CMS-10551 Interview Topic Guide for Semi-Structured Interview

Attachment VIII. — Interview Topic Guide for Semi-Structured Interview of Nursing Home Quality Leaders

Qualitative Interview Guide for Nursing Homes

Organization Name:

Respondent Name:

Respondent Position:

Interviewer Name:

Interview Date:

INTRODUCTION AND PURPOSE OF THE INTERVIEW

Thank you for agreeing to participate in the interview today. I’d like to briefly review the purpose of this interview and the confidentiality provisions that were described in the email we sent you.

• We are conducting interviews with nursing homes on behalf of the Centers for Medicare & Medicaid Services (CMS).

• CMS implements a variety of performance measures in the nursing home setting to assess the quality and efficiency of care provided to Medicare beneficiaries. CMS reports nursing home performance scores on its Nursing Home Compare website.

• The purpose of today’s interview is to learn about your perspective of your nursing home’s experiences in reporting and working to improve performance on the CMS measures and your efforts to improve the quality and efficiency of care at your nursing home.

CONSENT/CONFIDENTIALITY PROVISIONS

• All of your responses are confidential.

• No one outside of the project will have direct access to the information you provide. The evaluation team will only produce summary information from the set of interviews. You will not be identified by name or nursing home affiliation.

• You do not have to participate in the interview. You can stop at any time for any reason. Your decision regarding whether to participate will not affect your institution’s Medicare reimbursement or quality scores.

• You can decline to discuss any topic that we raise.

Do you have any questions? (YES/NO)

Do you agree to participate in the interview? (YES/NO)

As we mentioned in our email, we would like to tape the interview if that is all right with you.

Do you agree to be tape recorded? (YES/NO)

[If yes:] Great. Let’s get started. I’ll start the recording.

[If no:] That’s fine. We will take notes – and not tape the discussion. Let’s get started.

Nursing Home Interview Protocol

[Note to interviewer: An asterisk (*) indicates a question that should be skipped if there will not be sufficient time to complete all questions.]

I’d like to start by asking you about your background and a few characteristics of your nursing home.

Respondent Background

1. We understand that you are the _____________ [title/position] at __________ [nursing home name]. Is that correct?

1. [If not correct:] What is your job title or position?

2. [If not Director of Nursing:] What is your educational / professional background?

3. How long have you been working at ________ [nursing home name]?

4. How long have you been the ________ [title/position] here?

Nursing Home Characteristics

5. Is your nursing home affiliated with a larger entity or corporation? (YES/NO)

6. How many competitor nursing homes exist within your nursing home’s service area? [If needed: Are there 0, 1, 2, 3, or more nursing homes that are considered competitive?]

1. Compared to your competitors, how well does your nursing home perform on the CMS quality measures? [Better than, comparably, worse than, don’t know]

7. Do you face a shortage of physicians or nurses in your area that makes it difficult to staff your facility? (YES/NO)

1. [If facing a nursing shortage:] Is the nursing shortage for a particular type of nurse, for example, Registered Nurses, Licensed Vocational Nurses, or Certified Nursing Assistant?

8. Approximately what percentage of the patients your nursing home admits are covered under the following (should total 100%):

Type of Insurance	Percent
Medicare
Commercial insurance
Medicaid
Private pay/other
Uninsured
	100%

Innovations in the Delivery of Care

I’d like to now talk about CMS measurement programs and innovations or changes your nursing home may be making in the way care is being delivered. In some cases, I will ask you to specifically reflect on your experiences related to the CMS quality measurement program for nursing homes, which requires reporting on Minimum Data Set (MDS) data, from which a number of quality measures are created.

I’d like to make sure you have the full list of the most recent CMS quality measures. They should have been sent to you by email in advance of our interview. Do you have the list?

[If yes:] Great, can you take a minute or two to review the list of measures?

[If no/doesn’t have the list:] I will send you the list by email right now. Once you receive it, please take a minute or two to review the measures.

9. Are you familiar with these quality measures? (YES/NO)

1. [If no:] Can you help me identify the senior leader within your nursing home who would be most familiar with your nursing home’s efforts to improve performance on these measures? Thank you for your time. [Then end the current interview.]

10. In your experience, have the CMS measures and measurement program led your nursing home to change anything about how it delivers care? (YES/NO)

[If yes:]

1. Please describe the changes your nursing home has made.

1. Which of the changes that you’ve mentioned have been implemented nursing home-wide (i.e., across your entire organization)?

2. Have any of the changes focused on addressing specific CMS measures? (YES/NO)

1. [If yes:] Which measures?

[If no, go to Q10:]

2. Why do you believe that CMS measurement programs have not led to changes in care delivery? [If needed, prompts include improvement not needed, lack of resources, quality initiative fatigue]

11. Have you observed your nurses and other frontline clinical staff initiating any changes in response to quality measurement programs? (YES/NO)

[If yes:]

1. Please describe the changes the frontline clinical staff has made.

2. Do you think the changes frontline clinical staff has made have affected your nursing home’s performance specifically on the CMS performance measures? (YES/NO)

1. [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?

