QIN-QIO Draft SOW - 13th Scope.docx

Draft 13th Scope of Work Quality Improvement Network-Quality Improvement Organization (QIN-QIO) Statement of Work October 4, 2023 Table of Contents

Background

The purpose of this Quality Innovation Network (QIN) - Quality Improvement Organization (QIO) Statement of Work (SOW) is to support CMS’s vision for the 13th Scope of Work (QIO 13th SoW) through the procurement of expert healthcare quality improvement services from a qualified Network of Quality Improvement and Innovation Contractors (NQIIC) who are Quality Improvement Organizations. Through this QIN-QIO SOW, CMS seeks to promote optimal health and well-being through improved quality of care, equity, and outcomes for Medicare beneficiaries. Per 41 USC 3903, which outlines regulations for multiyear contracts defined as greater than one year but not more than five program years, this SOW is for a term of five (5) years also known as the 13th Scope of Work.

CMS’s QIN-QIO program assists providers with high quality, hands-on quality improvement assistance in meeting their needs, and the healthcare quality and safety goals for beneficiaries. CMS is aligning the 13th SoW QIO program with CMS’ Strategic Plan and the HHS Strategic Plan as well as the goals of CMS’ 2022 National Quality Strategy, CMS’ Behavioral Health Strategy and the CMS Framework for Health Equity. Furthermore, CMS is better aligning its QIO Program with its other quality levers such as quality reporting, value-based payment programs, and enforcement.

Statutory Authority

The statutory authority for the QIO program is found in Part B of Title XI of the Social Security Act. The statutory provisions originated with the Peer Review Improvement Act of 1982 (P.L. 97-248, §141-143, 96 Stat. 324) which established the Utilization and Quality Control Peer Review Organization program, now known as the QIO program. These provisions were significantly amended by the Trade Adjustment Assistance Extension Act of 2011 (P.L. 112-40, §261, 125 Stat. 401).

The statutory mission of the QIO program, as set forth in Section 1862(g) of the Act, requires the HHS Secretary to enter into contracts with QIOs for purposes of making determinations about whether items and services provided to Medicare beneficiaries are reasonable and necessary for the diagnosis or treatment of illness or injury, or to improve the functioning of a malformed body member, and are not for custodial care; this function is achieved through the Beneficiary and Family Centered Care (BFCC) QIO program. In addition, the Secretary must enter into contracts to improve the effectiveness, efficiency, economy, and quality of services delivered to Medicare beneficiaries. Toward those goals, Section 1154(a)[footnoteRef:2] of the Act requires the QIO contractors to perform one or more functions listed in that section. [2: https://www.ssa.gov/OP_Home/ssact/title11/1154.htm ]

The QIO statute, as amended by Section 261 of the Trade Adjustment Assistance Extension Act of 2011, also requires QIOs to perform, subject to the terms of their contracts, activities that the Secretary determines may be necessary for the purposes of improving the quality of care furnished to Medicare beneficiaries. This provision, in addition to several others as applicable, provides specific authority for what is included in the contracts of the QIOs. While the purpose of this QIN-QIO SOW is to carry out the goals listed in section 1862(g) of the Act, the QIO program requirement shall be fulfilled in a manner that supports CMS in its efforts to improve health and healthcare for all Medicare beneficiaries and promote quality of care.

Vision

The QIN-QIO Program will:

· Assist CMS-identified providers

· with performance challenges identified based on CMS’ measurement and enforcement data

· located in zip codes where health disparities and health inequities exist

· with limited or no access to quality improvement (QI) resources

· Align with CMS’ Strategic Plan and the HHS Strategic Plan; and the goals of CMS’ 2022 National Quality Strategy, CMS’ Behavioral Health Strategy and the CMS Framework for Health Equity

· Work through an intentionally designed partnership approach with relevant partners and community organizations who are dedicated to improving quality and safety, and the systems that undergird them. The work of QI is grounded in strong, sustainable partnerships with other federal, state, local, community and private sector partners.

