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 Toolkits36

D. Care Coordination and Service Delivery Best Practices 37

I. Background, Instructions and Timeline
A. 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:

 Reducing Avoidable Hospital Utilization;

 Core Populations;
 Behavioral Health and Substance Use Disorder Coordination;
 Clinical and Operational Efficiencies;
 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.

B. 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

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 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.

 September 1 – First day Implementation Plans may be submitted

 1 month time period / September 1 – September 30 - Implementation Plan
Submission Period (Implementation Plan Deadline: September 30)
 20 business day period / October 1 – October 28 – Review Period: Twenty business
day Department review period
 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
 10 business day period / November 15 – November 29 – Final Review Period: Ten
business day scoring period for revised and resubmitted Implementation Plans
 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.

C. 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:

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  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.
 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.

 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.
 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.
 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.

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 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 Points of Contact II.A.1.a. Pass / Fail
Implementation II.A.1.b.
Overview Role of Governance Structure II.A.2. Pass / Fail

Table 2: Approach to Intervention Implementation

Section Component Question Scoring
Section III.A Reporting Hospital III.A.1. Prepopulated
Overview of Name of Intervention III.A.2. Prepopulated
Intervention
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 Milestones III.B.1. 1-3
Intervention III.B.2.
Milestones III.B.3.

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II. 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.

A. 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.

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 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.

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III. 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.

A. 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 Intervention- Role will lead Name of Key Deliverables /

Individual Specific Role implementation Organization Responsibilities
of the
intervention

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 (Y/N)
Individual 1 ED Director Project lead Y Hospital Conduct or organize
and/or Pain training, lead
Specialist weekly team
meetings, track
data and determine
next steps in
improvement
efforts, provide
coaching and
feedback to ED
providers and staff
Individual 2 Hospital Lead quality N Hospital Run rapid
Quality improvement improvement
Director/ activities events, suggest
coordinator changes based on
and/or HTP data, support ED
Coordinator director in
developing
materials
Individual 3 Executive Remove N Hospital Bring budget and
Sponsor barriers to resource constraints
implementation relating to this
activities initiative to
executive
leadership
meetings, escalate
issues, review
progress
Individual 5 IT/Data Lead IT/data N Hospital Implement IT/data
Coordinator requests related initiatives,
escalate delays to
executive sponsor
Individual 6 ED Educator/ Education N Hospital Develop training
Trainer materials and train
all staff, provide
coaching throughout
intervention
Individual 7 Patient and Consultant N Hospital Consult on training
Family Liaison materials and
education, provide
coaching to staff
throughout
intervention,
connect with
community
partners, attend
team meetings

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 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.

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 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.

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

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 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:

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 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

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 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.

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 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.

B. 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).

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 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 Process 1. Completed gap
the Opioid Safety Gap Assessment assessment that
and is utilizing findings to prioritize highlights key areas of
and plan efforts for the initiative. focus.
2. Copy of
prioritization plan.
All project champions have been People 1. Signed commitment
identified and onboarded forms from all
including: champions will be
 ED medical director included along with
 ED nurse director their project roles.
 Pharmacy director
 Quality champion
 Communications and
marketing champion
 IT/data champion
The project leadership and Process 1. Meeting agenda

18 | HTP Implementation Plan Template and Milestone Requirements

 champions have read the Colorado and meeting minutes
ACEP 2017 Prescribing & Treatment from the review
Guidelines and reviewed the session
details of the guidelines with one
another.
The project team has specified the People 1. Completed project
roles, responsibilities, and scope of plan that includes
work for each project team scope, roles, and
member and champion and has responsibilities.
distributed this plan to all 2. Copy of email sent
necessary personnel. to project team
detailing this
information.
The project team has reviewed Technology 1. A copy of the test
with the data champion reports reports and/or
that will need to be created and screenshots of the
the champion is testing the reports reports being built.
to ensure they meet the needs of
the project team.
The data champion has worked Technology 1. Copy of report sent
with CHA to ensure data being to CHA.
submitted to them is 2. Screenshot of CHA
comprehensive. The project team dashboards.
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 People 1. Completed
champion has worked with the communication plan.
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

