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Index A American Medical Association, 286, 355 Annual Medical Services Review Reports, AARP, 201 288, 289292 Access to care Assessment of Peer Review Organization current inequities, 2021 program performance, 45, 136137 Medicare goals, 39 Assessment of QIO program Accountability challenges, 3639, 5556, 58 for data collection, 14, 122 contextual factors, 38, 60, 61 National Quality Coordination Board, contract performance evaluations and, 84, 85 10, 7677, 136 QIO boards, 71, 111, 132 cost-effectiveness evaluations, 17, 135 shared, 88 data sources for, 146159 Activities of daily living, Medicare demonstrated competency, 52 population characteristics, 21 education and communications Acute care performance measures, 86 interventions, 283, 288 for physician offices, 394395 funding decisions and, 139140 AdvanceMed, 341 funding for, 1718, 135 Advisory Council for Health Care Quality, goals of, 121 84 historical development, 34 Agency for Healthcare Research and home health technical assistance, 266268 Quality, 39, 86, 91, 92, 98, 134, 148 Hospital Payment Monitoring Program, recommendations for, 16, 128 314318 Ambulatory care performance measures, 86 hospital technical assistance, 268269, Ambulatory care Quality Alliance, 65, 86, 286287 103 identifying sources of improvement in American Association of Medical Colleges, quality of care, 5, 17, 5759, 66, 79, 286 134, 137, 238239 American Health Quality Association, 28, IOM methodology, 34, 2729, 33, 38 147, 148, 149, 156, 251 39, 143, 145159 American Hospital Association, 48, 286 levels of evaluation, 17, 134137 501

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502 INDEX nursing home technical assistance, 264 member expertise and affiliations, 6, 266 166168 performance classifications, 5, 357 member selection, 165, 169 physician practice technical assistance, participation in QIO evaluations, 136 269271 performance evaluation, 13, 169 progress toward goals and, 135 recommendations for, 1213, 110112 protection functions, 310311 size, 166 provider satisfaction, 273275 standing committees, 6, 166 QIO board performance, 6 strategic planning role, 6, 72 QIO Support Centers evaluation, 246, term limits, 166 357 transparency of membership and recommendations for, 1618, 134138 operations, 6, 13, 71, 111112, 190 research needs, 104105 Breakthrough Series collaborative, 198, scope, 2223, 38, 55, 137 246247 selection bias in, 277 Breast cancer, 45, 48, 51. See also shortcomings, 4, 910, 277, 356357, Mammography 359 Bronson Methodist Hospital, 240 study designs, 138, 145146, 466472 technical assistance performance, 257 272, 277 C See also Oversight of QIO program Assisting Providers in Developing the Cancer screening, 270. See also Mammography Capacity for Achieving Excellence, 192. See also Technical assistance Capability Enhancement Plan, 171 Asthma, 107, 396 Cardiovascular health, 44, 235. See also Heart failure; Myocardial infarction Atrial fibrillation, 236, 237 Award Fee Plan, 350 quality of care measures, 395 Case-control study designs, 467468 Case Review Information System, 339 B Case reviews and appeals Annual Medical Services Review Baldrige criteria, 64, 162, 239240 Reports, 288 Benefits Improvement and Protection Act, antidumping violations, 300 179180 beneficiary satisfaction, 320 Best practices, 109, 177. See also BIPA reviews, 310 Knowledge transfer case management, 298, 308 Best Practices Methods Special Study, 248 categories of case review, 300301, 322 249 change in diagnostic-related group, 301 BIPA reviews, 115, 183, 310 CMS monitoring, 339 Boards, QIO conflict of interest restrictions, 73 accountability, 6, 71, 111, 132 contracting for, 8, 116 compensation, 13, 169, 190 cost-effectiveness, 8, 6869, 116 conflict of interest restrictions, 7, 73 diagnostic-related group validation, 302 consumer representation, 6, 70, 110, early scope of work contracts, 4142 165166 fast track appeals, 300301, 309 diversity of health expertise on, 71, 110 historical development of Medicare 111, 190 quality assessment programs, 43, 50, financial oversight functions, 6, 72 297, 298, 322 functions, 165 hospital-issued notices of non-coverage, meeting frequency, 166 300, 303 member development and assessment, local circumstances and, 68, 161 71, 111

