  Communities included home health agencies, 
dialysis facilities, hospices, physician offices, and nursing homes, among 
others, with hospitals as a central component.  
Hospital Eligibility and Recruitment in the 10th Scope of Work 
For QIOs infection projects, CMS planned to determine hospital 
eligibility from self-reported infection rates.  Hospitals submit those rates 
to the Centers for Disease Control and Preventions (CDCs) infection rate 
database, called the National Healthcare Safety Network.6, 7  See Table 1 
for eligibility criteria by infection topic.   
Table 1: Hospital Eligibility for Infection Topics  
In  f ection Topic   CM  S  -de t e r mi ned   El  ig  i bi l i t  y  Cr i te ri a 
Hospitals with a central line-associated bloodstream   
Central line-associated 
infection rate equal to or greater than 1.5 per  
bloodstream infections  
1,000 central line days  
Catheter-associated urinary  Any hospital   
tract infections  
C-diff infections   Hospitals with a rate equal to or greater than    
6 health care-associated c-diff events per 10,000 
patient days  
Surgical site infections   Hospitals participating in other infection projects   
 
        Source:  QIO 10th Scope of  Work,  C.7.1.B.1.
 ____________________________________________________________ 
4 Ibid. 

5  CMS, QIO 10th Scope of  Work,  C.7.1, C.8, and C.7.4.A. 
 
6 76 Fed. Reg. 51436 and 51631  (August 18, 2011). 

7 75 Fed. Reg. 50042 and 50202  (August 16, 2010). 

QIOs Provide Support to More Than Half of Hospitals but Overlap With Other Quality Improvement Programs  
(OEI-01-12-00650)    2   
   
For QIOs readmissions projects, CMS provided ZIP Codes that defined 
potential communities to recruit.  One community may have included 
multiple ZIP Codes and provider types that worked together to reduce 
hospital readmissions.8   
To recruit an eligible hospital, QIOs contacted the hospitals leadership.  If 
the hospital voluntarily agreed to formally participate in a project for the 
duration of the scope of work, it signed a nonbinding memorandum of 
understanding.9  CMS set improvement targets for formally participating 
hospitals quality measures.  It held QIOs responsible for reaching the 
targets in its evaluation of each QIO.   
Ineligible hospitals could also participate in projects; however, they did so 
informally without signing memorandums of understanding.  In these 
cases, hospitals quality measures would not factor into CMSs evaluation 
of the QIOs.10    
How QIOs Conducted Quality Improvement Projects in the  
10th Scope of Work  
QIOs had latitude in how they accomplished quality improvement goals.  
They interacted with hospitals by convening group meetings, offering one-
on-one assistance, and providing educational materials.  
Group Meetings.  QIOs facilitated group meetings by bringing together 
providers in need of improvement, high-performing providers, and 
stakeholders. These meetings were both in person and via Webinar.  
One-on-One Assistance. One-on-one technical assistance is another way 
QIOs accomplished project goals.  Unlike the group meetings, this type of 
assistance allowed QIOs to tailor technical assistance to a particular 
hospitals needs, onsite at that hospital.  QIOs also responded to inquiries 
from hospitals on an ad hoc basis.   
Educational Materials.  QIOs distributed tools to assist providers with 
training. For example, QIOs compiled a Change Packet to outline 
potential strategies and actions hospitals could use to work towards a 
particular goal. 
When conducting quality improvement projects, QIOs could partner with 
other entities in their States, such as health departments, hospital 
associations, and private organizations, with the prior approval of CMS.  
____________________________________________________________ 
8  CMS, QIO 10th  Scope of Work,  C.8. 
 
9  CMS, QIO 10th Scope of  Work,  C.7.1.B.1.f and C.8.1.C.2.b. 
 
10 For readmissions projects, CMS evaluates QIOs partly on the statewide readmissions 

rate. CMS,  QIO 10th Scope of Work, Attachment J-10, Table 2, Measure IC-7. 
QIOs Provide Support to More Than Half of Hospitals but Overlap With Other Quality Improvement Programs  
(OEI-01-12-00650)    3   
   
However in forming such partnerships, QIOs could not duplicate federally 
or State-sponsored efforts.11  
CMS required QIOs to submit data that track their recruiting efforts, the 
outreach they did throughout the scope of work, and the way in which 
projects were proceeding.  These data included memorandums of 
understanding, lists of participating providers, activity reports, and 
performance measures.12  
The QIOs 11th Scope of Work  
In 2014, CMS announced major changes to the QIO program in the  
11th scope of work, which began in August 2014.  Instead of contracting 
with one QIO per State to conduct both quality improvement projects and 
case reviews, CMS awarded separate contracts for these functions.  CMS 
also contracts with fewer QIOs than one per State, instead treating the 
QIOs as regional entities. Furthermore, CMS increased the length of the 
11th scope of work to 5 years.  It estimates that the 11th scope of work will 
cost a total of $4 billion.  This funds quality improvement projects, 
overhead costs, and data assistance.13 CMS awarded contracts to 14 QIOs 
to conduct quality improvement projects and 2 QIOs to conduct case 
reviews for the entire country.14, 15    
Other CMS Quality Improvement Efforts  
CMS also leads the Partnership for Patients, a collaboration among 
multiple Federal departments, States, and private entities.16   The goals of 
this program are to reduce infections and reduce readmissions through 
improved transitions between care settings.17   Two of the key quality 
____________________________________________________________ 
11 Ibid,  C.7.1.B.3.  
  
12  CMS, QIO 10th  Scope of Work,  F. 
 
13 Department of Health and Human Services, Fiscal Year 2015 Justification of 

Estimates for Appropriations Committees. 
 
14 CMS, CMS Launches Next Phase of New Quality Improvement Program.  Accessed at  

http://www.cms.gov/Newsroom/MediaReleaseDatabase/Press-releases/2014-Press-
releases-items/2014-07-18.html on July 27, 2014. 

