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8 Technical Assistance for Quality Improvement CHAPTER SUMMARY During the 7th and 8th scopes of work (SOWs), Quality Improve- ment Organizations (QIOs) offered technical assistance to provid- ers to help them improve their quality of care. This task (Task 1) 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") and the modes of interaction. Next, the chapter discusses details of this task, as delineated in the contracts for the 7th and the 8th SOWs, including specific examples of projects and activities of the QIO Support Centers. Chapter 9 will discuss the impacts of these activi- ties on clinical outcomes and the transfer of knowledge. As technical assistants, the Quality Improvement Organizations (QIOs) use one-on-one consulting, collaborative activities, workshops, training ses- sions, root-cause analysis, and other techniques to assist providers with improving their health care processes and organizational systems. Budget constraints limit the degree to which QIOs can assist providers, as well as the number of organizations or individuals that they can assist within the state. Also, the presence of other quality improvement entities in the states can affect the demand for QIO technical assistance and the potential for partnering. These entities may include departments of health, state survey agencies, specialty societies, or private corporations. Although technical assistance can take many forms, the value of one methodology over another has not been determined, as will be discussed in Chapter 9. 192
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TECHNICAL ASSISTANCE FOR QUALITY IMPROVEMENT 193 DEFINING TECHNICAL ASSISTANCE "Technical assistance" can have different meanings. In general, it is the process by which QIOs work with providers, managed care organizations, and other stakeholders to improve patient outcomes. 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 mea- sures; 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. Recruitment of identified par- ticipants is generally left to the discretion of each QIO. Provider participa- tion is voluntary, but in many tasks the Centers for Medicare and Medicaid Services (CMS) stipulates the percentage of each provider type that the QIOs must recruit (CMS, 2002, 2005c). CMS expects the QIOs to demonstrate significant improvement in the identified participant group and, in some cases, greater improvement compared with statewide gains. These gains are evaluated by calculating the reduction in failure rate1 (Jencks et al., 2003). Many QIOs look to their identified participant group to act as leaders for other providers in the state, especially because CMS evaluates the QIOs, in part, on the basis of statewide improvements. QIOs often recruit identified participants using a number of criteria, including readiness for change, pro- vider volume or size, current level of quality performance, and other demo- 1A reduction in failure rate, also known as relative improvement, is the change in perfor- mance between the baseline and the follow-up (absolute improvement) divided by the differ- ence between the performance at the baseline and perfect (100 percent) performance. The reduction in failure rate may be viewed as a crude measures of improvement, as it does not distinguish between difficulty of improving from 90 percent to 95 percent versus from 70 per- cent to 85 percent, both having a 50 percent reduction in failure rate.
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194 MEDICARE'S QUALITY IMPROVEMENT ORGANIZATION PROGRAM graphics. The advantages and disadvantages of each of the methodologies related to these criteria are discussed in the next few sections. Readiness for Change When developing a strategy for the recruitment of identified partici- pants, 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. The "early adopters" are often highly regarded as opinion leaders in their communities and convince the "early majority" to adopt the innovation. Those in the "late majority" follow with adoption of the innovation because of overwhelming peer pressure. Finally, Rogers identified a group that he called the "laggards," who are the last to adopt any innovative idea or process, skeptical, and resistant to any change. This model proposes that as innovators and early adopters embrace a new process or philosophy, the process of natural diffusion will spread ideas to the rest of the community. Because CMS evaluates QIOs, in part, on the basis of statewide improvements, QIOs may opt to target opinion leaders of the community, hoping that if these providers change their practice pat- terns, the rest of the community will follow, leading to greater widespread change over time. Some studies show the use of opinion leaders to be ef- fective in changing practice patterns for specific interventions, but other studies show mixed results (Thomson O'Brien et al., 2005; Davis, 1998; Soumerai et al., 1998). In telephone interviews, many QIO chief executive officers (CEOs) expressed the value of working with early adopters: "Early adopters/willing participants are a huge resource for massive education be- cause they have proven knowledge of how things can work." On the other hand, QIOs might theoretically focus on the laggards who need the extra push and individualized attention provided through one-on- one relationships with QIOs. Early adopters may alter their practices on their own or with minimal assistance through other programs offered in the state. Additionally, early adopters may already be involved in other state programs and so may feel no need to participate with QIOs. High-Volume Versus Low-Volume Providers One theoretical methodology for recruiting identified participants is to target either providers with large patient populations (high-volume provid- ers) or those with small patient populations (low-volume providers). By working with high-volume providers, QIOs may hope to achieve a greater impact because of the larger number of beneficiaries seen by these provid- ers. However, others may believe that low-volume providers should be as-
