Carrie Finley (Host): Welcome to the Superior HealthCast: Quick Takes for Quality Care. Here, we explore practical, forward-thinking ways to improve healthcare quality with one quick, meaningful conversation at a time. So in this episode, we take a deep dive into the role of Commence Health as the BFCC-QIO and how it partners with QIN-QIOs to address Medicare beneficiary quality of care concerns and support improvement efforts.

So, you will be able to find this and future episodes on the Superior Health Quality Alliance website or your favorite podcast streaming platform. So, I'm your host today. And my name is Carrie Finley. I'm a registered nurse and a quality improvement advisor with Superior Health Quality Alliance, and I'm excited to be here with my guests, Dr. Matthew Stofferahn from Commence Health and Patty Stephenson-Neal from Superior Health.

Dr. Matthew Stofferahn is the Executive Medical Director for Commence Health's BFCC-QIO, where he oversees clinical review activities that help protect Medicare beneficiaries' rights to high-quality care. And Patty Stephenson-Neal is a quality improvement advisor with Superior Health Quality Alliance, who brings more than 30 years of healthcare experience and a deep commitment to quality improvement in long-term care. So, thank you both for joining us today. And both of our speakers' bios are on our Superior Health website if you'd like to learn more.

So now, before we jump into the discussion, let's just take a moment to define a few acronyms that listeners may hear throughout the episode . We'll be talking about the BFCC-QIO, which stands for the Beneficiary and Family Centered Care Quality Improvement Organization, and the QIN or QIN-QIO, which stands for the Quality Innovation Network Quality Improvement Organization. If you'd like a deeper introduction to the QIO program, be sure to check out our earlier episode, which is "Meet Your Partner in Quality Care: Superior Health," or visit our website.

So, to start off this conversation, let's begin by laying a foundation for our listeners. Dr. Stofferahn, many healthcare providers are familiar with either the BFCC-QIO or the QIN-QIO, but not always both. Can you explain who Commence Health is as the BFCC-QIO and how its role differs, yet complements the work of the QIN-QIO?

Dr. Matthew Stofferahn: Yeah, sure, Carrie, and thanks for having me. I really appreciate it. So, the different QIO types really focus their activity towards certain stakeholders. So, the way that we interact specifically with healthcare providers might be different and probably affects how familiar an individual provider might be with either type of QIO.

So as you mentioned, the BFCC, which I represent, is the Beneficiary and Family Centered Care QIO. And so, just as the name implies, we really face beneficiaries and families and provide services directly to them. And there's kind of three main buckets of those services.

One is that we process appeals. For instance, if a beneficiary is being discharged from a hospital or their post-acute service is being terminated, for instance, if they're in a skilled nursing facility, they can appeal that decision to the BFCC-QIO, and we help them make a decision about that. We also offer advocacy services to beneficiaries, and that really is just meant to facilitate communication between beneficiaries and providers.

And then, the last bucket is something that is probably most pertinent to this conversation, and that's looking at quality of care complaints. So if a Medicare beneficiary receives care that they don't feel is up to standard, they can report that to us, and then we can look into it and investigate further.

And I should say that all of these services are provided to Medicare beneficiaries at no additional cost, but they are all focused on individual beneficiaries. And so, we can contrast that with the QINs or the Quality Innovation Networks. They're generally working more directly with providers to improve the quality of healthcare that they provide more generally preparing for emergencies, coordinating care, improving patient safety, those types of things. And those interventions are really aimed at improving healthcare more broadly rather than just to specific patients.

And so, the way that the two QIOs kind of intersect is, for example, if a BFCC receives a complaint from a patient about the quality of care that they received, we would look at the medical records. And if we find that indeed the provider might have fallen short in providing care to that beneficiary, we can engage the QIN. And then, the QIN can work with the provider to analyze the case, develop a plan to improve quality.

And in that sense, we really like to engage the beneficiary and their family as a team member in the quality improvement team. And as a result of that process, we can actually look to improve the quality of care for all patients so that their complaint really becomes an opportunity or a catalyst for quality improvement with the help of the QIN. 

