CMS-10551 Standardized Hospital National Provider Survey

Attachment XIII. — Standardized Nursing Home National Provider Survey

Nursing Home National Provider Survey for the

National Impact Assessment of CMS Quality and Efficiency Measures

Version 2.0

October 1, 2014

ACKNOWLEDGMENTS

This survey is being developed/prepared under contract to the

Centers for Medicare & Medicaid Services (CMS) by:

Health Services Advisory Group, Inc. (HSAG) and

The RAND Corporation

1776 Main Street

Santa Monica, CA 90401

The survey may not be circulated or used without permission from CMS, HSAG, and the RAND Corporation. All questions related to the development or use of this survey should be sent to Beverly Weidmer of the RAND Corporation at [email protected] or Kyle Campbell of HSAG at [email protected].

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-NEW. The time required to complete this information collection is estimated to average 40 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

DEFINITION OF KEY TERMS IN THIS SURVEY

CMS quality and efficiency measures: Measures of clinical processes and outcomes, patient experience with care, patient safety, resource use or cost of care, and structural measures (such as nursing home’s use of clinical database registries). These measures are reported by nursing homes to the Centers for Medicare & Medicaid Services (CMS) and can be found at http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/index.html. Measures come from resident assessment data that nursing homes routinely collect on the residents at specified time intervals during their stay. These measures assess the resident’s physical and clinical conditions and abilities, as well as preferences and life-care wishes.

Accountable Care Organizations (ACO): ACOs are networks of healthcare providers and organizations (usually hospitals and ambulatory care 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 for a defined patient population.

Clinical decision support (CDS): 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.¹

Culture of safety: Organizations with a positive safety culture are characterized by communications founded on mutual trust, by shared perceptions of the importance of safety, and by confidence in the efficacy of preventive measures.

Integrated Delivery System (IDS): An IDS is an integrated network of healthcare providers and organizations (such as nursing home, primary and specialty care, hospital, rehabilitation, home health care, and 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 a form of managed care.

Lean/Six Sigma Engineering: Redesign or re-engineering concepts that were originally developed to increase the efficiency of production and reduction of errors within manufacturing companies. Lean/Six Sigma has been adopted by healthcare organizations to identify problems or inefficiencies and take actions to address these issues. “Lean” and “Six Sigma” emphasize focusing on customer satisfaction, problem solving, and elimination of waste and involving employees in identifying and resolving the problem.

Learning Organization: An organization that encourages and supports continuous employee learning, critical thinking, and risk-taking with new ideas.

Plan, Do, Study Improvement Cycles (PDSA): PDSA is a tool that is used for accelerating quality improvement that involves developing a plan to test the change (Plan), carrying out the test (Do), observing and learning from the consequences (Study), and determining what modifications should be made to the test (Act).

Situation Background Assessment Recommendation (SBAR): SBAR Situation Background Assessment Recommendation (SBAR) is a standardized way of communicating that promotes patient safety by helping individuals communicate with each other with a shared set of expectations. Staff and physicians can use SBAR to share patient information in a concise and structured format.

YOUR NURSING HOME’S EXPERIENCE WITH 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?

¹ Very well

² Somewhat well

³ Not well at all

3. Thinking about the full list of CMS nursing home measures, do you think the CMS measures are clinically important?

¹ Yes

² Mostly yes

³ Mostly no

⁴ No

4. Do you think nursing homes should be held responsible for performance on the CMS measures?

¹ Yes

² Mostly yes

³ Mostly no

⁴ No

5. Have you experienced difficulties with improving performance on any of the CMS measures?

¹ Yes on many of the measures

² Yes on some of the measures

³ No  If “No,” go to question 8

6. Based on your nursing home’s experience, is it more difficult to improve on certain types of measures than on others? Such as….

(Mark one in each row)

1. Clinical process measures (for example: Percent of patients Yes No who were assessed and appropriately given the seasonal
   Influenza vaccine [Short Stay])

2. Patient outcomes measures (for example: Percent of Residents Yes No
   with a Urinary Tract Infection [Long Stay])

3. Patient Experience measures (for example: CAHPS Nursing Yes No Home Survey results)

4. Patient Safety measures (for example: Percent of residents Yes No
   experiencing one or more falls [Long Stay])

7. Have any of the following contributed to your nursing home’s difficulties with improving performance on the CMS measures?

