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This document is a draft statement of work for the 13th Scope of Work period of the Quality Improvement Network-Quality Improvement Organization program. It outlines required services for quality improvement, beneficiary protections, and healthcare innovation support. Key services include developing quality measures; implementing initiatives to reduce hospital readmissions, healthcare-associated infections, and opioid misuse; providing technical assistance to providers; supporting value-based payment models; and conducting data analysis to advance health equity. The statement of work establishes a performance period from 2023 to 2028 and requires coordination across federal agencies including the Centers for Medicare and Medicaid Services and the Administration for Community Living. It focuses on improving care outcomes while reducing costs and burden for beneficiaries and providers.
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| QIN-QIO DRAFT SOD 10.4.23.docx | DOCX document | |
| Appendix 4_Detailed List of Measures with Specifications DRAFT.docx | DOCX document | |
| Appendix 7_ROI_template DRAFT 10.4.2023.xlsx | XLSX spreadsheet | |
| Appendix 6_Success Story Template DRAFT 10.4.2023.docx | DOCX document | |
| Appendix 8_Additional Standards Guidelines and Best Practices for Data Submission Management Analytics and Reporting DRAFT 10.4.2023.docx | DOCX document | |
| Appendix 1_A3C Example and Template DRAFT 10.4.2023.docx | DOCX document | |
| Question Submission Format.xlsx | XLSX spreadsheet | |
| QIN-QIO Draft SOW - 13th Scope.docx | DOCX document | |
| Appendix 9_CMS Security Privacy Requirements DRAFT 10.4.2023.docx | DOCX document | |
| Appendix 5_Assessment tool- Use of Data for QI DRAFT 10.4.2023.docx | DOCX document | |
| Appendix 3_AHQT Technical Readiness Assessment Survey DRAFT.docx | DOCX document | |
| Appendix 10_13thSOW Terminology DRAFT 10.4.2023.docx | DOCX document |
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Foundational Aim 2: Advancing Healthcare Quality Through Technology
The Business Case Guiding Strategies
Why Advancing Healthcare Quality Through Technology -Ensure providers and clinicians in underserved areas are leveraging modern IT systems for data collection and advanced analytics to improve quality and outcomes.
Support integration of quality data requirements, standards, and systems within the context of an interoperable learning health system.
Overarching Strategies Guiding Implementation CMS National Quality Strategy CMS Health Equity Strategy CMS Behavioral Health Strategy
Appendix 2
CMS National Quality Strategy – 4 Priority Areas Equity and Engagement Safety and Resiliency Outcomes and Alignment Interoperability and Scientific Advancement https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/CMS-Quality-Strategy
CMS Health Equity Strategy - The first pillar of the Centers for Medicare & Medicaid Services’ (CMS) Strategic Plan. CMS is working to advance health equity by designing, implementing, and operationalizing policies and programs that support health for all people served by our programs by incorporating the perspective of lived experiences and integrate safety net providers and community-based organizations into our programs. We are focusing on a person-centric approach as part of an overarching CMS Quality Strategy, which strives toward creating a care journey that is free from inequity while optimizing opportunities and access for underserved populations. We work toward identifying measurable interventions to close gaps in quality care and outcomes.
Priority 1) Expand the Collection, Reporting, and Analysis of Standardized Data Priority 2) Assess Causes of Disparities Within CMS Programs and Address Inequities in Policies and Operations to Close Gaps Priority 3) Build Capacity of Health Care Organizations and the Workforce to Reduce Health and Health Care Disparities Priority 4) Advance Language Access, Health Literacy, and the Provision of Culturally Tailored Services Priority 5) Increase All Forms of Accessibility to Health Care Services and Coverage https://www.cms.gov/About-CMS/Agency-Information/OMH/health-equity-programs/cms-framework-for-health-equity
CMS Behavioral Health Strategy – Goal 1: Strengthen Equity and Quality in Behavioral Health Care – Quality measurement, CMS Quality Measures Inventory, Health Equity Goal 2: (not for this) Improve access to substance use disorders prevention, treatment, and recovery services – innovative models Goal 3: (not for this) Ensure effective pain treatment and management Goal 4: Improve access and quality of mental health care and services – Medicaid Community-Based Mobile Crisis Services Goal 5: Utilize data for effective actions and impact on behavioral health – Mapping Medicare Disparities Tool https://www.cms.gov/cms-behavioral-health-strategy
Advancing Healthcare Quality Through Technology: Quality Improvement Intervention Design Framework
| Assess Readiness for Patient-Generated Health Data (PGHD) Integration | Evaluate PGHD and IT decisions (PGHD) | Involve Care Teams in Refining Documentation Workflows to Minimize Burden (EvidNow) |
| Educate Organization on PGHD (PGHD) | Provide Access to Patients and Caregivers by Providing Streamlined Enrollment to Portal (ONC-PE) | |
| Evaluate the Costs of Implementation (PGHD) | Improve Data Accuracy and Transparency and Secure Staff Trust (EvidNow) | |
| Identify and Build CDS Features (PCDC-CDS, HHS-CDS) | ||
| Identify and Train Data Coordinators and Additional IT Support (EvidNow) | Improve Care Delivery with Health IT (ONC-PE) |
| Prepare Your Organization for a Clinical Decision Support (CDS) Integration Project (PCDC-CDS) | Design EHR to Support 4Ms Documentation for all Specialties Across the Continuum of Care (4Ms) |
| Develop Your EHR Dataset and Extract Data (PCDC-CDS) | |
| Train Providers and Staff on the CDS and the Larger QI Initiative (PCDC-CDS, HHS-CDS) | Initiate Healthcare Data Sharing with a Partner Organization (CHCS) |
| Secure Stakeholder Engagement and Identify Champions (HHS-CDS, ONC-PI) | Incorporate Best Practices for Privacy, Data Security, and Technical Implementation (CHCS) |
| Define Process for CDS Technical Maintenance and Usage Auditing (HHS-CDS) | |
| Educate Workforce on Legal Compliance and Practice Policies and Workflows Related to Medical Records Access (AMA) | Ensure All Patients Can Access and Understand Information (ONC-PE) |
| Integrate Patient-Generated Health Data and SDOH Screening Data with EHRs (ONC-PE) | |
| Establish Process for Patient Access to Medical Records in Alignment with State & Federal Regulations (AMA) |
GOVERNANCE
SYSTEM DESIGN & POLICIES
PROCESS
WORKFORCE
INDIVIDUALS, CAREGIVERS, & COMMUNITIES
CMS Initial AHQT Assessment Focus Areas Focus areas guided review and selection of resources for the AHQT IDF.
