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9
Impact of Technical Assistance
for Quality Improvement and
Knowledge Transfer
CHAPTER SUMMARY
This chapter reviews the literature base for quality improvement
and knowledge transfer, two concepts important to the provision
of technical assistance to help health care providers improve the
quality of care that they provide. To understand the effectiveness of
the technical assistance provided through the Quality Improvement
Organization (QIO) program or the extent to which the program
goals have been achieved, it is necessary to first understand how
similar quality improvement efforts have fared in the larger health
care environment outside of the QIO program. This chapter pre-
sents discussions on the following topics related to quality improve-
ment: quality improvement interventions in general and in QIOs,
approaches to quality improvement, and an overview of knowl-
edge transfer and its impact within the QIO environment.
QUALITY IMPROVEMENT
The Quality Improvement Organizations (QIOs) seek to achieve qual-
ity improvement through the use of various interventions to enhance the
efficiency and effectiveness of care received by Medicare beneficiaries. This
section examines the impacts that QIOs' quality improvement interventions
have on the delivery of health care. With specific reference to the QIOs, the
Centers for Medicare and Medicaid Services (CMS) defines interventions as
activities adopted by providers, beneficiaries, or the QIOs to facilitate
change to improve health care delivery processes, structures, or behaviors
(CMS, 2005b). To assess and explain the impacts of quality interventions
by the QIOs, the impacts of these interventions throughout the health care
industry must be reviewed. Thus, this discussion first examines the litera-
230
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IMPACT OF TECHNICAL ASSISTANCE 231
ture regarding quality improvement in general and then assesses the litera-
ture on QIO quality improvement interventions.
A literature review conducted for this project provides an overview of
evidence on improving health care quality. (For details on each study, see
Table A.1 in Appendix A.) The studies included in the literature review
were categorized by study design; the findings of studies with more rigorous
methodologies were considered more heavily (see Table A.2 in Appendix
A). The studies reviewed paint an inconclusive picture of the effectiveness
of quality improvement programs, whether they are conducted by QIOs or
other organizations, for both Medicare and nonMedicare services.
Although health care quality improvement interventions have been dis-
cussed for decades, the emerging evidence base supporting their effective-
ness remains sparse and therefore difficult to use as a basis for making
policy decisions. Comprehensive studies of specific types of interventions
are limited in part because of the many different methods of approaching
quality improvement. Quality improvement resulting from specific inter-
ventions, however, is difficult to measure because many of the impacts of
the interventions are qualitative, it often takes more time than is allowed by
the study to demonstrate measurable improvements, and the interventions
themselves are not described at a level of detail that allow them to be
replicated.
Quality improvement interventions tend to target multiple components
of complex organizations, all of which are subject to many internal and
external influences, making evidence of effectiveness almost impossible to
detect (Ovretveit and Gustafson, 2003). If improvement has been made,
attribution of this success cannot be determined because of the wealth of
players often involved in enhancing the quality of care. Conversely, the
reason why quality improvement interventions fail also remains inconclu-
sive, despite qualitative studies suggesting that specific organizational cul-
ture characteristics play a role (Bradley et al., 2001).
These limitations in the assessment of quality improvement overall, as
well as the assessment of specific quality improvement interventions, re-
sult in various types of study designs and different levels of reliability of
the study results. Few of the studies reviewed contained true control
groups, and even fewer were the more stringently devised randomized
control trials. The majority of the studies measured improvement as the
change from the baseline in the group receiving the intervention and were
either prospective or retrospective in design. One research method used to
temper some of the limitations and control for changes in the environ-
ment is to stagger implementation of the intervention. The intervention is
put into practice twice: once in the original study intervention group and
once again in the designated control group after the conclusion of the
original study (Chu et al., 2003). Analyses assessing time trends are espe-
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232 MEDICARE'S QUALITY IMPROVEMENT ORGANIZATION PROGRAM
cially important in evaluations of quality improvement interventions, as
the desired changes often take longer to achieve than the lengths of the
interventions themselves and because a potential disparity exists between
short- and long-term achievements.
Impact of Health Care Quality Interventions
As mentioned above, many different approaches have been tried to
achieve quality improvement in health care. Although some studies that the
committee examined found no change in the quality of care delivered as a
result of the selected interventions; most cited some level of improvement
ranging in levels of statistical significance. Most interventions approach
quality improvement by targeting three aspects of health care: structure,
process, and outcome. Structure refers to the characteristics of a care set-
ting, including material resources, human resources, and organizational
structure. Process describes what and how care is actually provided and
received. Outcome denotes the impact of health care services on health sta-
tus and patient satisfaction. In theory, improvement in structure drives a
good process, which in turn drives a good outcome (Donabedian, 1988).
The following discussion assesses the literature on interventions that target
processes and outcomes and then discusses the literature on other interven-
tions that focus on structure and audit-feedback.