15 CMS, CMS Launches Improved  Quality Improvement Program.   Accessed at 

http://cms.gov/Newsroom/MediaReleaseDatabase/Press-releases/2014-Press-releases-
items/2014-05-09.html on May 20, 2014. 
 
16 CMSs Center for Medicare & Medicaid Innovation oversaw Partnership for Patients at 
 
its inception; however, aspects of it were transferred to the  Center for Clinical Standards 

and Quality in December 2013. 

17 CMS, About the Partnership for Patients. Accessed at  
http://partnershipforpatients.cms.gov/about-the-
partnership/aboutthepartnershipforpatients.html on May 13, 2014. 
QIOs Provide Support to More Than Half of Hospitals but Overlap With Other Quality Improvement Programs  
(OEI-01-12-00650)    4   
   
improvement efforts of the program are Hospital Engagement Networks 
(HENs) and the Community-based Care Transitions Program (CCTP).18  
Hospital Engagement Networks. HENs are organizations that identify and 
share best practices across member hospitals.  HENs do this via learning 
collaboratives, identification of  mentor hospitals to help poorly 
performing hospitals, training programs, and technical assistance.  In 
December 2011, CMS awarded $218 million to 26 entities to serve as 
HENs.19    
Community-based Care Transitions Program. Under this program, CMS 
reimburses community organizations to better coordinate Medicare 
patients discharges between provider settings.  CMS awards communities 
2-year agreements, which it can extend annually on the basis of 
performance.  CMS selected the first round of communities in November 
2011.20   The CCTP is funded up to $300 million until the program ends in 
2015.21  
Concerns With QIOs Quality Improvement Projects  
Provider Recruitment. In 2011, the Medicare Payment Advisory 
Commission (MedPAC) found that low-performing hospitals lack 
resources to complete quality improvement projects.22   A 2007 
Government  Accountability Office (GAO) report found that QIOs did not 
work with providers on the basis of need, but rather selected providers 
according to their willingness to work with QIOs.23  
Duplication of Other Efforts. A 2012  GAO report found that QIOs and 
HENs duplicated each others infection projects.  In response to that 
report, CMS stated that it would address QIO and HEN duplication by the 
____________________________________________________________ 
18 Ibid. 

19 CMS, Hospital Engagement Networks:  Connecting Hospitals to Improve Care. 

Accessed at http://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2011-
Fact-sheets-items/2011-12-14.html on May  29, 2014. 
 
20 CMS, First Site Selections for the Community-Based Care Transitions Program. 

Accessed at http://www.cms.gov/Medicare/Demonstration-
Projects/DemoProjectsEvalRpts/downloads/CCTP_FirstSiteSelections.pdf on May 29, 

2014. 

21 CMS, Community-based Care Transitions Program. Accessed at 

http://innovation.cms.gov/initiatives/CCTP/index.html on  May 19, 2014.  Pub. L. 113-6   

1520. 

22 MedPAC, Report to the Congress:  Medicare and the Health Care Delivery System  
(June 2011). 
23 GAO,  Federal Actions Needed to Improve Targeting and Evaluation of Assistance by 
Quality Improvement Organizations,  GAO-07-373, May 2007.  The report evaluated  
QIOs 7th scope of  work.  The 9th and 10th scopes of work addressed this finding by  
defining eligibility pools and recruitment targets.   
QIOs Provide Support to More Than Half of Hospitals but Overlap With Other Quality Improvement Programs  
(OEI-01-12-00650)    5   
   
end of 2012.24   According to a Mathematica Policy Research report, three-
quarters of QIOs reported that their 9th scope of work hospital projects 
overlapped with projects offered by other entities.25   The MedPAC report 
found that providers work with an increasing number of Federal and 
private entities that focus on improving quality, which reduces providers  
willingness and ability to participate in QIOs projects.  MedPAC 
recommended that the QIO program be fundamentally changed to provide 
funding directly to hospitals. This funding would enable those providers 
to select the entities that best fit their quality improvement needs.26  
Data Quality. The 2007 GAO report found that QIOs deliverables did 
not contain enough detail to attribute quality improvement to their 
projects.27  The Institute of Medicine (IOM) called for QIOs to collect 
more meaningful data on quality improvement projects.28   In 1998, the 
Office of Inspector General (OIG) also found incomplete and inaccurate 
information in QIOs database and reporting systems.  The lack of these 
data prevented OIG from conducting a more extensive analysis.29  
Quality Improvement.  Both the IOM and a study published in the Journal 
of the American Medical Association were unable to attribute quality 
improvements to QIOs work.30, 31 
 
 
 ____________________________________________________________ 
24 GAO,  CMS Innovation Center:  Early Implementation Efforts Suggest Need for 
Additional Actions to Help Ensure Coordination with Other CMS  Offices, GAO-13-12 
(Nov. 2012).  
25 Mathematica Policy Research, Independent Evaluation of  the Ninth Scope of Work  
(Nov. 2011). 
 
26 MedPAC, Report to the Congress:  Medicare and the Health Care Delivery System 
 
(June 2011). 

27 GAO,  Federal Actions Needed to Improve Targeting and Evaluation of Assistance by 

Quality Improvement Organizations,  GAO-07-373 (May  2007).  The report evaluated 

QIOs 7th scope of  work, which did not require QIOs to track each meeting occurrence 

and the providers that attended it. 

28 IOM,  National Academy of Sciences, Medicares Quality Improvement Organization 
Program: Maximizing Potential (2006).   

29 OIG,  Monitoring and Evaluating the Health  Care Quality Improvement Program, 

OEI-01-98-00440 (Aug. 1998). 
  
30  IOM, National Academy of Sciences, Medicares Quality Improvement Organization  
Program: Maximizing Potential (2006).   

