The Medicare Acute Care Episode Demonstration (CMS-10317)

The Medicare Acute Care Episode Demonstration

ACE OMB FocusGroup-and-Interview Protocols

The Medicare Acute Care Episode Demonstration (CMS-10317)

OMB: 0938-1117

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Evaluation of the Acute Care Episode (ACE) Demonstration
Protocols for
Key Stakeholder Interviews and Focus Groups

IMPAQ International, LLC

Table of Contents
Introduction ................................................................................................................................... 1
Site Visit One ................................................................................................................................. 1
Key Stakeholder Interviews ................................................................................................... 1
Chief Executive Officer/Chief Financial Officer/Chief Operations Officer................. 3
Hospital Managers (Directors/Managers/VPs of Cardiac Medicine and/or
Orthopedics) .................................................................................................................. 4
ACE Manager (Individual designated as the primary local coordinator of the
demonstration) .............................................................................................................. 5
Focus Groups ......................................................................................................................... 6
Focus Group Participants: Physicians ........................................................................... 7
Focus Group Participants: Non-Physicians .................................................................. 8
Focus Group Participants: Beneficiaries ....................................................................... 9
Site Visit Two............................................................................................................................... 10
Key Stakeholder Interviews ................................................................................................. 10
Chief Executive Officer/Chief Financial Officer/Chief Operations Officer............... 11
Hospital Managers (Directors/Managers/VPs of Cardiac Medicine, Orthopedics,
Nursing, Procurement, Physical Therapy, etc.) .......................................................... 12
ACE Manager (Individual designated as the primary local coordinator of the
demonstration) ............................................................................................................ 13
Focus Groups ....................................................................................................................... 14
Focus Group Participants: Physicians ......................................................................... 15
Focus Group Participants: Non-Physicians ................................................................ 16
Focus Group Participants: Beneficiaries ..................................................................... 17

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Introduction
Qualitative data will be collected from individuals who are directly involved in the
implementation and management of the Acute Care Episode (ACE) Demonstration or who are
affected by it. Data collection will take place over two rounds of site visits to the five
demonstration sites in Texas, Oklahoma, Colorado, and New Mexico. Through semi-structured
interviews and focus groups, qualitative information will be gathered from key decision-makers
and stakeholders such as hospital administrators and executive management, implementing staff
at the demonstration hospitals, and Medicare beneficiaries who have undergone demonstration
procedures at the hospitals.
The interview and focus group protocols are guide questions to be used during the site visits.
They are purposefully general so as not to preclude additional insights that might be shared and
to allow enough flexibility to capture new knowledge and situations that may arise during the
evaluation process. As qualitative research, the findings will be catalogued and analyzed,
keeping in mind that these are individuals’ observations and perceptions, with no attempt made
by the team to quantify or prioritize responses. Protocols are established to ensure that the
subject areas planned for the demonstration are comprehensively explored and that the
discussions are presented to all participants in a consistent fashion.

Site Visit One
Near the end of the first year of the demonstration, site visits will take place at each
demonstration hospital. The focus of site visit one, will be on questions related to the planning
and implementation of the demonstration, initial changes made in response to the demonstration,
initial perceptions of how the demonstration has affected care, how the incentives are operating,
and initial satisfaction. The evaluation team will also use this site visit to identify changes made
in the site design that could impact the quantitative analyses and to identify areas for
examination between the demonstration and the control hospitals.
Key Stakeholder Interviews
Individuals responsible for managing key components of the planning and implementation of the
demonstration will be interviewed to gather information about the hospital’s interest in the
demonstration, expectations of the demonstration, plans to meet demonstration goals, and
challenges faced during the first year of the demonstration. These persons may include the Chief
Executive Officer, the Chief Financial Officer, the Chief Operational Officer, department heads
(nursing, cardiothoracic surgery, orthopedic surgery, etc.), the ACE manager/liaison, or others,
depending on the organizational structure of the particular hospital.

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A letter of introduction will be sent to each hospital at least one month prior to the site visit. The
letter will address the CEO and the ACE manager/liaison at each site, describe the purpose of the
interviews, and facilitate further discussions of the site visit logistics. The interviews will be
conducted by senior members of the evaluation team with the use of the structured protocols in
this document. They will be conducted on site at the hospital and will take up to 90 minutes.
Agreement for video/audio taping will be obtained prior to the interviews. Because the key
stakeholders are all persons who will be interviewed during their work hours about specific
work-related activities that are components of the demonstration, no additional compensation
will be offered. In cases where an ACE demonstration site includes multiple hospitals, the
interviews with the staff of each hospital will be coordinated.

