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The Quadruple Aim
Quadruple Aim

A Conceptual Framework

Improving the U.S. health care system requires four aims: improving the experience of care, improving the health of populations, reducing per capita costs and improving care team well-being. HITEQ Center resources seek to provide content and direction aligned with the goals of the Quadruple Aim

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Successful use of Health IT enabled Quality Improvement requires a strong organizational foundation. This includes understanding motivating factors as well as barriers, communicating the value of using Health IT to improve quality and outcomes, and building buy in and commitment throughout all levels of the organization. Resources in this section provide ideas and guidance on how to navigate this critical first step.

AirTable interactive PCMH Tracking and Support Tool

AirTable interactive PCMH Tracking and Support Tool

NCQA's Patient Centered Medical Home Recognition, Updated with Version 7 Standards in 2021!

HITEQ's AirTable interactive PCMH Tracking and Support Tool is intended to help health centers gauge track and support their transformation process for achieving PCMH recognition. Of course, completing this does not guarantee passing PCMH recognition process, it is intended to help you assess, plan, and monitor!

Health centers should reference requirements from NCQA to ensure a complete understanding of the requirements prior to using the HITEQ tool. Some helpful links are included below:

  • Download PCMH Standards and Guidelines from NCQA, be sure to download the year in which you will be seeking recognition!
    • When downloading the standards and guidelines, you will also get a folder of resources-- there is an Excel-based self-assessment in there that health centers may find helpful.
  • Read more about HRSA PCMH Support
  • Access the PCMH Toolkit for Health Centers from NCQA 
  • Review the PCMH Recognition Process
    • ​Be sure to submit your Notice of Intent to HRSA a couple weeks before you plan to enroll in Q-PASS.
    • Many EHR or population health vendors support PCMH recognition by having their functionality 'prevalidation' by NQCA, thereby giving their users 'transfer credit' to achieve a number of PCMH criteria. If your health IT vendor(s) are prevalidated then you will receive some transfer credits, meaning you will not need to provide additional evidence beyond proof that you use the vendor and its specific components. If your EHR vendor is prevalidated then reach out to the contact listed for their letter of prevalidation and information about transfer credits. 

Review process: The review of the evidence for PCMH recognition is done through an interactive, multi-meeting process rather than a single submission. There are three virtual reviews (often called virtual check-ins) over up to 12 months. Each virtual check-in will center around your NCQA reviewer reviewing criteria evidence you have submitted through Q-PASS. Any remaining virtual check-ins allow practices the opportunity to revise or resubmit previous criteria. Learn more about virtual check-ins here. 

Timeframe: Plan for 3 to 12 months to implement transformation processes. Most policies and procedures must be in place for 3 months in order to be meet the requirements for recognition. Recognition needs to be completed within 12 months of enrollment. PCMH now requires annual reporting.


HITEQ AirTable interactive PCMH Tracking and Support Tool - Updated to align with Version 7 of Standards and Guidelines!

HITEQ's interactive AirTable PCMH Tracking and Support tool can be accessed for free here.

To use this tool for yourself, make a copy of the Master PCMH Support tool, and duplicate the base and save it to your own free AirTable account (click here to set one up and check out this video for an overview). More information on duplicating the AirTable to save for yourself can be found here.


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Intended AudienceHealth Center Leadership, Care teams, Quality Improvement Staff


This resource collection was compiled by the HITEQ Center staff with guidance from HITEQ Advisory Committee members and collaborators of the HITEQ Center.