9th Scope of Work

Ninth Scope of Work Begins at IQH

IQH has been awarded the Centers for Medicare & Medicaid Services (CMS) Ninth Scope of Work contract that is primed to set the course for quality improvement efforts for the next three years in the state.

IQH is one of 41 contractors for 53 states and U. S. territories participating in Medicare's Quality Improvement Organization (QIO) Program that extends from Aug. 1, 2008, through July 31, 2011. The contract focuses on improving the quality and safety of health care services to Medicare beneficiaries.

The program builds on the administration's health care quality improvement initiatives and a growing evidence base about how to improve the quality and efficiency of health care delivery. It also implements several recommendations from the Institute of Medicine, the Government Accountability Office, and members of Congress about how the program can deliver maximum benefit to patients at the greatest value to the government. The new contracts provide additional tools for CMS and the QIOs themselves to track, monitor and report on the impact that QIOs have on the care provided in their states.

9th Scope of Work Theme Executive Summaries

Beneficiary Protection

Overview

Under the Medicare-funded "Ninth Scope of Work," a three-year work plan that begins August 1, 2008, QIOs will continue to carry out statutorily mandated review activities, such as:

Reviewing the quality of care provided to beneficiaries;
Reviewing beneficiary appeals of certain provider notices;
Reviewing potential anti-dumping cases; and
Implementing quality improvement activities as a result of case review activities.

Opportunity for Quality Improvement

Individual patient complaints and provider medical record reviews are important starting points for analysis of quality improvement needs among providers. In the 9th SOW, QIOs will be increasing their efforts to link case review activities to improvements in the quality of care, specifically by developing quality improvement activities focused on system-wide changes. QIOs will utilize all data related to case review activities to identify problems related to the quality of care and design quality improvement activities aimed at helping providers correct these problems. The QIOs will be responsible for collaborating with all pertinent CMS contractors to ensure that all available data are considered and to maximize opportunities for quality improvement.

QIO Activities

The activities involved in the Beneficiary Protection Theme will focus on nine tasks:

Case reviews
Quality improvement activities (QIAs)
Alternative dispute resolution (ADR)
Sanction activities
Physician acknowledgement monitoring
Collaboration with other CMS contractors
Promoting transparency through reporting
Quality data reporting
Communication (education and information)

In carrying out these activities, QIOs are required to ensure consistency and value and must adhere to CMS policies and procedures. This includes the QIO responsibility to refer cases to the Department of Health and Human Services' Office for Civil Rights for further investigation if the QIO finds that care is being compromised or denied due to discrimination on the basis of race, color, national origin, disability, or age.

In the 9th SOW, QIOs will now be required to use ADR techniques in appropriate beneficiary complaint cases for which there are no significant concerns about the quality of care provided. ADR options include mediation, facilitated resolution, and external resolution. Mediation involves a mediator in a face-to-face or telephone meeting. Facilitated resolution consists of a QIO facilitator interacting with all parties to generate a resolution or agreement, and does not typically involve a face-to-face meeting. External resolution occurs through direct communication between the provider and the complainant facilitated by the QIO, which follows up to ensure that direct communication occurred and no further review is needed.

With regard to confirmed quality of care concerns, QIOs must follow all CMS instructions. This includes allowing the provider an opportunity for discussion, imposing a corrective action plan where appropriate, and referring cases to the Office of Inspector General (OIG) when a QIO identifies a case in which the provider violates or fails to comply with any obligation in Section 1156(a) of the Social Security Act.

Each QIO must maintain a beneficiary hotline to provide callers with information concerning Medicare beneficiary rights and responsibilities, beneficiary protections, and the various QIO programs and initiatives. The helpline must be staffed during normal business hours with the capability to record calls received outside business hours.

In addition, QIOs must actively promote, and support hospitals in, submission of quality data for reporting and Annual Payment Update (APU) purposes. QIOs must have a basic understanding of all measures, deadlines for submission, and the impact on the APU. QIOs will offer educational and technical assistance to providers on the use of CMS systems and reporting tools such as CART, QualityNet, and the QIO Clinical Warehouse.

Finally, QIOs will continue to fulfill other responsibilities on a regular basis. These responsibilities include physician acknowledgement monitoring, whereby the QIOs ensure that hospitals have a physician acknowledgement statement on file for physicians billing for services provided in the hospital. The QIOs must also work with the Beneficiary Satisfaction Survey Contractor that is surveying beneficiaries regarding their satisfaction with the QIO complaint process. The QIO is responsible for providing complete and timely information to the Survey Contractor. Finally, QIOs must provide an annual public report of all medical service reviews, using a template provided by CMS.

Resources

CMS: http://www.cms.gov/BeneComplaintRespProg/

MedQIC: http://www.medqic.org (click on "Beneficiary Protection")

Patient Safety

Overview

QIO activities under the Patient Safety Theme will focus on six primary topics:

Reducing rates of health care-associated methicillin-resistant Staphylococcus aureus (MRSA) infections;
Reducing rates of pressure ulcers in nursing homes and hospitals;
Reducing rates of use of physical restraints in nursing homes;
Improving inpatient surgical safety and heart failure treatment in hospitals;
Improving drug safety; and
Providing quality improvement technical assistance to nursing homes in need.

