Editor’s note: This is the seventh in a series of articles related to topics presented at the 2007 Symposium on Regulatory Issues for Management in Long-Term Care (SORIM LTC). For slides and video of the presentations, visit www.SORIMLTC.com.

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uality Improvement Organizations (QIOs) monitor the appropriateness, effectiveness, and quality of care provided to Medicare beneficiaries. They are private contractor extensions of the Centers for Medicare & Medicaid Services (CMS), under whose direction they work with consumers and physicians, hospitals, and other caregivers to refine care delivery systems to make sure patients—particularly those who are underserved—get the right care at the right time. The program also safeguards the integrity of the Medicare Trust Fund by ensuring that payment is made only for medically necessary services and investigating beneficiary complaints about quality of care.
       Although QIOs have much to offer providers and the patients they care for, there are many misunderstandings and misconceptions about them. To clarify those, ECPN recently spoke with Kevin Warren, MHA, LNFA, CPHQ, Senior Vice President, Operations, for TMF Health Quality Institute (Austin, Tex), who presented at the 2007 SORIM LTC on how QIOs can drive quality.

       ECPN: How long have QIOs been around, and how have they evolved?
       Warren: They’ve gone through multiple iterations. I can speak specifically to TMF, which has been around since 1971. We were chartered as a private, non-profit organization of licensed physicians involved in reviewing quality and performing medical review of care delivered by Texas physicians. In 1984, TMF was awarded the Medicare peer review organization (PRO) contract to do medical review for Medicare beneficiaries. Since that time, the program has changed from the PRO designation to the Quality Improvement Organization (QIO) designation. That’s when we began efforts into the quality aspect of the work, beginning with hospitals. In 2000, the program expanded for the first time into long-term care as well as additional effort into the ambulatory side in working with physician offices. In 2003, QIOs expanded into home health. We’re now working with nursing homes, home health, physicians, and hospitals.
       ECPN: Are there misconceptions as to the QIO’s purpose?
       Warren: I’d say the two things you run into across the country are a lack of brand awareness and a lack of understanding or awareness of what our function and responsibility is on the quality side of the work. QIOs have a history of being a peer-review organization responsible for assessing whether appropriate care was provided and responding to beneficiary complaints, and it’s that brand awareness that’s now in play. There’s also a misconception related to the ties to regulatory. We’re not a regulatory agency but rather a consultative organization—a program funded from the federal government. But I’ve had people ask if our funding comes from the state government to do this work, which it does not. We don’t write deficiencies. What we do is free of charge.
       ECPN: How do nursing homes typically respond to the start of the QIO process?
       Warren: Initially, I think you do have that, “We’re the government, and we’re here to help you,” hurdle to clear, but we overcome that. When I’m asked, “What’s your role? What can you do for me?” I say, “My intent is to help you look at your processes and make those that work work well and those that work well work better.” The goal is to provide the right care for every resident, at the right time, every time. So, once the nursing home becomes comfortable, I really do believe it creates a great working opportunity, because there’s another set of eyes there to help them identify their critical processes and steps in achieving that level of performance and quality that staff, residents, and family members expect and deserve.
       ECPN: What types of things do QIOs do and measure?
       Warren: In the nursing home setting, our primary focus is reduction in pressure ulcers, reductions of physical restraints, reductions in chronic pain, and assisting with workforce retention and turnover and resident and staff satisfaction. The other key piece is target setting, which is encouraging facilities into the process of setting goals and being able to measure the impact of the changes they’re making to ensure that desired improvement occurs.
       ECPN: What effects do you see, generally?
       Warren: I think that the biggest thing, the main take-away point, we impress upon facilities is getting them into the habit of understanding that you cannot achieve sustained improvement unless you identify and fix the root cause. It’s teaching them how to dig deeper. For example, it wouldn’t be prudent to assume that the reason a facility has an increase in the number of pressure ulcers is merely because residents are not being turned as frequently as necessary. There may be a number of factors associated with the increase, and these factors may be resident-specific. The adage is to ask “Why?” five times. Along the same line, another key item we stress is that the root cause is almost always a system failure, not a person’s. When you remove the person from the process, the problem often either remains or reoccurs. It’s getting the facility to focus on the process, not the people.
       ECPN: Where do you see QIOs going in the future?
       Warren: We would welcome the chance to work with more facilities. We’re limited now, working with anywhere from 10–15% of the facilities in each state based on contract funding levels. In Texas, the QIO program is funded at about $0.45 per Medicare beneficiary per month to provide quality consulting support to nursing homes, home health agencies, physician offices, and hospitals as well as the beneficiary protection and review efforts. We’re talking about making a difference every year at the cost of two trips to the coffee shop. We hope that we can be funded to engage more facilities—to look at how we can assist them in the continuum of care, how we can help them reduce readmission rates, and how we can help and improve upon the measures we now work on. It’s continuing to focus on those items, to focus on chronic pain management, to see how it can expand. I think there’s also an opportunity to look at how to ensure the communication between the hospital setting and the nursing home in readmissions.
       ECPN: On one of the slides in your SORIM presentation, you mentioned, “Avoiding the Big Bang.” What did you mean?
       Warren: Avoiding the big bang means starting small. Whenever you make a change in a process, it’s critical that you start small, on one shift or one unit. Avoid the big bang. Meaning, you’ve got this new process change y

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ou want to do, so you send out a memo, do an all-staff education—you’re gonna do this across the organization. Many times, what happens because you didn’t account for all of the variations that exist is the process change may not work exactly as planned, and staff members become frustrated with the “improved” process. It’s difficult to measure the true effectiveness of any change when you start facility-wide. But if you start small on one shift and maybe as simply as changing the process for capturing data on admission, if you start with the first patient being admitted and apply that process to the entire shift, then you can look at applying it facility-wide. That way, what you’ve done is help to alleviate and minimize some of the critical errors you hope to fix before you roll it out so it continues to improve and move in the right direction. By doing this type of rollout, it helps you gain support. Keep in mind, the faster the staff identifies the flaws in the “improved” process, the harder it is to gain long-term buy-in, and staff begins to say, “Here they go again.” But if you start small and they see it working and the value added, they want to be included. They hear, “Hey, that works, this is effective, this is helping me do what I got into long-term care to do in the first place—to help residents in need.”