Process Measures
One common finding in the literature was the demonstrated improve-
ment in process measures due to the implementation of clinical practice
guidelines. This conclusion was determined from the findings of both ran-
domized controlled trials and cohort studies (Ornstein et al., 2004; Joseph
et al., 2004; Halm et al., 2004). Clinical practice guidelines are evidence-
based recommendations developed to direct decision making for the provi-
sion of care. An example of a guideline for a process measure is the percent-
age of providers who document taking a patient's blood pressure during an
office visit. The use of process guidelines generally led to increases in the
documentation of care processes for a variety of conditions (cardiovascular
diseases, pneumonia, and tobacco use) and a variety of care settings (physi-
cians' offices and hospitals). However, the resulting levels of statistical sig-
nificance varied, with studies citing significant improvement in only one of
many measures (one study looked at 14 process measures) (see Table A.1 in
Appendix A). One randomized controlled trial, however, evaluated guide-
lines in the context of a larger, more systemwide intervention, and found
only marginal change in physician adherence (Ornstein et al., 2004). The
more systemwide effects of the intervention were not separated from those
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IMPACT OF TECHNICAL ASSISTANCE 233
of the guidelines themselves, complicating any conclusions that guidelines
alone enhance quality. The provision of guidelines also does not necessarily
lead to the dissemination of new knowledge regarding care practices (Centor
et al., 2003).
Outcomes
Another theme detected in the literature review was a lack of demon-
strated improvement in health outcomes (such as patient health status) as a
result of the use of treatment guidelines for desired outcomes. For example,
a desired outcome derived from the observance of diabetes care guidelines
is control of hemoglobin A1c levels in diabetes patients to less than 8 per-
cent mg/dL. The same studies that failed to demonstrate improvement in
process measures were used to evaluate outcomes. These studies were de-
signed as randomized controlled trials and cohort studies. The studies evalu-
ated multiple conditions and care settings. Outcomes based on treatment
guidelines did not change significantly during the study periods, with use of
the guidelines having from no impact to only a marginal impact (Ornstein
et al., 2004; Joseph et al., 2004; Halm et al., 2004) (see Table A.1 in Ap-
pendix A). The impacts of interventions on outcomes may, however, take
longer to identify than the duration of the study, thereby resulting in false
conclusions about an intervention. Changes in outcomes may also be influ-
enced by patient behaviors, over which providers have limited control.
Other Interventions
Conclusions about other types of interventions cannot be drawn be-
cause of a lack of a robust evidence base and inconsistent results. For in-
stance, research gaps exist concerning structural issues and audit-feedback
(Jamtvedt et al., 2004; Coleman et al., 2004; Mark et al., 2004).
Although improved performance on the process and outcome measures
presented in studies are a good starting point for obtaining improvements
in quality, performance should ultimately keep getting better. Structural
issues such as nurse staffing levels were addressed in a cohort study. Im-
provements in mortality rates were found in association with increases in
the numbers of registered nurses on staff, but the improvements could not
be solely ascribed to those increases. Also, a diminishing marginal effect of
increased staff members was found on improvements of mortality rates.
Although the evidence base for improvements in health care quality attrib-
utable to structural changes is emerging, it is sparse (Mark et al., 2004).
Provider and organizational characteristics are also important struc-
tural issues to be considered for the achievement of continuous improve-
ments. One qualitative study used interviews to evaluate whether cor-
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234 MEDICARE'S QUALITY IMPROVEMENT ORGANIZATION PROGRAM
relations between provider characteristics and quality improvement exist
(Bradley et al., 2001). The researchers identified provider characteristics
and measured quality improvement in terms of the percentage of patients
who had received beta-blockers at discharge. Hospitals with greater
amounts of improvement had four similar characteristics: shared goals
throughout the institution, strong administrative support, high levels of
physician leadership, and high-quality feedback. The levels of innovation
were not, however, found to correlate with high or low levels of perfor-
mance (Bradley et al., 2001).
To prepare an organization to be receptive to change, researchers iden-
tified the following dimensions of success: strategy, culture, technique, and
structure. The improvement mechanism must target strategic conditions and
processes within the organization. The organization must foster a culture
that supports the mechanism, and it must ensure that staff are properly
trained and given the necessary tools to implement the intervention techni-
cally. The last dimension is structure, which refers to the mechanisms used
to adopt and spread better practices throughout the organization. All four
dimensions must be present for successful change to occur (Shortell et al.,
1998; Heller and Arozullah, 2001). However, it is very difficult to develop
the strategic and cultural dimensions if the organization does not already
have these attributes. Technique and structure are somewhat easier to de-
velop. For example, the organization can purchase expertise, but it takes
longer to develop a supportive culture.
In health care settings, audit and feedback refers to the process in which
provider performance is evaluated and reported back to the provider, which
allows the provider to make improvements. The committee's present review
found that the audit and feedback method inconsistently provides signifi-
cant improvements. The coupling of these efforts with other types of im-
provement interventions also did not yield better results. A major limitation
to the committee's systematic review was the lack of high-quality studies, as
it was noted that the participants in many studies had low levels of compli-
ance at the baseline and the studies had small sample sizes. Improved re-
porting of the details about the actual intervention was also found to be
needed (Jamtvedt et al., 2004).
