Led by the Centers for Medicare & Medicare Services (CMS), the Quality Improvement Organization (QIO) Program works with health care providers and local and tribal communities to improve health care quality, access, value and equity for people with Medicare. This effort is carried out through five initiatives:
Quality Innovation Network-Quality Improvement Organizations
- Twelve Quality Innovation Network-Quality Improvement Organizations (QIN-QIOs) work directly with nursing homes, health care providers and community coalitions serving rural and underserved areas to improve the quality and safety of care for people with Medicare. You can find the QIN-QIO that serves your state here.
Hospital Quality Improvement Contractors
- Nine Hospital Quality Improvement Contractors (HQICs) work directly with small, rural and critical access hospitals to improve health care quality and safety for people with Medicare.
American Indian Alaska Native Healthcare Quality Initiative
- The American Indian Alaska Native Healthcare Quality Initiative (AIANHQI) works directly with Indian Health Service (IHS) hospitals to improve the quality of health care for people with Medicare who are American Indian or Alaska Native.
Opioid Prescriber Safety & Support
- The Opioid Prescriber Safety & Support (OPSS) initiative provides national outreach and education to eligible providers to promote safe opioid prescribing practices and to spread knowledge of non-opioid pain management therapies.
Beneficiary and Family-Centered Care-Quality Improvement Organizations
- Two Beneficiary and Family Centered Care-Quality Improvement Organizations (BFCC-QIOs) help people with Medicare and their families exercise their right to high-quality health care. They do this by managing quality of care concerns, conducting Immediate Advocacy and reviewing appeals of discharge or decisions to end Medicare-covered services. You can find the BFCC-QIO that serves your state here.
- Inform health care providers about medical record review at their facility. This is done through the facility's designated QIO Liaison. A facility can select, designate or change its QIO Liaison by notifying its BFCC-QIO in writing.
- Monitor and administer physician acknowledgement statements for hospitals. Federal law requires hospitals that are paid under the Prospective Payment System to obtain a signed acknowledgement form from physicians who have admitting privileges at a particular hospital. Physician acknowledgements remain in effect as long as the physician has admitting privileges at the hospital.
- Monitor and administer provider Memorandums of Agreement (MOAs). Under federal law, facilities must have an MOA with their state's BFCC-QIO to receive information about medical review activity at their facility. MOAs outline the BFCC-QIO and provider responsibilities during the review process.
Partners Supporting QIO Program Initiatives
The Beneficiary and Family Centered Care National Coordinating Oversight and Review Center (BFCC NCORC) supports BFCC-QIOs as they work to improve the quality of health care delivered to people with Medicare and their families. Initiatives include:
- Ensuring case reviews are efficient, systematic and thorough.
- Using national data to identify opportunities for quality improvement and increased patient safety.
- Collaborating with the Centers for Medicare & Medicaid Services (CMS) and other partners to support the rights and services for people with Medicare.
- Engaging people with Medicare and their families to improve how health care is delivered.
- Raising awareness about people with Medicare’s rights under the Medicare program.
The Clinical Data Abstraction Center (CDAC) supports the QIO Program and other special CMS programs and projects such as the End Stage Renal Disease (ESRD) program and the Medicare Patient Safety Monitoring System (formerly known as the Quality and Safety Review System). To perform these functions, the CDAC is authorized to request medical records on behalf of CMS as part of statutory review functions performed by BFCC-QIOs. This authority is separate and apart from the Hospital Inpatient Quality Reporting (IQR) Program data validation efforts.
For the period of May 8, 2019, through May 7, 2024, the CDAC will request Medicare beneficiary medical records from providers and abstract clinical data from the records as required by CMS for the purpose set forth in section 1154 of the Social Security Act. The CDAC does not perform any BFCC-QIO review functions as identified in section 1154 and as such, if in the due course of the CDAC’s abstraction process, a potential patient harm is identified, the CDAC will refer that medical record for further clinical review to the BFCC NORC.