19 | HTP Implementation Plan Template and Milestone Requirements

 changes and/or updates to the
initiative.
The project team has created a People 1. A training calendar
training and education process for showing who is being
full time faculty and staff that trained, when, and on
includes: what topic.
 Education on trigger point 2. Copies and/or
injections/IV nerve blocks screenshots of
 Stigma/bias training educational materials
 Patient satisfaction and including slide decks,
communication skills handouts, videos, etc.
 Messaging to patients/families
 ALTO administration and side
effects (for nursing and
pharmacy staff)
The project team has developed an People 1. A plan describing
orientation and education process the process for
for locum tenens ED providers and educating staff who
float pool nurses to ensure are not in the ED
sustainment of ALTO guidelines. regularly or employed
directly by the
hospital.
The project team and patient and Patient Engagement 1. Educational
family liaison have developed materials including
educational materials for patients slide decks, handouts,
and families and a process for videos, etc.
distributing these materials. These 2. Agenda item
materials have been approved by discussing these
our hospital’s patient and family materials at a PFAC
engagement council (PFAC). meeting.
3. A description of the
process and workflow
for printing and
storing these
materials.
4. A copy of the
clinician workflow

20 | HTP Implementation Plan Template and Milestone Requirements

 that includes the
distribution of these
materials.
The project team has reviewed Process 1. Copies of updated
high-risk policies to ensure policies.
medications such as Ketamine and 2. Agenda from P&T
IV drip lidocaine can be given for noting the discussion
pain in the ED. The project team around policies.
has 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 Process 1. Documentation
medication approval and stocked showing approval of
medications for use in the ED for medications.
the following medications: 2. Documentation of
 Ketamine pain dose IV and drip appropriate stock of
– IV push may require less medications.
concentrated product (50mg/5
ml prefilled syringes)
 Lidocaine IV and patches
 Capsaicin topical
 Gabapentin
The IT champion has updated the Technology 1. Screenshots of
smart pump medication libraries to updated libraries
reflect offered medication reflecting new
therapies including standard drip therapies.
concentration, dosages and
maximum dose limits.
The project team, along with the Technology 1. Screenshots of the
IT champion, has created an ED new ALTO order set.
ALTO order set to be included in
the hospital Electronic Health
Record (EHR).
The IT/data champion has created Technology 1. Copy of data

21 | HTP Implementation Plan Template and Milestone Requirements

 all data reports and conducted a reports.
test run of the reports to ensure all
fields populate correctly (e.g.,
dates, medications, doses, dosing,
units, etc.).
ED staff have completed training People 1. Attendance list for
for this initiative. trainings.
Patient education materials were Patient engagement 1. Raw count of
piloted to ensure they number of patients
appropriately engaged patients. reached.
2. Feedback from the
pilot.
The project team held a final People, process, 1. People: percentage
planning meeting including beta technology, patient of employees trained
testing the launch, ensuring each engagement and copies of any
of the following is complete: communications that
 All patient resources went out to staff
incorporated feedback from the and/or patients
pilot, are completed and are reminding them of the
being handed out to patients initiative and new
o Handouts made processes.
o Handouts printed and
placed in central 2. Process: final
location/pt. discharge versions of ALTO
materials, etc. order sets, clinical
o Posters made pathways, and
o Posters hung in ED (if policies that have
applicable) been updated.

 All clinical processes have been

3. Technology:
updated, clearly communicated
screenshot of first
to staff, and are now being
monthly data report.
utilized
o Order sets
4. Patient
o Pain pathways
Engagement: photos
o Policies
of posters hanging (if
 All team members are trained,
applicable) and
ready for launch and there have
photos of the patient

22 | HTP Implementation Plan Template and Milestone Requirements

 been no key turnover issues for materials in the ED.
the team
 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 Continuous improvement 1. Completed plan for
quality improvement, the project performance
team has selected a performance improvement for the
improvement strategy such as the ED ALTO initiative
Institute for Healthcare that specifically
Improvement (IHI) Plan-Do-Study- details what method
Act (PDSA) model for change and of quality
has detailed a strategy for using improvement will be
this method during the continuous used.
improvement phase.
The project team has continued to Continuous improvement 1. Agendas from
monitor performance and make weekly huddles and a
updates to protocols and processes summary of changes
by holding weekly huddles. These made based on
huddles include a review of the discussions at the
data so far including ED ALTO order huddle will be
set usage and feedback from provided.
patients and staff. Each huddle 2. Raw counts of ED
allows for slight changes to be ALTO order set usage.
made to ensure staff is 3. Documented
comfortable with this initiative and written or oral
the appropriate patients are being feedback from staff
reached. and patients.
The project team, led by the Continuous improvement 1. Summary of PDSA
quality improvement champion, activities including
completed a Plan-Do-Study-Act changes made, results
(PDSA) cycle to continue to of those changes, and
improve upon efforts utilizing the any updates to

