1_AttachmentJ-3.pdf

QIO Communications Handbook

Please Note: Updates and additions to the current version of the handbook are shown in red.

Table of Contents

Introduction

Reports and Deliverables Communications 8th SOW Contract Deliverables and Due Date Annual Medical Services Review Report Communications Diary and Planning Tool Stakeholder and Provider Surveys Partnership and Communications Plan PARTner Internal Quality Control

Outreach Partnerships with ESRD Networks Partnerships with Stakeholders Beneficiary Outreach Beneficiary Helpline Provider Outreach QIO Program Priorities Document IHI “100,000 Lives” Campaign Remaking American Medicine Physician Voluntary Reporting Program (PVRP) Welcome to Medicare Outreach Items Exhibits

Creating Materials Communications Activities Overview Key Messages Outreach Material Description Developing New Materials for Tasks 1 or 3 Impact Statement Guidelines QIO Proper Reference CMS Proper Reference Screening Process Publication Numbering System/Disclaimer Copyrights DHHS Logo and CMS Identity Mark Guidelines QIO Sharing Peer Reviewed Journal Articles and Abstracts Plain Language Cultural Competence Medicare+Choice References

Table of Contents 2 Updated 02/20/07

Resources Listserves CMS Press Mailing List CMS Publication Ordering System MedQIC QIOnet Qualitynet.org Dashboard/Reports Qnet Quest Contact Information

Other Relevant CMS Policy Confidentiality/Disclosure/Release of Information Information Collection QIO Affiliations (Conflict of Interest/Endorsement) Retention of Materials Beneficiary Satisfaction Surveys Public Health Efforts

Technical Information Website Guidelines and Standards Hardware and Software Catalogs

Index

Table of Contents 3 Updated 02/20/07 he QIO Communications Handbook is designed as a resource to support Quality Improvement Organization (QIO) communications staff. QIOs conduct a variety of communications activities that may include positioning the organization as a resource to the general public in support of Centers for Medicare & Medicaid Services (CMS) initiatives, as well as communications efforts that support specific contract tasks. The handbook is also a resource and reference for CMS staff in both the Central and Regional Offices (RO) who work with QIO Contract communications requirements.

T

Serving as a comprehensive reference guide to all existing CMS communications guidelines, policies, procedures and other information related to communications, the handbook places necessary information in one location for easier reference. The handbook’s functionality is further enhanced with links* to the original documentation for each item. When possible, the summaries quote actual policy. In some instances, paraphrasing was necessary. However, readers are encouraged to always use the link or references to check the policy for exact language.

The handbook will be updated each time a CMS communications-related policy, guideline or procedure is released or revised.

Note: CMS policies and procedures are contractually binding. Summaries of key policies, procedures and guidelines contained in this document are not intended to replace CMS policy. Questions about policy clarification should be directed to a QIO’s RO Project Officer (PO).

* Most links in this document are directed to the QIOnet (http://qionet.sdps.org/). You must view this document on a Standard Data Processing System (SDPS) computer or the links will appear to be broken. If you find any links that should be updated, please contact the Communications QIOSC at 1-877-865-3793.

QIO Communications Handbook Updated 02/20/07 http://qionet.sdps.org/ http://qionet.sdps.org

Reports and Deliverables

Communications 8th Scope of Work (SOW) Contract Deliverables and Due Dates

Deliverable Date Due Submission Method Partnership and Communications Plan

August 31, 2005 and every 6 months thereafter

PARTner and Electronically by request to PO, Communications

GTL, RO

Communications Specialist and Communications QIOSC

List of key stakeholders November 21, 2005, update monthly with any changes

PARTner and by email to FRYS1@westat.com

Due Dates

QIO Annual Medical Services Review Report

Annually, see below for exact due dates based on contract year.

PARTner

(QIO 8th SOW Contract, F.2)

QIO Annual Medical Services Review Report

QIOs must produce a report at least once per year using the Annual Medical Services Review Report template. Allow up to 20 working days for PO approval. Once the PO has approved the report, it should be posted on your QIO website; print copies should also be available upon request. The report must be published no later than 90 days following the end of the each contract year, with the exception of the third year.

During the third year of the contract, the annual report is due 90 days from the end of the 33rd month and covering months 25 through 33.

Program Progress Reports #8990300 and #8990400 are available to complete the report. These reports do not include data for ‘Cases per 10,000 Part A Medicare Beneficiaries’ or ‘Total Part A Medicare Beneficiaries in the State.’ You will need to identify the data for these fields.

To access the reports go to the QIOnet (http://qionet.sdps.org), select Dashboard/Reports. Select Program Progress/Program Progress Reports. These reports can be found under the CRIS Management Reports folders. The current report template is in SDPS Memo #06-376-CR.

(SDPS Memo #06-376-CR) (SDPS Memo #04-369-CR) (SDPS Memo #SDPS 03-459-CR; QIO Manual, Chapter 12, 12400-12440)

Reports and Deliverables 5 mailto:FRYS1@westat.com http://www.cms.hhs.gov/QualityImprovementOrgs/Downloads/8thSOW.pdf http://qionet.sdps.org/ http://qionet.sdps.org/sdps_memos/sdps_memos_2006/06376cr.htm http://qionet.sdps.org/sdps_memos/sdps_memos_2006/06376cr.htm http://qionet.sdps.org/sdps_memos/sdps_memos_2004/04369cr.htm http://qionet.sdps.org/sdps_memos/sdps_memos_2003/03459cr.htm http://cms.hhs.gov/manuals/downloads/qio110c12.pdf http://qionet.sdps.org

Communications Diary and Planning Tool

The Communications Diary and Planning Tool is no longer required.

