Introduction to Quality of Care Reviews

5000 – Introduction to Quality of Care Reviews (Rev. 28, Issued: 10-21-16, Effective: 10-21-16, Implementation: 10-21-16) This Chapter provides instructions and guidance for the Beneficiary and Family Centered Care Quality Improvement Organizations (QIOs) to follow in conducting Quality of Care Reviews and for the Quality Innovation Network (QINs) in assisting providers and practitioners in improving the quality of health care through Quality Improvement Initiatives (QIIs). The phrase “quality health care” refers to the degree to which health care services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge. A Quality of Care Review focuses on whether the quality of services provided to beneficiaries is consistent with professionally recognized standards of health care. In conducting a Quality of Care Review, the QIO is responsible for reviewing actual care and services to determine where the provided care and services fall within the range of professionally recognized standards of health care. NOTE: In the course of conducting a Quality of Care review, if a QIO identifies an issue requiring a different type of review, the QIO must follow the relevant regulations and supporting QIO Manual Chapter instructions specific to that review activity.