CMS-10550 Structured Research Question Mapped to Survey Questions

Hospital Standardized Survey: Research Questions Mapped to Survey Questions

Attachment IV — Hospital Standardized Survey: Research Questions Mapped to Survey Questions

2018 National Impact Assessment of Medicare Quality Measures

Research Questions	Formative Interview Goals	Section of Hospital Standardized Survey	Hospital Standardized Survey 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. We are interested in understanding what changes your hospital has made in the way care is being delivered to improve its quality performance. Has your hospital made any of the following changes in order to improve performance on the CMS measures? a. Adopted practices to become a “learning organization.” b. Implemented a “culture of safety.” c. Implemented an electronic health record (EHR). d. Implemented electronic tools to support frontline clinical staff, such as clinical decision support, condition-specific electronic alerts, or automated prompts. e. Implemented risk prediction tools to identify and manage high-risk patients. f. Implemented an electronic health information system that shares key patient information with providers in the community (e.g., nursing homes and ambulatory care providers). g. Implemented standardized care protocols or checklists. h. Implemented appropriateness criteria to guide physician decision making for selected procedures, imaging studies, or tests. i. Implemented a post-discharge continuity of care program to prevent readmissions. j. developed a system for tracking patient outcomes. k. Adopted care redesign/re-engineering (e.g., Deming/Lean Engineering, Six Sigma, Plan, Do, Study, Act (PDSA) improvement cycles). I. Provided training to physicians and/or nurses on quality improvement strategies. m. Provided routine feedback on your hospital’s performance on CMS measures to physicians and other clinical staff. n. Used performance on CMS measures as a basis for determining pay for physicians or other clinical staff. o. Implemented an internal incentive or bonus program for senior leaders and/or senior management based on performance on CMS measures. p. Gave hospital staff awards or other special recognition tied to quality performance. q. Increased the number of staff dedicated to quality improvement or quality management. r. Identified Physician/Nurse champions for quality improvement initiatives or projects. s. Implemented quality improvement initiatives targeted to specific CMS measures. t. Obtained technical assistance from CMS (i.e., a CMS Quality Improvement Organization) or from private organizations (e.g., quality improvement collaboratives, consulting firms) in collecting and reporting performance measures. u. Implemented interdisciplinary rounds or team “huddles” or formation of multi-specialty patient care teams. v. Implemented or changed communication protocols to support or improve collaboration among clinicians and staff (i.e., Situation Background Assessment Recommendation (SBAR), hand off or paging protocols, etc.) w. Implemented changes to how nursing staff is deployed (e.g., change in staffing levels or work hours, use of contract or contingent staff) x. Other change or innovation. Please specify:
			9. Have the changes your hospital has made in response to the CMS measures led to improvements in areas of care not measured by CMS?
			10. Has your hospital measured or documented the actual improvements in the areas of care not measured by CMS?
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	13. There are many factors that influence a hospital’s decision to invest in efforts to improve its quality performance. Please rank the importance of each of the following factors in your hospital’s decision to invest in quality improvement efforts for CMS measures. a. Potential to receive financial incentives for improved performance (i.e., pay for performance) b. Threat of financial penalties for low performance (e.g., non-payment for hospital readmissions within 30 days or for hospital-acquired infections) c. Public reporting of your hospital’s performance results on the CMS Hospital Compare website d. Participation in alternative payment models (e.g., ACOs, bundled payment arrangements) where there is an opportunity for shared reward (savings) and shared financial risk
			14. Many different factors may help a hospital improve their performance. Please rank the top 3 factors that have helped your hospital improve performance on some or all of the CMS measures. a. Your hospital’s organizational culture b. Hospital leadership support and engagement c. Effective relationship between management and staff d. Having dedicated resources for quality improvement d. Internal incentives tied to performance on CMS measures f. Internal accountability for performance on CMS measures g. Having strong data systems h. Providing feedback to clinical and nursing staff on performance on CMS measures i. Having a system-wide focus on quality and quality improvement j. Networking with other hospitals and health systems to identify elements of high-performing organizations k. Investments in care redesign or re-engineering l. Investments in patient safety m. Other (please specify):
			19. How often do meetings of your hospital’s board include a review and discussion of the hospital’s performance on the CMS measures?
			20. Which of the following best describes your hospital’s board? 1 Board is more engaged in financial performance issues than quality performance issues. 2 Board is equally engaged in financial performance issues and quality performance issues. 3 Board is more engaged in quality performance issues than financial performance issues.
			21. On a scale from 0 to 10, where 0 is not at all supportive and 10 is extremely supportive, how would you describe the hospital board of director’s support of your hospital’s efforts to improve performance on CMS measures?
			22. On a scale from 0 to 10, where 0 is not at all supportive and 10 is extremely supportive, how would you describe the hospital leadership’s (e.g., the C-Suite executive management) support of your hospital’s efforts to improve performance on CMS measures?
			23. On a scale from 0 to 10, where 0 is not at all and 10 is a great deal, how much does your hospital leadership promote a culture of quality?
			24. On a scale from 0 to 10, where 0 is not at all supportive and 10 is extremely supportive, how would you describe the nursing leadership’s support of your hospital’s efforts to improve performance on CMS measures?
			25. On a scale from 0 to 10, where 0 is not at all supportive and 10 is extremely supportive, how would you describe physicians’ support of your hospital’s efforts to improve performance on CMS measures?
Are there unintended consequences associated with implementation of CMS quality measures?	Potential undesired effects associated with the measures.	• Undesired effects of CMS quality measurement programs	15. Has your hospital observed any undesired effects stemming from using or reporting CMS measures?