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INDEX 503 notices of discharge and Medicare structure of QIO program in, 325328 appeal rights, 300, 303 uses of QIO data, 123124 organizational capacity for, 169170 See also Oversight of QIO program; patterns and trends, 116 Quality Improvement Organization problem identification in, 116117 program process, 298, 303307 Certification in quality improvement, 64, provider perceptions, 68, 322323 162 provider profiling activities, 307 Certified Professional in Healthcare Quality, QIO performance evaluation, 310311 64 quality improvement and, 318319 Chief executive officers' perceptions and quality reviews, 302 opinions range of outcomes, 305308 of beneficiary education activities, 288 recommendations for QIOs, 89, 13, 293 1718, 112, 115117, 138, 139 of case reviews, 68 referral sources, 298 of CMS data collection and processing, role of QIO, 7, 8, 6869, 297, 298 343345 sanctions, 307 of collaboratives, 198 types of reviews, 301303. See also of contract recompetition, 346347 Diagnosticrelated coding groups; data collection, 151154 Utilization reviews of Hospital Payment Monitoring utilization reviews, 302 Program, 321322 See also Complaint investigation and knowledge transfers, 251 resolution organizational relationship concerns, Cataract surgery, 300, 323 355356 Center for Healthcare Quality, 226227 of public reporting, 283285 Centers for Medicare and Medicaid Services of QIO Support Centers, 175179, 247, (CMS), structure and functions 349350 access to QIO data, 147, 154, 156, 172 of recruitment of providers, 67, 107, 173 109110, 195, 196 administrative office, 325 of staff, 64 Administrator's Quality Council, 78 Chronic illness Contracts Office, 325, 326327 among Medicare beneficiaries, 2, 21, health care system relationships, 103 129 knowledge transfers to QIOs, 249 collaborative intervention for quality National Quality Coordination Board improvement, 243 and, 89, 90, 91, 93, 100 performance measures, 387, 388, 395 national system for measurement and 397 performance and, 27 transitions in care, 2 Program Office, 325, 326 Claims data, recommendations for, 14, 121 QIO and End-Stage Renal Disease Clarification letters, 334 Steering Committee, 325326 Clinical Data Abstraction Centers, 44, 125, QIO perceptions of, 326, 327, 330, 331, 184, 312, 341343 332, 334, 336, 348 Clinical practice guidelines, 232233 QIO performance evaluation Clinton Medical Clinic, 213 methodology, 466472 CMS. See Centers for Medicare and quality improvement efforts, 2, 9192, Medicaid Services, structure and 103 functions recommendations for, 1117, 105106, CMS Abstraction and Reporting Tool, 339 109, 110, 121122, 126128 341 regional offices, 327328 Cochrane Database of Systematic Reviews, staff characteristics, 65 148

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504 INDEX Collaboration Comprehensive measurement, 88 current practice in QIOs, 22, 64, 65 Conditions of Participation, 22, 107 Group Award Fee, 350 Confidentiality knowledge transfer and, 243, 246247 beneficiary access to complaint leadership for, 198 outcomes, 124125, 297 model for quality improvement, 240, data sharing restrictions, 7, 1314, 74, 241243, 252 121, 124125, 188 national resource teams for, 133 in data submitted for QIO research, 149, pressures for competition, 60 158 recommendations for, 14, 106, 127 future challenges, 124 strategies for quality improvement, 35 as obstacle to technical assistance, 173 36 public perceptions, 124 for technical assistance, one-on-one QIO performance evaluation and, 29, consulting vs., 197198 74 Colorado Foundation for Medical Care, recommendations, 1314, 121 133, 225226 Conflict of interest restrictions Committee on Redesigning Health Insurance beneficiary protection and, 8, 73 Performance Measures, Payment, and on QIO contracting, 7, 73, 141, 171 Performance Improvement Programs, QIO data auditing and, 125126 1, 1920, 2324, 27, 38, 145 rationale, 73, 171 Competition for QIO contracts, 345347 recommendations, 18, 139 case review, 8 shortcomings of current system, 73, 141, diffusion of innovation and knowledge 171 and, 60, 245, 347. See also Consumer Advisory Council, 70, 169, 287, Knowledge transfer 288 NQCB implementation and, 9496, 100 Consumer Assessment of Healthcare recommendations for, 15, 127 Providers and Systems, 86, 355, shortcomings of current system, 7273 389 strategies for improving, 6, 131 Consumer Assessment of Health Plans Support Center contracts, 133 Survey, 185 See also Contracting Consumers and beneficiaries Complaint investigation and resolution access to QIO data, 124125, 172 beneficiary perception and knowledge, 8, confidentiality of medical data, 124 114 data gathering for QIO program case review requirements, 300 evaluation, 156 complainant access to outcomes of, 297 intervention to increase awareness of contracting for, 13, 112, 113114 rights, 8, 279 costs, 322 knowledge transfers, 250251 data management, 14, 121, 124125, perceptions of case review experiences, 297 320 historical development of QIO program, as primary client in complaint review, 8, 50 114 outcomes, 69, 319, 320 protection function of QIO. See Case patterns, 69, 113 reviews and appeals QIO role, 7 QIO board representation, 6, 12, 70, recommendations for QIOs, 13, 1718, 110111, 165166, 168 112115, 138, 139 QIO program evaluation methodology, role of QIO, 22, 297 28 shortcomings of current system, 8 quality improvement activities and, 40, volume, 319, 320 50, 108 See also Case reviews and appeals uses of QIO data, 123

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INDEX 505 See also Complaint investigation and subcontracting, 52, 170171 resolution; Educational and support contracts, 10, 16, 74, 77, 128, communication interventions; Public 184185, 353, 357 reporting on performance See also Competition for QIO contracts; Continuous quality improvement, 44 Core contract; Scopes of work recommendations for QIO management, Cooperative Cardiovascular Project, 44, 16, 128 238, 248 Contract Officers, 16, 75, 128, 327 Coordination of care Contracting QIO strategic planning and, 9, 78 Award Fee Plan, 350 recommendations for QIO, 12, 106 for beneficiary protection activities, 8, See also Transitions, care in 13, 112, 113114, 116, 139, 170 Core contract characteristics of contracting finances, 1718, 69, 138139, 180183, organizations, 162, 190 190 clarification letters, 334 historical development, 4647 CMS oversight, 326327 length of, 15, 127 conflict of interest restrictions, 7, 18, 73, NQCB implementation and, 100 139, 141, 171 performance evaluation, 17, 134 contract management, 76, 131132, performance periods, 15, 127 133134 QIO oversight, 74 contract rounds, 265, 266, 268, 270, recommendations for, 14, 1516, 126, 278, 348 127128 current system, 21, 190 selection criteria, 15 for data collection and management, 96 strategies for improving competition, 97, 341 9495 demonstrated capacity for case review, subcontracting, 171 169170 timetable, 1516, 77, 128 funding allocation, 52, 6970 Corporate Nursing Home Collaboratives, knowledge transfer considerations, 15, 133 127 Cost of care length of contracts, 11, 15, 7778, 132, case review effects, 69 347, 349, 358 government spending, 62 noncompetitive renewal, 259, 260261, historical development of Medicare 345346, 358 quality assessment programs, 41, 42 NQCB implementation and, 9091, 93 Medicare spending, 2, 21, 129 96, 100 payment errors, 116 oversight of QIO activities, 10, 7677, quality of care and, 20 345347, 348350, 356357 Costs of QIO program and services physician-access or physician case reviews, 6869, 116 sponsorship requirements, 110, 112, clinical data abstraction, 341342 161162 complaint investigation and resolution, policy direction and, 351352 322 for program evaluation, 136 cost-effectiveness, 17, 135 QIO Support Centers, 16, 128, 133 education and communications activities, 134, 349350 288, 293 recommendations for, 1416, 126, 127 eighth SOW, 51, 179 128 funding, 1718, 6970, 138141, 179 special study solicitations, 183184 180 staff characteristics of contracting Peer Review Organization program organizations, 163164 budget, 43 strategies for improving, 131132 program evaluation, 17