· Function in a meaningful and uniquely curated role to avoid duplication of effort and relieve provider burden by applying CMS’ A3C Model (Assessment / Coordinate / Complement / Create) (Table 4). This model requires the QIN-QIO to conduct an initial assessment/environmental scan at the state level, identify the quality initiatives in place or planned for, and determine their own role – to coordinate, complement or create within the state’s healthcare quality landscape.

· Use CMS’ reimagined program design which involves an integrated regional model, facilitating seamless coordination between various provider settings in the community, with the QIN-QIO for that Region working alongside key partners in the field.

· Approach providers through a strategic, provider-focused communication that reflects the spirit of service.

· Lead with an initial assessment of the providers’ needs, strategically prioritizing those that fall within the scope of the 13th SOW.

· Target QI models where evidence suggests they will improve outcomes. CMS will lead and direct QI both on the “what” and majority of “how” QI is implemented based on an Intervention Design Framework (IDF). The QIN-QIO will co-design with CMS, part of the “how” in the course of the work. The IDF is a structured collection of proven best practices curated to achieve the outcomes related to each of the clinical sub-aims and foundational aims.

· Ensure that all technical assistance that the QIO provides augments the providers’ own QI journey, fits within the providers’ quality roadmap for their organization, and helps strengthen their quality management systems, creating a culture of safety, and focusing on leadership and governance that are fundamental to quality improvement. Essentially, CMS requires the QIN-QIO to help strengthen providers’ organizational capacity and ability to maintain focus on quality and safety. The work of the QIN-QIO is therefore focused towards building long term, sustainable practices to generate QI.

· Empower beneficiaries and their families as active partners in their care, at every step in the QI journey.

· Ensure all QI data including but not limited to assessments, planning, partner engagement, interventions, and outcomes are reported, tracked, and updated using the CMS-designated technology solution

As a result of the QIN-QIO Program, service providers will:

· Receive the assistance they need “where they are” in a post-pandemic world to ensure equitable quality healthcare to the people they serve.

· View the QIN-QIO Program as a valuable, expert CMS resource that strengthens and enhances their own quality improvement journey.

· Have new opportunities to connect with other providers as part of robust “learning communities.”

· Have 24/7 easy access to “on-demand” QI tools and training resources from CMS alongside the practical, hands-on technical assistance from the QIN-QIO that is valuable in practice, and not reliant on education alone.

· Have access to timely data relevant to their current practice, to work on improvements to quality of care and outcomes.

· Gain insights through analysis of data from their own practice compared to regional and national benchmarks for which they might otherwise not have access.

· Be able to regularly give CMS feedback about the quality of services they receive, leading to continuous improvement and accountability for the QIN-QIO.

· Recognize QIN-QIO assistance as a CMS program that serves as a responsive, supportive resource in providing high quality, safe care, including during emergency situations.

· Be aware of and connected with community resources that they can lean on, coordinate with and educate beneficiaries on.

· Have access to a change package for climate change to decrease the carbon footprint of their facilities.

· Receive support and guidance on adoption of emerging modern technology such as AI tools, machine learning, ambient sensors, and hand hygiene monitoring to improve patient safety, workforce infrastructure, and staff engagement.

As a result of the QIN-QIO Program, beneficiaries will experience:

· Available, timely culturally appropriate services, and access to education on health and safety, whether vaccinations, and other preventive services or options to the necessary specialized services.

· Higher levels of control of hypertension, diabetes, and chronic kidney disease including education about access to home dialysis and transplants. This will reduce the incidence of strokes, heart attacks, hospitalizations, amputations, reduce the number of beneficiaries who require dialysis each year, and improve patient choice in kidney care.

· Safer hospital inpatient and nursing home stays, with reduced healthcare acquired infections, adverse drug events, falls, and pressure injuries.

