Quality Improvement and Management in Healthcare

Domain 1: Data Collection, Stratification and Use

Desired Outcomes/ Measures

Intent of Measures

Operationalizing the Measure

Supporting Tools and Resources

Increase the collection, stratification and use of race, ethnicity, language (REaL) preference data.

Measure(s):

· Percent of workforce (staff and clinicians) trained regarding collection of self- reported REaL data.

· Percent of patient records with REaL data preference complete with opportunity for verification at multiple points of care, beyond just registration .

Data collection, stratification and use are essential to developing initiatives

to eliminate disparities in health outcomes. By collecting, stratifying and using REaL patient data along with other data points such as sexual orientation, gender identity, geographic location, veteran status and disability status, hospitals and health systems can better identify disparities

in patient

populations.

REaL data can be collected at various points of care or within the community. For example, Henry Ford Health System, an AHA 2020 Carolyn Boone Lewis Equity of Care Award Honoree, collects REaL data for more than 90% of patients, as a result of their “ We Ask Because We Care” campaign.

The data is stratified

and used to implement programs and improve outcomes in maternal and infant health, diabetes management and prevention, and other areas.

Addressing Health Care Disparities through Race, Ethnicity and Language (REaL) Data (2020)

This brief contains multiple resources and case studies of how

hospitals are using REaL data to better understand disparities in care.

URL: https://ifdhe.aha.org/addressing-health-care-disparities- through-race-ethnicity-and-language-real-data

Building an Organizational Response to Health Disparities (2020)

This resource features a compilation of reports, guides, toolkits,

training tools, webinars, books and articles regarding REaL data collection, stratification and use.

URL: https://www.cms.gov/About-CMS/Agency-Information/ OMH/Downloads/Data-Collection-Resources.pdf

Evaluation of the National Standards for Culturally and Linguistically Appropriate Services in Health and Health Care (National CLAS Standards) (2018)

This toolkit describes the National CLAS Standards and provides

meaningful and practical guidance on delivering culturally and linguistically appropriate services.

URL: https://minorityhealth.hhs.gov/assets/PDF/ Evaluation_of_the_Natn_CLAS_Standards_Toolkit_PR3599_ final.508Compliant.pdf

Framework for Stratifying Race, Ethnicity & Language Data (2014)

This guide provides a framework that allows hospitals and

health systems to stratify patient data to identify health care disparities. This framework consists of five steps.

URL: http://www.hpoe.org/Reports-HPOE/REAL-data- FINAL.pdf

Domain 1: Data Collection, Stratification and Use

Desired Outcomes/ Measures

Intent of Measures

Operationalizing the Measure

Supporting Tools and Resources

Increase the collection, stratification and use of data (sexual orientation, gender identity and disability status) among broader culturally diverse populations.

Measure(s):

· Percent of patient records with sexual orientation, gender identity and disability status data complete with opportunity for verification at multiple points of care, beyond just registration.

Atrium Health, AHA’s 2019 Carolyn Boone Lewis Equity of Care Award Honoree, developed a “ Demographic Data Wall,” which is used

to identify disparities in population health

measures and stratifies race, ethnicity, language, sexual orientation and gender identity data allowing clinical leaders to identify gaps in outcomes across populations.

Do Ask, Do Tell: A Toolkit for Collecting Data on Sexual Orientation and Gender Identity in Clinical Settings (2020) This toolkit provides specific sexual orientation and gender identity (SOGI) questions recommended by national LGBTQ organizations. It also describes how to collect these data in electronic health record (EHR) systems, how to use these data to support clinical processes, and how to train clinical staff to interact with LGBTQ patients in ways that are affirming and welcoming.

URL: https://doaskdotell.org/ehr/toolkit/

Ready, Set, Go! Guidelines and Tips For Collecting Patient Data on Sexual Orientation and Gender Identity (SOGI) (2018)

This guide helps hospital and health systems begin to

implement sexual orientation and gender identity (SOGI) data collection.

URL: https://www.lgbtqiahealtheducation.org/wp-content/ uploads/2018/03/Ready-Set-Go_2018.pdf

· Percent of workforce trained regarding collection of sexual orientation, gender identity and disability status for patients.

