CMS-10315.Supporting Statement Part A, B, and Instrument

The Centers for Medicare & Medicaid Services (CMS) and the U.S. Department of Health and Human Services (DHHS) are requesting OMB clearance for the Nursing Homes in Need (NHIN) Survey. The NHIN is a component of the Patient Safety Theme of the Quality Improvement Organization (QIO) Program’s 9th Scope of Work (SOW). The statutory authority for this scope of work is found in Part B of Title XI of the Social Security Act (the Act) as amended by the Peer Review Improvement Act of 1982. The Act established the Utilization and Quality Control Peer Review Organization Program, now known as the Quality Improvement Organization (QIO) Program.

The statutory mission of the QIO Program, as set forth in Section 1862(g) of the Act, is to improve the effectiveness, efficiency, economy, and quality of services delivered to Medicare beneficiaries.

Based on statutory language and the experience of CMS in administering the QIO Program, CMS has identified the following requirements for the QIO Program:

Improve quality of care for beneficiaries;
Protect the integrity of the Medicare Trust Fund by ensuring that Medicare pays only for services and goods that are reasonable and medically necessary and that are provided in the most appropriate setting;
Protect beneficiaries by expeditiously addressing individual complaints, such as beneficiary complaints; provider-based notice appeals; Emergency Medical Treatment and Labor Act (EMTALA) violations; and other related statutory QIO responsibilities.

As a general matter, Section 1862(g) of the Act mandates the Secretary enter into contracts with QIOs for the purpose of determining that Medicare services are reasonable and medically necessary, and for the purposes of promoting the effective, efficient, and economical delivery of health care services, and of promoting the quality of services of the type for which payment may be made under Medicare. CMS interprets the term “promoting the quality of services” to involve more than QIOs reviewing care on a case- by-case basis, but as covering a broad range of proactive initiatives that will promote higher quality. CMS has, for example, included in the SOW Themes in which the QIO will provide technical assistance to Medicare-participating providers and practitioners in order to help them improve the quality of the care they furnish to Medicare beneficiaries. Additional authority for these activities appears in Section 1154(a)(8) of the Act, which requires that QIOs perform such duties and functions and assume such responsibilities and comply with such other requirements as may be required by the Medicare statute. CMS regards these activities as appropriate if they will directly benefit Medicare beneficiaries.

Section 1154(a)(10) of the Act specifically requires QIOs “coordinate activities, including information exchanges, which are consistent with economical and efficient operation of programs among appropriate public and private agencies or organizations, including other public or private review organizations as may be appropriate.” CMS regards this as specific authority for QIOs to coordinate and operate a broad range of collaboratives and community activities among private and public entities, as long as the predicted outcome will directly benefit the Medicare program. In addition, Section 1156(c) of the Act states that it is the duty of each QIO to use such authority or influence as it may possess as a professional organization, and to enlist the support of any other professional or governmental organization having influence or authority over healthcare practitioners or entities furnishing services in its area, in assuring that each practitioner or entity shall comply with all obligations imposed on them under Section 1156(a). Under these obligations, providers and practitioners must assure that they will provide services of a quality that meets professionally recognized standards of care.

The QIO Program aims to improve the quality of care and protect Medicare beneficiaries through the following themes and sub-national requirements:

Beneficiary Protection;
Patient Safety;
Prevention;
Prevention: Disparities;
Care Transitions; and
Prevention: Chronic Kidney Disease (CKD).

The NHIN program exists under the Patient Safety Theme. The QIO in each state will provide special technical assistance to a small number of nursing homes in need of assistance with quality improvement efforts. This is a mandatory component of the QIO SOW under Patient Safety.

This special technical assistance will be for the QIO to conduct a root cause analysis (RCA) with one nursing home in its state per year (three over three years). Under this component, it is expected that within the first quarter of each year of the 9^th SOW contract period, CMS will assign one nursing home to each QIO. The determination of which nursing homes are eligible under this component will be made by CMS. Some of these facilities may meet criteria for Special Focus Facilities (SFF). The intent of this component is that each state QIO will work with three nursing homes over the three-year contract period; these assignments are expected to be spaced out so that each state QIO will get one nursing home assigned approximately every 12 months.