31 Claire Snyder and Gerard  Anderson, Do  Quality Improvement Organizations  Improve 

the Quality of  Hospital Care for Medicare Beneficiaries? Journal of the American 

Medical Association, Vol. 293, No. 23, pp. 2900-2907 (2005).   

QIOs Provide Support to More Than Half of Hospitals but Overlap With Other Quality Improvement Programs  
(OEI-01-12-00650)    6   
   
METHODOLOGY 
Scope 
This evaluation focuses on QIOs quality improvement projects with 
Medicare hospitals during the 10th scope of work. We focused on 
hospitals participation in these projects during 2013.  
Data Sources and Collection  
Hospital Questionnaire. We surveyed a stratified random sample of  
410 hospitals by participation in QIO projects (from the population of 
3,456 hospitals enrolled in Medicare in 2013).  We received responses 
from 385 hospitals, for a weighted response rate of 93 percent.  See 
Appendix A for response rate by stratum.    
We conducted the survey from February to April 2014.  In the 
questionnaire, we asked hospitals whether they worked with their QIOs in  
2013 and, if they did, how they participated in projects. We asked about 
this time period because, as of the date of our survey, QIOs should have 
completed recruiting hospitals for 10th scope of work projects. 
Additionally, we asked about other entities that hospitals worked with on 
quality improvement projects in 2013.  We pretested the questionnaire 
with hospital staff in three States.  
CMS Documents. We obtained from CMS the list of hospitals that 
formally work with QIOs.  We also obtained from CMS the lists of 
hospitals that work with HENs or the CCTP.   We requested from CMS 
lists of hospitals eligible for infection projects and communities QIOs 
could recruit for readmissions projects. 
We also reviewed CMS policy memorandums and guidance to QIOs 
issued throughout the 10th scope of work. 
CASPER.  We obtained hospital characteristic data from the Certification  
and Survey Provider Enhanced Reporting (CASPER) system.  We  
analyzed data for hospitals enrolled in Medicare at the start of the  
10th scope of work in August 2011. 
Site Visits. We conducted site visits at three hospitals in two States and 
QIOs representing four States (one QIO holds contracts for two States).  
We purposively selected States on the basis of geographic diversity and 
number of Medicare beneficiaries served.  We interviewed hospital staff 
about the quality improvement projects they work on with QIOs and other 
entities. We interviewed QIO staff about the methods by which they 
interacted with hospitals and how they recruited hospitals.  
 
QIOs Provide Support to More Than Half of Hospitals but Overlap With Other Quality Improvement Programs  
(OEI-01-12-00650)    7   
   
Data Analysis  
Hospital Questionnaire. We analyzed the questionnaire responses to 
determine how hospitals participated, both formally and informally, in 
quality improvement projects during 2013.  We determined how 
frequently hospitals attended group meetings, received one-on-one 
assistance, and used written education materials.  We also analyzed the 
responses to determine how often hospitals worked with entities other than 
QIOs on the same project topics.  We  projected the questionnaire results to 
the population of hospitals enrolled in Medicare.  When we did not 
project, we refer explicitly to hospitals in our sample.  See Appendix B for 
confidence intervals and point estimates for data points from the 
questionnaire. 
CMS Documents. We analyzed CMSs lists of hospitals to identify 
hospitals that formally worked with QIOs during the 10th scope of work 
and also worked with HENs or participated in the CCTP as of February 
2013 and January 2014, respectively.   These lists contain the entire 
population of formally participating hospitals.  We also reviewed CMS 
policy memoranda and guidance for instances related to hospital 
recruitment and coordination with HENs.  
Site Visits. We performed qualitative data analysis on the information we 
obtained during our site visits. For example, we reviewed the data for 
common themes.   
Limitations  
We did not independently verify the information obtained from hospitals 
and CMS. 
Standards 
This study was conducted in accordance with the Quality Standards for 
Inspection and Evaluation issued by the Council of the Inspectors General 
on Integrity and Efficiency. 
   
QIOs Provide Support to More Than Half of Hospitals but Overlap With Other Quality Improvement Programs  
(OEI-01-12-00650)    8   
   
FINDINGS 
In 2013, over half of hospitals participated with QIOs 
on quality improvement projects 
Overall, 55 percent of hospitals worked with QIOs on quality 
improvement projects.  Nineteen percent of hospitals worked on only 
infection projects, 10 percent of hospitals worked on only readmissions 
projects, and 26 percent worked on both. 
Of the hospitals that worked with QIOs, most formally participated by 
signing memorandums of understanding to work with QIOs at the start of 
the projects. CMS required QIOs to report on formally participating 
hospitals and evaluated those hospitals improvements throughout the 
project. However, CMS staff told us that CMS allowed informal 
participation from hospitals that did not officially sign memorandums of 
understanding to work on quality improvement projects.  We refer to all 
hospitals that worked with QIOs, formally and informally, as participating  
hospitals.  
Most participating hospitals attended QIOs meetings and used 
their written materials  
In 2013, the majority of participating hospitals attended most of QIOs  
meetings, which included in person meetings and Webinars.  Seventy-two 
percent of hospitals that participated in infection projects attended at least 
half of QIOs meetings, and 60 percent of hospitals that participated in 
readmissions projects attended at least half.  Fewer than 10 percent of 
participating hospitals attended all of QIOs meetings.  When participating 
hospitals attended few or no meetings, hospitals reported that limited 
hospital resources, such as staff and funding, most commonly influenced 
their infrequent attendance.   
Most participating hospitals used QIOs written materials, such as 
pamphlets, checklists, and protocols.  Eighty-two percent of hospitals 
participating in infection projects used these written materials, and  
70 percent of hospitals participating in readmissions projects used them.  
Almost half of participating hospitals received one-on-one onsite 
assistance for infection and readmissions projects, typically once or on a 
quarterly basis in 2013. 
 