(SDPS Memo #05-276-GN)

Stakeholder and Provider Satisfaction Surveys

Stakeholder Survey Consistent with QIO 8th SOW contract requirements and as part of QIO evaluation on performance, stakeholders will be surveyed to gauge their knowledge and perception of value of collaboration with a QIO. Through their state chapter or local contact, QIOs are required to work with 15 national CMS-identified stakeholders. These CMS-identified stakeholders are in addition to the 15 QIO-submitted stakeholders required for a total of 30 stakeholders per QIO.

For QIOs in states where there may be no local chapter of an organization listed, a QIO should notify its Project Officer by email (with a copy to the Communications GTL) about the need for an exemption in working with that organization. Exemptions will be discussed and approved by the Project Officer on a case-by-case basis.

Using the Stakeholder template, QIOs are required to email the template to FRYS1@WESTAT.com and upload into PARTner any updates monthly (as necessary) by the last working day of the month.

If you have questions regarding the key stakeholder list, please check Qnet Quest.

(QIO 8th SOW Contract C.6.B.1.5.a) (SDPS Memo #05-303-CM) (SDPS Memo #05-416-GN)

The aggregated composite scores by state and the national average scores from the 2006 Stakeholder Satisfaction and Knowledge Survey are posted on the SDPS CMS Dashboard. A summary report is available as part of SDPS Memo 06-217-GN. The next stakeholder survey is scheduled for Summer 2007.

(SDPS Memo #06-217-GN)

For the round 2 stakeholder surveys, updates of contact information may be submitted until April 13, 2007. QIOs should use the stakeholder template to submit changes.

No changes in the stakeholder list will be accepted unless the QIO receives an approval from CMS.

(QIO 8th SOW Contract, C.4.B.14) (SDPS Memo #06-352-CO)

Reports and Deliverables 6 http://qionet.sdps.org/sdps_memos/sdps_memos_2005/05276gn.htm mailto:FRYS1@WESTAT.com http://www.cms.hhs.gov/QualityImprovementOrgs/Downloads/8thSOW.pdf http://www.cms.hhs.gov/QualityImprovementOrgs/Downloads/8thSOW.pdf http://www.cms.hhs.gov/QualityImprovementOrgs/Downloads/8thSOW.pdf http://qionet.sdps.org/sdps_memos/sdps_memos_2005/05303cm.htm http://qionet.sdps.org/sdps_memos/sdps_memos_2005/05416gn.pdf http://qionet.sdps.org/sdps_memos/sdps_memos_2006/06217gn.htm http://www.cms.hhs.gov/QualityImprovementOrgs/Downloads/8thSOW.pdf http://www.cms.hhs.gov/QualityImprovementOrgs/Downloads/8thSOW.pdf http://www.cms.hhs.gov/QualityImprovementOrgs/Downloads/8thSOW.pdf http://qionet.sdps.org/sdps_memos/sdps_memos_2006/06352co.pdf mailto:FRYS1@WESTAT.com

Provider Survey Westat will be conducting the surveys. The QIO will subcontract with Westat within two weeks following receipt of a signed contract from CMS. This subcontract must incorporate the requirements in Attachment J-10 of the RFP. To start the contracting process, contact Westat:

Contact: Vasudha Narayanan Email: QIOsurvey@westat.com Toll Free line: 888-518-2690

QIOs will send provider contact information directly to Westat through QualityNet Exchange. Westat will provide the template that was developed for submitting the necessary provider contact information to the QIOs. No information/data should be provided to Westat by the QIO prior to execution of the Refresher Modification and the QIOs agreement (subcontract) with Westat is in place.

(SDPS Memo #06-369-CO)

For the round two provider surveys (round one has been canceled), updates of contact information may be submitted until April 13, 2007.

(QIO 8th SOW Contract, C.4.B.14) (SDPS Memo #06-352-CO)

The following table shows the type of survey respondents by setting:

Task Identified Participants Non-Identified Participants Nursing Home (1a) X X Home Health (1b) X X Hospital (1c1) X X Hospital (1c2) X X Physician Practice (1d1) X Physician Practice (1d2) X X Physician Practice/pharmacy/ PDPs

X

Managed Care* X X

* 1d2 and 1d3

(SDPS Memo #05-416-GN) (SDPS Memo #07-066-GN)

For task 1d2, QIOs will need to provide a listing of 15 to 25 partner contacts with whom it works to conduct its 1d2 statewide activities for Mammography and Diabetes. These contacts will be entered into the template provided by Westat.

(SDPS Memo #07-066-GN)

For task 1d1 IPG only, the Satisfaction with QIO Services and Knowledge/Perception about CMS Quality Activities questions will be contained in the Office System Survey (OSS). Practices in the IPG will complete the OSS in August 2006 and October 2007. For QIO evaluation in task 1d1, survey responses for all practices that

Reports and Deliverables 7 mailto:QIOsurvey@westat.com http://qionet.sdps.org/sdps_memos/sdps_memos_2006/06369co.pdf http://www.cms.hhs.gov/QualityImprovementOrgs/Downloads/8thSOW.pdf http://www.cms.hhs.gov/QualityImprovementOrgs/Downloads/8thSOW.pdf http://www.cms.hhs.gov/QualityImprovementOrgs/Downloads/8thSOW.pdf http://qionet.sdps.org/sdps_memos/sdps_memos_2006/06352co.pdf http://qionet.sdps.org/sdps_memos/sdps_memos_2005/05416gn.pdf http://qionet.sdps.org/sdps_memos/sdps_memos_2007/07066gn.htm http://qionet.sdps.org/sdps_memos/sdps_memos_2007/07066gn.htm complete an OSS at baseline (August 2006) or remeasurement (October 2007) will be used to evaluate the QIOs Satisfaction and Knowledge/Perception score.