· Greater attentiveness to and coordination of behavioral health care, including regular screening for depressive symptoms, easy access to suicide prevention services, easier and more seamless access to effective substance use disorder treatments, and rapid and compassionate assessment for chronic pain conditions, with effective treatment that does not lead to addiction.

· Better coordination of care across settings, with fewer readmissions both back to the hospital, and from post-acute settings back to the hospital.

· Reduced reliance on accessing expensive emergency departments for primary care and for treatment of chronic disease exacerbations.

· Have access to community resources available to them for disease management, prevention and wellness.

· Preparedness and mitigation of the health effects of climate change such as heat, air pollution, flooding

· Decreased patient harm with the use of digital health tools, modern technology, AI.

· For frail, vulnerable, and disadvantaged populations, beneficiaries will experience a more welcoming, understanding and receptive health care environment that delivers high quality, safe, timely, and effective care more reliably.

Scope

In the 13th SOW, the QIN-QIO shall focus their efforts to achieve the CMS-identified Clinical Aims and Foundational Aims. Figure 1 illustrates the various aims and sub-aims of the QIO program.

Figure 1: CMS QIN-QIO 13th SOW Aims and Sub-aims

Metrics and Outcomes

For the 13th SoW, the QIN-QIO Program will evaluate performance based upon the following metrics organized by Foundational Aim, and Clinical Aims and Sub-aims in the table below. There are a total of 15 focus areas (2 foundational aims and 13 sub-aims), as shown below.

Figure 2: Metrics and Outcomes

Figure 3: Number of Outcomes metrics by aims and setting *Individual settings do not add to total as some measures include and cross-settings

Figure 4. Number of outcome metrics by aim and quality measurement program alignment.

*All universal measures included in this contract are also included in value-based purchasing programs

Table 1: Provider Outcome Metrics Table

Foundational Aim: Quality Management Infrastructure and Emergency Preparedness

Nursing Homes

Under development

Nursing Homes

Under development

Under development

Foundational Aim: Advancing Healthcare Quality Through Technology (AHQT)

Tier 0 (Limited Technology) - lack electronic health records (EHR) or broadband internet connection

Tier 1 (Basic Technology) - have EHR with ability to electronically input and store data at the point of care

Tier 2 (Interoperability Adopter) - capability to meet requirements of Promoting Interoperability program or has Office of the National Coordinator (ONC) certified EHR Hospitals Clinicians

SNF

REH

Under development

Aim: Prevention and Chronic Disease Management

Aim: Patient Safety

Aim: Behavioral Health

Aim: Care Coordination

Table 2: QIN Process measures to be monitored

Under development

Emergency Preparedness/ Quality Management Infrastructure

Tier 2 (Interoperability Adopter) - capability to meet requirements of Promoting Interoperability program or has ONC certified EHR

Tier 3 (Interoperability Champion) - capability to leverage FHIR-based Application Programming Interfaces (API) to share and integrate electronic health information Under development

Program Design

CMS has structured the QIN-QIO Regions to align with established HHS Regions and provide an equitable balance of providers and beneficiaries between the QIN-QIOs, as shown below.

Northeast

CMS QIN-QIO (1)

Mid-Atlantic

CMS QIN-QIO (2)

Southeast

CMS QIN-QIO (3)

Great Lakes

CMS QIN-QIO (4)

Southcentral

CMS QIN-QIO (5)

Midwest

CMS QIN-QIO (6)

West

CMS QIN-QIO (7)

Table 3: Crosswalk of QIN-QIO Regions to HHS Regions

Figure 5: Map of CMS QIO-QIN Regions

CMS will require the QIN-QIO to work with the following established provider types:

· Nursing homes

· Hospitals

· Clinician Practices

· Community organizations (clinical and non-clinical) CMS may include additional provider types as needed.

In order to determine the list of service providers to target for QIN-QIO efforts, CMS used 2022 data to evaluate (1.) provider poor performance on selected quality metrics; (2.) zip code analysis based on sociodemographic factors; (3.) enforcement data; and (4.) providers not submitting quality reporting data.

