• The diagram below illustrates the Guide’s focus on helping health centers adapt to the intensifying performance improvement imperatives they face (pyramid tip). The Guide does this by providing strategies and tools to help analyze and improve critical workflows and information flows (layers beneath the pyramid tip).
• For an introduction to the Guide that was presented as part of a webinar, see here (the pertinent discussion is between these times/markers on the recording: 43:46-58:44)


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• Everyone in a health center has a stake in successful quality improvement, and many different staff roles might be the first to encounter this Guide. For initial review, roles including QI/clinical/data/operations team members or leads are likely most appropriate. To drive substantial improvements, these tools and strategies should then be shared and used more widely with pertinent health center team members responsible for the organization’s clinical, operational and other activities key to successful QI. A QI team is typically the driving force behind the cross-stakeholder work outlined in this Guide. (For more on building QI teams, see here.)  
• Various organizations that support (or depend on information from) QI efforts within health centers can also become better QI partners by understanding and applying the strategies and tools in this Guide. These partners include:  
  • Support organizations such as HCCNs, PCAs, payers and others  
  • Organizations that supply health centers with technology that play a critical QI role, such as EHR and population health software vendors   

• Payment reforms seek to transform healthcare to achieve 3 key goals (often referred to as the ‘Triple Aim’ or ‘Three-part Aim’):  
  • Better care for individuals  
  • Better health for populations  
  • Lower cost  

Key stakeholders assert that to achieve these goals, it’s important to also improve work life for clinicians and staff. Adding this dimension to the 3 goals above is referred to as the ‘Quadruple Aim.’

• This shift to value-based payment is driven by both the public and private sector, and directly affects FQHC financial health. For example, the Merit-based Incentive Payment System is transforming Medicare by tying provider payments to performance on quality measures, clinical performance improvement activities, costs, and use of health IT. Medicaid and private payers are also driving transformation through increasing use of value and/or risk-based contracts that require successful QI.  
• Many health centers already use robust QI approaches (such as those outlined in this quality improvement primer) as part of UDS measure reporting and improvement efforts. Many likewise leverage powerful health IT capabilities (such as population health management tools including disease/condition registries; EHR tools to enhance ordering, documentation and data review; and SMS texting with patients) in this QI work. The drivers noted above, however, require increasingly sophisticated and effective approaches to health IT-enabled Quality Improvement (health IT/QI). (Other closely related terms include eCQI (used by ONC and CMS) and CDS-enabled QI (CDS/QI), so those are terms referenced in some materials in this Guide as well).  
• The framework, strategies, and tools in this Guide can help your organization enhance its health IT/QI approach and results. In addition to the benefits this delivers in addressing payment drivers noted above, it can also improve staff satisfaction by streamlining care workflows, improve health center business strength by avoiding duplicated efforts and decreasing costs, and improve patient satisfaction by meeting their care needs more efficiently and effectively.

The Essential CDS/QI Worksheet is a core resource for analyzing and improving target-focused care. A preliminary workflow analysis and enhancement brainstorming exercise can be accomplished in as little as an hour by one or more health center staff reviewing the tutorial and using this worksheet. More comprehensive QI projects addressing all the steps in the pathway typically take up to a year or longer. In any case, the QI work should be a collaborative process involving all stakeholders within the health center, and ideally key partners as well (such as the HCCN or PCA working with the health center, and their EHR and population health software vendors).

