Medication Safety and Adverse Drug Event Prevention (A Web-based Survey)
The Centers for Medicare and Medicaid Services, or CMS, is conducting this survey to learn about the resources that you find to be helpful for medication safety and preventing adverse drug events, defined as injuries resulting from medical interventions related to a drug. Adverse drug events (ADEs) include medication errors, adverse drug reactions, allergic reactions, and overdoses.
This survey is voluntary, you may stop participating in the survey at any time, and you do not have to answer every question. Neither your name nor the name of your business will ever appear in any reports from the findings. Your responses will remain private and will not in any way affect your business’s relationship with CMS.
PRA Disclosure Statement
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 10-20 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 [List Program Specific Contact].
Please click next to begin
S1. In what state do currently work?
[Drop down of all 50 states plus District of Columbia]
S2. Which of the following best describes your specific occupation within a medical practice/ pharmacy/? Please select one.
[SINGLE PUNCH]
Medical Doctor (MD, DO, DPM; including PCPs and Specialists)
Nurse Practitioner
Physician Assistant
Registered Nurse
Pharmacist
Technician
Office/Practice Manager
[If S2 = “Technician” OR “Office/Practice Manager” OR “Other”, STOP SURVEY. ELSE PROCEED TO S3]
S3. In what setting do you primarily work? Please select one.
[SINGLE PUNCH]
Acute-care hospital or general hospital
Specialty care hospital
Physician’s office or group practice
Nursing home or long-term care facility
Urgent care center
Home health agency
Community or retail pharmacy
Rehabilitation center
Other
[IF “Physician’s office or group practice,” or “Community or retail pharmacy” ASK S4. ELSE SKIP TO S9].
S4. Approximately how many [INSERT “providers” IF S3 = “Physician’s office or group practice” OR “pharmacists” IF S3 = “Community or retail Pharmacy”] are employed at your [INSERT “practice” IF S3 = “Physician’s office or group practice” OR “pharmacy” IF S3 = “Community or retail pharmacy]?
[0 to 100]
[Set the initial range to 0-100, and if someone says a higher number, they get prompted to confirm that what they entered is right, and then the upper limit of the range is raised]
S5. Is the [INSERT “practice” or “pharmacy” depending on participant’s setting] where you primarily work part of any of the following?
[SINGLE PUNCH PER ITEM] [RANDOMIZE ITEMS]
[ITEMS]
[IF S3 = “Physician’s office or group practice”] Network of practices
[IF S3 = “Community or retail pharmacy”] Corporate chain
[IF S3 = “Community or retail pharmacy”] Pharmacy co-op
[ALL] Health system
[RESPONSES]
Yes
No
S6. Does your [INSERT “practice” OR “pharmacy” depending on participant’s setting] have any programs or protocols in place to reduce or prevent adverse drug events among your patients/customers?
[SINGLE PUNCH]
Yes
No
[IF S6 = YES, ASK S7; ELSE SKIP TO S9.]
S7. How familiar are you with your [INSERT “practice” OR “pharmacy] programs or protocols to reduce or prevent adverse drug events?
[SINGLE PUNCH]
Very familiar
Somewhat familiar
Not very familiar
Not familiar at all
[IF S7 = “Not very familiar” OR “Not familiar at all”, SKIP TO S9; IF S7 = “Somewhat familiar” OR “Very familiar”, PROCEED TO S8]
S8. Has your [INSERT “practice” OR “pharmacy”] worked with or received assistance from any of the following organizations to develop programs or protocols to reduce or prevent adverse drug events?
[MULTI PUNCH]
An external consultant
A government agency
[INSERT NAME OF LOCAL QIO. Based on Sample Variable ‘QIO’], the Quality Improvement Organization (QIO) in [INSERT State. Based on Sample Variable ‘State’]
None [THIS OPTION CAN ONLY BE CHOSEN IF ALL OTHER OPTIONS ARE NOT CHOSEN]
S9. How long have you worked in the field of healthcare?
[SINGLE PUNCH]
Less than 1 year
1 - 3 years
4 - 6 years
7 - 10 years
More than 10 years
S10. How many years have you been at your current position?