(QIO 8th SOW Contract, C.6.B.1.5.a)

Partnership and Communications Plan

Using the template provided by the CommQIOSC, QIOs are required to submit their partnership and communications plan to the Program Activity Reporting Tool (PARTner) on August 31, 2005 and every 6 months thereafter. The partnership and communications plan provides CMS with an overview of the strategies and tactics the QIO will use to achieve the goals and objectives of the QIO Program.

CMS will review and may suggest modifications to the QIO’s partnership and communications plan based on QIO Program priorities.

(QIO 8th SOW Contract, C.4.B.8.a) (SDPS Memo #05-276-GN)

PARTner

Program Activity Reporting Tool (PARTner) is an SDPS application developed to allow QIOs to collect information required by CMS for capturing “identified participants,” tracking quality improvement activities, hospital payment monitoring activities, deliverables and narratives.

The following must be posted to PARTner for informational use by CMS:

• Partnership and Communications Plan;

• List of key stakeholders

The following postings to PARTner involve approvals by CMS:

• Annual Medical Services Review Report;

• Peer-Reviewed Journal Publications and Conference Abstracts; and

• Information Collection Activities.

(SDPS Memo #02-366-PA)

The PARTner Document Storage window is used to add and modify document information, as well as to upload and download files. To add a new document:

1. Access the Document Storage Listing window by selecting the PARTner/Document Storage Listing.

2. From the Document Storage Listing window, select the insert icon. The Document Storage window is then displayed.

3. In the Drive field, select the drive where your document is located.

4. In the Directory field, select the directory where your document is located. If the directory selected contains sub-directories, the sub-directories will be displayed in the Directory field. Continue selecting directories until you locate the directory in which your document is located.

Reports and Deliverables 8 http://www.cms.hhs.gov/QualityImprovementOrgs/Downloads/8thSOW.pdf http://www.cms.hhs.gov/QualityImprovementOrgs/Downloads/8thSOW.pdf http://www.cms.hhs.gov/QualityImprovementOrgs/Downloads/8thSOW.pdf http://www.cms.hhs.gov/QualityImprovementOrgs/Downloads/8thSOW.pdf http://qionet.sdps.org/sdps_memos/sdps_memos_2005/05276gn.htm http://qionet.sdps.org/sdps_memos/sdps_memos_2002/02366pa.htm

5. In the File Name field, select the File Name of the document you want to upload to the database.

6. Select the State Code from the drop-down list.

7. In the Category field, select the category applicable to the document you are uploading to the database.

8. In the Subcategory field, select the appropriate subcategory for the document.

9. In the Deliverable Due Month field, enter the month and year the deliverable is due. This field is available for entry only if the subcategory selected is a deliverable.

10. Select the Upload icon to upload the document.

11. To exit the Document Storage window, select the Close Window icon.

If you inadvertently upload an incorrect document, you can delete it the same day you upload it. If you don’t realize the incorrect document was uploaded until a later day, notify your PO of the error. Also enter a note in the Notes field on the Document Storage window indicating it is not the correct document. Then upload the correct document.

(PARTner User’s Guide, available on SDPS computers at t:/instruct/partug/PARTner User Guide.pdf)

Internal Quality Control

The QIO shall implement an IQC program as described in Sections 13000-13030 of the QIO Manual.

The IQC plan must include the following elements:

• Identify tasks/subtasks and/or activities that are included

• Identify measures/monitors of performance

• Develop a plan for how you will meet goals/targets

• Use measures that enable you to determine if performance is proceeding acceptably

• At least annually, use measures, results, and other information to assess whether you are likely to meet goals/targets. Analyze any causes of failure, and project changes in the process that you believe will improve performance

• Improve your process

• Determine whether improvements were successful and make further adjustments to the process as needed.

CMS encourages each QIO to collaborate with other QIOs in developing and implementing IQC programs. The QIO shall share lessons learned with other QIOs using available mechanisms, including QIO conferences, newsletters, and databases.

(QIO 8th SOW Contract, C.4.B.10) (QIO Manual, Chapter 13)

Reports and Deliverables 9 http://www.cms.hhs.gov/manuals/downloads/qio110c13.pdf http://www.cms.hhs.gov/QualityImprovementOrgs/Downloads/8thSOW.pdf http://www.cms.hhs.gov/QualityImprovementOrgs/Downloads/8thSOW.pdf http://www.cms.hhs.gov/QualityImprovementOrgs/Downloads/8thSOW.pdf http://www.cms.hhs.gov/manuals/downloads/qio110c13.pdf

Outreach To accomplish the goals of the QIO program, CMS requires the QIO to manage its resources as efficiently and effectively as possible. QIOs may only conduct provider, practitioner, stakeholder and beneficiary communication activities in support of Tasks 1 and/or 3. The QIO should integrate communications to ensure consistent messaging across all Tasks and subtasks and to coordinate national initiatives.

(QIO 8th SOW Contract, C.4.B.8)

The QIO shall have available the following communication expertise: health education, health promotion, social marketing and formative research, public relations, market research, media, web design, social and behavioral sciences.

