HTP Implementation Plan Template and Milestone …



Colorado Hospital Transformation Program

Implementation Plan Template and Milestone Requirements

May 20, 2021

Table of Contents

I. Background, Instructions and Timeline 4

A. Implementation Plan 4

B. Implementation Plan Process and Timeline 4

C. Implementation Plan Scoring 5

II. Organizational Approach to Implementation 8

A. Implementation Overview 8

III. Approach to Intervention Implementation 9

A. Overview of Intervention 9

B. Intervention Milestones 12

IV. Milestone Requirements 14

A. Overview 14

B. Milestone Requirements 15

C. Milestone Development and Review Process 20

D. Ongoing Program Reporting of Milestones and Validation Process 21

E. Milestone Amendments 22

F. Intervention Course Correction 23

G. Payment 23

V. Program Timeline 24

Appendix A

I. Hospital Index Measure: Background 26

A. PY2Q2 Impact Milestone: Current Quality Improvement Capacity in Key Functional Areas 26

B. Continuous Learning and Improvement Milestones 29

PY3Q2 Milestone: 31

Appendix B

I. Quality Improvement Resources 33

A. Models for Improvement 33

B. Assessment Tools 34

C. Stakeholder Engagement Toolkits 36

D. Care Coordination and Service Delivery Best Practices 37

Background, Instructions and Timeline

Implementation Plan

Hospitals that have been accepted into the Hospital Transformation Program (HTP) must submit an Implementation Plan detailing the strategies and steps they intend to take in implementing each of the intervention(s) outlined in their applications impacting the six program priority areas: (a) Care Coordination and Care Transitions; (b) Complex Care Management for Target Populations; (c) Behavioral Health and Substance Use Disorder Coordination; (d) Maternal Health, Perinatal Care and Improved Birth Outcomes; (e) Social Determinants of Health; and (f) Total Cost of Care.

Within those priorities, hospitals are expected to implement interventions that address quality measures across five HTP Focus Areas:

0. Reducing Avoidable Hospital Utilization;

0. Core Populations;

0. Behavioral Health and Substance Use Disorder Coordination;

0. Clinical and Operational Efficiencies;

0. Population Health and Total Cost of Care.

Section II of the Implementation Plan will include the hospital’s proposed organizational approach to implementation. Section III will include the approach to implementation of each intervention approved for participation via the Hospital Application. Hospitals must complete Section III for each intervention.

Implementation Plans cover the five-year duration of the HTP. Hospitals will have an opportunity to revisit their planned milestones and if needed, submit milestone amendments and course corrections through the quarterly reporting process. The process for amending milestones and for course correction is outlined in the HTP Milestones Requirements section of this document.

Implementation Plan Process and Timeline

Implementation Plans must be submitted during the Implementation Submission Period (from September 1, 2021 – through September 30, 2021) after approval of the hospital’s HTP application. Hospitals will submit their Implementation Plans in the online submission tool. The entirety of the Implementation Plan has been recreated in the Implementation Plan submission tool for hospitals to complete and submit by 11:59 pm on September 30, 2021. Certain elements of information will be pre-populated in the Implementation Plan submission tool from the approved HTP Application. HTP primary contacts will be emailed a unique link to the submission tool where they will be able to complete their Implementation Plan. The email with the link to the submission tool will also be made available in the HTP Colorado Collaboration, Performance, and Analytics System (CPAS) portal.

Following the submission due date, the Department will have 20 business days to review and score all Implementation Plans. At the conclusion of the review period, participating hospitals may receive a request for information (RFI) or receive notification that the Implementation Plan has been approved without RFI. Hospitals that receive an RFI will have 10 business days to complete revisions within the Implementation Plan submission tool. Revised implementation plans will be reviewed within 10 business days.

0. September 1 – First day Implementation Plans may be submitted

0. 1 month time period / September 1 – September 30 - Implementation Plan Submission Period (Implementation Plan Deadline: September 30)

0. 20 business day period / October 1 – October 28 – Review Period: Twenty business day Department review period

0. 10 business day period / October 29 – November 12 - Revise and resubmit period: Ten business day period within which any plan requiring additional revisions and / or supporting details should be completed by hospital

0. 10 business day period / November 15 – November 29 – Final Review Period: Ten business day scoring period for revised and resubmitted Implementation Plans

0. 2 months following due date/November 30 – Expected final Implementation Plans approved

All hospital final implementation plans will be made public and posted online enabling stakeholders to review how their hospitals plan to achieve the goals of the Hospital Transformation Program.

Implementation Plan Scoring

Implementation Plans collect the hospital approach on the Organizational Approach to Implementation and the Approach to Intervention Implementation. The Approach to Intervention Implementation must be completed for each of the hospital’s interventions. Except for questions that are prepopulated from the Hospital Application, responses will be scored on either a pass / fail or a numerical basis as outlined below.

Pass / fail scores will be based on the following:

0. Fail: The response is incomplete because it does not address one or more parts of the question asked. More information must be provided for the answer to be considered complete.

0. Pass: A complete response was provided to all applicable aspects of the question.

Implementation Plans must earn passing scores for every pass / fail response to be approved. Any question receiving a failing score during the review period will be returned to the participant with specific instructions for revisions prior to resubmission.

Numerical scores will be based on a one to three (1-3) scoring rubric.

0. A score of one (1) will be given to answers that need substantial revision. Scores of one indicate that responses are either incomplete (do not address one or more part(s) of the question asked) or do not demonstrate a satisfactory approach. Examples of responses that would not demonstrate a satisfactory approach include:

✓ A response to Question III.A.6. that does not include a plan for identifying and engaging the intervention’s target population including addressing barriers to recruitment and resulting gaps in engagement.

✓ A response to Question III.A.7. that does not describe the resources that will need to be re-purposed from other areas, built, acquired, or secured through a partner or in some way.

✓ A response that describes supporting documentation for an impact milestone that is insufficient to validate its completion.

0. A score of two (2) represents a generally complete and satisfactory response to the question (criteria for scores of one outlined above do not apply) with only limited clarification or additional information needed to ensure responses are detailed enough to provide the Department with a complete and accurate understanding of the response. Any additional information or clarification needed will be specifically cited by the Department.

0. A score of three (3) represents a complete, sufficiently detailed and acceptable response and approach to the topic addressed (criteria for scores of one and two outlined above do not apply).

Participants must earn scores of three (3) for every response included in their Implementation Plan for it to be approved. Any question receiving a one (1) or two (2) during the initial Implementation Plan review period will be returned to the hospital with specific instructions for revision prior to resubmission. The Department will provide technical assistance aimed at ensuring Implementation Plans receive approval.

The tables below summarize the questions in the Implementation Plan and the applicable scoring. Questions that will be prepopulated in the Implementation Plan submission tool from the Hospital Application will not be scored and are marked as “prepopulated” in the scoring column of the tables below.

Table 1: Organizational Approach to Implementation

|Section |Component |Question |Scoring |

|Section II Implementation |Points of Contact |II.A.1.a. |Pass / Fail |

|Overview | |II.A.1.b. | |

| |Role of Governance Structure |II.A.2. |Pass / Fail |

Table 2: Approach to Intervention Implementation

|Section |Component |Question |Scoring |

|Section III.A Overview of |Reporting Hospital |III.A.1. |Prepopulated |

|Intervention | | | |

| |Name of Intervention |III.A.2. |Prepopulated |

| |Primary Quality Measure(s) |III.A.3. |Prepopulated |

| |Identification of Existing Interventions |III.A.4. |Pass / Fail |

| |Principal Administrative Roles |III.A.5. |Pass / Fail |

| |Target Population |III.A.6. |1 – 3 |

| |Major Functions and Resources |III.A.7. |1 - 3 |

| |Challenges and Risks |III.A.8. |1 - 3 |

| |Ongoing CHNE |III.A.9. |Pass / Fail |

|Section III.B Intervention |Milestones |III.B.1. | 1 - 3 |

|Milestones | |III.B.2. | |

| | |III.B.3. | |

Organizational Approach to Implementation

This section contains the prompts HTP participants will respond to within the Implementation Plan submission tool that relate to the hospital’s organizational approach to implementation.

Implementation Overview

II.A.1.a. Please fill out the following information for the hospital’s primary contact.

Primary Contact Name:      

Primary Contact Title:      

Primary Contact Address:      

Primary Contact Phone Number:      

Primary Contact Email Address:      

II.A.1.b. Please fill out the following information for the hospital’s secondary contact.