[SINGLE PUNCH]
Less than 1 year
1 - 3 years
4 - 6 years
7 - 10 years
More than 10 years
[IF S6 = YES AND IF S7 = “Somewhat familiar” OR “Very familiar” PROCEED TO Q1. ALL ELSE TERMINATE].
Quality Improvement Initiatives
Since [for practices display ‘January 2015’. For pharmacies display ‘September 2016’], has your [INSERT “practice” or “pharmacy”] begun or continued working on any quality improvement (QI) activities with the goal of reducing or preventing adverse drug events related to the following medications?
[MULTI PUNCH]
Opioids
Anticoagulants
Diabetes medications
RESPONSES:
Yes, began new QI activities
Yes, continued existing QI activities
No, haven’t worked on QI activities
[IF AT LEAST ONE ITEM IN Q1=YES, ASK Q2. ELSE, SKIP TO Q3].
How effective would you say your organization has been in reducing or preventing adverse drug events related to these medications?
[FOR EACH ITEM CHOSEN IN Q1, INSERT ITEM IN Q2. DISPLAY ITEMS IN SAME ORDER AS Q1. DO NOT INSERT ITEMS NOT CHOSEN IN Q1]
[ROWS]
Opioids
Anticoagulants
Diabetes medications
[COLUMNS]
Not effective at all (1)
2
3
4
Very effective (5)
Does your [INSERT “practice” OR “pharmacy”] use any of these methods or activities for medication safety or prevention of adverse drug events?
[MULTI PUNCH]
[RANDOMIZE ITEMS]
Screening or review of data, reports or graphs for [IF S3 = ‘physician’s office or group practice’ INSERT ‘patients’ OR IF S3 = ‘community or retail pharmacy’ INSERT ‘customers’] at risk for adverse drug events
Medication reconciliation
Pharmacist case management for patients with several medications
Medication management review
Instituting electronic health record (EHR) or electronic medical record (EMR)-populated notifications of drug interactions and/or allergies
Medication bag reviews
Medication take-back events or appointments
Medication therapy management (MTM) coordination across health care settings
Risk assessment for opioid use disorders
Opiate or opioid agreements
Collaboration with a coalition or learning group in your community
[IF S3 = “Physician’s office or group practice”] Audits of medical records against pharmacy orders
Increasing access to Naloxone
Educating [IF S3 = “physician’s office or group practice” INSERT ‘patients’ OR IF S3 = “community or retail pharmacy” INSERT ‘customers’] on opioid guidelines
Teaching [IF S3 = “physician’s office or group practice” INSERT ‘patients’ OR IF S3 = “community or retail pharmacy” INSERT ‘customers’] and family members how to identify and treat an adverse drug event
Coordinating with hospitals, skilled nursing facilities or other healthcare services around transfers of [IF S3 = “physician’s office or group practice” INSERT ‘patients’ OR IF S3 = “community or retail pharmacy” INSERT ‘customers’] from these facilities
Training [IF S3 = “physician’s office or group practice” INSERT ‘patients’ OR IF S3 = “community or retail pharmacy” INSERT ‘customers’] on ADE-related topics
Documenting and monitoring adverse drug event rates within your [IF S3 = “physician’s office or group practice” INSERT ‘patients’ OR IF S3 = “community or retail pharmacy” INSERT ‘customers’]
Involving [INSERT “patients” IF S3 = “Physician’s office or group practice” OR “customers” IF S3 = “Community or retail pharmacy”] or their family members in your efforts to improve medication safety?
Other (Specify)
None [THIS OPTION CAN ONLY BE CHOSEN IF ALL OTHER OPTIONS ARE NOT CHOSEN]
How would you gauge the extent to which you involve [INSERT “patients” IF S3 = “Physician’s office or group practice”, “customers” IF S3 = “Pharmacy” or their family members in your efforts to improve medication safety?
[SINGLE PUNCH]
Do not involve recipients or family at all (1)
2
3
4
Highly involve recipients or family (5)
To the best of your knowledge, was your [INSERT “practice” OR “pharmacy”] working in each of the following methods or activities before [for practices display ‘January 2015’. For pharmacies display ‘September 2016]?
[FOR EACH ITEM A-SL
MENTIONED IN Q3, INSERT ITEM. DISPLAY ITEMS IN SAME ORDER AS Q3.]