(QIO 8th SOW Contract, C.4.B.11)

Partnerships with ESRD Networks

QIOs shall assist ESRD Network(s) to promote the Fistula First Project among providers. All QIO activities must have documented approval or collaboration of the appropriate ESRD Network or the Network Coordinating Center.

(QIO 8th SOW Contract, C.4.B.8.b)

Partnerships with Stakeholders

QIOs shall partner with stakeholders to achieve 8th SOW goals. Such partnerships may expand awareness of the program and should include the following areas:

• Public reporting of provider performance measure results;

• Pay-for-performance programs that reward improvements in quality;

• Increasing awareness of the services and value offered by the QIO Program; and

• ESRD Networks’ initiatives, including the National Fistula First Project.

(QIO 8th SOW Contract, C.6.B.2.g.iii)

QIO partnerships shall also coordinate QIO activities with stakeholders working on comparable efforts. This may involve creating, joining, and supporting partnerships with similar goals and objectives, or facilitating dialogue among stakeholders.

Specific guidance is provided in the Task Descriptions in Section C.6.

(QIO 8th SOW Contract, C.4.B.7)

QIOs should meet at least twice per year with organizations directly affected by the activities of the QIO program. These organizations should include, but are not limited to, state and local provider organizations, medical societies, specialty societies and state licensure agencies. All meetings should be appropriately documented.

(QIO Manual, Chapter 12, 12210)

Refer to QIO Affiliations for related policy section.

Outreach 10 http://www.cms.hhs.gov/QualityImprovementOrgs/Downloads/8thSOW.pdf http://www.cms.hhs.gov/QualityImprovementOrgs/Downloads/8thSOW.pdf http://www.cms.hhs.gov/QualityImprovementOrgs/Downloads/8thSOW.pdf http://www.cms.hhs.gov/QualityImprovementOrgs/Downloads/8thSOW.pdf

Beneficiary Outreach

QIOs may conduct beneficiary communication activities only as it relates to Task 1 and 3 and as it relates to:

• The purpose of the QIO program;

• The rights of Medicare beneficiaries under the QIO program; and

• How these rights may be exercised.

This includes advising beneficiaries that they should receive “An Important Message from Medicare” from hospitals during their stay.

(QIO Manual Chapter 12, 12100) (QIO 8th SOW Contract, C.4.B.8.j)

QIOs must evaluate beneficiary outreach efforts in support of Tasks 1 and 3. Some methods QIOs can use to evaluate beneficiary outreach activities are listed below.

QIOs are required to use measurement and evaluation results when developing and carrying out new educational initiatives. Results also should be shared with other QIOs, QIOSCs and clearinghouses.

• Compare the population reached to the total Medicare population in your state.

• Determine if the information presented meets beneficiaries’ needs.

• Determine if the information is presented effectively.

• Determine if the information achieves the desired outcome.

• Determine if education materials are produced in a cost effective manner.

• Evaluate partnership activities.

(QIO Manual Chapter 12, 12140)

For all new beneficiary-targeted outreach materials related to Task 3, with the exception of appeals such as of Hospital Issued Notice of Non-coverage (HINN) and Notice of Discharge and Medicare Appeal Rights (NODMAR) materials, QIOs shall publish and promote the national 1-800-MEDICARE helpline. For appeals materials such as HINN and NODMARs, QIOs shall promote and publish its own toll-free helpline.

(TOPS Memo # 2003-11; Note: the contents of this memo replace the policy included in the QIO Manual, Chapter 12, 12120.)

In instances where a QIO partners with a local, regional or national non-profit or advocacy organization in the development and publication of topic-specific ads or other outreach materials, the contact information for the partner organization may also be included in the material. See the QIO Affiliations section for more partnership information.

(SDPS Memo #04-217-GN)

Outreach 11 http://www.cms.gov/manuals/downloads/qio110c12.pdf http://www.cms.hhs.gov/QualityImprovementOrgs/Downloads/8thSOW.pdf http://cms.hhs.gov/manuals/downloads/qio110c12.pdf http://qionet.sdps.org/tops_memos/03-11.htm http://qionet.sdps.org/sdps_memos/sdps_memos_2004/04217gn.htm

Beneficiary Helpline

QIOs must maintain a cost-free beneficiary helpline staffed during normal working hours. This helpline should provide information regarding Medicare beneficiary rights and responsibilities, beneficiary protections, health education issues related to active QIO projects and beneficiary complaints. QIOs must make appropriate referrals when information or assistance that the beneficiary request is not related to QIO activities or responsibilities and must make a monthly record of these calls on the 1-800-MEDICARE Issues Tracking Log and fax to CMS at the end of each month.

(QIO Manual Chapter 12, 12110-12115)(SDPS Memo #05-158-GN) (QIO 8th SOW Contract, C.6.B.3a.2.e)

QIOs are not required to maintain a TDD line. If a QIO receives a call from a TDD line, they may forward those calls to Medicare’s TDD line.

(QUEST Question #23645)

See previous section, Beneficiary Outreach on when it is appropriate to promote and publish this QIO helpline.

Provider Outreach

QIOs shall offer to send a physician representing the QIO to meet with medical and administrative staff of each hospital, which it reviews.

(QIO 8th SOW Contract, C.4.B.8.c)

QIO Program Priorities Document

CMS developed the priorities document to describe the QIO program and 8th SOW topics to providers and other partners. The program priorities document is available publicly in PDF version or for QIO customization in Word version. You can access both versions at http://www.medqic.org/dcs/ContentServer?cid=1097592510511&pagename=Medqic %2FMQLiterature%2FLiteratureTemplate&c=MQLiterature. Limited quantities are available in hard-copy by contacting MedQIC.

