Quality Improvement in Health Care

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Abstract
The Medicare Peer Review Organization (PRO) program began in the mid 1980s in response to concerns with medical necessity and qualityof care of services delivered to the elderly and disabled, and paidfor by the federal Medicare program. As part of their legislated oversight, PROs reviewed a random sample of hospital medical records. Using locally developed and maintained clinical criteria, PRO nurse and physician reviewers made determinations about the medical necessity of the inpatient stay and services, and identified issues with the quality of care delivered. Within 10 years of its initiation, however, criticisms of the PRO program, based in the reliability and validity of review findings, combined with national interest in quality improvement, led HCFA to refocus the program. PROs currently emphasize clinical and process quality improvement, through collaborative working relationships with providers and consumers.

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