• Scanning these evidence-based strategies and tools will give health centers and their partners a sense for whether/how they can augment your current QI work. Users can then apply these approaches and resources with their team to the depth that would be most valuable and feasible (given available time and resources). For a “quick win” exercise to identify potential high-yield, target-focused care process improvement opportunities, see this presentation Health IT Enabled QI: A Guide to Improvement. For additional ideas on introductory QI exercises, see the brief slide set, Five Minutes of Quality Improvement: Tackling Small QI Tasks. Contact the HITEQ Center for support on implementing the QI approach in this Guide.  
• Strategies and tools from this Guide in action:  
  • CDS Learning Session ‘Quick Win’ Exercise: Sixteen community health centers in New Orleans conducted a valuable ‘Quick Win’ exercise using an earlier version of the Essential CDS/QI worksheet (see here for further details about this exercise and results).
    • In this activity, small teams from each health center (e.g., a clinician and administrator) were given a 20-minute overview of several key health IT/QI concepts and tools outlined in this Guide (the broad CDS definition, CDS 5 Rights framework, and an earlier version of the CDS/QI Worksheet, each of which is explained later in this guide).  
    • Immediately following, for just 20 minutes, each team independently used an enlarged version of the Essential CDS/QI Worksheet on a flip chart to document key workflows and information flows for their improvement target (e.g., lipid or diabetes control). During this time, they also brainstormed refinements to one or more of the CDS 5 Rights “who, what, when, where, how” dimensions.  
    • During the report-out following this brainstorming, health centers noted excitement about trying these enhancements to improve care processes and outcomes related to their target.  
  • Using the Guide for Yearlong, Target Focused QI: Other QI projects have used the strategies and tools outlined in this Guide in yearlong, target focused QI efforts and have realized benefits for quality improvement and care processes, and increasingly in outcomes. In many cases these efforts involved collaboration with HCCNs and/or HIE/EHR/population management software vendors. These initiatives include:  
    • A network of health centers in CA working on blood pressure control. The lead health center in this project, Petaluma Health Center, is a 2015 Million Hearts Hypertension Control Champion. View project report slides.  
    • Improving blood pressure and diabetes in control in Trenton, NJ that included a health center among the participants. View project report slides .  
    • Health centers in several states working on hypertension diagnosis and management (several of which are achieving aggressive blood pressure improvement targets). Link to project overview.

• Cultivate a shared commitment within your team to improving care delivery and results, including fully leveraging health IT capabilities. Successful QI efforts deliver a ‘win-win-win’ for patients and their care teams, as well as broader organizational goals. This infographic and report examines characteristics of health centers that have achieved high clinical, financial and operational performance.

• Ensure that key foundations for successful QI efforts are in place. For example, leadership and team support; stable well-utilized health IT systems such as EHR, population management software; bandwidth and capacity for the QI work; and shared understanding about QI goals and processes. 
• For some specific resources around ensuring key foundations, see here for Motivating Factors for Engaging in Health IT-enabled QI, and Engaging the Data Creators. 
• Also, see here for A Buyer’s Guide to Business Intelligence Tools. 
• Here is a tool to assess analytics capability in health centers, that also provides insights into the nuance of working with data and building a data-driven culture. A brief video introduction to using this tool is here.  
• Ensure access to and validate data that will underpin the QI efforts. For example, ensure that EHR and/or population management software can deliver needed data and reports, and produce the same values for targeted performance measures and related data as manual review/calculation. See here for questions to consider to help determine if you are fully utilizing your EHR capabilities for population management, and if additional tools are needed. This checklist can help with data validation and interpretation (a webinar that includes an introduction to this checklist is here, and the pertinent discussion is between these times/markers on the recording: 8:15- 43:45). See here for a basic auditing tool (Excel Template) for data reports, and a case study on data validation.  
• Identify and address barriers to collaboration on effective process improvement (such as stakeholder conflicts or conflicting goals) among all concerned, including providers, care delivery and quality staff, partners (e.g., health IT vendors), and patients.  
• Layer the approach and tools outlined below onto your general QI methodology, as well as any current target-focused QI activities. If no QI framework is in place, consider using the approach outlined in this Guide as a starting point, and build that out further through options such as those provided in the primer, Continuous Quality Improvement (CQI) Strategies to Optimize your Practice.

