Form CMS-10550 Qualitative Interview Guide

Hospital Qualitative Semi-structured Interview Guide: Mapping Research Questions to Interview Questions

Attachment III — Hospital Semi-structured Qualitative Interview Guide: Mapping Research Questions to Interview Questions

2018 National Impact Assessment of Medicare Quality Measures

Research Questions	Formative Interview Goals	Section in Hospital Semi-structured Qualitative Interview Guide	Hospital Semi-structured Qualitative Interview Questions
Is the collection and reporting of performance measure results associated with changes in provider behavior (i.e., what specific changes are providers making in response)?	How the CMS performance measures are changing the way in which your hospital is delivering care.	Innovations in the delivery of care	8. Are you familiar with these quality and efficiency measures?
			9. In your experience, have the CMS measures and measurement programs led your hospital to change anything about how it delivers care? a. Please describe the changes your hospital has made. i. Which of the changes that you’ve mentioned have been implemented hospital-wide (i.e., across your entire organization)? ii. Have any of the changes focused on addressing specific CMS measures? b. If no, Why do you believe that CMS measurement programs have not led to changes in care delivery?
			10. Now, I would like you to think about your frontline physicians and other clinical staff. Have you observed frontline clinical staff initiating any changes in response to quality measurement programs? [If yes:] a. Please describe the changes the frontline clinical staff has made. b. Do you think the changes frontline clinical staff has made have affected your hospital’s performance specifically on the CMS performance measures? i. [If yes:] Which of the actions taken by frontline clinical staff do you believe have had the largest impact on your performance on the CMS measures? c. Are there areas captured in the CMS measures where it has been difficult to get physicians and other clinical staff to change their behavior? [If yes:] i. If yes, please describe which areas. ii. Why do you think it was difficult to achieve changes in frontline staff behavior? iii. How did your hospital address these barriers?
			11. Do you think any of the changes your hospital has made have affected your hospital’s performance specifically on the CMS performance measures? a. [If yes:] Based on your experience, which of the changes have had the largest impact on your performance?
			12. Have the changes your hospital has made in response to the CMS measures led to improvements in quality of care outside of the clinical areas that the CMS measures cover (i.e., spillover effects)? a. [If yes:] What measures has your hospital used to track improvements in other areas?
What factors are associated with changes in performance over time?	Factors that are driving your hospital’s investments in performance improvement.	• Factors associated with change in quality performance • Perspectives of hospital leadership and other stakeholders • Organizational structure and delivery system reform initiatives	13. For the CMS performance measures where your hospital is performing well [interviewer to have hospital performance list ready], what factors do you think help your hospital perform highly?
			14. For those measures where your hospital’s performance is lagging [interviewer to have hospital performance list ready], what factors do you believe inhibit higher performance?
			15. From your perspective, is it harder to improve scores on some CMS measures than others? a. [If yes:] Which measures, and why?
			16. Thinking about the full list of CMS measures we are discussing, do you think the CMS measures are clinically important? a. Why or why not?
			17. Do you think hospitals have sufficient control over care to be held responsible for performance on these measures? [If no:] a. Who do you think should be responsible? b. Are there other areas where CMS should consider measures to gauge your hospital’s quality performance?
			18. What do you see as the most important driver of your hospital’s investments to improve performance at your hospital?
			19. How important are each of the following as drivers of improvement in your hospital? a. Public reporting of quality scores on Hospital Compare? b. The potential to receive financial incentives for improvement or high performance? c. The threat of financial penalties for poor performance? d. Receipt of technical assistance2 related to quality improvement from CMS, a Quality Improvement Organization (QIO), Hospital Engagement Network, or community collaborative?
			20. Does your hospital participate in any non-CMS quality measurement reporting programs? Please specify. a. [If yes:] How important are the CMS measurement programs as drivers of improvement relative to other programs that measure the quality and efficiency of care in your hospital (e.g., Leapfrog, private payer programs)?
			21. Does your hospital participate in an Accountable Care Organization (ACO)? [If yes:] a. Are you part of one of the Medicare ACOs? b. Does your hospital participate in a Medicaid ACO? c. Are you part of an ACO arrangement i. [If yes:] How many different private insurer ACOs is your hospital part of? d. Is your hospital financially at risk (i.e., downside risk) in any of these ACO arrangements?
			22. Is your hospital part of an integrated delivery system?
			23. Is your hospital participating in any other type of alternative payment model? [If yes:] a. Are these shared savings models? b. Is your hospital at risk financially in any of these arrangements?
			24. What is the position of the person who directs quality improvement activities in your hospital? a. Does this person [or these persons] report to an executive manager, such as the Chief Medical Officer (CMO) or Chief Executive Officer (CEO)?
			25. Does your organization have a quality improvement department?
			26. Has your hospital used any of the following care redesign methods to improve quality? a. Deming/lean processes (i.e., constantly improve the system of production and service to improve quality and decrease cost)? b. Six Sigma (i.e., measurement-based strategy/data-driven approach for eliminating defects; focuses on process improvement and variation reduction)? c. Plan, Do, Study, Act (PDSA) improvement cycles? d. Other methods? Please specify.
