Form CMS-10557 PACE Pilot Test Evaluation

PACE Pilot Test Evaluation Survey
Dear Pilot Survey Participant:
Thank you for volunteering to collect pilot data for the development of healthcare quality
measures for PACE programs. Your PACE site participated in the pilot data collection of four quality
measures (Pressure Ulcer Rate and Preventions, injury falls, pressure ulcers, and readmissions). We now
need your feedback on the four measures and the data collection process. Specifically, we want to know
about your ability to conform to the standardized measure definitions, we can estimate the average
amount of time it took to collect and report the data, and identify any issues you had with data
availability.
Please click this web link, which contains the PACE pilot data collection evaluation
survey: http://XXX.edu. We estimate that the survey will take no more than 30 minutes of your time.
Please complete the survey by [date], 2015. Again, thank you for your participation in this pilot data
collection, and we look forward to your valuable feedback.
Thank you again for the incredible work that you do.
Sincerely,
Darryl Roberts, PhD, MS, RN
Senior Social Scientist
Econometrica, Inc.

PRA Disclosure Statement
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 0938-1185. The time required to complete this information collection is
estimated to average 30 minutes, 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.

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PACE Data Collection Experience Survey
Please complete the following evaluation. We encourage you to consult with as many staff members as
possible that assisted with the pilot data collection.
Total Falls and Injury Falls
A. Questions about Feasibility
1. Please check the data sources used to collect the data elements: (Mark all that apply)
a. Site clinical records – papers
b. Site clinical records – electronic
c. Other (please specify them)
2. Approximately how much time was spent collecting information on the data elements?
__________ hours
3. Approximately how much time was spent entering the data elements on the web page?
__________hours
4. Please rate the overall burden of effort involved in collecting the data elements for “Total Fall
Rates” (1=very low burden, 2=low burden, 3=medium, 4=high burden, 5=very hard burden)
5. For each of the data elements listed below, please indicate which most accurately describes the
availability of the respective data element.
Data element

On
hand
and
easy to
find

On
hand,
but
hard to
find

Could
not
find,
could
not
collect

Comments

Date of Fall
Participant Age
Participant Gender
Clinician who documented fall
Fall was assisted by a clinician or
trained family member
Injury Level
6.

Please rate the level of difficulty you had in obtaining information for each of the data elements
listed below.
Data element

Very
easy

Easy

Somewhat Somewhat Difficult Very
Comments
easy
difficult
difficult

Date of Fall
Participant Age
Participant Gender
2

Clinician who
documented fall
Fall was assisted by
a clinician or trained
family member
Injury Level
B. Questions about Usability
Please indicate the degree to which you agree or disagree with the following statements:
7. In general, collecting “Total Falls” data is useful for quality improvement at your PACE site.
(Strongly agree, agree, tend to agree, tend to disagree, disagree, strongly disagree)
8. In general, collecting “Fall Injury Level” data is useful for quality improvement at your PACE
site.
(Strongly agree, agree, tend to agree, tend to disagree, disagree, strongly disagree)
9. The national comparison report of Total Fall Rates will be useful for quality improvement at your
PACE site.
(Strongly agree, agree, tend to agree, tend to disagree, disagree, strongly disagree)
10. The national comparison report of Fall Injury Level will be useful for quality improvement at
your PACE sites.
(Strongly agree, agree, tend to agree, tend to disagree, disagree, strongly disagree)
11. Overall, which comparison reports will you use when looking at Total Fall and Fall Injury Level
trends and comparisons with other PACE sites?
Very
frequently

Frequently

Sometimes

Not at all

Does not
apply

All PACE sites
PACE site by Caseload
size (Site size)
Metropolitan status
Academic affiliation
status
Tax status
Years of Operation

C. Questions about Validity/Reliability
Please indicate the degree to which you agree or disagree with the following statements:
12. Overall, the data elements of total falls were clearly defined in the Data Collection Guidelines.
(Strongly agree, agree, tend to agree, tend to disagree, disagree, strongly disagree)
13. Each of the following elements of Fall data was clearly defined in the Data Collection Guidelines.