(TOPS Memo #2006-01).

IHI “100,000 Lives” Campaign

QIOs may choose to participate in the “100,000 Lives” campaign by providing technical assistance or serving as partner in areas that are within the QIO scope of work.

QIOs may assist providers to implement interventions addressing 8th SOW indicators for Task 1c and 1d3. QIOs may lead campaign launch and implementation and act as

Outreach 12 http://cms.hhs.gov/manuals/downloads/qio110c12.pdf http://qionet.sdps.org/sdps_memos/sdps_memos_2005/05158gn.pdf http://www.cms.hhs.gov/QualityImprovementOrgs/Downloads/8thSOW.pdf http://www.qnetquest.org/ http://www.cms.hhs.gov/QualityImprovementOrgs/Downloads/8thSOW.pdf http://www.medqic.org/dcs/ContentServer?cid=1097592510511&pagename=Medqic%2FMQLiterature%2FLiteratureTemplate&c=MQLiterature http://www.medqic.org/dcs/ContentServer?cid=1097592510511&pagename=Medqic%2FMQLiterature%2FLiteratureTemplate&c=MQLiterature http://qionet.sdps.org/tops_memos/06-01.pdf a “node”. These activities may include coalition participation, and outreach to the public, providers, and health plans.

(SDPS Memo # 05-218-GN)

Remaking American Medicine

The Public Broadcast Service (PBS) is preparing a four-part, prime-time, nationally broadcast series – The Remaking of American Medicine – featuring institutions and individuals in the forefront of efforts to change systems of care to improve quality.

CMS considers QIO support of the following activities allowable under the 8th SOW contract: coalition building, sponsorship, coordination with local PBS affiliates and development of local programming. Activities outside of those suggested should be discussed with your PO and the Communications GTL prior to implementation.

(SDPS Memo #04-223-GN) (SDPS Memo #05-218-GN)

Physician Voluntary Reporting Program (PVRP)

QIOs shall support PVRP while implementing their DOQ-IT project. QIOs are expected to:

• Support PVRP participation by making information available to physicians and stakeholders.

• Support physicians by providing technical assistance regarding PVRP participation and submission of information.

• Support physicians in EHR adoption and improvement on performance measures.

Information regarding the program, registration for Qnet Exchange and using it to obtain feedback reports, and performance measure specifications will be available at http://cms.hhs.gov/physicianfocusedqualinits/.

(QIO 8th SOW Contract, C.6.B.1d1.2.a.i)(SDPS #06-072-PO)

Welcome to Medicare Visit

The QIO shall promote statewide quality improvement by working with public health, provider groups, and other broad-based agencies to support the use of appropriate preventive and disease-based care processes, including the “Welcome to Medicare Visit”.

(QIO 8th SOW Contract, C.6.B.1d1.2.a.i)

Outreach 13 http://qionet.sdps.org/sdps_memos/sdps_memos_2005/05218gn.htm http://qionet.sdps.org/sdps_memos/sdps_memos_2004/04223gn.htm http://qionet.sdps.org/sdps_memos/sdps_memos_2005/05218gn.htm http://cms.hhs.gov/physicianfocusedqualinits/ http://www.cms.hhs.gov/QualityImprovementOrgs/Downloads/8thSOW.pdf http://qionet.sdps.org/sdps_memos/sdps_memos_2006/06072po.pdf

Outreach Items

Outreach items such as displays and pens may be used as part of a comprehensive plan for communication with a target audience. Outreach items may be provided by the QIO at no cost to the recipient and used for the purposes of extending the impact and reinforcing the awareness of a CMS message about its programs and the role of the QIO in supporting those programs or initiatives.

A QIO’s organization name, with or without a logo, may be included on an item or exhibit as long as:

• It is not the only or primary message on the item; and

• It includes the phrase “The Medicare Quality Improvement Organization for

(insert state)” immediately after the QIO name.

Please note, no QIO name or logo should compete in size or placement with the primary CMS quality improvement intervention or quality care message.

(QIO 8th SOW Contract, C.4.B.8.f.2)

For all new beneficiary-targeted outreach materials related to Task 3, with the exception of appeals such as of Hospital Issued Notice of Non-coverage (HINN) and Notice of Discharge and Medicare Appeal Rights (NODMAR) materials, QIOs shall publish and promote the national 1-800-MEDICARE helpline. For appeals materials such as HINN and NODMARs, QIOs shall promote and publish its own toll-free helpline.

(TOPS Memo # 2003-11; Note: the contents of this memo replace the policy included in the QIO Manual, Chapter 12, 12120.)

Exhibits

Exhibits or public displays may be used, if necessary, to attract the attention of a specific target audience who would benefit from direct QIO interaction about a CMS quality improvement intervention or quality care information.

(QIO 8th SOW Contract, C.4.B.8.f.1)

Outreach 14 http://www.cms.hhs.gov/QualityImprovementOrgs/Downloads/8thSOW.pdf http://qionet.sdps.org/tops_memos/03-11.htm

Creating Materials

Communications Activities Overview

To accomplish the goals of the QIO program, CMS requires the QIO to manage its resources as efficiently and effectively as possible. QIOs may only conduct provider, practitioner, stakeholder and beneficiary communication activities in support of Tasks 1 and/or 3. The QIO should integrate communications to ensure consistent messaging across all Tasks and subtasks and to coordinate national initiatives.