Leverage Guidelines and Clinical Decision Support to Improve Care Quality Identify Opportunities to Improve Efficiency and Affordability without Degrading Quality Workflow Analysis Facilitate Error-Free Communication and Coordination with Other Providers and Resources Identify, Describe and Meet the Needs of those Populations Most At Risk including addressing Social Determinants of Health Promote and Support Beneficiaries and their Families to Fully Engage in Their Care Ensure Equitable Access to Timely Care Reduce the burden associated with reporting to quality payment and value-based purchasing programs
© 2023 THE MITRE CORPORATION. ALL RIGHTS RESERVED.
Office of the National Coordinator for Health Information Technology – Patient Engagement Playbook (ONC-PE) What it is: Toolkit outlining strategies to help organizations engage patients in use of Health IT.
Target Setting: Hospital or Ambulatory Care Practices Link to Resource: Patient Engagement Playbook (healthit.gov) Relevant Links:
Electronic Health Records - Health IT Playbook
Guide to Integrate Patient-Generated Digital Health Data (PGHD) into Electronic Health Records in Ambulatory Care Settings (PGHD) What it is: Agency for Healthcare Research and Quality (AHRQ)-developed guide with evidence-based, practical steps for implementation of PGHD in clinical care.
Target Setting: Ambulatory Care Resource Link: Guide to Integrate Patient-Generated Digital Health Data into Electronic Health Records in Ambulatory Care Settings | Digital Healthcare Research (ahrq.gov) Relevant Links:
Patient-Generated Health Data | HealthIT.gov
EvidenceNOW: Optimize Health Information Systems to Extract Data and Support Use of Evidence in Practice (EvidNow) What it is: The AHRQ EvidenceNOW Model is a guide for delivering external support to primary care practices to improve healthcare quality and implement new evidence into care delivery.
Target Setting: Hospital or Ambulatory Care Practices Resource Link: Key Driver 3: Optimize Health Information Systems to Extract Data and Support Use of Evidence in Practice | Agency for Healthcare Research and Quality (ahrq.gov)
HHS Best Practice Guides for Telehealth (HHS-Tele) What it is: Best practice guides for implementing telehealth services for a variety of conditions (e.g., behavioral health, chronic disease) and populations (e.g., American Indian and Alaska Natives, Rural) Target Setting: Ambulatory Care Resource Link: Best practice guides | Telehealth.HHS.gov Relevant Links:
AMA Digital Health Research (2022) https://www.ama-assn.org/system/files/ama-digital-health-study.pdf Physicians’ Motivations and Key Requirements for Adopting Digital Health Adoption and attitudinal shifts from 2016 to 2022.
Barbosa, Kina Zhou, Emma Waddell, Taylor Myers, E. Ray Dorsey, Improving Access to Care: Telemedicine Across Medical Domains. Annual Review of Public Health, Volume 42, Issue 1. April 2021, Pages 463-481. doi: 10.1146/annurev-publhealth-090519-093711.
Mandy Truong, Ladan Yeganeh, Olivia Cook, Kimberley Crawford, Pauline Wong, Jacqueline Allen, Using telehealth consultations for healthcare provision to patients from non-Indigenous racial/ethnic minorities: a systematic review, Journal of the American Medical Informatics Association, Volume 29, Issue 5, May 2022, Pages 970–982, https://doi.org/10.1093/jamia/ocac015.
Translating Evidence Into Practice: A How-To Manual for Implementing Clinical Decision Support (CDS) (PCDC-CDS) What it is: A guide developed by the Primary Care Development Corporation (PCDC) to help primary care practices develop and implement clinical decision support for chronic disease management. The Primary Care Development is a nonprofit organization and a U.S. Treasury-certified community development financial institution (CDFI), with a 30-year history of investing in communities that need it most to improve the health of residents, including FQHCs, behavioral health institutions, and safety net hospitals.
Target Setting: Primary Care Resource Link: How to Implement Evidence Using Clinical Decision Support | Agency for Healthcare Research and Quality (ahrq.gov) Relevant Links:
Clinical Decision Support | Agency for Healthcare Research and Quality (ahrq.gov)
HHS ONC-CDC Health Information Technology Integration Framework (HHS-CDS) What it is: Guidance on clinical decision support (CDS) for project staff, clinicians and technical professionals Target Setting: Hospitals or Ambulatory Care Resource Link: HHS ONC - CDC Health Information Technology Integration Framework Select Quick Link “CDS Framework” on page 4 Relevant Links:
Evidence of Effectiveness for Clinical Decision Support Systems (cdc.gov)
Initiating Health Care Data Sharing with a Social Service Organization (CHCS) What it is: Guide for increasing health-related data exchange between health systems and social service organizations in their community.
Target Setting: Health Systems and Social Service Organizations Resource Link: Play | Initiate Health Care Data Sharing with a Social Service Organization (bettercareplaybook.org)
Age-Friendly Health Systems: Guide to Electronic Health Record Requirements for Adoption of the 4Ms (4Ms) What it is: This implementation guide was designed as a resource for health systems to build the 4Ms (What Matters, Medication, Mentation, and Mobility), and associated care practices, into the EHR. The 4Ms are an evidence-based framework to guide all care of older adults wherever and whenever they touch health system’s services.