Justification – NHIN Survey

Need and Legal Basis

As mentioned in Section 1, the legal basis for this data collection is contained in Section 1862(g) of the Act. The CMS designee, QualMed Surveys, LLC, (QMS) of Rockville, MD, will administer the NHIN Survey to nursing homes to evaluate nursing home satisfaction with the technical assistance process (NHIN Survey data) and their perception of effectiveness of QIO technical assistance.

Note that the NHIN Survey is not intended to generate statistics about the nursing home population. The NHIN Survey is being used as a tool for obtaining feedback for performance improvement activities. The goal is to collect information from the nursing homes participating in the QIO program to help CMS and the QIOs improve the interventions.

Information Users

The NHIN Survey constitutes a new information collection that will be used by CMS to obtain information on nursing home satisfaction with technical assistance strategies delivered as a component of the NHIN. The information collected through this survey will allow CMS to help focus the NHIN task to maximize the benefit to participating nursing homes.

Use of Information Technology

The NHIN Survey will be administered via telephone by trained and experienced interviewers. Responses will be entered into a pre-programmed Computer-Assisted Telephone Interviewing (CATI) interface.

The NHIN Survey is being administered via telephone for three main reasons. First, the population size (53 nursing homes surveyed one time each during Years 1 and 2 of the 9^th SOW and twice during Year 3) is not large enough to justify the cost of programming a Web survey. Second, respondents to the NIHN Surveys are to be the most knowledgeable respondent in each respective nursing home. Telephone screening would be required to identify this person. Due to agency turnover, this individual may not be the same person at each data collection interval. Finally, data collections coordinated during the 8^th SOW have found that not all nursing homes use the internet for conducting business. To maximize response rates, we will collect data via the telephone.

Duplication of Information

This is a new data collection measuring the satisfaction with technical assistance offered to nursing homes as a component of the NHIN program. The information collected does not duplicate any other effort and the information cannot be obtained from any other source.

Small Businesses

While the administration of the NHIN Survey may have an impact on small nursing homes, this impact will be minimal as the survey is expected to take no more than 20 minutes to administer.

Less Frequent Collection

The NHIN Survey will be used to evaluate nursing homes’ satisfaction with technical assistance received as a component of the NHIN program. Given that technical assistance is delivered to participating nursing homes based on individual need, it has been deemed, in consultation with CMS that a bi-annual data collection will serve to meet the needs of the NHIN participants in providing feedback on technical assistance and the needs of CMS in refining their technical assistance delivery.

QIOs will use the results as a process improvement tool to note areas for improvement during the 9^th SOW and inform the 10^th SOW.

Special Circumstances

There are no special circumstances.

Federal Register/Outside Consultation

The 60-day Federal Register Notice published on March 19, 2010. The development of the NHIN Survey was conducted in consultation with CMS personnel and QMS personnel. Please see Attachment 1 for a copy of the Federal Register Notice.

Table 1-1. Personnel Consultation

Organization	Name	Contact Information
Centers for Medicare & Medicaid Services	Robert Kambic	Phone: 410-786-1515 Email: [email protected]
Centers for Medicare & Medicaid Services	Francina Spencer	Phone: 410-786-4614 Email: [email protected]
Centers for Medicare & Medicaid Services	Maaden Eshete	Phone: 410-786-0045 Email: [email protected]
Centers for Medicare & Medicaid Services	Jade Perdue	Phone: 410-786-5611 Email: [email protected]
QualMed Surveys, LLC	William Strang	Phone: 301-251-0300, x212 Email: [email protected]
QualMed Surveys, LLC	David Bercham	Phone: 301-251-0300, x215 Email: [email protected]
QualMed Surveys, LLC	Vasudha Narayanan	Phone: 510-204-9920 Email: [email protected]
QualMed Surveys, LLC	Stephanie Fry	Phone: 301-294-2872 Email: [email protected]
QualMed Surveys, LLC	Sherman Edwards	Phone: 301-294-3993 Email: [email protected]

Payment/Gifts to Respondents

There will be no payments or gifts to respondents.