Impact of QIO Quality Improvement Interventions with Providers
The evidence about the impact of QIO quality interventions compared
with the impact of other health care quality interventions is mixed. This
conclusion is most prominently derived from studies in which researchers
found that the trends for hospital systems and hospitals that did and did not
participate in QIO interventions were similar (Ellerbeck et al., 2000;
Dellinger et al., 2005).
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IMPACT OF TECHNICAL ASSISTANCE 235
Process Measures
Studies using process measures to evaluate the effects of QIO efforts to
improve quality used a variety of designs: randomized controlled trial de-
signs, quasiexperimental designs, cohort study designs, and cross-sectional
study designs. These studies looked at the use of practice guidelines for the
care processes for multiple conditions (diabetes, cardiovascular disease, and
pneumonia) and were conducted in hospitals, academic medical centers,
and physicians' offices. Echoing the findings from the quality improvement
intervention literature of studies assessing non-QIO-related interventions,
improvements in quality were found as a result of the QIO-related interven-
tions (Marciniak et al., 1998; Ellerbeck et al., 2000; Holman et al., 2001;
Kiefe et al., 2001; Sheikh and Bullock, 2001; Sutherland et al., 2001; Luthi
et al., 2002; Gould et al., 2002; Chu et al., 2003; Burwen et al., 2003;
Berner et al., 2003; McClellan et al., 2003; Massing et al., 2003; Daniel
et al., 2004a).
Outcomes
Many studies looked at the impact that QIO interventions have on
outcomes. Those studies examined a variety of outcomes in patients with
diabetes, cardiovascular disease, and pneumonia seen in the hospital and
the physician's office settings and used quasiexperimental and cohort meth-
odological designs. As has been found in the broader literature on quality
improvement, interventions by QIOs to improve outcomes have not yet
been demonstrated to result in significant change. Although some studies
found improvements in quality, the results of many of them are inconclu-
sive. The limitations described in the broader literature on quality improve-
ment are the same, such as a limited ability to control patient behaviors
(Marciniak et al., 1998; Ellerbeck et al., 2000; Sheikh and Bullock, 2001;
Sutherland et al., 2001; Holman et al., 2001; Luthi et al., 2002; Gould et al.,
2002; Chu et al., 2003; McClellan et al., 2003; Massing et al., 2003; Daniel
et al., 2004a) (see Table A.1 in Appendix A).
Only one study evaluated in the committee's literature review focused
on patient behaviors. That study examined patient adherence to a health
maintenance organization's guidelines for the frequency of mammography
upon receipt of one of three types of reminders. This QIO-related ran-
domized control trial found that only telephone reminders coupled with
the option to schedule an appointment were effective; publicity campaigns
encouraging screening and mail reminders were not effective (Barr
et al., 2001).
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236 MEDICARE'S QUALITY IMPROVEMENT ORGANIZATION PROGRAM
Other Interventions
Studies of other types of interventions that have been performed by
QIOs or that use improvement tools developed by QIOs have yielded in-
conclusive results. For example, the impact of educating second-year medi-
cal students on the use of process guidelines and reminders provided by
QIOs generated some significant improvement (Gould et al., 2002). A study
conducted by a QIO audit and feedback in hospitals could not conclusively
find methods to yield improvements for the following five conditions: acute
myocardial infarction, heart failure, pneumonia, stroke, and atrial fibrilla-
tion. Consistent with the general limitations of quality intervention studies,
a true causal relationship could not be drawn because of the lack of con-
trols in that study (Schade et al., 2004).
National Evaluations of QIO Technical Assistance Efforts
Various reviews have evaluated various elements of the technical assis-
tance provided by the QIO program, but none could ascribe the improve-
ments directly to the efforts of the QIOs.
One study compared the national and state-level improvements in 22
QIO measures of quality in the hospital and the physician's office settings
between the time periods of 19981999 and 20002001 (from the end of
the 6th scope of work [SOW] to the beginning of the 7th SOW). That cross-
sectional study built upon earlier efforts that found that the quality of care
provided by the states was inconsistent (Jencks et al., 2000). The study
found that care for fee-for-service beneficiaries on the whole improved dur-
ing this time period, as the national and the state averages for 20 of the 22
measures increased. In general, states with lower baselines yielded higher
rates of absolute improvement in the quality of care. The study also ranked
states on the appropriate provision of care on the basis of the same 22
measures. The result was a geography-specific pattern of care, with better
care being delivered in the northern states than in the southern states. The
levels of improvement followed a similar pattern. The improvements cited
in that study could not be attributed directly to the QIO program, however,
for many of the reasons discussed above. However, that study was designed
to look at quality trends and not to assess the impact of the QIO program
(Jencks et al., 2003).
Another study randomly surveyed 105 hospital directors of quality of
care across the nation to determine their perceptions of QIO effectiveness.