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TECHNICAL ASSISTANCE FOR QUALITY IMPROVEMENT 195 sisted first, as they are the most likely to lack the resources and staff exper- tise needed to investigate options, adopt change systems, and learn quality improvement techniques. In telephone interviews, one QIO CEO stated: "Critical access hospitals (small and rural) usually welcome us with open arms. In facilities with very few providers, they are often so overworked that they do not have anyone to do the quality documentation. Here, the QIO has to take more responsibility." High Performers Versus Low Performers QIOs may recruit participants by targeting either high performers or low performers, but this method is confounded by the difficulty in defining that distinction. In fact, in telephone interviews, many QIO CEOs expressed concern for how this distinction can be made. In theory, high performers may be either those who produce a consistent level of quality care or those who have demonstrated significant improvements from the baseline. Pay- for-performance programs or public reports may help to identify the low performers, which may help the QIOs to determine who would benefit the most from assistance. Because pay-for-performance programs provide fi- nancial incentives for improved quality, providers may be more willing to work with QIOs to improve their performance. In telephone interviews, 10 of 20 QIO CEOs independently proposed that a barrier to technical assis- tance is a lack of motivation of providers to work on quality. All 10 agreed that pay for performance or sanctions would be strong motivators for pro- viders to work with QIOs. Additionally, in site visits to 11 QIOs, four raised the issues of pay for performance and public reporting as potentially strong motivators for providers to work with QIOs. High Performers Some QIOs prefer to work with high performers. In telephone inter- views, many QIO CEOs expressed the idea that high performers are the key to the diffusion of best practices. For example, two CEOs commented, "Dif- fusion of quality comes from good providers spreading the word," and "When you include high performers, you get more diffusion to other pa- tients. 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 fail- ure rate), QIOs may have difficulty reaching contract goals when they are working with very high performers. If a provider is already performing highly, it may be more difficult to improve upon the failure rate.
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196 MEDICARE'S QUALITY IMPROVEMENT ORGANIZATION PROGRAM Low Performers Alternatively, QIOs may choose to recruit low performers on the basis of the opinion that low performers, by definition, are the ones who need the most immediate help. Greater absolute and relative gains in quality may be achieved by bringing the low performers up to the level of the majority of providers. QIOs may perceive that high performers are already doing well and that their limited resources are most effectively spent in the areas of greatest need. Alternatively, some QIOs encourage participation in their quality interventions by all providers and include any providers who agree to the conditions of the program. This enables QIOs to meet their participa- tion level requirements and offer assistance to all who are willing and able to participate. In telephone interviews, all QIO CEOs said they preferred working with providers with a mix of performance levels. 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 state- wide. The CEOs thought that providers might perceive the focus of the QIO program to be a return to weeding out "bad apples" rather than pro- moting quality. They also questioned how to define "worst performers" and how CMS would evaluate the QIOs. Eighteen of 20 CEOs thought that a focus on the worst providers was not workable and has many disadvantages, such as the possibility of losing champions, diminishing diffusion of ideas, and increased investment in time and money. Only two CEOs thought that the focus on the worst- performing providers would not have much of an effect on their QIOs. However, they did qualify that by saying that the QIO might have to do more handholding of the poorer performers. Sixteen of the 20 CEOs thought that diffusion to other providers would be negatively affected if there was a focus on the worst-performing providers. Eighteen of the 20 CEOs raised the issue that poor performers barely have sufficient infra- structure for day-to-day survival, let alone quality improvement systems. All CEOs said that the worst performers would require more financial resources per site than the other providers. They require more intensive interventions (e.g., one-on-one onsite assistance and longer periods of inter- vention), and they need support for data and communications systems. Some providers do not even have the components of a basic communications infrastructure, like e-mail. Funds from CMS for the direct provision of tech-