3

Data element

Strongly Agree Tend to
agree
agree

Tend to
disagree

Disagree Strongly Comments
disagree

Date of Fall
Participant Age
Participant
Gender
Clinician who
documented fall
Fall was assisted
by a clinician or
trained family
member
Injury Level

14. Overall, Total Fall data collection processes were implemented consistently over the month at
your PACE site.
(Strongly agree, agree, somewhat agree, somewhat disagree, disagree, strongly disagree)
15. Overall, Fall Injury Level data collection processes were implemented consistently over the
month at your PACE site.
(Strongly agree, agree, somewhat agree, somewhat disagree, disagree, strongly disagree)
16. Each of the following elements of Fall data was collected consistently during your data collection
periods based on the Data Collection Guidelines.
Data element

Strongly Agree Tend to
agree
agree

Tend to
disagree

Disagree Strongly Comments
disagree

Date of Fall
Participant Age
Participant
Gender
Clinician who
documented fall
Fall was assisted
by a clinician or
trained family
member
Injury Level
17. Were there other components (inclusion/exclusion criteria) related to total falls that you would
like to see because they are important in order to capture total falls at the PACE site and useful
for your specific reporting, administration planning, improvement of care quality, or other needs
at your PACE site? (Yes, No)
If yes, please list and provide the components and brief rationale.
Component

Rationale

4

18. What, if any, parts of the Data Collection Guidelines were incomplete or unclear. Please be
specific and suggest language changes if appropriate.
Part of Data Collection Guidelines
Definitions
Inclusion and Exclusion Criteria
Data Elements
Others

Question or Suggestion for Improvement

19. Please list any other comments about the pilot data collection that you think would be helpful as
we finalize the Data Collection Guidelines. (Text box)

Pressure Ulcer and Pressure Ulcer Prevention
D. Questions about Feasibility
20. Please check the data sources used to collect the data elements: (Mark all that apply)
a. Site clinical records – papers
b. Site clinical records – electronic
c. Other (please specify them)
21. Approximately how much time was spent collecting information on the data elements?
__________ hours
22. Approximately how much time was spent entering the data elements on the web page?
__________hours
23. Please rate the overall burden of effort involved in collecting the data elements for “Pressure
Ulcer Rate and Prevention Rates” (1=very low burden, 2=low burden, 3=medium, 4=high
burden, 5=very hard burden)
24. For each of the data elements listed below, please indicate which most accurately describes the
availability of the respective data element.
Data element

On
hand
and
easy to
find

On
hand,
but
hard to
find

Could
not
find,
could
not
collect

Comments

Participant Age
Participant Gender
Total Number of New Pressure Ulcers
5

Pressure Ulcer Stage
Days Since Last Documented Risk
Assessment
Risk Status
Pressure Ulcer Prevention Used in
Last 24 Hours
Skin Assessment Documented
Pressure Redistribution Surface
Routine Repositioning
Nutritional Support
Moisture Management
25. Please rate the level of difficulty you had in obtaining information for each of the data elements
listed below.
Data element

Very
easy

Easy

Somewhat Somewhat Difficult Very
Comments
easy
difficult
difficult

Participant Age
Participant Gender
Total Number of
New Pressure Ulcers
Pressure Ulcer Stage
Days Since Last
Documented Risk
Assessment
Risk Status
Pressure Ulcer
Prevention Used in
Last 24 Hours
Skin Assessment
Documented
Pressure
Redistribution
Surface
Routine
Repositioning
Nutritional Support
Moisture
Management
E. Questions about Usability
Please indicate the degree to which you agree or disagree with the following statements:
26. In general, collecting “Pressure Ulcer” data is useful for quality improvement at your PACE site.
(Strongly agree, agree, tend to agree, tend to disagree, disagree, strongly disagree)
27. In general, collecting “Pressure Ulcer Stage” data is useful for quality improvement at your
PACE site.
(Strongly agree, agree, tend to agree, tend to disagree, disagree, strongly disagree)
6