Secondary Contact Name:      

Secondary Contact Title:      

Secondary Contact Address:      

Secondary Contact Phone Number:      

Secondary Contact Email Address:      

II.A.2. Governance Structure - Describe how the governance structure outlined in response to Question 3 of the HTP Application will be engaged in the implementation and execution of the hospital’s HTP participation. Address how leadership will ensure oversight and support, including sign off/approval for resources, and address their role in the following functional areas, as applicable:

• People (Workforce / Training)

• Processes of Care

• Technology and Data Systems

• Patient Engagement / Target Population

Note from CHA: The below example addresses the key components of many hospitals’ HTP governance structures. Please use this only as an example and refer to what you wrote in your implementation plan. Your response should not be specific to the ED ALTO initiative, but rather touch on the how the governance structure will support all HTP initiatives.

Please seek to limit response to 1,000 words.

|The governance structure outlined in our organization’s HTP Application incorporates multiple components that will allow for effective |

|oversight and support of each initiative. As outlined, each measure will have an executive sponsor. This sponsor will receive monthly |

|updates from each measure’s lead explaining progress on the initiative including the most recent available data reports and |

|documentation, barriers to improving, challenges faced, resource needs, and lessons learned/successes. This allows the executive sponsor |

|to be aware of the intricacies of the initiatives without having to attend every meeting. Because the executive sponsor will receive data|

|reports and documentation of changes to clinical and operational processes, they will be able to objectively see the progress of the |

|initiative and ask any follow up questions needed to ensure they appropriately understand what components of each initiative have led to |

|success and which need to be improved upon. This communication process allows the executive sponsor to remove barriers, suggest |

|improvements, and either directly provide needed resources or request resources at our organization’s monthly leadership meetings. The |

|executive sponsor will report these details to their fellow executive leadership quarterly. The executive sponsor will also approve all |

|final documentation for each initiative. |

| |

|Additionally, we also noted in our governance structure a strong commitment to patient and family engagement. Each initiative will |

|involve a patient and family liaison to connect with both the community and staff to ensure all patient-facing materials are appropriate |

|and relevant. They will also work with the initiative leads to consult on and attend trainings for clinicians and staff and the |

|development of patient-facing materials and communications. This liaison will ensure that the patient voice is not just an afterthought |

|but is an active part of the development and implementation of all components of HTP. |

| |

|Lastly, as outlined in our governance structure, each initiative will be assigned an IT coordinator to support any changes to the EHR or |

|data reports that need to be created or amended. The IT coordinators will attend team meetings and work actively on each initiative they |

|are assigned to, allowing for IT and data requests to be completed in a timely manner. Any data or IT requests that cannot be completed |

|in a timely manner will be escalated to the executive sponsor. |

Approach to Intervention Implementation

Hospitals must complete this section in the Implementation Plan submission tool separately for each of the interventions (or statewide priority) approved for inclusion in the HTP.

Overview of Intervention

|III.A.1. |Reporting Hospital |WILL BE PREPOPULATED FROM APPLICATION |

|III.A.2. |Name of Intervention |WILL BE PREPOPULATED FROM APPLICATION |

|III.A.3. |Primary Measure(s): |WILL BE PREPOPULATED FROM APPLICATION |

III.A.4. Is this an existing intervention (an intervention that the hospital previously planned and is currently implementing or executing)? (See definition in the HTP Milestones Requirements section of this document.)

|Yes |

|No |

Note from CHA:

• We anticipate most hospitals will have called the ED ALTO measure “existing” in their HTP applications.

• The ONLY difference in next steps for a new or existing intervention is the timeline in which milestones must be completed in.

III.A.5. The below chart is for principal internal and external administrative roles for this intervention. If there are more than five individuals working on this intervention, please list the five individuals with the greatest leadership roles or most time dedicated to this intervention.

Note from CHA: The chart below has been updated to include POSSIBLE roles that might be related to this intervention. For your application, please include the roles that are most relevant to your organization.

| |Name of Individual |Intervention-Specific Role|Role will lead |Name of Organization |Key Deliverables / |

| | | |implementation of the | |Responsibilities |

| | | |intervention (Y/N) | | |

|Individual 1 |ED Director and/or Pain |Project lead |Y |Hospital |Conduct or organize training, |

| |Specialist | | | |lead weekly team meetings, track |

| | | | | |data and determine next steps in |

| | | | | |improvement efforts, provide |

| | | | | |coaching and feedback to ED |

| | | | | |providers and staff |

|Individual 2 |Hospital Quality |Lead quality improvement |N |Hospital |Run rapid improvement events, |

| |Director/ coordinator |activities | | |suggest changes based on data, |

| |and/or HTP Coordinator | | | |support ED director in developing|

| | | | | |materials |

|Individual 3 |Executive Sponsor |Remove barriers to |N |Hospital |Bring budget and resource |

| | |implementation activities | | |constraints relating to this |

| | | | | |initiative to executive |

| | | | | |leadership meetings, escalate |

| | | | | |issues, review progress |

|Individual 5 |IT/Data Coordinator |Lead IT/data requests |N |Hospital |Implement IT/data related |

| | | | | |initiatives, escalate delays to |

| | | | | |executive sponsor |

|Individual 6 |ED Educator/ Trainer |Education |N |Hospital |Develop training materials and |

| | | | | |train all staff, provide coaching|

| | | | | |throughout intervention |

|Individual 7 |Patient and Family |Consultant |N |Hospital |Consult on training materials and|

| |Liaison | | | |education, provide coaching to |

| | | | | |staff throughout intervention, |

| | | | | |connect with community partners, |

| | | | | |attend team meetings |

III.A.6.a. Briefly describe the intervention’s target population for the intervention. This should align with the hospital’s approved HTP Application. (Please respond in no more than two sentences.)

|The target population for this intervention is Emergency Department patients admitted with primary and secondary diagnoses where|

|alternatives to opioids (ALTO) is an appropriate first line/alternative approach to manage pain. The target population will |

|exactly align with the measure specifications outlined in the HTP SW-BH3 measure specification and the CHA data manual for this |

|measure (reference that document here for additional information on the exact inclusion and exclusion criteria). |

III.A.6.b. Describe how individuals within the target population will be identified and engaged in the intervention. (Please seek to limit response to 500 words.)

|The target population will be identified and engaged in several ways. First, because of the large target population for this |

|intervention, physicians and nurses will be trained extensively in limiting their opioid usage and increasing their ALTO usage |

|for all ED patients meeting this initiative’s inclusion criteria. Physicians and nurses will be provided training on stigma and |

|bias to better engage patients that come to the ED with pain or existing OUD. Clinicians frequently consider opioids as the |

|first line of treatment for any patient the comes to the ED complaining of pain. However, the only way to reduce opioid ordering|

|in the ED is to shift the mindset of these clinicians. By training clinicians to consider ALTOs when they hear about pain |

|instead of opioids will allow the target population to be engaged in this initiative. Further, patients who come to the ED with |

|OUD may be stigmatized or seen as “drug seeking” by their clinicians. Again, training clinicians to work better with these |

|patients will ensure that they are not prescribed opioids and that those patients are willing to return for care to the hospital|

|when needed. |

| |

|Further, the patient and family liaison will work closely with the project team to develop appropriate patient education |

|materials around opioids, opioid prescribing, and the risk associated with opioid use. Patient materials will be created |

|explaining the risk of opioid usage and how pain relief may be provided as effectively in other ways. Patients will be provided |

|information on addiction to ensure patients feel confident in a first line approach of ALTO for pain management (both |

|pharmaceutical and non-pharmaceutical) before considering opioids. The goal is to ensure that patients feel confident that their|

|pain will be managed using the safest approach. Additionally, a process will be developed for printing and storing patient |

|education materials, as well as coaching patients on these materials to ensure all patients, when appropriate, are able to |

|receive these materials in a timely manner. |

| |

|Although this intervention does not include recruitment per se, patients may be resistant to taking ALTOs over opioids. In this |

|case, the patient’s physician will explain the hospital’s policy around opioid usage and will escalate any issues to the ED |

|Director as needed. |

| |

|Lastly, patients at high risk for OUD will be brought to a pain management committee to ensure their pain is being appropriately|

|managed using the approach outlined above. A random selection of patients will be reviewed regularly to determine if appropriate|

|opioid and ALTO ordering was utilized and identify gaps in processes to continuously improve by sharing specific examples and |

|monitoring trends. |

III.A.7.a. Describe what major functions and resources, supporting the initiative throughout the course of implementation are already in place, or are not in place and will need to be re-purposed from other areas, built, acquired, or secured through a partner or in some way.

