Department of Health and Human Services 

OFFICE OF 

INSPECTOR GENERAL 

Q

O

UALITY IMPROVEMENT 

RGANIZATIONS PROVIDE 

SUPPORT TO MORE THAN 

HALF OF HOSPITAL BUT 

OVERLAP WITH OTHER 

PROGRAMS 

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 CMS’s 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 CMS’s 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 nonFederal 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 CMS’s 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 CMS’s 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 Prevention’s (CDC’s) 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 

I n fection Topic C M S-d e t e rm ine d E l i g ib i l i t y C r it er ia 

Central line-associated 

bloodstream infections 

Hospitals with a central line-associated bloodstream 

infection rate equal to or greater than 1.5 per 

1,000 central line days 

Catheter-associated urinary 

tract infections 

Any hospital 

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 hospital’s 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 CMS’s 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 oneon-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 

hospital’s 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-Pressreleases-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-releasesitems/2014-05-09.html on May 20, 2014.
 16 CMS’s 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-thepartnership/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 other’s 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/DemonstrationProjects/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 
 

 

 

QIOs Provide Support to More Than Half of Hospitals but Overlap With Other Quality Improvement Programs 

(OEI-01-12-00650) 6 

 

 

end of 2012.24 According to a Mathematica Policy Research report, threequarters 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 

QIO’s 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, Medicare’s 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, Medicare’s 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). 
 

 

 

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 CMS’s 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 
 

0% 10% 20% 30% 40% 50%

 

 

 

 

 

 

Factor 

Positive previous experience with QIO 

QIO’s expertise on quality improvement methods 

QIO’s access to comparative data 

No fee to work with QIO 

* Upcoming Medicare payment penalty 

QIO’s ability to convene providers 

QIO’s clinical expertise 

Recommendation from other hospital 

1% 

4% 

13% 

13% 

11% 

17% 

15% 

26% 

0% 

6% 

2% 

7% 

14% 

15% 

17% 

38% 

Percentage of participating hospitals in our sample that 

identified the factor as most influencing their decision to 

work with their QIO on a: 

Readmissions Project Infection Project 

QIOs Provide Support to More Than Half of Hospitals but Overlap With Other Quality Improvement Programs 

(OEI-01-12-00650) 10 

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 

* 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 
 

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 

 

Benefit 

Connect with hospital working on similar projects 60% 

Provide comparative data reports 66% 

Define 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. 

 

 

 

Percentage of responding hospitals that 

reported the benefit differentiated the QIO 

from other quality improvement entities 

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

 

Benefit 

Provide comparative data reports 

Connect with hospital working on similar projects 

Explain data reports 

Define clinical measures to track 

Provide information on Medicare policy 

Provide actionable quality improvement plans 

Connect with nonhospital health care providers 

Conduct gap analysis 

Connect with mentor hospital 

Provide onsite training 

78% 

71% 

67% 

65% 

66% 

53% 

61% 

63% 

56% 

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. 

 

 

QIOs Provide Support to More Than Half of Hospitals but Overlap With Other Quality Improvement Programs 

(OEI-01-12-00650) 12 

 

Percentage of responding hospitals that 

reported the benefit differentiated the QIO 

from other quality improvement entities 

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 CMS’s management of those programs. 

CMS agreed with GAO’s 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) 13 

To learn more about the potential duplication that we identified through 

the hospital questionnaire, we analyzed CMS data to determine the 

overlap of CMS’s 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 CMS’s 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. 
 

 

safety.” Alternatively, some hospitals noted that QIOs and HENs 

collaborate well and “share resources, speakers, and expertise.” 

Most participating hospitals also worked with nonFederal 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 State’s Department of Health and its State’s 

Hospital Association, which received HEN funding. Members of the 

partnership host meetings together and promote one another’s 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 
 

 

 

 

 

QIOs Provide Support to More Than Half of Hospitals but Overlap With Other Quality Improvement Programs 

(OEI-01-12-00650) 15 

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 CDC’s 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 CMS’s 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). 
 

 

 

Effort/Topic CCTP awarded 

CCTP
 

HEN
 

QIO 10th scope of work
 

C-diff recruitment
 

Other infection project recruitment
 

Readmissions project recruitment
 

CDC reporting required 

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.

Chart 5: Timeline of CMS Quality Improvement Efforts 

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 CMS’s 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 
 

QIOs Provide Support to More Than Half of Hospitals but Overlap With Other Quality Improvement Programs 

(OEI-01-12-00650) 17 

 

 

 

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 CMS’s quality improvement resources. 

Finally, the overlap among CMS’s 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 CMS’s 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 CMS’s consolidation. 
 