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Site Visit One
Key Stakeholder Interview:
Chief Executive Officer/Chief Financial Officer/Chief Operations Officer
1. Please elaborate on the reasons why [hospital name] decided to participate in the Acute
Care Episode Demonstration. What components of the demonstration (quality of care, cost
control, and/or coordination of care) were most important to you in choosing to participate?
2. Prior to the demonstration, what strategies were in place to address changes in patient
volume, to implement quality improvement, to control cost, and to improve coordination of
care? What strategies were implemented in the first year of the demonstration?
3. Do you expect that the demonstration will influence the reputation of your hospital? Would
this lead to increased market share and/or increased beneficiary satisfaction?
4. In the past year, have you observed changes in volume at your hospital that you attribute to
participation in the demonstration?
5. What challenges have you faced meeting the demonstration goals of quality improvement,
cost-control, and efficient coordination of care?
6. How are quality metrics monitored (ACE metrics and the hospital’s internal metrics)?
What steps are taken to meet quality benchmarks?
7. To what extent were physicians willing, or resistant, to participate in the demonstration?
8.

When implementing new demonstration-related protocols, how do you monitor physician
compliance? How do you get the physicians on board?

9. Other than beneficiary shared savings payments, what other non-monetary incentives does
your hospital offer ACE beneficiaries?
10. In the first year of the demonstration, have you made any changes to your implementation
strategy? What would you have done differently?
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of
information unless it displays a valid OMB control number. The valid OMB control number for this information
collection is 0938-XXXX. The time required to complete this information collection is estimated to average (1.5
hours) or (90 minutes) per response, including the time to review instructions, search existing data resources,
gather the data needed, and complete and review the information collection. If you have comments concerning the
accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security
Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

IMPAQ International, LLC

Site Visit One
Key Stakeholder Interview:
Hospital Managers (Directors/Managers/VPs of Cardiac Medicine and/or Orthopedics)
1. What are the reasons [hospital name] decided to participate in the Acute Care Episode
Demonstration? What components of the demonstration (quality of care, cost control,
and/or coordination of care) were most important to you in choosing to participate?
2. Prior to the demonstration, what strategies in your department were in place to address
changes in patient volume, to implement quality improvement, to control costs, and to
improve coordination of care? What strategies were implemented in the first year of the
demonstration?
3. In the past year, have you observed changes in your department in patient volume,
quality, coordination of care, and cost control? Have these changes met your
expectations?
4. Do you expect that the demonstration will influence the reputation of your hospital?
Would this lead to increased market share and/or increased beneficiary satisfaction?
5. How are quality metrics monitored (ACE metrics and the hospital’s internal metrics)?
What steps are taken to meet quality benchmarks?
6. What challenges have you faced meeting the demonstration goals of quality
improvement, cost-control, and efficient coordination of care? How have you addressed
these challenges?
7. To what extent were physicians willing, or resistant, to participate in the demonstration?
How did other staff react to the demonstration?
8.

When implementing the new demonstration-related protocols, how do you monitor
physician and staff compliance? How do you get them on board?

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of
information unless it displays a valid OMB control number. The valid OMB control number for this information
collection is 0938-XXXX. The time required to complete this information collection is estimated to average (1.5
hours) or (90 minutes) per response, including the time to review instructions, search existing data resources,
gather the data needed, and complete and review the information collection. If you have comments concerning the
accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security
Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

IMPAQ International, LLC

Site Visit One
Key Stakeholder Interview:
ACE Manager (Individual designated as the primary local coordinator of the demonstration)
1. As the ACE manager, what are your main responsibilities at the hospital in relation to the
demonstration? Does your primary role involve financial transactions and claims
processing or are do you work with department managers and participating physicians?
2. What strategies have been developed for the demonstration to address changes in patient
volume, quality, controlling costs, and coordination of care? How were these strategies
developed and who was involved?
3. What challenges have you faced meeting the demonstration goals of quality
improvement, cost-control, and efficient coordination of care? How have you addressed
these challenges?
4. What, if any, new initiatives did your hospital introduce in response to the demonstration
in the areas of quality, coordination of care, and marketing?
5. Other than beneficiary shared savings payments, what non-monetary incentives does your
hospital offer ACE beneficiaries?
6. How are quality metrics monitored (ACE metrics and the hospital’s internal metrics)?
What steps are taken to meet quality benchmarks?
7. What instruments/tools have you used to monitor demonstration performance or
successes? Have there been any issues in physician payments? Including the beneficiary
shared savings payments, how does the beneficiary incentive program work at your
hospital?