Confidentiality

All data collected via the NHIN Survey will be kept in physically secured storage areas. All electronic data and related databases will be password protected and maintained on secure servers.

The institutional review board (IRB) convened by Westat, Inc., of Rockville, Maryland, has granted approval for this data collection under the auspices of U.S. Department of Health and Human Services (DHHS) regulation 45 CFR § 46.

Sensitive Questions

The proposed data collection contains no questions of a sensitive nature.

Burden Estimate (Hours and Wages)

The total estimated annualized hour burden of this data collection is approximately 17.5 hours based on 53 respondents (one respondent each from the 53 nursing homes participating in the NHIN program annually) being surveyed annually during Years 1 and 2 of the 9^th SOW. Average survey administration time is estimated to be 20 minutes, or 0.33 burden hours. The respondents will be interviewed over the telephone.

Table l-2. Estimated annual burden – Years 1 and 2 of the 9^th SOW

Respondents by Role/occupation	Estimated Number of Respondents	Estimated Burden per Respondent (Hours)	Total Burden Estimate (Hours)	Annualized Cost Estimate
Administrators of nursing homes participating in the NHIN program.	53	.33	17.5 annually	$1050 annually (@$30/hr)

Respondents by Role/occupation

Estimated Number of Respondents

Estimated Burden per Respondent (Hours)

Total Burden Estimate (Hours)

Annualized Cost Estimate

Administrators of nursing homes participating in the NHIN program.

.33

17.5 annually

$1050 annually

(@$30/hr)

The total estimated annualized hour burden of this data collection is approximately 35 hours based on 53 respondents (one respondent each from the 53 nursing homes participating in the NHIN program annually) being surveyed bi-annually during Year 3 of the 9^th SOW. Average survey administration time is estimated to be 20 minutes, or 0.33 burden hours. The respondents will be interviewed over the telephone.

Table l-3. Estimated annual burden – Year 3 of the 9^th SOW

Respondents by Role/occupation	Estimated Number of Respondents	Estimated Burden per Respondent (Hours)	Total Burden Estimate (Hours)	Annualized Cost Estimate
Administrators of nursing homes participating in the NHIN program.	53	.33	17.5 hours per round 35 hours annually	$1050 per round $2100 annually (@$30/hr)

Respondents by Role/occupation

Estimated Number of Respondents

Estimated Burden per Respondent (Hours)

Total Burden Estimate (Hours)

Annualized Cost Estimate

Administrators of nursing homes participating in the NHIN program.

.33

17.5 hours per round

35 hours annually

$1050 per round

$2100 annually

(@$30/hr)

Capital Costs

There are no capital and startup nor operation and maintenance cost associated with this data collection.

Cost to the Federal Government

The annualized cost to the Federal Government is $90,598 for the contractor (QMS) to conduct, analyze, and report on this data collection activity. This figure includes the following costs as outlined in the budget submitted by QMS and approved by CMS: direct labor, fringe, computer, telephone, overhead, and general and administrative costs.

Program/Burden Changes

This is a new data collection.

Publication and Tabulation Duties

There are no publication or tabulation agreements in place other than CMS-mandated reporting duties.

Expiration Date

The expiration date and the PRA disclosure notice will be printed on all hard copy versions of the survey. Survey respondents will be notified that the NHIN Survey has been approved by OMB and will be provided with the expiration date of the approval.

Certification Statement

The certification is included in this submission. No exceptions apply.

c. Collection of Information Employing Statistical Methods

Respondent Universe and Sampling

The NHIN Survey will be a census of 53 nursing homes (one respondent at each nursing home) working with their respective QIOs. The survey will be conducted one time for each of the nursing homes assisted in the first two years under the 9^th SOW and twice with nursing homes assisted in the third year. The survey will elicit satisfaction data only and will not involve sampling. Nursing home contact information will be provided by the QIOs.