3. Are there areas captured in the CMS measures where it has been difficult to get physicians and other clinical staff to change their behavior? (YES/NO)

[If yes:]

1. Please describe which areas.

2. Why do you think it was difficult to achieve changes in frontline staff behavior?

3. 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? (YES/NO)

1. [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? (YES/NO)

1. [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.] (YES/NO)

1. [If yes:] What measures has your nursing home used to track improvements in other areas?

Factors Associated with Change in Quality Performance

I’d like you to look at the measures list that we sent you. On this list, you will see the individual measures and your performance score for those measures for the most recent reporting year.

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? [If needed, examples include overall resources, data systems, the organization’s culture, internal incentives, leadership engagement, frontline staff engagement, investments in care redesign]

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? [If needed, examples include overall resources, data systems, the organization’s culture, insufficient internal incentives, lack of leadership or frontline staff engagement, few investments in care redesign]

17. From your perspective, is it harder to improve scores on some CMS measures than others? (YES/NO)

1. [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?

1. Why, or why not?

19. Do you think nursing homes have sufficient control over care to be held responsible for performance on these measures? ,(YES/NO)

[If no:]

1. Who do you think should be responsible?

2. Are there other areas where CMS should consider measures to gauge your nursing home’s quality performance?

Many factors may influence your nursing home to invest in improving performance on the CMS measures.

20. What do you see as the most important driver of your nursing home’s investments to improve performance at your nursing home?

Drivers of improvement might include public reporting of quality scores on Nursing Home Compare, the potential to receive financial incentives for improvement or high performance, the potential for financial penalties for low performance, receipt of feedback reports with quality results, receipt of technical assistance¹ related to quality improvement from CMS, regulatory compliance and survey visits, and pressure from organizations making referrals, such as hospitals.

21. *How important are each of the following as drivers of improvement in your nursing home? (very important, somewhat important, not important)

1. Public reporting of quality scores on Nursing Home Compare?

2. The potential to receive financial incentives for improvement or high performance?

3. The potential for financial penalties for low performance?

4. Receipt of feedback reports with quality results?

5. Receipt of technical assistance related to quality improvement from CMS?

6. Regulatory compliance and survey visits?

7. Pressure from organizations making referrals, such as hospitals?

Organizational Structure and Delivery System Reform Initiatives

22. Does your facility have a quality improvement department or specific quality improvement personnel? (YES/NO/DON’T KNOW)

1. [If yes:] To whom does the Director of Quality (or similar position) report?

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? (YES/NO/DON’T KNOW)

1. [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? (YES/NO/DON’T KNOW)

24. *Has your nursing home used any of the following care redesign methods to improve quality?² (YES/NO/DON’T KNOW)

1. Deming/lean processes (i.e., constantly improve the system of production and service to improve quality and decrease cost)? (YES/NO/DON’T KNOW)

2. Six Sigma (i.e., measurement-based strategy/data-driven approach for eliminating defects; focuses on process improvement and variation reduction)? (YES/NO/DON’T KNOW)

3. Plan, Do, Study, Act (PDSA) improvement cycles? (YES/NO/DON’T KNOW)

4. Other methods? Please specify.

25. Does your nursing home participate in an Accountable Care Organization (ACO)?³ (YES/NO/DON’T KNOW)

[If yes:]

1. Are you part of one of the Medicare ACOs? (prompts: Medicare Shared Savings Program, Pioneer ACOs, Advanced Payment) (YES/NO/DON’T KNOW)

2. Does your nursing home participate in a Medicaid ACO? (YES/NO/DON’T KNOW)

3. Are you part of an ACO arrangement with a private commercial insurer? (YES/NO/DON’T KNOW)

1. [If yes:] How many different private insurer ACOs is your nursing home part of?

4. Is your nursing home financially at risk (i.e., downside risk) in any of these ACO arrangements? (YES/NO/DON’T KNOW)

26. Is your nursing home part of an integrated delivery system?⁴ (YES/NO/DON’T KNOW)

27. Is your nursing home participating in any other type of alternative payment model (prompts: global budgets, bundled payments for selected procedures)? (YES/NO/DON’T KNOW)

[If yes:]

1. Are these shared savings models? (YES/NO/DON’T KNOW)

2. Is your nursing home at risk financially in any of these arrangements? (YES/NO/DON’T KNOW)

28. Does your nursing home have an electronic health record (EHR)? (YES/NO)

[If yes:]

1. Is your nursing home’s EHR able to electronically exchange information with providers in your community (e.g., ambulatory physicians and hospitals)? (YES/NO/DON’T KNOW)

1. [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?

2. Does your EHR have clinical decision support⁵ functions embedded in the system to assist clinicians and providers? (YES/NO/DON’T KNOW)

1. [If yes:] For what clinical areas or functions?

2. Do any of the clinical decision supports address CMS quality measure areas? Which areas?

3. 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)?