Target Setting: Inpatient and Ambulatory Settings Resource Link: IHI_Age_Friendly_Health_Systems_Cerner_Implementation_Guide.pdf Relevant Links: AgeFriendlyHealthSystems_GuidetoUsing4MsCare_FINAL_July2020.pdf (hubspotusercontent-na1.net)
Capturing High Quality Electronic Health Records Data to Support Performance Improvement
(ONC-PI)
What it is: This Learning Guide documents the approaches, lessons learned, and best practices of ONC Beacon Communities for improving the quality of data captured within EHRs. It includes implementation objectives and supporting tactics for success, provider sorties, resource and cost considerations, and reference documents.
Target Setting: Inpatient and Ambulatory Settings Resource Link: Capturing High Quality Electronic Health Records Data To Support Performance Improvement (healthit.gov)
Patient Records Electronic Access Playbook (AMA) What it is: This Playbook developed by the American Medical Association is an educational and reference manual designed for medical professionals who are involved in patient health record sharing. It compiles the legal requirements that staff must follow for patient record sharing, as well as guidance and best practices for staff to make compliance more efficient in day-to-day operations.
Target Setting: Hospitals, Ambulatory Practices, Long Term Care Facilities Resource Link: Patient Records Electronic Access Playbook | AMA (ama-assn.org)
Foundational Aim 1:
Quality Management Infrastructure and Emergency Preparedness
The Business Case Guiding Strategies Why Quality Management Infrastructure and Emergency Preparedness - Quality Management Infrastructure: In healthcare, quality management refers to the administration of systems design, policies, and processes that minimize, if not eliminate, harm while optimizing patient care and outcomes. The objective of quality management is to ensure that a particular product, service, or organization will consistently fulfill its intended purpose Emergency Preparedness: Ensure resilience in the health care system to prepare for and adapt to future public health challenges and emergencies, including extreme weather events, infectious diseases and pandemics, human-caused events, and cyber-attacks.
Overarching Strategies Guiding Implementation CMS National Quality Strategy CMS Health Equity Strategy CMS Behavioral Health Strategy
Safety and Resiliency Outcomes and Alignment Interoperability and Scientific Advancement https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/CMS-Quality-Strategy
CMS Health Equity Strategy - The first pillar of the Centers for Medicare & Medicaid Services’ (CMS) Strategic Plan. CMS is working to advance health equity by designing, implementing, and operationalizing policies and programs that support health for all people served by our programs by incorporating the perspective of lived experiences and integrate safety net providers and community-based organizations into our programs. We are focusing on a person-centric approach as part of an overarching CMS Quality Strategy, which strives toward creating a care journey that is free from inequity while optimizing opportunities and access for underserved populations. We work toward identifying measurable interventions to close gaps in quality care and outcomes.
Priority 1) Expand the Collection, Reporting, and Analysis of Standardized Data Priority 2) Assess Causes of Disparities Within CMS Programs and Address Inequities in Policies and Operations to Close Gaps Priority 3) Build Capacity of Health Care Organizations and the Workforce to Reduce Health and Health Care Disparities Priority 4) Advance Language Access, Health Literacy, and the Provision of Culturally Tailored Services Priority 5) Increase All Forms of Accessibility to Health Care Services and Coverage https://www.cms.gov/About-CMS/Agency-Information/OMH/health-equity-programs/cms-framework-for-health-equity
CMS Behavioral Health Strategy – Goal 1: Strengthen Equity and Quality in Behavioral Health Care – Quality measurement, CMS Quality Measures Inventory, Health Equity Goal 2: (not for this) Improve access to substance use disorders prevention, treatment, and recovery services – innovative models Goal 3: (not for this) Ensure effective pain treatment and management Goal 4: Improve access and quality of mental health care and services – Medicaid Community-Based Mobile Crisis Services Goal 5: Utilize data for effective actions and impact on behavioral health – Mapping Medicare Disparities Tool https://www.cms.gov/cms-behavioral-health-strategy
| Ensure Senior Leadership and Stakeholders (HCIS) are engaged and knowledgeable, prioritizing EP planning and training | Establish an Organizational Plan for Mitigation, Preparedness, Response and Recovery Based on Risk Assessment, Utilizing an All-Hazards Approach (CMS, HICS, CDC, AHRQ-EP) | Establish Safety and Continuity of Care Protocols and ensure it is in place to implement on a team level (CDC) | Provide training on EP Regulations and Compliance Requirements during onboarding as well as through at minimum annual attestation through employees that could be impacted by an emergency (CMS, HICS) | Establish and maintain at least one unique Partnership with Community Representatives and the Public Health Preparedness System to Build Trust with Diverse Racial/Ethnic, Immigrant and LEP populations(OMH) |
| Designate an Emergency Program Manager and Establish an Emergency Management Committee that include members from all major service lines (HICS) | Develop a Facility Operations Plan including Supply Chain Evaluation and Preparation (CDC) | Develop and Implement Emergency Preparedness Policies and Procedures Aligned with Emergency Plan (CMS) | Help Develop and Maintain a Communication Plan and ensure that all service lines are aware as well as its role (CMS, CDC, AHRQ-EP) | Coordinate with Federal, State, Tribal, and Local Agencies and Other Health Care Facilities in the Community (CDC, HICS). Ensure all contact information and mode of communication is ready to be deployed when needed. |
| Help Build Capacity to Assess and Respond to Unique needs of Diverse Communities by designating accountability by a member of the Emergency Management Committee (OMH) | Identify Roles and Responsibilities of Key Decision Makers to Ensure Maintenance of Facility or Agency Operations (CDC) | Develop Crisis Standards of Care Protocols and Policies for use in Conditions of Overwhelming Resource Scarcity (CDC) | Develop and Maintain a functional Training and Testing Program (CMS, CDC) that is part of onboarding new hires and maintained through an annual employee attestation. | Develop and Test Drill Exercises that Reflect the Community and Incorporate Scenarios that Explicitly Involve Culturally and Linguistically Diverse Populations by involving all backgrounds of people that represent your service demographics within the drills (OMH) |