Washington Group Training on Disability Data Collection and Analysis (2015)

This training module aims to help understand the approach

and guiding principles of the Washington Group on Disability Statics and deepen knowledge of how to collect and analyze disability.

URL: https://hilearngo.handicap-international.org/ workspaces/176/open/tool/home#/tab/-1

Domain 1: Data Collection, Stratification and Use

Desired Outcomes/ Measures

Intent of Measures

Operationalizing the Measure

Supporting Tools and Resources

Identify and monitor the collection and use of patient social needs such as: food insecurity, housing stability, transportation

needs, education needs, social support, financial stability, employment, physical safety and other measures that are specific to your population’s needs.

Measure(s):

· Percent of patient records with social needs data complete with opportunity for verification at multiple points of care, beyond just registration.

· Percent of workforce trained regarding collection of social needs areas for patients.

Rush University Medical Center, an AHA 2019 Carolyn Boone Lewis Equity of Care Award Honoree, implemented social needs screening across the system and community settings

to identify risk factors associated with social needs (food insecurity, housing instability and transportation). For example, Rush works to mitigate the social determinants of health

(SDOH) through strategic partnerships that provide food delivery services to older adults.

PRAPARE Implementation and Action Toolkit (2019) Toolkit with resources, best practices and lessons learned to guide implementation, data collection and responses to social determinant needs. Contains standardized patient risk assessment tool as well as a process and collection of resources to identify and act on the SDOH.

URL: http://www.nachc.org/research-and-data/prapare/ toolkit/

Screening for Social Needs: Guiding Care Teams to Engage Patients (2019)

This tool helps hospitals and health systems facilitate sensitive

conversations with patients about their nonmedical needs that may be a barrier to good health.

URL: https://www.aha.org/toolkitsmethodology/2019-06- 05-screening-social-needs-guiding-care-teams-engage- patients

ICD-10-CM Coding for Social Determinants of Health (2018)

This brief provides an overview on ICD-10 coding for SDOH. It also features a list of AHA tools and resources for hospitals, health systems and clinicians that address the social needs and the SDOH.

URL: https://www.aha.org/system/files/2018-04/value- initiative-icd-10-code-social-determinants-of-health.pdf

Domain 2: Cultural Competency Training

Desired Outcomes/ Measures

Intent of Measures

Operationalizing the Measure

Supporting Tools and Resources

Implement and/or monitor cultural competency training amongst all employees and clinicians to ensure culturally responsive care within strategic planning

efforts, operations, yearly employee trainings, clinical care, social services and other

areas specific to your organization.

Measure(s):

Cultural competency and unconscious/ implicit bias trainings increase health care professionals’ understanding

of factors that are important to patients and

play a key role in care decisions. These trainings also provide

an opportunity for health care professionals to be mindful of unconscious and implicit biases that may occur when interacting with patients and team members.

Chatham Hospital, a member of the University of North Carolina Health System and an AHA 2020 Carolyn Boone Lewis Equity of Care Honoree, administers trainings

in communication, cultural competency and unconscious bias to employees. These trainings can be implemented yearly as part of continuing

education for employees.

Becoming a Culturally Competent Health Care Organization (2013)

This guide provides a high-level overview for becoming a

culturally competent health care organization and includes two case studies.

URL: http://www.hpoe.org/Reports-HPOE/becoming_ culturally_competent_health_care_organization.PDF

Building a Culturally Competent Organization: The Quest for Equity in Health Care (2011)

This guide explores the case for cultural competency and

provides guidance for health care leaders to build a culturally competent organization.

URL: https://www.aha.org/ahahret-guides/2011-05-11- building-culturally-competent-organization

· Percent of employees and clinicians who have completed cultural competency training.

· Percent of patient and family complaints related to cultural competency.

· Rate of patient satisfaction scores (HCAHPS, CG-CAHPS)

pre- and post- cultural competency training stratified by race, ethnicity and language preference.

Domain 2: Cultural Competency Training

Desired Outcomes/ Measures

Intent of Measures

Operationalizing the Measure

Supporting Tools and Resources

Increase unconscious and implicit bias training amongst all employees and clinicians to ensure that associations or attitudes that are reflexive do not alter perceptions, behaviors, interactions or decision-making.