(Mark one in each row)

1. Difficulty identifying improvement strategies Yes No

2. Difficulty implementing improvement strategies Yes No

3. Difficulty identifying processes of care that lead to Yes No

Improved patient outcomes

4. Difficulty getting front-line staff to change behavior Yes No

to improve performance

5. Insufficient resources (e.g., staffing, training, tools) Yes No

6. Inadequate Health Information Technology (IT) resources and

capabilities (e.g., clinical decision support, longitudinal tracking of

outcomes, electronic medication administration system) Yes No

7. Staff turnover Yes No

8. Lack of senior leadership support Yes No

9. Lack of sufficient support from patient’s physicians, nurses Yes No

or other staff

10. Lack of sufficient time for patient’s physicians, nurses Yes No

or other staff to participate

11. Difficulty with coding or documentation (e.g., lack of consistency Yes No

across staff, insufficient documentation)

12. Lack of training on improvement processes Yes No

13. A challenging or complex patient population Yes No

14. Culture that does not support improvement efforts Yes No

15. Other reason (please specify: _______________________________) Yes No

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?

Type of Change or Innovation	Has this change or innovation been made in your nursing home?	If change was made, has it helped improve your nursing home’s performance on one or more CMS measures?
Organizational Culture
a. Adopted practices to become a “learning organization.”	☐Yes ☐No	☐Yes, definitely ☐Yes, somewhat ☐No ☐Don’t know/Not sure
b. Implemented a “culture of safety.”	☐Yes ☐No	☐Yes, definitely ☐Yes, somewhat ☐No ☐Don’t know/Not sure
Health Information Technology
c. Implemented an electronic health record (EHR).	☐Yes ☐No	☐Yes, definitely ☐Yes, somewhat ☐No ☐Don’t know/Not sure
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).	☐Yes ☐No	☐Yes, definitely ☐Yes, somewhat ☐No ☐Don’t know/Not sure
e. Implemented an electronic health information system that shares key patient information with providers in the community (e.g., hospitals and ambulatory care providers).	☐Yes ☐No	☐Yes, definitely ☐Yes, somewhat ☐No ☐Don’t know/Not sure

Type of Change or Innovation	Has this change or innovation been made in your nursing home?	If change was made, has it helped improve your nursing home’s performance on one or more CMS measures?
Care Process Redesign
f. Implemented risk prediction tools to identify and manage high-risk patients.	☐Yes ☐No	☐Yes, definitely ☐Yes, somewhat ☐No ☐Don’t know/Not sure
g. Implemented standardized care protocols or checklists.	☐Yes ☐No	☐Yes, definitely ☐Yes, somewhat ☐No ☐Don’t know/Not sure
h. Implemented appropriateness criteria to guide physician decision making for selected procedures, imaging studies, or tests.	☐Yes ☐No	☐Yes, definitely ☐Yes, somewhat ☐No ☐Don’t know/Not sure
i. Adopted care redesign/re-engineering (e.g., Deming/Lean Engineering, Six Sigma, Plan, Do, Study, Act (PDSA) improvement cycles).	☐Yes ☐No	☐Yes, definitely ☐Yes, somewhat ☐No ☐Don’t know/Not sure
j. Implemented interdisciplinary rounds or team “huddles” or formation of multi-specialty patient care teams.	☐Yes ☐No	☐Yes, definitely ☐Yes, somewhat ☐No ☐Don’t know/Not sure
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.)	☐Yes ☐No	☐Yes, definitely ☐Yes, somewhat ☐No ☐Don’t know/Not sure
Feedback and Monitoring of Performance
l. Developed a system for tracking patient outcomes.	☐Yes ☐No	☐Yes, definitely ☐Yes, somewhat ☐No ☐Don’t know/Not sure

Type of Change or Innovation	Has this change or innovation been made in your nursing home?	If change was made, has it helped improve your nursing home’s performance on one or more CMS measures?
Changing Provider Incentives
m. Provided routine feedback on your nursing home’s performance on CMS measures to physicians, nurses, and other staff.	☐Yes ☐No	☐Yes, definitely ☐Yes, somewhat ☐No ☐Don’t know/Not sure
n. Used performance on CMS measures as a basis for determining pay for nurses or other staff.	☐Yes ☐No	☐Yes, definitely ☐Yes, somewhat ☐No ☐Don’t know/Not sure
o. Implemented an internal incentive or bonus program for senior clinical leaders and/or senior management based on performance on CMS measures.	☐Yes ☐No	☐Yes, definitely ☐Yes, somewhat ☐No ☐Don’t know/Not sure
p. Gave nursing home staff awards or other special recognition tied to quality performance.	☐Yes ☐No	☐Yes, definitely ☐Yes, somewhat ☐No ☐Don’t know/Not sure
Changes in Staffing
q. Increased the number of staff dedicated to quality improvement or quality management. ☐Yes ☐No	☐Yes ☐No	☐Yes, definitely ☐Yes, somewhat ☐No ☐Don’t know/Not sure
r. Identified Physician/Nurse champions for quality improvement initiatives or projects.	☐Yes ☐No	☐Yes, definitely ☐Yes, somewhat ☐No ☐Don’t know/Not sure
s. Implemented changes to how nursing staff is deployed (e.g., change in staffing levels or work hours, use of contract or contingent staff)	☐Yes ☐No	☐Yes, definitely ☐Yes, somewhat ☐No ☐Don’t know/Not sure