| Assess Capacity to Deliver Evidence Based Emergency Preparedness Program annually (GTO) | Implement Emergency and Standby Power Systems and Plan for Possible IT Service Interruptions or Loss of Services (CMS, CDC) | Conduct Program Review/Evaluation at least annually and Plan for and Execute Improvement Processes. Results and recommendations must be approved by the Emergency Management Committee. (HCIS) | Ensure Plan for Annual Training and Onboarding Education Related to Emerging Infectious Diseases (AHRQ-EP) | |
| Develop System for Disease Surveillance and Reporting for Patients/Residents and Personnel (CDC) | Establish Process for Monitoring, Managing and evaluating at least annually the Mental Health of Personnel, Residents/Patients, and their Families During a Crisis (CDC) | Ensure full participation in regular Table Top Exercises by including a member from each team that would be impacted by the exercise within scope of the project (i.e. EMR system goes down consider who would need to be involved) | ||
| Establish an Incident Command System as well as define what triggers its use (HICS) | Outline Steps to Maintain a Surveillance and Reporting System Specific to an Outbreak and ensure need to know parties are involved in the development and implementation (AHRQ-EP) | Ensure the facility's onboarding and ongoing education contains EP training | ||
| Identify and Understand the Distinctive Needs of Diverse Communities specific to your service area population demographic, Particularly as they Relate to Race, Ethnicity, Culture, Language and Trust (OMH) | Designate a Staff Member to Monitor CDC and state and local Public Health Agency Websites for Guidance and Recommendations During an Outbreak as well how to communicate to leadership in the event one occurs (AHRQ-EP) | |||
| Define Goals and Desired Outcomes of an EP program using SMART goals (GTO) | Conduct Needs and Resources Assessment annually (GTO) | |||
| Review Best Practices and Assess Fit with Population/Community annually (GTO) | Conduct Process and Outcome Evaluation (GTO) at least annually and Engage in Continuous Process Improvement (GTO) | |||
| Develop a Detailed Workplan for EP that is approved by the EP Committee (GTO) | ||||
| Ensure Plan to Conduct biannual Table Top Exercises |
Emergency Preparedness: Quality Improvement Intervention Framework
SYSTEM DESIGN & POLICIES
PROCESS
Quality Management Infrastructure: Intervention Design Framework
| Ensure the establishment of a workplace violence committee with accountability at the highest levels of the organization (e.g., regular reporting to the CEO or Board) (OSHA Guidelines in Preventing WPV, MHA WPV Gap Analysis | ||
| Implement a zero tolerance policy in the organization for workplace violence (Engaging Patients and Families in WPV Prevention, OSHA Guidelines Preventing WPV, MHA WPV Gap Analysis) | ||
| Ensure QAPI program aligns with organizational objectives and federal, state, tribal quality strategies; AHRQ Clinical Practice Guidelines, (IHI Framework Governance) | ||
| Train staff in quality improvement methodology (Patient Safety & Quality: An Evidence-Based Handbook for Nurses | ||
| All parties (caregivers, patients, healthcare providers, etc.) understand their specific roles in the QI process | ||
| Leadership embracing Diversity, Equity, and Inclusion (DEI Resource) | ||
| Follow a quality management model and Complete assessment of current quality management program, identify gaps, and develop action plans to close gaps(AHRQ Quality Indicators, AHRQ's Programs | ||
| ) | Implement protocols that can be adapted to the patient’s need(s) – 4Ms in Care For Older Adults, Closing the Gap, IHI Health Equity, | Ensure each QI project managed by dedicated interdisciplinary teams are shared at least quarterly with those staff not part of the QI Project Patient Safety & Quality: An Evidence-Based Handbook for Nurses, (AHRQ)'s Programs) |
| All SLT approved QAPI metrics are uploaded to applicable sites so performance is publicly available on reporting websites, e.g., CMS Compare. NHSN | |
| Engaged leadership focused on improvement by assessing GQA annually (IHI Framework Governance) | |
| Policies to include: Clinical evidence, data to be utilized, patient population, roles & responsibilities (AHRQ Clin. Prac. Guideline, AHRQ Ways To Approach Quality, (AHRQ)'s Programs) | |
| Create rolling schedule for reporting QAPI topics to governance body that assures all approved QAPI topics are covered throughout the year | Ensure staff have dedicated time to focus on QI initiatives (protected staff time) (AHRQ)'s Programs, IHI Whole System Quality) |
Coach to Assign C-suite executive accountable for oversight of quality management plan (IHI Framework Governance, (AHRQ)'s Programs) IHI Whole System Quality)
| Quality Improvement efforts need to have sufficient resources (e.g. funding, time), including protected staff time (AHRQ)'s Programs) | |
| ,IHI Whole System Quality) | Implement a data-driven QAPI process to integrate evidence into practice (AHRQ)'s Programs) |
| Ensure a dedicated multidisciplinary team for QAPI projects that include Subject Matter Experts (SMEs) that are appropriate to the project which should include a project owner, manager, clinical staff, IT support, and SLT sponsorship (AHRQ Programs, IHI Whole System Quality ) | |
| Review specific QAPI metrics at board meetings at least quarterly based on reporting schedule (IHI Framework Governance) |
Multidisciplinary team inclusion throughout the QI process and assigned for each program to enable optimization of efforts (AHRQ)'s Programs
Include all QAPI topics and their focus to be discussed and approved within board agenda at least annually ( IHI Framework Governance)
PROCESS
Summary of Resources Additional Quality Grid Resources
AHRQ Quality Indicators MHA Workplace Violence Prevention Gap Analysis OSHA Guideline Preventing WPV AHRQ Clinical Practice Guidelines AHRQ Ways To Approach Quality Improvement Process IHI Whole System Quality IHI Health Equity Closing the Quality Gap 4Ms for Care in Older Adults
CDC Long-Term, Home Health & Hospice Care Planning Guide for Public Emergencies (CDC) What it is: Planning guide for long-term care providers to improve their facility's or agency's preparedness for a public health emergency.
