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8 Technical Assistance for Quality Improvement
Pages 192-229

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From page 192...
... was entitled Improving Beneficiary Safety and Health Through Clinical Quality Improvement in the 7th SOW and Assisting Pro viders in Developing the Capacity for and Achieving Excellence in the 8th SOW. This chapter presents an overview of this task and reviews general policy issues, including how QIOs may choose the providers they will work with intensely (the "identified partici pants," who work in an "identified participant group")
From page 193...
... Fundamentally, QIOs provide technical assistance by the following means, among others: · detecting areas in need of improved performance; · helping identify the root causes of problems; · helping implement interventions and systems changes; · teaching process improvement methodologies and promoting best practices; · facilitating knowledge transfer; · reducing reporting burdens on providers; · collecting, aggregating, and analyzing data on performance measures; and · working with stakeholders to coordinate quality improvement efforts. RECRUITMENT OF IDENTIFIED PARTICIPANTS Identified participants are the providers with whom the QIOs work intensely on quality improvement projects.
From page 194...
... Readiness for Change When developing a strategy for the recruitment of identified participants, some QIOs look to the five categories derived from Rogers' theory on the diffusion of innovations. By this theory, "innovators" initiate the process by embracing new ideas.
From page 195...
... For example, two CEOs commented, "Diffusion of quality comes from good providers spreading the word," and "When you include high performers, you get more diffusion to other patients. You are also more likely to engage specialty providers." However, because CMS evaluates QIOs on the basis of the amount of increased improvement achieved (by calculation of the reduction in the failure rate)
From page 196...
... Telephone Interviews: Working with Low Performers When the QIO CEOs reacted to how a mandate to work only with the worst-performing providers would affect how they operate and what the likely outcomes would be, they stated that it would require more resources and would affect the diffusion of their quality improvement efforts statewide. The CEOs thought that providers might perceive the focus of the QIO program to be a return to weeding out "bad apples" rather than promoting quality.
From page 197...
... This method would be useful for evaluation purposes because it eliminates selection bias (participation by the most highly motivated providers) and allows the greatest range of providers to be involved with the QIO program.
From page 198...
... Identified participants work with collaboratives for 12 to 18 months. They come together in follow-up conferences.
From page 199...
... During the 8th SOW, requirements to work with underserved local populations are incorporated into part of the Physician Office Task. TECHNICAL ASSISTANCE DURING THE 7TH AND 8TH SOWS Over the last 35 years, the QIO program's priorities have evolved along with the environment of health care (see Chapter 1)
From page 200...
... Projects expanded to include provider settings, in addition to the hospital: nursing homes, physicians' offices, and home health agencies (CMS, 2002)
From page 201...
... The QIOs had to enlist at least 10 percent of the nursing homes in the state to serve as members of the identified participant group (CMS, 2002)
From page 202...
... The impacts of the various quality initiatives are discussed in Chapter 9. 8th SOW In the 8th SOW, QIOs work with two groups of identified participants, in addition to their work on statewide nursing home activities (CMS, 2005c)
From page 203...
... Additionally, for both groups, QIOs collect and monitor data on the retention of certified nursing assistants and aides for at least 90 percent of the identified participants. For the first group of identified participants, QIOs work with providers to improve upon the clinical quality of care for nursing home residents.
From page 204...
... , it encourages QIOs to work with as many of these providers as possible. TABLE 8.3 Minimum Numbers of Participants for Second Identified Participant Group in the Nursing Home Setting Number of Nursing Homes Minimum Number of in State or Jurisdiction Identified Participants <30 1 31­300 2 More than 300 3 SOURCE: CMS (2005c)
From page 205...
... as a primary tool for the collection of outcomes data in the home health care setting. OASIS includes publicly reported quality measures related to the demographics, the physical and mental health, and the health care utilization of each Medicare patient receiving home health care (see Table A.5 in Appendix A)
From page 206...
... 206 MEDICARE'S QUALITY IMPROVEMENT ORGANIZATION PROGRAM BOX 8.2 Clarifying the Definition for Intractable Pain Makes the Difference "A small hospital-based home health agency (HHA) in urban Indiana successfully used the Outcome-Based Quality Improvement (OBQI)
From page 207...
... Ten percent of the identified participants
From page 208...
... . These agencies may act as a substitute for one of the identified participants in the evaluation process if one of the original participants goes out of business or changes ownership.
From page 209...
... However, under the contract for the 8th SOW, Task 1c1 requires QIOs to also work with three groups of identified participants related to the defined strategies: the Appropriate Care Measure group, which focuses on clinical performance measurement; the Surgical Care Improvement Project group, which focuses on process im
From page 210...
... Additionally, Public Health Service hospitals and hospitals owned by Indian tribes may also be included under specific conditions. All identified participants in all groups (except for critical access hospitals of the Surgical Care Improvement Project group)
From page 211...