28. The national comparison report of Pressure Ulcer Rate will be useful for quality improvement at
your PACE site.
(Strongly agree, agree, tend to agree, tend to disagree, disagree, strongly disagree)
29. The national comparison report of Pressure Ulcer Prevention activities will be useful for quality
improvement at your PACE site.
(Strongly agree, agree, tend to agree, tend to disagree, disagree, strongly disagree)
30. Overall, which comparison reports will you use when looking at Pressure Ulcer Rate and
Prevention and Fall Injury Level trends and comparisons with other PACE sites?
Very
frequently

Frequently

Sometimes

Not at all

Does not
apply

All PACE sites
PACE site by Caseload
size (Site size)
Metropolitan status
Academic affiliation
status
Tax status
Years of Operation

F. Questions about Validity/Reliability
Please indicate the degree to which you agree or disagree with the following statements:
31. Overall, the data elements of Pressure Ulcer Rate and Prevention were clearly defined in the Data
Collection Guidelines. (Strongly agree, agree, tend to agree, tend to disagree, disagree, strongly
disagree)
32. Each of the following elements of Pressure Ulcer data was clearly defined in the Data Collection
Guidelines.
Data element

Strongly Agree Tend to
agree
agree

Tend to
disagree

Disagree Strongly Comments
disagree

Participant Age
Participant
Gender
Total Number of
New Pressure
Ulcers
Pressure Ulcer
Stage
Days Since Last
Documented Risk
Assessment
Risk Status
Pressure Ulcer
7

Prevention Used
in Last 24 Hours
Skin Assessment
Documented
Pressure
Redistribution
Surface
Routine
Repositioning
Nutritional
Support
Moisture
Management

33. Overall, Pressure Ulcer data collection processes were implemented consistently over the month
at your PACE site.
(Strongly agree, agree, somewhat agree, somewhat disagree, disagree, strongly disagree)
34. Overall, Pressure Ulcer Stage data collection processes were implemented consistently over the
month at your PACE site.
(Strongly agree, agree, somewhat agree, somewhat disagree, disagree, strongly disagree)
35. Each of the following elements of Pressure Ulcer and Prevention data was collected consistently
during your data collection periods based on the Data Collection Guidelines.
Data element

Strongly Agree Tend to
agree
agree

Tend to
disagree

Disagree Strongly Comments
disagree

Participant Age
Participant
Gender
Total Number of
New Pressure
Ulcers
Pressure Ulcer
Stage
Days Since Last
Documented Risk
Assessment
Risk Status
Pressure Ulcer
Prevention Used
in Last 24 Hours
Skin Assessment
Documented
Pressure
Redistribution
Surface
Routine
Repositioning
8

Nutritional
Support
Moisture
Management
36. Were there other components (inclusion/exclusion criteria) related to Pressure Ulcer Rate and
Preventions that you would like to see because they are important in order to capture Pressure
Ulcer Rate and Preventions at the PACE sites and useful for your specific reporting,
administration planning, improvement of care quality, or other needs at your PACE site? (Yes,
No)
If yes, please list and provide the components and brief rationale.
Component

Rationale

37. What, if any, parts of the Data Collection Guidelines were incomplete or unclear. Please be
specific and suggest language changes if appropriate.
Part of Data Collection Guidelines
Definitions
Inclusion and Exclusion Criteria
Data Elements
Others

Question or Suggestion for Improvement

38. Please list any other comments about the pilot data collection that you think would be helpful as
we finalize the Data Collection Guidelines. (Text box)

Hospital Readmissions and Participant Days
G. Questions about Feasibility
39. Please check the data sources used to collect the unplanned readmissions: (Mark all that apply)
a. Site clinical records – papers
b. Site clinical records – electronic
c. Other (please specify them)
40. Please check the data sources used to collect the participant days: (Mark all that apply)
a. Caseload records – papers
b. Caseload records – electronic
c. Other (please specify them)