Health Care organizations utilizing the Implicit Association Test (IAT) (2019)

This guide outlines four ways organizations can use the Implicit

Association Test to improve health equity and quality of care. URL: https://www.aonl.org/system/files/media/file/2019/04/ ifd-implicit-association-0419.pdf

Measure(s):

· Percent of employees and clinicians who have completed unconscious/implicit bias training.

· Rate of patient satisfaction scores (HCAHPS, CG-

CAHPS) pre- and post- unconscious/implicit bias training.

Domain 3: Diversity & Inclusion in Leadership and Governance

Desired Outcomes/ Measures

Intent of Measures

Operationalizing the Measure

Supporting Tools and Resources

Identify and act on opportunities to increase and foster diversity, equity and inclusion

in governance and leadership to reflect the community your organization serves.

Measure(s):

· Percent of governance members who represent diverse and inclusive backgrounds.

Increasing diversity, equity and inclusion in governance and leadership will support hospitals and health systems to reflect communities

they serve and most importantly to reduce health care disparities.

It also aides in increasing employee

engagement as well as promoting or attracting talent.

Northwell Health, an AHA 2019 Carolyn Boone Lewis Equity of Care Award Honoree, is

committed to diversifying their workforce through

a health care workforce development program. Women represent 72 percent of Northwell Health’s workforce with 44 percent serving in executive roles.

AHA’s Institute for Diversity and Health Equity Summer and Fall Enrichment Program

This program provides a 10-week paid internship for graduate students from diverse backgrounds. Students engage in experiential learning in hospitals and health systems across the country.

URL: https://ifdhe.aha.org/summer-enrichment-program- overview

Certificate in Diversity Management in Health Care The CDM program is the only comprehensive diversity certificate fellowship focused solely on health care and developed by diversity practitioners.

URL: https://ifdhe.aha.org/certificate-diversity-

management-health-care-cdm

· Percent of leadership who represent diverse and inclusive backgrounds.

· Percent of emerging leaders who represent diverse and inclusive backgrounds.

Recruiting for a Diverse Health Care Board (2020)

This article features best practices, processes and a sample board demographic/attribute profile matrix for recruiting diverse board members to better reflect community diversity.

URL: https://trustees.aha.org/recruiting-diverse-health- care-board

· Percent of diverse and inclusive employees who participate in employee resource groups.

Domain 3: Diversity & Inclusion in Leadership and Governance

Desired Outcomes/ Measures

Intent of Measures

Operationalizing the Measure

Supporting Tools and Resources

Local Hiring: Building the Pipeline to a Healthy Community Webinar (2018)

This webinar features resources for health systems to develop an inclusive, local hiring pipeline through creating more external community connections and internal career paths.

URL: https://www.healthycommunities.org/inclusive-local- hiring-building-pipeline-healthy-community

Henry Ford Health System Board Essential for Diversity (2017)

This blog describes how Henry Ford Health System’s executive diversity recruitment committee helps the organization stay committed to improving its talent pipeline, talent development practices, supplier diversity and other things essential to an inclusive culture.

URL: https://trustees.aha.org/articles/1300-henry-ford- health-system-board-essential-for-diversity

How and Why to Increase Board Diversity (2011)

This blog provides a case and steps for increasing board diversity and guiding questions for discussion.

URL: https://trustees.aha.org/articles/916-how-and-why-to- increase-board-diversity

Domain 3: Diversity & Inclusion in Leadership and Governance

Desired Outcomes/ Measures

Intent of Measures

Operationalizing the Measure

Supporting Tools and Resources

Increase transparency of data sharing with the

governance body through ensuring health equity, diversity and inclusion data-driven practices

are embedded within governance committees.

Measure(s):

· Percent of opportunities in which health equity, diversity and inclusion data are used to drive strategic decisions

with governance committees.

Hospitals and health systems can work to establish a health equity, diversity and

inclusion committee at the governance level and this committee could report data at a frequency deemed appropriate by the board. This committee may also operate as a subcommittee of the quality and patient safety committee of the board.

Trustee’s Guide to Population Health: Building New Foundations Linking Care with Community

This video series highlights six modules for boards to

view along with a discussion guide designed to prompt conversation and reflection.

