Stay tuned for news about the QIO Program 13th SoW

QIO Program 12^th SoW (2019-2024)

The QIO Program has completed the 12^th Scope of Work (SoW), which began in November 2019 and ended in November 2024. The QIO Program has two core contract functions: case review and health care quality improvement support. Both functions are carried out through five initiatives:

• Two Beneficiary and Family Centered Care-Quality Improvement Organizations (BFCC-QIOs) help people with Medicare and their families exercise their right to high-quality health care. They do this by managing quality of care concerns, conducting immediate advocacy and reviewing appeals of discharge or decisions to end Medicare-covered services.
• Twelve Quality Innovation Network-Quality Improvement Organizations (QIN-QIOs) work directly with nursing homes, health care providers and community coalitions to improve the quality and safety of care for people with Medicare.
• Nine Hospital Quality Improvement Contractors (HQICs) work directly with small, rural and critical access hospitals to improve health care quality and safety for people with Medicare.
• The American Indian Alaska Native Healthcare Quality Initiative (AIANHQI) works directly with Indian Health Service (IHS) hospitals to improve the quality of health care for people with Medicare who are American Indian or Alaska Native.
• The Opioid Prescriber Safety & Support (OPSS) initiative provides national outreach and education to eligible providers to promote safe opioid prescribing practices and to spread knowledge of non-opioid pain management therapies.

What are QIOs currently doing? 

CMS relies on the QIO Program to improve the quality of health care for all people with Medicare at the local level. The 12^th SoW focused on areas that provide taxpayer value, maximize impact on the health care system and align with CMS and U.S. Department of Health and Human Services goals and priorities:

• Reduce opioid utilization and misuse among people with Medicare.
• Reduce adverse drug events and health care-associated infections in nursing homes.
• Increase chronic disease management, including cardiac and vascular health, diabetes and slowing and preventing end-stage renal disease among people with Medicare.
• Increase quality of care transitions to reduce unnecessary hospital admissions, readmissions and emergency department visits.
• Improve COVID-19 and infection control in communities serving people with Medicare, including nursing homes.
• Increase COVID-19, influenza and pneumococcal immunizations in people with Medicare.
• Provide widespread access to infection prevention and control training for nursing homes serving small, rural, vulnerable and disparate populations.

How do QIOs improve health delivery, status, and cost? 

Nationally, the QIO Program works with leading organizations like AARP, the American Cancer Society, the Centers for Disease Control and Prevention, the Visiting Nurse Associations of America and many more. QIN-QIOs work with state and local chapters of these organizations, engaging them as community partners in learning and action networks and improvement collaboratives that rapidly effect large-scale change for the better. Collaboratively, they work toward four major goals: promoting effective prevention and treatment of chronic disease by promoting safe care that is patient and family-centered, reliable and accessible; making care safer and reducing harm caused in the delivery of care; promoting effective communication and coordination of care; and making care more affordable.

At the community level, QIN-QIOs work with Area Agencies on Aging to improve the experience of patients as they transfer from one care setting to another. They also work with state health departments to reduce the number of health care-acquired infections. QIN-QIOs unite hospital associations, medical groups, health plans, and numerous community-based partners to address the unique medical, social, and economic factors affecting care in the area.

Beneficiary and Family Centered Care (BFCC)-QIOs, which manage beneficiary complaints and quality of care reviews, also collaborate with QIN-QIOs, state health associations, beneficiary advocacy organizations and other stakeholders to spread the word about the services BFCC-QIOs provide to Medicare beneficiaries and their families and initiate quality improvement initiatives.

Quality Evaluation and Improvement Contracts Descriptions

CMS carries out important evaluation and improvement activities for public benefit and services programs to ensure Medicare and Medicaid beneficiaries receive cost effective high quality, evidence-based services, consistent with the principle of beneficence.   CMS and the quality improvement contractors use patient identifiable information for program planning and outcomes assessment. Although the primary purpose of the Quality Improvement Organizations (QIO) program is to improve healthcare quality, evaluation activities sometimes produce generalizable knowledge (which might be interpreted by some as meeting the definition of human subjects’ research).

All of CMS’s QIO program contractors comply with strict privacy protection standards to safeguard identifiable information, including those related to Federal Information Security Management Acts of 2002 and 2014, the Health Insurance Portability and Accountability Act, and regulations specific to the Quality Improvement Organization program (42 CFR 480).

The following QI project listing includes only QI projects that potentially qualify as human subjects research but qualify for an exemption and the corresponding common rule exemption for each such QI project:

• The work conducted under the contract, Network of Quality Improvement and Innovation Contractors (NQIIC) Independent Evaluation Contractor, for the 12th Statement of Work (12SoW).  This contract collects data, conducts analysis, and develops reports to monitor progress toward 12SoW program goals and impact of program outcomes.  This activity studies, evaluates, and improves a public benefit program and thereby falls under the 45 CFR 46.104(d)(5) exemption from human subjects research requirements.

For quality improvement projects that include human subjects research and do not meet the criteria for a common rule exemption, CMS will comply with Institutional Review Board (IRB) requirements.