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506 INDEX public reporting, 287 Delmarva Foundation for Medical Care, recommendations for, 17, 18 205, 224225 special study and support contract Demographic variation in quality of care, 5, spending, 357 2021, 57, 83 technical assistance, 6263 Department of Health and Human Services, Crossover studies, 470 U.S., 19, 69, 286, 351352 Crossing the Quality Chasm: A New Health confidentiality rules, 172 System for the 21st Century, 1920 recommendations for, 11, 1314, 1718, Cultural Competency Organizational 105106, 121122, 134, 135, 138 Assessment, 222223 139 Depression, 107 quality of care measures, 396 D Diabetes, 5, 45, 48, 49, 107, 213, 216, 233, 235, 270, 271 Dashboard section of QIONet, 75, 154, quality of care measures, 395 262, 329, 337338 Diagnostic-related coding groups Data collection monitoring, 312 accountability, 14, 122 review of changes in, 301 aggregation, 14, 97, 121 validation, 301, 302, 311 auditing, 97, 125126 Diffusion of innovation theory, 244. See in care transitions, 129130 also Knowledge transfer CMS activities, 341343 Doctor's Office QualityInformation confidentiality issues, 7, 1314, 74, 121, Technology, 52, 107, 184, 215, 343 124125, 149, 158, 188 DynKePRO, 341 diagnostic-related group validation, 301, 302, 311 historical development of QIO program, E 49 home health agency outcomes, 205 Early adopters, 67, 107, 109110, 194 infrastructure support, 26 Educational and communication oversight, 74, 7576 interventions, 144 QIO program evaluation methodology, CEO perceptions of, 288293 2729, 33, 3839, 146159 consumer utilization of information sites, for quality improvement, 122123 280282, 295 real-time, 75, 89 current performance, 8, 295 recommendations for, 11, 1314, 106, evaluation of QIO performance, 283, 288 121126 funding, 293 scopes of work evolution, 44 goals, 279 staff and CEO interviews, 151154, 155, historical development of Medicare 157 quality improvement programs, 39, technical assistance and, 7, 15, 9697, 48, 50 106107, 123, 130 importance of, 108 timeliness, 10, 122, 342345, 358 nursing home interventions, 279280 users of provider performance data, QIO spending, 288, 293 123124 QIO Support Center activities, 177, validation activities, 14, 97, 122, 126 293295 web-based, 149150 QIO program, 7, 67 See also Information technology; recommendations for QIOs, 12, 106 Performance measurement scope of, 279280, 287288 Data Warehouse, QIO, 125 telephone help lines, 280, 287288 Delirium interventions, 223224 See also Public reporting on performance

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INDEX 507 Effectiveness of care service delivery to underserved goals for health care system, 24 populations, 272 measurement challenges, 5 subcontracting in, 171172 program evaluation, 17, 135 technical assistance evaluation Efficiency of care methodology, 259264, 410429 goals for health care system, 24 technical assistance in, 66, 70, 192, 200, measurement, 84 202204, 208, 209218, 220, 227 Eighth SOW 228 Award Fee Plan, 350 transformational change goals, 352 beneficiary protection activities, 112, use of data from, for QIO program 309, 310311 analysis, 2829, 30, 146, 157158 clinical data abstraction, 342 Electronic health records, 21, 26, 76, 107, collaboration incentives, 5960, 64 120, 123 complexity, 76 Emergency Medical Treatment and Labor conflict of interest restrictions, 73 Act, 300, 301 contract competition, 72, 77 End-stage renal disease, 86 contract management, 7778 quality of care measures, 395 contractor concerns, 352353 End-Stage Renal Disease Networks, 22, 215 core contract, 182183 Equitable care delayed release, 10, 77, 132, 351352 goals for health care system, 24 deliverables, 430433 measurement, 84 distinguishing features, 78, 5152, 162 Evidence-based practice, 22 education and communication activities, Experimental Medical Care Review 67, 294295 Organizations, 39 funding, 69, 70, 139, 179 home health agency technical assistance, 267268 F Hospital Payment Monitoring Program, Failure rate, 193 315318 hospital technical assistance, 269 Fast track appeals, 300301, 309 improvement outcomes, 5758 Federation of American Hospitals, 286 Fee-for-service contracts, 165166, 311 information technology in, 107 knowledge transfer in, 130131, 250 Feedback on provider performance, 14, 121, managed care organization technical 234, 236 Financial management assistance, 272 nursing home technical assistance, 265 BIPA reviews, 183 266 conflict of interest restrictions, 18, 73, 139, 141 perceptions of CMS management in, 65 performance evaluation methodology, core contract finances, 180183 259261, 265266, 267268, 269, Hospital Payment Monitoring Program, 311, 320321 270271, 275276, 277 population health initiatives, 98 improper payments in Medicare, 311 private practice technical assistance, 312 non-CMS revenues for QIOs, 185186 270271 program evaluation findings, 18, 139 Peer Review Organization program program priorities in, 9, 129, 352 budget, 43 protection function of QIO, 7, 22 providerQIO relationships, 113 provider satisfaction, 275276 QIO board function, 72 public reporting requirements, 285 QIO spending and performance improvement, 265, 266, 268, 270, QIO Support Centers, 173175 272, 278