Procedures for Collecting Information

The NHIN Survey will be a census administered to administrators of 53 nursing homes. The data collection protocol for the NHIN Survey will be a telephone- based survey with telephone followup reminders to maximize the response rate. QIOs are present in 53 states and territories. Through the NHIN program, QIOs are working with one nursing home per year in their state/territory. The NHIN survey respondent will be the person who interacts with the QIO most frequently, typically the nursing home administrator or a member of the senior management staff.

Sample file. CMS will receive a list containing respondent contact information.

Data Collection. Data collection will begin with telephone calls to the respondents who will be asked if they would like to take the survey at the present time of the phone call or if they would like to schedule an appointment at a later time. CMS contact information will be given to the respondents should they have any questions regarding NHIN Survey itself. The respondents will also be provided with the OMB expiration date for the NHIN Survey.

Non-Response Follow-up

One week after the nursing home administrator receives the initial phone call, CMS will make a reminder phone call. A notice will also be sent to the Quality Improvement Coordinator at the respective QIO informing him/her that the nursing home administrator has not responded to the initial phone call. The Quality Improvement Coordinator will then remind the nursing home administrator about the survey. During the remaining data collection period, CMS will conduct followup telephone calls using experienced and well-trained telephone interviewers. The Quality Improvement Coordinator at the respective QIOs will receive a notice every time a followup phone call is made.

Tests of Procedures

No tests of procedures will be carried out.

Personnel Consultation

Individuals contained in Table 1-3 consulted on the development of the NHIN Survey and administration procedures.

Table 1-4. Personnel Consultation

Organization	Name	Contact Information
Centers for Medicare & Medicaid Services	Robert Kambic	Phone: 410-786-1515 Email: [email protected]
Centers for Medicare & Medicaid Services	Francina Spencer	Phone: 410-786-4614 Email: [email protected]
Centers for Medicare & Medicaid Services	Maaden Eshete	Phone: 410-786-0045 Email: [email protected]
Centers for Medicare & Medicaid Services	Jade Perdue	Phone: 410-786-5611 Email: [email protected]
QualMed Surveys, LLC	William Strang	Phone: 301-251-0300, x212 Email: [email protected]
QualMed Surveys, LLC	David Bercham	Phone: 301-251-0300, x215 Email: [email protected]
QualMed Surveys, LLC	Vasudha Narayanan	Phone: 510-204-9920 Email: [email protected]
QualMed Surveys, LLC	Stephanie Fry	Phone: 301-294-2872 Email: [email protected]
QualMed Surveys, LLC	Sherman Edwards	Phone: 301-294-3993 Email: [email protected]

Survey Materials

Please see Attachment 2 for a copy of the Patient Safety NHIN Survey.

Since there are no sensitive data being collected through the NHIN survey and there is little to no risk to respondents, CMS has requested and received a waver of formal informed consent from the IRB of record for the study. Passive consent will be implied as respondents choose to participate in the voluntary telephone study. Respondents are informed that they may skip any questions they do not wish to answer and they may terminate the interview at any time.

The NHIN Survey will include questions to determine if the QIO has conducted a root cause analysis and developed an action plan. These will be followed by questions about their satisfaction with the QIO and their perceived value of the QIO’s assistance. The NHIN Survey will address the following:

Background information;
Current work – information and assessment;
Satisfaction with QIOs;
Value of QIO assistance;
Sources of information; and
Respondent comments.

All survey protocol and correspondence will be translated into Spanish and bi-lingual telephone interviewers will be used as needed.

CENTERS FOR MEDICARE & MEDICAID SERVICES

Survey Management, Analysis, Reporting, and Technical Support

Attachment 1

Office of Management and Budget

Federal Register Notice

DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Medicare & Medicaid Services

[Document Identifier: <#########>]

Agency Information Collection Activities: Proposed Collection; Comment Request

AGENCY: Centers for Medicare & Medicaid Services

In compliance with the requirement of section 3506(c)(2)(A) of the Paperwork Reduction Act of 1995, the Centers for Medicare & Medicaid Services (CMS) is publishing the following summary of proposed collections for public comment. Interested persons are invited to send comments regarding this burden estimate or any other aspect of this collection of information, including any of the following subjects: (1) The necessity and utility of the proposed information collection for the proper performance of the agency's functions; (2) the accuracy of the estimated burden; (3) ways to enhance the quality, utility, and clarity of the information to be collected; and (4) the use of automated collection techniques or other forms of information technology to minimize the information collection burden.