[ROWS]
Screening or review of data, reports or graphs for [IF S3 = “physician’s office or group practice” INSERT ‘patients’ OR IF S3 = “community or retail pharmacy” INSERT ‘customers’] at risk of adverse drug events
Medication reconciliation
Pharmacist case management for patients with several medications
Medication management review
Instituting EHR or EMR-populated notifications of drug interactions and/or allergies
Medication bag reviews
Medication take-back events or appointments
Medication therapy management (MTM) coordination across health care settings
Risk assessment for opioid use disorders
Opiate or opioid agreements
Collaboration with a coalition or learning group in your community
[IF S3 = “Physician’s office or group practice”] Audits of medical records against pharmacy orders
Increasing access to Naloxone
Educating [IF S3 = “physician’s office or group practice” INSERT ‘patients’ OR IF S3 = “community or retail pharmacy” INSERT ‘customers’] on opioid guidelines
Teaching [IF S3 = “physician’s office or group practice” INSERT ‘patients’ OR IF S3 = “community or retail pharmacy” INSERT ‘customers’] and family members how to identify and treat an adverse drug event
Coordinating with hospitals, skilled nursing facilities or other healthcare services around transfers of [IF S3 = “physician’s office or group practice” INSERT ‘patients’ OR IF S3 = “community or retail pharmacy” INSERT ‘customers’] from these facilities
Training [IF S3 = “physician’s office or group practice” INSERT ‘patients’ OR IF S3 = “community or retail pharmacy” INSERT ‘customers’] on ADE-related topics
Documenting and monitoring adverse drug event rates within your [IF S3 = “physician’s office or group practice” INSERT ‘patients’ OR IF S3 = “community or retail pharmacy”]
Involving [INSERT “patients” IF S3 = “Physician’s office or group practice” OR “customers” IF S3 = “Community or retail pharmacy”] or their family members in your efforts to improve medication safety?
[COLUMNS]
Yes
No
Outcome Attribution to QIO
The next several questions ask about different programs, organizations, and other resources your [INSERT “practice” OR “pharmacy”] may have used when developing and implementing quality improvement activities related to preventing and reducing adverse drug events. These questions refer to your efforts since [for practices display ‘January 2015’. For pharmacies display ‘September 2016’].
Please select the programs below that your [INSERT “practice” OR “pharmacy”] has used to promote medication safety or prevent adverse drug events.
[ROWS]
QIO Collaborative or Campaign for Medicine Management (also known as QIN-QIO), or [INSERT NAME OF LOCAL QIN-QIO. Based on Sample Variable ‘QIO’]
Transforming Clinical Practices Initiative (TCPI)
Choosing Wisely Campaign
[IF S3 = “Pharmacy”] Pharmacy Quality Alliance (PQA)
[For practices] Everyone with Diabetes Counts (EDC)
[COLUMNS]
Yes
No
Please select other national or state agencies/organizations that your [practice/pharmacy] use to promote medication safety or prevent adverse drug events.
[ROWS]
State Prescription Drug Monitoring Program
[IF S2 = “pharmacist”] [INSERT STATE] Board of Pharmacy
[FOR all] [INSERT STATE] Board of Health
Other resources from [INSERT STATE Based on Sample Variable ‘State’] Department of Health
Agency for Health Research and Quality (AHRQ)
Substance Abuse and Mental Health Services Administration (SAMHSA)
National Quality Forum
Other federal/state agency 1. _____________________________
Other federal/state agency 2. _____________________________
[COLUMNS]
Yes
No
Did your [practice/pharmacy] use information and resources from any of these organizations?
[ROWS]
The American Diabetes Association
The American Heart Association
[IF S2= ‘Nurse Practitioner or Physician Assistant’] The American Association of Nurse Practitioners or American College of Nurse Practitioners
[IF S2= ‘Nurse Practitioner or Physician Assistant’] The American Academy of PAs (AAPA)
[IF
S2 = ‘Medical Doctor’] The American Medical
Association, or American College of Physicians,
or American Academy of Family Physicians
[IF S2 = ‘Medical Doctor’ AND S3 = “Physician’s office or group practice”] The American Medical Group Association (AMGA)
[IF
S32
= “Pharmacists”] The American Pharmacists
Association
[IF S2 = “Pharmacists”] The [INSERT STATE] Pharmacists Association
[IF
Sv32
= “Pharmacists”] The National Association of
Chain Drug Stores (NACDS) or The National Community Pharmacists
Association
[IF S2 = “Nurse Practitioner or Physician Assistant”] American Association of Nurse Practitioners or American College of Nurse Practitioners
[IF S2 = “Nurse Practitioner or Physician Assistant” OR “Registered Nurse”] American Nurses Association
Other organization/resource 1______________________________
Other organization/resource 2______________________________
[COLUMNS]
Yes
No
Here are some other resources that may have been used when working on reducing ADEs. Please check if your organization uses any of the following.