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508 INDEX QIO statewide investments, 137, 181182 public reporting on performance, 50 special studies, 184 QIO effects on quality of care in, 57 support contracts, 184185 QIO expenditures, 181, 182 support for program evaluations, 17, 135 quality of care measures, 387 See also Costs of QIO program and seventh SOW performance evaluation, services 404405 Fistula First, 354 technical assistance to, 205208, 224 Florida Medical Quality Assurance, Inc., 225, 266268 219 Home Health Compare, 86, 280 Formative evaluation, 45 Hospital Compare, 280, 286 Freedom of Information Act, 172 Hospital Payment Monitoring Program, 251 CEO perceptions, 321322 CMS expenditures, 322 G effects, 320321, 323 QIO performance evaluation, 314318 Governance of QIOs. See Boards, QIO; QIO Support Center, 314 Management of QIOs; Oversight of reports, 312314 QIO program role of, 50, 298, 311312, 315 Government Task Leaders, 16, 76, 128, screening procedures, 312 133, 178179, 246, 331332, 355 Hospital Quality Alliance, 65, 86, 103, 356 285286 Grijalva reviews, 301, 310 Hospitals categories of case review, 300, 301 H critical access system hospitals, 212 eighth SOW performance evaluation, Health Care Excel, 205 418423 Health care facilities, 161, 171 evidence of quality improvement, 57 Health Care Financing Administration, 43, notices of non-coverage, 300, 303 4445, 48, 136137 performance data, 341343 Health Care Quality Improvement Initiative, prospective payment hospitals, 208211 43, 44, 241 public reporting on performance, 50, Health Insurance Portability and 285287 Accountability Act, 14, 74, 121 QIO effects on quality of care in, 57, Health Plan Employer Data and 236238 Information Set, 86 QIO expenditures, 181, 182 Health Services Advisory Group, 202, 294 quality of care measures, 389393 295, 355 rural, 212213 HealthShare, 97 seventh SOW performance evaluation, Healthy People 2010, 135 406407 Healthy People 2010 Partnership for Heart technical assistance to, 208213, 225 Disease and Stroke, 226 226, 227, 268269 Heart failure, 48, 49, 107, 225226, 236, timeliness of CMS data collection, 344 237 Human factors model for quality quality of care measures, 392, 396 improvement, 240, 241 Hemodialysis, 51 Home health agencies eighth SOW performance evaluation, I 415419 Identified participants, 192 evolution of quality improvement efforts, definition, 193 48, 49 in eighth SOW, 203204, 210212, performance data, 341 215, 227228

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INDEX 509 impact of QIO interventions with, 272 J 273 recruitment, 193197 Joint Commission on Accreditation of Immunizations, 49, 51, 98, 207, 213, 216, Healthcare Organizations, 39, 48, 268, 271, 354 50, 107, 286, 342, 355 Implicit review, 40 Improving Beneficiary Safety and Health Through Clinical Quality K Improvement, 192. See also Knowledge transfer Technical assistance barriers to, 60, 245, 347 Indian Health Service, 62 with beneficiaries, 250251 Individual-level measurement, 88 CMS to QIO, 249 Infectious disease, 49, 225226, 242 collaborative model for quality Information technology improvement and, 243, 246247 for CMS public reporting function, 75 conditions for, 244245 76 definition and characteristics, 243 CMS systems and tools, 337341 diffusion of innovation theory, 244 implementation resources, 107108 early adopters as preferred recipients of infrastructure, 26 technical assistance and, 194 QIO oversight, 7576 evidence base, 244245, 252 QIO programs to promote, 52, 107 local circumstances and, 248249 recommendations for, 12, 106 mechanisms, 5960 support contracts, 185 participants and pathways, 243, 245 utilization by providers, 21, 26 payment incentives and, 244245 Innovation, 86 QIO Support Centers in, 59, 134, 246 diffusion of innovation theory, 247 244 QIO to provider, 249250 early adopters as preferred recipients of QIO to QIO, 247249, 251 technical assistance, 67, 107, 109 recommendations for, 15, 16, 127, 128 110, 194 role in quality improvement, 243244 QIO Support Centers and, 178 strategies for improving, 130131 Institute for Clinical Systems Integration, technical assistance effects, 144 93 Institute for Healthcare Improvement, 93, 99, 198, 246247, 354 L Institute of Medicine, 1, 34, 19, 22, 37, 4243, 82, 136137 Lean principles, 64, 240, 241 QIO performance analysis, 262272, Leapfrog Group, 86 387397 Literature review for QIO studies, 148149 Insurance, health Local circumstances current population coverage, 21, 83 case review and, 40, 68, 161 in health care system quality knowledge transfer and, 130131, 248 improvement, 25 249 reform goals, 24 National Quality Coordination Board International comparison, quality of care, and, 86 21 QIO Support Center sensitivity to, 177 International Standards Organization 9000, technical assistance projects and, 198 64, 240, 241 199, 227 Iowa Foundation for Medical Care, 226, Long-term care performance measures, 86, 294, 336, 337 397 Longitudinal measurement, 88, 124 Lumetra, 223, 226, 227, 308309