Type of Change or Innovation	Has this change or innovation been made in your nursing home?	If change was made, has it helped improve your nursing home’s performance on one or more CMS measures?
Other
t. Provided training to nurses, nurses’ aides, and other staff on quality improvement strategies.	☐Yes ☐No	☐Yes, definitely ☐Yes, somewhat ☐No ☐Don’t know/Not sure
u. Implemented quality improvement initiatives targeted to specific CMS measures.	☐Yes ☐No	☐Yes, definitely ☐Yes, somewhat ☐No ☐Don’t know/Not sure
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.	☐Yes ☐No	☐Yes, definitely ☐Yes, somewhat ☐No ☐Don’t know/Not sure
w. Other change or innovation. Please specify: __________________________	☐Yes ☐No	☐Yes, definitely ☐Yes, somewhat ☐No ☐Don’t know/Not sure

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?

¹ Yes

² No  If “No,” go to question 11

³ Don’t know

10. Has your nursing home measured or documented the actual improvements in the areas of care not measured by CMS?

¹ Yes

² No

CHALLENGES TO REPORTING THE CMS MEASURES

11. Has your nursing home experienced difficulties in reporting the CMS measures?

¹ Yes

² No If “No,” go to question 13

12. Which of the following reasons have contributed to your nursing home’s difficulties in reporting CMS measures?

(Mark all that apply)

¹ Difficulty capturing the data needed for measure construction

² Difficulty extracting the data from the EHR or other data systems/registries

³ Difficulty interpreting measure specifications

⁴ Insufficient or inadequate staffing or other resources

⁵ Challenges with CMS reporting tools or interface

⁶ Other reason (please specify: _________________________________)

FACTORS ASSOCIATED WITH CHANGE IN QUALITY PERFORMANCE

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.

(Please rank by order of importance where 1 is the most important and 4 is the least important)

_____ 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.

Mark here if your nursing home has had no improvement on any CMS measures  Go to question 15.

(Rank order the 3 most important from 1-3. Assign 1 to the most important factor, 2 to the next most important factor, and 3 to the next most important factor.)

______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:________________________________________)

UNDESIRED EFFECTS OF CMS QUALITY MEASUREMENT PROGRAMS

The use of quality and efficiency measures may potentially result in undesired effects. The next questions ask about your nursing home’s knowledge of or experience with undesired effects of the CMS measures and their use in public reporting and pay for performance. All of the responses you provide are confidential and are intended to help CMS in modifying reporting programs so as to avoid the programs’ causing undesired effects. Your candid feedback is important in helping CMS improve these programs so that they work well for providers and their patients.

15. Has your nursing home observed any undesired effects stemming from using or reporting CMS measures?

¹ Yes, definitely

² Yes, somewhat

³ No

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?

(Mark one in each row)

a. Fewer resources for quality improvement in areas of clinical

care that are not the focus of CMS performance measures Yes No

b. Focus on narrow improvement for specific measures rather

than across the board improvement in care Yes No

c. Overtreatment of patients to ensure that a measure is met Yes No

d. Increased focus on documentation or coding of data to attain
a higher score Yes No

e. Changing coding of data or documentation to ensure that
a measure is met Yes No

f. Avoiding sicker or more challenging patients when
providing care Yes No

The next questions ask about other nursing homes’ experience with undesired effects of the CMS measures and their use in public reporting and pay for performance.

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?

¹ Yes, definitely

² Yes, somewhat

³ No

⁴ Don’t know

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?

(Mark one in each row)

a. Fewer resources for quality improvement in areas of clinical
care that are not the focus of CMS performance measures Yes No Don’t know

b. Focus on narrow improvement for specific measures rather
than across the board improvement in care Yes No Don’t know

c. Overtreatment of patients to ensure that a measure is met Yes No Don’t know

d. Increased focus on documentation or coding of data to
attain a higher score Yes No Don’t know

e. Changing coding of data or documentation to ensure that
a measure is met Yes No Don’t know

f. Avoiding sicker or more challenging patients when
providing care Yes No Don’t know

PERSPECTIVES OF NURSING HOME LEADERSHIP AND OTHER STAKEHOLDERS

19. Does your nursing home have a board of directors?

¹ Yes

² No  If “No,” go to question 23

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? (Mark one)

¹ More than four times per year

² Quarterly

³ Twice per year

⁴ Annually

⁵ Less than once per year

21. Which of the following best describes your nursing home’s board of directors?

(Mark one)

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?

0 – Not at all supportive

1

2

3

4

5

6

7

8

9

10 – Extremely supportive

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?

