Form 1 : CHGME Program Quality Bonus Payment System Initiatives

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of information unless it displays a currently valid OMB control number. The OMB control number for this project is 0906xxxx-New. Public reporting burden for this collection of information is estimated to average 32.41 hours per response,
including the time for reviewing instructions, searching existing data sources, and completing and reviewing the collection
of information. Send comments regarding this burden estimate or any other aspect of this collection of information,
including suggestions for reducing this burden, to HRSA Reports Clearance Officer, 5600 Fishers Lane, Room 14N136B,
Rockville, Maryland, 20857

Children’s Hospitals Graduate Medical Education Program
Quality Bonus Payment System
Initiatives Reporting Form

Section (1)

(a) Organization Name:
(b) Doing Business As Name:

(c) Hospital Website:
(d) City:

(e) State:

(f) Zip Code:

(g) County:

(h) Submitted by:
(j) Title:

(i) Date:

Section (2a)

Integrated Care Models
(a) Name of Initiative:

(b) Initiative Type:

Clinical rotation / formal curricula
Field placement/ experiential learning activity
Community outreach project
Faculty development programs or activities
Grand rounds/ seminar
Research
Workgroup/ task force
N/A

(c) Role of
CHGME Hospital:

Major participating organization

(d) Brief Narrative
Describing Initiative's
Purpose & Goals:

(e) Names of Other
Participating
Organizations:

(g) If so, approximately how many? 1

(f) Are CHGME Trainees involved?

Yes

(h) Role of CHGME Trainees:

Resident led initiative

(i) Initiative Outcomes &
Highlights:

(j) Benefits to Trainees:

(k) Is Supporting Documentation Attached?

Yes

Section (2b)

Integrated Care Models #2
(a) Name of Initiative:

(b) Initiative Type:

Clinical rotation / formal curricula
Field placement/ experiential learning activity
Community outreach project
Faculty development programs or activities
Grand rounds/ seminar
Research
Workgroup/ task force
N/A

(c) Role of
CHGME Hospital:

Major participating organization

(d) Brief Narrative
Describing Initiative's
Purpose & Goals:

(e) Names of Other
Participating
Organizations:

(g) If so, approximately how many? 1

(f) Are CHGME Trainees involved?

Yes

(h) Role of CHGME Trainees:

Resident led initiative

(i) Initiative Outcomes &
Highlights:

(j) Benefits to Trainees:

(k) Is Supporting Documentation Attached?

Yes

Section (2c)

Integrated Care Models #3
Name of Initiative:

(a) Initiative Type:

Clinical rotation / formal curricula
Field placement/ experiential learning activity
Community outreach project
Faculty development programs or activities
Grand rounds/ seminar
Research
Workgroup/ task force
N/A

(b) Role of
CHGME Hospital:

Major participating organization

(c) Brief Narrative
Describing Initiative's
Purpose & Goals:

(d) Names of Other
Participating
Organizations:

(g) If so, approximately how many? 1

(e) Are CHGME Trainees involved? Yes

(h) Role of CHGME Trainees:

Resident led initiative

(i) Initiative Outcomes &
Highlights:

(j) Benefits to Trainees:

(k) Is Supporting Documentation Attached?

Yes

Section (3a)

Telehealth and/or Health Information Technology
(a) Name of Initiative:
Clinical rotation / formal curricula
Field placement/ experiential learning activity
Community outreach project
(b) Initiative Type: Faculty development programs or activities
Grand rounds/ seminar
Research
Workgroup/ task force
N/A

(c) Role of CHGME
Major participating organization
Hospital:

(d) Brief Narrative
Describing Initiative's
Purpose & Goals:

(e) Names of Other
Participating
Organizations:

(g) If so, approximately how many? 1

(f) Are CHGME Trainees involved? Yes

(h) Role of CHGME Trainees:

Resident led initiative

(i) Initiative Outcomes &
Highlights:

(j) Benefits to Trainees:

(k) Is Supporting Documentation Attached?