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TECHNICAL ASSISTANCE FOR QUALITY IMPROVEMENT 197 nology or the support of technology acquisition by poor performers may be necessary. Random Selection Another option for the recruitment of identified participants is random selection, which, to date, the QIOs have not used. This method would be useful for evaluation purposes because it eliminates selection bias (partici- pation by the most highly motivated providers) and allows the greatest range of providers to be involved with the QIO program. Such an approach, com- bined with the random allocation of providers to interventions, would per- mit an accurate evaluation of the impact of the quality interventions. How- ever, because participation with QIOs is voluntary, it would be impossible to enforce participation by unwilling providers who are chosen randomly. One could, however, sample with replacement, in which those providers who choose not to participate would be replaced by other randomly se- lected providers who agree to participate. In multiple interviews and visits, the QIO staff expressed the opinion that the willingness of the provider to participate is an important part of the success of their technical assistance work. In telephone interviews, the QIO CEOs echoed this sentiment: "Re- alizing that the QI [quality improvement] process is voluntary, the issue is really whether the poorest performers want to make change. If the provider has no desire to improve quality, the QIO's hands are tied unless the perfor- mance is so egregious that it requires sanctioning." INTERACTION WITH PROVIDERS One-on-One Consulting Versus Collaboratives QIOs generally interact with providers through (1) individual consulta- tion and (2) community, statewide, and national collaboratives. One-on- one consultation provides direct, specialized attention. By receiving techni- cal assistance tailored to their needs, providers may be more likely to adopt changes. However, the development of multiple individualized relationships can be labor-intensive and cost prohibitive. This relationship can be espe- cially complicated when many parties are involved, such as when organiza- tions that hold contracts in more than one state work with integrated deliv- ery networks or large nursing home chains. Even if this method leads to big changes in quality improvement, it would be in a small subset of the pro- vider population because current budget restraints do not allow individual- ized assistance to every provider. On the other hand, one-on-one consulting
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198 MEDICARE'S QUALITY IMPROVEMENT ORGANIZATION PROGRAM with key providers, such as those who would act as opinion leaders, could help disseminate information as effectively. Collaboratives can foster relationships among providers and allow the sharing of best practices, but their impacts on quality measures and health outcomes are unclear (see Chapter 9). The success of this type of interaction depends to some extent on the topic chosen, the enthusiasm of the partici- pants, and the organization of the collaborative (Ovretveit et al., 2002). Successful collaboratives must not only have strong leadership, but the par- ticipants also must be effective leaders when they return to their practice settings. The literature shows that effective leadership is the key to organi- zational change (Joshi, 2000; Shortell et al., 2004; Bradley et al., 2005). The Institute for Healthcare Improvement (IHI) developed a model for a Breakthrough Series collaborative that has been widely adapted by many organizations, including the QIO program, and has been used for many topic areas. The Breakthrough Series model creates a structured collabora- tive that lasts 6 to 15 months, during which the collaborative teams partici- pate in three learning sessions (meetings in which all participants gather together to learn and share experiences), followed by three action periods (implementation of changes, tailored to local settings). Further support is provided through conference calls, Internet-based conferences, and site vis- its (Institute for Healthcare Improvement, 2003). Box 8.1 presents a de- scription of the IHI's Spread Initiative, a typical example of an IHI collabo- rative. A detailed evaluation of the impacts of these and other methods is presented in Chapter 9. Telephone Interviews: Collaboratives In telephone interviews, 13 QIO CEOs talked about collaboratives. Four of the 13 mentioned the IHI model specifically, with 2 saying that they modify it because of the costs and time associated with the IHI model. Overall, QIOs widely use collaboratives, regardless of the model. One QIO CEO stated, "We have a large state geographically. We deploy collabora- tives in our work in all settings. Identified participants work with col- laboratives for 12 to 18 months. They come together in follow-up confer- ences. There is lots of learning and sharing of collected data." Another indicated, "We use collaboratives as much as possible, especially through the hospital association. We have about 60 percent voluntary participation. We use an IHI model, though [it is] less intense; IHI requires so much meet- ing time that we did not think that would work for our providers." Nationally Defined Projects Versus Local Needs As described in Chapter 2, the QIO program has undergone an evolu- tion in which the core contract contains an increased emphasis on standard-
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TECHNICAL ASSISTANCE FOR QUALITY IMPROVEMENT 199 BOX 8.1 IHI's Spread Initiative Overview "IHI's Spread Initiative is a collaborative improvement project to help organizations establish processes and practices to spread successful change throughout their health care systems." How It Works "During the one-year membership in The Spread Initiative, partici- pants will meet three times for Learning Sessions. During these ses- sions, IHI's expert faculty will guide participants in the development of spread goals and outcomes measures, and lead discussions about proven methods for successful spread of improvement throughout the organization. Between Learning Sessions, participants will work with IHI faculty and each other--through conference calls, a list serve, and email--and with colleagues at their own organizations to test and imple- ment recommended changes. Throughout the process, IHI faculty will guide organizations through the necessary steps, and will formally assess their progress on a monthly basis, providing customized feedback and guidance based on results." SOURCE: Institute for Healthcare Improvement (2005). ized national projects and less emphasis on projects related to local needs. On the site visits to 11 QIOs, 5 specifically expressed frustration with the lack of flexibility in their contracts to address local needs. Of those 5, 3 suggested the need to return to a more balanced mix of local and national projects. They suggested the possibility of substituting a local project for a national task if the QIO has successfully achieved a high level of perfor- mance on that task in previous scopes of work (SOWs), but there is concern that the high level of performance will regress if performance on the waived national task is not actively monitored. 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). Predecessor organiza-