That cross-sectional study found that 60 percent of quality directors be-
lieved that certain QIO interventions, such as the provision of performance
data and education materials, were helpful or very helpful. However, the
same survey disclosed that in the absence of QIO interventions, only 25 per-
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IMPACT OF TECHNICAL ASSISTANCE 237
cent of directors thought that the quality of the care delivered would have
been worse. Although the study found that QIOs were mostly viewed as
partners for improving care, as opposed to their previous role as adversar-
ies, the researchers noted the need to engage senior-level support (both phy-
sicians and hospital management) to further the QIOs' impacts. These find-
ings were based on the opinions of those interviewed and not on quantitative
measures of actual impacts (Bradley et al., 2005).
A recent study evaluated the effectiveness of QIO interventions on im-
proving the quality of care in hospitals. That quasiexperimental study com-
pared the differences in care in five clinical areas (atrial fibrillation, acute
myocardial infarction, heart failure, pneumonia, and stroke) delivered by
participating (n = 199) and nonparticipating (n = 142) hospitals in Mary-
land, New York, Nevada, Utah, Washington state, and Washington, D.C.
The researchers collected data on 15 indicators at the baseline (19981999)
and at the follow-up (20002001). The data revealed that nonparticipating
hospitals were generally for profit and smaller than the participating hospi-
tals. (The researchers defined "participating hospitals" as those that either
collected measurement data or implemented changes in their procedures as
a result of efforts made by their respective QIOs.) At the baseline, data for
5 of 15 indicators differed significantly, with nonparticipating hospitals
performing better than participating hospitals on 2 of these 5 indicators;
participating hospitals performed better on the other three indicators. At
the follow-up, the data showed significant differences on four indicators,
with the participating hospitals performing better on all of them. However,
at the baseline, differences between participating and nonparticipating hos-
pitals were found on only two of these four indicators. When the baseline
performance and the follow-up performance were compared, researchers
found significant differences (P < 0.05) between participating and nonpar-
ticipating hospitals for only 1 of the 15 indicators (the patient was screened
for pneumococcal immunization or given the pneumococcal vaccine [P =
0.005]). They concluded that, overall, hospitals participating with QIOs
were no more likely to improve than nonparticipating hospitals. Impor-
tantly, a general trend of improvement was found for both participating
and nonparticipating hospitals (Snyder and Anderson, 2005).
The findings of that study concur with those of other studies that show
that quality improvements have been made over time, but the study con-
cludes that the improvements cannot be directly attributed to the activities
of the QIOs (Jencks et al., 2003). Although that study has strength because
of its use of a comparison group, it also has limitations. In particular, the
distinction between participating and nonparticipating hospitals is very
broad, and precise descriptions of the interventions are lacking. A lack of
descriptive details also makes it difficult to discern the exact roles that the
QIOs played. The effects of other quality interventions that were concur-
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238 MEDICARE'S QUALITY IMPROVEMENT ORGANIZATION PROGRAM
rently under way in the hospitals included in the study are unknown. Each
participating hospital did not necessarily participate in QIO activities or
focus on improving all 15 indicators at the same time, which biased the
impacts of the interventions and thus does not allow comparisons of
the improvements on specific indicators within a clinical area. Additionally,
the study examined only a limited subset of the hospitals in the country and
only one portion of the QIO program. Moreover, the data reflect the results
from the 6th SOW; evaluated changes thus do not reflect the major strate-
gic shifts made by the QIO program in the 7th SOW and is not indicative of
the effectiveness of the current program.
Although the studies described above cannot ascribe improvements in
the quality of the care delivered directly to the efforts of the QIOs, this is
not to say that QIO interventions have been unsuccessful. Some studies find
that the efforts of QIOs have had positive impacts. One of the building
blocks for promoting quality improvement through the QIO program is the
Cooperative Cardiovascular Project (see Chapter 1). The Cooperative Car-
diovascular Project was part of the initial movement in 1992 to shift the
strategy of CMS to providing technical assistance to providers (Jencks and
Wilensky, 1992). The Cooperative Cardiovascular Project pilot lasted from
1992 to 1995 and assessed quality improvement activities for acute myo-
cardial infarction patients in Alabama, Connecticut, Iowa, and Wisconsin.
The quality of care was evaluated on the basis of improvements in 26 mea-
sures of processes and outcomes. The researchers found that not all eligible
patients received treatments either at all or in a timely manner. Despite this
finding, the Cooperative Cardiovascular Project successfully attained sig-
nificant documented improvements in process measures (Ellerbeck et al.,
1995; Marciniak et al., 1998; Holman et al., 2001; Burwen et al., 2003),
thereby promoting the use of quality improvement efforts.
In addition to the Cooperative Cardiovascular Project, other studies of
QIO activities support the effectiveness of QIO interventions (Sutherland
et al., 2001; Gould et al., 2002; Chu et al., 2003; Daniel et al., 2004b).
While these studies all targeted physicians, no other commonalities were
readily identified in the articles. The positive effects were limited, and do
not demonstrate the impact of the QIO program overall.