 

 

 

Take additional steps to coordinate, and reduce 

overlap between, the QIO program and CMS’s 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. CMS’s 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. CMS’s evaluations found that hospitals exhibited quality 

improvement; however, it could not attribute that improvement to QIOs or 

HENs. 

We support CMS’s actions to continue to coordinate and evaluate its 

quality improvement initiatives. OIG requests details on CMS’s efforts 

and the results of those efforts in its final management decision. 

We made one change to the report based on CMS’s technical comments. 

For the full text of CMS’s 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 

Stratum 

Hospitals 

(N) 

Hospitals 

Sampled (n) 

Hospitals 

Responded (#) 

Response 

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 
 

Weighted 

Data element description frequency 

QIO project participation 

Only infection projects 630.6 

Only readmissions projects 315.0 

Both infection and readmissions projects 824.3 

Participating hospitals 1,005.0 

Meeting attendance for QIO infection projects 

All 112.2 

95-percent 

confidence limit (#) 

Lower Upper 

490.6 770.7 

214.5 415.4 

659.8 988.8 

951.1 1,059.0 

50.6 173.8 

Percent 

19.7 

9.9 

25.8 

31.4 

7.7 

95-percent 

confidence limit (%) 

Lower Upper 

15.7 24.4 

7.1 13.5 

21.0 31.2 

29.5 33.4 

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 

Quarterly 242.7 

Annually 312.9 

Never 765.0 

-

17.7 

150.1 

223.5 

596.0 

-

69.5 

335.3 

402.3 

933.9 

-

3.0 

16.7 

21.5 

52.6 

-

1.6 

11.5 

16.1 

44.5 

-

5.5 

23.6 

28.1 

60.6 

Unable to determine 90.7 32.3 149.2 6.2 3.3 11.5 

Frequency of QIOs’ onsite assistance for readmissi

Weekly 

Monthly 

Quarterly 

Annually 

Never 

ons projects 

-

48.4 

246.7 

216.7 

494.8 

-

25.3 

149.1 

120.8 

363.3 

-

71.5 

344.4 

312.5 

626.3 

-

4.2 

21.7 

19.0 

43.4 

-

2.6 

14.9 

12.5 

34.5 

-

6.9 

30.5 

27.9 

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 

Overlap with any other Federal efforts 1,438.0 

Overlap with non-Federal efforts 

Overlap with hospital association 1,194.0 

Overlap with State/local government 686.3 

Overlap with private entity 637.6 

Overlap with insurer 541.1 

Overlap with government contractor 154.5 

Overlap with any other non-Federal efforts 1,505.0 

Response rate 

Overall weighted response rate 3197 

Infection project only stratum 550.8 

Readmissions project only stratum 447.1 

Infection and readmissions project strata 238 

No project stratum 1,961 

1,117.0 

1,247.0 

1,016.0 

536.6 

502.7 

408.7 

88.8 

1,315.0 

3085 

512.8 

425.1 

290.0 

1,852 

1,486.0 

1,629.0 

1,372.0 

835.9 

772.4 

673.5 

220.3 

1,695.0 

3309 

547.5 

469.2 

246.9 

2,070 

73.5 

81.3 

67.5 

38.8 

36.0 

30.6 

8.7 

85.0 

93.2 

98.0 

92.9 

95.0 

91.7 

66.3 

74.8 

60.0 

31.8 

29.4 

24.2 

5.7 

78.5 

89.1 

93.1 

86.7 

90.3 

85.0 

79.7 

86.4 

74.1 

46.3 

43.2 

37.7 

13.2 

89.8 

95.8 

99.4 

96.4 

97.5 

95.6 

APPENDIX B 

Point Estimates and Confidence Intervals 

QIOs Provide Support to More Than Half of Hospitals but Overlap With Other Quality Improvement Programs 

(OEI-01-12-00650) 21 
APPENDIXC 

Agency Comments 

</c..rt-~Sf.JJ.VIC4.~ {/fE. 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 Communitybased 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 

implementation of quality improvement activities. As 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 

(OEI-01-12-00650) 22 
 

 

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 
 

Office of Inspector General

http://oig.hhs.gov 

The mission of the Office of Inspector General (OIG), as mandated by Public Law 95-452, as 

amended, is to protect the integrity of the Department of Health and Human Services 

(HHS) programs, as well as the health and welfare of beneficiaries served by those 

programs. This statutory mission is carried out through a nationwide network of audits, 

investigations, and inspections conducted by the following operating components: 

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audits with its own audit resources or by overseeing audit work done by others. Audits 

examine the performance of HHS programs and/or its grantees and contractors in carrying 

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The Office of Investigations (OI) conducts criminal, civil, and administrative investigations 

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The Office of Counsel to the Inspector General (OCIG) provides general legal services to 

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