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200 MEDICARE'S QUALITY IMPROVEMENT ORGANIZATION PROGRAM tions attempted to control wasteful and ineffective practices by identifying outliers at the local level. As national standards of care gained acceptance, the QIO program developed national projects. In the 6th SOW, QIOs per- formed some standardized work in the hospital setting, but other projects were local in nature and differed from state to state (CMS, 1999). In the 7th SOW, all quality improvement projects in each state were standardized to achieve the same goals by use of the same measures. Projects expanded to include provider settings, in addition to the hospital: nursing homes, physi- cians' offices, and home health agencies (CMS, 2002). As the program pro- gressed from a focus on cost containment to a focus on improved quality, the SOWs changed to reflect those priorities. Today, the QIO program stresses broader quality improvement in a shorter period of time. The 8th SOW looks to achieve transformational cultural and systems changes rather than the incremental changes more characteristic of the 7th SOW (CMS, 2002, 2005c). Technical assistance activities relate to five dimensions of performance defined by CMS: · Improvement in performance measure results (such as increased rate of mammography screening in the physician's office setting), · Improvement in clinical performance measurement and reporting (such as attaining a 25 percent level of self-reporting of expanded measures in the hospital setting), · Systems adoption and use (such as the implementation of an elec- tronic health record), · Implementation of key process changes (such as implementation of an immunization assessment survey by home health agencies), and · Changes in organizational culture (such as data collection by nurs- ing homes on satisfaction of residents and staff). Overall, the QIOs believe that they are extremely capable in their role as technical assistants. On the site visits to 11 QIOs, the QIO staff attributed their successes in the provision of technical assistance to positive relation- ships in the community (11 QIOs), internal experience and skills (9 QIOs), and a dedicated staff and a culture of quality (9 QIOs). When the QIOs were asked about challenges or threats to their technical assistance activi- ties, 2 QIOs voiced a need for more knowledge sharing, 3 related a need for more help from Quality Improvement Organization Support Centers (QIOSCs), and 6 discussed the difficulty of engaging providers. Other is- sues mentioned included a lack of information and a lack of experience with communications technology, the need for funding for start-up work before the contract begins, and individual staffing problems. When the QIOs were questioned about opportunities for new areas in which the QIOs could offer technical assistance, 2 QIOs mentioned information and communica-
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TECHNICAL ASSISTANCE FOR QUALITY IMPROVEMENT 201 tions technology and 4 identified pay for performance and public reporting. One QIO recommended more crosscutting initiatives. NURSING HOMES 7th SOW With the release of public reports on the performance of nursing homes in November 2002 (CMS, 2004), CMS added Task 1a to the 7th SOW for QIOs to work with nursing homes. Details of the work of the QIOs on public reporting initiatives are discussed in Chapter 11. For technical assis- tance, CMS charged the QIOs to work with nursing homes on quality im- provement projects to help improve performance on selected measures cho- sen from the Minimum Data Set, which was developed to assess the quality of care for both long-term and short-stay residents. The QIOs chose to work on between three and five of the following publicly reported quality of care measures: · Decrease in pain, · Decrease in infections, · Decrease in pressure sores, · Decrease in use of restraints, · Decrease in delirium, · Improvement in ability to ambulate, and · Improvement in ability to perform basic daily tasks (see Table A.5 in Appendix A). The measures were examined both at the statewide and at the individual nursing home levels. CMS expected the QIOs to partner with stakeholders such as state nursing home associations, professional societies, or local chapters of the AARP. CMS also expected the QIOs to interact with the Nursing Home QIOSC and offer quality improvement information to all nursing homes in the state. 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). On average, the QIOs actually worked with 15 percent of the facilities in their individual states, with participa- tion ranging from 10 percent to 100 percent (Rollow, 2005). QIO activities included one-on-one consultations between the QIO's medical director and the nursing home's medical director, the provision of manuals on the use of restraints and on fall prevention to all directors of nursing in the state, the development of e-mail listserves with all nursing homes to share ideas, and the management of workshops with continuing education units (CMS, 2004). Several QIOs initiated innovative programs.