Provider QIN-QIO Interaction

CMS requires:

· The QIN-QIO to utilize the CMS QIN-QIO Region nomenclature in all interactions with providers under this contract with CMS for the 13th SoW program.

· The CMS QIN-QIO Region name must be utilized in all verbal and written communication and shall be used as the official branding for the QIN-QIO work under the 13th SoW. Refer to column 1 of the Table above for the nomenclature that bidders must agree to comply with if selected as a CMS QIN-QIO. For instance, the QIN-QIO for Region 6 shall adopt the following branding: Midwest CMS QIN-QIO 6. The QIN-QIO shall use the “Midwest CMS QIN-QIO 6” name on all branding and marketing, educational, outreach and technical assistance services with providers, states, regions and partners and interested parties.

· The regional structure establishes the QIN-QIO with complete accountability for the QIN-QIO work within their entire Region. This includes partner, community and provider engagement in its entirety and coordination of the work within their member states.

The QIN-QIO shall:

· Establish a strong and visible leadership presence, and accountability framework within the Region. At the Regional Level, the QIN-QIO must form an Executive Leadership Council (ELC) inclusive of the C-Suite leadership of the QIN-QIO and community partners to demonstrate accountability for engagement, collaboration, and QI outcomes. The ELC must meet quarterly to review progress of the work within that Region using an ELC Executive Dashboard for on-going reassessment and re-evaluation, tracking their performance over time towards desired results. The ELC Executive Dashboard will be submitted for CMS review every quarter.

· Create and implement a coherent and meaningful Communication Plan with the providers, QI partners, and interested parties that is proactive, positive, and inclusive, demonstrating ongoing collaboration throughout the program term. The QIN-QIO must use provider-focused, value-driven communication approaches to meet providers where they are, assess their needs and then work to respond to those needs within the context of the contract and the program. The QIN-QIO must NOT share CMS contract details, requirements, and payment arrangements with providers and partners and interested parties, ensuring that the contract burden is not imposed on them.

· Provide the best possible customer experience to providers and other partners and interested parties they engage with. The QIN-QIO must respond to feedback received through provider experience surveys, must support CMS in ensuring adequate response rates for provider feedback surveys, and must document (Feedback & QIN-QIO Improvements) and demonstrate improvements, both to CMS and the partners and interested parties, in response to the feedback.

· Maintain awareness of the QI efforts within their assigned region using the A3C model.

Program Timeline

The diagram immediately below outlines an implementation plan for the QIN-QIO program, from contract start date to end date. It is a big-picture, visual representation of the chronological sequence of events that will help CMS staff and contractors understand the operational timeline of the QIN-QIO Program, as shown below.

Figure 6: Five Year QIN-QIO program and Contract Period

Clinical Quality Improvement Model

CMS’ program design involves an integrated regional model wherein the QIN-QIO shall have complete accountability for the QIN-QIO work within their Region, working alongside key partners in the QI field and facilitating seamless coordination between various provider settings in the community. See Journey Map, below. The five-year QIN-QIO program will be implemented in three (3) distinct phases:

Phase 1: Foundational Set up The Foundational Set-up is the first phase of the QIN-QIO program, and is the critical, formative phase of the program where CMS will provide on-boarding of the QIN-QIO to CMS infrastructure for program management and implementation, and where the QIN-QIO shall conduct their own internal staff on-boarding, create and establish regional and state partnerships, and conduct state-level A3C model. The first three steps of the Foundational Set-up, as outlined in the table above, include QIO on-boarding, partner engagement and state level A3C assessments. During this period, the QIN-QIO shall establish a strong foundational set up, and coordinate with key partners (state and local health departments, provider associations and other QI entities) first so that QI is a unified agenda. The QIN-QIO must leverage their associations with other partners for outreach to providers so that the provider is aware of the QIN-QIO assistance, and ready to engage effectively, with support from other entities.