 
QIOs Provide Support to More Than Half of Hospitals but Overlap With Other Quality Improvement Programs  
(OEI-01-12-00650)    9   
   
Participating hospitals in our sample most commonly reported 
that positive previous experiences prompted them to work 
with QIOs  
Participating hospitals positive previous experiences were a larger factor  
in their decisions to work with QIOs than any other factor, including 
QIOs expertise on quality improvement methods and access to 
comparative data.  See Chart 1 for the factor that most influenced 
hospitals decisions to participate in QIOs projects.  
Chart 1:  The Factor That Most Influenced Hospitals Decisions To 
Participate in Their QIOs Projects 
  Factor 
38% 
Positive p revious experience with  QIO 
26% 
 
17% 
QIOs  expertise on quality improvement  methods 
  15% 
  15% 
QIOs access  to  comparative data 
17% 
 
14% 
No fee to  work  with QIO 
  11% 
  7% 
Upcoming Medicare payment penalty* 
13% 
 
2% 
QIOs  ability  to  convene providers 
13% 
 
6% 
QIOs clinical  expertise 
  4% 
0% 
Recomm endation  from other hospital 
1% 
 
0%Percentage1  0o%f participa2ti0n%g hospital3s0 i%n our sam4p0le%  that   50%
identified the factor  as  most influencing  their decision  to  
 
work with   their QIO  on a:   
  Readmissions Project  Infection Project 
* For fiscal years beginning on or after October 1,  2012, Medicare reduced  payments to hospitals with excess 

readmissions (SSA   1886(q)).  

Source:  OIG analysis of data from hospital questionnaire, 2014. 

 
All participating hospitals in our sample reported receiving 
benefits by working with QIOs  
Participating hospitals reported receiving the most benefit by QIOs  
connecting hospitals with other hospitals working on similar projects, 
defining clinical measures for hospitals to track, providing comparative 
data reports, and explaining data reports.  Of those benefits, hospitals 
reported that QIOs comparative data reports most differentiated them  
QIOs Provide Support to More Than Half of Hospitals but Overlap With Other Quality Improvement Programs  
(OEI-01-12-00650)    10   
   
from other entities that conduct quality improvement activities. These 
reports showed each hospital where it ranked on infection and 
readmissions rates within its State.  
Although fewer participating hospitals reported receiving benefits from  
QIOs conducting gap analyses, providing onsite training, and providing 
information on Medicare policy, hospitals reported that these benefits also 
differentiated QIOs from other entities.  Gap analyses identify  
shortcomings in hospitals processes and plans for improving them.  See 
Charts 2, below, and 3, on the following page, for more information on 
benefits hospitals received from working with QIOs on infection and 
readmission projects. 
In addition to reporting specific benefits, nearly a third of participating 
hospitals offered positive feedback about QIOs in their responses to our 
questionnaire. These hospitals reported that QIOs were knowledgeable, 
responsive, and helpful. Five percent of participating hospitals provided 
negative feedback about QIOs, typically concerning lack of 
responsiveness from their QIOs. 
 
 
Chart 2:  Benefits Reported by Hospitals Working With QIOs on Infection 
Projects  
Percentage of  responding hospitals  that  
  reported the benefit differentiated the QIO 
from other quality improvement  entities  
Benefit 
 
Connect with hospital  working on similar projects  60% 
 
Provide comparative data reports  66% 
D efine clinical  measures to track  62% 
Explain data reports  65% 
 
Provide actionable quality improvement plans  62% 
 
Provide information on Medicare policy  65% 
  Connect with mentor  hospital  55% 
Connect with nonhospital health care providers  41% 
 
Conduct gap analysis  55% 
  
Provide onsite  training  63% 
  0  50  100  150  200 
Participating hospitals in our sample reporting: 
 
Some benefit   Great  benefit 
    Source:  OIG analysis of data from hospital questionnaire, 2014.  
   
QIOs Provide Support to More Than Half of Hospitals but Overlap With Other Quality Improvement Programs  
(OEI-01-12-00650)    11   
   
Chart 3:  Benefits Reported by Hospitals Working With QIOs on  
Readmissions Projects 
Percentage of  responding hospitals  that  
reported the benefit differentiated the QIO 
 
from other quality improvement  entities  
Benefit 
 
Provide comparative data reports  78% 
 
Connect  with  hospital working on similar projects  71% 
  Explain data reports  67% 
Define clinical  measures to track  65% 
 
Provide information on Medicare policy  66% 
 
Provide actionable quality improvement plans  53% 
Connect with nonho spital health care providers  61% 
Conduct gap analysis  63% 
 
Connect with mentor  hospital  56% 
 
Provide onsite  training  47% 
  0  50  100  150  200 
Participating hospitals  in our sample reporting: 
 
  Some benefit   Great  benefit 
 Source:  OIG analysis of data from hospital questionnaire, 2014. 
 