[ROWS]
[IF S5’pharmacy co-op’ = YES] Pharmacy Co-Op
[IF S5 ‘network of practices’= Yes AND S5 ‘health system’ =No] “Group leadership” [IF S5 ‘network of practices’= Yes AND S5‘health system’ =Yes] “Group/health system leadership” [IF S5 ‘network of practices’= No AND S5‘health system’ =Yes] “Health system leadership”
Electronic medical record/electronic health record software and software provider
[IF S3 = “physician’s office or group practice” The Joint Commission
Epocrates
Point-of-care references such as UpToDate and DynaMed
External consultant
Academic or trade journal/conference
Ideas and initiatives developed by your [INSERT “practice’s” OR “pharmacy’s”] own staff.
Other source 1______________________________
Other source 2______________________________
[COLUMNS]
Yes
No
You indicated that the sources of information below helped with your efforts to reduce adverse drug events. Please indicate how helpful you found each resource in your quality improvement efforts to improve medication safety and reduce adverse drug events.
In other words, how much would you say each program contributed to your organization’s ability to promote medication safety or prevent adverse drug events since [for practices display ‘January 2015’. For pharmacies display ‘September 2016’]?
[INSERT ONLY RESOURCES SELECTED IN Q.6]
[ROWS]
QIO Collaborative or Campaign for Medicine Management (also known as QIN-QIO), or [INSERT NAME OF LOCAL QIN-QIO. Based on Sample Variable ‘QIO’]
Transforming Clinical Practices Initiative (TCPI)
Choosing Wisely Campaign
[IF S3 = “Pharmacy”] Pharmacy Quality Alliance (PQA)
[For practices] Everyone with Diabetes Counts (EDC)
State Prescription Drug Monitoring Program
[IF S2 = “pharmacist”] [INSERT STATE] Board of Pharmacy
[For all] [INSERT STATE] Board of Health
Other resources from [INSERT STATE. Based on Sample Variable ‘State’] Department of Health
AHRQ (Agency for Health Research and Quality)
Substance Abuse and Mental Health Services Administration (SAMHSA)
National Quality Forum
[DO NOT INSERT “OTHER” RESPONSE]
[DO NOT INSERT “OTHER” RESPONSE]
The American Diabetes Association
The American Heart Association[IF S2 = ‘Medical Doctor’] The American Medical Association, American College of Physicians, or American Academy of Family Physicians
[IF S2 = ‘Medical Doctor’’ AND S3 = “Physician’s office or group practice”] The American Medical Group Association (AMGA)
[IF S2 = “Pharmacists”] The American Pharmacists Association
[IF S2 = “Pharmacists”] The [INSERT STATE] Pharmacists Association
[IF S2 = “Pharmacists”] The National Association of Chain Drug Stores (NACDS) or National Community Pharmacists Association
[IF S2 = “Nurse Practitioner or Physician Assistant”] American Association of Nurse Practitioners or American College of Nurse Practitioners
[IF S2 = “Nurse Practitioner or Physician Assistant” OR “Registered Nurse”] American Nurses Association
[DO NOT INSERT “OTHER” RESPONSE]
[DO NOT INSERT “OTHER” RESPONSE]
[IF S5_CHAIN = YES] Corporate office
[IF S5_Co-op = YES] Pharmacy Co-Op
[IF S5_NETWORK = Yes AND S5_System=No] “Group leadership” [IF S5_NETWORK = Yes AND S5_System=Yes] “Group/health system leadership” [IF S5_NETWORK = No AND S5_System=Yes] “Health system leadership”
Electronic medical record/electronic health record software and software provider
[IF S3 = “physician’s office or group practice”] The Joint Commission
Epocrates
Point-of-care references such as UpToDate and DynaMed
External consultant
Academic or trade journal/conference
Ideas and initiatives developed by your [INSERT “practice’s” OR “pharmacy’s”] own staff.