Because of the QIO program's voluntary nature, its goal of the provi-
sion of a public good, and the QIOs' method of involving many partners in
each intervention program, it is difficult to attribute in a causal manner the
activities of QIOs to quality improvement, as these activities cannot be eas-
ily distinguished from those of other organizations also working to improve
quality (Jencks et al., 2000). This does not mean that the QIO program is
ineffective; rather, it is difficult to measure its effect separately, as is the case
with quality improvement efforts in general. Although other organizations
work to enhance the quality of care, their efforts can work in tandem with
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IMPACT OF TECHNICAL ASSISTANCE 239
the efforts of the QIOs. For example, a demonstration project in Texas
found that the efforts of a state-sponsored program did not duplicate those
of a QIO that provided technical assistance (Cortes, 2004).
Given the limited research available, it remains unknown what drives
both successful and unsuccessful quality interventions by QIOs. More evi-
dence is needed to identify these potential drivers. While the QIO program
looks to further develop its quality improvement activities, some lessons
can be gleaned from the rest of the industry.
APPROACHES TO QUALITY IMPROVEMENT
Many approaches to managing quality improvement focus on improv-
ing systemwide processes within provider settings; these approaches are not
limited to use within health care settings, however, and are often adapted
from other industries for use by health care organizations. As many health
care organizations work toward improving quality and decreasing costs,
these approaches have become increasingly more relevant to understand. If
QIOs are to successfully work in collaboration with some of the hospitals,
physicians' offices, and health care plans that have turned to these methods,
the QIOs need to be informed. When these processes are implemented, it is
important for all players (providers) to agree to participate as well as to
keep the customers (patients) as the focus for improvement. The approaches
described below represent a mixture of tools, methodologies, and goals for
improving quality; they are not independent of each other, as some focus on
streamlining processes within individual organizations, whereas others tar-
get large organization or multi-organization systems. In addition, process
and systems are often combined to achieve higher quality:
· Baldrige criteria. Baldrige criteria are indicators of organizational
performance excellence used to evaluate organizations in different indus-
tries. The seven criteria are leadership; strategic planning; customer and
market focus; measurement, analysis, and knowledge management; a focus
on human resources; process management; and results. Organizations that
apply and exemplify these criteria are awarded the Baldrige National Qual-
ity Award, which symbolizes excellence in quality and performance. The
United States Congress established the Baldrige National Quality Award in
1987, and it is presented annually by the President of the United States.
Awards are given for five sectors: manufacturing, service, small business,
education, and health care. In any given year, awards may be given to one
or more organizations in any or all of the five sectors. Recent award recipi-
ents for the health care sector include: Saint Luke's Hospital of Kansas City,
Kansas City, MO (2003); Baptist Hospital, Inc., Pensacola, FL (2003);
Robert Wood Johnson University Hospital Hamilton, Hamilton, NJ (2004);
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240 MEDICARE'S QUALITY IMPROVEMENT ORGANIZATION PROGRAM
and Bronson Methodist Hospital, Kalamazoo, MI (2005) (NIST, 2005).
Individual states have also created similar awards on the basis of the criteria
presented above.
· Collaborative methodology. The model for improvement has been
extrapolated to the collaborative methodology, which refers to a semi-
structured gathering of providers from various health care organizations to
improve a common process of care by sharing experiences, best practices,
and lessons learned with each other (Ovretveit et al., 2002). The methods
used often include meetings, web-based conferences, and teleconferences
(see Chapter 8 for further discussion).
· Human factors. Human factors is a tool used to redesign processes
and systems to better use the attributes controlled by both the physical and
the cognitive abilities of the people involved in the delivery of care. By
understanding the human aspects of why errors occur, processes and sys-
tems can become more safe, effective, efficient, and patient centered (NAE
and IOM, 2005; Qualis Health, 2005c).
· International Standards Organization Standard 9000 (ISO 9000).
ISO 9000 is a standard that provides process guidelines and requirements
for quality management. On the basis of an external audit, an organization
can be certified to ISO 9000, which signifies that it has demonstrated the
ability to adhere to processes of quality improvement. The ISO 9000 family
includes guidelines for quality management, quality management systems,
and quality assurance.
· Lean principles. Lean principles aim to streamline processes with the
goal of reducing waste and eliminating zero-value-added tasks and re-
sources. Lean principles can also be used to simplify systems. For example,
by tracking patients across the care system, services can become more effec-
tive and efficient in improving quality and minimizing costs.
· Plan, Do, Study (Change), Act (PDSA) Cycle. The PDSA Cycle is a
method for continuously improving the quality of processes: plan for a
change, do a trial of the planned change, study the results, and act to imple-
ment the next steps based on the results. In the PDSA Cycle, change refers
to implementing change in the process.
· Six Sigma. Six Sigma is a data-driven problem-solving methodology
that is used to minimize variations in processes and builds on statistical
process control. Individuals can build Six Sigma competencies through train-
ing and continuous practice with application of the method in various
projects. The competency levels include green belt (entry level), black belt
(middle), and master black belt (expert).
· Root-cause analysis. Root-cause analysis is an approach taken to
understand the reasons why an event has occurred. The recurrence of ad-
verse events can be eliminated by looking systematically at the managerial
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246 MEDICARE'S QUALITY IMPROVEMENT ORGANIZATION PROGRAM
tion, these multiple paths of knowledge transfer can help strengthen the
communication and effectiveness of the QIO program.
