Quality Improvement Organizations (QIOs)

Background

The concept of QIOs emerged soon after the passage of the Medicare program (Title XVIII of the Social Security Act) in 1965, at a time when national priorities were directed on efforts to contain rising healthcare costs. Prior to that time, hospital and medical peer groups had set the precedent in establishing quality assessment criteria and in the creation of a hospital-accrediting organization (today, the Joint Commission) to enforce quality standards. These efforts not only laid the groundwork for the standards for hospitals participating in the Medicare program, they also propelled the U.S. Congress to authorize a pilot program in 1971 for an experimental medical care review organization (EMCRO) to assess and monitor utilization of inpatient and ambulatory services, which served as the initial model for a national quality review program. A year later, the professional standards review organizations (PSROs) were established as the first national quality assurance program to focus on utilization review of hospitals and physician outliers as a way to control costs. Physician groups, however, opposed the PSROs, because they were unable to demonstrate that results from such approaches affected cost containment. A decade later, the passing of the federal Peer Review Improvement Act of 1982 (as part of the Tax Equity and Fiscal Responsibility Act of 1982) led Medicare to replace the PSROs with peer review organizations (PROs). The PROs refocused their efforts on monitoring utilization and outcomes for specific Diagnosis Related Group (DRG) assignment, readmissions, hospital operations, complications, and mortality rates. The success of the PROs led to expanding reviews in nursing facilities, home health agencies, hospital outpatient services, physician offices, and managed-care organizations. By the end of the 20th century, Medicare shifted away from a quality assurance focus on case review to quality improvement approaches that influenced patterns in clinical-care processes and outcomes. Hence, by 2002, the PROs were renamed quality improvement organizations (QIOs) to reflect the changing definitions of quality and national priorities toward measurement and population-based improvement effects.

Evolution and Current Status

QIOs constitute the nation's foremost infrastructure for quality improvement that is administered by the Centers for Medicare and Medicaid Services (CMS) as part of a larger program financed mainly through monies from the Medicare Trust Fund. CMS contracts with QIOs to provide services in all 50 states, the Virgin Islands, the District of Columbia, and Puerto Rico, plus several QIO support centers that operate solely as national resource clearinghouses. Moreover, CMS has developed and oversees a complex communication and information systems technology service for the QIO program comprising a standard data-processing system (SDPS) that serves as a centralized repository [Page 991]of clinical data information interfacing with two clinical data abstraction centers (CDAC) and all QIOs. In addition, this service operates a centralized case review information system (CRIS) to track and report on case review activities as well as a protected intranet Web site used by the QIO community to share measurement tools and resources for the SDPS used in the national measures reporting activities.

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