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Focus Groups
Focus groups will be conducted on site at each participating hospital in a room provided by the
facility. The sessions will last 90 minutes and be held at various times of the day to
accommodate staff schedules and the travel needs of beneficiaries who are likely to be older
adults.
Participants will be welcomed and made comfortable. A brief written questionnaire will be
administered, with assistance given as needed, to gather basic information about each participant
(site, age, sex, demonstration study role [beneficiary, staff/area/role]). Participants will be
assisted in locating a seat and will be allowed to mingle and secure refreshments. Each session
will begin with a welcome by the moderator, an orientation to the setting, and an explanation of
how the session will be conducted. Written informed consent will be obtained from each
participant. General ground rules will be established about respectful listening (no criticism of
others’ statements). Participants will be cautioned about revealing confidential information and
they will be informed that they are free to participate in the discussion as little or as much as they
desire, including withdrawing from the group. The moderator will ensure that each individual
has an opportunity to participate as much as he/she is willing, without being made to feel
pressured.
Staff will be invited to participate in either a physician focus group or a non-physician focus
group (e.g. nurses, physical therapists, occupational therapists). Staff will not be offered an
incentive to participate, since the focus groups will be held during normal work hours, and staff
may be provided with compensatory time by their organization. Complying with the needs of the
various components of the evaluation was a requirement for participating in the demonstration,
so organizations are expected to make staff available to the focus groups. An appropriate meal
will be provided. The session will begin with a general overview of the demonstration — when,
how, and why it began, its components, the persons responsible for various aspects of the
process, etc. This general discussion will frame the responses below to ensure that participants
are focused on the appropriate set of processes and activities because there may be concomitant
institutional initiatives that could be confused with the ACE demonstration.
Beneficiary focus groups reflect the individual’s own acute care episode experience. Exploring
the issues below at both site visits allows us to understand the beneficiary experience as the
demonstration matures (early versus later stages). Areas of focus include the effects of marketing
the demonstration, the effect of financial incentives, and beneficiary satisfaction.

IMPAQ International, LLC

Site Visit One
Focus Group Participants: Physicians
1. How has the demonstration affected your scope of activity at this hospital and the provision
of services?
2. Are you satisfied with the organizational/protocol changes that have taken place at the
hospital as a result of the demonstration?
3. Of those of you who have privileges at other hospitals, are there aspects of the
demonstration that persuaded you to perform the procedures here?
4. In your department, has the demonstration affected relationships between physicians,
nurses, and other support staff?
5. Is the demonstration facilitating real changes in quality improvement strategies and cost
reduction or simply reinforcing former initiatives?
6. As physicians, do you feel that there is pressure from administrators to conform to new
expectations of efficiency and cost savings? How have administrators encouraged
physicians to comply?
7. Have the hospital’s gainsharing policies influenced you to adjust your practices in order to
control costs and/or improve quality?
8. From your perspective, how has the demonstration affected the coordination of care, length
of stay, number and type of services provided, and other processes included in performing
ACE procedures?
9. As a result of changes to coordination of care, have you altered your patient discharge
process, number of discharges to post-acute care centers, and/or observed any differences
in patient readmission patterns?

IMPAQ International, LLC

Site Visit One
Focus Group Participants: Non-Physicians
1. How has the demonstration affected your scope of activity at this hospital and the provision
of services?
2. Are you satisfied with the organizational/protocol changes that have taken place at the
hospital as a result of the demonstration?
3. Is the demonstration facilitating real changes in quality improvement, coordination of care,
and cost reduction or simply reinforcing former initiatives?
4. Do you feel there is pressure from administrators to conform to new expectations of
efficiency and cost savings? How have administrators encouraged staff to comply?
5. Are there hospital incentives that have influenced you to adjust your practices in order to
control costs and/or improve quality? What are those incentives?
6. In your department, has the demonstration affected relationships between physicians,
nurses, and other support staff?
7. From your perspective, how has the demonstration affected the coordination of care, length
of stay, number and type of services provided, and other processes included in performing
ACE procedures?

IMPAQ International, LLC

Site Visit One
Focus Group Participants: Beneficiaries
1. When you underwent [applicable demonstration procedure] at this hospital, were you
aware that this hospital was part of the Acute Care Episode (ACE) Demonstration? Or that
the hospital was as a Medicare Value Based Care Center? When and how did you learn
about the demonstration?
2. Why did you have your [demonstration procedure] at this hospital? Did you and/or your
physician consider other hospitals?
3. Were you aware of any incentives or benefits offered at this hospital prior to your
procedure? When did you learn about these offerings? Did they make a difference in
deciding where to have your procedure?
4. Were you satisfied with the care you received during your hospitalization? What aspects of
your experience contributed to your satisfaction (e.g. hospital amenities, your relationship
with your care providers, the follow-up care you received, financial incentives)?