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510 INDEX M quality assessment activities, historical evolution of, 3536, 37, 3948 Mammography, 5, 49, 213, 216, 271 quality improvement efforts, 103 Managed care organizations quality of care trends, 102 categories of case review, 300301 spending, 2, 21, 129 current quality of care, 5 telephone help lines, 280, 287288, 295 notices of discharge and Medicare Medicare, Medicaid, and SCHIP Benefits appeal rights, 300 Improvement and Protection Act, peer review organization and, 41 115, 182183, 310 QIO board representation, 165166 Medicare + Choice/Medicare Advantage, 11, quality improvement in, 57 40, 41, 52, 66, 69, 106, 215, 217, quality of care case reviews, 302 223, 272 technical assistance to, 221223, 272 fast track appeals, 300301 Management of QIOs QIO Support Center, 227 familiarity with quality improvement seventh SOW performance evaluation, methodologies, 64, 241 408409 leadership qualities, 164165 Medicare Payment Advisory Commission, 38 National Quality Coordination Board Medicare Peer Review Organization and, 90100 Evaluation Plan, 4445 program priorities, 9, 14, 36, 129, 199 Medicare Prescription Drug, Improvement, 200, 352, 358 and Modernization Act (2003), 1, 19, quality improvement outcomes and, 59 23, 66, 83, 94, 115, 215, 221, 286, scopes of work revisions and, 134 342 strategic planning, 9, 72, 74, 7879 Medicare Quality Improvement See also Boards, QIO; Chief executive Community, 174, 249, 294, 335336 officers' perceptions and opinions Medicare Trust Funds, 40, 52 Mediation, 114, 297, 320 QIO funding, 69 historical development of QIO program, role of Hospital Payment Monitoring 50 Program, 50, 298, 311 indicators for, 307308 role of QIO program, 7, 22 Medicaid, 25, 39, 62, 91 MedQIC. See Medicare Quality Medical Care Evaluation Studies, 40 Improvement Community Medical chart abstraction Memos and letters, 334 assessment, 116 MetaStar, 202 auditing, 125126 Myocardial infarction, 5, 45, 48, 49, 225 costs, 342 226, 236, 237 data sharing, 1314, 121 quality of care measures, 391392 future of, 76 See also Clinical Data Abstraction Centers N Medicare, 62, 91 beneficiary characteristics, 2, 21, 129 National Center for Health Services categories of case review, 300 Research, 39 coverage, 21 National Committee for Quality Assurance, evidence of quality improvement, 5661, 50, 86, 355 79 National Healthcare Quality Report, 135 in health care system quality National Nursing Home Collaborative, 202 improvement, 2425 National Quality Coordination Board hospital-issued notices of non-coverage, (NQCB) 300 accountability functions, 85 patterns and trends in quality of care, authorities and responsibilities, 85, 86, 45 8990

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INDEX 511 CMS and, 89, 90, 93, 100 technical assistance to, 201204, 223, contracting authority, 9091 264266 data collection and management activities, 9697 functions, 2627 O goals, 85 health care system monitoring function, Office of Management and Budget, 69, 351352 90 independence, 85 Oklahoma Foundation for Medical Quality, infrastructure support, 26 213, 225226 Omnibus Budget Reconciliation Act, 4142 membership, 85 population health promotion, 98 On-call physicians, 8 private sector relationships, 93 Osteoporosis quality of care measures, 396 397 public reporting activities, 98 QIOs and, 2527, 90100, 104 Outcome and Assessment Information Set, quality improvement function, 103104 205, 207, 224 Outcome-Based Quality Improvement, 205, quality improvement program management, 92 207, 224 recommendation for, 8485 Oversight of QIO program, 34, 7479, 120, 135136, 144 research agenda, 90 stakeholder relationships, 85 access to QIO data, 125 starter set of performance measures, 86 CMS personnel, 329333 communications, 16, 75, 128, 333336, structure, 92 system performance evaluations, 99 355, 358 National Quality Forum, 50, 286, 355 contracting activities, 10, 11, 74, 7678, 345347, 348350 National resource teams, 133 National Surgical Infection Prevention criteria for quality measures, 354355 Collaborative, 209, 241 current system, 911 data flow, 10, 74, 7576, 341343, 358 Nonequivalent control group study design, 469470 data lag issues, 342345 Notices of discharge and Medicare appeal identification of staff roles and responsibilities, 16, 128 rights, 300, 303 Nursing Home Compare, 86, 280, 282 information and communications Nursing Home Quality Initiative, 50 technology, 337341 opportunities for improvement, 911 Nursing homes, 48, 49 data collection, 344 organizational relations, 355356 educational and communication organizational structure, 325328, 358 policy formulation, 351353 interventions, 279280 eighth SOW performance evaluation, program coordination, 16, 128, 353 410415 356, 358 program guidance functions, 351 Medicare telephone help line, 280282 performance data, 341 QIO performance evaluation public reporting on performance, 50, methodology, 257261, 277 recommendations for, 1416, 126128 283285 QIO effects on quality of care in, 57, shortcomings in overall program 264266 evaluations, 910, 356357, 359 site visits, 347348 QIO expenditures, 181182 quality of care in, 21 special studies, 183184 quality of care measures, 201, 387 strategic planning, 9, 74, 7879, 351 support contract management, 185 seventh SOW performance evaluation, 404405