Target Setting: Long-term, home health, or hospice care providers Link to Resource: ltc_planning_guide.docx (live.com) Links to other relevant resources:
Partnering with the Healthcare Supply Chain during Disasters (hhs.gov)
CMS Emergency Preparedness Rule and Associated Toolkits from Wisconsin Department of Health (CMS) What it is: Summary of CMS Emergency Preparedness rule and toolkits to provide facilities that fall under the new rule an overview of the requirements for their provider type, as well as sample templates and worksheets to support their planning efforts.
Target Setting: Variety of healthcare settings including Rural Health Clinics and Federally Qualified Health Centers, Long Term Care Facilities and Hospitals.
Link to Resource: Core EP Rule Elements | CMS and CMS Emergency Preparedness Rule Toolkits | Wisconsin Department of Health Services Links to full rule and other resources:
CMS and Disasters: Resources at Your Fingertips (hhs.gov) Emergency Preparedness Rule | CMS
Guidance for Integrating Culturally Diverse Communities into Planning for and Responding to Emergencies: A Toolkit (OMH) What it is: Reference guide, with summaries of key principles, practices, and strategies for appropriately working with diverse communities.
Target Settings: Agencies, organizations, and professionals involved in preparedness planning and response.
Link to Resource: omh_diversitytoolkit.pdf (hhs.gov) Links to other relevant resources:
Planning for an Emergency: Strategies for Identifying and Engaging At-Risk Groups (cdc.gov) ph_workbookFINAL.pdf (cdc.gov)
Hospital Incident Command System Guidebook (HICS) What it is: A guidebook to assist hospitals and other types of healthcare providers such as rehabilitation centers and urgent care centers in preparedness and response planning.
Target Setting: Hospitals Link to Resource: HICS_Guidebook_2014_11.pdf (ca.gov) Links to other relevant resources:
NIMS Components - Guidance and Tools | FEMA.gov
Guidance for Incorporating Infection Prevention and Control into an Emergency Preparedness Plan (AHRQ-EP) What it is: This resource provides guidance on the critical components of a nursing home’s emergency preparedness plan but does not supersede or override any regulatory requirements.
Target Settings: Long-term, home health, or hospice care providers Link to Resource: Incorporating Infection Prevention and Control into an Emergency Preparedness Plan (ahrq.gov)
Getting To Outcomes® Guide for Community Emergency Preparedness (GTO) What it is: Getting To Outcomes® (GTO) is a user-friendly process for comprehensive planning, implementation guidance, and evaluation of programs and community initiatives. It is designed to help organizations run programs well and get desired outcomes. This guide is designed to lead the user through the ten steps of GTO and provide supplemental information and resources to improve planning, implementation, evaluation, improvement, and sustainability of a community emergency preparedness (CEP) program.
Target Settings: Hospitals, Ambulatory Care, Nursing Homes, Community-based organizations Link to Resource: https://www.rand.org/pubs/tools/TL259.html
Workplace Violence Committee Accountability to Highest Organizational Leadership What it is: Public Services Health & Safety Association, Engaging Patients and Families in Workplace Violence Prevention: A Handbook for Organizational Leaders in Healthcare Target Setting: Inpatient and Ambulatory Settings Resource Link: cjiisgpvb00bbfxj7ew8jrt7l-p8-vprtlben0317-engaging-patients-and-families-in-workplace-violence-prevention-and-sample-brochure.pdf (terraform-20180423174453746800000001.s3.amazonaws.com)
Leadership Embracing Diversity, Equity, and Inclusion (DEI) What it is: Article from the International Journal of Health Policy and Management that details the impact of leadership in DEI that outlines key steps successful leaders implemented to adopt a culture of DEI Target Setting: Inpatient and Ambulatory Settings Resource Link: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7444435/
Engaged leadership focused on improvement What it is: Literature review published in the Implementation Science Journal that outlines strategies for successful quality improvement efforts, including detailing leaderships role in its success.
Target Setting: Inpatient and Ambulatory Settings Resource Link: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7199331/
Implement a Zero Tolerance Policy in the Organization for Workplace Violence What it is: Public Services Health & Safety Association, Engaging Patients and Families in Workplace Violence Prevention: A Handbook for Organizational Leaders in Healthcare Target Setting: Inpatient and Ambulatory Settings Resource Link: https://terraform-20180423174453746800000001.s3.amazonaws.com/attachments/cjiisgpvb00bbfxj7ew8jrt7l-p8-vprtlben0317-engaging-patients-and-families-in-workplace-violence-prevention-and-sample-brochure.pdf
Quality Improvement efforts need to have sufficient resources (e.g. funding, time), including protected staff time
What it is: Patient Safety & Quality: An Evidence-Based Handbook for Nurses; Chapter 44:Tools and Strategies for Quality Improvement and Patient Safety
Resource Link: https://www.ncbi.nlm.nih.gov/books/NBK2682/?report=reader
Multidisciplinary team inclusion throughout the QI process enables optimization of efforts
What it is: Journal Article in the Indian Journal of Public Health that outlines the principles for good quality management in healthcare
Resource Link: https://journals.lww.com/IJPH/Fulltext/2013/57030/Quality_Management_in_Healthcare.4.aspx
Implement protocols that can be adapted to the patient’s need(s) What it is: Patient Safety & Quality: An Evidence-Based Handbook for Nurses; Chapter 44:Tools and Strategies for Quality Improvement and Patient Safety
Resource Link: https://www.ncbi.nlm.nih.gov/books/NBK2682/?report=reader
Implement a data-driven QAPI process to integrate evidence into practice
What it is: The Agency for Healthcare Research and Quality (AHRQ)'s programs offer practical information to help a variety of health care organizations, providers, and others make care safer in all health care settings, with a variety of tools and programs available
Resource Link: Agency for Healthcare Research and Quality (ahrq.gov)
Board and C-Suite Accountability for Quality Management Program
What it is: The Institute for Healthcare Improvement issued a white paper on the framework for effective board governance of health system quality Target Setting: Inpatient and Ambulatory Settings Resource Link: Framework for Effective Board Governance of Health System Quality | IHI - Institute for Healthcare Improvement IHI_Governance-of-Quality-Assessment.pdf
Climate Resilience
Health Information Technology Integration Framework – HHS, ONC, CMS
Patient Engagement Playbook (HHS - ONC-PE, CDC) - Office of the National Coordinator for Health Information Technology (ONC)
Capturing High Quality Electronic Health Records Data to Support Performance Improvement (ONC)
