Quality Improvement Organization

HealthInsight New Mexico is designated by the Centers for Medicare & Medicaid Services (CMS) as our state’s Quality Improvement Organization (QIO). This work centers on health care processes and data reporting that affects Medicare beneficiaries.

The QIO Program is the largest federal program dedicated to improving health quality at the community level. QIOs in every state and territory, united in a network administered by CMS, have the flexibility to respond to local needs. QIOs work with consumers, health care providers and health plans, and industry stakeholders and other partners to refine care delivery systems to make sure patients get the right care at the right time, particularly patients from underserved populations. QIOs also help safeguard the integrity of the Medicare Trust Fund by investigating beneficiary complaints about quality of care and using the complaints as a basis for implementing targeted quality improvement initiatives with individual health care providers.

Health care providers and other quality stakeholders who participate in HealthInsight New Mexico’s QIO initiatives can:

• Improve Individual Patient Care. HealthInsight New Mexico’s patient safety initiatives in hospitals focus on reducing central line bloodstream infections by implementing the Comprehensive Unit-Based Safety Program (CUSP), catheter-associated urinary tract infections, Clostridium difficile and surgical site infections. All Medicare-participating hospitals in New Mexico also will receive technical assistance for reporting inpatient and outpatient quality data to CMS. In nursing homes, work initially targets pressure ulcers and physical restraints, then evolves to address other health care-acquired conditions, such as falls and catheter-associated urinary tract infections. To decrease adverse drug events, HealthInsight New Mexico is bringing clinical pharmacists, physicians and facilities together in local Patient Safety Clinical Pharmacy Services Collaboratives (PSPC), following the successful HRSA model.
• Improve Health for Populations and Communities. HealthInsight New Mexico is assisting physician practices that want to use their electronic health record (EHR) systems to coordinate preventive services and report related quality measures to CMS. Practices also can participate in a learning network focused on reducing patient risk factors for cardiac disease. HealthInsight New Mexico is also partnering with the New Mexico Health Information Technology Regional Extension Center (NM HITREC) to promote health IT integration into clinical practice.
• Integrate Care for Populations and Communities. HealthInsight New Mexico is bringing together hospitals, nursing homes, patient advocacy organizations and other stakeholders in community coalitions. Goals are to build capacity for improving care transitions and to support coalitions that apply for grant funding through Section 3026 of the Affordable Care Act.
• Deliver Beneficiary and Family Centered Care. QIO Program improvement initiatives result in safer, more effective patient care, lead to better health for populations and communities, and drive lower health care costs through improvement. QIOs also fulfill CMS’ obligation to protect the rights of Medicare beneficiaries by reviewing complaints about quality and appeals about the denial or discontinuation of health care services.

Medicare’s QIO Program demonstrates CMS’ commitment to consistent, high-quality care for Medicare beneficiaries across the country. The Program—originally known as the Utilization and Quality Control Peer Review Organization (PRO) Program—was created by the Social Security Act, as amended by the Peer Review Improvement Act of 1982. The Program’s statutory mission is to improve the effectiveness, efficiency, economy, and quality of services delivered to Medicare beneficiaries. In the early years, PROs conducted medical record reviews to ensure that Medicare was paying for medically necessary care, while doing limited quality improvement work in the form of patient case reviews. In the early 1990s, the PRO Program evolved into the QIO Program following a landmark study of the Program by the Institute of Medicine, and was given a significantly enhanced mission to drive health care quality improvement. HealthInsight New Mexico (formerly NMMRA) has served continuously as the state’s only federally contracted PRO or QIO since 1984.

For more information about QIOs, see the CMS Web site.