23 | HTP Implementation Plan Template and Milestone Requirements

 IHI model for improvement. This processes or
PDSA cycle focused on health workflows.
equity, reviewing data for this
measure by race/ethnicity to
target and reduce any disparities.
The project team, led by the Continuous improvement 1. Summary of PDSA
quality improvement champion, activities including
completed a second and distinct changes made, results
Plan-Do-Study-Act (PDSA) cycle to of those changes, and
continue to improve upon efforts any updates to
utilizing the IHI model for processes or
improvement. workflows.
The project team, led by the Continuous improvement 1. Copy of the patient
patient and family liaison, survey and a summary
conducted a survey of patients to of results.
determine satisfaction and 2. Description and
engagement in this initiative. supporting evidence
Results of the survey were used to of work completed in
make updates to the ED ALTO response to the
initiative. 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.

24 | HTP Implementation Plan Template and Milestone Requirements

 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.

IV. Milestone Requirements

A. 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

25 | HTP Implementation Plan Template and Milestone Requirements

 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.

B. 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):

1. “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.

2. “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).

26 | HTP Implementation Plan Template and Milestone Requirements

 3. “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.

27 | HTP Implementation Plan Template and Milestone Requirements

 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.

28 | HTP Implementation Plan Template and Milestone Requirements

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)
Q2 Impact Milestone: Impact Milestone: N/A N/A
Jan -
March Y/N; Y/N;
Milestone Milestone
Functional Area(s) Functional Area(s)
Planning and and Description and Description
Implementation
Phase Q4 Impact Milestone: Impact Milestone: N/A N/A
Milestones July -
Y/N; Y/N;
Sept

Milestone Milestone
Functional Area(s) Functional Areas
and Description and Description
Q2 N/A N/A Milestone Milestone
Jan - Description Description
Continuous March
Improvement
Phase Q4 N/A N/A Milestone Milestone
Milestones July - Description Description
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).

29 | HTP Implementation Plan Template and Milestone Requirements

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)

Impact Impact N/A N/A

Milestone: Y/N; Milestone: Y/N;
Q2
Jan -
Milestone Milestone
March Functional Functional Areas
Planning and Area(s) and and Descriptions
Implementation Descriptions
Phase
Impact N/A N/A N/A
Milestones
Milestone: Y/N;
Q4
July -
Milestone
Sept Functional
Area(s) and
Descriptions

Q2 N/A N/A Milestone Milestone

Jan- Description Description
Continuous
March
Improvement
Phase
Q4 N/A Milestone Milestone Milestone
Milestones
July -
Description Description Description
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).

30 | HTP Implementation Plan Template and Milestone Requirements

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 Impact Milestone N/A N/A N/A

Implementation
Phase Milestones

Q2 N/A Milestone Milestone Milestone

Jan - Description; Description; Description;
March
Continuous Continuous Continuous
Improvement Improvement Improvement
Activities, Impact Activities, Impact Activities, Impact
and Reporting and Reporting and Reporting

Milestone Milestone Milestone Milestone

Continuous Description; Description; Description; Description;
Improvement
Phase Milestones Current State Current State Current State Current State
Assessment; Assessment; Assessment; Assessment;
Q4
July -
Stakeholder Continuous Continuous Continuous
Sept Assessment; Improvement Improvement Improvement
Activities, Impact Activities, Impact Activities, Impact
Continuous and Reporting and Reporting and Reporting
Improvement
Activities, Impact
and Reporting

31 | HTP Implementation Plan Template and Milestone Requirements

C. Milestone Development and Review Process
HTP participants are required to create milestones that demonstrate progress toward
intervention goals. When proposing milestones, hospitals must list the supporting documentation
it plans to submit for each milestone. For Planning and Implementation milestones, supporting
documentation must be submitted specific to each applicable functional area.

“Supporting documentation” should unambiguously demonstrate the reported status of the

milestone. Participants are urged to define and submit supporting documentation that:

 Indicates it was completed in a timely manner (e.g. agendas from meetings that occurred
within the timeframe of the milestone);
 Substantiates that the milestone was completed (e.g. submission of a gap assessment that
was developed in pursuing a milestone calling for the development of a gap assessment).