Yes

Section (3b)

Telehealth and/or Health Information Technology #2
(a) Name of Initiative:
Clinical rotation / formal curricula
Field placement/ experiential learning activity
Community outreach project
(b) Initiative Type: Faculty development programs or activities
Grand rounds/ seminar
Research
Workgroup/ task force
N/A

(c) Role of
CHGME Hospital:

Major participating organization

(d) Brief Narrative
Describing Initiative's
Purpose & Goals:

(e) Names of Other
Participating
Organizations:

(g) If so, approximately how many? 1

(f) Are CHGME Trainees involved? Yes

(h) Role of CHGME Trainees:

Resident led initiative

(i) Initiative Outcomes &
Highlights:

(j) Benefits to Trainees:

(k) Is Supporting Documentation Attached?

Yes

Section (3c)

Telehealth and/or Health Information Technology #3
(a) Name of Initiative:
Clinical rotation / formal curricula
Field placement/ experiential learning activity
Community outreach project
(b) Initiative Type: Faculty development programs or activities
Grand rounds/ seminar
Research
Workgroup/ task force
N/A

(c) Role of
CHGME Hospital:

Major participating organization

(d) Brief Narrative
Describing Initiative's
Purpose & Goals:

(e) Names of Other
Participating
Organizations:

(g) If so, approximately how many? 1

(f) Are CHGME Trainees involved? Yes

(h) Role of CHGME Trainees:

Resident led initiative

(i) Initiative Outcomes
& Highlights:

(j) Benefits to Trainees:

(k) Is Supporting Documentation Attached?

Yes

Section (4a)

Population Health
(a) Name of Initiative:
Clinical rotation / formal curricula
Field placement/ experiential learning activity
Community outreach project
(b) Initiative Type: Faculty development programs or activities
Grand rounds/ seminar
Research
Workgroup/ task force
N/A

(c) Role of
CHGME Hospital:

Major participating organization

(d) Brief Narrative
Describing Initiative's
Purpose & Goals:

(e) Names of Other
Participating
Organizations:

(f) Are CHGME Trainees involved? Yes

(h) Role of CHGME Trainees:

Resident led initiative

(i) Initiative Outcomes &
Highlights:

(j) Benefits to Trainees:

(k) Is Supporting Documentation Attached? Yes

(g) If so, approximately how many? 1

Section (4b)

Population Health #2
(a) Name of Initiative:
Clinical rotation / formal curricula
Field placement/ experiential learning activity
Community outreach project
(b) Initiative Type: Faculty development programs or activities
Grand rounds/ seminar
Research
Workgroup/ task force
N/A

(c) Role of
CHGME Hospital:

Major participating organization

(d) Brief Narrative
Describing Initiative's
Purpose & Goals:

(e) Names of Other
Participating
Organizations:

(g) If so, approximately how many? 1

(f) Are CHGME Trainees involved? Yes

(h) Role of CHGME Trainees:

Resident led initiative

(i) Initiative Outcomes &
Highlights:

(j) Benefits to Trainees:

(k) Is Supporting Documentation Attached?

Yes

Section (4c)

Population Health #3
(a) Name of Initiative:
Clinical rotation / formal curricula
Field placement/ experiential learning activity
Community outreach project
(b) Initiative Type: Faculty development programs or activities
Grand rounds/ seminar
Research
Workgroup/ task force
N/A

(c) Role of CHGME
Hospital:

Major participating organization

(d) Brief Narrative
Describing Initiative's
Purpose & Goals:

(e) Names of Other
Participating
Organizations:

(g) If so, approximately how many? 1

(f) Are CHGME Trainees involved? Yes

(h) Role of CHGME Trainees:

Resident led initiative

(i) Initiative Outcomes
& Highlights:

(j) Benefits to Trainees:

(k) Is Supporting Documentation Attached?