URL: https://trustees.aha.org/trustees-guide-population- health-building-new-foundations-linking-care-community

Tackling Health Equity: A Two-Part Podcast for Trustees This two-part podcast discusses how hospital and health system boards across are advancing health equity in their communities.

URL: https://trustees.aha.org/tackling-health-equity-how- boards-can-do-it

Domain 3: Diversity & Inclusion in Leadership and Governance

Desired Outcomes/ Measures

Intent of Measures

Operationalizing the Measure

Supporting Tools and Resources

Assess and disseminate accountability and collaboration of executives responsible for driving health equity, diversity and inclusion initiatives and programs.

Measure(s):

· Percent of executives/ leaders who have explicit roles or goals related to driving health equity, diversity and inclusion practices

in their performance expectations.

Hiring health equity, diversity and inclusion professionals or aligning initiatives related to health equity, diversity and inclusion amongst existing executives is

a widely recognized practice for driving initiatives within the system, especially when outcomes are tied to executive compensation.

Best Practices for Building Leadership Diversity Programs (2020)

This guide highlights best practices for building leadership

diversity programs and case studies demonstrating these elements.

URL: https://ifdhe.aha.org/system/files/media/file/2020/08/ best-practices-for-building-leadership-diversity-programs. pdf

Domain 4: Strengthen Community Partnerships

Desired Outcomes/ Measures

Intent of Measures

Operationalizing the Measure

Supporting Tools and Resources

Increase, improve, strengthen and evaluate partnerships with community-based organizations, faith- based organizations, government agencies (including public health

departments), businesses, educational institutions and other organizations

to meet patients’ and communities’ needs.

Measure(s):

· Percent of community partners that align with strategic priorities of the hospital or health system or community health needs assessment.

Increasing, improving and/ or strengthening existing community partnerships can

help hospitals and health systems better implement community health strategies to improve care, create a network of sustainable partnerships

to address social needs and optimize

patient navigation strategies.

After analyzing data and evaluating community health efforts, hospitals and health systems can outreach to specific community-based organizations to help meet their needs toward achieving their community health goals. Hospitals and health systems can also utilize community partners to serve as key stakeholders to help plan targeted interventions

to improve community

health efforts. Evaluating the effectiveness of community partnerships can be assessed through partner engagement, teamwork and community responsiveness. For example, Henry Ford Allegiance Health in Michigan supports a unified community effort to identify emerging issues, take effective action and meet people’s needs during the pandemic.

Hospital Community Cooperative

This cooperative brought together 10 hospitals with community organizations to collectively address key SDOH in their communities and promote health equity. Case studies cover addressing homelessness, reducing cancer disparities and integrating social services.

URL: https://www.aha.org/center/population-health/hcc

Creating Cross-Sector Partnership That Succeed in Health Care (2020)

This easy-to-use guide features action steps for building trust,

gaining alignment, establishing processes and operationalizing a strategic plan.

URL: https://www.aha.org/system/files/media/file/2020/06/ AHA-Crosswalk-Presentation.pdf

Hospital-Community Partnerships to Build a Culture of Health: A Compendium of Case Studies (2017)

This compendium features case studies of effective and

sustainable partnerships between hospitals and the communities they serve.

URL: https://www.aha.org/system/files/hpoe/Reports- HPOE/2017/hospital-community-partnerships-case-study- compendium.pdf

Domain 4: Strengthen Community Partnerships

Desired Outcomes/ Measures

Intent of Measures

Operationalizing the Measure

Supporting Tools and Resources

A Playbook for Fostering Hospital-Community Partnerships to Build a Culture of Health (2017)

The playbook outlines ways to advance hospital-community

partnerships by using methods and strategies to develop and evaluate effective and sustainable collaborations.

URL: https://www.aha.org/system/files/hpoe/Reports- HPOE/2017/A-playbook-for-fostering-hospitalcommunity- partnerships.pdf

Community Health Assessment Toolkit (2017)

This toolkit offers a nine-step pathway for conducting a community health needs assessment and developing implementation strategies.

URL: ht tps://www.healthycommunities.org/resources/ community-health-assessment-toolkit