CMS Independent Evaluation Center (IEC) OMB No. xxxx-xxxx
Nursing Home Administrator Survey Expires xx/xx, 20xx
[READ IF CONTACTED WITH LETTER OR EMAIL ONLY]
We are calling you on behalf of the Centers for Medicare and Medicaid Services, or CMS, to learn about quality improvements in nursing home facilities and the types of resources that are helpful in this area. We are conducting a [10/20 minute survey --more for QIO facilities] asking about the resources that your facility uses for quality improvement efforts.
We hope [FACILITY NAME] will participate in the survey and provide information that will help CMS improve its quality improvement programs. You should know that this survey is voluntary, you may stop participating in the survey at any time, and you do not have to answer every question. You should also know that neither your name nor the name of your facility will ever appear in any reports from the findings. What you say on the survey will remain private and will not in any way affect your facility’s relationship with CMS.
For this survey, we are seeking the person who [for QIO facilities] works most closely with [INSERT NAME OF LOCAL QIN-QIO] / [for non-QIO facilities] is most knowledgeable about the quality improvement activities your nursing home has been working on. If your nursing home is part of a nursing home chain, we would like to interview someone that works at [FACILITY NAME] rather than someone at corporate office who is responsible for quality improvement for several facilities.
Before my first question, I need to tell you this survey has been approved by the Office of Management and Budget (OMB) as required by the Paperwork Reduction Act. The OMB approval number for this survey is 0938-XXXX.
Introduction and Informed Consent 2
[READ IF CONTACTED VIA EMAIL AND ARRANGED MEETING TIME]
We are calling you on behalf of the Centers for Medicare and Medicaid Services, or CMS, to learn about quality improvements in nursing home facilities and the types of resources that are helpful in this area. We scheduled this time to conduct a [10/20 minute survey --more for QIO facilities] asking about the resources that your facility uses for quality improvement efforts. Is this still a good time for you to participate in this survey?
You should know that this survey is voluntary, you may stop participating in the survey at any time, and you do not have to answer every question. You should also know that neither your name nor the name of your facility will ever appear in any reports from the findings. What you say on the survey will remain private and will not in any way affect your facility’s relationship with CMS.
Before my first question, I need to tell you this survey has been approved by the Office of Management and Budget (OMB) as required by the Paperwork Reduction Act. The OMB approval number for this survey is 0938-XXXX.
Introduction and Informed Consent 3
[READ IF CALLED PREVIOUSLY AND ARRANGED NEW MEETING TIME]
We are calling back on behalf of CMS, to learn about quality improvements in nursing home facilities and the types of resources that are helpful in this area. We scheduled this time to conduct a [10/20 minute survey --more for QIO facilities] asking about the resources that your facility uses for quality improvement efforts. Is this still a good time for you to participate in this survey?
Before my first question, I need to tell you this survey has been approved by the Office of Management and Budget (OMB) as required by the Paperwork Reduction Act. The OMB approval number for this survey is 0938-XXXX.
Introduction and Informed Consent 4
[READ IF PREVIOUSLY BEGAN CONDUCTING SURVEY AND NOW CALLING TO CONTINUE SURVEY]
We are calling back on behalf of CMS, to learn about quality improvements in nursing home facilities and the types of resources that are helpful in this area. We scheduled this time to finish conducting a survey asking about the resources that your facility uses for quality improvement efforts. Is this still a good time for you to complete this survey?
[DO NOT READ]
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. The time required to complete this information collection is estimated to average 15 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 Disclaimer*****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 Mr. Robert Kambic at 410-786-1515.