Please address the following functional areas and resources, at a minimum, when responding[1]:

• People (Workforce / Training)

• Processes of Care

• Technology and Data Systems

• Patient Engagement / Target Population

III.A.7.b. Use the following space to describe the major functions and resources that are already in place. (Please seek to limit response to 1,000 words.)

|Our hospital already has an opioid stewardship program in place. The opioid stewardship group meets monthly. The charter lays out the |

|purpose of this group as well as specific roles and responsibilities of the members. This group discusses opioid-related initiatives |

|throughout the hospital to ensure an organization-wide commitment to addressing the opioid epidemic, as well as alignment with all related |

|initiatives. |

| |

|To ensure the appropriate capture of data, our hospital is partnering with the Colorado Hospital Association (CHA) on this measure. We have|

|a data representative that will work closely with CHA to submit data. This partnership will allow us the ability to view our data on a |

|regular basis to make improvements to our efforts. |

| |

|In 2019, CHA, The CO Medical Society and Colorado Consortium for Prescription Drug Abuse Prevention launched an initiative to address the |

|opioid epidemic – Colorado’s Opioid Solution: Clinician United to Resolve the Epidemic (CO’s CURE). CO’s CURE brought together diverse |

|clinical specialties, all committed to resolving the opioid epidemic in CO through the development of opioid prescribing guidelines that |

|seek to treat patients’ pain more effectively while reducing unnecessary exposure to opioids. Our hospital utilizes OpiSafe which provides |

|an integrated link to the CO CURE guidelines. |

| |

|To support education, our hospital has a learning platform where physicians and nurses complete required trainings. This platform includes |

|education around safe opioid ordering. Our organization has an education team that produces educational content and provides trainings on a|

|variety of clinical topic areas. |

| |

|Our organization has a patient and family engagement council that regularly discusses patient and family engagement in hospital |

|initiatives, as well as reviews patient facing materials. This council meets monthly and includes five patients and family members from our|

|community, our director of patient experience, and the head of our human resources department. |

III.A.7.c. Use the following space to describe the major functions and resources that are not in place and will need to be re-purposed from other areas, built, acquired, or secured through a partner or in some way. (Please seek to limit response to 1,000 words.)

Note from CHA: Below are examples of resources that may need to be acquired or repurposed. Make sure to emphasize that your organization is utilizing the work from the CO CURE initiative and will use these resources to align with and enhance your current state. There is no one size fits all. The resources are there as guidance – it will have to be integrated and adjusted to the current state/capabilities of your organization.

|In 2017, CHA developed the Colorado Opioid Safety Pilot, which our hospital participated in. The pilot study was conducted in 10 hospital |

|EDs over a six-month span with a goal of reducing the administration of opioids in those EDs by 15%. Our hospital will re-purpose any |

|lessons learned in this pilot study and apply them to the HTP SW-BH3 measure specifications. We will partner with CHA on the data process |

|as outlined in the CHA SW-BH3 Data Manual in order to comply with the data requirements of the HTP measure. This data will also be |

|visualized and utilized to drive continuous improvement. |

| |

|Our hospital will need to add a focus on ED ALTO to the opioid stewardship group. We will do this by adding a standing agenda meeting to |

|the opioid stewardship meetings that specifically address the ED ALTO initiative. |

| |

|Although we have a patient and family engagement council, we will need to make sure we have a representative specifically weighing in on |

|patient and family engagement as it relates to opioid stewardship to ensure this initiative is understood by patients and families. We will|

|also have this representative join the CHNE process to ensure they understand the needs of the community regarding OUD and opioid usage in |

|general. |

| |

|We will need to utilize our existing IT and data resources to develop or update clinical pathways for each pain condition, and we will need|

|to update existing order sets to ensure they align opioid and ALTO recommendations. |

| |

|Lastly, we will need to update educational materials for staff to ensure they align with the goals of the ED ALTO initiative. We will |

|utilize the checklist, education modules, and other resources that are available from CHA as a starting point to surface what can be used |

|and what needs to be re-purposed for our organization. |

III.A.8.a. Describe any major challenges and risks to intervention implementation and how the hospital will mitigate those challenges and risks. In the response, specifically address the following areas:

Note from CHA: Below are example of possible barriers and ways to mitigate them. Please use barriers that are relevant to your facility in your final application.

• Workforce;

• Budget;

• Health Information Technology;

• Regulatory Barriers; and

• Challenges related to engaging difficult-to-reach populations.

III.A.8.b. Use the following space to describe any major challenges and risks to intervention implementation. (Please seek to limit response to 750 words.)

|There are several challenges that we anticipate relating to our workforce. Both faculty and staff have many competing priorities and, |

|although we would like them to prioritize this initiative, we recognize that it can put an incredible burden on all employees to plan, |

|develop materials for, train staff, and implement a new initiative in an already overwhelmed area like the ED. These many priorities can |

|lead to additional administrative responsibilities for clinicians and even possible clinician burnout, both negatively impacting patient |

|engagement. Additionally, the culture of the organization always poses a threat to new initiatives. Clinicians are used to prescribing |

|opioids as a first line of treatment and changing that habit will take time. Further a lack of knowledge around how to interpret data and |

|conduct PDSA cycles may limit the efficiency with which we are able to target areas for improvement and make effective changes. Other |

|challenges include a lack of knowledge around current opioid prescribing guidelines and non-pharmacologic ALTOs or a reluctance to use new |

|ALTOs like Ketamine and Lidocaine, staff turnover, and lack of leadership engagement. |

| |

|Resource constraints further pose a challenge to this initiative. Lack of funding to pay clinicians overtime to attend trainings or lack of|

|funding to develop training poses a risk to properly training staff for this initiative. Further, a lack of funding for new or innovative |

|ALTO treatments or therapies, like music therapy, could limit our hospital’s ability to fully implement this initiative. |

| |

|Health Information Technology and regulatory barriers likewise pose challenges for this initiative. Our hospital has struggled previously |

|to run reports from our EHR in a timely manner. Additionally, our PDMP is an incredibly valuable tool in improving our opioid stewardship, |

|but our current PDMP is “pull” instead of “push” meaning clinicians must remember to check the PDMP for each patient. Further, the PDMP |

|only captures patients in Colorado and will not be useful for patients visiting from out of state. Lastly, the inability to interpret any |

|data that is generated poses a potential challenge. |

III.A.8.c. Use the following space to describe how the hospital will mitigate the challenges and risks described above. (Please seek to limit response to 750 words.)

|To reduce the burden on clinicians from competing priorities that may lead to excessive administrative responsibilities and burnout, we |

|will utilize leadership to stress the importance of the Hospital Transformation Program and explain that this is a multi-year program that |

|will not be de-prioritized. We will also emphasize the results of our CHNE process explaining to all staff that reducing opioids is a top |

|priority of our community. Additionally, we will share our HTP application and implementation plan with staff so they can understand each |

|step of the initiative. Lastly, we will solicit feedback from staff and incorporate that feedback into our continuous improvement efforts. |

|By making clear this is a priority of our organization and our community and by giving staff the ability to provide input and adequate time|

|to understand the initiative, we can limit confusion, excess paperwork, and the fatigue of a chaotic launch mitigating the likelihood of |

|staff burnout. |

| |

|To address the culture of opioid prescribing we will share with all faculty and staff the role clinicians can play in reducing opioids in |

|the community. We will also employ change management techniques, such as involving every employee in this initiative, creating strong |

|support from leadership, and providing compelling data on the impact such programs can have on patients and their families. We will also |

|solicit feedback regularly from staff to understand the challenges they are facing in changing their ordering habits. |

| |

|To address the lack of knowledge around data and quality improvement we will work closely with our quality improvement team to help ED |

|staff better understand the data and how to perform PDSA cycles. We will also provide training to staff on quality improvement principles |

|and the quality improvement team will utilize quality improvement worksheets for each PDSA cycle such as those that are available on the |

|Colorado Hospital Association website here. |

| |

|To address the lack of knowledge around current opioid prescribing guidelines and non-pharmacologic ALTOs we will provide training to ED |

|faculty and staff. To address a reluctance to use new ALTOs like Ketamine and Lidocaine, we will provide training from organizations who |

|have already implemented this initiative to speak to their experience, such as those provided in the Emergency Medical Minute podcast |

|series here. |

| |

|To mitigate complications that come with staff turnover, we will require all new staff to complete online trainings related to the ED ALTO |

|initiative, such as those that are available on the Colorado Hospital Association website here. |

| |

|To mitigate a lack of leadership engagement this initiative will be assigned an executive sponsor specifically dedicated to addressing |

|challenges and removing barriers as it relates to the ED ALTO for HTP initiative. |

| |

|To mitigate issues related to a lack of funding for training, this initiative will utilize the many training materials that are already |

|available free of cost and will emphasize shorter, more effective trainings so clinicians do not need to take substantial amounts of time |

|out of their days to complete trainings. We will also emphasize coaching by ED champions to make clinicians aware of how they can limit |

|opioid ordering. |

| |

|To address possible delays in data reports, this initiative will have an IT coordinator specifically focused on this project. We will also |

|utilize reports and interpretations of those reports from CHA, so we do not need to dedicate internal resources to doing so. |

| |

|To address the limitations of the PDMP, we will create a best practice alert encouraging clinicians to check the PDMP whenever they order |

|an opioid for the first time for a patient. We will also add reminders to training materials explaining the importance of utilizing the |

|PDMP. Clinicians will also be trained to screen all patients for risk of OUD, thus capturing patients who may not appear in the PDMP. |

| |

|To address the possible stigmatization of patients who use drugs, we will require all staff to participate in stigma and bias training such|

|as the Dell Medical School Modules here. |

| |

|To mitigate the risk that patient educational materials may be insensitive or irrelevant to the patient population, all new materials that |

|are developed will be brought to the patient and family engagement council for approval. |