• ‘Clinical Decision Support’ (CDS) is a key underpinning for the QI approach outlined in this Guide, but its meaning here might be different than what you have in mind (especially if ‘alert’ figures prominently in your definition). In this Guide, CDS is defined as a process for improving health-related decisions and actions with pertinent knowledge and patient information to enhance health and care delivery. Under this definition, CDS is about supporting care decisions and actions, ideally in a manner that makes the appropriate decisions and actions the easy ones to execute. That is, facilitating workflow not interrupting it – as alerts often do. There are many different ways to provide this support (e.g., CDS intervention types). See the CMS CDS tipsheet page for more details, including example CDS intervention types (e.g., order sets, focused patient data summaries, documentation templates).  
• The CDS 5 Rights framework is a best practice QI approach (recommended by CMS in the tipsheet above) to support decisions and actions that drive performance targeted for improvement. It asserts that optimizing care processes and outcomes requires getting the right information to the right people in the right formats through the right channels at the right times (see figure below). The tools and approaches outlined in this Guide help organizations implement this framework and enhance the contributions, experience and results for those involved in care delivery.  

• The Essential CDS/QI Worksheet (see excerpt images below) is a core health IT/ QI tool best used for initial efforts to map care processes and reveal potential enhancements. That is, to document and analyze target-focused information flows and workflows, and to brainstorm improvement opportunities (see figure with excerpts from this worksheet below). The tutorial that follows provides guidance and examples on how the worksheet can be used. to streamline and enhance care processes. (The Enhanced CDS/QI Worksheet,  pointed to below under the bullet titled 'For a deeper dive into health IT/ QI Foundations', is a more robust but more complicated tool for those already skilled in using the Essential CDS/QI Worksheet)
  • View the Tutorial on how to use the Essential CDS/QI Worksheet  
  • See a completed Outpatient Essential CDS/QI Worksheet Example that uses this tool to illustrate the workflows and information flows that produced very high levels of blood pressure control in a small practice: Ellsworth Hypertension QI Case Study Note: this example used an earlier version of the Essential CDS/QI Worksheet that did not contain the ‘Foundational Activities’ section. This case study was originally developed for ONC and is also posted on here on healthit.gov.
• Attend to key QI project success factors:  
  • Focus on People, Process, and Technology (in that order), recognizing that engaging everyone involved is critical for success.  

• Focus on ‘the most important things’ when selecting improvement targets, opportunities to enhance care processes for the target, and activities to ensure successful implementation of those process changes.  

• QI activities involve a chain of stakeholders including health center QI leads, clinicians and staff, and ultimately patients. As the QI project unfolds and each of these groups is touched by the effort, seek to escalate engagement, insights, and momentum toward goals.

• For a deeper dive into health IT/QI foundations, consider these resources:  
  • Tasks and Key Lessons from each chapter in “Improving Outcomes with Clinical Decision Support, and Implementer’s Guide, 2nd Edition.” These bulleted lists provide detailed guidance on successful CDS-enabled QI programs and interventions.  
  • Enhanced CDS/QI Worksheet: Similar in concept to Essential version, but with additional space to document/review optimal care activities for the target, and the individual CDS 5 Rights dimensions for the current state. Consider using only after you are comfortable with the Essential CDS/QI Worksheet version (Note: this example used an earlier version of the Enhanced CDS/QI Worksheet that did not contain the 'Foundational Activities' section.  
    • View the Tutorial on how to use this Enhanced Worksheet [download the PDF and run locally for best results].  
    • See a completed Outpatient Example: CHC Inc. hypertension QI case study  
  • White papers and guides on HIT-CDS/QI:  
    • Qualis Health: Integrating Clinical Decision Support Tools into Ambulatory Care Workflows for Improved Outcomes and Patient Safety  
    • AHRQ: Using Health Information Technology to Support Quality Improvement in Primary Care  

• Consider targets associated with business imperatives, such as UDS reporting (especially for conditions where the health center is under-performing), and value-based payment initiatives from the private sector and CMS (e.g., the Quality Payment Program which is radically overhauling Medicare payments to clinicians, and related value/risk-based payment models for Medicaid). Seek QI synergies with pertinent health center initiatives such as PCMH recognition and HRSA Health Center Quality Improvement Grant Awards.  
• Examine local performance gaps and improvement opportunities when reviewing payment drivers noted above and selecting targets.
  • See the figure below from the HIMSS guidebook on improving outcomes for examples of local factors to consider in selecting targets for quality improvement intervention.

Image Reference: Osheroff JA, Teich JM, Levick D, et. al. Improving Outcomes with Clinical Decision Support: An Implementer’s Guide, 2nd ed. Chicago: HIMSS. 2012.  