Eight out of ten participating hospitals also worked 
with other federally funded efforts on the same topics 
as QIOs  
Eighty-one percent of participating hospitals also worked to reduce 
readmissions and the same types of infections with federally funded 
efforts in 2013.  This includes 74 percent of participating hospitals that 
also worked with another CMS quality improvement effort, HENs, on 
those projects. A 2012 GAO report found overlap between QIOs and 
HENs and raised concerns about CMSs management of those programs.  
CMS agreed with GAOs recommendation to quickly address this overlap.  
CMS issued a memorandum to QIOs about HENs that recognized the 
potential risk of duplication of effort, in the absence of continuous 
coordination and communication.  It encouraged QIOs to coordinate with 
HENs through various methods, such as jointly offering training, notifying 
one another of new recruitment, and tracking hospitals that work on both 
efforts.32   
 
 ____________________________________________________________ 
32 CMS, Revised:  Coordination and Communication between the Hospital Engagement  
[Network], SDPS Memo Number 12-402-CO (January 3,  2013).  
QIOs Provide Support to More Than Half of Hospitals but Overlap With Other Quality Improvement Programs  
(OEI-01-12-00650)    12   
   
To learn more about the potential duplication that we identified through 
the hospital questionnaire, we analyzed CMS data to determine the 
overlap of CMSs quality improvement efforts at formally participating 
hospitals (i.e., hospitals that signed memorandums of understanding to 
work with their QIOs). To do so, we analyzed CMSs lists of hospitals 
that signed up to formally participate in QIOs projects, hospitals that 
work with HENs, and hospitals that participated in the CCTP.    
According to these data, 83 percent of formally participating hospitals 
worked on similar topics with at least one of these two other CMS quality 
improvement efforts.  Seventy-nine percent of formally participating 
hospitals worked with HENs, and 27 percent participated in the CCTP.   
CMS instructed QIOs to work with hospitals and help organize 
communities to apply to the CCTP, but provide ongoing assistance only to 
those that were not selected.33  See Chart 4 for the portion of formally 
participating hospitals that worked on other Federal efforts. 
Chart 4:  Portion of Formally Participating Hospitals That Worked on Other 
CMS Quality Improvement Efforts During the 10th Scope of Work  
 
 Source:  OIG analysis of CMS data, 2014. 
 
The QIOs we visited reported that they were aware of the potential for 
overlap with HENs. Staff at one QIO we visited stated that they attempted 
to avoid duplicating HENs efforts by focusing their catheter-associated 
urinary tract infection efforts on different units within the same hospital. 
When hospitals commented on Federal program overlap, the majority 
viewed it negatively.  One noted that there seems to be increasing 
redundancy in targeted improvement  efforts, particularly since the 
introduction of the HEN. Another remarked on the fragmented nature of 
all of the Federally funded programs focused on quality and patient 
____________________________________________________________ 
33  CMS, QIO 10th  Scope of Work,   C.8.1.C.1. 
QIOs Provide Support to More Than Half of Hospitals but Overlap With Other Quality Improvement Programs  
(OEI-01-12-00650)    13   
   
safety.  Alternatively, some hospitals noted that QIOs and HENs 
collaborate well and share resources, speakers, and expertise. 
Most participating hospitals also worked with non-
Federal entities on the same topics as QIOs 
Eighty-five percent of participating hospitals also worked with entities 
outside the Federal Government on infection and readmissions projects in 
2013. These entities included insurers, private entities, and hospital 
associations, as well as local and State government programs.   
See Table 2 on the following page for the types of entities that hospitals 
worked with on the same topics as QIOs. 
Table 2: Types of Entities That Participating Hospitals Worked With on the 
Same Topics as QIOs  
 
Entity   Hospital (#)   Hospital (%)  
 
Hospital Association   1,194   67%  
 
State / Local Government   686  39%  
 
Private Entity   638  36%  
 
Insurer   541  31%  
 
Other Government Contractor   155  9%  
      
Source:  OIG analysis of data from hospital questionnaire, 2014. 
Staff at the three QIOs we visited reported that they collaborated with both 
public and private entities on group meetings.  One QIO reported forming 
a formal partnership with its States Department of Health and its States 
Hospital Association, which received HEN funding.  Members of the 
partnership host meetings together and promote one anothers Webinars.  
One hospital reported that all of [its] interactions with the QIO on 
improvement projects [were] through participation in collaborative 
events. The three hospitals we visited, each of which worked with its 
QIO on infection projects, also worked with two or more non-Federal 
entities on infection projects. These entities included statewide patient 
safety collaboratives, private consulting groups, and hospital associations. 
About 10 percent of hospitals declined to work with QIOs when recruited 
by them.  Hospitals reported that limited resources and working with other 
entities on similar quality improvement projects influenced their decisions 
to decline. In fact, staff at one QIO we visited said they had difficulty 
recruiting hospitals for infection projects because many Federal, State, and 
local agencies were working on similar projects.     
QIOs Provide Support to More Than Half of Hospitals but Overlap With Other Quality Improvement Programs  
(OEI-01-12-00650)    14   
   
 
Data problems and timing of other CMS quality 
improvement efforts hampered QIOs ability to target 
eligible hospitals and avoid duplicating those efforts 
To identify hospitals eligible to work on certain infection topics, QIOs 
needed baseline infection rates from CMS.   
In the second half of 2011, CMS launched three quality improvement 
efforts:  QIOs 10th scope of work, HENs, and the CCTP.   These three 
efforts each had similar goals to reduce infection rates and hospital 
readmissions.  HENs and CCTPs began 5 and 4 months, respectively, into 
the 10th scope of work. 
QIOs reported problems in key CMS data for recruiting 
hospitals for infection and readmissions projects  
CMS did not require hospitals to report c-diff rates to CDCs infection rate 
database until January 2013, after QIOs recruitment period had concluded 
for that topic.34   Therefore, those data were largely incomplete and 
unavailable for QIOs to use to identify eligible hospitals.  The QIOs we 
visited implemented workarounds to identify eligible hospitals, including 
analyzing claims data, asking hospitals what their infection rates were, and 
getting data from the State departments of health.  See Chart 5 on the 
following page for a timeline of CMSs quality improvement efforts. 
Indeed, when we reviewed CMS policy memorandums issued to QIOs 
during the 10th scope of work, we found examples of QIOs concerns and 
confusion about recruitment for infection projects.35  
Furthermore, CMS could not provide us with lists of hospitals eligible to 
participate in infection projects. Without the lists, we could not determine 
the extent to which QIOs recruited hospitals most in need of 
improvement.   
Finally, CMS did provide QIOs with lists of ZIP Codes to identify 
communities for readmissions projects.  However, the three QIOs we 
visited described using other methodologies to recruit for readmissions 
projects.  In fact, CMS later redefined eligible hospitals as those that were 
part of any community interested in working on readmissions projects.36 
 ____________________________________________________________ 
34 76 Fed. Reg. 51476, 51631  (August 18, 2011). 