0 – Not at all supportive

1

2

3

4

5

6

7

8

9

10 – Extremely supportive

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?

0 – Not at all

1

2

3

4

5

6

7

8

9

10 – A great deal

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?

0 – Not at all supportive

1

2

3

4

5

6

7

8

9

10 – Extremely supportive

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?

0 – Not at all supportive

1

2

3

4

5

6

7

8

9

10 – Extremely supportive

USE OF HEALTH INFORMATION TECHNOLOGY

These next questions are about your nursing home’s use of and outside provider access to Health Information Technology.

27. Does your nursing home have an electronic health record (EHR)?

¹ Yes

² No If “No,” go to question 33

28. Is your nursing home’s EHR able to exchange information electronically across all units in the nursing home?

¹ Yes

² No

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?

¹ Yes, all key clinical data

² Yes, some key clinical data

³ No  If “No,” go to question 31

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?

(Mark one in each row)

a. Diagnostic/treatment summary Yes, all Yes, Some No

b. Lab tests/Imaging results Yes, all Yes, Some No

c. Prescribed medications Yes, all Yes, Some No

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)?

¹ Yes, for all or most patients

² Yes, for some patients

³ No

32. Does your nursing home’s EHR have an interface or other tools that help with…

(Mark one in each row)

a. Medication tracking and reconciliation? Yes No

b. Evidence-based treatment or clinical decision support? Yes No

c. Collection of CMS measures? Yes No

d. Reporting of CMS measures? Yes No

e. Tracking or monitoring of quality of care

and/or patient outcomes? Yes No

f. Administration of medication? Yes No

33. Not including an EHR, does your nursing home use any other software or electronic tools that help with….

(Mark one in each row)

a. Collection of CMS measures? Yes No

b. Reporting of CMS measures? Yes No

CHARACTERISTICS OF YOUR NURSING HOME

These next questions will help us to describe the nursing homes that participate in this survey.

34. Is your nursing home affiliated with a nursing home system?

¹ Yes

² No

35. Is your nursing home part of an integrated delivery system?²

¹ Yes

² No

36. How many competitor nursing homes exist within your nursing home’s service area?

¹ 0

² 1

³ 2

⁴ 3

⁵ 4

⁶ 5

⁷ 6 or more

37. Compared to your competitors, how well does your nursing home perform on the CMS quality measures?

¹ Better

² About the same

³ Worse

⁴ Don’t know

38. Do you face a shortage of nurses in your area?

¹ Yes

² No

39. Does your nursing home participate in any of the following types of Accountable Care Organizations (ACO’s)?

(Mark one in each row)

a. Medicare Shared Savings Program Yes No

b. Medicare Pioneer ACO Yes No

c. Medicare’s Advanced Payment Model ACO Yes No

d. Medicaid ACO Yes No

e. A private, commercially insured ACO arrangement Yes No

(within an HMO or PPO)

40. Is your nursing home participating in any other type of alternative payment model that may have shared savings or shared risk (e.g., Global budgets, bundled payments for selected procedures)?

¹ Yes

² No

41. Does your nursing home participate in other non-CMS quality and efficiency measure reporting programs sponsored by:

(Mark one in each row)

a. Medicaid Yes No

b. The state where you nursing home is located Yes No

3. Commercial insurers Yes No

4. Employer or multi-stakeholder collaboratives Yes No

42. Across your nursing home’s entire book of business, approximately what percentage of your patients is comprised of…?

(Please provide your best estimate. Your estimates should add to 100%.)

__________% Medicare only patients

__________% Medicaid only and Dual eligible (Medicare and Medicaid) patients

__________% Commercially-insured patients

__________% Private-pay patients

__________% Uninsured patients

RESPONDENT BACKGROUND

43. Which of the following best describes your job title or position within this nursing home?

(Mark one)

¹ Chief Executive Officer

² Chief Medical Officer

³ Chief Nursing Officer

⁴ Senior leader responsible for quality of clinical care (e.g., VP for Quality)

⁵ Member of a team responsible for measuring and reporting quality of clinical care

⁶ Some other role (Please specify: ________________________________)

44. How many years have you been in your current position within this nursing home?

¹ Less than one year

² One to three years

³ More than 3 years

45. Are you a physician?

¹ Yes (please specify Specialty: ______________________________________)

² No

46. Did anyone else help you complete this survey?

¹ Yes

² No  Thank you for completing this survey!

47. What is the job title or position of the other person or persons who helped you complete the survey?

Thank you for taking the time to complete the survey.

Please make a copy for yourself and send the original back to the [VENDOR NAME] in the pre-paid envelope to:

[INSERT VENDOR ADDRESS HERE]

1 Source: http://www.healthit.gov/policy-researchers-implementers/clinical-decision-support-cds

2 An Integrated Delivery System (IDS) 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 a form of managed care.

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