Host: That's a great overview of the relationship between these organizations. Dr. Stofferahn, let's dive a little deeper into how that partnership works in practice. When a Medicare beneficiary files a quality of care complaint with Commence Health, what factors determine whether that concern should also be referred to the QIN-QIO for quality improvement follow-up? 

Dr. Matthew Stofferahn: Yeah. So when we get a concern from a beneficiary, the first step in determining when to contact the QIN about that is really for us to review the medical records that pertain to that complaint, and we use that to determine whether the standard of care was met. And that's really important because not all bad health outcomes are necessarily due to bad care or are necessarily preventable.

Sometimes bad things happen even when good care is given. So, we really want to determine if a beneficiary's concern actually represents an opportunity for improvement first. And we do that by looking at the medical records, and specifically those records are looked at by an independent board-certified, actively practicing physician. And their professional opinion is used to help determine whether the record supports that a healthcare provider did not meet the standard of care based on the information that was available to the provider at the time that they gave that care.

So if the physician reviewer confirms that this does indeed represent an opportunity for improvement, there's a couple factors that can help us decide whether to refer that case to the QIN. One might be the severity of the missed opportunity. So if the opportunity for improvement is really great, then it's probably more likely that that provider might need additional help in implementing that opportunity for improvement.

The type of remediation is another factor. So if there's a concern that can really be remediated relatively simply, maybe some education, maybe an alternative suggestion. I'm thinking, for instance, if a physician prescribed the wrong antibiotic for an infection, that might be something that we can fix just by educating that physician or suggesting resources just to get on the latest guidelines for how to treat pneumonia, for instance. But if the concern looks like a scenario in which the QIN will be able to really provide direct help to the provider to fix an underlying cause of that issue; for instance, helping them to perform a root cause analysis to figure out what led to the problem or develop a plan to fix some systemic vulnerability that led to the problem, then we'll go ahead and make that referral.

Host: Great. Building on that let's start with Dr. Stofferahn. What is the purpose of forwarding certain BFCCC-QIO referrals to the QIN-QIO? And how does that process help support healthcare providers and improve patient outcomes? 

Dr. Matthew Stofferahn: So, the ultimate purpose in making such referrals is to improve the quality of care for patients in our healthcare system. And we really try to keep that first and foremost in our mind when we work with the QIN. We really try to think ahead about what type of opportunity this case might represent for the provider and what tools the QIN might engage to make quality improvement gains related to that specific issue or issues.

Once we pass the case along to the QIN, they really take the baton and use their own judgment to determine the best way to leverage the referral into an opportunity for lasting quality improvement. And I'll probably let Patty speak to that part. 

Host: Yeah. Patty, so you heard Dr. Stofferahn describe the referral process from the Commence Health perspective. So, let's take a look at what happens after those referrals reach the QIN-QIO. Can you share what you are experiencing on the Superior Health QIN-QIO side?

Patty Stephenson-Neal: Thank you, Carrie. And as this is my first opportunity to answer, I want to say thank you as well for having me here today. As Dr. Stofferahn described, the BFCC-QIO referral process helps ensure that opportunities for quality improvement identified through clinical chart reviews are connected with resources that can assist providers in strengthening care delivery. Once a referral reaches Superior Health QIN-QIO, we review the information provided and assign it to a quality improvement advisor whose expertise best aligns with the topic and provider setting.

The QIA then connects with the provider to better understand their current practices and any contributing factors related to the concern or, most importantly, help conduct a root cause analysis of the concern. From there, our focus is on identifying opportunities for improvement and providing practical support. This may include sharing resources, discussing best practices, or helping the provider develop strategies that strengthen care processes and improve outcomes for patients. We view the referral as an opportunity to partner with providers and support sustainable quality improvement efforts. 

Host: Yeah. Well, that leads perfectly into what providers experience firsthand when they hear from the QIN-QIO. Patty, continuing on that train of thought, if a provider receives outreach from the QIN-QIO following a referral from Commence Health, what should they expect during that interaction? 

Patty Stephenson-Neal: First, I want to start off in saying that, from the QIN-QIO perspective, we recognize that healthcare organizations are working in complex environments and are committed to providing practical provider-centered support. When we reach out following a referral, we are not there to conduct a survey or enforcement activity. We are there to partner with providers, review the concern, understand their current processes and policies, and identify collaboratively whether opportunities exist to improve care delivery.

