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New 'Statement of Work' Sets Ambitious Quality Goals for Medicare

By John Reichard, CQ HealthBeat Editor

March 7, 2011 -- A proposal setting out goals for improving the quality of care in Medicare is a "call to action" to make dramatic improvements in the program, says an executive with one of the entities responsible for carrying out the agenda.

Known to insiders as the "10th Statement of Work," the draft proposal lays out responsibilities for Quality Improvement Organizations. QIOs contract with Medicare to weed out excessive treatment but also to ensure that beneficiaries aren't shortchanged on care. Their duties include working with doctors, hospitals, and nursing homes to re-engineer the delivery of care to make it safer and more efficient.

The QIO executive, who requested anonymity in order to speak freely, said the draft proposal is "innovative" and "expansive" and attributed the unusual tone of the document to Centers for Medicare and Medicaid Services Administrator Donald M. Berwick. Berwick is much admired in the quality improvement field, and the latest QIO "to do" list gives him a chance to stamp his imprint on Medicare.

"I think you have to credit Berwick for the inspirational tone of the statement of work," the executive said. Every three years CMS updates the statement of work; this update is scheduled to take effect Aug. 1.

The document says its goal is to "ensure the right care, at the right time, every time." Among its aims are to improve "care transitions leading to the reduction of readmissions" to the hospital and to use data to "drive dramatic improvement in communities."

Readmissions are a red flag suggesting that a patient wasn't treated properly during his or her first stay in the hospital. When the patient is discharged from the hospital and moves from one setting of care to another, instructions for follow-up care to ensure a full recovery may be lost in the process or become unclear in the mind of the patient or of subsequent caregivers.

"The most effective interventions may depend on changes in the processes of care at a community level that engage more than one provider (including hospitals, home health agencies, dialysis facilities, nursing homes, and physician offices), as well as patients, families, and community health care stakeholders," the draft proposal says.

"The QIO shall form relationships with many community organizations and play a coordinating role to ensure communitywide adoption of improved practices." That too is a hallmark of Berwick's career; as head of the Boston-based Institute for Healthcare Improvement he enlisted a variety of provider groups to work toward common quality improvement goals, such as reducing deaths of hospital patients from medical errors.

"These efforts aim to reduce readmissions following hospitalization by 20 percent over three years and to yield sustainable and replicable strategies to achieve high-value health care for sick and disabled Medicare beneficiaries," the document says.

Another goal is to reduce the number of medical conditions caused by substandard treatment in nursing homes. QIOs are supposed to contribute to the goal of reducing health-care-acquired conditions by Medicare patients in nursing homes by 40 percent over three years.

The QIO executive said that the organizations have tended to focus on relatively small groups of providers to more easily demonstrate that their efforts improve quality of care. But the latest proposal is notable because of its emphasis on broader, communitywide involvement, the executive said.

Comments on the draft document are due March 15. The final version will come out this spring.

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