Form CMS-10686 Resource Assessment

Resource Assessment

As one of our Quality Insights QIN-QIO partners, we are interested in receiving your feedback.
Please take a few minutes to help us understand how to best support your quality improvement
efforts by responding to the following questions.
1. Which best describes your clinical setting?
Dialysis Center

Hospital

Emergency Department / Urgent Care Center

Nursing Home

Home Health

Pharmacy

Hospice

Physician Office

Other (please specify)

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Resource Assessment

Section 1 – Resources/Tools (e.g. posters, flyers, change packages, best practice intervention
packages (BPIPs), toolkits, guidelines)
2. What format do you prefer to receive resource/tools from Quality Insights? (mark all that apply)
Printed
Electronic via email attachment
Electronic via web site where I can download each resource
Other (please specify)

3. When you receive PRINTED materials from your Quality Insights contact, which of the following best
describes your normal practice?
Read then throw away
Read then file for later reference
Read then share with other staff
I don’t usually read the material
Other (please specify)

4. When considering ELECTRONIC materials (e-newsletters, e-bulletins, e-postcards) from Quality
Insights, which frequency fits your routine best?
Weekly

Quarterly

Monthly

Never – I don’t read this form of communication

Every other month
Other (please specify)

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Resource Assessment

Section 2 – Educational Section (e.g. webinars, Live Chat, e-learns, CEs)

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Resource Assessment

5. What kind of learning venue do you prefer? (mark all that apply)
Live online event
Recorded online event
E-learning courses (recorded electronic course)
Electronic resources for reading or downloading
Other (please specify)

6. When considering live and recorded educational events, what length of time do you find best for
learning?
15 minutes
30 minutes
60 minutes
Greater than 60 minutes
Other (please specify)

7. What frequency of educational events is best for your current professional setting?
Weekly
Twice a month
Monthly
Quarterly
Other (please specify)

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Resource Assessment

Section 3 – Social Media
8. In which of the following social media platforms do you engage in a professional context? (mark all that
apply)
Facebook
Instagram
LinkedIn
Pinterest
Twitter
Other (please specify)

9. What entices you to click on a social media post? (mark all that apply)
Video
Subject matter
Link to other publication
Image/pictures/graphics
Other (please specify)

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Resource Assessment

Section 4 – Quality Insights
10. What are the most valuable services you receive from Quality Insights? (check all that apply)
Data Reports
Educational Webinars
Networking Opportunities
Technical Assistance
Tools / Resources
Other (please specify)

11. What comes to mind when you think of Quality Insights?

12. How could Quality Insights improve our services?

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-XXXX (Expires XX/XX/XXXX). The time required to complete this information
collection is estimated to average 5 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.
****CMS Disclosure**** Please do not send applications, claims, payments, medical records or any documents containing sensitive information to the PRA
Reports Clearance Office. Please note that any correspondence not pertaining to the information collection burden approved under the associated OMB
control number listed on this form will not be reviewed, forwarded, or retained. If you have questions or concerns regarding where to submit your documents,
please contact Krista Davis at [email protected].

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