Providers should expect a collaborative conversation, not a regulatory review. The QIA will explain the reason for the outreach and review the concern with the provider to better understand their perspective, current processes, and again policies surrounding the concern.

Together, we'll determine whether an opportunity for quality improvement exists. If it does, we can work with the provider on a focused time-limited performance improvement plan. Throughout that process, the QIA serves as a resource by providing evidence-based practices, educational tools, workflow support, and quality improvement coaching tailored to the provider's specific needs.

Host: Yeah. So, I know one misconception that we occasionally hear is that a referral automatically means a provider is in trouble. Dr. Stofferahn, some providers may worry that a referral from the BFCC-QIO to the QIN-QIO is punitive. What would you like providers to understand about the intent of these referrals and the role of the QIN-QIO?

Dr. Matthew Stofferahn: Yeah. It really is understandable that there would be some trepidation for a provider if they receive a letter that says that care that was provided fell below the standard of care. But it's really important, as Patty mentioned, that patients and providers alike know that this process is absolutely not meant to be punitive or threatening.

We do have the capability and the authorization from CMS to report situations of really gross and flagrant violations for potential sanctions. But like Patty mentioned, the vast majority of these concerns really involve well-meaning providers that are doing the best that they can for their patients in a complex environment, and we really try to honor that.

So, our reviewers, like I mentioned, are actively practicing physicians. They are healthcare providers as well, and so they understand really just how difficult today's healthcare environment can be to provide effective care. And we also engage providers when we send them letters to discuss these cases with us after we do a preliminary review.

And oftentimes those discussions lead to the provision of additional information that really shows that they perhaps did provide good care, and we can resolve the concern right at that point. So, we really do try to maintain an air of collaboration, and we really are not trying to focus on any sort of punitive measures.

But if we still ultimately decide that the standard of care wasn't met, the tools that we have available like education, root cause analyses, quality improvement plans, they really aren't punishments. They're really tools and opportunities to improve care. Even in cases where we might even consider a sanction if the opportunity for improvement is really great, we can still often prevent the sanction by working with providers in good faith to develop those corrective action plans and to really remediate the concern that led to the quality of care complaint in the first place.

And also, I should mention that our letters are protected information by a federal law, so they really are confidential, and they cannot be used for legal procedures. So, providers should really feel secure in engaging with the QIO program for quality improvement.

Host: Yeah. Well, building on that message of partnership and improvement rather than punishment. Patty, what are the expectations for providers who are contacted regarding a BFCC-QIO referral, and how can they make the most of quality improvement support that may be offered?

Patty Stephenson-Neal: Absolutely. Providers who are contacted regarding a BFCC-QIO referral should understand that the outreach is intended to be supportive, collaborative, and focused on improvement. The referral represents an opportunity to take a closer look at a concern that has been identified and determine whether there are opportunities to strengthen care processes and patient outcomes. When you're contacted from the QIN-QIO with our follow-up, we are looking more at that entire process rather than just that specific patient's concern.

The biggest expectation is engagement. We encourage providers to approach the conversation openly and share information about their processes, challenges, and goals. Providers who engage fully in the process often find the greatest value comes from having a trusted partner to help them evaluate opportunities, test solutions, and strengthen systems of care. The shared goal is continuous improvement that leads to better care, better outcomes, and a better experience for patients, families, and healthcare teams.

Host: Yeah. So, we've talked about the process in provider engagement, but it may be helpful for listeners to hear how this collaboration comes together in the real world. Dr. Stofferahn, can you share an example of how Commence Health and a QIN-QIO work together to identify opportunities for improvement while supporting providers in delivering high-quality beneficiary-centered care?

Dr. Matthew Stofferahn: Absolutely. Yeah. So, one example might be, let's say we receive a complaint from a family member of a beneficiary, and the beneficiary was admitted to the hospital for treatment of an infection, like a pneumonia or a urinary tract infection. But we get a complaint that the beneficiary didn't receive their home medications. And while they were in the hospital, they had a stroke, and that really wasn't the reason why they were in the hospital in the first place.

