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AHEADII Assessment

Instructions

  • Each team member completing this assessment will select the organization they coach from the drop-down menu.

  • Complete the assessment on behalf of the organization you coach, adding their score and any comments from their assessment here (essentially copying and pasting from the initial assessment). This will provide a secure place to store assessment results and make it easier to generate reports.

    If you have any questions, email Lakisa Fauchon at lakisa_fauchon@jsi.com.

How established and embedded are your organization's equity, diversity, and inclusion (EDI) goals? Our EDI goals and work plans...
are not documented or operationalized internally.
are shared with some of the workforce, but have not been operationalized.
have been shaped by a smaller group of team members and may be shared by leadership. Policies are beginning to be meaningfully operationalized, measured, and updated.
are documented, operationalized, and celebrated in policies across the entire organization, from hiring to advancement, creating a culture of diversity, equity, and inclusion. Leaders communicate a commitment to promoting equity in all aspects of the organization’s work.
To what extent does your organizational culture and infrastructure support delivery of care that is equitable for all patient populations? Our organization...
does not have a standardized process to train its workforce, and/or healthy equity trainings are provided sparingly.
has a process to train its workforce to deliver culturally responsive and humble care and linguistically appropriate services (according to CLAS Standards).
has assigned a lead with responsibility and accountability for health equity efforts. This role engages with clinical champions, patients, and families (e.g., Patient and Family Advisory Councils) and/or community partners in strategic and action planning activities to reduce disparities in health outcomes for all patient populations.
has made a commitment to ensure equitable health care that is prioritized and delivered to all persons through leadership accountability, written policies, protocols, pledges or strategic planning documents by organizational leadership and a board of directors.
How is your organization's EHR supported? (Not a scaled question). For EHR support, our organization uses...
Does your organization have access to and use registries to manage patients with chronic conditions? Our organization's patient registries are...
not available.
available and not used.
available and used regularly for some chronic conditions.
available and used regularly for several chronic conditions.
To what extent are data from different internal and external sources/systems consistent and readily available through the organization’s analytics systems and tools? Important internally generated data are...
stored in separate systems, and are not consistent, or require extensive time-consuming manual efforts to integrate.
used to create specific reports combining data from different internal sources, but are only available for limited sets of data on a project-by-project basis. Some effort is made to identify, combine, and use important external data, but it is not reconciled or audited.
periodically combined with selected external data sources to support performance measurement needs for strategic goals. Automated data feeds to a repository and are available with limited manual intervention.
combined with multiple external sources systematically (fully automated) to provide full data insight on performance relative to industry and help drive achievement of the Quintuple AIM framework.
To what extent are the right data tools in place to meet the needs of all users in your organization? The data available...
are largely raw and require additional processing to convert them into useful, actionable information. Access to and timeliness of actionable data is based on individuals that process the data (i.e., QI and IT staff).
are used to generate reports, typically monthly, that provide actionable information for selected departments. Reports may be generated at any time. Data and information to support the care team is limited.
are used to generate reports, typically in real time, that provide actionable information for all departments, and reporting capability is widely available. Data and information selectively support proactive care efforts and point-of-care decision-making to improve care.
are widely accessible in a variety of formats and delivery modes, including dashboards, to provide actionable information required by all data collaborators. Advanced analytics (prescriptive, predictive) provide intelligence on proactive care management and improving and sustaining business and quality outcomes.
How does your organization approach the collection of demographic data, including race, ethnicity, and language (REAL) and sexual orientation and gender identity (SOGI) data? Prompt: What percentage of patients have REAL and/or SOGI data documented in the EHR? Our organization...
does not collect REAL or SOGI data.
collects REAL, gender, and income data as required by funders or other reporting entities.
collects and stratifies REAL, SOGI, and Income data gathered, and considers opportunities for improvement within programs and services together with the team.
fulfills Building Upon Basic Changes criteria and has a training program for all staff focused on respectfully, consistently, and effectively collecting REAL and SOGI data. We can illustrate, through longitudinal outcome data, how our efforts are impacting health and race disparities in the communities we serve. Our organization looks at collecting additional demographic data beyond REAL and SOGI data, such as disability status, veteran status, geography, and/or other social determinants of health/risk factors (e.g., housing, education, employment, food security).
To what extent does your organization verify the accuracy and completeness of patient self-reported demographic REAL and SOGI data? Our organization...
does not have a standardized process in place and/or verification occurs rarely or not at all.
has a standardized process in place to: • Evaluate the accuracy and completeness (percent of fields completed) for REAL data and SOGI. • Evaluate and compare organization-collected REAL data to local community demographic data.
addresses system-level issues to improve the collection of self-reported REAL data (e.g., changes in patient registration screens/fields, data flow, workforce training).
has a standardized process in place to: • Evaluate accuracy and completeness of additional demographic data (beyond REAL), such as SOGI, disability status, veteran status, geography and/or other social determinants of health/risk factors such as housing, income, education, employment, food security, incarceration history, and others. • Evaluate and compare organization collected health equity data to local community demographic data.
To what extent does your organization have a process to train its workforce to deliver culturally responsive care and linguistically appropriate services (according to CLAS Standards). Our staff...
are not prepared and/or confident OR it is unclear the overall level of preparedness and/or confidence.
are somewhat aware of the importance of REAL and SOGI data collection and some staff have started taking initial steps such as participation in training sessions.