Type of Information Collection Request: New

Title of Information Collection: Survey Management, Analysis, Reporting and Technical Support (SMART) Patient Safety Nursing Homes in Need (NHIN) Survey.

Use: The Centers for Medicare & Medicaid Services (CMS) and the U.S. Department of Health and Human Services (DHHS) are requesting OMB clearance for the Nursing Homes in Need (NHIN) Survey. The NHIN is a component of the Patient Safety Theme of the Quality Improvement Organization (QIO) Program’s 9th Scope of Work (SOW). The statutory authority for this scope of work is found in Part B of Title XI of the Social Security Act (the Act) as amended by the Peer Review Improvement Act of 1982. The Act established the Utilization and Quality Control Peer Review Organization Program, now known as the Quality Improvement Organization (QIO) Program.

The QIO in each state will provide special technical assistance to a small number of nursing homes in need of assistance with quality improvement efforts. This special technical assistance will be for the QIO to conduct a root cause analysis (RCA) with one nursing home in its state per year (three over three years). Under this component, it is expected that within the first quarter of the contract period, CMS will assign one nursing home to each QIO. The determination of which nursing homes are eligible under this component will be made by CMS. Some of these facilities may meet criteria for Special Focus Facilities (SFF). The intent of this component is that each state QIO will work with three nursing homes over the three-year contract period; these assignments are expected to be spaced out so that each state QIO will get one nursing home assigned approximately every 12 months.

The NHIN Survey is a new information collection to be used by CMS to obtain information on nursing home satisfaction with technical assistance strategies delivered as a component of the NHIN. The NHIN Survey will be a census of 53 nursing homes working with their respective QIOs. The survey will be conducted one time for each of the nursing homes assisted in the first two years under the 9^th SOW and it will be conducted twice with nursing homes assisted in the third year. The information collected through this survey will allow CMS to help focus the NHIN task to maximize the benefit to participating nursing homes. The NHIN Survey will be administered via telephone by trained and experienced interviewers. Responses will be entered into a pre-programmed Computer-Assisted Telephone Interviewing (CATI) interface.

Background information;
Current work – information and assessment;
Satisfaction with QIOs;
Value of QIO assistance;
Sources of information; and
Respondent comments.

All survey protocol and correspondence will be translated into Spanish and bi-lingual telephone interviewers will be used as needed.

Form Number: <##########>

Frequency: 4 times in 3 years

Affected Public: Businesses and other for-profit and not-for-profit institutions.

Number of Respondents: 53

Total Annual Respondents: 53

Total Annual Hours (years 1 and 2 of the 9^th SOW): 17.5 hours

Total Annual Hours (year 3 of the 9^th SOW): 35 hours

To obtain copies of the supporting statement and any related forms for the proposed paperwork collections referenced above, access CMS' Web Site at http://www.cms.hhs.gov/PaperworkReductionActof1995, or E- mail your request, including your address, phone number, OMB number, and CMS document identifier, to [email protected], or call the Reports Clearance Office at (410) 786-1326.

In commenting on the proposed information collections please reference the document identifier or OMB control number. To be assured consideration, comments and recommendations must be submitted in one of the following ways by <DATE>:

Electronically. You may submit your comments electronically to http://www.regulations.gov. Follow the instructions for ``Comment or Submission'' or ``More Search Options'' to find the information collection document(s) accepting comments.

By regular mail. You may mail written comments to the following address: CMS, Office of Strategic Operations and Regulatory Affairs, Division of Regulations Development, Attention: Document Identifier/OMB Control Number, Room C4-26-05, 7500 Security Boulevard, Baltimore, Maryland 21244-1850.