III.A.9. Describe how this intervention will benefit from the hospital’s ongoing Community and Health Neighborhood Engagement efforts. (Please seek to limit response to 500 words.)

|The ongoing CHNE process allows our hospital to better understand the needs of our community and connect with community partners. Our CHNE |

|engaged police officers, local family practitioners, dentists, the health department, and many others. By hearing from these diverse groups|

|of stakeholders we were able to understand the needs of our community beyond the walls of our hospital. For instance, the perspective of |

|the police department is invaluable particularly when it comes to reducing opioid prescribing, which leads to greater opioid usage in the |

|community. The police department sees daily that the community is struggling with substance use disorders and are already acting as |

|valuable partners in this initiative aimed at reducing opioid use in the community. Further, primary care providers are crucial to our |

|hospital’s ability to limit opioid prescribing and increase the use of ALTOs. If patients are receiving opioid from their primary care |

|providers it may be more challenging to treat their acute or chronic pain in the ED. Working with primary care practitioners, dentists, and|

|others allows a diverse group of health care providers to work together to not only reduce the use of opioids but support one another in |

|determining the best approach to challenging cases and addressing a culture that still often stigmatizes individuals who use drugs. |

Intervention Milestones

Hospitals must propose and record in the Implementation Plan submission tool one milestone in both Quarters 2 and 4 (Q2 and Q4) for each Program Year (PY) starting with PY2Q2 (Jan. – Mar. 2023). Milestones should be discrete tasks that, when completed, have an easily identifiable, quantifiable, and definable goal that has been reached or action that has been completed. The milestones established must be completed by the end of the quarter for which the milestone is applicable (Q2 or Q4).

All milestones should be associated with their applicable phase: Planning and Implementation or Continuous Improvement. Distinct milestone requirements apply to each phase, and timing of the phases depends on whether the intervention is new or existing. Planning and Implementation milestones should be completed no later than PY3Q4 (Jul.- Sept. 2024) and Continuous Improvement milestones should begin no later than PY4Q2 (Jan. – Mar. 2025), with accelerated milestones for existing interventions subject to the timeline outlined in this document. Hospitals may complete Planning and Implementation milestones at any point prior to PY4Q2 and begin reporting Continuous Improvement milestones. Additionally, unique considerations apply for the Hospital Index Measure, as outlined in the Milestones Requirements section of this document.

The submission tool will guide hospitals through recording milestones per intervention for each applicable program year quarter. Hospitals will indicate the milestone phase and whether it is an impact milestone. Interventions will be prepopulated in the submission tool based on the hospital’s approved HTP Application.

Note from CHA: the below are tasks your organization will likely need to meet to successfully launch the ED ALTO initiative, however, some of these you may have already implemented. Please modify the below tasks to align with your organizational needs, resources, and typical processes. Remember that multiple tasks can make up one milestone. See the CHA website here for more details on pre-launch activities.

|Task |Functional Area |Possible Documentation |

|The project lead has completed the Opioid Safety Gap |Process |1. Completed gap assessment that |

|Assessment and is utilizing findings to prioritize and | |highlights key areas of focus. |

|plan efforts for the initiative. | |2. Copy of prioritization plan. |

|All project champions have been identified and onboarded |People |1. Signed commitment forms from all |

|including: | |champions will be included along with|

|ED medical director | |their project roles. |

|ED nurse director | | |

|Pharmacy director | | |

|Quality champion | | |

|Communications and marketing champion | | |

|IT/data champion | | |

|The project leadership and champions have read the |Process |1. Meeting agenda and meeting minutes|

|Colorado ACEP 2017 Prescribing & Treatment Guidelines and| |from the review session |

|reviewed the details of the guidelines with one another. | | |

|The project team has specified the roles, |People |1. Completed project plan that |

|responsibilities, and scope of work for each project team| |includes scope, roles, and |

|member and champion and has distributed this plan to all | |responsibilities. |

|necessary personnel. | |2. Copy of email sent to project team|

| | |detailing this information. |

|The project team has reviewed with the data champion |Technology |1. A copy of the test reports and/or |

|reports that will need to be created and the champion is | |screenshots of the reports being |

|testing the reports to ensure they meet the needs of the | |built. |

|project team. | | |

|The data champion has worked with CHA to ensure data |Technology |1. Copy of report sent to CHA. |

|being submitted to them is comprehensive. The project | |2. Screenshot of CHA dashboards. |

|team has worked with CHA to ensure the organization can | | |

|access dashboards and visualizations relating to ED ALTO | | |

|on the CHA data platform, ODHIN. | | |

|The marketing and communications champion has worked with|People |1. Completed communication plan. |

|the project team to develop a communication plan that | | |

|emphasizes communication strategies for effectively | | |

|engaging the community, patients, and families and | | |

|instructions for intentional leadership rounding to | | |

|determine if people know about changes and/or updates to | | |

|the initiative. | | |

|The project team has created a training and education |People |1. A training calendar showing who is|

|process for full time faculty and staff that includes: | |being trained, when, and on what |

|Education on trigger point injections/IV nerve blocks | |topic. |

|Stigma/bias training | |2. Copies and/or screenshots of |

|Patient satisfaction and communication skills | |educational materials including slide|

|Messaging to patients/families | |decks, handouts, videos, etc. |

|ALTO administration and side effects (for nursing and | | |

|pharmacy staff) | | |

|The project team has developed an orientation and |People |1. A plan describing the process for |

|education process for locum tenens ED providers and float| |educating staff who are not in the ED|

|pool nurses to ensure sustainment of ALTO guidelines. | |regularly or employed directly by the|

| | |hospital. |

|The project team and patient and family liaison have |Patient Engagement |1. Educational materials including |

|developed educational materials for patients and families| |slide decks, handouts, videos, etc. |

|and a process for distributing these materials. These | |2. Agenda item discussing these |

|materials have been approved by our hospital’s patient | |materials at a PFAC meeting. |

|and family engagement council (PFAC). | |3. A description of the process and |

| | |workflow for printing and storing |

| | |these materials. |

| | |4. A copy of the clinician workflow |

| | |that includes the distribution of |

| | |these materials. |

|The project team has reviewed high-risk policies to |Process |1. Copies of updated policies. |

|ensure medications such as Ketamine and IV drip lidocaine| |2. Agenda from P&T noting the |

|can be given for pain in the ED. The project team has | |discussion around policies. |

|also worked with ED providers and pharmacy and | | |

|therapeutics committee (P&T) to change high-risk policies| | |

|to meet the recommended Colorado ACEP ALTO guidelines. | | |

|The project team has secured medication approval and |Process |1. Documentation showing approval of |

|stocked medications for use in the ED for the following | |medications. |

|medications: | |2. Documentation of appropriate stock|

|Ketamine pain dose IV and drip – IV push may require less| |of medications. |

|concentrated product (50mg/5 ml prefilled syringes) | | |

|Lidocaine IV and patches | | |

|Capsaicin topical | | |

|Gabapentin | | |

|The IT champion has updated the smart pump medication |Technology |1. Screenshots of updated libraries |

|libraries to reflect offered medication therapies | |reflecting new therapies. |

|including standard drip concentration, dosages and | | |

|maximum dose limits. | | |

|The project team, along with the IT champion, has created|Technology |1. Screenshots of the new ALTO order |

|an ED ALTO order set to be included in the hospital | |set. |

|Electronic Health Record (EHR). | | |

|The IT/data champion has created all data reports and |Technology |1. Copy of data reports. |

|conducted a test run of the reports to ensure all fields | | |

|populate correctly (e.g., dates, medications, doses, | | |

|dosing, units, etc.). | | |

|ED staff have completed training for this initiative. |People |1. Attendance list for trainings. |

|Patient education materials were piloted to ensure they |Patient engagement |1. Raw count of number of patients |

|appropriately engaged patients. | |reached. |

| | |2. Feedback from the pilot. |

|The project team held a final planning meeting including |People, process, technology, patient |1. People: percentage of employees |

|beta testing the launch, ensuring each of the following |engagement |trained and copies of any |

|is complete: | |communications that went out to staff|

|All patient resources incorporated feedback from the | |and/or patients reminding them of the|

|pilot, are completed and are being handed out to patients| |initiative and new processes. |