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202 MEDICARE'S QUALITY IMPROVEMENT ORGANIZATION PROGRAM Health Services Advisory Group (Arizona's QIO) focused on the high per- formers among its participating nursing homes to determine common fea- tures and to try to replicate their successes in other locations (CMS, 2004). MetaStar (Wisconsin's QIO) evaluated innovative nursing home models around the country to better understand the implementation of resident- based models of care (CMS, 2004). The National Nursing Home Collabo- rative operated on a larger level by the Process Improvement QIOSC con- tract was held by Qualis Health through its QIO work for Washington state. In this project, 43 QIOs each worked with a subset of the participat- ing nursing homes in their home states to improve pressure ulcer manage- ment (CMS, 2004; Eloranta, 2005). Qualis Health conducted this collabo- rative in the style of IHI to learn how to identify, measure, monitor, and treat pressure ulcers. The impacts of the various quality initiatives are dis- cussed 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). In this subtask, QIOs focus on improving clinical performance on specific measures (as reported on the Nursing Home Compare website), setting improvement targets, and analyzing resident and staff satisfaction, which includes monitoring of workforce turnover. Statewide Statewide, QIOs provide assistance to any nursing home that requests assistance with their performance on clinical measures. QIOs also set state- wide targets for decreasing the frequency of pressure ulcers in high-risk patients, decreasing the frequency of use of physical restraints, and helping all nursing homes set their own annual targets for these measures (and oth- ers, if desired). CMS does not define the requirements for these targets-- those are left to the discretion of each nursing home. QIOs may opt to work with a subset of nursing home providers on the documentation of specific processes of care (CMS, 2005c), including: · Skin inspection and pressure ulcer risk assessment, · Screening and treatment for depression, · Evaluation of physical restraint requirements or alternatives, and · Pain assessment and treatment. If a QIO chooses this activity, the providers must document information on 50 percent of their new admissions. For the QIO to receive credit for this
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TECHNICAL ASSISTANCE FOR QUALITY IMPROVEMENT 219 · Dually enrolled (3), and · Rural beneficiaries (19). The reference group for nonrural projects was white, non-dually eligible Medicare beneficiaries residing or receiving care in the same geographic area as the underserved population. The reference group for rural projects was Medicare beneficiaries residing or receiving care in all urban counties of the state. CMS granted a waiver to the QIO for the U.S. Virgin Islands because the entire population was considered "underserved" (CMS, 2002, 2004). The QIOs targeted a subset of the underserved population in their states, called the intervention group, which had to be at least 25 percent of the underserved population's entire size. The QIO addressed one quality measure used in either Task 1c or Task 1d for its underserved population. If the QIO was continuing a project from the 6th SOW, the QIO was encour- aged to increase the size of its intervention group. In this subtask, the QIOs also supported state Quality Assessment and Performance Improvement projects to reduce health disparities (see the discussion of managed care later in this chapter). The story presented in Box 8.4 demonstrates a successful intervention by Florida Medical Quality Assurance, Inc. (Florida's QIO), which used multiple techniques, including beneficiary education, the use of opinion leaders, partnering with key stakeholders, communications tools, use of QIOSC materials, and individualized assistance to providers to improve the rate of hemoglobin A1c testing in the African-American population (CMS, 2002, 2004). 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. They expressed concern that access issues are not addressed by the QIOs as much because there is a tendency to look at the care of people who already have access. They also related logis- tical difficulties with the study of underserved populations, including suffi- cient sample sizes, the increased use of services by all populations, and spe- cial geographical needs. The following are comments of some of the CEOs: · "I don't think the issue is the quality of care delivered in the area, but it is the issue of access instead. For example, people in rural areas or even midcity often do not have transportation to care."
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220 MEDICARE'S QUALITY IMPROVEMENT ORGANIZATION PROGRAM BOX 8.4 Glycosylated Hemoglobin A1c Testing Among African Americans in Florida "The Florida Medical Quality Assurance, Inc. (FMQAI) sought to re- duce the disparity in glycosylated hemoglobin A1c (HbA1c) use between African American Medicare beneficiaries and non-African American Medi- care beneficiaries with diabetes in the state. "FMQAI used previous statement of work (scope of work) research to identify barriers, such as beneficiary knowledge regarding the impor- tance of healthcare screening techniques for diabetes. FMQAI also found a need for providers to learn about the healthcare disparity, existent bar- riers to care, and providers systemic changes that could address pre- scribing HbA1c for African Americans such as diabetic beneficiary identi- fication and follow up by the provider. "The QIO identified existing networks, used them to enhance com- munication, and employed African Americans from the community to lead the project team and build partnerships with community champions. Out- reach tools were designed with target audience involvement and included mailings, radio public service announcements, and press releases. The QIO also worked with stakeholders to develop a culturally sensitive edu- cation program. FMQAI made presentations at public meetings with local health departments and church groups and developed an Internet web- site. 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 dis- tance required to go to serve their needs." 8th SOW In the 8th SOW, CMS integrated efforts to take a more community- based 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 ad- dressed in Task 1d2 (CMS, 2005b).