Guide to Integrate Patient-Generated Digital Health Data into Electronic Health Records in Ambulatory Care Settings (PGHD) (AHRQ)
EvidenceNOW: Optimize Health Information Systems to Extract Data and Support Use of Evidence in Practice (EvidNow) (AHRQ)
Best Practice Guides for Telehealth (HHS-Tele) (HHS)
Translating Evidence Into Practice: A How-To Manual for Implementing Clinical Decision Support (CDS) (Primary Care Development Corporation (Guide developed through AHRQ funded project)
Initiating Health Care Data Sharing with a Social Service Organization (Center for Health Care Strategies)
Age-Friendly Health Systems: Guide to Electronic Health Record Requirements for Adoption of the 4Ms (Institute for Healthcare Improvement – IHI)
Patient Access Electronic Records Playbook (AMA)
| Assign C-suite executive accountable for oversight of climate resilience and sustainability in the organization | ||||
| Develop a set of relevant measures of resilience for the facility and the community (e.g., length of disruptions in operations, harm associated with emergency events, harm associated with climate-related exposures, expense of damage) | Conduct assessment for local climate-related exposures, creating rank-ordered list of threats to facility operations and identifying local populations most vulnerable to both acute and chronic climate-related threats, aided by tools like SCRHCFI | Train all staff to understand acute and chronic risks presented by climate change to their local populations, using tools like SCRHCFI, OCCHE Referral Guide for Health Professionals and ASPR tools | Participate in community climate resilience planning. | |
| Establish aims for facility and community resilience, using tools like the Sustainable and Climate Resilient Health Care Facilities Initiative (SCRHCFI) toolkit and RISC 2.0 to self-assess and identify gaps and goals | Maintain and address prioritized list of needed infrastructure and capacity improvements to enhance hardening (e.g., buildings, energy management, land use, transportation) based on analysis of vulnerabilities (flood, fires, wind, etc.), aided by tools like SCRHCFI | Identify screening tools, clinical protocols and referrals to anticipate and address most common chronic and acute threats to vulnerable local populations for use in key care settings (e.g., primary care, ED, discharge planning), using tools like OCCHE Referral Guide for Health Professionals | Identify multidisciplinary team of facility leaders on climate resilience – with clear hierarchies and responsibilities for incident command situations - and provide them with time and specialized training | |
| Broadly communicate threats associated with climate-related crises and their aftermath to local patients and families (including consideration of projected risks rather than relying on retrospective data alone). | ||||
| Establish joint aims for regional health system and community resilience in collaboration with regional and community partners (e.g., public health officials, ambulatory facilities, LTC facilities) | ||||
| Maintain up-to-date plans for response to all hazards with a focus on local climate-specific threats (includes communications and continuity of operations plans and attention to prevention, protection, mitigation, response and recovery) | Test introduction of anticipatory guidance and clinical actions in key care settings and assess effectiveness for most vulnerable populations (exchanging learning with other facilities) | Conduct regular training and simulation for all staff | Communicate specific threats (both acute and chronic) to most vulnerable populations on a regular basis | |
| Find funding for key investments in resilient and sustainable infrastructure, taking advantage of federal financing opportunities (e.g., Inflation Reduction Act programs supporting investments in resilient infrastructure) | Maintain agreements with local and regional healthcare facilities/stakeholders to ensure optimization of resources and continuity of care (regional care coalitions) | Identify and train on local emergency response method (including plans for coordination with other facilities, evacuation plans, assessment of post-event risks to local populations) | Verify that vulnerable populations understand risks, required actions (e.g., how to reduce risk, how to access care in an emergency) and available resources | |
| Review progress on key metrics of readiness and resilience at every Board meeting | ||||
| Using Climate and Health Outlook and similar tools, circulate regular forecasts of acute and chronic climate-related threats to clinical teams to be addressed through care delivery | Identify and gradually make improvements to critical infrastructure through available financing programs (e.g., Inflation Reduction Act programs, programs noted in OCCHE Compendium) | |||
| Conduct regular (e.g., annual) simulations to test readiness of emergency response to climate challenges |
Climate Resilience: Quality Improvement Intervention Framework
SYSTEM DESIGN & POLICIES
PROCESS
Climate Resilience: Summary of Resources
| Resource Name | Source | Page |
| Sustainable and Climate Resilient Health Care Facilities Initiative (SCRHCFI) toolkit (includes supports for facility self-assessment, planning, etc.) | HHS/Office of Climate Change and Health Equity (OCCHE) | |
| Protecting Vulnerable Patient Populations from Climate Hazards: A Referral Guide for Health Professionals (frontline guidance to help care providers refer vulnerable patients to federal resources) | HHS/OCCHE | |
| Compendium of Federal Resources for Health Sector Emissions Reduction and Resilience (includes resources like FEMA’s Building Resilient Infrastructure and Communities Program) | HHS/OCCHE | |
| Inflation Reduction Act “Quickfinder” (opportunities from the IRA for health sector investments in resilience and sustainability) | HHS/OCCHE | |
| Climate and Health Outlook (monthly forecast of climate-related threats for different regions of the country) | HHS/OCCHE | |
| Climate Change Resilience and Healthcare Systems Considerations (plus other valuable supports from RISC 2.0, Hospital Preparedness Program) | HHS/ASPR | |
| Climate Change and Social Vulnerability in the United States: A Focus on Six Impacts | EPA | |
| Health Systems Resilience Toolkit (2022)/Operational Framework for Building Climate-Resilient Health Systems (2015) | WHO | |
| Resilience Analysis and Planning Tool | FEMA |
Health Equity
Health Information Technology Integration Framework – HHS, ONC, CMS
Patient Engagement Playbook (HHS - ONC-PE, CDC) - Office of the National Coordinator for Health Information Technology (ONC)
Capturing High Quality Electronic Health Records Data to Support Performance Improvement (ONC)
Guide to Integrate Patient-Generated Digital Health Data into Electronic Health Records in Ambulatory Care Settings (PGHD) (AHRQ)
EvidenceNOW: Optimize Health Information Systems to Extract Data and Support Use of Evidence in Practice (EvidNow) (AHRQ)