Dated: <DATE>

<TITLE>

[FR Doc. <##-#####>, Filed <DATE>, <TIME OF DAY>]

BILLING CODE: <#########>

__________ _________________________

Date <CMS SIGNATORY>

<TITLE>

CENTERS FOR MEDICARE & MEDICAID SERVICES

Survey Management, Analysis, Reporting, and Technical Support

Attachment 2

Nursing Homes in Need Survey

The questionnaire that follows maps to the following reporting sub-composites:

Satisfaction with the QIO Questions C4, C6, C7, C8, 10

Value - does the provider perceive value in the QIO’s interventions?

Root Cause Analysis Question B3

Action Plan Questions B7, B8

Across All interventions and Assistance Questions D1, D2, D3, D4

Other data not rolled up into composite score but required for analysis:

Background information Questions A1, A2, A3

Current work

About Root Cause Analysis and Action Plans Questions B1, B2, B5, B6

Methods used to assist practices Questions C2, C3

Other information about the assistance/intervention

Usefulness Question C1

Frequency of contact Question C5

Ease of access Question C9

Sources of information Questions E1, E2, E3

Open ended comment Questions B4, B9, F1

NOTE: THESE SCORING PARAMETERS WILL NOT APPEAR ON THE FINAL SURVEY

SECTION A: Background Information

How long have you been the main contact for the QIO?

Less than 3 months
3 months to less than 6 months
6 to 12 months
More than 12 months

What is your job title? _________________________________________________________

A3. What is the size of your nursing home?

Less than 50 beds
50-99 beds
100-199 beds
200 or more beds

SECTION B: Current Work with The QIO

Are you familiar with the root cause analysis (RCA) performed by {QIO NAME} for your facility?

Yes
No → Please Go to Question C1

Which of the following issues were addressed in the RCA? Please check all that apply.

Management capabilities, e.g., corporate, facility and the relationship between the two

Financial capabilities, e.g., fiscal structure and controls
Staffing, e.g., level of staffing, skills/education, recruitment and retention
Procedures and processes of care, e.g., adequacy, correlation between admission policy and staff capabilities
Communication, e.g., among management and staff, and staff to staff
Processes of care and outcomes for reducing pressure ulcers
Processes of care and outcomes for reducing use of physical restraints

Did the RCA appropriately identify the key areas in which you could improve? Would you…

Strongly Agree
Somewhat Agree
Neither Agree Nor Disagree
Somewhat Disagree
Strongly Disagree

Please give us your comments on the RCA

Are you familiar with the Action Plan to address issues in the RCA that {QIO NAME} developed for your facility?

Yes
No → Please Go to Question C1

Which of the following issues were addressed in the RCA? Please check all that apply.

Management capabilities, e.g., corporate, facility and the relationship between the two
Financial capabilities, e.g., fiscal structure and controls
Staffing, e.g., level of staffing, skills/education, recruitment and retention
Procedures and processes of care, e.g., adequacy, correlation between admission policy and staff capabilities
Communication, e.g., among management and staff, and staff to staff
Processes of care and outcomes for reducing pressure ulcers
Processes of care and outcomes for reducing use of physical restraints

Did the Action Plan correctly identify the areas in which you most needed improvement? Would you…

Strongly Agree
Somewhat Agree
Neither Agree Nor Disagree
Somewhat Disagree
Strongly Disagree

Was the Action Plan effective in improving quality at your facility? Would you…

Strongly Agree
Somewhat Agree
Neither Agree Nor Disagree
Somewhat Disagree
Strongly Disagree

Please give us your comments on the Action Plan

SECTION C

This section asks about how your received assistance from your QIO and your satisfaction with the assistance.

Thinking about all the information you received from the QIO, {QIO NAME}, how useful was the information you received? Would you say it was …

Very Useful
Useful
Somewhat Useful
Not Useful At All

Through which of the following methods of communication have you received information or assistance from {QIO NAME}?

	Yes	No
Site visits		
Training workshops, seminars or conferences		
One-to-one telephone communication		
Telephone conference calls		
Email		
From the QIO’s website		
Other:		
Please describe ____________________________________

Of these methods, which one method do you prefer?

___________________________________________

Thinking about all the ways through which you received information about quality improvement projects from the QIO, how satisfied or dissatisfied were you with the way in which information was presented to you?