|Handouts made | | |

|Handouts printed and placed in central location/pt. | |2. Process: final versions of ALTO |

|discharge materials, etc. | |order sets, clinical pathways, and |

|Posters made | |policies that have been updated. |

|Posters hung in ED (if applicable) | | |

|All clinical processes have been updated, clearly | |3. Technology: screenshot of first |

|communicated to staff, and are now being utilized | |monthly data report. |

|Order sets | | |

|Pain pathways | |4. Patient Engagement: photos of |

|Policies | |posters hanging (if applicable) and |

|All team members are trained, ready for launch and there | |photos of the patient materials in |

|have been no key turnover issues for the team | |the ED. |

|Data reports have been beta tested and are now being sent| | |

|monthly | | |

|Communication plan was launched, and intentional | | |

|leadership rounding was completed | | |

|In consultation with the director of quality improvement,|Continuous improvement |1. Completed plan for performance |

|the project team has selected a performance improvement | |improvement for the ED ALTO |

|strategy such as the Institute for Healthcare Improvement| |initiative that specifically details |

|(IHI) Plan-Do-Study-Act (PDSA) model for change and has | |what method of quality improvement |

|detailed a strategy for using this method during the | |will be used. |

|continuous improvement phase. | | |

|The project team has continued to monitor performance and|Continuous improvement |1. Agendas from weekly huddles and a |

|make updates to protocols and processes by holding weekly| |summary of changes made based on |

|huddles. These huddles include a review of the data so | |discussions at the huddle will be |

|far including ED ALTO order set usage and feedback from | |provided. |

|patients and staff. Each huddle allows for slight changes| |2. Raw counts of ED ALTO order set |

|to be made to ensure staff is comfortable with this | |usage. |

|initiative and the appropriate patients are being | |3. Documented written or oral |

|reached. | |feedback from staff and patients. |

|The project team, led by the quality improvement |Continuous improvement |1. Summary of PDSA activities |

|champion, completed a Plan-Do-Study-Act (PDSA) cycle to | |including changes made, results of |

|continue to improve upon efforts utilizing the IHI model | |those changes, and any updates to |

|for improvement. This PDSA cycle focused on health | |processes or workflows. |

|equity, reviewing data for this measure by race/ethnicity| | |

|to target and reduce any disparities. | | |

|The project team, led by the quality improvement |Continuous improvement |1. Summary of PDSA activities |

|champion, completed a second and distinct | |including changes made, results of |

|Plan-Do-Study-Act (PDSA) cycle to continue to improve | |those changes, and any updates to |

|upon efforts utilizing the IHI model for improvement. | |processes or workflows. |

|The project team, led by the patient and family liaison, |Continuous improvement |1. Copy of the patient survey and a |

|conducted a survey of patients to determine satisfaction | |summary of results. |

|and engagement in this initiative. Results of the survey | |2. Description and supporting |

|were used to make updates to the ED ALTO initiative. | |evidence of work completed in |

| | |response to the results of the survey|

| | |(if applicable). |

III.B.1. Please answer the following questions with information related to this intervention’s milestone.

What phase does this milestone fall under?

|Planning and Implementation |

|Continuous Improvement |

III.B.2. Is this the impact milestone for this intervention?

|Yes |

|No |

III.B.3.a. Please indicate which Functional Area(s) applies to this milestone. Select all that apply. Impact milestones must include all Functional Areas.

|People |

|Process |

|Technology |

|Patient Engagement/ Target Population |

For each applicable Functional Area, indicate the following:

III.B.3.b. Please include a brief description of the [People, Process, Technology, Patent Engagement / Target Population] Functional Area for this milestone (no more than two sentences).

Functional Area Description Definition – A short description of the actions that will constitute the completion of the milestone.

| |

For each applicable Functional Area, indicate the following:

III.B.3.c. Please describe the supporting documentation which will be provided in support of the Functional Area for this milestone (no more than two sentences).

Supporting Documentation Definition – The name and a brief description of the materials that will be submitted as evidence of the milestone’s completion.

| |

Milestone Requirements

Overview

Beginning in Program Year (PY) 2 (Oct. 2022 – Sept. 2023) of the Hospital Transformation Program (HTP), participating hospitals can earn at-risk dollars under the HTP through completion and reporting on intervention milestones.

“Milestones” are defined as key activities or deliverables that reflect successful completion of key steps toward the participant’s intervention and subsequent achievement of HTP goals. Milestones should be important to the hospital’s overall development process. Milestones should be discrete tasks that, when completed, have an easily identifiable, quantifiable, and definable goal that has been reached or action that has been completed. Each milestone, when completed, will require the submission of the supporting documentation described in the Implementation Plan and will be used by the Department to validate whether the milestone has been successfully completed.

Interventions and their accompanying milestones should be developed with an anticipated date of reaching their full scale or near-to-full scale levels of impact by the conclusion of PY3 (Oct. 2023 – Sept. 2024). This will be demonstrated by the inclusion (and achievement) of an impact milestone as the final milestone for the Planning and Implementation phase as outlined below. HTP participants applying to use an existing intervention should submit milestones at the same level of definition as those entities that are applying to use new interventions, but those milestones must be proposed at an accelerated timeline as outlined below.

Starting in PY1 (Oct. 2021 – Sept. 2022), participating hospitals will be required to submit quarterly reports that address progress on milestones and associated interim activities related to each HTP intervention’s progress. Milestones will be reported and at-risk dollars evaluated semi-annually, with associated “interim activities” reported in the intervening quarters.

“Interim activities” should track progress towards intervention milestones. Payment is not specifically tied to the successful completion of interim activities. However, interim activity progress toward completion of milestones must be reported and the Department will use interim activities to understand overall implementation progress.

As transformation activities are inherently dynamic, the HTP will allow each participant to submit proposed milestone amendments along with their HTP reports for Q2 and Q4. Each amended milestone will need to be submitted along with justification for the change. Hospitals will also have opportunities for course corrections as outlined in further detail below.

Milestone Requirements

The HTP is built around three primary phases for measuring progress. Milestones should be developed and submitted under phases one and three below (phase two is comprised only of performance metrics):

0. “Planning and Implementation Phase”: These milestones should document the process through which the participant will complete all necessary preliminary activities (e.g. preparation, gap assessments) that support implementation. The final set of this phase’s milestones should focus on implementation activities resulting in the intervention’s inception.

0. “Performance Phase”: The performance phase is comprised of all performance measures that will begin determining, in part, participating hospital payments of at-risk dollars beginning in PY3 (Oct. 2023 – Sept. 2024).

0. “Continuous Improvement Phase”: This second phase of milestones must focus on how the participant is incorporating continuous quality improvement practices into the intervention’s ongoing operation. These milestones could include documented progress toward deploying quality improvement teams, cycle completions for quality improvement exercises or the development and use of various types of quality improvement forums, technical assistance programs or other quality improvement capacity development.

Each milestone occurring during the Planning and Implementation phase must also be identified as affecting one or more of the following “Functional Areas.”:

• People: These milestones could include activities related to workforce development, including training new or existing staff members, redeploying staff members into materially new roles or identifying key project personnel.

• Process: These milestones include activities related to a material shift in how clinical processes (e.g. patient hand-offs, post discharge follow-ups) will be completed as a result of the proposed intervention.

• Technology: These milestones apply to the updating, acquisition or repurposing of underlying electronic health data storage, use or exchange either within or across the HTP participant’s primary service units or with the state’s health information exchange (CORHIO).

• Patient Engagement / Target Population: These milestones include the identification and enrollment of patients that fall within target populations. Patient Engagement milestones should be included for all interventions and must include quantifiable impact milestones relative to progress toward reaching full engagement of the target population as outlined in more detail below.

The final milestone for each intervention’s Planning and Implementation phase shall be an “impact milestone” that demonstrates that the intervention has been fully implemented. The impact milestone should address all functional areas (if one or more functional areas are not applicable to the intervention, the hospital should demonstrate that).

For example, if the intervention is based on increasing Social Needs screeners where the target population is all inpatient admission patients, impact milestone supporting documentation could include:

• People: The total number of individuals trained to properly administer the screener and assigned to screen;

• Process: The policies and protocols for implementing and administering the new screener;

• Technology: A screenshot of the system that has been implemented or updated to accept screener data;

• Patient Engagement / Target Population: Aggregated, de-identified thirty day results of health screener for all patients in the inpatient setting.

The achievement of the final Planning and Implementation milestone will be dependent on the milestone’s activities being successfully completed and will indicate the conclusion of the Planning and Implementation phase for that intervention. All future milestones should be designated as Continuous Improvement phase milestones.

Planning and Implementation milestones for new interventions should be completed no later than PY3Q4 (Jul. – Sept. 2024) and Continuous Improvement milestones should begin no later than PY4Q2 (Jan. – Mar. 2025). However, hospitals may complete Planning and Implementation milestones at any point prior to PY4Q2 (Jan. – Mar. 2025) and begin reporting Continuous Improvement milestones.