(QIO 8th SOW Contract, C.4.B.8)

Before creating new materials, CMS expects QIOs to:

• Consult the relevant information clearinghouse prior to developing new material (see Developing New Materials for Tasks 1 and 3 for more information);

• Consult the ESRD Networks and ESRD Network Coordinating Center for renal-related material; and

• Consider using already-developed, non-copyrighted materials available from other sources for use or modification. With documented permission from the owner as needed, a QIO may modify such materials when required for the QIO's communications strategy with local audiences and partners. CMS expects QIOs to utilize existing, non-copyrighted materials and resources to the extent possible when undertaking communications activities similar to those for which the materials/resources were originally developed.

If new materials are created, CMS expects QIOs to:

• Develop new materials in the most efficient and effective methods possible;

and

• Make the materials available to the general QIO community through the relevant QIOSC (see QIO Sharing for more information).

(QIO 8th SOW Contract, C.4.B.8)

Key Messages

QIOs shall ensure that key messages are integrated appropriately into all materials to ensure a unified voice. QIOs should use draft key messages, which are available in the Communication Tools section on the front page of the Communications Clearinghouse.

Outreach Material Description

“Outreach” is defined as non-peer-reviewed products (electronic or hardcopy) that will be distributed outside your QIO to any audience: i.e., healthcare providers, stakeholders, information intermediaries or Medicare beneficiaries. Outreach materials include but are not limited to CDs, newsletters, brochures, pamphlets, posters, audio/visual materials and clinical intervention materials. All such products

Creating Materials 15 http://www.cms.hhs.gov/QualityImprovementOrgs/Downloads/8thSOW.pdf http://www.cms.hhs.gov/QualityImprovementOrgs/Downloads/8thSOW.pdf http://qionet.sdps.org/7thSOW/commclhouse/index.shtml http://qionet.sdps.org/7thSOW/commclhouse/index.shtml must contain a publication number and disclaimer (see Publication Numbering System/Disclaimer for more information).

(TOPS Memo #2004-06)

Developing New Materials for Tasks 1 and 3

Before a QIO develops new communications materials, the relevant information clearinghouse (if available) should be consulted. If suitable materials are available through the clearinghouse, the QIO is expected to use the content in original form or adapt for local use.

• When developing Task 1 materials, consult the Medicare Quality Improvement Community (MedQIC) and consider contacting the relevant

QIOSC.

• When developing Task 3 materials, consult QIOnet (including the Communications Clearinghouse) and consider contacting the relevant QIOSC.

(QIO 8th SOW Contract, C.4.B.8.d)

QIOs shall ensure that key messages are integrated appropriately into all materials to ensure a unified voice. QIOs should use draft key messages, which are available on the Communications Clearinghouse.

If materials from Tasks 1 and 3 are to be used in activities involving media on a national scale, materials may require CMS review and approval process. Once a submitted document has been approved and any required changes made, the QIO shall provide a copy of the final version to the appropriate QIOSC in a format prescribed by CMS.

For all new beneficiary-targeted outreach materials related to Task 3, with the exception of appeals such as of Hospital Issued Notice of Non-coverage (HINN) and Notice of Discharge and Medicare Appeal Rights (NODMAR) materials, QIOs shall publish and promote the national 1-800-MEDICARE helpline. For appeals materials such as HINN and NODMARs, QIOs shall promote and publish its own toll-free helpline.

(TOPS Memo # 2003-11; Note: the contents of this memo replace the policy included in the QIO Manual, Chapter 12, 12120.)

Impact Statement Guidelines

QIO impact statements are used to communicate statewide QIO data and attribute improvements demonstrated by the data to the work of the QIO. The statements target external audiences including providers, state legislators, media, stakeholders, and the general public.

The following guidelines should be followed when developing impact statements.

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1. Include information that provides context for the QIO Program and the data presented.

2. When appropriate, articulate differences between those providers that work with the QIO (such as identified participants) and those that do not.

3. Identify data source(s) and methodology(ies) for all data presented.

4. Outline specific measurable achievement by setting rather than as a cross-setting aggregate.

5, 6, 7. Reporting on “lives improved,” cost savings and project impact each have detailed specific guidance. See TOPS Memo #2007-01 for details.

8. Promote activities that are CMS and QIO Program priorities, such as (a) adoption and use of health information technology, (b) beneficiary protection, and (c) other topics that may be identified by CMS.

9. May include local success stories as examples of impact.

10. Include a publication number and disclaimer.

Please note: None of the data or other content provided by the QIO in impact statements can be used in lieu of the contractual evaluation criteria specified in the SOW contract and its supporting documents to determine eligibility for interim award fees, final award fees, or group award fees or to determine if the QIO has met the SOW contract performance criteria to be eligible to have its contract renewed non-competitively.

(TOPS Memo #2007-01)

QIO Proper Reference

When referring to your organization, use the term Quality Improvement Organization or QIO. In describing contract work with CMS, QIOs may choose to identify themselves as "Medicare QIOs."

(TOPS Memo #2002-02) QIO program branding elements are currently in development.

CMS Proper Reference

In written references to the Centers for Medicare & Medicaid Services, QIOs must use the ampersand (&) and not the word "and." When referring to the Agency using an acronym, QIOs shall use the acronym "CMS."

(TOPS Memo #2002-02)

The proper reference to CMS is:

The Centers for Medicare & Medicaid Services (CMS), an agency of the U.S.

Department of Health and Human Services. Note that an ampersand (&) rather than the word “and” is used when referring to the Centers for Medicare & Medicaid Services (CMS).

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The correct possessive form of CMS is “CMS’” For example: CMS’ quality initiatives cover nursing home, home health and hospital care.