35 CMS, Questions and Answers Regarding the 10th  Scope of  Work, SDPS Memo 
 
Number 11-222-GN  (August 23, 2011); Questions and Answers  Regarding the  10th 
 
Scope of  Work, SDPS Memo Number  11-299-CO (October 21, 2011). 

36 CMS, Revised:  Questions and  Answers Regarding the 10th Scope of Work, SDPS 
 
Memo Number 12-041-GN, Q.486 (February 10, 2012). 
QIOs Provide Support to More Than Half of Hospitals but Overlap With Other Quality Improvement Programs  
(OEI-01-12-00650)    15   
   
 
Chart 5: Timeline of CMS Quality Improvement Efforts 
E ffort/Topic    CCTP awarded 
 
CCTP 

 
  HEN 

 
QIO  10th scope of work 

C-diff recruitment
 
   
Other infection project recruitment
  CDC reporting required 
Readmissions project recruitment
 
 
2011  2012  2013  2014 
 
        Overseen by the Center for Medicare & Medicaid  Innovation.

        Overseen by the Center for Clinical Standards and Quality.

 
   Source:  OIG review of CMS materials.
 
QIOs were already recruiting hospitals when CMS awarded 
HEN contracts and CCTP agreements 
CMS announced the HENs 5 months into the 10th scope of work.  HENs 
began recruiting hospitals after QIOs had already concluded their 
recruitment for some infection  topics.  Furthermore, CMS awarded the 
first round of CCTP agreements 4 months into the 10th scope of work and 
continued to select communities into 2013.  This timing would have made 
it difficult for QIOs to avoid duplicating the HEN and CCTP efforts.  See 
Chart 5 on the previous page for a timeline of CMSs quality improvement 
efforts. 
In fact, two of the QIOs we visited told us that CMS asked them to not 
duplicate HENs efforts even though CMS had not identified the HENs or 
the hospitals with which HENs were working.  Another QIO we visited 
had greater awareness of HENs at their launch because it was in an official 
partnership with an entity that received HEN funding.  That QIO also 
subcontracts for a HEN. 
 
 
 
 
 
 
 
 
   
QIOs Provide Support to More Than Half of Hospitals but Overlap With Other Quality Improvement Programs  
(OEI-01-12-00650)    16   
   
CONCLUSION AND RECOMMENDATIONS 
QIOs reached more than 50 percent of hospitals, and those hospitals 
valued working with QIOs. However, QIOs quality improvement 
projects overlapped efforts of other Federal, State, and private 
entities. Over 80 percent of hospitals that worked on quality improvement 
projects with QIOs in 2013 also worked with other federally funded 
quality improvement efforts on similar topics, raising questions of 
duplication among Federal efforts.  In addition, 85 percent of these 
hospitals also worked with non-Federal entities on similar topics. 
CMS funding for the QIOs 10th scope of work, HENs, and the CCTP  
totals about $1 billion to work on the same topics.37   With limited Federal 
resources, it is crucial to know the effectiveness of each effort.38   Although 
overlapping efforts may produce greater benefits together than one effort 
alone, overlap makes it difficult to attribute quality improvement to any 
one effort.  Knowing the effectiveness of each effort is key to effective 
management of CMSs quality improvement resources. 
Finally, the overlap among CMSs quality improvement efforts raises 
concerns about how well CMS coordinates those efforts.  It is important to 
ensure that CMS coordinate its efforts and resources to avoid duplication.  
Previous work by GAO identified the potential overlap among QIOs and 
other Federal efforts and raised concerns about CMSs coordination of its 
quality improvement efforts.  In December 2013, CMS consolidated 
oversight of its efforts by moving HENs under the Center for Clinical 
Standards and Quality, the same Center that oversees QIOs.39 Our findings 
underscore that overlap remains a concern. 
Therefore we recommend that CMS: 
 
 
 
____________________________________________________________ 
37 This amount includes CMS funding for the duration of each effort.
  
38 Peter Pronovost et al., Did  Hospital Engagement Networks Actually Improve Care?  

The New England Journal of Medicine, Volume  371, Number 8, August 21, 2014,  

pp. 691-693. 

39 CMS, Proposed Realignment of the Partnership for Patients Function from the Center 

for Medicare & Medicaid Innovation to the Center for Clinical Standards and  Quality 

(July 11, 2013).  The CCTP remains under the Center for Medicare & Medicaid 

Innovation.   We conducted the analysis for  this report before CMSs consolidation.  

QIOs Provide Support to More Than Half of Hospitals but Overlap With Other Quality Improvement Programs  
(OEI-01-12-00650)    17   
   
Take additional steps to coordinate, and reduce 
overlap between, the QIO program and CMSs other 
quality improvement efforts 
Reducing overlap among QIOs, HENs, and the CCTP could lead to better 
use of limited Federal funds and more  targeted assistance to hospitals in 
need of improvement.  CMSs consolidation of efforts under one Center 
was an important first step.  CMS should further coordinate efforts to 
ensure that they are complementary and not duplicative.  It could specify 
which hospitals each effort should target or focus each effort on a specific 
problem.  CMS could also consolidate the efforts themselves.  
Determine the relative contribution of each of its 
quality improvement efforts 
CMS should determine how each of its individual improvement efforts 
affects quality improvement.  We realize that each effort may be better at 
improving quality in different settings or uniquely contributing towards a 
larger goal.  However, identifying the relative contribution of each effort 
would help CMS to allocate its resources more efficiently.   
Furthermore, we acknowledge that attributing quality improvement to a 
single effort can be difficult and that improvement may unfold over a 
longer horizon than a single scope of work or project period.  However,  
CMS could consider intermediate metrics, such as the percent of poorly 
performing providers successfully recruited and retained through the 
duration of the project, provider attendance at meetings and training 
sessions, and provider feedback on the utility of Federal assistance.  
Finally, CMS should ensure that it has access to baseline data before using  
metrics to define hospital eligibility.    
 