S1. Are you the best person at [FACILITY NAME] to complete this survey?
a. Yes
b. No
c. DK
d. Refused
[IF S1=NO, ASK S2; IF S1=Yes, PROCEED TO SURVEY QUESTIONS]
S2. Can you provide us the name of the person most responsible for improving quality in your nursing home?
a. Yes
b. No
c. DK
d. Refused
Record Name
Record Title
Record phone number
[IF S2=No or DK, ASK S3]
S3. Can you direct us to someone that is likely to be able to assist in identifying the right person?
a. Yes
b. No
c. DK
d. Refused
Record Name
Record Title
Record phone number
[IF YES IN S2 OR S3]
Great! We will update our files accordingly. Thank you for directing us to someone that may be able to help. We appreciate your assistance. [UPDATE SAMPLE RECORD AND RETURN TO QUEUE]
[IF NO IN S3]
Thanks for taking the time to speak to us. [SEND TO ACCOUNT GROUP TO SEEK REPLACEMENT]
Quality Improvement Initiatives
Since August 2014 has your facility worked on any quality improvement activities addressing the following topics?
[RANDOM ORDER]
Reducing antipsychotics (when not medically necessary)
Increasing patient mobility
Decreasing C. Diff (Clostridium Difficile) infections
Preventing hospitalizations and/or re-hospitalizations
[Probe:] Is your facility working on any other quality improvement activities?
[RECORD OTHER GOAL 1]
[RECORD OTHER GOAL 2]
[RECORD OTHER GOAL 3]
a. Yes
b. No
c. Don’t Know
d. Refuse
With 5 being very effective and 1 being not effective at all, how effective would you say your organization has been in addressing the following quality improvement topics?
[MATCH ORDER OF Q1; ONLY INCLUDE ITEMS MENTIONED IN Q1 (A-E)]
Reducing antipsychotic medication
Increasing patient mobility
Decreasing C. Diff (Clostridium Difficile) infections
Preventing hospitalizations and/or re-hospitalizations
a. Don’t know
b. Refused
Outcome Attribution to QIO
[QUESTIONS Q3 THROUGH Q8 WILL BE ASKED FOR UP TO TWO GOALS MENTIONED IN Q2 THAT RECEIVED THE HIGHEST RATING. IF THERE ARE MORE THAN TWO GOALS WITH THE SAME RATING, SELECT THE TWO HIGHER PRIORITY GOALS BASED ON A HEIRARCHICAL LIST OF GOALS
1) Increasing patient mobility
2) Reducing anti-psychotic medication
3) Decreasing C.Diff (Clostridium Difficile) infections
4) Preventing hospitalization and/or re-hospitalizations
5) Other specify 1
6) Other specify 2
7) Other specify 3]
What did your organization do to work towards [INSERT GOAL]?
[RECORD ANSWER]
Now I’m going to read a list of activities your facility may have implemented since August 2014 (or the last two years) to [INSERT GOAL]. [FIRST TIME DISPLAY: You may have mentioned some of these before]. Please indicate to the best of your knowledge whether your facility has done any of the following: [READ RESPONSE CATEGORIES]
Have you:
INTERVIEWER: SELECT EACH ITEM FOR WHICH RESPONDENT ANSWERS ‘YES’
A. Discussed this specific issue with the appropriate people,
B. Measured how you’re doing; tracking if the outcome improved,
C. Developed a process for documenting progress or lessons learned
D. Developed new care guidelines
E. Implemented new guidelines
F. Set goals and benchmarks to address the problem
G. Used Plan-Do-Study-Act cycles to test a change addressing the problem
[PROBE:] Any other activities?
H. [RECORD OTHER INITIATIVES 1]
I. [RECORD OTHER INITIATIVES 2]
J. [RECORD OTHER INITIATIVES 3]
a. Yes
b. No
c. Don’t Know
d. Refuse
[READ FOR FIRST GOAL] I’m going to read a list of programs, agencies, or sources of information that you may have used in improving quality at your facility. As I read each one, please tell me if you worked with or used this resource when working on [INSERT GOAL].