Best Practice Guides for Telehealth (HHS-Tele) (HHS)
Translating Evidence Into Practice: A How-To Manual for Implementing Clinical Decision Support (CDS) (Primary Care Development Corporation (Guide developed through AHRQ funded project)
Initiating Health Care Data Sharing with a Social Service Organization (Center for Health Care Strategies)
Age-Friendly Health Systems: Guide to Electronic Health Record Requirements for Adoption of the 4Ms (Institute for Healthcare Improvement – IHI)
Patient Access Electronic Records Playbook (AMA)
| Create a Health Equity Scorecard (EBP) |
| Identify the key health equity metrics that the scorecard will measure. (Demographics, access to care, health outcomes, patient experience, workforce diversity, community engagement, etc.) (EBP, CLAS) |
Develop policies and procedures to collect and report on these metrics. (PREPARE)
Develop a process for annually updating the scorecard.
Analyze the data and identify areas where the health care system can improve its performance on health equity.
Develop and implement action plans to address these areas. (PRAPARE, IHI) Train all staff on how to use the scorecard and contribute to its improvement. (EBP)
Create a culture of accountability for health equity performance (can be integrated into employee scorecard).
Educate patients and communities about the scorecard and how they can use it to advocate for themselves.
Solicit feedback from patients and communities on the scorecard and how it can be improved. (RHIH)
Design systems that are easy to navigate for diverse community members to access preventative care services. (AHRQ-HL)
Implement a system to proactively remind and encourage patients to utilize preventative care services while working to reduce financial and accessibility barriers to preventative care (such as subsidized services or mobile clinics). (AHRQ-HL) Initiate community-health checkpoints or kiosks that facilitate effortless access to basic preventative care, such as screenings and initial consultations. (AHRQ-HL)
Establish seamless and quick referral processes for additional preventative services, such as specialist screenings or targeted health workshops. (AHRQ-HL) Deploy community health workers to focus on preventative care education and facilitation.
| Develop training modules that equip the healthcare workforce to address community specific health issues through preventative care interventions. (EBP) | Organize community engagement sessions, workshops and health fairs that promote the utilization of available preventative care services at locations frequented by the community. (AHRQ-HL) |
| Health Equity Scorecard: Access to Care Metric – Patient Travel Time |
Measure the average time patients travel to access healthcare services
Report these metrics to the Governing Body (Board) quarterly. (EBP) Review and enhance policies related to patient appointment scheduling and telehealth to minimize patient travel. (AHRQ-HL)
Audit and optimize hospital location, telehealth platforms, and partnerships with transportation providers (Uber, Lyft, etc).
| Streamline appointment scheduling processes and enhance transportation support, especially for underprivileged demographics. (AHRQ-HL) | Train staff on effective patient scheduling, telehealth service delivery and patient transportation coordination. (AHRQ-HL) | Implement feedback loops with communities to continually assess and improve travel and access issues in real-time. (AHRQ-HL) |
| Equitable Health Outcomes |
Implement policies that prioritize and allocate resources to tackle health disparities in disease incidence and life expectancy. (EBP) Develop and implement system that effectively track and analyze data on disease incidence, prevalence and life expectancy across various demographic groups. (PREPARE, EBP) Implement processes that allow for the systematic identification of disparities in health outcomes and trigger targeted interventions. (IHI, AHRQ-HL)
| Develop processes that not only respond to current disparities but also anticipate and mitigate future disparities through predictive modeling and proactive interventions. (IHI, AHRQ-HL) | Train healthcare providers and staff in culturally competent care and interventions that are tailored to the specific needs and preferences of diverse demographic groups. (EBP) | Involve community members in designing and implementing interventions aimed at improving health outcomes, ensuring cultural and social appropriateness. (AHRQ-HL) |
| Inclusive and Culturally Competent Care Delivery |
Audit and suggest refinements for policies focusing on comprehensive language services and demographic representation in staffing. (CLAS) Evaluate, design and upgrade systems ensuring availability and effective utilization of language services. (AHRQ-HL)
| Analyze and strategize on hiring practices for representative staffing. (CLAS, AHRQ-HL) | Assess, streamline and optimize processes ensuring effective deployment of language services and hiring from diverse backgrounds. (CLAS, AHRQ-HL) | Evaluate and enhance training programs focused on effective communication and cultural competency. |
| (CLAS, AHRQ-HL) | Engage communities to understand gaps in service delivery and collaborate on strategies on improvement. |
(CLAS, AHRQ-HL)
Develop a Health Equity Committee Establish a governance structure to oversee health equity initiatives and to provide funding for these initiatives.
| Develop policies and procedures that support health equity, such as culturally competent care standards and anti-bias training. (CLAS) | Implement a process for tracking and reporting on health equity metrics. (AHRQ-HL) | Provide training on health equity for all staff. (CLAS) | Educate patients and communities about their rights and resources. (CLAS) |
| Provide culturally competent care coordination and support services. | Develop culturally appropriate care coordination and support services that meet the needs of patients from diverse backgrounds. (IHI) | Provide culturally competent care and language services. (CLAS) | |
| Hire staff from diverse backgrounds that are represent the diversity in the community. (CLAS) | |||
| Educate patients and caregivers about social determinants of health and how to access resources. (IHI) | |||
| Enhanced Preventative Care Utilization |
Establish and uphold policies that mandate regular community health assessment and tailor preventative care initiatives accordingly. Ensure alignment of policies with community-specific health needs, considering demographic and epidemiological data. (PRAPARE, IHI)
Health Equity: Quality Improvement Intervention Design Framework
SYSTEM DESIGN & POLICIES
PROCESS
Improving Health Equity: Guidance for Health Care Organizations (IHI) What it is: A guide developed by the Institute for Healthcare Improvement (IHI) to assist Health Care Organizations in achieving health equity. The original IHI white paper outlining the five-component framework was turned into five individual guides, one for each component.