 
 
   
QIOs Provide Support to More Than Half of Hospitals but Overlap With Other Quality Improvement Programs  
(OEI-01-12-00650)    18   
   
AGENCY RESPONSE AND OFFICE OF INSPECTOR GENERAL  
RESPONSE 
CMS concurred with both recommendations.   
Regarding the first recommendation, CMS stated that it will continue its 
ongoing efforts to reduce duplication.  It said that its Quality Council 
oversees and coordinates the QIO Program, the Partnership for Patients, 
and other quality improvement initiatives.  CMS noted that although these 
initiatives share similar goals, they avoid duplication by collaborating and 
using different methods to drive improvement.   
Regarding the second recommendation, CMS stated that it evaluated 
whether the QIO program achieved its aims for past scopes of work and 
will include intermediate metrics in its 11th scope of work. CMS also 
evaluated HENs. CMSs evaluations found that hospitals exhibited quality 
improvement; however, it could not attribute that improvement to QIOs or 
HENs. 
We support CMSs actions to continue to coordinate and evaluate its 
quality improvement initiatives.  OIG requests details on CMSs efforts 
and the results of those efforts in its final management decision. 
We made one change to the report based on CMSs technical comments. 
For the full text of CMSs comments, see Appendix C. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
QIOs Provide Support to More Than Half of Hospitals but Overlap With Other Quality Improvement Programs  
(OEI-01-12-00650)    19   
   
APPENDIX A 
Sampling Methodology  
We sampled from four mutually exclusive strata based on the CMS list of 
hospitals formally participating (i.e., hospitals that signed memorandums 
of understanding) in projects with QIOs during the 10th statement of work. 
This resulted in a sample of 410 hospitals; we sent those hospitals a 
questionnaire asking the extent to which and the ways in which hospitals 
participated in QIOs quality improvement projects.  See Table A1 below 
for the size and response rate for each stratum.  
Table A1:  Size and Response Rate, by  Stratum 
Hospitals  Hospitals  Hospitals  Response 
Stratum  (N)  Sampled (n)  Responded (#)  Rate 
Infection projects only  562  100  98  98% 
Readmissions projects only  486  100  92  92% 
Infection and readmissions projects  251  100  95  95% 
No projects  2,157  110  100  92% 
Total   3,456  410  385  94% 
 
   
QIOs Provide Support to More Than Half of Hospitals but Overlap With Other Quality Improvement Programs  
(OEI-01-12-00650)    20   
   
APPENDIX B 
 
Point Estimates and Confidence Intervals 
95-percent  95-percent  
Weighted   confidence limit (#)  confidence limit (%) 
Data element description   frequency   Lower  Upper   Percent   Lower  Upper  
QIO project participation 
Only infection projects  630.6   490.6   770.7   19.7  15.7  24.4 
Only readmissions projects  315.0   214.5   415.4   9.9  7.1  13.5 
Both infection and readmissions projects  824.3   659.8   988.8   25.8  21.0  31.2 
Participating hospitals  1,005.0   951.1   1,059.0   31.4  29.5  33.4 
Meeting attendance for QIO infection projects 
All   112.2   50.6  173.8   7.7  4.5  13.0 
Most  596.0   472.5   719.5   41.0  33.5  48.9 
Half  345.7   220.2   471.2   23.8  17.0  32.2 
Few  243.2   150.0   336.5   16.7  11.5  23.7 
None   39.2  0.0  92.1  2.7  0.7  9.8 
Unable to determine  118.6   41.4  195.7   8.1  4.3  14.9 
Meeting attendance for QIO readmission projects 
All   99.7  40.4  159.0   8.8  4.8  15.3 
Most  373.1   264.2   482.0   32.7  24.9  41.7 
Half  209.1   124.2   294.0   18.4  12.4  26.4 
Few  249.4   145.5   353.2   21.9  14.8  31.1 
None   44.1  2.6  85.6  3.9  1.5  9.6 
Unable to determine  163.9   76.3  251.5   14.4  8.6  23.1 
Frequency of QIOs onsite assistance for infection projects 
Weekly  - - - - - -
Monthly  43.6  17.7  69.5  3.0  1.6  5.5 
Quarterly  242.7   150.1   335.3   16.7  11.5  23.6 
Annually  312.9   223.5   402.3   21.5  16.1  28.1 
Never   765.0   596.0   933.9   52.6  44.5  60.6 
Unable to determine  90.7  32.3  149.2   6.2  3.3  11.5 
Frequency of QIOs onsite assistance for readmissions projects 
Weekly  - - - - - -
Monthly  48.4  25.3  71.5  4.2  2.6  6.9 
Quarterly  246.7   149.1   344.4   21.7  14.9  30.5 
Annually  216.7   120.8   312.5   19.0  12.5  27.9 
Never   494.8   363.3   626.3   43.4  34.5  52.8 
Unable to determine  132.7   60.7  204.6   11.6  6.8  19.2 
Use of QIOs' written materials for infection projects 
Did use  1,197.0   1,015.0   1,379.0   82.2  75.3  87.6 
Did not use  169.4   94.8  244.1   11.6  7.5  17.6 
Unsure   88.8  29.9  147.7   6.1  3.2  11.5 
Use of QIOs' written materials for readmissions projects 
Did use  792.5   632.9   952.2   69.6  60.3  77.5 
Did not use  215.5   131.3   299.7   18.9  12.9  26.8 
Unsure   131.2   52.4  210.0   11.5  6.4  19.8 
Overlap with other Federal efforts 
Overlap with HENs  1,302.0   1,117.0   1,486.0   73.5  66.3  79.7 
Overlap with any other Federal efforts  1,438.0   1,247.0   1,629.0   81.3  74.8  86.4 
Overlap with non-Federal efforts  
Overlap with hospital association  1,194.0   1,016.0   1,372.0   67.5  60.0  74.1 
Overlap with State/local government  686.3   536.6   835.9   38.8  31.8  46.3 
Overlap with private entity  637.6   502.7   772.4   36.0  29.4  43.2 
Overlap with insurer   541.1   408.7   673.5   30.6  24.2  37.7 
Overlap with government contractor   154.5   88.8  220.3   8.7  5.7  13.2 
Overlap with any other non-Federal efforts  1,505.0   1,315.0   1,695.0   85.0  78.5  89.8 
Response rate  
Overall weighted response rate   3197   3085   3309   93.2  89.1  95.8 
Infection project only stratum   550.8   512.8   547.5   98.0  93.1  99.4 
Readmissions project only stratum  447.1   425.1   469.2   92.9  86.7  96.4 
Infection and readmissions project strata   238  290.0   246.9   95.0  90.3  97.5 
No project stratum   1,961   1,852   2,070   91.7  85.0  95.6 
 