are actively building upon the basics of REAL and SOGI data collection. Most or all have attended training sessions and are comfortable discussing the importance of collecting these data with patients.
are confident and fully prepared in collecting accurate and detailed REAL and SOGI data. They have successfully integrated REAL and SOGI data collection into routine practice. Important changes, such as robust staff training, data systems and processes, and patient education, have been implemented, and staff members are highly competent in these areas.
To what extent does your organization ensure accurate data across the organization? Data quality...
is not a priority. Most efforts are focused on cleanup and individual intervention. Data quality review does not occur with rigor or regularity in the organization.
reviews occur within selected teams, departments, or sites, but the efforts are usually one-time efforts and not sustained on an ongoing basis.
tracking reports for each department are produced on a regular basis and are integrated and aligned across the organization. Common errors are assessed and training occurs to address them.
and data collection and aggregation are highly automated with built-in data quality checks and exception reports. Measures of data quality inform and support the prioritization of ongoing data quality efforts and trace errors to individuals for training.
To what extent does your organization have a systematic approach to developing and implementing a data strategy that supports the organization’s health equity strategic goals and objectives? Our data strategy...
or data needs are not explicitly considered when defining or implementing strategic plans and objectives. Data needed to evaluate progress toward goals is often missing.
may be evident for specific projects and efforts (i.e., Patient-centered Medical Home [PCMH ]recognition, Meaningful Use [MU], Uniform Data System [UDS]), but is not well-documented, widespread, or integrated with organization strategy.
involves departmental plans and organizational strategy with an analytics approach. The data strategy also addresses increasing data literacy throughout the organization.
and data analytics strategy are aligned and widely understood, including consideration of data from external sources that are critical to achieving goals. Strategy is periodically reviewed and updated to remain responsive to changing priorities.
To what extent does your organization turn data into measures that assess performance on the organization's health equity strategic goals? Performance measures...
are not in place, or there are very few measures beyond those mandated by federal, state or other reporting such as UDS, MU are used.
are developed as needed to monitor selected clinical/business processes. Teams or departments are beginning to measure performance but measurement areas are not well connected.
are developed to monitor clinical/business process performance of strategic priorities. Teams or departments measure performance in alignment with strategic goals.
are a strategically balanced set of clinical, operational, financial, and patient experience measures that are in place to systematically monitor performance for all strategic priorities (e.g., MU, P4P, PCMH).
How effectively does your organization act on the results of data analyses and reports, ensuring that change and improvement efforts are prioritized with assigned accountability and demonstrate measurable impact and sustainability? Using data to make improvement...
is not a primary consideration. Instead, the focus is on fixing a specific problem. Individuals in the organization are involved in ad hoc efforts and informal knowledge sharing is the primary source of acting on data. Information quality is too uneven to permit acting on it with confidence.
is recognized as important by senior leadership but limited to major projects. Some departments/sites are more successful at improvement efforts than others, but there is limited accountability for measurable outcomes.
results in measurable outcomes being used to routinely demonstrate impact of prioritized improvement efforts. Most departments/sites successfully leverage data for improvement and sustainability, and there is some accountability for measurable outcomes.
results in measurable outcomes driving organization focus and improvement efforts towards industry-leading performance with clear accountability, incentives, and consequences for improvement. Data literacy is pervasive. Staff in our organization are fully trained to leverage data for improvement.
To what extent does your organization promote data literacy and require supporting data to make decisions? Data and information...
management is mostly focused on accurate historical data and retrospective reporting.
are available and used by department leadership, but not uniformly required when making operational decisions or changing strategy.
are used by managers and leaders on a regular basis, pushed down and across the organization, and are required to support business cases and key decisions. Managers and leaders are held accountable for data accuracy and quality.
are used to make data-driven decisions made in the organization at all levels. All staff know how their day-to-day actions affect performance metrics and achievement of goals. Data literacy is a hallmark of the organization.
To what extent do skills, roles, and staff exist within the organization to understand existing data, explore new sources of data, and present insights from data. Staff that understand existing organizational data, explore new sources of data, and present insights from data...
are limited, and there are no analytics staff. Analytic capabilities ebb and flow with staff turnover in informal roles/skills.
consist of de facto roles for experts within the organization or limited assigned roles for analysts (i.e., part-time or not the staff member’s primary responsibility).
consist of dedicated and centralized analytic staff that participate in cross-functional teams, and support data-driven decision-making. Analytic staff may be provided by a support organization (network, consortia, organization), but not always sufficient for all analytic needs.
consist of advanced analytic skills at the organization (e.g., research scientist, clinical informaticist, epidemiologist). Analysts promote advanced uses of data (e.g., predictive modeling) and build data literacy across the organization.
To what extent does IT provide the needed staff, services, and resources to help the organization integrate and support data analysis and visualization tools? IT support...
for analytics consists mainly of maintenance and support of database platforms that capture health record data (e.g., EHR, PM). Dedicated analytic systems or tools are limited in functionality and utility.
for analytics includes reporting and data mining from existing systems and basic analytics support. Analysis tools are limited to spreadsheets and databases, with limited functionality for systematic reporting, advanced data analyses, and self-service analytics.
extends to analytic systems to meet needs of selected high-priority areas. There are pockets of IT analytic support for some departments or data collaborators who have interest, but analytic systems are not fully integrated with existing health IT platforms (“standalone analytics”).
extends to analytic systems that interface with and leverage existing IT platforms, fully support organizational data needs to achieve strategic goals, and support a data-driven culture, with self-service analytics for all departments and data collaborator groups.