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512 INDEX P Pharmacotherapy coordination of care, 9 Pain management, 49, 205206 risks, 2, 21 Part D prescription drug benefit, 9, 19, 22, See also Part D prescription drug benefit 52, 7879, 129, 217218, 271 Physician Consortium for Performance eighth SOW performance evaluation, Improvement, 93 428429 Physician offices and practices Pathways to Quality Health Care series, ix, data collection, 343 xi, 20, 33 eighth SOW performance evaluation, Patient-centered care 424425 goals for health care system, 1, 24 QIO Support Center, 226 measures of, 84 quality of care measures, 394397 QIO quality improvement activities and, seventh SOW performance evaluation, 108 406407 Patient Safety and Quality Improvement technical assistance to, 213218, 227, Act, 103 269271 Pay-for-performance system, 38, 60, 63, timeliness of CMS data collection, 344 195 345 Payment Error Prevention Program, 48 Pilot programs, 248, 353 Payment incentives, 20, 25, 26, 33, 62, 82, Plan, Do, Study, Act Cycle, 44, 240 103, 244245 Pneumonia, 48, 49, 235, 236, 237 PDSA Cycle. See Plan, Do, Study, Act Cycle quality of care measures, 392393 Peer Review Improvement Act, 40, 70, 160 Population-based measurement, 88 Peer Review Organizations, 37, 4041, 42 Population health promotion 45, 48, 68, 136137, 160 data collection, 14, 121 Performance measurement QIO role, 98 confidentiality, 124 Preventive care crosscutting measures, 398 quality of care measures, 394 goals, 8384 Primaris, 294 historical development of QIO program, Private sector 50 contracting with local QIOs, 141 implementation of national system, 76, in health care system quality 89, 90, 106108 improvement, 25 leadership for development of, 2425, National Quality Coordination Board 84 and, 93 levels of, 8789 organizations with quality improvement QIO funding and, 140 services, 99100, 104, 435436 recommendations for national system, Processes of care measurement, 84, 232 20, 26, 33 233, 235 recommendations for QIO, 11, 14, 17, Professional Standards Review 105109, 121, 134135, 138 Organizations, 40 standardization, 8384, 86 Program Activity Reporting Tool, 338339 users of QIO data, 123124 Program for Evaluating Payment Pattern See also Assessment of QIO programs; Electronic Reports (PEPPER), 312 National Quality Coordination Project Officers, 16, 65, 75, 77, 128, 328, Board; Public reporting on 329330 performance Prospective payment system, 41 Performance Measurement: Accelerating Protection function of QIO, 7, 22, 30, 52, Improvement, 20, 2527, 29, 33, 34, 144, 297 62, 82, 8392 confidentiality of clinical data, 74, 124 Performance planning, 171 125

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INDEX 513 historical development, 48, 50 Public reporting on performance provider perception, 68, 318 CEO perceptions, 283285 QIO performance evaluation, 310 complexity of presentation, 283285 in QIO Support Centers, 308309 current practice, 103 spending, 322 current QIO data collection and, 106107 strategies for improving, 8 data management demands, 7576 See also Case reviews and appeals; hospital data, 50, 285287 Hospital Payment Monitoring leadership for development of, 84 Program; Medicare Trust Funds national system, 20, 89 Providers of care National Quality Coordination Board barriers to knowledge transfer, 245 activities, 27, 98 in case review process, 305306 pressures for competition among QIOs case reviewers, 303, 305 and, 60 cataract surgery assistants, 300 QIO and, 6, 11, 14, 18, 2526 conflict of interest restrictions, 73 QIO spending, 287 data access restriction, 124125 quality improvement and, 5253, 83, data collection needs, 123 285 information technology, 21, 26 in seventh SOW, 50 Medicare quality improvement shortcomings of current system, 83 initiatives, 22 Standard Data Processing System and, 10 on-call physicians, 8 timeliness of data collection for, 122 Peer Review Organization relationships, 41, 4243 perceptions of QIO protection function, Q 68 QIONet, 28, 75, 124, 154, 249, 336 performance data reporting requirements, 89 Qualis Health, 202, 246247, 293294 performance improvement and Quality Assurance in Medicare, 136 Quality Chasm series, 1, 1920, 3738, 83 satisfaction with QIOs, 265, 266, 268, 270, 272 Quality Coordination Team, 353354 physician-access or physician Quality Council, 353354 QIO program sponsorship requirements for QIOs, 12, 72, 110, 112, 161162 funding, 1718, 6970, 73, 138141, QIO board membership, 6, 12, 70, 71, 179180, 186187, 190 historical development, 34, 36, 37, 48 110111, 167, 168 QIO knowledge transfers to, 249250 51, 56, 160 QIO relationships, 3, 6, 8, 36, 56, 65, National Quality Coordination Board and, 2527, 90100, 104 67, 68, 112113, 125126, 318 QIO resource allocation, 12 non-CMS services, 185186 readiness for change, 194 physician-access or physician sponsorship requirements, 72, 110, recruitment to QIO improvement projects, 67, 107, 109110, 193197, 112, 161162 227 provider and stakeholder relationships, 3, 6, 8, 36, 56, 65, 67, 68, 112113, relationships within health care system, 24 125126, 318, 355356 satisfaction with QIOs, 273275, 278 quality improvement outcomes, 5661, 66, 79, 104105, 230, 234239, 252, settings for QIO technical assistance, 66 uses of QIO data, 123 276278 workforce retention, 5152 recommendations for, 3, 1118, 29, 33, 34, 102, 105106, 110111, 112, See also Performance measurement; Physician offices and practices; 121122, 126128, 134135, 138 Technical assistance 139

