Quality Improvement Organizations

Quality Improvement Organizations (QIOs) are responsible for monitoring the reliability, effectiveness, and quality of care provided to Medicare beneficiaries by health care organizations. They are private contractor extensions of the federal government operating under management of the U.S. Centers for Medicare and Medicaid Services (CMS). Below, three of the many QIOs operating in the U.S. are discussed.

MPRO is the federally designated quality improvement organization for Michigan contracted by CMS.

To improve quality, safety and efficiency of health care provision across the healthcare continuum in Michigan.

First, to improve the quality of care for beneficiaries by working with the Michigan health care providers to promote evidence-based medicine in all health facilities including hospital, physician office, nursing home, and home health (MPRO,2011). Secondly, to safe guard the integrity of the Medical Trust Fund by checking that the beneficiaries are charged only for the services that are necessary, affordable, and are provided in the right conditions. Thirdly, to address individual complaints in order to safeguard the beneficiaries interests. Lastly, to provide consultative services, medical and utilization review, and data analysis to all medical beneficiaries and agencies, and other third party payers (MPRO, 2011).

Methods of monitoring quality

MPRO has staffs who are experts in various fields providing physician reviews, clinical quality improvement services, patient safety services, and data analysis across the continuum. In addition, MPRO provide several trainings and continuing education events for Michigan providers on health care quality improvement programs.

The American College of Cardiology in partnership with MPRO and the health care providers in Michigan implemented the GAP initiative that has positively influenced the quality of health care provided to patients in Michigan and across the nation (MPRO, 2011). The GAP initiative has been replicated internationally significantly reducing the number of the heart attack patients who die in the first year of attack.


FMQAI is the Florida's Medicare Quality Improvement Organization and the End Stage Renal Disease (ESRD) Network of Florida under contract with the CMS (FMQAI, 2011). 

To ensure that quality, effective, efficient, and economical health care services are offered to the Medicare beneficiaries.

First, to ensure improved quality and safety of the health care provided to the beneficiaries. Secondly, to collaborate with each individual client to modify a preparedness plan aimed at creating effective compliance guidelines while substantiating eligibility of payments (FMQAI, 2011). Thirdly, to offer medical record review services that ensure the care offered to patients is reliable, adequate, and within medical standards. Fourthly, to facilitate health service research through analytical tools and sharing of expertise. Moreover, to offer consultation services aimed at improving quality of health care. In addition, to offer a platform for dispute resolutions between health care providers and complainants ensuring satisfaction. Lastly, to act as the liaison between patients and ESRD providers.

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Methods of monitoring quality

Perform independent medical record reviews in the continuum. Secondly, offer technical assistance to hospitals to enable them comply with Medicare billing and coding regulations. Lastly, it offers general quality improvement services monitoring including physician reviews and clinical quality improvement services.

It has been a national leader in reducing unnecessary hospital admissions since 2003 (FMQAI, 2011).

3. Qualis Health

Qualis Health, headquartered in Seattle, Washington offers healthcare and improves the quality of health care provided directly to over 10 million people across the country (Qualishealth, 2011).

To generate, apply and disseminate knowledge to improve the quality of healthcare delivery and health outcomes.

Qualis Health liaises between the medical beneficiaries and healthcare providers across the country to ensure quality health care services by offering the following services between the two parties: case management, utilization management, healthcare information technology consulting, and healthcare quality, safety and efficiency consulting. In addition, it leads several initiatives for transformation of health care in the U.S. including Washington & Idaho Regional Extension Center (WIREC) patient-centered medical home and Care Transitions Project of Whatcom County (Qualishealth, 2011).

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Methods of monitoring quality.

Through partnering between healthcare providers and Qualis Health staff of quality improvement consultants, data experts and clinical leaders to redesign processes for sustainable change and care delivery.

For excellence in provision of it services Qualis Health as won several awards including: winner of Leadership Level from the Washington State Quality Award 2010, recognized as one of Washington State's 100 Best Company To Work for by Seattle Business magazine 2009, Winner Utilization Management Program Case In Point Platinum Awards 2010, Winner Medicaid Case Management Program Case In Point Platinum Awards 2010 among many others (Qualishealth, 2011).

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