[DO NOT INSERT “OTHER” RESPONSE]
[DO NOT INSERT “OTHER” RESPONSE]
[COLUMNS]
Very helpful
Somewhat helpful
A little helpful
Not helpful at all
[IF at Q7 RESPONDENT GAVE MORE THAN ONE ITEM THEIR HIGHEST RATING (FOR EXAMPLE, Q7 A_= “Very helpful” AND Q7_B = “Very helpful”, OR Q4_A = “Somewhat helpful” AND Q7_B = “Somewhat helpful” AND Q7_C = “Somewhat helpful” AND THERE WERE NO “Very helpful” RESPONSES), THEN ASK Q7AA FOR THE ITEMS GIVEN HIGHEST RATING ON Q7; OTHERWISE SKIP TO Q7A]
[Q7AA IS A ‘TIE-BREAKER’ QUESTION TO FORCE RESPONDENTS TO CHOOSE AN ANSWER OPTION IN Q7 WITH THE MOST IMPACT]
Q7AA. Which sources of information, design or assistance had the most impact on your [INSERT “practice’s” OR “pharmacy’s”] ability to medication safety or prevent adverse drug events since [for practices display ‘January 2015’. For pharmacies display ‘September 2016’?
[SINGLE PUNCH]
QIO Collaborative or Campaign for Medicine Management (also known as QIN-QIO), or [INSERT NAME OF LOCAL QIN-QIO. Based on Sample Variable ‘QIO’]
Transforming Clinical Practices Initiative (TCPI)
Choosing Wisely Campaign
[IF S3 = “Pharmacy”] Pharmacy Quality Alliance (PQA)
[For practices] Everyone with Diabetes Counts (EDC)
State Prescription Drug Monitoring Program
[IF S2 = “pharmacist”] [INSERT STATE] Board of Pharmacy
[For all] [INSERT STATE] Board of Health
Other resources from [INSERT STATE. Based on Sample Variable ‘State’] Department of Health
Agency for Health Research and Quality (AHRQ)
Substance Abuse and Mental Health Services Administration (SAMHSA)
National Quality Forum
[DO NOT INSERT “OTHER” RESPONSE]
[DO NOT INSERT “OTHER” RESPONSE]
The American Diabetes Association
The American Heart Association
[IF S2 = ‘Medical Doctor’ or ‘Behavioral Health Clinician’] The American Medical Association, American College of Physicians, or American Academy of Family Physicians
[IF S2 = ‘Medical Doctor’ or ‘Behavioral Health Clinician’ AND S3 = “Physician’s office or group practice”] The American Medical Group Association (AMGA)
[IF S2 = “Pharmacists”] The American Pharmacists Association
[IF S2 = “Pharmacists”] The [INSERT STATE] Pharmacists Association
[IF S2 = “Pharmacists”] The National Association of Chain Drug Stores (NACDS) or National Community Pharmacists Association
[IF S2 = “Nurse Practitioner or Physician Assistant”] American Association of Nurse Practitioners or American College of Nurse Practitioners
[IF S2 = “Nurse Practitioner or Physician Assistant” OR “Registered Nurse”] American Nurses Association
[DO NOT INSERT “OTHER” RESPONSE]
[DO NOT INSERT “OTHER” RESPONSE]
[IF S5_CHAIN = YES] Corporate office
[IF S5_Co-op = YES] Pharmacy Co-Op
[IF S5_NETWORK = Yes AND S5_System=No] “Group leadership” [IF S5_NETWORK = Yes AND S5_System=Yes] “Group/health system leadership” [IF S5_NETWORK = No AND S5_System=Yes] “Health system leadership”
Electronic medical record/electronic health record software and software provider
[IF S3 = “physician’s office or group practice”] The Joint Commission
Epocrates
Point-of-care references such as UpToDate and DynaMed
External consultant
Academic or trade journal/conference
Ideas and initiatives developed by your [INSERT “practice’s” OR “pharmacy’s”] own staff.