(The CMS Communications Handbook is currently being revised and is not available electronically; this link will be updated as soon as it’s available)

Screening Process

A new screening process is in development for the 8th SOW. Until this process is issued via a TOPS memo, QIOs are to follow the existing review process.

A review process is in place for communications work involving CMS-directed high-profile activities (e.g., the Medicare Prescription Drug, Improvement and Modernization Act of 2003 [MMA]).

Materials requiring prior review and approval include:

• Products referencing or quoting the DHHS Secretary or CMS Administrator

• Products the QIO proposes for use nationally

• Products for which the QIO requests use of the DHHS logo or CMS identity mark

• Newly developed or substantially modified products for other high-profile

CMS activities (e.g., MMA, P4P)

Unless mentioned above, QIO-developed materials that support ongoing public reporting activities for the Nursing Home and Home Health Quality Initiatives are exempt from review.

Submission Instructions:

1. Email materials to the review contact (reviews@moqio.sdps.org) with the following required subject line:

“REVIEW REQUESTED BY: [DATE NEEDED], [TARGET MEDIA

OR AUDIENCE], [TYPE OF PRODUCT]”

2. Include the QIO contact name and telephone number in the message.

3. Copy your QIO’s RO DQI communications lead and project officer.

4. Provide rationale for fast-track or immediate response requests, including an explanation of the product’s time sensitivity.

You will be contacted via e-mail with any required changes and suggestions. QIOs are responsible for making required changes to products prior to production or distribution. Suggested changes included in the review results are optional and may be used at the QIO’s discretion.

(SDPS Memo #04-111-GN)

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RHQDAPU

A review process is in place for materials created for the Reporting Hospital Quality Data for Annual Payment Update (RHQDAPU) Initiative. CMS authorizes QIOs to produce materials as long as they adhere to the CMS review guidelines as follows:

• QIOs must rely on CMS-approved materials to develop their RHQDAPU products.

• QIO products that contain the language verbatim from CMS-approved materials do not require clearance.

• QIO products that reflect added content or information to address hospital enrollment and participation in the RHQDAPU Initiative must be submitted for review by the Hospital Data Collection and Communications QIOSCs.

QIOs must submit items directly to the Communications QIOSC for coordination of review to ensure consistency with approved messaging.

CMS has implemented the following expedited review process:

1. Submit products to reviews@moqio.sdps.org. The Communications QIOSC will provide confirmation of receipt and coordinate clearance.

2. The Hospital Data Collection and Communications QIOSCs will conduct simultaneous reviews.

3. The QIO will receive review results as follows:

• Product cleared for production - adheres to approved messaging; no further clearance required (response will be received directly from the Communications QIOSC).

• Product not cleared - does not adhere to approved messaging or content is inaccurate (response will be received from GTL).

• CMS clearance required - product uses different language or contains new language, which requires Office of General Council (OGC) review. (Note:

Communications and/or 2b GTLs will pursue OGC review and advise QIOSC when clearance has been obtained.)

(SDPS Memo # 04-181-HD)

Publication Numbering System/Disclaimer

All QIO and QIOSC outreach materials and publications, in direct support of a contract task, require a publication number and disclaimer as outlined in SDPS Memo # 07-067-GN. These requirements do not apply to QIO or QIOSC correspondence, or to individualized provider performance feedback reports.

• Outreach materials are defined as non-peer-reviewed products (electronic or hardcopy) that will be distributed outside your QIO or QIOSC to any audience:

i.e., healthcare providers, stakeholders, information intermediaries or Medicare beneficiaries. In the case of QIOSCs and Special Project QIOs, this includes materials prepared for distribution to QIOs. Outreach materials include but are not limited to CDs, newsletters, brochures, pamphlets, posters, audio/visual materials and clinical intervention materials.

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• Publications are defined as any peer-reviewed, referenced, and/or refereed document a QIO submits on its own behalf to a professional or trade journal and which results from a CMS-funded quality improvement activity.

Numbering System TOPS Memo #99-23 requires all QIO outreach materials and publications for any contract task to be assigned a unique number for QIO internal tracking purposes, even if the material does not require a disclaimer or positioning statement. This includes QIO materials that display the DHHS logo and CMS identity mark.

Disclaimer Individual disclaimers and/or publications numbers are required for the following publications and outreach materials:

• Materials containing DHHS logo and CMS identity mark (see DHHS logo and

CMS identity mark guidelines section for instructions)

• Materials used to contain/present other information

• Shortened CMS materials

• Peer-reviewed journal articles

• Conference abstracts

• Outreach materials routed through the CMS review process

• Radio advertisements

• Print and television advertisements

• Promotional outreach items

• QIOSC-developed materials

• All other outreach materials

(SDPS Memo # 07-067-GN)

QIO website pages do not require a publication number and disclaimer. Individual outreach materials posted on the site (PDFs, Word documents, etc.,) do require a publication number and disclaimer.

(Quest Question #30555)

Copyrights

Information and artwork created and published by the Federal Government is part of the public domain, whether authored by government employees or under contract.

No copyright can be claimed by private persons or organizations.

In the case of peer-reviewed journals, no copyright transfer agreement is needed between a QIO and the journal, as work done on behalf of CMS should not be copyrighted.

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DHHS Logo and CMS Identity Mark Guidelines

The DHHS Logo and CMS identity mark (logo) cannot be used by QIOs without CMS clearance. These materials should still be numbered using the QIO’s internal publication numbering system. A disclaimer is not required if clearance is obtained to use the DHHS Logo or CMS identity mark.