When milestones are created and submitted in Implementation Plans, the Department will
evaluate each to validate its appropriateness for the HTP participant’s intended intervention
goals. The Department will review and approve or request revision to all submitted milestones
based on the following criteria:

1. Does the milestone constitute a necessary step in completing implementation activities

for the submitted intervention?
2. Does the milestone include a description or functional area description(s) that is / are
sufficient to define what constitutes completion?
3. Does the milestone include a description of the supporting documentation that will be
used to validate completion and is that documentation sufficient to prove the milestone’s
completion?
4. Is the milestone appropriately categorized under one of the two applicable developmental
phases (Planning and Implementation or Continuous Improvement)?
5. Are Planning and Implementation milestones properly identified under one or more of the
four functional areas (people, process, technology, patient engagement / target
population)?
6. Are milestones scheduled for completion in either Q2 or Q4, with at least two proposed
for completion for each program year between PY2-PY5 (Oct. 2022 – Sept. 2026)?
7. Does the final Planning and Implementation milestone include an impact milestone as
defined above with all four functional areas addressed?

When the Department completes its evaluation of submitted milestones as part of the
Implementation Plan review, it will score based on the one to three (1-3) scoring rubric and may
offer suggested revisions. Hospitals will have an opportunity to accept the milestone revisions if
present or propose a new milestone.

32 | HTP Implementation Plan Template and Milestone Requirements

D. Ongoing Program Reporting of Milestones and Validation Process
Quarterly reports will be submitted within 20 business days following the end of the reporting
quarter. All reports will be reviewed by the Department for progress and completion of the
milestones identified in the HTP participant’s approved Implementation Plan.

All quarterly reports will be evaluated based on, but not limited to, the following criteria:

 Was the report submitted on time?

For Q1 and Q3 reports on interim activities:
 Was at least one interim activity linked to the milestone that will be submitted
in the immediately subsequent quarter reported?
For Q2 and Q4 reports on milestone completion:
 Was the milestone completed by the end of the applicable quarter (Q2 or Q4)?
 Was the supporting documentation submitted for the milestone sufficient to
validate its completion?
The Department will validate the quarterly reports to determine at-risk funds earned for
reporting each quarter. For the milestone completion reports submitted for Q2 and Q4, the
Department will also determine at-risk funds earned for milestone completion. The schedule
below outlines the quarterly reporting validation process.

Validation Process Activity Completion Date

Report submission due date + 1

Department begins review of all submitted quarterly reports
business day

Department reviews all supporting documentation Report submission due date + 15

(milestones) / responses regarding interim activities business days

Report submission due date + 20

Department initial review of quarterly report complete
business days

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

Report submission due date + 31

Requests for reconsideration of scoring decisions due
business days

Report submission due date + 45

Department issues final scores for quarterly reports
business days

33 | HTP Implementation Plan Template and Milestone Requirements

E. 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

Q2 or Q4 Report submission due date
Department begins review of amended milestone(s)
+ 1 business day
Department reviews milestone amendment(s) for sufficient Q2 or Q4 Report submission due date
justification and completed milestone requirements + 15 business days

Department completes review of proposed milestone Q2 or Q4 Report submission due date

amendment(s) + 20 business days

Department notifies participant of approval, approval with

Q2 or Q4 Report submission due date
modifications or rejection of proposed milestone
+ 21 business days
amendment(s)

Participant accepts Department’s approval, approval with

modifications or rejection of proposed milestone Q2 or Q4 Report submission due date
amendment(s) OR requests to resubmit and submits an + 31 business days
updated milestone amendment(s)

Department issues final approval /denial of amended

Q2 or Q4 Report submission due date
milestone(s). If approved, amended milestone(s) become
+ 45 business days
part of the participant’s Implementation Plan.

34 | HTP Implementation Plan Template and Milestone Requirements

F. 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.

G. 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.

35 | HTP Implementation Plan Template and Milestone Requirements

V. Program Timeline

36 | HTP Implementation Plan Template and Milestone Requirements

Appendix A -
Colorado Hospital Index
Measure – Hospital
Transformation Program
Milestone Reporting

37
I. 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.

A. 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:

o People: workforce development; identification key project personnel
o Process: shifts in clinical and quality processes;
o Technology: updating, acquisition or repurposing underlying electronic health data
storage; data use; data exchange
o Patient Engagement / Target population: identification of patients that fall within
target populations;

38 | Appendix A: Hospital Index Measure

 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)

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

39 | Appendix A: Hospital Index Measure

 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)

40 | Appendix A: Hospital Index Measure

 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.

B. 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?

41 | Appendix A: Hospital Index Measure

 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).

