Medicare Quality Improvement Organizations (QIOs) are the successors to the Peer Review Organization (PRO) program created in 1982 by Congress to monitor beneficiaries’ quality of care and safeguard the integrity of the Medicare trust fund. In the early years, PROs conducted review work to ensure Medicare was paying for medically necessary care. Early quality efforts were limited largely to reviewing individual patients’ care, a process known as case review. In the early 1990s, the Institute of Medicine conducted a major study of the program, and as a result, Medicare shifted the main focus of the program to proactive community-based quality improvement and beneficiary education. QIOs, under contract with the Centers for Medicare & Medicaid Services (CMS), now work in partnership throughout the healthcare system with physicians, hospitals, nursing homes and home health agencies to help ensure the right care for every person every time. QIO activity in these provider settings is structured around four key strategies: performance measurement and reporting, adoption of health information technology, redesign of care processes and transformation of organizational culture. QIOs also protect Medicare beneficiaries and the Medicare program by reviewing beneficiary complaints, hearing appeals and monitoring and improving hospital payment error rates.

How QIOs Work

QIOs are a nationwide field force of experts dedicated to making health care safer and more effective in every state. QIOs serve as a resource for local health care professionals and consumers and collaborate with doctors, hospital personnel, and nursing home and home health professionals to examine their practices and improve systems of care. QIO assistance is provided at no cost to providers and helps ensure care is safe, effective, timely, patient-centered, efficient and equitable. QIOs measure progress in health care quality using widely accepted clinical indicators.

What Americans Can Expect from the QIO Program

• Hospital treatments will be safer, with fewer errors, resulting in fewer infections.
• Nursing homes will offer a more patient-directed experience with services based on the residents’ needs.
• Technology will be implemented to assist providers in meeting their patients’ needs.
• Home health care will accelerate patient recovery and reduce hospitalizations.

How QIO Work is Evaluated

QIOs are accountable to the public. Each QIO must demonstrate statewide improvement in quality measures and achieve a greater degree of improvement in a subset of providers that the QIO works with more intensively. Also, each QIO will be evaluated for provider satisfaction with the assistance they receive from their QIO as well as the level of provider and stakeholder knowledge of the QIO’s services.

Oklahoma Foundation for Medical Quality (OFMQ) is the original and only QIO for the state of Oklahoma. For over 30 years, OFMQ has led efforts to improve societal health and to encourage the cost-effective provision of quality medical services through medical review, quality improvement projects and public education.