For existing interventions, it is expected that hospitals will reach their full scale at an accelerated pace. “Existing interventions” are those interventions the hospital had implemented or was implementing on the day it submitted the HTP Application. The hospital may propose planning milestones specific to the enhancement of the intervention to meet HTP requirements (including impact milestones) and implementation milestones. However, final Planning and Implementation phase milestones for existing interventions must occur no later than PY3Q2 (Jan. – March. 2024). Similarly, the hospital should propose Continuous Improvement milestones to begin no later than PY3Q4 (July – Sept. 2024). Hospitals proposing to leverage existing interventions that are already at full scale at the beginning of the HTP should include an impact milestone as the first and only Planning and Implementation milestone for such interventions prior to moving on to Continuous Improvement milestones.

The tables below map the Implementation Plan milestone inputs expected for the course of the program, depending on whether the intervention is new, existing, or relates to the Hospital Index Measure.

Submission of Proposed Milestones (New)*

|Phase |Q |PY2 |PY3 |PY4 |PY5 |

| | |(Oct. 2022 – Sept. 2023) |(Oct. 2023 – Sept. 2024) |(Oct. 2024 – Sept. 2025) |(Oct. 2025 – Sept. |

| | | | | |2026) |

|Planning and |Q2 |Impact Milestone: Y/N; |Impact Milestone: Y/N; |N/A |N/A |

|Implementation Phase |Jan - |Milestone Functional Area(s) |Milestone Functional Area(s) | | |

|Milestones |March |and Description |and Description | | |

| |Q4 |Impact Milestone: Y/N; |Impact Milestone: Y/N; |N/A |N/A |

| |July - |Milestone Functional Area(s) |Milestone Functional Areas and| | |

| |Sept |and Description |Description | | |

|Continuous Improvement |Q2 |N/A |N/A |Milestone Description |Milestone Description |

|Phase Milestones |Jan - | | | | |

| |March | | | | |

| |Q4 |N/A |N/A |Milestone Description |Milestone Description |

| |July - | | | | |

| |Sept | | | | |

*Impact Milestones for New interventions must be completed by the end of PY3 (Sept. 2024) and must address all Functional Areas. Continuous Improvement Phase Milestones must begin no later than PY4Q2 (Jan. – Mar. 2025).

Submission of Proposed Milestones (Existing)*

|Phase |Q |PY2 |PY3 |PY4 |PY5 |

| | |(Oct. 2022 – Sept. 2023) |(Oct. 2023 – Sept. 2024) |(Oct. 2024 – Sept. 2025) |(Oct. 2025 – Sept. 2026) |

|Planning and |Q2 |Impact Milestone: Y/N; |Impact Milestone: Y/N; |N/A |N/A |

|Implementation Phase |Jan - |Milestone Functional Area(s)|Milestone Functional Areas | | |

|Milestones |March |and Descriptions |and Descriptions | | |

| |Q4 |N/A |Milestone Description |Milestone Description |Milestone Description |

| |July - | | | | |

| |Sept | | | | |

* Impact Milestones for existing interventions must occur prior to PY3Q4 (Jul. – Sept. 2024). Continuous Improvement milestones must begin prior to PY4 (Oct. 2024 – Sept. 2025).

Submission of Proposed Milestones (Hospital Index Measure)*

* Under the Hospital Index Measure, hospitals only complete one impact milestone, during PY2Q2 (Jan. – Mar. 2023). Continuous Improvement milestones begin PY2Q4 (Jul. – Sept. 2023) and continue for the remainder of the program. Please reference Appendix A of this document for additional guidance and clarification around the Hospital Index Measure.

|Phase |Q |PY2 |PY3 |PY4 |PY5 |

| | |(Oct. 2022 – Sept. 2023) |(Oct. 2023 – Sept. 2024) |(Oct. 2024 – Sept. 2025) |(Oct. 2025 – Sept. 2026) |

|Planning and Implementation Phase Milestones |Q2 |

| |Jan - March |

|Department begins review of all submitted quarterly reports |Report submission due date + 1 business day |

|Department reviews all supporting documentation (milestones) / responses regarding interim |Report submission due date + 15 business days |

|activities | |

|Department initial review of quarterly report complete |Report submission due date + 20 business days |

|Department notifies participant that scores received for quarterly reporting are available on|Report submission due date + 21 business days |

|CPAS portal | |

|Requests for reconsideration of scoring decisions due |Report submission due date + 31 business days |

|Department issues final scores for quarterly reports |Report submission due date + 45 business days |

Milestone Amendments

Throughout the HTP, various factors may require a participant to shift its implementation strategies. New evidence-based models may emerge, or other key developments or operating characteristics of facilities may shift, requiring an amended approach to intervention completion. To allow for the flexibility to address unexpected barriers or outcomes, adopt new approaches and pursue innovative and emerging models of care, participants will be provided milestone amendment periods. This amendment process will occur as part of the reports for the second and fourth quarter of each program year. Note that only milestones due in future quarters may be amended.

To amend a single or multiple milestone(s), participants must record proposed milestone amendments along with reports for Q2 and / or Q4 that adequately address the following conditions for any proposed amended milestone:

• Milestone(s) for proposed amendment are clearly identified;

• Documentation to validate milestone completion is specified;

• Justification for amending the milestone(s) is provided;

• All the requirements outlined above regarding the development and submission of initial milestones have been satisfactorily met.

Following the submission of amended milestones, the Department will initiate a review and approval process in parallel with quarterly report filing review timelines:

|Milestone Amendment Activity |Completion Date |

|Department begins review of amended milestone(s) |Q2 or Q4 Report submission due date + 1 business day |

|Department reviews milestone amendment(s) for sufficient justification and completed |Q2 or Q4 Report submission due date + 15 business days |

|milestone requirements | |

|Department completes review of proposed milestone amendment(s) |Q2 or Q4 Report submission due date + 20 business days |

|Department notifies participant of approval, approval with modifications or rejection of |Q2 or Q4 Report submission due date + 21 business days |

|proposed milestone amendment(s) | |

|Participant accepts Department’s approval, approval with modifications or rejection of |Q2 or Q4 Report submission due date + 31 business days |

|proposed milestone amendment(s) OR requests to resubmit and submits an updated milestone | |

|amendment(s) | |

|Department issues final approval /denial of amended milestone(s). If approved, amended |Q2 or Q4 Report submission due date + 45 business days |

|milestone(s) become part of the participant’s Implementation Plan. | |

Intervention Course Correction

If a milestone is not completed, a portion of at-risk payments will be withheld. Hospitals subject to loss of at-risk dollars for missed (not completed) milestones may submit a course correction plan with the report for the quarter during which the milestone was missed (e.g. if a Q4 milestone was not completed, the course correction plan should be submitted with the report for that quarter). If the Department notifies the hospital that it has determined the hospital missed a milestone based on its review of the hospital’s report (i.e. the hospital did not report missing the milestone), a course correction plan may be submitted 30 days after the final determination by the Department that the milestone was missed. 50% of all lost at-risk dollars may be earned back by submitting a course correction plan. Hospitals may submit a course correction plan once per intervention.

“Course correction plans” must provide insights into the root causes of a missed milestone and detail the process the program participant intends to pursue to either complete the missed milestone as previously defined or provide insight as to why the missed milestone will not or should not be completed. Course correction plans must also provide operational insights into how future milestones associated with the intervention will be completed by their previously intended deadlines. Part of the hospitals’ plan for correcting an intervention’s course may involve amending future milestones. While the course correction plan could discuss amending future milestones as part of the way forward, the course correction plan is not the mechanism by which milestones are amended. All milestone amendments must be submitted as an official milestone amendment, as discussed in the previous section of this document. As a result, if a course correction plan discusses milestone amendments which are not separately submitted as milestone amendments, no changes to the hospital’s milestones will be recognized. As a reminder, as outlined above, milestones may also be amended prospectively through reports for Q2 and Q4 and there is no limit to how often a hospital may prospectively amend milestones.

Payment

HTP participants will be paid monthly throughout the term of the program. Payments of at-risk dollars made for Q4 of the ramp up period (Application Period) will be determined by the participant’s successful completion of their Program Application. Payments of at-risk dollars made for PY1 will be determined by the participant’s successful completion of their Implementation Plan and in part, on successfully reporting in each participant’s quarterly filings. Payments of at-risk dollars for PY2 to PY5 (Oct. 2022 – Sept. 2026) will, in part, be based on ongoing reporting of milestones and interim activities in each participant’s quarterly filings.

