CMS-10551 Structured Research Guide

Nursing Home Standardized Survey: Research Questions Mapped to Survey Questions

Attachment IV — Nursing Home Standardized Survey: Research Questions Mapped to Survey Questions

2018 National Impact Assessment of Medicare Quality Measures

Research Questions	Formative Interview Goals	Section in Nursing Home Standardized Survey	Nursing Home Standarized 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 nursing home is delivering care.	Innovations in the delivery of care	8. We are interested in understanding what changes your nursing home has made in the way care is being delivered to improve its quality performance. Has your nursing home 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 (CDS), condition-specific electronic alerts, automated prompts, or medication administration system (MAR). e. Implemented an electronic health information system that shares key patient information with providers in the community (e.g., hospitals and ambulatory care providers). f. Implemented risk prediction tools to identify and manage high-risk patients. g. Implemented standardized care protocols or checklists. h. Implemented appropriateness criteria to guide physician decision making for selected procedures, imaging studies, or tests. i. Adopted care redesign/re-engineering (e.g., Deming/Lean Engineering, Six Sigma, Plan, Do, Study, Act (PDSA) improvement cycles). j. Implemented interdisciplinary rounds or team “huddles” or formation of multi-specialty patient care teams. k. 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.) l. Developed a system for tracking patient outcomes. m. Provided routine feedback on your nursing home’s performance on CMS measures to physicians, nurses, and other staff. n. Used performance on CMS measures as a basis for determining pay for nurses or other staff. o. Implemented an internal incentive or bonus program for senior clinical leaders and/or senior management based on performance on CMS measures. p. Gave nursing home 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 changes to how nursing staff is deployed (e.g., change in staffing levels or work hours, use of contract or contingent staff) t. Provided training to nurses, nurses’ aides, and other staff on quality improvement strategies. u. Implemented quality improvement initiatives targeted to specific CMS measures. v. Obtained technical assistance from CMS (i.e., a CMS Quality Improvement Organization) or from private organizations (e.g., quality improvement collaboratives, consulting firms) to collect and report CMS quality measures. w. Other change or innovation. Please specify:
			9. Have the changes your nursing home has made in response to the CMS measures led to improvements in areas of care not measured by CMS?
			10. Has your nursing home 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 nursing home's investments in performance improvement.	• Factors associated with change in quality performance • Perspectives of nursing home leadership and other stakeholders	13. There are many factors that influence a nursing home’s decision to invest in efforts to improve its quality performance. Please rank the importance of each of the following factors in your nursing home’s decision to invest or not 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 nursing home readmissions within 30 days or for nursing home-acquired infections) c. Public reporting of your nursing home’s performance results on the CMS Nursing Home 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 nursing home improve its performance. Please rank the top 3 factors that have helped your nursing home improve performance on some or all of the CMS measures. a. Your nursing home’s organizational culture b. Nursing home leadership support and engagement c. Effective relationship between management and staff d. Having dedicated resources for quality improvement e. 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 physicians, nurses, and other staff on performance on CMS measures i. Having a system-wide focus on quality and quality improvement j. Networking with other nursing homes 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. Does your nursing home have a board of directors?
			20. How often do meetings of your nursing home’s board of directors include a review and discussion of the nursing home’s performance on the CMS measures?
			21. Which of the following best describes your nursing home’s board of directors? 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.
			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 nursing home board of director’s support of your nursing home’s efforts to improve performance on CMS measures?
			23. 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 home leadership’s (e.g., the C-Suite executive management) support of your nursing home’s efforts to improve performance on CMS measures?
			24. On a scale from 0 to 10, where 0 is not at all and 10 is a great deal, how much does your nursing home leadership promote a culture of quality?
			25. 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 staff’s support of your nursing home’s efforts to improve performance on CMS measures?
			26. On a scale from 0 to 10, where 0 is not at all supportive and 10 is extremely supportive, how would you describe your physician staff’s support of your nursing home’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 nursing home 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 nursing home as a result of your nursing home 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 nursing homes 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 nursing homes 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 nursing home faces related to improvement on the CMS measures	• Use of health information technology • Nursing home's experience with CMS measures • Challenges to Reporting the CMS Measures	27. Does your nursing home have an electronic health record (EHR)?
			28. Is your nursing home’s EHR able to exchange information electronically across all units in the nursing home?
			29. Are health providers in your community (i.e., ambulatory care physicians, hospitals) able to access your nursing home’s EHR or health information system to obtain key clinical data on patients?
			30. Which of the following types of information are health providers in your community (i.e., ambulatory care physicians, hospitals) able to access electronically through your nursing home’s EHR or health information system? a. Diagnostic/treatment summary b. Lab tests/Imaging results c. Prescribed medications
			31. Is your nursing home able to access electronically information on your patients from other providers in your community (i.e., ambulatory care physicians, hospitals)?
			32. Does your nursing home’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? f. Administration of medication?
			33. Not including an EHR, does your nursing home 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 nursing home’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 nursing home’s performance on the CMS measures reflect the improvements in care that your nursing home makes?
			3. Thinking about the full list of CMS nursing home measures, do you think the CMS measures are clinically important?
			4. Do you think nursing homes 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 nursing home’s experience, is it more difficult to improve on certain types of measures than on others? Such as….
			7. Have any of the following contributed to your nursing home’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 staff to change behavior to improve performance e. Insufficient resources (e.g., staffing, training, tools) f. Inadequate Health Information Technology (IT) resources and capabilities (e.g., clinical decision support, longitudinal tracking of outcomes, electronic medication administration system) g. Staff turnover h. Lack of senior leadership support i. Lack of sufficient support from patient’s physicians, nurses or other staff j. Lack of sufficient time for patient’s physicians, nurses or other 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 challenging or complex patient population n. Culture that does not support improvement efforts o. Other reason (please specify: )
			11. Has your nursing home experienced difficulties in reporting the CMS measures? (Yes/No) 12. Which of the following reasons have contributed to your nursing home’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 34-47)

9/15/2015 Confidential Material: This material has not been publicly disclosed - Internal Government Use Only 10