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TECHNICAL ASSISTANCE FOR QUALITY IMPROVEMENT 221 betes HbA1c <7,' a train-the-trainer module, and a diabetes education module for beneficiaries. Another beneficiary intervention involved face- to-face interaction and educational presentations, seminars, and involve- ment at trade shows. FMQAI implemented the Front Porch initiative, which involved a `Closing the Gap' grant, the SHARE program, the Frenchtown initiative, and diabetic educators. "The QIO provider intervention targeted physicians' offices and in- cluded an adaptation of the Oklahoma Foundation for Medical Quality, Inc. methodology. FMQAI visited `best practice' offices and recruited those physicians to become FMQAI consultants, who conducted other provider office visits. The QIO also made direct mailings, which contained recruitment materials and a `project-in-a-box' with tools for system changes. Other efforts involved physician-to-physician mailings, QIO partner articles, presentations, and face-to-face contact with providers by teleconferencing. Diabetic educators and pharmacists also assisted the QIO in working with physicians. "The HbA1c-testing rate for the target population showed an abso- lute improvement of 14.6 percent. There was a reduction in the disparity of HbA1c use between African American Medicare beneficiaries and non- African American Medicare beneficiaries with diabetes of 3.1 percent." SOURCE: QSource: The Center for Healthcare Quality (2005). MANAGED CARE By law, the QIOs must also review the services provided to beneficia- ries in managed care plans. 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. CMS chooses the clinical topic for the national project each year. Past topics included diabetes, community-acquired pneu- monia, congestive heart failure, and clinical health care disparities or cul- turally and linguistically appropriate services (CMS, 2005a). In 2005, CMS did not assign a specific topic because of the overwhelming work that re- sulted from implementation of the Medicare Prescription Drug, Improve- ment, and Modernization Act (P.L. 108-173). Instead, organizations per- formed a task of their choosing based on local needs (Moreno, 2004). In years with an identified clinical topic, the organizations could initiate addi- tional projects on topics in response to local needs.
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222 MEDICARE'S QUALITY IMPROVEMENT ORGANIZATION PROGRAM Under Task 1f of the 7th SOW, the QIOs supported Medicare+Choice organizations' (M+COs') performance of QAPI projects. The QIOs encour- aged consistent practice patterns for beneficiaries, regardless of the type of plan in which they were enrolled. CMS required the QIOs to invite all Medicare+Choice organizations in the state to participate in any projects related to Tasks 1a to 1e. If possible, a QIO was supposed to offer technical assistance to Medicare+Choice organizations for any quality improvement activities not specifically related to QAPI project requirements. This work continued collaborations initiated during the 6th SOW. No specific set of measures existed for this task, but the QIOs reported on their activities to CMS on a quarterly basis (CMS, 2002). Box 8.5 gives an example of how BOX 8.5 Cultural Competency Organizational Assessment (CCOA) Pilot "CMRI (now known as Lumetra) sponsored a pilot project utilizing the Organizational Self-Assessment tool and protocol developed by Dennis Andrulis, PhD, MPH, a research professor at the department of Preventive Medicine & Community Health at the State University of New York, Downstate Medical Center. "In consultation with Dr. Andrulis, the original self-assessment tool was modified to meet the needs of the managed care community. 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. "The M+COs who participated in the CCOA Pilot have been given permission by CMS to use that experience as the basis for their 2003 QAPI Project. More importantly, the participants contributed to the devel- opment of an organizational self-assessment tool that can be used by all types of managed care organizations nationwide. Dr. Andrulis is consult- ing with each participant plan confidentially about their scoring results and `next steps.' Although all participants note that the self-assessment took a lot of hard work, they enthusiastically acknowledge how valuable the experience has been to their organization. They report increased awareness of organizational resources and improved inter-departmental communications. The CCOA pilot results help their organizations to develop a multi-year action plan to address issues related to cultural competency." SOURCE: Lumetra (2005).