Program Timeline

[pic]

Appendix A -

Colorado Hospital Index Measure – Hospital Transformation Program

Milestone Reporting

Hospital Index Measure: Background

The SW-COE1 Hospital Index Measure is a statewide measure of avoidable care across procedural episodes. A hospital’s index score will be compared to a baseline index score.

The Hospital Index Measure is designed to stand up and support a continuous learning environment, which may then be leveraged for other interventions or hospital processes. Hospitals can best address this measure by following the laid out guidance, particularly for reporting performance for the impact milestone for PY2Q2 (Jan. – Mar. 2023) and the continuous learning and improvement milestones starting PY2Q4 (Jul. – Sept. 2023) until the end of the program. There are pre-defined milestones to support achievement of the Hospital Index Measure.

PY2Q2 (Jan. – Mar. 2023) Impact Milestone: Current Quality Improvement Capacity in Key Functional Areas

The impact milestone should evaluate the current quality improvement capacity in key functional areas. If one or more functional areas are not applicable to the intervention, the hospital should demonstrate that. The achievement of the impact milestone will be dependent on the milestone’s activities being successfully completed. The achievement of the final impact milestone will indicate the conclusion of the Planning and Implementation phase for that intervention and all future milestones should be designated as Continuous Improvement phase milestones. Hospitals will be required to have an impact milestone no later than PY2Q2 (Jan. – Mar. 2023) and continuous improvement milestones beginning no later than PY2Q4 (Jul. – Sept. 2023).

The Department will use the following questions and prompts when evaluating Hospital Index milestones. This includes questions to investigate a hospital’s current capacity to run effective quality improvement (QI) initiatives through the lens of applicable functional areas and help uncover gaps that could deter from success in the HTP’s continuous improvement phase.

Functional Areas to address:

People: workforce development; identification key project personnel

Process: shifts in clinical and quality processes;

Technology: updating, acquisition or repurposing underlying electronic health data storage; data use; data exchange

0. Patient Engagement / Target population: identification of patients that fall within target populations;

Impact Milestone Functional Area – People:

1) Governance Structure – (Predefined element to demonstrate impact milestone; required)

a. Describe the quality improvement governance structure at your hospital and include an organizational chart where appropriate. Include roles including departmental or unit-based leadership positions, data analysts and executive leadership positions related to quality improvement.

2) Staff Engagement – (Predefined element to demonstrate impact milestone; required)

a. How does your hospital engage interdisciplinary teams in quality improvement efforts?

b. Does your hospital offer protected time to quality leadership or frontline staff to engage in quality improvement initiatives?

c. How does the hospital engage quality leaders in institutional quality initiatives?

d. How do quality leaders engage frontline staff in quality improvement initiatives?

e. How does your hospital disseminate performance data related to quality initiatives to staff in both quality leadership positions and frontline positions? (i.e. accessible dashboards, report distribution, presentations at regularly scheduled series or huddles, public postings in patient accessible areas, etc.).

3) Professional Development – (Predefined element to demonstrate impact milestone; required)

a. How does your hospital teach quality improvement skills and rapid cycle improvement techniques (i.e. Six Sigma Lean, Plan-Do-Study-Act (PDSA) Framework, Model for Improvement, etc.)[2] to staff across all levels?

Impact Milestone Functional Area – Process:

1) Readiness – (Predefined element to demonstrate impact milestone; required)

a. Hospital Index measure requires the HTP team to coordinate with teams from different departments to maintain or improve performance in the top five highest weighted episode groups. How will your hospital leverage your current quality structure to monitor hospital index performance and implement quality improvement initiatives to meet your performance target?

b. What gaps exist in your current quality structure that you will need to address to successfully run a continuous quality improvement effort for this measure?

Impact Milestone Functional Area – Technology:

1) Analytics – (Predefined element to demonstrate impact milestone; required)

a. Describe the staff available to analyze and report hospital level quality data and from what sources this team can obtain relevant data (i.e. electronic health record (EHR), claims engine, etc.).

b. Is the analytics team centralized? Does this team primarily focus on hospital level measures? Are additional analysts available to assist local quality initiatives?

c. The following procedure codes in the chart below are used to calculate performance in the Hospital Index measure. After consulting with your analytics team, what is the feasibility of monitoring the frequency of these procedures in a recurring report by service area?

|Episode Description |Episode Type |

|Bariatric Surgery |Procedural |

|Breast Biopsy |Procedural |

|C-Section |Procedural |

|CABG &/or Valve Procedures |Procedural |

|Cataract Surgery |Procedural |

|Colonoscopy |Procedural |

|Colorectal Resection |Procedural |

|Coronary Angioplasty |Procedural |

|Gall Bladder Surgery |Procedural |

|Hip Replacement / Revision |Procedural |

|Hysterectomy |Procedural |

|Knee Arthroscopy |Procedural |

|Knee Replacement / Revision |Procedural |

|Lumbar Laminectomy |Procedural |

|Lumbar Spine Fusion |Procedural |

|Lung Resection |Procedural |

|Mastectomy |Procedural |

|Pacemaker / Defibrillator |Procedural |

|Prostatectomy |Procedural |

|Shoulder Replacement |Procedural |

|Tonsillectomy |Procedural |

|Transurethral Resection Prostate |Procedural |

|Upper GI Endoscopy |Procedural |

|Vaginal Delivery |Procedural |

Impact Milestone Functional Area - Patient Engagement / Target Population:

(Predefined elements to demonstrate impact milestone; required)

a. While not directly measured in the course of your effort to improve your hospital index performance, begin to consider how your effort to monitor potentially avoidable costs (PAC) could impact patient experience, delivery of care, outcomes and/or satisfaction.

b. Describe how the hospital will utilize its Hospital Index dashboard and information to monitor PAC performance and equity for patients by reviewing disaggregated data by race, ethnicity, language, gender, etc., and how that could impact how the hospital approaches patient experience, delivery of care, outcomes, or satisfaction.

Continuous Learning and Improvement Milestones

After the State reports performance on the Hospital Index measure, these questions guide a hospital through key assessments and planning steps to begin their continuous improvement process. Hospitals should also describe their plan to implement quality improvement strategies to improve or maintain their Index performance. Please see Appendix B for additional resources on conducing current state assessments and planning out the continuous improvement process.

PY2Q4 (Jul. – Sept. 2023) Milestone:

1) Current State Assessment of Top 5 Episodes Driving the Hospital Index Score (Predefined element for Q4 milestone each PY beginning with PY2 (Oct. 2022 – Sept. 2023); required)

a. In the chart below, list the top 5 episodes with the greatest weighted impact on your Hospital Index score and indicate what type of action is needed to achieve the state set benchmark (i.e. Maintain performance or improve)?

| |Top 5 Episodes |Maintain or Improve Performance? |

|1 | | |

|2 | | |

|3 | | |

|4 | | |

|5 | | |

b. For each episode, please answer the following questions (Required):

1. Number of clients associated with specified episode:

2. Top 2 categories of service for each episode:

c. Consider factors such as the procedure code or DRG, provider type, service location, and specific rendering/attending providers that drive high/low PAC in this episode to answer the following questions:

1. What is driving PAC?

2. What is contributing to low PAC?

3. Are there any themes/trends in services used more/less within an episode type that are associated with high/low PAC?

4. Provide demographic stratifications associated with this episode including: age, race, gender, and county.

2) Stakeholder Assessment – (Predefined element of first continuous learning and improvement milestone, required)

a. Proposed approach for each episode, please answer the following questions to identify and assess stakeholders that you must engage to implement a quality improvement initiative.

1. Describe the stakeholders that must be engaged to implement a quality improvement initiative to improve this episode’s PAC.

2. Based on your current perception, are the stakeholders impacted by the project in agreement that improvement is needed?

3. Based on your current perception, please rate the collective commitment to this project regarding the stakeholders involved.

4. Based on your current perception, please assess the local environment’s readiness for change.

3) Continuous Improvement Activities, Impact and Reporting – (Predefined element of first continuous learning and improvement milestone, required)

a. Please describe the approach to the quality initiative(s) required to improve your index score. Describe what continuous learning and improvement model(s)/strategies you will be implementing (rapid cycle improvement, etc.). Below are suggested ways to approach this:

1. Describe your next intervention indicating how long each test cycle will last and how many tests you hope to complete during the next reporting cycle.

2. Comment on the scope of your intervention with the following considerations:

o Where will the intervention take place?

o What population will it focus on?

o What is the size of the population it will affect?

o Can you ensure the first test of your intervention has a minimized scope?

3. What will you measure to know that you have successfully implemented the intervention for your initial rapid cycle test of change?

4. What will you measure to know if your intervention led to an improvement? (i.e. describe a proxy measure to assess progress towards the state set benchmark).

5. Describe the data collection and reporting method for each intervention’s process and proxy outcome measures.

6. Describe your process for reviewing and disseminating the results of your first test of change. How you will engage the necessary stakeholders and then plan to either abandon, alter or implement at a larger scale?