42 | Appendix A: Hospital Index Measure

 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?

43 | Appendix A: Hospital Index Measure

Appendix B -
Quality Improvement
Resources – Hospital
Transformation Program

44
I. 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.
A. Models for Improvement
1. Resource: Practice Facilitation Handbook, AHRQ. Accessed online:
https://www.ahrq.gov/ncepcr/tools/pf-handbook/index.html

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.

2. Resource: Science of Improvement: How to Improve, Institute for Healthcare

Improvement (IHI). Accessed online:
http://www.ihi.org/resources/Pages/HowtoImprove/ScienceofImprovementHo
wtoImprove.aspx

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.

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

http://medicare.qualishealth.org/qi-basics/model-for-improvement

45 | Appendix B: Quality Improvement Resources

 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.

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

online: https://www.ahrq.gov/evidencenow/tools/pdsa-worksheet.html

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.

5. Resource: QI Tips: A Formula for Developing a Great Aim Statement, National

Institute for Children’s Health Quality. Accessed online:
https://www.nichq.org/insight/qi-tips-formula-developing-great-aim-
statement

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.

6. Resource: Worksheet for Developing Your Quality Improvement Project, John Hopkins
Medicine. Accessed online:
https://www.hopkinsmedicine.org/armstrong_institute/_files/patient
%20safety%20and%20quality%20improvement%20project%20tools/
spirit_toolkit/module%203_worksheet%20for%20qi%20project.pdf

Key Takeaways: A worksheet that includes guidance in writing an aim statement,

establishing measures, selecting changes, testing changes, and writing a project
summary.

B. Assessment Tools
1. Resource: Organizational Quality Assessment Tool, HEALTHQUAL. Accessed online:
https://healthqual.ucsf.edu/sites/g/files/tkssra931/f/HEALTHQUAL
%20OA_February%202018.pdf

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.

2. Resource: Registries for Evaluating Patient Outcomes: A User's Guide: 4th Edition,
AHRQ. Accessed online:
https://effectivehealthcare.ahrq.gov/products/registries-guide-4th-edition/
users-guide

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

46 | Appendix B: Quality Improvement Resources

 practices to guide design, operation, analysis, and evaluation of patient registries. It
provides concise, practical information to help registries address technological and
other changes.

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

https://www.advisory.com/topics/population-health-roi/2020/04/pha-
resource-library

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.

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

Accessed online: https://www.aafp.org/family-physician/patient-care/the-
everyone-project/toolkit.html

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.

5. Resource: Screening for Social Determinants of Health in Populations with Complex

Needs: Implementation Considerations, Center for Health Care Strategies. Accessed
online: https://www.chcs.org/media/SDOH-Complex-Care-Screening-Brief-
102617.pdf

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.

6. Resource: Protocol for Responding to and Assessing Patients’ Assets, Risks, and
Experiences (PRAPARE), National Association of Community Health Centers. Accessed
online: https://www.nachc.org/research-and-data/prapare/

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.

47 | Appendix B: Quality Improvement Resources

 7. Resource: Community Health Assessment for Population Health Improvement:
Resource of Most Frequently Recommended Health Outcomes and Determinants, CDC.
Accessed online: https://stacks.cdc.gov/view/cdc/20707

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.

8. Resource: Blueprint for Complex Care, The National Center for Complex Health &
Social Needs. Accessed online:
https://www.nationalcomplex.care/wp-content/uploads/2019/03/Blueprint-
for-Complex-Care_UPDATED_030119.pdf

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.

C. Stakeholder Engagement Toolkits

1. Resource: One Health Stakeholder Mapping Toolkit, USAID. Accessed online:
https://s3.amazonaws.com/one-health-app/static/docs/toolkits/Stakeholder_
Mapping_Toolkit/Stakeholder_Mapping_Toolkit_Overview.pdf

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.

2. Resource: Stakeholder Mapping, Reproductive Health National Training Center.

Accessed online:
https://rhntc.org/sites/default/files/resources/fpntc_stakeholder_mapping_20
20-04-27.pdf

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.

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

https://www.countyhealthrankings.org/sites/default/files/media/document/
resources/Stakeholder%20Mapping.pdf

48 | Appendix B: Quality Improvement Resources

 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.

D. 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:
http://www.ihi.org/resources/Pages/IHIWhitePapers/IHICareCoordinationMode
lWhitePaper.aspx

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.

49 | Appendix B: Quality Improvement Resources