Opportunity for Quality Improvement

The requirements of the Patient Safety Theme, also known as the CMS National Patient Safety Initiative (NPSI), are designed to address areas of patient harm for which there is evidence of how to improve safety by improving health care processes and systems. The Theme brings forward several components from the previous SOW (surgical care, heart failure, pressure ulcers and restraints in nursing homes, and drug safety), allowing QIOs to build on the progress they have made with providers over the past three years.

With the new SOW, however, the safety focus also pushes into new areas (MRSA, pressure ulcer prevention in hospitals, and QIO technical assistance for nursing homes in need), giving providers and QIOs the chance to broaden the scope of their patient safety-related improvement activities.

QIO Activities

QIO activities under the NPSI will support the development of an "all-teach, all-learn" community in action to meet the goals within each component of the Initiative. To that end, CMS is requesting that QIOs identify two to three individuals from each QIO to serve as National Quality Improvement Leaders. These individuals will serve as liaisons between QIO senior leadership and the work that is occurring at the patient care level in each state/jurisdiction. They will also liaise with health care executives in their respective states/jurisdictions to highlight the work occurring at the national level in their provider groups. The National Quality Improvement Leaders will come together up to three times per year to share practices that are proving to be successful at the local level.

QIOs will have a wealth of tools available to them to assist in reaching the final 28-month goals for specific quality measures. These include survey instruments geared toward leadership and/or patient safety processes in hospitals and nursing homes. Additionally, QIOs can draw upon successful tools that were utilized in the 8th SOW. It is expected that as successful tools and practices develop, the QIOs will share these with one another for implementation in other QIO communities.

QIOs may expand their local quality improvement communities by reaching out to potential patient safety partners and encouraging their participation to expand upon the momentum that will be created by the CMS NPSI.

Resources

Most recent version of 9th SOW: http;//www.cms.hhs.gov/QualityImprovementOrgs

MedQIC: http://www.medqic.org (Click on "hospital" or "nursing home" tabs for resources)

AHRQ: http://www.ahrq.gov (Resources available on clinical topics and drug therapy)

Hospital Compare: http://www.medicare.gov

Nursing Home Compare: http://www.medicare.gov

Prevention

Overview

The overall goal of the Prevention Theme is to improve the quality and frequency of preventive health care services in order to optimize beneficiary quality of life and health care efficiencies. The Prevention theme consists of three focus areas: Core Prevention, Diabetes Disparities, and Chronic Kidney Disease (CKD). The Core Prevention work builds on the QIO 8th SOW by focusing on the QIO ability to impact the rates of two cancer screenings (mammography and colorectal cancer CRC screening) and two immunizations (influenza and pneumococcal) among Medicare beneficiaries in each state/jurisdiction.

QIOs will work with a selected group of practices in their states/jurisdictions to accomplish the national tasks. Practices enrolled with a QIO to improve rates of mammography and CRC screenings and immunizations must have already implemented electronic health records (EHRs) certified by a certifying body recognized by the Secretary of Health and Human Services. Collaborating practices will work with their QIOs to implement care management processes, using their certified EHRs, that focus on breast cancer and CRC screening and influenza and pneumococcal vaccination.

Opportunity for Quality Improvement

QIO interventions that support health information technology (HIT) have the potential to improve screening rates through timely notification of providers and patients when a mammogram or CRC screening should be scheduled. Influenza and pneumococcal vaccination levels among adults 65 years of age and older remain well below the Healthy People 2010 objective of 90%. There is a need for more effective strategies for delivering vaccines to high-risk persons, their providers, and household contacts.

Published research reveals that racial/ethnic minority patients are generally less likely to receive routine medical services than white patients, with African Americans having fewer routine physician visits and more visits to the emergency room. Diabetes Self Management Education (DSME) is a proven intervention for allowing patients to control their disease by working with their health care provider.

QIO Activities

The primary activities involved in the national Prevention Theme will focus on nine tasks:

Recruiting participating practices;
Identifying the pool of non-participating practices;
Promoting care management processes for preventive services using EHRs;
Completing assessments of care processes;
Assisting with data submission;
Monitoring statewide rates (mammograms, CRC screens, influenza and pneumococcal immunizations);
Administering an assessment of care practices;
Producing an Annual Report of statewide trends, showing baselines and rates; and
Submitting plans to optimize performance at 18 months.

QIOs will recruit a pre-agreed-upon number of practices to participate, securing at least 80% of the targeted number by the end of Quarter 2. QIOs will also identify non-participating practices with EHR capability.

The QIO will educate each participating practice on using its EHR capabilities to improve rates of screenings and immunizations, using Doctor's Office Quality-Information Technology University (DOQ-IT University). At the end of the 18th month, at least 80% of the participating practices should report tracking of each preventive service for at least 75% of patients or patient encounters. This will be determined by an assessment of care practices.

Each participating practice will use its certified EHR to report breast cancer and CRC screening and influenza and pneumococcal immunization data directly to the CMS Clinical Data Warehouse. Reporting will begin during Quarter 3 and continue quarterly thereafter. Every two weeks, beginning in Quarter 3, the QIO will report to CMS the number of and rates for practices that are reporting data.

QIOs will assist both collaborating and comparison practices to complete an assessment of care processes by the end of Month 16. This will assess practices' EHR capabilities and current care processes related to breast and CRC screening and immunizations. Ninety percent of participating practices and 65% of comparison practices must complete this assessment.