Beneficiary and Family-Centered Care-QIO – Recommendations and

5125 –Beneficiary and Family-Centered Care-QIO – Recommendations and Referrals for Quality Improvement Initiatives and Technical Assistance (Rev. 28, Issued: 10-21-16, Effective: 10-21-16, Implementation: 10-21-16) Pursuant to the QIO’s contract obligations, the Beneficiary and Family-Centered Care-QIO must make recommendations to Quality Innovation Network (QIN) - QIO or other CMS- designated contractor(s) for conducting quality improvement initiatives (QIIs) associated with quality of care issues. QIIs may be the result of any Beneficiary and Family-Centered Care review function and could include system-wide change QIIs and non-system-wide change QIIs. A Quality Improvement Initiative (QII) is any formal activity designed to support quality improvement that uses proven methodologies to achieve these improvements. The improvements may relate to safety, health care, health, and value, and may involve providers, practitioners, beneficiaries, and/or communities. See 42 CFR §476.1. A QII may consist of system-wide and/or non-system-wide changes and may be based on a single, confirmed concern or multiple confirmed concerns. Pursuant to the QIO’s contract obligations to develop and implement QIIs, QIIs must be considered for all confirmed concerns EXCEPT the following: 1. When it is determined that a practitioner(s) and/or provider(s) grossly and flagrantly failed to provide care that is of a quality that meets professionally recognized standard(s) of health care. (See §1156(a) of the Act.) 2. When the care failed in a substantial number of cases (more than three) to substantially comply with the obligation to provide care that is of a quality that meets the professionally recognized standard(s) of health care. (See §1156 of the Act.) NOTE: In either of the above instances, the QIO must initiate sanction proceedings in accordance with Manual Chapter 9. These proceedings will, if appropriate, involve the implementation of Corrective Action Plans. To fulfill the contract obligations to develop and implement QIIs, QIN-QIOs must consider all aspects of the referral case. QIN-QIOs must employ data analysis techniques to identify potential opportunities to improve care. In addition, QIOs should consider the impact of changes within, and across, settings. For example, if a practitioner provides care in more than one setting (e.g., an inpatient acute care setting and a skilled nursing facility), the QIO should use information available from all settings to determine improvements in one or all of the settings. QIOs may work with one, several, or all related practitioner(s)/provider(s) concerned to improve the level of the practitioner's/provider’s performance; related practitioners/providers could include other practitioners/providers in the same setting(s) or other members of the practice setting. However, QIOs may not share information among providers without the specific consent of the practitioner(s) and/or provider(s). The Beneficiary and Family-Centered Care-QIOs are not responsible for conducting technical assistance with QIIs. This responsibility falls on the Quality Innovation Network-QIOs. However, the Beneficiary and Family-Centered Care-QIOs are in a position where they can recognize major areas in need of improvement. This includes completing a quality of care review whenever a medical record is requested for utilization review—such as medical necessity, level of care, and higher-weighted DRGs (See QIO Manual Chapter 4)—in addition to quality of care reviews for beneficiary complaints and other General Quality of Care reviews. Therefore, the QIO’s input is important in designing quality improvement efforts that address trends in health care delivery that require improvement. See § 5125.1 for additional information about QIO’s responsibilities related to QIIs.