9

41. Approximately how much time was spent collecting information on unplanned hospital
readmissions? __________ hours
42. Approximately how much time was spent collecting information on participant days?
__________ hours
43. Approximately how much time was spent entering both measures on the web page?
__________hours
44. Please rate the overall burden of effort involved in collecting the data elements for unplanned
hospital readmissions (1=very low burden, 2=low burden, 3=medium, 4=high burden, 5=very
hard burden)
45. Please rate the overall burden of effort involved in collecting the data elements for participant
days (1=very low burden, 2=low burden, 3=medium, 4=high burden, 5=very hard burden)
46. For each of the data elements listed below, please indicate which most accurately describes the
availability of the respective data element.
Data element

On
hand
and
easy to
find

On
hand,
but
hard to
find

Could
not
find,
could
not
collect

Comments

Number of unplanned hospital
admissions
Number of participant days
47. Please rate the level of difficulty you had in obtaining information for each of the data elements
listed below.
Data element

Very
easy

Easy

Somewhat Somewhat Difficult Very
Comments
easy
difficult
difficult

Number of
unplanned hospital
admissions
Number of
participant days
H. Questions about Usability
Please indicate the degree to which you agree or disagree with the following statements:
48. In general, collecting Unplanned Hospital Readmissions data is useful for quality improvement at
your PACE site.
(Strongly agree, agree, tend to agree, tend to disagree, disagree, strongly disagree)
49. The national comparison report of Unplanned Hospital Readmissions will be useful for quality
improvement at your PACE site.
10

(Strongly agree, agree, tend to agree, tend to disagree, disagree, strongly disagree)

50. Overall, which comparison reports will you use when looking at Unplanned Hospital
Readmission trends and comparisons with other PACE sites?
Very
frequently

Frequently

Sometimes

Not at all

Does not
apply

All PACE sites
PACE site by Caseload
size (Site size)
Metropolitan status
Academic affiliation
status
Tax status
Years of Operation

I. Questions about Validity/Reliability
Please indicate the degree to which you agree or disagree with the following statements:
51. Overall, the data elements of unplanned hospital readmissions were clearly defined in the Data
Collection Guidelines. (Strongly agree, agree, tend to agree, tend to disagree, disagree, strongly
disagree)
52. Each of the following elements of was clearly defined in the Data Collection Guidelines.
Data element

Strongly Agree Tend to
agree
agree

Tend to
disagree

Disagree Strongly Comments
disagree

Unplanned
Hospital
Readmissions
Participant Days

53. Overall, Unplanned Hospital Readmissions data collection processes were implemented
consistently over the month at your PACE site.
(Strongly agree, agree, somewhat agree, somewhat disagree, disagree, strongly disagree)
54. Overall, Participant Days data collection processes were implemented consistently over the
month at your PACE site.
(Strongly agree, agree, somewhat agree, somewhat disagree, disagree, strongly disagree)
55. Each of the following elements was collected consistently during your data collection periods
based on the Data Collection Guidelines.
Data element

Strongly Agree Tend to
agree
agree

Tend to
disagree

Disagree Strongly Comments
disagree

Unplanned
11

Hospital
Readmissions
Participant Days
56. Were there other components (inclusion/exclusion criteria) related to Unplanned Hospital
Readmissions or Participant Days that you would like to see because they are important and
useful for your specific reporting, administration planning, improvement of care quality, or other
needs at your PACE site? (Yes, No)
If yes, please list and provide the components and brief rationale.
Component

Rationale

57. What, if any, parts of the Data Collection Guidelines were incomplete or unclear. Please be
specific and suggest language changes if appropriate.
Part of Data Collection Guidelines
Definitions
Inclusion and Exclusion Criteria
Data Elements
Others

Question or Suggestion for Improvement

58. Please list any other comments about the pilot data collection that you think would be helpful as
we finalize the Data Collection Guidelines. (Text box)

12