Back in the spring, dozens of Quality Improvement Organizations were put on the defensive with a blistering critique of their performance from the Institute of Medicine. Too many of the nation's 53 QIOs — federal contractors charged with improving the quality of Medicare services — were dominated by boards controlled by physicians who were unable to handle complaints fairly or who were unwilling to educate the public that they even had a place to hear those complaints, said the prestigious healthcare group. The IOM forcibly called for others to step in to take responsibility for much of the QIOs' work. But anyone who might have expected the QIOs to roll over and submit to a restructuring that would have severely limited their scope of activities would have been dead wrong. In recent months, the QIO's main champion in Washington D.C., the American Health Quality Association, has mounted an aggressive counterattack. QIOs and their backers are determined to not only retain all their responsibilities in Medicare, but to expand their authority. New legislation is being pushed on Capitol Hill that is designed to make QIOs one of the main advocates of quality in the federal program for seniors, putting them squarely behind popular initiatives such as improved information technology, pay-for-performance programs to encourage best practices, improved reporting processes for complaints and a plan to reduce racial and ethnic disparities in healthcare. All of those reforms are outlined in the Medicare Physician Payment Reform and Quality Improvement Act, which has been sponsored by Rep. Michael Burgess (R-TX). The laws governing QIOs were written 20 years ago, says David Schulke, the executive vice president of AQHA, and it's far past time for a legislative makeover that can allow QIOs to do the work they were created for: quality improvement and complaint resolution. As for the IOM report, says Schulke, the QIOs got their message loud and clear. "Every 10, 15 years QIOs undergo major changes," says Schulke. "And now the IOM has led two of those cycles in the 35-year history of the program. It's fair to say that the IOM is essential to causing this next big round (of changes)." Last March the IOM lambasted QIOs in general for creating boards that were primarily made up of physicians and often biased in the way they handled Medicare beneficiaries' complaints about the program. The IOM also criticized QIOs for failing to properly educate seniors on the work they do and keeping too much of their work hidden from the public in general. "QIOs consider providers, not beneficiaries, to be their primary clients," summed up the IOM, "and a QIO may not want to antagonize the providers." As a result, the IOM recommended that the state-based QIOs should no longer be responsible for fielding complaints, turning that over instead to a few national or regional groups while concentrating their efforts on quality improvement work with physicians and hospitals. In response, many QIOs have called for an aggressive restructuring of their boards to include nurses and patient advocates. And they want more discretion in how their budgets are allocated to give them some flexibility in addressing local needs. But while QIOs recognize the need for major changes, Schulke adds, they're not supporting the IOM's call for a new round of players to be brought in to handle complaints. Most of those complaints would eventually land right back with QIOs, he says, leading to nothing more than a fresh layer of unnecessary bureaucracy in the process. Given the legislative authority, say QIO backers, they can raise the standard of medicine in Medicare. "I don't know if it will pass this year," says Schulke. "It seems unlikely with the crowded agenda they have in the fall." But eventually he's confident that the QIO bill will be picked up in another piece of legislation and approved by lawmakers. In the meantime, he says, many of the QIOs around the country have gone ahead to institute reforms of their own. One of the most prominent examples of that, he adds, has been QSource®, the QIO in Tennessee that was among the first of the state-based groups to sign off on many of the IOM's recommendations and begin pushing for change. QSource is also an eager proponent of the new bill. "I certainly think it would allow for some improved efficiencies," agrees Raymond Dawson, QSource's director of operational support. "It also allows for improved accountability." Waiting passively on the sidelines for federal regulators to decide their fate, though, is not an option. Adds Schulke: "The only way you can really get trouble with change you can see coming is to wait for it. We're not waiting for it."