QIO Support Centers
QIOSCs provide technical assistance to QIOs, just as the QIOs offer
technical assistance to providers, to achieve improvements in care, as dis-
cussed in Chapters 7 and 8. QIOSCs are critical to the sharing of informa-
tion among QIOs. Unlike the core QIO contracts, which are based on a
point scale (see Chapter 10), CMS assesses QIOSCs on how satisfactorily
their deliverables are met on the basis of the judgment of the Government
Task Leader in charge of each QIOSC (see Chapter 13). CMS's evaluations
of the QIOSCs in the 7th SOW led to a redesign of the QIOSC system for
the 8th SOW (see Chapter 8) (personal communication, J. Taylor, April 29,
2005). With recognition of the unique feedback that QIOs can provide to
the QIOSC system as the customers of the QIOSCs, a survey that assessed
QIO satisfaction with the QIOSCs was added to the 8th SOW as part of the
redesign of the SOW. Evaluation of QIOSC effectiveness by CMS will there-
fore be a function of satisfaction from both the Government Task Leaders
and the QIOs.
One approach used to transfer knowledge in the QIO program is the
Process Improvement QIOSC, which was created in the 7th SOW and which
has been renamed the Performance Improvement QIOSC in the 8th SOW.
Qualis Health led this QIOSC in both the 7th and the 8th SOWs. The goal
of this QIOSC is to ensure the efficiency and effectiveness of QIO processes
by creating a "culture of shameless stealing" to exchange best practices
(Qualis Health, 2005b). To achieve this goal, this QIOSC trains both QIOs
and providers on running and facilitating collaboratives following the de-
sign of the Institute for Healthcare Improvement Breakthrough Series Col-
Beneficiaries
QIO Provider
CMS QIOSCs
QIO Provider
FIGURE 9.1 Knowledge transfer in the QIO program.
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IMPACT OF TECHNICAL ASSISTANCE 247
laborative (see Chapter 8). Although the evidence base for collaborative
initiatives remains inconclusive, as discussed earlier in this chapter, in the
7th SOW, Qualis Health assisted with the implementation of more than
seven collaboratives, each of which focused on different aspects of technical
assistance tasks. Many of the providers involved in collaboratives made
improvements, such as increasing the rate of antibiotic use from 78 to
91 percent among patients with pneumonia in 14 critical access hospitals in
an 8-month collaborative in Idaho (Qualis Health, 2005a). However, be-
cause of the limitations of measuring and attributing improvement, the im-
pact of the QIO intervention cannot be separated from those of other
possible interventions or factors. Beyond instilling a culture of quality im-
provement through collaboration, the leaders of these initiatives hope that
the providers involved transfer the knowledge that they have gained to oth-
ers in their communities.
On the basis of the interviews with QIOSC CEOs and staff, the QIOSCs
mentioned the following as barriers to their missions: imprecise evaluation
methods, the rigidity of CMS oversight, a lack of contract flexibility, the
timing of the QIOSC contract (which is aligned with the start of the SOW,
and thus does not allow the QIOSCs time to develop materials before the
beginning of the SOW), and the timing of the approval and distribution of
the tools developed by the QIOSCs.
In telephone interviews with 20 QIO CEOs, the QIOSCs received mixed
reviews in terms of both expertise and timeliness. The following are some of
the criticisms of the QIOSCs from the overall assessments of the QIOSCs
by the QIO CEOs:
· QIO task-related materials were not made available in a timely
enough manner, at times forcing QIOs to produce their own.
· The focus or the target of the materials was not always applicable to
all states because of differences in state sizes, regional influences, and popu-
lation demographics.
· The innovativeness of the interventions and the materials did not
necessarily lead to significant changes in areas where the QIOs needed
support.
· The flow of information was backwards, in that the QIOs offered
more support to the QIOSCs than the other way around.
QIO-to-QIO Knowledge Transfer
The development and alteration of interventions at the state level but
with maintenance of the core attributes of the interventions that can result
in improvement are key to successful quality improvement within each state
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248 MEDICARE'S QUALITY IMPROVEMENT ORGANIZATION PROGRAM
because of differences in local environments. The QIOs can develop and
alter interventions independently or partner with other public or private
organizations. Interventions often develop in the QIO program as part of
pilot tests or special studies. An example of a successful pilot program was
the Cooperative Cardiovascular Project, which began as a four-state pilot
project in 1995 that was eventually implemented on a national scale. An
11-state pilot project that was under way at the time of this writing and that
was expected to conclude in July 2005 is testing the ability of providers to
assess specific process and outcome measures to reduce preventable hospi-
talizations in the home health setting (AHQA, 2005). If the pilot is success-
ful, the 11 states in the pilot will be able to pass on the lessons learned and
help other QIOs implement the intervention. In telephone interviews with
the QIO CEOs, 8 of 20 CEOs commented that pilot testing is beneficial
because it allows experience with the task at hand to be obtained before all
QIOs are required to do the task.