Target Setting: Health Care Organizations (including Hospitals, Ambulatory Practices, and Long-Term Care Facilities) Resource Link: Improving Health Equity: Guidance for Health Care Organizations | IHI - Institute for Healthcare Improvement (Includes Link to original White Paper and the five guides) Note: IHI requires account creation and log in to access. There is no cost to set up an account.
Guide for The National Standards for Culturally and Linguistically Appropriate Services in Health and Health Care (CLAS) What it is: The Blueprint is an implementation guide to help advance and sustain culturally and linguistically appropriate services within your organization. It offers concise, practical information on how to use the National Standards for Culturally and Linguistically Appropriate Services (CLAS) in Health and Health Care. The Behavioral Health Guide is a companion document to the Blueprint for Advancing and Sustaining CLAS Policy and Practice. Together these documents provide concrete, feasible implementation strategies for the health and behavioral healthcare community to improve the provision of services to all individuals, regardless of race, ethnicity, language, socioeconomic status, and other cultural characteristics Target Setting: Appropriate for a variety of settings including Hospitals, Ambulatory Care, and Long-term Care Resource Links:
The Blueprint - Think Cultural Health (hhs.gov) Behavioral Health Implementation Guide For The National Standards for Culturally and Linguistically Appropriate Services in Health and Health Care (hhs.gov)
Health Literacy Universal Precautions Toolkit (AHRQ-HL) What it is: The purpose of this Toolkit is to provide evidence-based guidance to support primary care practices in addressing health literacy. The Toolkit can help practices reduce the complexity of health care, increase Target Setting: Primary Care, although some tools are applicable to other settings as well.
Resource: AHRQ Health Literacy Universal Precautions Toolkit, 2nd Edition Relevant Links:
Creating Linguistically and Culturally Competent Suicide Prevention Materials: CalMHSA-CulturalGuide-v12.5.pdf (sprc.org) Patient Engagement | Health Literacy | CDC
Rural Health Information Hub (RHIH) - Health Equity Toolkit What it is: A toolkit to assist in implementing a program to incorporate strategies to advance health equity in a rural community.
Target Setting: Healthcare organizations serving rural communities Resource: Module 2: Evidence-Based and Promising Strategies to Advance Health Equity in Rural Communities - RHIhub Toolkit (ruralhealthinfo.org)
Adopting a Trauma-Informed Approach to Improve Patient Care: Foundational Organization-Level Steps (CHCS) What it is: A guidebook to assist hospitals and other types of healthcare providers such as rehabilitation centers and urgent care centers in preparedness and response planning.
Target Setting: Healthcare Organizations Resource Link: Adopting a Trauma-Informed Approach to Improve Patient Care: Foundational Organizational-Level Steps | Playbook (bettercareplaybook.org) Relevant Links:
Key Ingredients for Successful Trauma-Informed Care Implementation (samhsa.gov) SAMHSA's Concept of Trauma and Guidance for a Trauma-Informed Approach
Fostering Resilience and Recovery: A Change Package (Advancing Trauma-Informed Primary Care) (NC-FRR) What it is: A change package to provide information, action steps and tools to guide implementation of a trauma-informed primary care approach.
Target Setting: Primary Care, though applicable to other ambulatory care practices and hospitals settings.
Resource: Fostering Resilience (thenationalcouncil.org)
Protocol for Responding to and Assessing Patients’ Assets, Risks and Experiences (PRAPARE) Implementation and Action Toolkit What it is: Toolkit developed by the National Association of Community Health Centers (NACHC) and its partners to provide users with the resources, best practices, and lessons learned to guide implementation, data collection, and responses to social determinant needs. PRAPARE® is a national effort to help health centers and other providers collect and apply the data they need to better understand their patients’ social drivers of health.
Target Setting: Hospital or Ambulatory Settings Resource Link: PRAPARE Toolkit – PRAPARE Relevant Links:
The AHC Health-Related Social Needs Screening Tool (cms.gov)
Adapting Evidence-Based Practices for Under-Resourced Populations (EBP) What it is: This guide focuses on the process of adapting evidence-based practices (EBPs) for under-resourced populations who experience obstacles in obtaining healthcare services because of their socio-demographic characteristics, and the research supporting such adaptations. The guide provides examples of research on adapted EBPs for mental health and substance use disorders for clients with a wide range of demographic characteristics.
Target Setting: Community leaders and advocates, behavioral health practitioners, administrators, and organizational decision-makers in a variety of settings (Community-based organizations, hospitals, ambulatory care facilities, behavioral health facilities, and/or LTC facilities).
Resource: AHRQ Health Literacy Universal Precautions Toolkit, 2nd Edition
A Practical Guide to Implementing the National CLAS Standards: For Racial, Ethnic and Linguistic Minorities, People with Disabilities and Sexual and Gender Minorities What it is: The National CLAS Standards are intended to advance health equity, improve quality, and help eliminate health care disparities by establishing a blueprint for health and health care organizations.
The CLAS Standards are divided into four themes:
Principal Standard Governance, Leadership, and Workforce Communication and Language Assistance Engagement, Continuous Improvement, and Accountability Target…
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