Phase 2: Quality Improvement Execution The Quality Improvement Execution phase is the second phase of the QIN-QIO program and requires the QIN-QIO to be accountable for the QIN-QIO work within their entire Region. This includes partner, community and provider engagement in its entirety and coordination of the work within their member states. This phase is grounded in a “hands-on” implementation support using front-line, high engagement and high-value approach with providers that allows the QIN-QIO to respond to provider needs actively and impactfully. This phase also includes outcomes reporting with on-going developmental evaluation that aims to provide rapid, near real-time feedback to nurture learning and allow for strategy adjustments to ensure trajectory towards desired results. Each cycle ends with performance evaluation using sound data analytics and review of return on investment (ROI); data on CQI processes and outcomes; intervention delivery; and experiential feedback from providers and other partners.

Phase 3: Completion This is the last of the three phases and consists of the final reporting and transition activities as the current scope of work ends and the new work begins. It may also include hand-off activities (including partnerships, provider relationships and other key elements) from the incumbent contractor to the incoming contractor, as shown below.

Figure 7: QIN-QIO Journey Map Quality Improvement Tasks

QIN-QIOs shall utilize the highest standard of quality improvement capabilities to successfully perform the following tasks:

Task 2.1 - Conduct A3C Model Task 2.2 - Implement a Provider Engagement Strategy Task 2.3 - Establish a Provider Service Agreement Task 2.4 - Conduct Provider Assessment Task 2.5 - Formulate a Quality Action Plan Task 2.6 - Report on Interventions and Outcomes

Conduct A3C Model

At the beginning of the program, the QIN-QIO must conduct the state-level A3C Model for all states and territories within their region. QIN-QIOs shall utilize the A3C model to assess the healthcare landscape, identify key partners and interested parties s, and evaluate all the local QI activities in relation to the clinical sub-aims and foundational aims. The QIN-QIO shall then tailor their role to complement, coordinate, and/or create QI initiatives to meet the needs of the providers and beneficiaries in that state. Table 4 outlines the A3C Model, as shown below.

A3C Model

A: Assess the State’s landscape for healthcare quality and safety, and identify federal, state, local, community organizations and private partners and interested parties and their quality-related activities. Utilize this Assessment to identify the most impactful, necessary, and unique role for the QIN-QIO.

Based on the Assessment, the QIN-QIO shall advise CMS on whether they will work in a role that either coordinates, complements or creates initiatives.

Table 4: A3C Model

While the 3Cs may not be mutually exclusive, they are intended to provide the QIN-QIO with a primary focus to guide QI activities and an opportunity to provide unique impact that may lend itself to a clearer attribution capacity for the program, a necessary and impactful role for the QIN-QIO, avoidance of duplicative services and reduction of undue burden on providers. It also provides a strong narrative for the role of the QIN-QIO and the necessity of that role in the healthcare environment.

A template for QIN-QIOs to use to complete their A3Cs, along with sample A3Cs, can be found in Appendix 1.

The A3C Model must be completed for all states within the QIN-QIO region no later than 10 months after contract award, then updated annually thereafter.

Implement a Provider Engagement Strategy

In the 13th SOW, CMS is evolving the provider engagement approach and is transitioning from a provider recruitment/enrollment model to an engagement/customer service model. The QIN-QIO provide services and shall be expected to put the needs of the providers they work with front and center in the work that they do. During engagement, the QIN-QIO shall assess the kind of support that is needed by their customers (healthcare providers within a community and the facilities in which they work). Based on assessment of provider needs, and the QIN-QIO’s in-depth knowledge of the aims, the QI contractor should then design and offer technical assistance, solutions, support, and collaboration to meet the needs of the customer/provider. The QIN-QIO must align the provider’s needs within the relevant areas of the Statement of Work. If there is no readily recognizable alignment, then the QIN-QIO must work to find alignment, discuss with CMS on strategy, and in the meantime, prioritize the provider’s needs that align with the contract. The QIN-QIO must use this engagement opportunity with the assessment and response, to service the provider appropriately.