In the telephone interviews, the CEOs also identified non-QIOSC QIOs
as sources of information and assistance. This is echoed by responses to a
question in the web-based data collection tool that asked the respondents to
name the top three QIOs that they would turn to for help with technical
assistance tasks. Fifty-seven percent of all the responders (88 of 155) said
that they would approach a non-QIOSC QIO for support.
Best Practice Methods Special Study
Innovations created at the state level may not, however, be applicable
to all QIOs because of variations among the states. A special study entitled
the Best Practice Methods Special Study, run by the Process Improvement
QIOSC, was a two-part study of the 7th SOW for determination of how
successful interventions and lessons learned can best be transferred among
the QIOs. The first part of this special study distinguished high-performing
QIOs from low-performing QIOs on the basis of statistically significant
comparisons of statewide performance with national performance on the
12 hospital measures used in both the 6th and the 7th SOWs. Using this
categorization of QIOs as a platform, the QIOSC administered surveys to
the QIOs in the high-performing group (eight QIOs) and low-performing
group (nine QIOs). With the recognition of limitations because of recall
bias and the relatively small sample size, the study identified the organiza-
tional characteristics of high-performing QIOs that resulted in the high-
quality performance: staff empowerment, low staff turnover, flexibility, and
staff in place at the beginning of the SOW. The QIOs with good reputations
among providers scored higher. Greater CEO and board involvement were
also associated with higher-performing QIOs. Standardized ("one-size-fits-
all") interventions were associated with lower-performing QIOs; the higher-
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IMPACT OF TECHNICAL ASSISTANCE 249
performing QIOs were able to customize interventions to meet their local
needs. Differences in patient age, population education, and the frequency
of provider interactions were not found to be associated with either high- or
low-performing QIOs.
The second part of the Best Practice Methods Special Study examined
the portability of the best practices identified in the first part of the study.
Fifty hospitals participated in the second part of the study, 10 hospitals
from each of the five participating QIOs from the states of Arizona, Colo-
rado, Maryland, South Carolina, and Washington. Upon the implementa-
tion of similar processes of care for smoking cessation counseling and dis-
charge planning, the special study attempted to determine whether certain
QIO characteristics or interventions are transferable to other states, which
would delineate the ability to transfer knowledge of best practices among
QIOs in various environments (CMS, 2005a).
The Medicare Quality Improvement Community (MedQIC) is a pub-
licly available web-based resource that primarily serves as an interface
among CMS, QIOs, and Medicare providers. Support is available in the
forms of tools such as fact sheets, templates, slides, presentations, specific
information on process measures and guidelines for their collection, litera-
ture, and success stories for both clinical and consumer education. The QIOs
and providers may also find contact information on the website for staff at
the appropriate QIOSC. Providers can rank the tools available, as well as
suggest new tools. A forum within MedQIC called QNet Quest is a data-
base of answers to frequently asked questions. Through this database, pro-
viders can directly ask the QIOs for support (see Chapter 13 for a further
discussion of MedQIC).
CMS-to-QIO Knowledge Transfer
CMS uses a variety of methods to communicate with QIOs, including
memos, e-mails, face-to-face meetings, and various information and com-
munications technology tools (see Chapter 13). In the telephone interviews,
the QIO CEOs also cited CMS working groups and meetings with CMS
Regional Offices as methods of knowledge transfer. CMS uses QIONet, an
intranet site provided under the auspices of CMS's Standard Data Process-
ing System available only to QIOs and CMS groups, to share information
and tools for the purpose of improving program management and achiev-
ing program goals (see Chapter 13).
QIO-to-Provider Knowledge Transfer
The transfer of knowledge from QIOs to providers stemmed from the
widespread sharing of materials beyond the identified groups of partici-
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250 MEDICARE'S QUALITY IMPROVEMENT ORGANIZATION PROGRAM
pants through the inclusion of a broader group of providers in meetings and
through the inclusion of stakeholder groups that could then communicate
with their memberships. Participants are provided with materials so that
they can try to make changes on their own without receiving additional
technical assistance from the QIO. In the telephone interviews with the
QIO CEOs, the CEOs stressed the importance of champions and the use of
stakeholder organizations. Additionally, the CEOs often mentioned how
the electronic age aids with the transfer of knowledge within their states,
particularly when providers are dispersed geographically or have limited
time to spend away from their offices. QIOs use on-site meetings and tech-
nology like webex and other video teleconferencing methods. Some QIOs
develop and send out compact discs containing quality improvement
related presentations to those providers who do not attend their meetings.
Many QIOs hold statewide quality forums for the presentation of best prac-
tices for providers within their states and give out awards for achievement.
Other QIOs publish articles in their state medical journals as well as in
national medical journals. In telephone interviews, one QIO CEO men-
tioned the possibility of tying some quality improvement efforts to continu-
ing medical education credits for physicians as a way to increase their
participation.
Knowledge Transfer with Beneficiaries
Beneficiaries are an integral part of knowledge transfer. Input on how
care is received is important in CMS's and QIOs' evaluations of the QIO
program and the performance of individual QIOs. Beneficiaries also relate
their perceptions of care to providers, who can then provide feedback to the
QIOs. Knowledge is indirectly transferred from beneficiaries to CMS
through the QIOs. Examples of the means of knowledge transfer from ben-
eficiaries to QIOs include consumer advisory councils, representation of
consumers on QIO boards, and beneficiary surveys on their satisfaction
with the mediation of beneficiary complaints (see Chapters 11 and 12).