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514 INDEX structure and functions, 1, 23, 67, 21 R 22, 36, 5153, 6674, 104, 125126, 143, 160169, 188, 325328 Race/ethnicity, quality of care and, 5, 21, See also Assessment of QIO programs; 57, 83 Oversight of QIO program; Support Randomized controlled trials for program Centers, QIO evaluation, 17, 59, 135, 138, 231, QIO Support Centers. See Support centers, 468469 QIO Redesigning health insurance, 19, 20, 24 Quality Improvement Roadmap, 24, 78, Regional Offices, CMS, 327328, 334335 354 Regional variation Quality of care in hospital performance improvement, clinical conceptualization, 3738, 5253 268 current system, 2, 45, 2021, 83, 102 in performance improvement, 266, 278 103, 107 in physician office performance goals for health care system, 2425, 37 improvement, 270 38 in quality of care, 5, 2021, 57, 83, 236 identifying causes of improvement in, 5, Reporting Hospital Quality Data for Annual 17, 5759, 66, 79, 134, 137, 238239 Payment Update, 285, 286 impact of case review activities, 318319 Research international comparison, 21 distribution of special study findings, literature review for QIO studies, 148 184 149, 364386 literature review for QIO studies, 148 measure design and selection, 354355 149, 364386 organizational readiness for change, 234 National Quality Coordination Board performance measurement and, 2425, role, 90 83, 84 provider receptivity to quality private sector organizations with quality improvement, 110 improvement services, 99100 QIO effectiveness in quality process measures, 232233, 235 improvement, 104105 public reporting on performance and, Robert Wood Johnson University Hospital, 5253 239240 QIO effects, 5, 4849, 5661, 6365, Root-cause analysis, 11, 106, 240241 66, 79, 104105, 137, 230, 234239, Rural areas, 49, 64, 161 252, 276278 seventh SOW performance evaluation, Quality Coordination Team, 353354 408409 quality improvement interventions, QIO technical assistance projects, 212213, and non-QIO, 230234 218220, 271272 rationale for government intervention to improve, 6162 recommendations for improving QIO S contribution to, 11, 109110 Saint Luke's Hospital, 239 relationship components, 38 Sanctions, complaint-related, 69, 113, 307 role of QIO program, 23, 7, 22 Scientific Officers, 16, 65, 128, 328, 330 strategies for improving, 83, 103, 232, 331 239243, 252 Scopes of work (SOW), 34, 36 structural aspects, 232, 233234 beneficiary satisfaction surveys, 250251 technical assistance to improve, 98, 192 case review functions, 9, 112 220, 230231, 236239 CMS and QIO staff expertise for, 65 variations in service delivery, 5, 2021, competition, 7273 83, 236 conflict of interest restrictions, 73 Quality Partners of Rhode Island, 223 contract competition, 95

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INDEX 515 data collection assistance, 106, 107 contract renewal, 259, 345346 definition, 334 core contract, 181182 development timetable, 1516, 77, 132 deliverables, 430433 educational and communication distinguishing features, 7, 4851, 190 functions, 67 educational and communication fifth, 44, 45, 179 interventions, 67, 279280, 283, first, 41 285288, 293294 fourth, 4445 funding, 69, 179, 186187 funding, 67, 69, 70, 140, 179, 180 home health agency technical assistance, home health agency technical assistance, 266 205208 Hospital Payment Monitoring Program, hospital technical assistance, 208213 311315, 320322 knowledge transfer incentives, 251 hospital public reporting, 285287 long-range planning, 120121, 132 hospital technical assistance, 268 ninth, 1516, 18, 127128, 129, 131, information technology in, 106, 107 132, 139140 knowledge transfer in, 250251 National Quality Coordination Board managed care organization technical implementation and, 94 assistance, 272 nursing home technical assistance, 201 nursing home technical assistance, 264 204 265 origins and development, 4152 performance data collection, 341, 342 performance evaluations, 10, 60, 76, performance improvements among 77 identified participants, 272273 performance planning requirements, 171 population health initiatives, 98 population health promotion in, 98 private practice technical assistance, private practice technical assistance to, 269270 213218 program priorities in, 129, 352 program priorities, 9, 129, 199200 provider satisfaction, 273275 QIO management and, 134 QIO Support Centers, 173 QIO Support Center functions and, 133 service to underserved populations, 64, recommendations for improving, 1416, 271272 126128, 129, 130132 special studies, 357, 402403 second, 4142 subcontracting in, 171172 service to underserved populations, 218 support contracts, 184185, 357, 399 220 401 sixth, 48, 64, 179, 341342 technical assistance evaluation technical assistance provisions, 192, methodology, 257259, 262264, 227228 404409 tenth, 140 technical assistance in, 66, 192, 200, third, 43 201202, 205, 207209, 213, 218 timeliness of data collection, 122 220 transition of contract during, 348 use of data from, for QIO program See also Eighth SOW; Seventh SOW analysis, 2829, 30, 3839, 146, Seventh SOW 149150, 157158 beneficiary protection activities, 112, Six Sigma program, 64, 240 308, 318320 Small practice settings, 6, 26, 52, 104, 123 board characteristics and performance, Social Security Act, 40 71, 166169 Socioeconomic status, quality of care and, 5, collaboration incentives, 60, 241 57 contract competition, 72, 73 Southeast Health Disparities Collaborative, contract management, 77 226