So once we get a complaint like that, we would want to request and look at the medical records pertaining to that complaint to verify that that is exactly what happened, and really to determine whether the beneficiary was provided with their home medications in a clinically appropriate manner. If they weren't, we would want to see some explanation as to why that didn't happen.

So for instance, if the patient took a blood thinner at home and they didn't get their blood thinner when they were admitted to the hospital, we would look for documentation as to why that is. If there's not a clear reason as to why the blood thinner wasn't given, we would probably confirm a concern in that circumstance, because one reason that someone is on a blood thinner in the first place is to prevent stroke, which happened to this patient.

So, the next step is really to determine the best step to remediate a concern once it's confirmed. We review individual complaints because we deal with individual beneficiaries, and even though we can tell when the care fell short, it's not always easy to tell why the care fell short or what the root cause of a breakdown was.

So if a provider might need help figuring out where a process breakdown occurred, that would be a reason we would refer that provider to the QIN for technical assistance. For instance, performing a root cause analysis, and that analysis might reveal problems that they might not have even been aware of.

Also, if a concern is potentially related to a systemic breakdown that might affect other patients, we would also refer that provider to the qIN for assistance, for instance, to set up a corrective action plan that's measurable that way they would know that they're fixing the problem and they're making similar events less likely to happen in the future.

So for instance, the example that I gave of a patient who didn't get his blood thinner when they were admitted to the hospital, the QIN could work with the provider in that instance to figure out why that occurred, the underlying reason or root cause. And if they find an issue that might affect other patients, for instance, in this case, the hospital might not have a standard process for medication reconciliation, which is a process where in major transitions of care, the physician or the pharmacist goes through a patient's medication list and determines whether it needs to be changed. If that's not in place, they can work with the provider to develop, implement, and then monitor that process, and that ultimately improves quality and safety for all patients moving forward.

Host: Yeah, absolutely. Well, as we begin wrapping up today's conversation, I'd like to leave our listeners with a few key takeaways. Starting with Dr. Stofferahn, can you share what is the most important thing healthcare providers should know about the relationship between the BFCC-QIO and the QIN-QIO and the value of engaging when follow-up occurs? 

Dr. Matthew Stofferahn: Yeah. The BFCC and the QIN are really two pillars of the same QIO structure. And we both like to work with providers towards a common goal, which is really just to make sure that patients are receiving the high-quality care that they deserve. We know that healthcare providers want that for their patients.

And like I mentioned, we're healthcare providers too. So, the QIO program is really your partner and your peer in creating effective, long-lasting quality improvement for all patients 

Host: Patty, before we close, I'd love to get your perspective as well.

Patty Stephenson-Neal: Yes. Just to support what Dr. Stofferahn said, both the BFCC-QIO and the QIN-QIO share a common goal: improving care for Medicare beneficiaries. When a referral is made, it's an opportunity to explore whether there are lessons to be learned or processes that can be strengthened. Providers who engage with the QIN-QIO gain access to quality improvement expertise, evidence-based resources, and individualized support. The earlier we can work together, the greater the opportunity to identify practical solutions and promote lasting improvements in care delivery.

Host: Patty, what final thoughts or advice would you like to leave our listeners with regarding quality improvement partnerships and responding to referral outreach?

Patty Stephenson-Neal: I definitely want to encourage providers to view referral outreach as an opportunity rather than an obligation. Healthcare is complex, and every organization can benefit from an outside perspective and access to additional resources. The QIN-QIO is here to support providers in identifying opportunities, building on strengths, and implementing practical improvements. When providers engage in that partnership, it often leads to a stronger process, improved outcomes, and ultimately a better experience for the patients and families they serve.

Host: Well, thank you, Dr. Stofferahn and Patty, for sharing your expertise and insights with us today. This has been a valuable conversation about how the BFCC-QIO and the QIN-QIO work together to support healthcare providers and improve care for Medicare beneficiaries. And thank you, listeners, for joining us for another episode of Superior HealthCast: Quick Takes for Quality Care.

Remember, you can find all of our episodes at www.superiorhealthqa.org and on your favorite podcast platform. We would love to hear from you, so please send your comments, questions, or suggestions for future episodes to info@superiorhealthqa.org, because your feedback helps shape the conversations that matter most to healthcare providers and the communities they serve. So until next time, stay inspired and keep striving for quality care.