It is also important for beneficiaries to receive information from CMS,
QIOs, and providers on the quality of care being delivered and what benefi-
ciaries themselves can do to promote better health. CMS publicly reports
data on the quality of care for individual nursing homes, home health agen-
cies, and hospitals through its Compare websites (see Chapter 11). For ex-
ample, CMS requires QIOs to maintain help lines to assist beneficiaries.
QIOs sometimes also supply providers with fact sheets to distribute to
patients.
How well knowledge has been transferred between beneficiaries and
CMS, QIOs, and providers is not well documented. In the 7th SOW, benefi-
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IMPACT OF TECHNICAL ASSISTANCE 251
ciary satisfaction surveys covered only mediation activities; in the 8th SOW,
however, beneficiaries will be surveyed on all the care that they receive.
The telephone interviews disclosed that many QIO CEOs found benefi-
ciary education to be valuable for quality improvement. For example, these
activities may help QIOs build rapport with providers. It is also unknown
whether consumers effectively use the data presented on the CMS Compare
websites or call in to the QIO help lines (see Chapter 11). The actual im-
pacts that these efforts have on beneficiaries and the quality of care that
they receive remain unclear.
Other Knowledge Transfer Mechanisms
Other mechanisms of spreading knowledge among the QIOs have de-
veloped, such as those carried out through the American Health Quality
Association (AHQA), which is the trade organization for the QIOs. Infor-
mal, unofficial groups of CEOs often come together on the basis of their
geographic region or state size, such as the Coral Initiative, which started
among five QIOs in the Midwest. Through AHQA and these other coali-
tions, QIOs meet periodically; learn about the latest program changes; and
share successes and failures via telephone conference calls, listserves, e-mail,
newsletters, etc. These groups foster a culture of sharing among the QIOs.
As described by the QIO CEOs in the telephone interviews, "The problem
is not the sharing but sifting out the scientifically based from the noise and
self-promotion," and "Already we have free flow of information. Perhaps
we have too much free flow because the focus is not on rigor in documenta-
tion. Lots of assertions are made about what works." The CEOs praised the
specialized groupings of QIOs for their effectiveness in sharing and solving
problems as well as the sharing that they perform through AHQA commit-
tees and conferences.
Many QIOs have been innovators of quality improvement, as interven-
tions are often adapted to best fit the needs of each state or jurisdiction.
However, if the development processes and successes of these variations are
not shared with other QIOs, opportunities for improvement may be lost.
Although some QIOs share their stories of innovation with others, an
"owner" of this function who can make the information widely available is
lacking. Although the QIOs are encouraged to publish articles regarding
their work, QIO evaluation formulas did not emphasize those efforts in the
7th SOW. In the 8th SOW, CMS added acceptance for publication in peer-
reviewed journals as an extra-credit point to the Hospital Payment Moni-
toring Program but not for other aspects of the SOW. Therefore, as QIOs
are under performance-based contracts with limited time and resources,
CMS provides little incentive to contribute to the literature.
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252 MEDICARE'S QUALITY IMPROVEMENT ORGANIZATION PROGRAM
SUMMARY
This chapter has discussed issues related to the impact of technical as-
sistance for quality improvement and knowledge transfer both in the health
care environment in general and in the QIO program in particular. The
following are some of the main themes of this chapter, which are reflected
in the findings and conclusions presented in Chapter 2:
· Quality improvement is difficult to achieve.
· The evidence for the impact of quality improvement interventions is
mixed. Conclusions drawn from the literature base for quality improve-
ment show that the quality improvements resulting from interventions in
health care in general and the QIO program in the particular are similar.
· Quality improvement interventions were able to consistently pro-
duce significant improvements in process measures; other interventions,
such as those focusing on outcomes and structure, were not found to yield
improvements. There are, however, many limitations to the methods by
which quality improvement interventions are documented and evaluated.
· Although the quality of care received by Medicare beneficiaries has
improved somewhat, researchers have been unable to attribute these changes
to the QIO program. This can be the result of various limitations, such as
how QIO interventions are currently evaluated or the fact that QIO inter-
ventions do not improve quality.
· A variety of approaches to quality improvement are being tried in
many industries, and QIOs are learning from these approaches.
· Collaboratives were often used to incite quality improvement in the
7th SOW. However, evaluations of collaboratives in the literature--both in
the general health care environment and in the QIO program--have pro-
vided inconclusive results on their impact on improving quality.
· On the basis of the information in the literature, it cannot be
determined what drives knowledge transfer in the general health care
environment.
· Knowledge transfer in the QIO program is not well documented,
making it difficult for the committee to find evidence for how effectively the
QIOs achieve it. There are many paths for the transfer of knowledge in the
QIO program; these could all be leveraged to achieve increased quality.
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Representative terms from entire chapter:
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