Post-COVID 19 public health emergency, CMS is directing the QIN-QIO to use a mixed method approach for engagement that will include leveraging a hybrid model and many different modalities of communication, including letters, emails, phone calls, virtual meetings, and on-site visits. The QIN-QIO should strive to meet face to face with providers when feasible to obtain hands-on experience of facility operations to enhance provider engagement. CMS recognizes the value of what can be learned on site. The modality of communication used, and the frequency of those communications should be based on conditions on the ground and tailored to meet provider needs.

After the QIN-QIO makes its assessment of provider needs and the technical assistance they can provide, the QIN-QIO shall send a plan for their provider engagement strategy to the facility CEO for review, input and sign off. It is vitally important for the QIN-QIO to obtain buy-in from the provider CEO, and for the CEO to reinforce that Quality Improvement and provider engagement to enhance quality outcomes be maintained as a governance priority. This provider assessment should focus on interventions related to provider engagement only.

The QIN-QIO must re-evaluate the Provider Engagement Strategy on an annual basis to update it and ensure the plan is being followed. The QIN-QIO shall continue to meet with the CEO, Senior Quality Leader and other members of the leadership of the healthcare workforce within the facility to refine, implement, and evaluate progress, as needed.

Establish a Provider Service Agreement

The QIN-QIO shall establish a Provider Service Agreement (PSA) with each provider wherein the QIN-QIO shall serve as the CMS QI resource; and the provider as the recipient of QIN-QIO services. The PSA is a mutually developed agreement between the QIN-QIO and the provider that is anchored in the assessment of the provider’s needs and includes the QIN-QIO’s service response to those needs. It will facilitate cooperation and sustained participation in the QI work. CMS will provide the QIN-QIOs with a Servicing Provider List (SPL), which includes providers that CMS has identified for the QIN-QIO to work with. Provider participation is dependent on maintaining an active Medicare Certification status.

· CMS will provide the target number of providers that QIN-QIO will need to create service agreements with, thereby including them in the program. The target threshold will be defined by CMS and will be set according to the regional needs. In the event that the PSA is terminated, the QIN-QIO will need to reach out to new service providers from the SPL to maintain their compliance with the target threshold set by CMS for each provider type.

· During the course of the program, the QIN-QIO will use a CMS provided database to verify the Medicare certification status of all service providers. If a change in certification status is identified, the QIN-QIO shall be notified to initiate the process of suspending or terminating their services.

The PSA shall be drafted by the QIN-QIO using CMS-provided guidelines. These guidelines include:

· A description of the nature of QI services and benefits to the provider in terms of meeting their needs and improving the quality and safety of services to beneficiaries. This includes addressing all the clinical aims and the foundational aims.

· The unique value that the specific QIN-QIO shall bring to the engagement with the provider that will meet the provider’s needs.

· Attestation of the voluntary participation of the provider in the QIN-QIO program.

· A commitment to fully participate in QI activities that create a culture of safety by implementing a quality management system, ensuring appropriate support from leadership and governing bodies, and prioritizing safety and quality within the organization.

· Agreement to share feedback to CMS about their experience with the QIN-QIO. Participation is voluntary; however, this is encouraged to help improve provider experience and enhance QIN-QIO services.

· Agreement that the provider will submit data to the QIN-QIO and CMS for QI purposes on a quarterly basis.

· The QIN-QIO shall inform the provider of the data specifications that need to be reported to CMS.

· The QIN-QIO shall support outpatient practices in developing processes to review and submit data routinely.

· The provider will be responsible for providing data if the data required to be reported cannot be directly obtained from the CMS Data Warehouse in a timely manner.

· For providers already submitting data to MIPS, CMS will be expecting these participating providers to submit data at the practice level or individual practitioner level to the QIN-QIO Program at CMS; ACO-level data is not an acceptable option as it is not informative regarding practice or practitioner level changes or their patient impacts. This reporting is to help monitor progress for quality improvement and will not be shared for public reporting nor for pay-for-performance purposes or scoring of quality improvement data collected. This submission does not replace MIPS reporting.