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TECHNICAL ASSISTANCE FOR QUALITY IMPROVEMENT 223 Lumetra (California's QIO) interacted with managed care plans in that state on its national project for 2003. In the 8th SOW, CMS did not define a separate task for the Medicare Advantage beneficiary population, but the QIOs must include Medi- care Advantage organizations in all of their activities at a level that is equiva- lent to their representation in the state. QIO SUPPORT CENTERS As described in Chapter 7, a QIOSC is a QIO that acts as a central resource on a specific task or crosscutting topic. QIOSCs conduct analyses, develop materials, and share information. In interviews with four QIOs (representing seven QIOSCs), all stated that they had various levels of inter- action with the QIOs. They provided information when they were asked, but they could not intervene in a QIO's activities unless they were asked to do so. They agreed that individual QIOs needed different levels of help, depending on their own skills. All QIOSCs saw their role as assistants to QIOs in their activities and as sources for the sharing of knowledge. The following sections present specific examples of QIOSC activities related to the role of QIOs in offering technical assistance to providers. Nursing Home QIOSC During the 7th SOW, Quality Partners of Rhode Island (Rhode Island's QIO) served as the Nursing Home QIOSC. In addition to providing general support, it provided technical information and reports, training, and imple- mentation materials to the QIOs. The QIOSC served a convening function for QIOs to communicate among themselves through the establishment of a community of practice, a group that comprised staff working on this spe- cific task in each QIO. Communities of practice regularly engaged in roundtables by telephone and communicated through a listserve. Addition- ally, the QIOSC helped develop and maintain a Nursing Home Information Clearinghouse, an Internet-based database of best practices, change con- cepts, interventions, and guidelines available to the QIOs and nursing homes. The data included findings from the literature, as well as the ex- periences of QIOs and nursing homes (CMS, 2004). Quality Partners of Rhode Island continues these activities as the Nursing Home QIOSC in the 8th SOW. Box 8.6 represents part of a document developed by the Nursing Home QIOSC in the 7th SOW to serve as a resource guide for the QIOs when they are working on delirium.
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224 MEDICARE'S QUALITY IMPROVEMENT ORGANIZATION PROGRAM BOX 8.6 Delirium: Tools and Web Links Resources for Creating Your Own Delirium Relief Resource Manual "Assessment: 10-Point Clock Test Screens http://www.psychiatrictimes.com/p981049.html A method of using clock-drawing tests to identify delirium. This tool is accompanied by an article, which describes the administration of the 10-Point Clock Test, as well as the interpretation of the score for cogni- tive impairment. Source: Psychiatric Times Confusion Assessment Method http://www.hartfordign.org/publications/trythis/issue13.pdf The Confusion Assessment tool has two parts. Part one is an as- sessment instrument that screens for overall cognitive impairment. Part two includes only those four features that were found to have the great- est ability to distinguish delirium from other types of cognitive impairment. Source: The Hartford Institute for Geriatric Nursing [adapted from Inouye, S., van Dyck, C., Alessi, C., Balkin, S., Siegal, A. & Horwitz, R. (1990). Clarifying confusion: the confusion assessment method. Annals of Internal Medicine, 113(12), 941948.] Mini-Mental State Examination (MMSE) 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. Because this was a new setting for QIOs, the QIOSC worked to orient the QIOs to the home health setting in general. They also provided OBQI system train- the-trainer programs to all the QIOs. The 3-day training included lectures on the state of the home health industry and OASIS (CMS, 2004). The Home Health QIOSC operated in a fashion similar to that described above for the Nursing Home QIOSC and maintained an information clearing-
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TECHNICAL ASSISTANCE FOR QUALITY IMPROVEMENT 225 A practical method for grading the cognitive state of patients for the clinician. Source: Marshal F. Folstein, MD; Susan E. Folstein, MD; Paul R. McHugh, MD Guidelines: Acute confusion and delirium http://www.guideline.gov/VIEWS/summary.asp?guideline=000536 &summary_type=brief_summary&view=brief_summary&sSearch_string =delirium Major recommendations including the assessment and management of delirium. Source: Research Dissemination Core. Acute confusion/delirium. Iowa City (IA): University of Iowa Gerontological Nursing Interventions Research Center; 1998. 41 p. [81 references] Practice Guideline For the Treatment of Patients with Delirium http://www.psych.org/clin_res/pg_delirium.cfm This practice guideline seeks to summarize data regarding the care of patients with delirium. It begins at the point where the psychiatrist has diagnosed a patient as suffering from delirium according to the DSM-IV criteria for the disorder. The purpose of this guideline is to assist the psychiatrist in caring for a patient with delirium. Source: American Psychiatric Association" SOURCE: Quality Partners of Rhode Island (2005). house. In the 8th SOW, the West Virginia Medical Institute (West Virginia's QIO) acts as the Home Health QIOSC. Hospital QIOSCs In the 7th SOW, the Colorado Foundation for Medical Care (Colo- rado's QIO) served as the Heart Failure QIOSC and focused on hospital- based measures of acute myocardial infarction and heart failure, whereas the Oklahoma Foundation for Medical Quality (Oklahoma's QIO) served as the Infectious Disease QIOSC and supported hospital tasks related to pneumonia and the prevention of surgical infections. These QIOSCs oper- ated in the same fashion described above for the other QIOSCs. For ex-