... (See Chapter 10 for discussion of evaluation of QIO performance.) Surgical Care Improvement Project Identified Participant Group The QIOs assist the Surgical Care Improvement Project group to standardize processes for the following conditions (see Table A.3c for measures related to some of these)
From page 212...
... Additionally, a QIO's state must have at least six critical access or rural prospective payment system hospitals for the QIO to work with an identified participant group. If this is not the case, the QIO must get approval from the Project Officer and Government Task Leader to perform this task.
From page 213...
... In the 7th SOW, the QIOs were required to work with at least 5 percent of the physicians in the state as identified participants. On average, the QIOs actually worked with about 7.5 percent of the eligible practitioners (Rollow, 2005)
From page 214...
... . As with other settings, the evaluation formulas and the criteria for the identified participant groups are more detailed and complex than those in the 7th SOW.
From page 215...
... The statewide work focuses on the promotion of quality initiatives, whereas the work with the identified participants focuses on the reliability of preventive care delivery and the effective management of chronic conditions. Additionally, the identified participants work on improving clinical performance through the use of health information and communications technologies and process redesign.
From page 216...
... All identified participants must complete office systems surveys at the baseline and undergo a remeasurement. To achieve success, the QIOs must help the identified participants achieve improvements in reporting, implementation of new care processes, and adoption of clinical information systems.
From page 217...
... CMS plans to work with the QIOs on developing methods for improving the dissemination of information and the implementation of registries. The QIOs will work with identified participants (physicians' practices or pharmacies)
From page 218...
... Option 3: Improving disease-specific therapy using integrated Medicare Part A, B, and D data This option focuses on physicians' practices that use electronic health records or electronic prescribing tools. It requires working with the identified participants for Task 1d1 who are using these technologies, as well as with others who are using the technologies but who are not working in the Task 1d1 identified participant group.
From page 219...
... . Telephone Interviews: Challenges In telephone interviews, many QIO CEOs mentioned difficulties with the design of interventions for the underserved population, including access versus quality; the resource-poor state of some providers; and the ability to track changes in populations whose providers bundled charges for tests into visits, such as the Indian Health Service.
From page 220...
... Intervention tools included key chains inscribed with the phrase `Dia · "In a rural area there might only be five or six Medicare admissions a month, so it is hard to break down rural facilities on an individual basis; we need 10 to 12 facilities to have adequate data." · "Trying to meet the needs of lower-scoring rural hospitals really adds to the QIOs' costs not only because of their needs but because of the distance required to go to serve their needs." 8th SOW In the 8th SOW, CMS integrated efforts to take a more communitybased approach to improve beneficiary health by incorporating underserved populations into Tasks 1a to 1d, by requiring the adequate representation of providers to underserved populations and, in many cases, in the selection of identified participants. Underserved populations are specifically addressed in Task 1d2 (CMS, 2005b)
From page 221...
... Independent of the QIO program, all Medicare managed care organizations must execute one national Quality Assessment and Performance Improvement (QAPI) project to improve health outcomes and beneficiary satisfaction.
From page 222...
... Five California M+COs participated in the pilot project. The participating plans contributed to the adaptation of the tool and shared their experiences with other M+COs at a meeting in December 2002 in Oakland, California.
From page 223...
... Additionally, the QIOSC helped develop and maintain a Nursing Home Information Clearinghouse, an Internet-based database of best practices, change concepts, interventions, and guidelines available to the QIOs and nursing homes. The data included findings from the literature, as well as the experiences of QIOs and nursing homes (CMS, 2004)
From page 224...
... http://www.minimental.com Home Health QIOSC In the 7th SOW, the Maryland-based QIO of the Delmarva Foundation for Medical Care served as the Home Health QIOSC as a result of a pilot study that it led during the 6th SOW. As with the Nursing Home QIOSC, the Home Health QIOSC offered general assistance as well as technical information, reports, and implementation materials to the QIOs.
From page 225...
... In the 8th SOW, the West Virginia Medical Institute (West Virginia's QIO) acts as the Home Health QIOSC.
From page 226...
... served as the Underserved/Rural QIOSC. This QIOSC provided support to the QIOs in a manner similar to that described above and collected a large scientific evidence base on disparities in health care quality.
From page 227...
... The following are some of the main themes of this chapter, which are reflected in the finding and conclusions presented in Chapter 2: · The activities involved under the broad term of technical assistance vary widely and include the implementation of interventions, the provision of support with public reporting, the provision of assistance with data collection and manipulation, and collaboration with stakeholders. · Recruitment of voluntary identified participants is largely left to the discretion of the QIO (aside from certain specific numeric or demographic requirements)
From page 228...
... 2005. Brief Report: National Nursing Home Improvement Collaborative Out comes Congress.
From page 229...
... 1998. Effect of local medical opinion leaders on quality of care for acute myocardial infarction: A ran domized controlled trial.


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