QIOs Provide Support to More Than Half of Hospitals but Overlap With Other Quality Improvement Programs  
(OEI-01-12-00650)    21  APPENDIXC 
Agency Comments 
{/fE. 
</c..rt-~Sf.JJ.VIC4.~
DEPARTMENT OF HEALTH & HUMAN SERVICES  Centers for Medicare & Medicaid Services 
"'>,, 
'4-lo'qq  Administrator 
Washington, DC 20201 
Date:  OCT 3 1 2014 
To: 	 Daniel R. Levinson 

Inspector General 

From: 	 Manlyn1 avenn~:~< 

Administrator 

Centers for MedU!are & Medicaid Services 

Subject: 	 OIG Draft Report: QIOs Work with a Substantial Number ofHospitals, However 
their Projects Overlap with Other Efforts, OEI-01-12-00650 
The Centers for Medicare & Medicaid Services (CMS) appreciates the opportunity to review and 
comment on the Office of the Inspector General's (OIG) draft report. CMS is committed to 
improving the quality ofhealth care for all Medicare beneficiaries and being a good steward of 
taxpayer dollars by continuously striving to maximize the effectiveness and efficiency of 
initiatives and services it oversees. The Quality Improvement Organization (QIO) Program is 
one of the largest federal programs dedicated to improving the effectiveness, efficiency, 
economy, and quality of services delivered to Medicare beneficiaries. The Partnership for 
Patients initiative includes the Hospital Engagement Networks (HENs) and the Community
based Care Transitions Program (CCTP) as well as numerous stakeholders, including physicians, 
nurses, hospitals, employers, patients and their advocates, and the federal and State governments. 
CMS takes pride in the fact that all participating hospitals in the selected sample reported 
receiving benefits from working with QIOs, as noted in the OIG draft report. The OIG also 
reported on feedback from hospitals stating that QIOs collaborated well with other quality 
improvement efforts. 
CMS has taken a holistic approach to improving the quality of health care for patients and 
families by implementing multiple initiatives with shared goals, but distinct activities. QIOs and 
the 'Partnership for Patients initiative, including the HENs and the CCTP, capitalize on their 
respective, distinct strengths. The Partnership for Patients initiative complements the QIOs to 
help provide a more comprehensive way of aligning quality improvement efforts and ensuring 
As 
implementation of quality improvement activities.  part of its stewardship of resources, CMS 
has taken steps to identifY and eliminate duplicative activities between the QIO Program and 
other quality initiatives in the Partnership for Patients. Since 2012, CMS has worked to 
collaborate, prevent duplication, and continuously monitor the efforts of HENs and QIOs, 
including developing clear plans to identifY respective accountabilities and arrangements to 
ertslire rio duplication of effort. The distinctive roles of CMS's quality initiatives are: 
 	 The QIOs worked with hospitals under the MedicarMunded roth Scope of Work to 
reduce hospital-acquired infections (HAis) and worked with communities to reduce 
hospital readmission. The QIOs have highly specialized expertise in data collection and 
QIOs Provide Support to More Than Half of Hospitals but Overlap With Other Quality Improvement Programs 
22 
(OEI-01-12-00650)   
   
   
QIOs Provide Support to More Than Half of Hospitals but Overlap With Other Quality Improvement Programs  
(OEI-01-12-00650)                   23   
   
  
   
QIOs Provide Support to More Than Half of Hospitals but Overlap With Other Quality Improvement Programs  
(OEI-01-12-00650)                   24   
   
   
QIOs Provide Support to More Than Half of Hospitals but Overlap With Other Quality Improvement Programs  
(OEI-01-12-00650)                   25   
   
ACKNOWLEDGMENTS 
This report was prepared under the direction of Joyce M. Greenleaf, 
Regional Inspector General for Evaluation and Inspections in the Boston 
regional office, and Kenneth R. Price and Russell W. Hereford, Deputy 
Regional Inspectors General. 
Ivan E. Troy served as the team leader for this study, and Alyson J. Cooper 
served as the lead analyst. Central office staff who provided support 
include Kevin Farber and Meghan Kearns.  
 
 
 
QIOs Provide Support to More Than Half of Hospitals but Overlap With Other Quality Improvement Programs  
(OEI-01-12-00650)    26   
   
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http://oig.hhs.gov  
 
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amended, is  to protect the integrity of the Department of  Health and Human Services  
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