Form CMS-10551 Qualitative Interview Guide

Nursing Home Semi-structured Qualitative Interview Guide Mapping Research Questions to Interview Questions

Attachment III — Nursing Home 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 Nursing Home Semi-structured Qualitative Interview Guide	Nursing Home 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 nursing home is delivering care.	Innovations in the delivery of care	9. Are you familiar with these quality measures?
			10. In your experience, have the CMS measures and measurement program led your nursing home to change anything about how it delivers care? a. Please describe the changes your nursing home has made. i. Which of the changes that you’ve mentioned have been implemented nursing home-wide (i.e., across your entire organization)? ii. Have any of the changes focused on addressing specific CMS measures? 1. [If yes:] Which measures? b. Why do you believe that CMS measurement programs have not led to changes in care delivery?
			11. Have you observed your nurses and other 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 nursing home’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? i. Please describe which areas. ii. Why do you think it was difficult to achieve changes in frontline staff behavior? iii. How did your nursing home address these barriers?
			12. Are there other initiatives besides CMS measurement and reporting programs that have led your nursing home to make changes in care delivery? a. [If yes:] Please describe the initiatives and the changes you have made in response to these initiatives.
			13. Do you think any of the changes your nursing home has made have affected your nursing home’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?
			14. Have the changes your nursing home 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)? [Example, if needed: For example, a focus on decreased restraint use might lead to improved performance on mobility and ADL measures.] a. [If yes:] What measures has your nursing home used to track improvements in other areas?
What factors are associated with changes in performance over time?	Factors that are driving your nursing home's investments in performance improvement.	• Factors associated with change in quality performance • Organizational structure and delivery system reform initiatives • Perspectives of different stakeholders and leaders	15. For the CMS performance measures where your nursing home is performing well [interviewer to have nursing home performance list ready], what factors do you think help your nursing home perform highly?
			16. For those measures where your nursing home’s performance is lagging [interviewer to have nursing home performance list ready], what factors do you believe inhibit higher performance?
			17. From your perspective, is it harder to improve scores on some CMS measures than others? a. [If yes:] Which measures, and why?
			18. Thinking about the full list of CMS measures we are discussing, do you think these CMS measures are clinically important? a. Why, or why not?
			19. Do you think nursing homes 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 nursing home’s quality performance?
			20. What do you see as the most important driver of your nursing home’s investments to improve performance at your nursing home?
			21. How important are each of the following as drivers of improvement in your nursing home? a. Public reporting of quality scores on Nursing Home Compare? b. The potential to receive financial incentives for improvement or high performance? c. The potential for financial penalties for low performance? d. Receipt of feedback reports with quality results? e. Receipt of technical assistance related to quality improvement from CMS? f. Regulatory compliance and survey visits? g. Pressure from organizations making referrals, such as hospitals?
			22. Does your facility have a quality improvement department or specific quality improvement personnel?
			23. [If part of a larger entity or corporation (“yes” on Question 5):] You indicated earlier that your nursing home is affiliated with a larger entity or corporation. Does the larger corporation have a quality improvement department or specific quality improvement personnel? a. [If yes:] Does the Director of Quality (or similar position) report to the C-suite (i.e., the executive management) of the larger entity or corporation?
			24. Has your nursing home 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.
			25. Does your nursing home participate in an Accountable Care Organization (ACO)? a. Are you part of one of the Medicare ACOs? b. Does your nursing home participate in a Medicaid ACO? c. Are you part of an ACO arrangement with a private commercial insurer? i. [If yes:] How many different private insurer ACOs is your nursing home part of? d. Is your nursing home financially at risk (i.e., downside risk) in any of these ACO arrangements?
			26. Is your nursing home part of an integrated delivery system?
			27. Is your nursing home participating in any other type of alternative payment models? [If yes:] a. Are these shared savings models? b. Is your nursing home at risk financially in any of these arrangements?
			28. Does your nursing home have an electronic health record (EHR)? [If yes:] a. Is your nursing home’s EHR able to electronically exchange information with providers in your community (e.g., ambulatory physicians and hospitals)? 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. 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 measure areas? Which areas? c. Does your EHR help your doctors and other health care providers monitor the quality of care they are providing? d. Does your nursing home use the EHR system to report the CMS quality measures?
			29. Does your nursing home provide nurses and clinicians with information about your nursing home’s performance on the CMS measures? a. [If yes:] How often do nurses and clinicians receive feedback on their performance on the measures?
			30. 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?
			31. On a scale of 0 to 10, with 0 being extremely unsupportive and 10 being extremely supportive, how would you characterize the physician staff’s support of the CMS measurement programs? a. Has this support changed over time?
			32. 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?
			33. Does your nursing home have a board of directors? [If yes:] a. On a scale of 0 to 10, with 0 being extremely unsupportive and 10 being extremely supportive, how would you characterize the nursing home board of directors’ support of the CMS measurement programs? i. Has this support changed over time? b. Is performance on the CMS quality measures on the board agenda at each board meeting?
Are there unintended consequences associated with implementation of CMS quality measures?	Potential undesired effects associated with the measures.	• Effects of performance measurement programs	36. Are you aware of any undesired effects in your nursing home 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 potential concern with the pain measure was that it might lead to over- use of scheduled narcotics 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 nursing homes 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. Nursing homes may also avoid sicker or more difficult patients in order to achieve higher scores on the quality measures. Have you heard of this happening? i. [If yes:] Have you heard it in association with any measures in particular? e. Nursing homes 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? (YES/NO/DON’T KNOW) i. [If yes:] Does it happen with any specific measures in particular?
			37. 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 nursing home 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 nursing home faces related to improvement on the CMS measures	• Perspectives of different stakeholders and leaders • Challenges to implementing CMS measures	30. 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?
			31. On a scale of 0 to 10, with 0 being extremely unsupportive and 10 being extremely supportive, how would you characterize the physician staff’s support of the CMS measurement programs? a. Has this support changed over time?
			32. 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?
			33. Does your nursing home have a board of directors? [If yes:] a. On a scale of 0 to 10, with 0 being extremely unsupportive and 10 being extremely supportive, how would you characterize the nursing home board of directors’ support of the CMS measurement programs? i. Has this support changed over time? b. Is performance on the CMS quality measures on the board agenda at each board meeting?
			34. Have you experienced difficulties in reporting the CMS measures? [If yes:] a. Please describe the difficulties. b. How did you address these difficulties?
			35. 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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