Yes

Section (5a)

Social Determinants of Health
(a) Name of Initiative:

(b) Initiative Type:

Clinical rotation / formal curricula
Field placement/ experiential learning activity
Community outreach project
Faculty development programs or activities
Grand rounds/ seminar
Research
Workgroup/ task force
N/A

(c) Role of
CHGME Hospital:

Major participating organization

(d) Brief Narrative
Describing Initiative's
Purpose & Goals:

(e) Names of Other
Participating
Organizations:

(f) Are CHGME Trainees involved? Yes

(h) Role of CHGME Trainees:

Resident led initiative

(i) Initiative Outcomes &
Highlights:

(j) Benefits to Trainees:

(k) Is Supporting Documentation Attached? Yes

(g) If so, approximately how many? 1

Section (5b)

Social Determinants of Health #2
(a) Name of Initiative:
Clinical rotation / formal curricula
Field placement/ experiential learning activity
Community outreach project
(b) Initiative Type: Faculty development programs or activities
Grand rounds/ seminar
Research
Workgroup/ task force
N/A

(c) Role of CHGME
Major participating organization
Hospital:

(d) Brief Narrative
Describing Initiative's
Purpose & Goals:

(e) Names of Other
Participating
Organizations:

(g) If so, approximately how many? 1

(f) Are CHGME Trainees involved? Yes

(h) Role of CHGME Trainees:

Resident led initiative

(i) Initiative Outcomes &
Highlights:

(j) Benefits to Trainees:

(k) Is Supporting Documentation Attached?

Yes

Section (5c)

Social Determinants of Health #3
(a) Name of Initiative:
Clinical rotation / formal curricula
Field placement/ experiential learning activity
Community outreach project
(b) Initiative Type: Faculty development programs or activities
Grand rounds/ seminar
Research
Workgroup/ task force
N/A

(c) Role of CHGME
Hospital:

Major participating organization

(d) Brief Narrative
Describing Initiative's
Purpose & Goals:

(e) Names of Other
Participating
Organizations:

(g) If so, approximately how many? 1

(f) Are CHGME Trainees involved? Yes

(h) Role of CHGME Trainees:

Resident led initiative

(i) Initiative Outcomes
& Highlights:

(j) Benefits to Trainees:

(k) Is Supporting Documentation Attached?

Yes

Section (6a)

Additional Initiatives to Improve Access and Quality of Care to
Rural and/or Underserved Communities
(a) Name of Initiative:
Clinical rotation / formal curricula
Field placement/ experiential learning activity
Community outreach project
(b) Initiative Type: Faculty development programs or activities
Grand rounds/ seminar
Research
Workgroup/ task force
N/A

(c) Role of CHGME
Major participating organization
Hospital:

(d) Brief Narrative
Describing Initiative's
Purpose & Goals:

(e) Names of Other
Participating
Organizations:

(g) If so, approximately how many? 1

(f) Are CHGME Trainees involved? Yes

(h) Role of CHGME Trainees:

Resident led initiative

(i) Initiative Outcomes &
Highlights:

(j) Benefits to Trainees:

(k) Is Supporting Documentation Attached?

Yes

Section 6b

Additional Initiatives to Improve Access and Quality
of Care to Rural and/or Underserved Communities #2
(a) Name of Initiative:
Clinical rotation / formal curricula
Field placement/ experiential learning activity
Community outreach project
(b) Initiative Type: Faculty development programs or activities
Grand rounds/ seminar
Research
Workgroup/ task force
N/A

(c) Role of CHGME Major participating organization
Hospital:

(d) Brief Narrative
Describing Initiative's
Purpose & Goals:

(e) Names of Other
Participating
Organizations:

(f) Are CHGME Trainees involved?

(h) Role of CHGME Trainees:

(g) If so, approximately how many? 1

Yes

Resident led initiative

(i) Initiative Outcomes &
Highlights:

(j) Benefits to Trainees:

(k) Is Supporting Documentation Attached?

Yes

Section 6c

Additional Initiatives to Improve Access and Quality of
Care to Rural and/or Underserved Communities #3
(a) Name of Initiative:
Clinical rotation / formal curricula
Field placement/ experiential learning activity
Community outreach project
(b) Initiative Type: Faculty development programs or activities
Grand rounds/ seminar
Research
Workgroup/ task force
N/A

(c) Role of
CHGME Hospital:

Major participating organization

(d) Brief Narrative
Describing Initiative's
Purpose & Goals:

(e) Names of Other
Participating
Organizations:

(f) Are CHGME Trainees involved? Yes

(h) Role of CHGME Trainees:

Resident led initiative

(i) Initiative Outcomes &
Highlights:

(j) Benefits to Trainees:

(k) Is Supporting Documentation Attached? Yes

(g) If so, approximately how many? 1