[DO NOT INSERT “OTHER” RESPONSE]
[DO NOT INSERT “OTHER” RESPONSE]
[CREATE VARIABLE TOPSOURCE = HIGHEST RATED ITEM FROM Q7 OR, IF MULTIPLE ITEMS TIED FROM Q7, RESPONSE TO Q7AA]
[ASK ALL]
7a. Why was [INSERT TOPSOURCE] the most helpful source of information?”
[Open-end]
Participation in QIN-QIO activities for non-QIO Practice/Facilities/Pharmacies
Before this survey, had you ever heard of Quality Improvement Organizations, otherwise referred to as QIOs?
[SINGLE PUNCH]
Yes
No
Before this survey, had you ever heard of [INSERT NAME OF LOCAL QIO. Based on Sample Variable ‘QIO’]?
[SINGLE PUNCH]
Yes
No
[IF Q8=No AND Q9=No, SKIP TO Q21. ELSE ASK Q10.]
Has your organization participated in any activities with [INSERT NAME OF LOCAL QIO. Based on Sample Variable ‘QIO’], the Quality Improvement Organization in [STATE. Based on Sample Variable ‘State’] (such as technical assistance using data, Learning and Action Networks or webinars)?
[SINGLE PUNCH]
Yes
No
[ASK Section IV QUESTIONS IF Q6 A=YES OR Q10=YES; If Q10=NO, SKIP TO Q21
[CREATE VARIABLE: QIOEXPERIENCE. IF Q10=No and Q6_A=No, Q=0. IF Q10=Yes AND Q6_A = No, QIOEXPERIENCE=1. IF Q10=No AND Q6_A = YES, QIOEXPERIENCE=2. IF Q10=Yes AND Q6_A = Yes, QIOEXPERIENCE=3.
Interaction with the QIN-QIO
These questions are about your interaction with the QIO that serves your area.
How long has your [INSERT “practice” OR “pharmacy” worked with [INSERT NAME OF LOCAL QIO. Based on Sample Variable ‘QIO’]?
[SINGLE PUNCH]
Before [for practices display ‘January 2015’. For pharmacies display ‘September 2016] Since January 2015 [for practices display ‘January 2015’. For pharmacies display ‘September 2016]
How much do you agree or disagree with the following statement?
My organization benefits from participating with [INSERT NAME OF LOCAL QIO. Based on Sample Variable ‘QIO’]
[SINGLE PUNCH]
Strongly disagree
Somewhat disagree
Neither agree nor disagree
Somewhat agree
Strongly agree
[IF Q12 = “Strongly disagree” or “Somewhat disagree” ASK Q12a. ELSE SKIP TO Q13.]
12a. Please explain why you disagree with this statement
[Open-end]
Do you know whom to contact at [INSERT NAME OF LOCAL QIO. Based on Sample Variable ‘QIO’], if you wanted help or advice from them on improving medical safety, or preventing ADEs?
[SINGLE PUNCH]
Yes
No
Approximately how many times did you or someone at your organization participate in one-on-one or small group meetings with someone from [INSERT NAME OF LOCAL QIO. Based on Sample Variable ‘QIO’] on the phone, through email exchanges, or in-person in the past twelve months?
[NUMERIC RESPONSE: RANGE 0-365]
[DON’T KNOW]
Apart from one-on-one exchanges, did your organization take part in meetings led by [INSERT NAME OF LOCAL QIO. Based on Sample Variable ‘QIO’] with other healthcare providers and pharmacists in the community, such as those working in hospitals, nursing homes, home health agencies or other types of healthcare providers?
[SINGLE PUNCH]
Yes
No
[If Q15=NO, SKIP to Q17]
Approximately how many times did you or someone from your organization participate in meetings with these other healthcare providers or pharmacists in the past twelve months?
[0 to 100]
How much do you agree or disagree with the following statements about these meetings organized by [INSERT NAME OF LOCAL QIO. Based on Sample Variable ‘QIO’]?
[ROWS]
Participants in these meetings act as a collaborative or coalition to increase coordination of care and/or reduce ADEs
Members actively participate in the meetings
If tasks need to be completed before the next meeting, members assume lead responsibility for tasks
Members actively plan, implement, and evaluate activities
Members commit a sufficient amount of time to achieve goals and nurture the collaboration
[COLUMNS]
Strongly disagree
Somewhat disagree
Neither agree nor disagree
Somewhat agree
Strongly agree
[IF OCCUPATION = Pharmacist, ASK Q18. ELSE SKIP TO Q19.]
How much do you agree or disagree with the following statement?
Since working with [INSERT NAME OF LOCAL QIO. Based on Sample Variable ‘QIO’] I have experienced improved relationships with prescribers
[SINGLE PUNCH]
Strongly disagree
Somewhat disagree
Neither agree nor disagree
Somewhat agree
Strongly agree
Activities and Resources Provided By QIN-QIO
Please indicate to the best of your knowledge whether your [INSERT “practice” or “pharmacy”] has used any of the following resources that may be provided by your QIO:
[ROWS]
Data, reports or graphs on adverse drug event-related hospitalizations or readmissions in your area
Resource materials such as tool kits on preventing ADEs from anticoagulants, diabetes agents, or opioids, or links to information online
Technical assistance with collecting data
Technical assistance on using data to monitor potential ADEs or occurrence of ADEs with IF S3 = “physician’s office or group practice” INSERT “patients”. IF S3 = “Community or retail pharmacy” INSERT “customers”]
Conference calls
Meetings or webinars on a specific topic
Any other general engagement or information resources?
[RECORD OTHER RESOURCE 1]
[RECORD OTHER RESOURCE 2]
[RECORD OTHER RESOURCE 3]
[COLUMNS]
Yes
No
Don’t Know
Overall, please mark the response that best describes your organization’s level of engagement with the medication safety technical assistance and resources provided by [INSERT NAME OF LOCAL QIO. Based on Sample Variable ‘QIO’] since [for practices ‘January 2015’. For pharmacies display ‘September 2016].
[SINGLE PUNCH]
Fully engaged
Moderately engaged
Minimally engaged
Not at all engaged
What quality improvement areas related to medication safety or adverse drug events is your [INSERT “practice” OR “pharmacy”] most in need of for additional assistance?
Please provide enough detail so that CMS can understand what type of assistance you would need for this quality improvement area.
[Open ended]
IF QIO EXPERIENCE = 0, ASK Q22. ELSE, SKIP TO FINAL SCREEN.
How useful would it be for your [INSERT “practice” OR, “pharmacy”] to adopt each of the following practices? [INSERT ACTIVITIES NOT CHOSEN IN Q3]
[ROWS]
Screening or review of data, reports or graphs for [IF S3 = “physician’s office or group practice” INSERT ‘patients’ OR IF S3 = “community or retail pharmacy” INSERT ‘customers’] at risk of adverse drug events
Medication reconciliation
Pharmacist case management for patients with several medications
Medication management review
Instituting EHR or EMR-populated notifications of drug interactions and/or allergies
Medication bag reviews
Medication take-back events or appointments
Medication therapy management (MTM) coordination across health care settings
Risk assessment for opioid use disorders
Opiate or opioid agreements
Collaboration with a coalition or learning group in your community
[IF S3 = “Physician’s office or group practice”] Audits of medical records against pharmacy orders
Increasing access to Naloxone
Educating [IF S3 = “physician’s office or group practice” INSERT ‘patients’ OR IF S3 = “community or retail pharmacy”] on opioid guidelines
Teaching [IF S3 = “physician’s office or group practice” INSERT ‘patients’ OR IF S3 = “community or retail pharmacy”] and family members how to identify and treat an adverse drug event
Coordinating with hospitals, skilled nursing facilities or other healthcare services around transfers of [IF S3 = “physician’s office or group practice” INSERT ‘patients’ OR IF S3 = “community or retail pharmacy” INSERT ‘customers’] from these facilities
Training [IF S3 = “physician’s office or group practice” INSERT ‘patients’ OR IF S3 = “community or retail pharmacy”] on ADE-related topics
Documenting and monitoring adverse drug event rates within your [IF S3 = “physician’s office or group practice” INSERT ‘patients’ OR IF S3 = “community or retail pharmacy”]
Involving [INSERT “patients” IF S3 = “Physician’s office or group practice”, “customers” IF S3 = “Community or retail pharmacy”] or their family members in your efforts to improve medication safety?
[COLUMNS]
Very helpful,
Somewhat helpful
A little helpful
Not at all helpful
Thank you for your time and for sharing your experiences.
| 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 | 2021-01-20 |