Very Satisfied
Somewhat Satisfied
Neither Satisfied Nor Dissatisfied
Somewhat Dissatisfied
Very Dissatisfied

Since {DATE}, thinking about all types of interactions, how frequently have you been in contact with {QIO NAME}? Would you say about …

Once a week or more
Once every two weeks
Once per month
Less than once per month

Since {DATE}, how satisfied are you with the amount of contact between your organization and {QIO NAME}? Would you say you are …

Very Satisfied
Somewhat Satisfied
Neither Satisfied Nor Dissatisfied
Somewhat Dissatisfied
Very Dissatisfied

Thinking about all of the times you have tried to contact the QIO, how satisfied are you with the ease of access to the QIO?

Very Satisfied
Somewhat Satisfied
Neither Satisfied Nor Dissatisfied
Somewhat Dissatisfied
Very Dissatisfied

How satisfied are you with the timeliness of the QIO’s response to your question or request for assistance? Would you say you are …

Very Satisfied
Somewhat Satisfied
Neither Satisfied Nor Dissatisfied
Somewhat Dissatisfied
Very Dissatisfied

Thinking about all the times you contacted the QIO, how often were you able to get through to the person you were trying to reach or to someone who could help you?

Always
Usually
Sometimes
Never

Thinking about all interactions with {QIO NAME}, how satisfied are you with your relationship with the QIO overall?

Very Satisfied
Somewhat Satisfied
Neither Satisfied Nor Dissatisfied
Somewhat Dissatisfied
Very Dissatisfied

SECTION D

Please indicate your level of agreement with the following statements about the information and assistance provided by the QIO.

When implementing our quality improvement projects, we used the information provided by {QIO NAME}. Would you…

Strongly Agree
Somewhat Agree
Neither Agree Nor Disagree
Somewhat Disagree
Strongly Disagree

The assistance we received from (QIO NAME} was worth the time and effort required on the part of our staff. Would you …

Strongly Agree
Somewhat Agree
Neither Agree Nor Disagree
Somewhat Disagree
Strongly Disagree

D3 We were able to implement this intervention because of the assistance from {QIO NAME}? Would you…

Strongly Agree
Somewhat Agree
Neither Agree Nor Disagree
Somewhat Disagree
Strongly Disagree

D4. In general, the assistance we received from the QIO was key to the efficient implementation of our quality improvement projects. Would you….

Strongly Agree
Somewhat Agree
Neither Agree Nor Disagree
Somewhat Disagree
Strongly Disagree

D5 Using a scale of 1 to 10, where 1 is “The QIO did not contribute at all” and 10 is “The QIO’s contribution was indispensable,” please rate the contribution of the QIO to your quality improvement projects.

1 = The QIO did not contribute at all

10 = The QIO’s contribution was indispensable

	1	2	3	4	5	6	7	8	9	10
										

Please mark the box that corresponds to your rating

SECTION E: Sources of Information

Is there an organization that you would prefer to use for quality improvement assistance, rather than the QIO, {QIO NAME}?

Yes
No
It would depend on cost and other factors
I don’t know

What organizations or information sources do you turn to when you need information or assistance for your quality improvement initiatives?

	Yes	No
Centers for Medicare & Medicaid Services (CMS)		
CMS Nursing Home Compare		
{QIO NAME}		
MedQIC		
The Agency for Health Research and Quality (AHRQ)		
The Institute for Health Improvement (IHI)		
The American Health Quality Association (AHQA)		
The National Quality Forum		
Other membership association websites (including AMDA, AAHSA, AHCA, etc.)		
Advancing Excellence in America’s Nursing Homes campaign		
Other:		
Please describe ____________________________________

Of these organizations or information sources listed in the previous question, which one organization provides you with the most useful information and assistance?

_________________________________________

COMMENTS

Please use the space below to provide additional comments on how you view the services received from the QIO.

Thank you for completing this survey.

File Type	application/msword
File Title	PRA - PATIENT SAFETY
Author	David Bercham
Last Modified By	CMS
File Modified	2010-03-12
File Created	2010-03-12

CMS-10315.Supporting Statement Part A, B, and Instrument