INTERVIEWER: Select each item for which respondent answers ‘yes’; ROTATE responses
The Partnership to Improve Dementia Care
QIO Collaborative [FIRST TIME DISPLAY or QIN-QIO, also known as [INSERT NAME OF LOCAL QIN-QIO]
Government agencies [FIRST TIME DISPLAY such as the Agency for Healthcare Research and Quality (AHRQ) or the [STATE] Department of Health]
Survey certification process
Professional organizations [FIRST TIME DISPLAY such as AMDA, AHCA, or NADONA]
[IF PART OF BROADER NETWORK/COMPANY] Corporate office
External consultant
Academic or trade journal/conference
Your staff’s own initiative
Are there any other sources of information you used when working on [INSERT GOAL]?
Other source 1. ________________________________
Other source 2. ________________________________
Other source 3. ________________________________
a. Yes
b. No
c. Don’t Know
d. Refuse
With 5 being most helpful and 1 being not helpful at all, how helpful was each of the following sources of information, design or assistance for your facility’s efforts to [INSERT GOAL]?
[LIST ONLY THOSE SOURCES CHECKED THROUGHOUT Q5]
The Partnership to Improve Dementia Care
QIO Collaborative
Government agencies
Survey certification process
Professional organizations
[IF PART OF BROADER NETWORK/COMPANY] Corporate office
External consultant
Academic or trade journal/conference
Your staff’s own initiative
Other source 1______________________________
Other source 2______________________________
a. Don’t Know
b. Refuse
[IF ON Q6 RESPONDENT GAVE MORE THAN ONE ATTRIBUTE (A – X) THEIR HIGHEST RATING (FOR EXAMPLE, Q6: A=5 AND B=5, OR Q6: A=5 AND B=5 AND C=5) THEN ASK Q7 FOR ATTRIBUTES GIVEN HIGHEST RATING ON Q6; ELSE SKIP TO Q8]
Which sources of information, design or assistance had the most impact on your facility’s ability to [INSERT GOAL]?
Now I’m going to read a list of the programs, agencies, and/or sources of information that you used in your efforts to [INSERT GOAL]. If you are able to, please write them down as I list them.
I am going to ask you to assign a percentage out of a total of 100% to each program. How much would you say each program contributed to your facility’s ability to [INSERT GOAL] over the last 12 months? What percentage would you assign to [READ FIRST SOURCE]
[The percentage (%) must total 100%.]
[LIST ONLY THOSE SOURCES CHECKED THROUGHOUT Q5]
___ % A. The Partnership to Improve Dementia Care
___ % B. QIO Collaborative
___ % C. Government agencies
___ % D. Survey certification process
___ % E. Professional organizations
___ % F. [IF PART OF BROADER NETWORK/COMPANY] Corporate office
___ % G. External consultant
___ % H. Academic or trade journal/conference
___ % I. Your staff’s own initiative
___ % J. Other source 1 ________________________________
___ % K. Other source 2 ________________________________
NUMERIC RESPONSE: RANGE 0-100, DON’T KNOW, REF
You have assigned [PERCENTAGE ASSIGNED] percent total so far. You have [SUBTRACT PRIOR RESPONSES FROM 100] percent left to distribute. What percentage would you assign to [READ NEXT SOURCE].
[REPEAT UNTIL ALL SOURCES ASSIGNED PERCENTAGES]
[READ FOR EACH ADDITIONAL GOAL] I am going to ask you about the same resources you may have used in improving [INSERT GOAL]. As I read each one, please tell me if you worked with or used this resource for [INSERT GOAL]. [REPEAT Q3-Q8]
When you were developing any of your quality improvement activities, did you involve residents and/or families?
a. Yes
b. No
c. Don’t Know
d. Refuse
Is your facility actively involved in a Quality Assurance and Performance Improvement plan, otherwise known as a QAPI plan?
a. Yes
b. Not yet, will be developing a plan
c. No
d. Don’t Know
e. Refuse
QIN-QIO Engagement for non-QIO Nursing Homes
SKIP TO SECTION IV IF Q4B=YES]
Have you ever heard of quality improvement organizations, otherwise referred to as QIOs?
a. Yes
b. No
c. Don’t Know
d. Refuse
Have you ever heard of [INSERT NAME OF LOCAL QIO]?