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516 INDEX Special studies, 51 funding, 51, 69, 185 dissemination of findings, 184, 190, 353 for Hospital Payment Monitoring funding, 6970, 184, 353 Program, 314 NQCB implementation and contracting knowledge transfer functions, 59, 246 for, 9495 247 oversight, 183184, 356 obstacles to service delivery, 247 patterns and trends, 184 performance evaluations, 10, 77, 357, proposals, 183184 359 recommendations for contracting, 14, recommendations for contracting, 14, 16, 126, 128 16, 126, 127, 128, 133134 seventh SOW, 357, 402403 redesign for eighth SOW, 173175 Staff qualifications and characteristics, 64, 65 relationships with external stakeholders, CMS offices, 328 177 Government Task Leaders, 331332 scopes of work and, 133 for information technology staffing, 178179 implementation, 107108 strategies for improvement, 178179 length of QIO employment, 163164, subcontracting, 171 190 technical assistance projects, 223227 Project Officers, 329330 timeliness of response, 178, 190, 247 QIO, implications of NQCB, 9394 Support contracts QIO program full-time employees, 333 contracting procedure, 185, 353 QIO Support Centers, 178179 finances, 10, 184185, 357 recommendations, 16, 128 oversight, 74, 77, 185 Scientific Officers, 330331 recommendations for, 16, 128 turnover, 164 seventh SOW, 184185, 357, 399401 Standard Data Processing System, 10, 75, See also Support Centers, QIO 334, 337 Surgical complications, 51 Standardization of performance measures, quality of care measures, 389391 8384 SurveyMonkey, 28, 149 Standards of care, 43 Systems-based measurement, 88 State Children's Health Insurance Program, 25, 62, 91 State QIO programs, 21 T Strategic Framework Board, 84 Technical assistance, 143144 Strategic planning CMS role, 74, 351 activities of, 192, 193, 227 current QIO program, 9, 7879 CMS evaluations of QIO performance, 200, 257261, 277, 404429 role of QIO boards, 72 Stroke, 48, 236, 237 confidentiality rules as obstacle to, 173 Subcontracting, 170171 current system, 227228 data collection and management, 9697, Summative evaluation, 45 Supply of health care services, 2021 123 Support Centers, QIO definition, 193 demand, 192 beneficiary protection activities, 308 309 funding, 18, 69, 70, 139, 192 CEO perceptions of, 175179, 247 future challenges, 108109 goals, 200 communication functions, 176 contracting, 9495, 133, 349350 to home health agencies, 205208, 224 expertise, 177 225, 266268 for hospital public reporting, 286 functions, 23, 51, 133, 173177, 190, 223, 228 to hospitals, 208213, 225226, 227, 268269

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INDEX 517 identification of high performers vs. low shortcomings of current system, 89 performers, 263264 strategies for improving QIO to identified participants, 272273 performance, 56, 7, 200201 to improve services for underserved See also Private sector populations, 216217, 218220, Telephone help lines, 280, 287288, 295 226227, 271272 Texas Hospital Association, 97 IOM evaluations of QIO performance, Texas Medical Foundation, 309, 314 262272, 387397 Timeliness in knowledge transfer, 144 of care, 24 to managed care organizations, 221 of data collection and availability, 122, 223, 272 342345, 358 needs assessment, 15, 127, 130 of Program Office response, 326 National Quality Coordination Board of public reporting, 283 implementation and, 96 of QIO response, 178, 190, 247, 274, 275 to nursing homes, 201204, 223, 264 To Err Is Human: Building a Safer Health 266 System, 19 one-on-one consulting vs. collaboratives, Total quality management, 44 197198 Transformational change, 51, 52, 177, 352 Part D prescription drug benefit, 217218 Transitions, care in performance data reporting current system, 2, 5, 21 requirements, 89 data collection, 129130 to physicians' offices and practices, 213 performance assessment, 9 218, 226, 227, 269271 strategic planning for, 78 private organizations with quality See also Coordination of care improvement services, 99100, 104 Transmittal of Policy System, 326, 327, 334 provider access and utilization, 59, 62 Transparency 63 data confidentiality restrictions and, 7, providerpatient volume and, 194195 74, 125 provider performance levels and, 67, QIO boards, 6, 71, 111112 107, 109110, 195197 recommendations for QIO program, 16, provider satisfaction, 275 128 provider's status as industry leader or TRICARE, 62 early adopter and, 67, 107, 109110, 194 purchase of, 6263 U QIO self-assessments, 200201 QIO Support Center activities, 223227 Underserved populations education and communication for quality improvement, 98, 104 quality improvement outcomes, 144, interventions for, 293 230231, 236239 eighth SOW performance evaluation, 426427 rationale for government role in, to improve quality of care, 6162 QIO goals, 49, 64, 98 recommendations for, 4, 11, 14, 15, seventh SOW performance evaluation, 408409 105107, 109, 127 recruitment of identified participants, technical assistance to improve service 193197, 227 for, 216217, 218220, 226227, 271272 role of QIO, 7, 22, 26, 6667 rural area services, 212213, 218220 Utilization and Quality Control Peer Review in scopes of work, 192 Organizations. See Peer Review Organizations sensitivity to local needs, 198199, 227 settings for, 66 Utilization review, 37, 39, 40, 42, 302

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518 INDEX V W Veterans Health Administration, 25, 62, 91, Webpage views, CMS sites, 280, 295 92 Workforce retention, 5152 Virginia Health Quality Center, 226