When planning to use the CMS identity mark, QIOs and QIOSCs should follow the following process:

1. Send product to the appropriate task-specific QIOSC for a clinical review.

2. Ensure content clearly and accurately reflects CMS-approved messages, correct placement of the CMS identity mark, and correct references to CMS and/or DHHS. Use the following primary resource to help assure appropriate use of the mark and logo:

http://www.cms.hhs.gov/Multimedia/Downloads/CMSMarkGuidelines_05112 2.pdf

3. Submit request for approval though the project officer. Copy Communications GTL and Communications QIOSC (commqiosc@waqio.sdps.org) on all related communications.

(SDPS Memo # 07-067-GN)

You may retain the logo and identity mark on materials without further clearance if you do not modify these materials or if you modify them only as follows. You may:

• Add your logo and contact information including name, address, etc., of your organization (note that the DHHS logo must be larger and more prominently placed than the CMS identity mark or any other logo);

• Select any color(s) to fit your corporate image;

• Add the names of local partners; and delete any text and references (but not author acknowledgments if included in CMS’ document) that you select to shorten the materials, without altering the message of the original document.

In this instance, you must include the following disclaimer on the materials:

“This is an edited version of a document prepared by the Centers for Medicare & Medicaid Services and/or its contractors. You can find the original, unedited version of the document at (fill-in the cms.gov website address here).”

(TOPS Memo # 99-30)

If the logo and identity mark appear on materials used to contain/present other information (folders, binders, covers, etc.) the cover should bear the following disclaimer:

“The enclosed material was prepared and assembled by (name of QIO) under contract with the Centers for Medicare & Medicaid Services (CMS). The contents presented do not necessarily reflect CMS policy.”

(TOPS Memo #99-23)

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No QIO name or logo should compete in size or placement with the primary CMS quality improvement intervention or quality care message.

(QIO 8th SOW Contract, C.4.B.8.f.2)

Incorrect uses of identity mark to avoid:

• Do not alter the position of the identity mark elements.

• Do not alter or change the typeface.

• Do not rotate any of the identity mark elements.

• Do not stretch, distort or otherwise alter the aspect ratio of the identity mark.

• Do not position the identity mark too close to the other items or images.

• Do not alter the color of any of the identity mark elements.

• Do not position the identity mark on colors that do not complement the mark’s colors.

• Do not position the identity mark on a photographic background where there is insufficient contrast between the photographic image and the identity mark and typography.

• Do not use any of the mark elements to create a new mark or graphic.

• Do not position the mark to bleed off any edge.

• Do not use the mark without the full agency name under the horizontal bar.

QIO Sharing

QIOs are expected to share newly created materials with the QIO community. QIOs must share materials with the relevant QIOSC, which will share with the proper clearinghouse and (if directed) to the QIO’s Project Officer. Each QIOSC may have its own submission requirements. The QIO Guidebook to QIOSC Resources, provides contact information for each QIOSC.

(QIO 8th SOW Contract, C.4.B.8.g)

Peer-Reviewed Journal Articles and Abstracts

Peer-reviewed, referenced and/or refereed documents for a professional or trade journal, which resulted from a CMS-funded quality improvement activity, must be cleared by your PO prior to submission. This also applies to abstracts submitted to professional meetings or conferences (excluding CMS, QIO and/or American Health Quality Association [AHQA] sponsored meetings).

POs have 30 calendar days from the date of receipt of the manuscript to respond. In the case of abstracts, your PO has 10 calendar days to respond. POs and/or other RO staff may provide you with substantive changes to the manuscript. Once you have addressed these issues and your PO has certified that they have been adequately addressed, you may submit the manuscript for publication. If you do not receive certification from your PO within 30 days of the PO’s receipt of the manuscript (or

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These documents (except abstracts) must have a special disclaimer:

The analyses upon which this publication is based were performed under Contract Number (contract number), funded by the Centers for Medicare & Medicaid Services, an agency of the U.S. Department of Health and Human Services. The content of this publication does not necessarily reflect the views or policies of the Department of Health and Human Services, nor does mention of trade names, commercial products, or organizations imply endorsement by the U.S.

Government. The author assumes full responsibility for the accuracy and completeness of the ideas presented.

(TOPS Memo #2004-06)

All publications (articles/abstracts) must meet the confidentiality requirements specified at 42 CFR Part 480, §1160 of the Social Security Act (the Act), and Chapter 10 of the QIO Manual.

Provide a copy of the article, as published, to your PO.

(QIO Manual, Chapter 12, 12510-12530)

This policy does not apply if any author of the publication is a staff member of CMS.

In those instances, the CMS author will be responsible for obtaining the appropriate clearances.

(TOPS Memo #2000-28)

Plain Language

The Federal Government's and its contractor's writing must be in plain language. By using plain language, we send a clear message about what the program is doing, what it requires, and what services it offers. Plain language documents have logical organization, easy-to-read design features, and use:

• Common, everyday words, except for necessary technical terms;

• "You" and other pronouns;

• The active voice; and

• Short sentences.

If you use the techniques in Writing User-Friendly Documents, a handbook available on the Internet at http://www.plainlanguage.gov, you will meet the goals of clarity.

Cultural Competence

Talent, language, images and illustrations must reflect the heterogeneity of the beneficiary population at large in regards to race, color, age, sex, physical handicaps and national origin. Sometimes, this may mean that separate ethnic or cultural versions may be required. Speech content or style, roles and demeanor of all persons portrayed

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Medicare+Choice References

Medicare Advantage is the new terminology for the Medicare+Choice program.