a. Yes
b. No
c. Don’t Know
d. Refuse
Have you ever heard of the [STATE] Nursing Home Quality Care Collaborative led by CMS and [INSERT NAME OF LOCAL QIO]?
a. Yes
b. No
c. Don’t Know
d. Refuse
Has your organization participated in any activities with [INSERT NAME OF LOCAL QIO] or the [STATE] Nursing Home Quality Care Collaborative (such as Learning and Action Networks or webinars)?
a. Yes
b. No
c. Don’t Know
d. Refuse
[ASK Q14-Q20 IF ON ANY ITERATION OF Q5B=YES OR Q13=YES; If Q13=NO, SKIP TO THANK YOU.]
Interaction with the QIN-QIO for QIO Nursing Homes
We now want to ask some questions about your interaction with the QIO that serves your area.
How long has your facility worked with [INSERT NAME OF LOCAL QIO]?
a. Since the beginning of this year
b. Sometime during 2015
d. Prior to 2015
e. Don’t Know
f. Refuse
Do you know whom to contact at [INSERT NAME OF LOCAL QIO], if you wanted help or advice from them on improving quality at your facility?
a. Yes
b. No
c. Don’t Know
d. Refuse
[ASK Q17 AND Q18 IF Q16 = YES, ELSE SKIP TO SECTION V]
Approximately how many times did you or someone at your facility have one-to-one or small-group meetings with someone from [INSERT NAME OF LOCAL QIO] on the phone, through email exchanges, or in-person in the past twelve months?
NUMERIC RESPONSE: RANGE 0-365, DON’T KNOW, REF
Approximately how many times did you or someone at your facility take part in bigger virtual meetings or workshops with someone from [INSERT NAME OF LOCAL QIO] in the past twelve months?
NUMERIC RESPONSE: RANGE 0-365, DON’T KNOW, REF
Activities and Resources Provided By QIN-QIO
Now I am going to read a list of resources your QIO may provide. Please indicate to the best of your knowledge whether your facility has used any of the following resources that may be provided by your QIO:
Technical assistance
Data
Resource Materials
Peer coaches
Learning to use QAPI methods or techniques
Learning session on mobility/fall prevention
Learning session on dementia care
Learning session on person-centered care
Learning session on staff stability
Learning session on consistent assignment
Reviews of PDSA or tests of change
Conference calls
Webinars on a specific topic
[PROBE:] Any other general engagement or information resources?
[RECORD OTHER RESOURCE 1]
[RECORD OTHER RESOURCE 2]
[RECORD OTHER RESOURCE 3]
a. Yes
b. No
c. Don’t Know
d. Refuse
Do you routinely receive data feedback from [INSERT NAME OF LOCAL QIN-QIO] on how your facility is doing?
a. Yes
b. No
c. Don’t Know
d. Refuse
Does your organization receive assistance from [INSERT NAME OF LOCAL QIN-QIO] to improve your Nursing Home Quality Care Collaborative composite score? Note that we’re not referring to the 5-Star Rating on Nursing Home Compare, rather the QIO’s composite score. [IF FURTHER EXPLANATION IS NEEDED, EXPLAIN THAT THE COMPOSITE SCORE COMBINES 13 QUALITY MEASURES.]
a. Yes
b. No
c. Don’t Know
d. Refuse
What quality improvement areas are you most in need of for additional assistance?
[RECORD ANSWER]
Thank you for your time and for sharing your experiences. Your comments are very helpful and insightful.
The time required to complete this information collection was estimated to average 15 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, I can provide you with the mailing address. Would you like this address?
[IF YES, READ BELOW]
You may send comments to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.
*****CMS Disclaimer*****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 Mr. Robert T Kambic at 410-786-1515.
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| File Title | Nursing Home Administrator Survey |
| Subject | Annual survey of quality improvement activities in CMS nursing homes both participating in and not participating in the QIN-QIO |
| Author | Booz Allen Hamilton |
| File Modified | 0000-00-00 |
| File Created | 2021-01-23 |