Quality Improvement Initiatives – Beneficiary and Family-Centered

5125.1 - Quality Improvement Initiatives – Beneficiary and Family-Centered Care QIO Responsibilities (Rev. 28, Issued: 10-21-16, Effective: 10-21-16, Implementation: 10-21-16) One of the contract responsibilities of the BFCC- QIO is to make recommendations to Quality Innovation Network QIOs 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-QIO function and could include system-wide change QIIs and non-system-wide change QIIs. CMS expects that not every confirmed non-sanctionable quality of care concern will require a QII. When the Beneficiary and Family-Centered Care QIO determines that concerns can be addressed by offering advice or an alternative approach to the practitioner and/or provider, the BFCC-QIO should include that recommendation as part of their Final Determination Letter to the provider, practitioner and/or provider (See Appendix 5-4.1, 5-5.1,5-6, and 5-7 for applicable letters). When the BFCC QIO determines that the practitioner and/or provider needs technical assistance with QII, the BFCC QIO will refer to the Quality Innovation Network-QIO. One of the BFCC-QIO’s contract duties is to provide recommendations and referrals to Quality Innovation Network-QIOs or other CMS-designated contractors for technical assistance be provided to health care practitioners and providers. This obligation arises when the BFCC-QIO has concluded a beneficiary complaint review and when the Beneficiary and Family-Centered Care-QIO has done at least one of the following: 1. Identified and confirmed quality of care concern(s) exist, after completion of the final review and including reconsideration if requested, that require QII; or 2. Has been approached by a practitioner and/or provider who is requesting the QIO’s assistance. The referral to the QIN-QIO or other CMS-designated contractor for technical assistance should occur after the notice to the beneficiary in connection with a complaint and notice to the provider that a quality of care concern has been identified; if a reconsideration is requested, the referral should occur after the reconsideration is performed. In performing its contract responsibilities, the Beneficiary and Family-Centered Care-QIO must analyze findings from the CMS-designated case review system, other information from review activities, and information from providers to: • Identify trends and patterns; • Identify needs for technical assistance related to CMS quality measures across provider settings to help providers and practitioners meet standards. (An example of a CMS quality measure is a measure found in the National Hospital Inpatient Quality Measures set.); and • Make recommendations or referrals to the Quality Innovation Network-QIO or other CMS-designated contractor for technical assistance that promotes evidence-based medical practice and patient-centered care principles to improve the quality of health care, improve outcomes to beneficiaries, and lower costs. NOTE: Beneficiary and Family-Centered Care-QIO identified trends and patterns are to be addressed in coordination with the Beneficiary and Family-Centered Care National Coordinating Center (NCC) (See §5095-Tracking and Trending of Data). These types of recommendations must be provided to the Beneficiary and Family-Centered Care-NCC before being communicated to the applicable Quality Innovation Network-QIO.