• Measure and understand your baseline performance on your target(s).
  • The CMS/ONC eCQI Resource Center has information about quality measure specifications for providers. The Checklist for Analyzing Performance Measure Data has detailed information about validating and interpreting these data.

• Use the CDS/QI worksheet to help examine patient-specific and population management information flows and workflows, as well as foundational activities such as EHR configuration, policies, staff training, etc., that are producing sub-optimal performance on the target. For example, if the QI target is hypertension control, consider the current status of staff competency and training on measuring blood pressure appropriately (foundational activities); registry use to identify and recall patients with poorly controlled blood pressure (population management activities); and optimizing pre-visit huddles, order set use, and patient engagement/care plan adherence tools (patient-specific supports).  
  • Walk through the care process (with special attention to the patient experience) and document results in the Essential CDS/QI Worksheet.  
  • Engage all care team members in the workflow/information flow and improvement analysis– including the patient, if possible.  
  • If you are comfortable with the Essential CDS/QI Worksheet, consider using the Enhanced CDS/QI Worksheet instead of, or in addition to, the Essential Worksheet for a deeper dive into the ‘optimal state’ and the details of each CDS 5 Rights dimension.  
• Analyze this current state (“what is?”) to identify opportunities to improve target-focused information flow, workflow and results; i.e., to better address the CDS 5 Rights for the target. Document these potential enhancements in the CDS/QI Worksheet. (Review the tutorial for the worksheet you are using (i.e., essential vs. enhanced) for guidance.) For example, consider enhancements such as:  
  • documentation templates, and related workflows for completing them, that make it easier to identify patient barriers to adherence with the care plan (foundational activity);  
  • text messages and/or personal calls to patients to decrease no-show rates (patient-specific support), and  
  • performance dashboards (and related conversations) to share target measure results with teams and clinicians as a springboard for brainstorming strategies to accelerate improvement (population management activities).  
• Review evidence-based best care practices for the target (“what should be”)  
  • Consider available best practice ‘change packages’ for the target:  
    • For hypertension management, the CDC Hypertension Control Change Package presents change concepts, change ideas, and proven tools that outline ‘what should be’ best practices in categories that correspond to the categories on the CDS/QI Worksheets (i.e., Foundation Activities, Population Management, and Patient-specific Supports (and its subcomponents)).  
    • For detecting hypertension that may be ‘Hiding in Plain Sight’ in health centers and diagnosing hypertension so it can be managed appropriately to reduce heart attacks and strokes, see this similarly-structured “HIPS” change package.  
    • For improving colorectal cancer screen rates as called for in the national "80% by 2018" campaign, see this similarly-structured change package  
  • Examine other case examples and best practices for successful target-focused care strategies (e.g., QI case studies published by ONC, and other resources):  
    • Case examples on hypertension control:  
      • Ellsworth Medical Clinic hypertension QI case study: narrative discussion and details presented in an earlier version of the Essential CDS/ QI Worksheet.  
      • CHC, Inc.² hypertension QI case study: narrative discussion and details presented in an earlier version of the Enhanced CDS/QI Worksheet. This study was originally developed for ONC and is also posted here on healthit.gov.  
      • EHR Innovations for HTN Challenge results  
    • Colorectal cancer screening recommendations for community health centers from the Oregon Primary Care Association and the National Colorectal Cancer Screening Roundtable   
    • Case example on tobacco use screening and smoking cessation support at Miramont Family Medicine. This case study was originally developed for ONC and is also posted here on healthit.gov  
• Define potential workflow and information flow enhancements for the target (“what could be here?”) by combining ‘top down’ approaches (i.e., starting from ‘what should be?’ best practices) and ‘bottom up’ approaches (i.e., improvement opportunities that emerge from the “what is?” analysis with stakeholders).  
• Prioritize identified enhancements to implement:
  • Identify several enhancements that are most likely to deliver the greatest benefit in the shortest time with the least effort for initial implementation (that is, use the “low hanging fruit” approach – see prioritization tools such as this Prioritization Matrix). Give special attention to changes that could yield strong benefits across multiple targets, or that appear especially promising for strengthening critical workflows and information flows (e.g., related to patient engagement, registry use to identify and close care gaps, pre-visit planning, and efficiently executing evidence-based care plans).