			16. In your opinion, do you think any of the following has occurred in your hospital as a result of your hospital being held accountable for performance on CMS measures? a. Fewer resources for quality improvement in areas of clinical care that are not the focus of CMS performance measures b. Focus on narrow improvement for specific measures rather than across the board improvement in care c. Overtreatment of patients to ensure that a measure is met d. Increased focus on documentation or coding of data to attain a higher score e. Changing coding of data or documentation to ensure that a measure is met f. Avoiding sicker or more challenging patients when providing care
			17. To your knowledge, have other hospitals observed any undesired effects stemming from the CMS measures and their use in public reporting and for payment/value-based purchasing?
			18. To your knowledge, have any of the following occurred in other hospitals as a result of being held accountable for performance on CMS measures? a. Fewer resources for quality improvement in areas of clinical care that are not the focus of CMS performance measures b. Focus on narrow improvement for specific measures rather than across the board improvement in care c. Overtreatment of patients to ensure that a measure is met d. Increased focus on documentation or coding of data to attain a higher score e. Changing coding of data or documentation to ensure that a measure is met f. Avoiding sicker or more challenging patients when providing care
Are there barriers to providers in implementing CMS quality measures?	Challenges your hospital faces related to improvement on the CMS measures	• Use of health information technology • Hospital's experience with CMS measures	26. Does your hospital have an electronic health record (EHR)?
			27. Is your hospital’s EHR able to exchange information electronically with all departments in the hospital?
			28. Are health providers in your community (i.e., ambulatory care physicians, nursing homes) able to access your hospital’s EHR or health information system to obtain key clinical data on patients?
			29. Which of the following types of information are health providers in your community (i.e., ambulatory care physicians, nursing homes) able to access electronically through your hospital’s EHR or health information system? a. Diagnostic/treatment summary b. Discharge instructions c. Lab tests/Imaging results d. Prescribed medications
			30. Is your hospital able to electronically access information on patients from other providers in your community (i.e., ambulatory care physicians, nursing homes)?
			31. Does your hospital’s EHR have an interface or other tools that help with… a. Medication tracking and reconciliation? b. Evidence-based treatment or clinical decision support? c. Collection of CMS measures? d. Reporting of CMS measures? e. Tracking or monitoring of quality of care and/or patient outcomes?
			32. Not including an EHR, does your hospital use any other software or electronic tools that help with… a. Collection of CMS measures? b. Reporting of CMS measures?
			1. In the last 12 months, has your hospital’s performance on CMS measures... 1 Improved across the board on all measures 2 Improved on some measures but not on others 3 Approximately stayed the same 4 Declined on some measures but not on others 5 Declined across the board on all measures
			2. In your opinion, how well does your hospital’s performance on the CMS measures reflect the improvements in care that your hospital makes?
			3. Thinking about the full list of CMS hospital measures, do you think the CMS measures are clinically important?
			4. Do you think hospitals should be held responsible for performance on the CMS measures?
			5. Have you experienced difficulties with improving performance on any of the CMS measures?
			6. Based on your hospital’s experience, is it more difficult to improve on certain types of measures than on others? Such as…. a. Clinical process measures (for example: Thrombolytic Therapy for patients with stroke [STK-4]) b. Patient outcomes measures (for example: Acute Myocardial Infarction [AMI] 30-Day Mortality Rate [MORT-30-AMI] or Hospital-Level Risk-Standardized Complication Rate [RSCR] following Elective Primary Total Hip Arthroplasty [THA] and Total Knee Arthroplasty [TKA]) c. Resource use measures (for example: OP-13: Cardiac Imaging for Preoperative Risk Assessment for Non-Cardiac Low-Risk Surgery) d. Patient Experience measures (for example: HCAHPS Survey results) e. Patient Safety measures (for example: Central-Line Associated Bloodstream Infection (CLABSI)) f. Hospital Acquired Conditions (for example: foreign object retained after surgery, air embolism, stage III and IV pressure ulcers, catheter-associated urinary tract infection [UTI], vascular catheter-associated infection, surgical site infection, deep vein thrombosis [DVT]/pulmonary embolism [PE]) g. Measures of hospital readmission within 30 days from hospital discharge, for Acute Myocardial Infarction (AMI), Heart Failure (HF) and Pneumonia (PN)
			7. Have any of the following contributed to your hospital’s difficulties with improving performance on the CMS measures? a. Difficulty identifying improvement strategies b. Difficulty implementing improvement strategies c. Difficulty identifying processes of care that lead to improved patient outcomes d. Difficulty getting front-line clinicians to change behavior to improve performance e. Insufficient resources (e.g., staffing, tools, training) f. Inadequate Health Information Technology (IT) resources and capabilities (e.g., clinical decision support or longitudinal tracking of outcomes) g. Staff turnover h. Lack of senior leadership support i. Lack of sufficient support from physicians or other clinical staff j. Lack of sufficient time for physicians or other clinical staff to participate k. Difficulty with coding or documentation (e.g., lack of consistency across staff, insufficient documentation) l. Lack of training on improvement processes m. A difficult patient mix (i.e., low socioeconomic status, clinically complex) n. Culture that does not support improvement efforts o. Other reason (please specify: )
			11. Has your hospital experienced difficulties in reporting the CMS measures? (Yes/No) 12. Which of the following reasons have contributed to your hospital’s difficulties in reporting CMS measures? (Mark all that apply): • Difficulty capturing the data needed for measure construction • Difficulty extracting the data from the EHR or other data systems/registries • Difficulty interpreting measure specifications • Insufficient or inadequate staffing or other resources • Challenges with CMS reporting tools or interface • Other reason (please specify:
What characteristics differentiate high and low performing providers?			To be analyzed using performance measure results and responses to survey questions in conjunction with information on Characteristics of your Nursing Home and Respondent Background Questions (Q 33-48)

9/15/2015 Confidential Material: This material has not been publicly disclosed - Internal Government Use Only 9