IMPAQ International, LLC

Site Visit Two
Site visit two will occur during year three of the demonstration (the final year). At that point in
time, all components of the demonstration should be fully operational. Key stakeholders will be
able to discuss the extent to which the demonstration met their expectations, what strategies were
implemented to achieve demonstration goals, significant challenges that could have been
avoided, assumptions that may not have withstood the actual implementation, and their
satisfaction with the experience.
Key Stakeholder Interviews
The focus of the interviews will be on how the demonstration evolved and changed in areas
including incentives and incentive structures, gainsharing, provision and coordination of care,
development of algorithms to reduce utilization or length of stay, efficiency and cost-saving
strategies, marketing, and changes in patient volume. Most discussion points will be the same as
during site visit one, but the participants will have had one to two years of experience with the
demonstration. The same key positions will be interviewed, although some personnel changes
may have occurred. The interview team will be mindful of these transitions, and will record the
length of time the incumbent has in the position.

IMPAQ International, LLC

Site Visit Two
Key Stakeholder Interview:
Chief Executive Officer/Chief Financial Officer/Chief Operations Officer
1. Did the demonstration meet your expectations in terms of changes to patient volume, cost
control, and quality/coordination of care?
2. What challenges did you face making changes to infrastructure, improving and monitoring
quality, and meeting cost-control goals? What strategy changes did you make to address
these challenges? Which strategies were most successful and why?
3. How were quality metrics monitored (ACE metrics and the hospital’s internal metrics)?
Did this evolve during the demonstration? What steps were taken to meet quality
benchmarks?
4. What were your marketing strategies for the demonstration and how did they affect volume
and your hospital’s reputation? Would you attribute these changes to the demonstration?
5. Have there been changes to the physicians’ willingness or resistance to the demonstration
and the demonstration-related protocols in particular over time? If so, do you think the
changes were a result of the gainsharing policies, financial incentives, other physician
benefits you introduced?
6. Were the gainsharing policies modified in response to the demonstration? Were other staff
or beneficiary incentives introduced/modified during the demonstration?
7. What “lessons learned” and potential refinements to the demonstration design would you
recommend for a larger scale implementation of this program?

IMPAQ International, LLC

Site Visit Two
Key Stakeholder Interview:
Hospital Managers (Directors/Managers/VPs of Cardiac Medicine, Orthopedics, Nursing,
Procurement, Physical Therapy, etc.)
1. Did the demonstration meet your expectations in terms of changes to patient volume, cost
control, and quality/coordination of care?
2. In your department, what challenges did you face making changes to infrastructure,
improving and monitoring quality, and meeting cost-control goals? What strategy
changes did you make to address these challenges? Which strategies were most
successful and why?
3. In your department have you seen changes in the areas of patient volume, quality
improvement, coordination of care, and cost control since the start of the demonstration?
Have these changes met your expectations?
4. How were quality metrics monitored (ACE metrics and the hospital’s internal metrics)?
Did it change over time? What steps were taken to meet quality benchmarks?
5. Have there been changes in your staff’s willingness or resistance to the demonstration
and the demonstration-related protocols in particular? If so, do you think the changes
were a result of the gainsharing policies, financial incentives, other benefits you
introduced?
6. Were the gainsharing policies modified in response to the demonstration? Were other
staff or beneficiary incentives introduced/modified during the demonstration?
7. What “lessons learned” and potential refinements to the demonstration design would you
recommend for larger scale implementation of this program?

IMPAQ International, LLC

Site Visit Two
Key Stakeholder Interview:
ACE Manager (Individual designated as the primary local coordinator of the demonstration)
1. Have your responsibilities as ACE manager changed over the course of the
demonstration?
2. Did the demonstration meet your expectations in terms of changes to patient volume, cost
control, and quality/coordination of care?
3. What challenges did you face meeting the demonstration goals of quality improvement,
cost-control, and efficient coordination of care? What strategy changes did you make to
address these challenges? Which strategies were most successful and why?
4. How were quality metrics monitored (ACE metrics and the hospital’s internal metrics)?
Did it change over time? What steps were taken to meet quality benchmarks?
5. What were your marketing strategies for the demonstration and how did they affect
volume and your hospital’s reputation? Would you attribute these changes to the
demonstration?
6. What, if any, new initiatives did your hospital introduce in response to the
demonstration?
7. Other than beneficiary shared savings payments, what other non-monetary incentives
does your hospital offer ACE beneficiaries? Did these change over time?
8. What “lessons learned” and potential refinements to the demonstration design would you
recommend for a larger scale implementation of this program?