· Agreement that service provider is free from any prohibited Conflicts of Interest Agreement to comply with CMS Privacy and Security Requirements and all applicable laws and regulations for the storing, maintaining, and transfer of health information.

· Attestation that PSA has been completed and signed by facility CEO.

All PSAs must be dated and signed by the provider and the QIO. The QIN-QIO shall document, and file all signed PSAs in the CMS-designated data system within 12 months after contract award.

The PSA may be terminated at any point during the QIN-QIO program due to any of the following:

· Breach of any part of the agreement

· Loss of Medicare certification

· Permanent closure of the provider

· Documented refusal of the provider to participate

· As decided by CMS

The QIN-QIO must comply with the retention targets for their region. Changes to the list of service providers must be included in the Monthly COR Report and discussed in the Monthly Monitoring Call.

Conduct Provider Assessment

The QIN-QIO shall conduct a comprehensive assessment of all providers. This includes but not limited to assessing the providers’ QI and patient safety needs; their readiness to participate in the QIN-QIO program and perform QI work; and their access to QI resources. Provider Assessments should also include an analysis of the Quality Management Infrastructure, as outlined in the Quality Infrastructure section below.

Initial provider assessment can begin shortly after establishing a PSA and must be completed 12 months after contract award and updated annually with the QI cycle. The QIN-QIO shall document the initial and updated provider assessments in the CMS-designated data system.

Formulate a Quality Action Plan

The QIN-QIO must create a Quality Action Plan (QAP) for each provider served, which should be based on the provider assessment conducted by the QIN-QIO and informed by the A3C model. The QAP should define the areas of focus, using the CQI Intervention Design Framework (IDF) to guide their planned interventions. The IDF is a structured collection of proven best practices curated to achieve each of the clinical sub-aims and foundational aims. The interventions are categorized under 5 key disciplines:

· Governance

· System design and policies

· Process

· Workforce

· Individuals, Families, and Communities

All IDFs can be found in Appendix 2. While CMS has prescribed specific evidence-based, proven best practices, the QIN-QIO shall co-design the list of planned actions to include additional interventions based on their knowledge base, subject matter expertise, experience, and approach to address the unique needs of the providers. The QIN-QIO should not rely on educational modalities alone, but will use education (toolkits, materials, webinars, emails) only, when necessary, to augment and complement the primarily provided, hands-on technical assistance and implementation support. Essentially, show how it is done by doing it with the providers, not merely telling them what to do.

The QAP specifies the scope of the QIN-QIO-provider work, focus areas, intervention plan, and the sequence of activities relevant to the service provided by the QIN-QIO to the provider, in addition the Quality Management Infrastructure. The plan will identify an overall approach as well as critical milestones, timelines, interventions, interim/ final targeted outcomes, and activities to be performed by the QIN-QIO to achieve all provider goals. The QAP will also include the AHQT Intervention Strategy, as outlined in the AHQT section below. The QAP will be discussed with the provider, ensuring provider commitment to the plan and support for the QI efforts.

The QAP must be completed and documented in the CMS-designated data system within 16 months after contract award and updated annually with the QI cycle.

Report on Interventions and Outcomes

During the course of the hands-on QI work, the QIN-QIO must document all interventions in support of the QAP. This includes actions using a front-line, high engagement and high-value approach with providers that allows the QIN-QIO to respond to provider needs actively and impactfully, not from a distance. Sole reliance on webinars, emails, and other non-direct communication strategies do not permit active and meaningful engagement with providers. For monitoring purposes, the intervention details shall be reported in the CMS-designated technology solution in near-real time or no later than 5 days after the provider interaction.

The providers and the QIN-QIOs shall be tasked to report on their progress towards achievement of desired outcomes based on data that is accessible to them. Using the CMS-designated technology solution, providers will report their outcomes on a quarterly basis and the QIN-QIOs shall report on their process and outcome measures following the data specifications and reporting frequency as detailed in Section 1.4.