PY3Q2 (Jan. – Mar. 2024) Milestone:

1) Continuous Improvement Activity, Impact and Reporting (Predefined element of each milestone each PY beginning with PY3 (Oct. 2023 – Sept. 2024); required)

Provide a narrative explanation responding to the following questions indicating whether your hospital has maintained your original improvement strategy or adopted a new one.

1. Describe your next intervention cycle and what you plan to complete during the next reporting cycle.

2. Please describe your current continuous quality improvement strategy to improve or maintain the top 5 episodes impacting your Hospital Index Score.

3. Please describe how you plan to either continue with the current strategy or adapt it to achieve the desired outcome in your Hospital Index Score.

4. What and how do you plan to report out to key stakeholders regarding what was learned during the next cycle?

Appendix B -

Quality Improvement Resources – Hospital Transformation Program

Quality Improvement Resources

As part of the continuous learning and improvement milestones, hospitals implement and describe their strategies to evaluate or improve their performance. A quality improvement program includes activities, such as monitoring, analyzing, and improving the quality of processes, aimed at specific health outcomes in a healthcare organization. The following sections detail additional resources on conducting current state assessments and planning out the continuous improvement process:

Models for Improvement

Assessment Tools

Stakeholder Engagement Toolkits

Care Coordination and Service Delivery Best Practices

While these resources are not meant to be exhaustive, hospitals may consider this list to assist in overall quality improvement initiatives.

Models for Improvement

1. Resource: Practice Facilitation Handbook, AHRQ. Accessed online:

Key Takeaways: The Practice Facilitation Handbook is designed to assist in the training of new practice facilitators as they begin to develop the knowledge and skills needed to support meaningful improvement in primary care practices. The handbook consists of 21 training modules, each 30 to 90 minutes long with varying requirements for pre-session preparation for learners. Each module contains a Trainer’s Guide, which includes a checklist of materials, the learning objectives for the session, and a list of readings and activities designed to develop basic knowledge and skills.

Resource: Science of Improvement: How to Improve, Institute for Healthcare Improvement (IHI). Accessed online:

Key Takeaways: ​The Model for Improvement, developed by Associates in Process Improvement, is a simple yet powerful tool for accelerating improvement. This model has been used very successfully by hundreds of health care organizations in many countries to improve many different health care processes and outcomes. The source includes information to support such quality improvement activities as developing the AIM statement, establishing measures, completing a PDSA worksheet, spreading change, and more.

Resource: Model for Improvement, Qualis Health. Accessed online:

Key Takeaways: The Model for Improvement is a time-tested method of quality improvement that is simple, highly effective, and supports a bottom-up approach to change. This resources includes a fillable worksheet and a webinar.  

Resource: Worksheet for Plan-Do-Study-Act (PDSA) Cycle Planning, AHRQ. Accessed online:

Key Takeaways: This worksheet is for primary care staff to help plan a quality improvement (QI) Plan-Do-Study-Act (PDSA) cycle, outlining the QI goals and how the practice will try to reach them, as well as providing space for actual outcomes and analysis of next steps. 

Resource: QI Tips: A Formula for Developing a Great Aim Statement, National Institute for Children’s Health Quality. Accessed online:

Key Takeaways: This webpage includes guidance on how to write a great aim statement. The aim statement is a clear, explicit summary of what your team hopes to achieve over a specific amount of time including the magnitude of change you will achieve. The aim statement guides your work by establishing what success looks like.

Resource: Worksheet for Developing Your Quality Improvement Project, John Hopkins Medicine. Accessed online:

Key Takeaways: A worksheet that includes guidance in writing an aim statement, establishing measures, selecting changes, testing changes, and writing a project summary.  

Assessment Tools

1. Resource: Organizational Quality Assessment Tool, HEALTHQUAL. Accessed online:

Key Takeaways: Organizational structure is fundamental to quality improvement success, and involves a receptive health care organization, sustained leadership, staff training and support, time for teams to meet, and data systems for tracking outcomes. This Organizational Assessment is a tool to evaluate the structure.  

Resource: Registries for Evaluating Patient Outcomes: A User's Guide: 4th Edition, AHRQ. Accessed online:

Key Takeaways: The fourth edition of the AHRQ publication, "Registries for Evaluating Patient Outcomes: A User's Guide," is a reference handbook that provides best practices to guide design, operation, analysis, and evaluation of patient registries. It provides concise, practical information to help registries address technological and other changes. 

Resource: Population Health Resource Library, Advisory Board. Accessed online:

Key Takeaways: This resource library is a collection of care decision guides, scripting, governance documents, tools, risk assessments, and evaluation forms that are critical to the success of operating population health initiatives. This library includes ready-to-use resources you can download and tailor to optimize your initiatives.

Resource: The EveryONE Project Toolkit, American Academy of Family Physicians. Accessed online:

Key Takeaways: AAFP’s EveryONE Project promotes diversity and addresses SDOH to advance health equity in all communities. The initiative offers education and resources to help you advocate for health equity, promote workforce diversity, and collaborate with other disciplines and organizations to reduce harmful disparities. This toolkit offers strategies for use in one’s practice and community to improve patient health and help individuals thrive.

Resource: Screening for Social Determinants of Health in Populations with Complex Needs: Implementation Considerations, Center for Health Care Strategies. Accessed online:

Key Takeaways: This brief examines how organizations participating in Transforming Complex Care, a multi-site national initiative funded by the Robert Wood Johnson Foundation, are assessing and addressing SDOH for populations with complex needs. It reviews key considerations for organizations seeking to use SDOH data to improve patient care, including: (1) selecting and implementing SDOH assessment tools; (2) collecting patient-level information related to SDOH; (3) creating workflows to track and address patient needs; and (4) identifying community resources and tracking referrals.

Resource: Protocol for Responding to and Assessing Patients’ Assets, Risks, and Experiences (PRAPARE), National Association of Community Health Centers. Accessed online:

Key Takeaways: The Protocol for Responding to and Assessing Patients’ Assets, Risks, and Experiences (PRAPARE) is a national effort to help health centers and other providers collect the data needed to better understand and act on their patients’ social determinants of health. The PRAPARE assessment tool consists of a set of national core measures as well as a set of optional measures for community priorities. As providers are increasingly held accountable for reaching population health goals while reducing costs, it is important that they have tools and strategies to identify the upstream socioeconomic drivers of poor outcomes and higher costs. 

Resource: Community Health Assessment for Population Health Improvement: Resource of Most Frequently Recommended Health Outcomes and Determinants, CDC. Accessed online:

Key Takeaways: Effective planning and decision-making for improving the health of a community requires good information about current health status and factors that will influence that health status. This document identifies the metrics - the population health outcomes and important risk and protective factors - that, when taken together, can describe the health of a community and drive action. Selection of these metrics reflects the weight of professional and academic judgment over the past three decades.

Resource: Blueprint for Complex Care, The National Center for Complex Health & Social Needs. Accessed online:

Key Takeaways: The Blueprint for Complex Care is a guide for advancing the field of complex care. NCCHSN gathered diverse, far-reaching perspectives through reviews of published literature, interviews, surveys, and an expert convening to develop a comprehensive understanding of the current state of complex care, and to shape our recommendations for strengthening the field. It outlines the current state of complex care and includes recommendations for the future.

Stakeholder Engagement Toolkits

1. Resource: One Health Stakeholder Mapping Toolkit, USAID. Accessed online:

Key Takeaways: This toolkit will guide you through the process of planning and executing stakeholder mapping. In addition to a step-by-step process, this toolkit also contains helpful tips and important considerations in the text boxes placed throughout the document.

Resource: Stakeholder Mapping, Reproductive Health National Training Center. Accessed online:

Key Takeaways: Stakeholder mapping is a tool used to analyze and prioritize the engagement of stakeholders when you are planning to implement an initiative. This tool will help you and your team generate information about stakeholders to understand their interests and assess their influence in order to successfully implement and sustain a new initiative. 

Resource: Stakeholder Mapping, Center for Creative Leadership. Accessed online:

Key Takeaways: This stakeholder analysis will help identify an individual’s or group’s interest, position, or other special factors that should be considered during the decision-making process. 

Care Coordination and Service Delivery Best Practices

1. Resource: Care Coordination Model: Better Care at Lower Cost for People with Multiple Health and Social Needs, IHI. Accessed online:

Key Takeaways: This IHI white paper outlines methods and opportunities to better coordinate care for people with multiple health and social needs, and reviews ways that organizations have allocated resources to better meet the range of needs in this population. There is special emphasis on the experience of care coordination with populations of people experiencing homelessness.

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[1] See section IV. Milestone Requirements, for more detailed definitions of each functional area.

[2] For more information and helpful resources, please see Appendix B of this document.

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