IMPAQ International, LLC

accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security
Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

Focus Groups
The focus of the site visit two focus groups will be on how the demonstration evolved and
changed in areas including incentives and incentive structures, gainsharing, provision and
coordination of care, development of algorithms to reduce utilization or length of stay, efficiency
and cost-saving strategies, marketing, quality of care, and changes in patient volume. Most
discussion points will be the same as during site visit one, but the participants will have had one
to two years of experience with the demonstration. For staff focus groups, the same key positions
will be interviewed, although some personnel changes may have occurred. The interview team
will be mindful of these transitions, and will record the length of time the incumbent has in the
position. For beneficiary focus groups, no changes will be made in protocol.

IMPAQ International, LLC

Site Visit Two
Focus Group Participants: Physicians
1. Did the demonstration meet your expectations in terms of changes to patient volume,
coordination of care, and the implementation of gainsharing policies?
2. How has the demonstration affected your scope of activity at this hospital and the provision
of services?
3. Of those of you who have privileges at other hospitals, were there aspects of the
demonstration that persuaded you to perform the procedures here? Were any new
incentives introduced during the demonstration to change your perspective?
4. Are you satisfied with the organizational/protocol changes that have taken place at the
hospital as a result of the demonstration?
5. Over the course of the demonstration, have you observed any changes in number and types
of procedures performed in your department? Do you attribute these changes to the
demonstration? If volume has increased, as physicians, how have you attempted to
maintain/improve quality of care in your department?
6. Over the course of the demonstration have the relationships between physicians, nurses,
and other support staff markedly improved or deteriorated as a result of the demonstration?
7. How do you coordinate with staff in your department to control costs and to meet quality
benchmarks?
8. As physicians, do you feel that there is pressure from administrators to conform to new
expectations of efficiency and cost savings? How have administrators encouraged
physicians to comply?
9. Were the gainsharing policies modified in response to the demonstration? Have the
hospital’s gainsharing policies influenced you to adjust your practices in order to control
costs and/or improve quality?
10. As physicians, what recommendations would you make if this demonstration were to be
implemented on a larger scale?
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of
information unless it displays a valid OMB control number. The valid OMB control number for this information
collection is 0938-XXXX. The time required to complete this information collection is estimated to average (1.5
hours) or (90 minutes) per response, including the time to review instructions, search existing data resources,
gather the data needed, and complete and review the information collection. If you have comments concerning the
accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security
Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

IMPAQ International, LLC

Site Visit Two
Focus Group Participants: Non-Physicians
1. Did the demonstration meet your expectations in terms of changes to patient volume and
coordination of care?
2. How has the demonstration affected your scope of activity at this hospital and the provision
of services?
3. Are you satisfied with the organizational/protocol changes that have taken place at the
hospital as a result of the demonstration?
4. Over the course of the demonstration, have you observed any changes in number and types
of procedures performed in your department? Do you attribute these changes to the
demonstration? If volume has increased, how have you attempted to maintain/improve
quality of care in your department?
5. Over the course of the demonstration, have the relationships between physicians, nurses,
and other support staff markedly improved or deteriorated as a result of the demonstration?
6. How do you coordinate with staff in your department to control costs and to meet quality
benchmarks? Did this evolve over time?
7. Do you feel that there is pressure from administrators to conform to new expectations of
efficiency and cost savings? How have administrators encouraged staff to comply?
8. Are there hospital incentives that influenced you to adjust your practices in order to control
costs and/or improve quality? What were those incentives?
9. What recommendations would you make if this demonstration were to be implemented on
a larger scale?

IMPAQ International, LLC

Site Visit Two
Focus Group Participants: Beneficiaries
1. When you underwent [applicable demonstration procedure] at this hospital, were you
aware that this hospital was part of the Acute Care Episode (ACE) Demonstration? Or that
the hospital is a Medicare Value-Based Care Center? When and how did you learn about
the demonstration?
2. Why did you have your [demonstration procedure] at this hospital? Did you and/or your
physician consider other hospitals?
3. Were you aware of any incentives or benefits offered at this hospital prior to your
procedure? When did you learn about these offerings? Did they make a difference in
deciding where to have your procedure?
4. Were you satisfied with the care you received during your hospitalization? What aspects of
your experience contributed to your satisfaction (e.g. hospital amenities, your relationship
with your care providers, the follow-up care you received, financial incentives)?

IMPAQ International, LLC

File Type	application/pdf
Author	Jasmine Ainetchian
File Modified	2010-05-18
File Created	2010-05-06