Quality Improvement Foundational AIMs Advancing Healthcare Quality through Technology Objective 1: Ensure providers and clinicians in underserved areas are using interoperable systems in support of data collection, data sharing, and analysis to improve quality and outcomes.

Use of health information technology (HIT) is imperative to assess, monitor, and improve healthcare quality, patient safety, and care coordination. Many providers and clinicians continue to lack basic knowledge and capacity to implement HIT to support data exchange between providers, payers, and patients, and to use data for improving quality and outcomes. This “digital divide” creates burden for patients, families, caregivers, providers, and clinicians, and increases costs and administrative waste. This burden is disproportionate for underserved populations.

Understanding an organization’s starting point—or baseline—is an essential first step in quality improvement, and the success of any healthcare organization, or cross-setting QI initiative is predicated on organizational culture, existing infrastructure, and access to necessary resources. The role of the QIN-QIO is to understand the individual needs of providers in their respective region(s), and to appropriately tailor evidence-based interventions to those needs, leveraging partner organizations, community resources, and quality improvement tools and methods accordingly. CMS is also striving to reduce health disparities and promote equitable care for all through technology.

In support of this task, the QIN-QIOs shall assess and support providers and clinicians with technical assistance in data exchange to educate, guide, and support building the infrastructure necessary to access, share, and use data for quality improvement purposes.

Objective 2: Support integration of quality data requirements, standards, and systems within the context of an interoperable learning health system.

Siloing of quality data isolates its utility for related purposes, including value-based payment, development of better clinical guidelines, and the coordination and delivery of improved care resulting from lessons learned from quality data. By aligning quality data standards with other aspects of a learning health system, the QIN-QIOs shall increase the ability to utilize data collected through quality improvement programs for measurement, payment, and research to efficiently inform quality improvement efforts. Advancing the use of technology and using interoperable standards can reduce the overall cost and burden associated with data collection and supports communication across the care continuum.

The QIN-QIOs shall coordinate with CMS, contractors, federal partners, and private organizations to incorporate aligned data format and transmission standards. QIN-QIOs shall ensure that providers have the necessary technical capabilities to advance healthcare quality through the standardization of data element and data sharing and exchange requirements. QIN-QIOs shall ensure that providers and vendors possess the necessary regulatory knowledge to understand and implement data standards consistent with CMS quality programs.

Figure 8: Learning Health System

AHQT Readiness Assessment and Tier Determination

In support of this task, the QIN-QIOs shall assess and support the readiness of providers and clinicians for data exchange to educate, guide, and support building the infrastructure necessary to access, share, and use data for quality improvement purposes.

CMS will provide the QIN-QIOs with a Servicing Provider List (SPL), as described in Section 1.2, which includes providers that CMS has identified for the QIN-QIOs to work with. The SPL contains a subset of providers who need AHQT focus. The QIN-QIO shall include AHQT to the Provider Service Agreement (PSA), following the guidelines outlined in Section 1.3.

The QIN-QIOs shall conduct an AHQT Readiness Assessment (Appendix 3) developed by CMS on each of the service providers to determine their level of readiness for data exchange. It uses a mix of foundational, technical, administrative, and operational questions to assess a provider or clinician’s readiness to transition systems and infrastructure to access, share, and use data for quality improvement. When combined, these questions provide a comprehensive and holistic view of the respondent's progress in this transition over the next five years. The service providers will complete the AHQT Readiness Assessments. The QIN-QIOs shall provide assistance as needed, ensuring proper and timely collection of pertinent information.

Upon completion of the AHQT Readiness Assessment, the QIN-QIO shall determine the provider’s AHQT Tier Level based on the findings and results.

The Baseline AHQT Readiness Assessment and Tier Determination must be documented in the CMS-designated technology solution and completed no later than 12 months after contract award.

Provider’s Level of Readiness