• Use a QI methodology (e.g., PDSA cycles) to engage frontline staff and other key stakeholders in care processes and results to design, implement and evaluate the prioritized changes. Be sure to do this work with all the stakeholders and not to them (i.e., seek and act on team members’ (and patients’) input and feedback throughout the process).

• Be ready to modify patient care and quality improvement activities, CDS intervention details (across any of the CDS 5 Rights dimensions), and other parameters if needed as improvement cycles unfold.

• Monitor implementation activities with structured tools that help you document and manage who’s doing what when, as well as the results.

• Sample monitoring tools:  
  • Worksheets from Chapter 8: Putting Interventions into Action and Chapter 9: Measuring Results and Continuously Refining the Program in Improving Outcomes with Clinical Decision Support: An Implementer’s Guide. Second Edition” provided with permission from HIMSS  
  • IHI PDSA Worksheet: http://www.ihi.org/resources/Pages/Tools/PlanDoStudyActWorksheet.aspx  
• Validate and analyze performance measure data to make sure that the results are accurate, and that the team understands what they mean and what to do about them. This checklist can support this process.

• As the scheduled initiative concludes, review the QI project with stakeholders to better understand what worked well, what could have been done better, and what useful tools were created.  
• Apply this learning and these results to strengthen ongoing ‘maintenance’ efforts on the current target and other target-focused QI initiatives.  
  • Transition target-related QI efforts from ‘project-focused’ to ‘this is how we do business.’ Build in ability to detect the need for, and implement, tweaks to target-related processes when required because of changes to people/processes/technology.  
  • Incorporate proactively the insights and results from each QI project into subsequent QI initiatives. Although a particular target-focused QI project may be time-limited, the QI and clinical teams should remain alert for ways to continually improve care across all targets. For example, learning from a QI project might indicate opportunities to more broadly modify clinical and quality work and roles, as well as health IT configurations (with this latter triggering feedback to developers about broadly needed enhancements).  
• Contact the HITEQ Center if you are interested in sharing results further with your peers, and opportunities for health IT/QI peer learning.  

• The content in this Guide is an adapted and expanded version of care process improvement guidance posted on healthit.gov . That original material was developed by Jerome Osheroff, MD, TMIT Consulting, LLC in collaboration with ONC and Deloitte, and this version on HITEQ was also developed by Osheroff/TMIT in collaboration with JSI and others.  
• Guide Reviewers (Individuals below each provided helpful feedback on an earlier draft of this guide; those marked with * provided particularly detailed feedback that led to substantial enhancements):
  • Sheila Allen, MPH; Chief Compliance and Quality Officer, HealthNet, Inc.
  • *Daren Anderson, MD; Director of the Weitzman Institute and VP/Chief Quality Officer of Community Health Center, Inc
  • Sasha East, MD; Internal Medicine Resident, Robert Wood Johnson University Hospital
  • Renu George, MD; Internal Medicine Resident, Robert Wood Johnson University Hospital
  • *Meg Meador, MPH, C-PHI;  NACHC Director of Clinical Integration and Education
  • *Jillian Maccini, MBA; Consultant, JSI
  • Laura Methvin, MD; Internal Medicine Resident, Robert Wood Johnson University Hospital
  • Alan Mitchell; Program Director, Performance Improvement, Primary Care Development Corporation (PCDC)
  • * Nivedita Mohanty, MD; Director of Evidence-based Practice, Alliance of Chicago
  • Rick Reifenberg MD, FAAP, FACP, Associate Medical Director, HealthNet Inc.  
• Refinements to material on this page to enhance its use and usefulness are planned based on user feedback (HITEQinfo@jsi.com).  
• Recommended citation for this Guide: Osheroff, Jerome A. "Improving Care Processes and Outcomes in Health Centers. HRSA Health Information Technology, Evaluation and Quality Center. JSI. 9 Sept. 2016. Web. 21 Nov. 2016