4. Does your nursing home use the EHR system to report the CMS quality measures? (YES/NO/DON’T KNOW)

29. Does your nursing home provide nurses and clinicians with information about your nursing home’s performance on the CMS measures? (YES/NO/DON’T KNOW)

1. [If yes:] How often do nurses and clinicians receive feedback on their performance on the measures?

Perspectives of Different Stakeholders and Leaders

We’re interested in how different leaders and groups within your nursing home have viewed and approached CMS quality measures and related public reporting and payment programs. We’d specifically like to ask about support from four general groups of stakeholders within the nursing home — executive management, physicians, nursing, and, if your nursing home has one, the board of directors. We are interested in the degree to which they have acted to enable and provide assistance for your nursing home's successful performance on 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 executive management team’s support of the CMS measurement programs?

1. 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?

1. 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?

1. Has this support changed over time?

33. *Does your nursing home have a board of directors? (YES/NO)

[If yes:]

1. 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?

1. Has this support changed over time?

2. Is performance on the CMS quality measures on the board agenda at each board meeting?

Challenges to Implementing CMS Measures

I’d like to talk about what you see as challenges to reporting the data/measures and improving your nursing home’s performance on the CMS measures.

34. Have you experienced difficulties in reporting the CMS measures? (YES/NO/DON’T KNOW) [If needed, prompts include measure specifications, challenges with CMS reporting tools, difficulty capturing or extracting the data, difficulty uploading MDS reports, insufficient resources, programming new measures each year]

[If yes:]

1. Please describe the difficulties.

2. How did you address these difficulties?

35. Have you experienced difficulties with improving performance on the CMS measures? (YES/NO/DON’T KNOW) [If needed, prompts include difficulty identifying appropriate improvement strategies or what processes need to be improved, inadequate IT capabilities, need for provider training, staff turnover, lack of leadership support, lack of clinician support or time, insufficient resources]

[If yes:]

1. Please describe these difficulties.

2. How did you address these difficulties?

Effects of Performance Measurement Programs

Some providers have expressed concern that CMS measurement programs might lead to undesired effects at times. CMS is interested in learning about possible undesired effects so it could modify the measurement and reporting program to minimize these effects. All of the responses you provide are confidential. Your candid feedback will be especially important in helping CMS improve these programs so that they work well for providers and patients.

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? (YES/NO/DON’T KNOW)

1. [If yes:] Please describe these undesired effects.

1. Why do you think these undesired effects have occurred?

2. What do you think could be done to mitigate those undesired effects?

[If no, or respondent is vague on specific undesired effects:]

2. 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? (YES/NO)

1. [If yes:] Can you give any other examples of measures where this might occur?

3. 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)

1. [If yes:] Have you seen or heard of a particular emphasis on coding for any measures in particular?

4. 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? (YES/NO/DON’T KNOW)

1. [If yes:] Have you heard it in association with any measures in particular?

5. 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)

1. [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?

1. Do you believe it will be more difficult for your nursing home to achieve high performance on outcome measures?

1. [If yes:] Why?

2. In your opinion, will inclusion of outcome measures result in any additional undesired consequences? (YES/NO/DON’T KNOW)

1. [If yes:] What could be done to mitigate the problem?

Closing

38. Based on your experience to date using CMS nursing home measures, what changes to the measures would you recommend?

1. What changes to the measurement programs would you recommend?

39. Is there anything else that I did not ask that you would like to comment on?

Thank you very much for your time.

1 Technical assistance refers to support provided to help nursing homes with approaches to and ideas for improving the quality of care they deliver. It may take such forms as webinars, toolkits, or coaching.

2 Some organizations utilize specific methodologies or frameworks to guide and insure consistency in improvement activities throughout the organization. Examples include the Model for Improvement or Plan, Do, Study, Act (PDSA); Cycle or Deming Cycle; Lean Improvement adapted from the Toyota Production System; Six-Sigma DMAIC (which stands for define, measure, analyze, improve, control); and the Seven-Step Method Problem-Solving Model. Other organizations have not adopted a specific improvement methodology.

3 Accountable Care Organizations are networks of healthcare providers and organizations (usually hospitals and physician groups, and possibly including nursing homes, home health, and hospice organizations), that agree to take some financial responsibility for reducing the costs and improving the quality of care of enrollees.

4 Integrated Delivery System is a network of healthcare providers and organizations (i.e., nursing home, primary and specialty care, rehabilitation, home health care, hospice) that provides or arranges to provide a coordinated continuum of services to a defined population. It may own or be closely aligned with an insurance product, usually using a form of managed care.

5 “Clinical decision support” (CDS) provides clinicians, staff, patients or other individuals with knowledge and person-specific information, intelligently filtered or presented at appropriate times, to enhance health and healthcare. CDS encompasses a variety of tools to enhance decision-making in the clinical workflow. These tools include computerized alerts and reminders to care providers and patients; clinical guidelines; condition-specific order sets; focused patient data reports and summaries; documentation templates; diagnostic support; and contextually relevant reference information, among other tools.” (Source: http://www.healthit.gov/policy-researchers-implementers/clinical-decision-support-cds)

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