			27. Does your hospital have an electronic health record (EHR)? [If yes:] a. Is your hospital’s EHR able to exchange information electronically within all departments in the hospital? i. [If “don’t know”:] Is there someone we can speak with in your organization who might be able to answer some of these questions about your EHR? b. Is your hospital’s EHR able to electronically exchange information with providers in your community (e.g., ambulatory physicians and nursing homes)? i. [If “don’t know”:] Is there someone we can speak with in your organization who might be able to answer some of these questions about your EHR? c. Does your EHR have clinical decision support5 functions embedded in the system to assist clinicians and providers? i. [If yes:] For what clinical areas or functions? ii. Do any of the clinical decision supports address CMS quality and efficiency measure areas? Which areas? d. Does your EHR help your doctors and other health care providers monitor the quality of care they are providing (Prompts: changes in patient functioning, summary results)? e. Does your hospital use the EHR system to report the CMS quality and efficiency measures?
			28. Does your hospital provide physicians, nurses, and other clinical staff (such as pharmacists and physical therapists) with information about your hospital’s performance on the CMS quality and efficiency measures? a. [If yes:] How often do physicians and nurses receive feedback on their performance on the measures?
			29. On a scale of 0 to 10, with 0 being extremely unsupportive and 10 being extremely supportive, how would you characterize the executive management team’s support of the CMS measurement programs?
			30. On a scale of 0 to 10, with 0 being extremely unsupportive and 10 being extremely supportive, how would you characterize the physicians’ support of the CMS measurement programs?
			31. On a scale of 0 to 10, with 0 being extremely unsupportive and 10 being extremely supportive, how would you characterize the nursing leadership’s support of the CMS measurement programs?
			32. Finally, on a scale of 0 to 10, with 0 being extremely unsupportive and 10 being extremely supportive, how would you characterize the hospital board of directors’ support of the CMS measurement programs?
Are there unintended consequences associated with implementation of CMS quality measures?	Potential undesired effects associated with the measures.	• Effects of performance measurement programs	35. Are you aware of any undesired effects in your hospital that stem from the CMS measurement program and the use of the measures in public reporting and payment/value-based purchasing efforts? a. [If yes:] Please describe these undesired effects. i. Why do you think these undesired effects have occurred? ii. What do you think could be done to mitigate those undesired effects? [If no, or respondent is vague on specific undesired effects:] b. One problem identified by hospitals was related to a pneumonia measure that assessed whether pneumonia patients were given initial antibiotic(s) within 6 hours after arrival. The concern was that hospitals might over-prescribe antibiotics, by providing antibiotics to patients with low probability of pneumonia in order to ensure the metric is met. Do you think such inappropriate changes in treatment occur as a result of the CMS measures? i. [If yes:] Can you give any other examples of measures where this might occur? c. Some are also concerned that hospitals might focus a great deal of effort on data coding to increase reimbursement or exclude sicker patients from the measure calculation. In your opinion, do you think the CMS measurement programs incentivize an increased focus on coding? (Clarify that we are not talking about more accurate coding) i. [If yes:] Have you seen or heard of a particular emphasis on coding for any measures in particular? d. Hospitals may also avoid sicker or more difficult patients in order to achieve higher scores on the quality and efficiency measures. Have you heard of this happening? (YES/NO/DON’T KNOW) ii. [If yes:] Have you heard it in association with any measures in particular? e. Hospitals might focus all their improvement efforts on areas of care where performance is being measured or financially incentivized and ignore or pay less attention to areas of care that are not measured. Do you think this happens? i. [If yes:] Does it happen with any specific measures in particular?
			36. CMS has been working to evolve the design of its measurement programs. For example, CMS has considered incorporating more outcome measures. Do you think this is a positive change? a. Do you believe it will be more difficult for your hospital to achieve high performance on outcome measures? i. [If yes:] Why? b. In your opinion, will inclusion of outcome measures result in any additional undesired consequences? i. [If yes:] What could be done to mitigate the problem?
Are there barriers to providers in implementing CMS quality measures?	Challenges your hospital faces related to improvement on the CMS measures	• Perspectives of hospital leadership and other stakeholders • Challenges to implementing CMS measures • Challenges to Reporting the CMS Measures	29. On a scale of 0 to 10, with 0 being extremely unsupportive and 10 being extremely supportive, how would you characterize the executive management team’s support of the CMS measurement programs? a. Has this support changed over time?
			30. On a scale of 0 to 10, with 0 being extremely unsupportive and 10 being extremely supportive, how would you characterize the physicians’ support of the CMS measurement programs? a. Has this support changed over time?
			31. On a scale of 0 to 10, with 0 being extremely unsupportive and 10 being extremely supportive, how would you characterize the nursing leadership’s support of the CMS measurement programs? a. Has this support changed over time?
			32. Finally, on a scale of 0 to 10, with 0 being extremely unsupportive and 10 being extremely supportive, how would you characterize the hospital board of directors’ support of the CMS measurement programs? a. Has this support changed over time?
			33. Have you experienced difficulties in reporting the CMS measures? a. Please describe the difficulties. b. How did you address these difficulties?
			34. Have you experienced difficulties with improving performance on the CMS measures? [If yes:] a. Please describe these difficulties. b. How did you address these difficulties?

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