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226 MEDICARE'S QUALITY IMPROVEMENT ORGANIZATION PROGRAM ample, the Infectious Disease QIOSC brought together representatives of the Infectious Diseases Society of America and the American Thoracic Soci- ety to develop joint guidelines for the treatment of community-acquired pneumonia. Examples of fact sheets include Antibiotic Timing and Selec- tion (developed by the Infectious Disease QIOSC) and Successful Inpatient Intervention Factors (developed by the Heart Failure QIOSC) (CMS, 2004). In the 8th SOW, the Iowa Foundation for Medical Care (Iowa's QIO) acts as the newly designed Hospital Reporting QIOSC. This QIOSC will provide data support for hospital reporting initiatives, help with the CMS Abstraction and Reporting Tool (see Chapter 13), and support validation for hospital-generated data and will perform overall data management (Qualis Health, 2005). The Oklahoma Foundation for Medical Quality (Oklahoma's QIO) operates the newly designed Hospital Interventions QIOSC to provide support for all Task 1c1 and Task 1c2 activities. Physician Office QIOSC In the 7th SOW, the Virginia Health Quality Center (Virginia's QIO) acted as the Physician Office QIOSC and thereby supported the QIOs in the same manner described above. Monthly calls included discussions of na- tional topics, as well as topics designed to target smaller groups of QIOs with specific demographic challenges. The QIOSC also supported the Medi- care Quality Improvement Community website through coordination with the Interventions QIOSC (CMS, 2004). The Virginia Health Quality Center acts as the Physician Office QIOSC in the 8th SOW. Additionally, it has three subcontractors: (1) Lumetra (California's QIO) for Medicare Advan- tage, (2) Lumetra (under a second subcontract) for Electronic Health Record Vendor Relations Updates, and (3) the Northeast Health Care Quality Foundation (New Hampshire's QIO) for Office System Survey (Qualis Health, 2005). Underserved QIOSC In the 7th SOW, the Center for Healthcare Quality (Tennessee's QIO) 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. Specific efforts included participation in the Healthy People 2010 Partnership for Heart Disease and Stroke and the Southeast Health Disparities Collaborative. The Underserved/Rural QIOSC also conducted a needs assessment in January 2003 (5 months after the first round of the 7th SOW started) in which it surveyed the QIO community on how the QIOSC could best serve its needs. The survey found that QIOs had a strong preference to learn from other
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TECHNICAL ASSISTANCE FOR QUALITY IMPROVEMENT 227 QIOs and other experts. As a result of this and other findings, the QIOSC held conference calls on intervention strategies, convened a 1-day confer- ence on rural health for hospitals and outpatient rural projects, led web- based training sessions, and provided written educational materials (CMS, 2004). The Center for Healthcare Quality continues its activities as the Underserved QIOSC in the 8th SOW. Medicare Advantage QIOSC In the 7th SOW, Lumetra (California's QIO) acted as the Medicare +Choice QIOSC. The QIOSC provided support in a way similar to that described above for other QIOSCs. In the 8th SOW, no QIOSC is dedicated solely to Medicare Advantage issues. Instead, Lumetra acts as a supporting contractor to the Physician Office QIOSC for Medicare Advantage issues. SUMMARY This chapter has discussed issues related to the technical assistance ac- tivities of the QIO program. 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 col- lection 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). The QIOs largely favor working with those showing an ea- gerness and readiness for change. · The QIOs have experience with many methods for interacting with providers, including collaboratives, one-on-one consulting, teleconferences, local or regional conferences, newsletters and other printed materials, and web-based tools. · The QIOs favor an increased ability to tailor interventions to local needs. · Because of the history of the QIO program, QIOs have the longest- standing relationships with hospitals. For some providers, particularly phy- sicians in ambulatory care, their interaction with QIOs has occurred over a much shorter length of time, and so many of those relationships are not fully developed. · The 8th SOW has many more detailed requirements for technical assistance activities than the 7th SOW did. The identified participant groups
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Representative terms from entire chapter: