Form MOPS-HP Questionnaire

OMB No. xxxx-xxxx: Approval Expires xx/xx/xxxx

MANAGEMENT AND ORGANIZATIONAL PRACTICES SURVEY-HOSPITALS
SECTION A
TENURE
Year

1

What year did you start working at this hospital? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Year

2

What year did you start working as a manager at this hospital? . . . . . . . . . . . . . . . . . .

SECTION B
ORGANIZATIONAL CHARACTERISTICS
Number

3

In 2020, how many licensed beds did this hospital have? . . . . . . . . . . . . . . . . . . . . . . .

SECTION C
MANAGEMENT PRACTICES
4

In 2019 and 2020, how frequently were the clinical key performance indicators reviewed by
CLINICAL MANAGERS at this hospital?
A CLINICAL MANAGER is someone who has employees directly reporting to them, with whom they
meet on a regular basis, and whose pay and promotion they may be involved with. A clinical manager is
involved in patient care decision-making.
A CLINICAL KEY PERFORMANCE INDICATOR is a quantifiable metric used to evaluate the success
of any clinical activity or function. For Questions 4, 5, and 6, consider key performance indicators that are
used in any clinical activities at this hospital.
2020

Select all that apply
Yearly . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Quarterly . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Monthly . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Weekly. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Daily . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Hourly or more frequently . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Never. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

MOPS-HP (10/14/2020)

1

2019

5

In 2019 and 2020, how frequently were the clinical key performance indicators given to
PROVIDERS at this hospital?
PROVIDERS include physicians, physicians’ assistants, advanced practice nurses, and others who are
responsible for evaluating, diagnosing, and treating patients. Typically, providers do NOT have
employees directly reporting to them.
2020

Select all that apply

2019

Yearly . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Quarterly . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Monthly . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Weekly . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Daily . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Hourly or more frequently . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Never. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

6

In 2019 and 2020, how frequently were the clinical key performance indicators given to
FRONTLINE CLINICAL WORKERS at this hospital?
FRONTLINE CLINICAL WORKERS include all clinical staff with direct patient care responsibilities (such
as nurses, nurses’ aides, physical/occupational/speech/respiratory therapists, radiology and laboratory
technicians), who do NOT have employees directly reporting to them. Do NOT include non-clinical
frontline staff such as food services, housekeeping, or maintenance staff.
2020

Select all that apply

2019

Yearly . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Quarterly . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Monthly . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Weekly . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Daily . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Hourly or more frequently . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Never. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

7

In 2019 and 2020, where were the physical display boards showing quality and other clinical
key performance indicators located at this hospital?
2020

Select one box for each year
All physical display boards were located in one place . . . . . . . . . . . . . . . . . . . . . . . .
Physical display boards were located in multiple places . . . . . . . . . . . . . . . . . . . . . .
We did not have any physical display boards, but personnel had
access to virtual display boards (for example, via email or intranet) . . . . . . . . . . . . .
We did not have any display boards, physical or virtual . . . . . . . . . . . . . . . . . . . . . .

MOPS-HP (10/14/2020)

2

2019

8

In 2019 and 2020, what best describes the time frame of hospital-wide goals for PATIENT
CARE at this hospital?
Examples of hospital-wide goals for patient care: infection rates, readmission rates, and wait times.
2020

Select one box for each year

2019

Main focus was on short-term (one year or less) patient care goals . . . . . . . . . . . . .
Main focus was on long-term (more than one year) patient care goals . . . . . . . . . . .
Combination of short-term and long-term patient care goals. . . . . . . . . . . . . . . . . . .
No hospital-wide patient care goals (SKIP to Question 11) . . . . . . . . . . . . . . . . . .

9

In 2019 and 2020, how much effort was required for this hospital to achieve its hospital-wide
goals for PATIENT CARE?
2020

Select one box for each year

2019

Possible to achieve without much effort . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Possible to achieve with less than normal effort . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Possible to achieve with normal effort . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Possible to achieve with more than normal effort . . . . . . . . . . . . . . . . . . . . . . . . . . .
Only possible to achieve with extraordinary effort . . . . . . . . . . . . . . . . . . . . . . . . . .

10

In 2019 and 2020, who was aware of the hospital-wide goals for PATIENT CARE at this
hospital?
2020

Select all that apply
Board of Directors and/or President . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Senior clinical managers, such as Chief Nursing Officer (CNO)
or Chief Medical Officer (CMO) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Senior non-clinical managers, such as Chief Financial Officer (CFO),
Chief Executive Officer (CEO), Chief Operating Officer (COO) . . . . . . . . . . . . . . . . . .
Clinical managers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Non-clinical managers (A non-clinical manager has employees reporting
to them but is NOT involved in patient care decision-making) . . . . . . . . . . . . . . . . . .
Providers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Frontline clinical workers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

MOPS-HP (10/14/2020)

3

2019

11

In 2019 and 2020, what best describes the time frame of FINANCIAL goals at this hospital?
2020

Select one box for each year

2019

Main focus was on short-term (one year or less) financial goals . . . . . . . . . . . . . . . .
Main focus was on long-term (more than one year) financial goals. . . . . . . . . . . . . .
Combination of short-term and long-term financial goals . . . . . . . . . . . . . . . . . . . . .
No financial goals (SKIP to Question 14) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
I am unfamiliar with financial goals at this hospital (SKIP to Question 14). . . . . . .

12

In 2019 and 2020, how much effort was required for this hospital to achieve its FINANCIAL
goals?
Select one box for each year

2020

2019

2020

2019

Possible to achieve without much effort . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Possible to achieve with less than normal effort . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Possible to achieve with normal effort. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Possible to achieve with more than normal effort . . . . . . . . . . . . . . . . . . . . . . . . . . .
Only possible to achieve with extraordinary effort . . . . . . . . . . . . . . . . . . . . . . . . . .

13

In 2019 and 2020, who was aware of the FINANCIAL goals at this hospital?
Select all that apply
Board of Directors and/or President . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Senior clinical managers (CNO, CMO) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Senior non-clinical managers (CFO, CEO, COO) . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Clinical managers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Non-clinical managers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Providers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Frontline clinical workers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

MOPS-HP (10/14/2020)

4

14

In 2019 and 2020, what was the primary way CLINICAL MANAGERS were promoted at this
hospital?
2020

Select one box for each year

2019

Promotions were based SOLELY on performance, ability, and managerial potential..
Promotions were based PARTLY on performance, ability, and managerial potential,
and partly on other factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Promotions were based mainly on factors OTHER THAN performance, ability,
and managerial potential . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Clinical managers were typically not promoted . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

15

In 2019 and 2020, what was the typical way PROVIDERS were promoted to managerial roles
at this hospital?
2020

Select one box for each year

2019

Promotions were based SOLELY on performance, ability, and managerial potential. .
Promotions were based PARTLY on performance, ability, and managerial potential,
and partly on other factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Promotions were based mainly on factors OTHER THAN performance, ability,
and managerial potential . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Providers were typically not promoted . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

16

In 2019 and 2020, what was the typical way FRONTLINE CLINICAL WORKERS were promoted
to managerial roles at this hospital?
2020

Select one box for each year
Promotions were based SOLELY on performance, ability, and managerial potential..
Promotions were based PARTLY on performance, ability, and managerial potential,
and partly on other factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Promotions were based mainly on factors OTHER THAN performance, ability,
and managerial potential . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Frontline clinical workers were typically not promoted . . . . . . . . . . . . . . . . . . . . . . .

MOPS-HP (10/14/2020)

5

2019

17

In 2019 and 2020, how long did the reassignment or dismissal process typically take after
first noting a CLINICAL MANAGER’S underperformance? Include time spent on remediation.
2020

Select one box for each year

2019

Within 6 months of identifying a clinical manager’s underperformance. . . . . . . . . . .
After 6 months of identifying a clinical manager’s underperformance . . . . . . . . . . . .
Underperforming clinical managers were rarely or never reassigned or dismissed . .

18

In 2019 and 2020, how long did the reassignment or dismissal process typically take after
first noting a PROVIDER’S underperformance? Include time spent on remediation.
2020

Select one box for each year

2019

Within 6 months of identifying a provider’s underperformance . . . . . . . . . . . . . . . . .
After 6 months of identifying a provider’s underperformance . . . . . . . . . . . . . . . . . .
Underperforming providers were rarely or never reassigned or dismissed . . . . . . . .

19

In 2019 and 2020, how long did the reassignment or dismissal process typically take after
first noting a FRONTLINE CLINICAL WORKER’s underperformance?
Include time spent on remediation.
2020

Select one box for each year

2019

Within 6 months of identifying a frontline clinical worker’s underperformance . . . . .
After 6 months of identifying a frontline clinical worker’s underperformance . . . . . .
Underperforming frontline clinical workers were rarely or never reassigned
or dismissed . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

20

In 2019 and 2020, how did this hospital typically address problems with patient care
delivered by PROVIDERS?
Please respond for clinical problems that were NOT serious reportable events.
2020

Select one box for each year
We fixed it but did not take further action . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
We fixed it and took action to make sure that it did not happen again. . . . . . . . . . . .
We fixed it and took action to make sure that it did not happen again and had a
continuous improvement process to anticipate problems like these in advance. . . . .
We tried to fix it, but did not remediate problem . . . . . . . . . . . . . . . . . . . . . . . . . . .
No action was taken . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

MOPS-HP (10/14/2020)

6

2019

21

In 2019 and 2020, how did this hospital typically address problems with patient care
delivered by FRONTLINE CLINICAL WORKERS?
Please respond for clinical problems that were NOT serious reportable events.
2020

Select one box for each year

2019

We fixed it but did not take further action . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
We fixed it and took action to make sure that it did not happen again . . . . . . . . . . .
We fixed it and took action to make sure that it did not happen again and had a
continuous improvement process to anticipate problems like these in advance. . . . .
We tried to fix it, but did not remediate problem. . . . . . . . . . . . . . . . . . . . . . . . . . . .
No action was taken . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

SECTION D
MANAGEMENT TRAINING
22

Which of the following types of management training courses have you participated in?
Select all that apply
Master of Business Administration (MBA) or executive MBA lasting at least one year
or more full time . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Other graduate-level degree programs lasting at least one year or more full time that
included management coursework . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Selected management courses shorter than one year but longer than one week . . . . . . . . . . . . . . . . .
Selected management courses lasting one week or less . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
I have not participated in any management training courses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

SECTION E
MANAGEMENT OF TEAM INTERACTIONS
23

In 2019 and 2020, who participated in meetings dedicated to the discussion of clinical
outcomes?
2020

Select all that apply
Board of Directors and/or President . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Senior clinical managers (CNO, CMO) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Clinical managers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Non-clinical managers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Providers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Frontline clinical workers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
We did not hold meetings dedicated to the discussion of clinical outcomes
(SKIP to Question 29). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

MOPS-HP (10/14/2020)

7

2019

24

In 2019 and 2020, how often did CLINICAL MANAGERS hold meetings that were dedicated to
the discussion of clinical outcomes at this hospital?
2020

Select all that apply

2019

Yearly . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Quarterly . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Monthly . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Weekly . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Daily or multiple times within a day . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

25

In 2019 and 2020, what best describes the intent of the meetings that were dedicated to the
discussion of clinical outcomes at this hospital?
2020

Select one box for each year

2019

The meetings were used exclusively to report past performance. . . . . . . . . . . . . . . .
The meetings were used exclusively to discuss ways to improve future performance
The meetings were used to report past performance, as well as ways to improve
future performance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

26

In 2019 and 2020, what best describes who could view data during meetings dedicated to the
discussion of clinical outcomes?
2020

Select all that apply

2019

Board of Directors and/or President . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Senior clinical managers (CNO, CMO) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Clinical managers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Non-clinical managers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Providers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Frontline clinical workers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
The meetings did not usually involve viewing data . . . . . . . . . . . . . . . . . . . . . . . . . .

27

In 2019 and 2020, what best describes what happened after meetings dedicated to the
discussion of clinical outcomes?
2020

Select one box for each year
Follow-up plans were drafted or revised, but adherence was not actively monitored
Follow-up plans were drafted or revised, and adherence was actively monitored . . .
No follow-up plans were drafted or revised (SKIP to Question 29). . . . . . . . . . . . .

MOPS-HP (10/14/2020)

8

2019

28

In 2019 and 2020, who could view follow-up plans drafted or revised after meetings
dedicated to the discussion of clinical outcomes?
2020

Select all that apply

2019

Board of Directors and/or President . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Senior clinical managers (CNO, CMO) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Clinical managers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Non-clinical managers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Providers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Frontline clinical workers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

SECTION F
STAFFING AND ALLOCATION OF HUMAN RESOURCES
29

In 2019 and 2020, who decided how work was allocated to clinical staff at this hospital?
2020

Select all that apply

2019

Senior clinical managers (CNO, CMO) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Senior non-clinical managers (CEO, CFO, COO) . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Clinical managers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Non-clinical managers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Providers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Frontline clinical workers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

30

In 2019 and 2020, how were FRONTLINE CLINICAL WORKERS moved to different units within
this hospital when needed (for example, in response to understaffing or increased patient care
needs)?
2020

Select one box for each year
Frontline clinical workers were moved to different units within this hospital
when needed, and ONE central office coordinated this process. . . . . . . . . . . . . . . . .
Frontline clinical workers were moved to different units within this hospital
when needed, but NO one central office coordinated this process. . . . . . . . . . . . . . .
Frontline clinical workers were not moved to different units within this
hospital when needed . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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31

In 2019 and 2020, who determined the typical ratios for nursing staff to patients at this
hospital?
2020

Select all that apply

2019

Senior clinical managers (CNO, CMO) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Senior non-clinical managers (CEO, CFO, COO) . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Clinical managers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Non-clinical managers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Providers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Frontline clinical workers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
State and/or federal regulations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

32

In 2019 and 2020, which best describes this hospital’s approach to staffing teams for clinical
care, based on the team members’ experience working together?
2020

Select one box for each year

2019

Typically, this hospital attempted to put individuals together with others with
whom they HAD worked extensively in the past . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Typically, this hospital attempted to put individuals together with others with
whom they HAD NOT worked extensively in the past . . . . . . . . . . . . . . . . . . . . . . . .
Typically, this hospital DID NOT ACCOUNT for the familiarity that individuals
had working together in the past . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

SECTION G
STANDARDIZED CLINICAL PROTOCOLS
33

In 2019 and 2020, who of the following USED standardized clinical protocols at this hospital?
2020

Select all that apply
Senior clinical managers (CNO, CMO) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Senior non-clinical managers (CEO, CFO, COO) . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Clinical managers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Non-clinical managers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Providers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Frontline clinical workers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
This hospital did not use standardized clinical protocols (SKIP to Question 38) . . .

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34

In 2019 and 2020, who of the following DEVELOPED new standardized clinical protocols at
this hospital?
2020

Select all that apply

2019

Senior clinical managers (CNO, CMO) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Senior non-clinical managers (CEO, CFO, COO) . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Clinical managers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Non-clinical managers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Providers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Frontline clinical workers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
No new standardized clinical protocols were created at this hospital. . . . . . . . . . . . .
Only state and/or federally-mandated clinical protocols were used at this hospital . .

33
35

In 2019 and 2020, who of the following MODIFIED or UPDATED standardized clinical
protocols at this hospital?
2020

Select all that apply

2019

Senior clinical managers (CNO, CMO) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Senior non-clinical managers (CEO, CFO, COO) . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Clinical managers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Non-clinical managers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Providers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Frontline clinical workers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Standardized clinical protocols were not usually modified or updated at this
hospital (SKIP to Question 37) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

33
36

In 2019 and 2020, within what time period did this hospital typically MODIFY or UPDATE its
standardized clinical protocols after the need to do so was first identified?
2020

Select one box for each year
Within one week of identifying the need . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Within one month of identifying the need . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Within three months of identifying the need . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Within six months of identifying the need . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
More than six months after the need was first identified . . . . . . . . . . . . . . . . . . . . . .

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37

In 2019 and 2020, who of the following MONITORED the appropriate use of standardized
clinical protocols at this hospital?
2020

Select all that apply

2019

Senior clinical managers (CNO, CMO) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Senior non-clinical managers (CEO, CFO, COO) . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Clinical managers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Non-clinical managers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Providers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Frontline clinical workers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
The appropriate use of standardized clinical protocols was not monitored at this
hospital . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

SECTION H
DOCUMENTATION OF PATIENTS’ MEDICAL RECORDS
38

In 2019 and 2020, what actions were taken at this hospital in response to PROVIDERS’
incomplete documentation of patients’ medical records?
2020

Select all that apply

2019

Required provider to meet with hospital senior managers or supervisors . . . . . . . . .
Required provider to meet with compliance office. . . . . . . . . . . . . . . . . . . . . . . . . . .
Required provider to undergo peer review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Required provider to meet with other staff not listed above . . . . . . . . . . . . . . . . . . .
Required provider to receive additional training . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Provider was reassigned or dismissed. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Provider was penalized financially . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
No actions were taken for providers’ incomplete documentation of patients’
medical records . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
There was no issue with providers’ incomplete documentation of patients’
medical records . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

39

In 2019 and 2020, what actions were taken at this hospital to recognize a PROVIDER fully
completing their documentation of patients’ medical records?
2020

Select all that apply
This hospital used NON-FINANCIAL incentives for complete documentation
of patients’ medical records. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
This hospital used FINANCIAL incentives for complete documentation of
patients’ medical records. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
This hospital used NO incentives for complete documentation of patients’
medical records, financial or non-financial. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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REMARKS

CONTACT INFORMATION
Name

Title

Street

City

State

Zip Code

Area Code and Phone Number

-

Email

-

THANK YOU FOR COMPLETING THIS SURVEY

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