Form CMS-10769 NQIIC Nursing Home Survey

OMB No. 0938-xxxx
Expires xx/xx, 20xx
Appendix A: NQIIC Nursing Home Survey Instrument
Introduction and Informed Consent 1
[READ IF CONTACTED WITH LETTER OR EMAIL ONLY]
We’re calling you on behalf of The Centers for Medicare & 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’re conducting a [20-minute survey] 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. This survey is voluntary. You may stop
participating in the survey at any time, and you don’t have to answer every question. Please
know that neither your name nor the name of your facility will ever appear in any reports from
the findings. What you say during the survey’s administration will remain private and will not in
any way affect your facility’s relationship with CMS.
For this survey, we’re seeking the person who [for NQIIC facilities] works most closely with
[INSERT NAME OF LOCAL QIN-QIO] and / [for non-NQIIC facilities] who 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’d like to interview someone who
works at [FACILITY NAME], rather than someone at the corporate office level who’s
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, or 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’re 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 [20-minute survey] 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 don’t 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, or OMB, as required by the Paperwork Reduction Act. The OMB
approval number for this survey is 0938-XXXX.

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Introduction and Informed Consent 3
[READ IF CALLED PREVIOUSLY AND ARRANGED NEW MEETING TIME]
We’re calling back 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 [20-minute survey] 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, or 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’re calling back 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 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 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.
Screener
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 S4]
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
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[IF S2 = No or DK, ASK S3]
S3. Can you direct us to someone who 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’ll update our files accordingly. Thank you for directing us to someone who 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]
S4. Can you please state your full name? [RECORD CORRECTIONS AS NEEDED]
S5. Please tell me your title or role. [RECORD CORRECTIONS AS NEEDED]
S6. How long have you worked at this facility regardless of role?
[Record years and months]
Not sure (approximately how long?)
Quality Improvement Initiatives for the Last 12 Months
1. Since March 2020, has your facility changed or developed new processes or protocols to
prevent and control the spread of COVID-19 infection?
a. Yes [GO TO Q2]
b. No [SKIP TO Q3]
2. [If Q1 = YES] During the first 6 months of COVID-19, what would you consider the top two
or three changes you made to your processes or protocols to respond to the pandemic?
(PROBE) [DO NOT NEED TO BE IN ORDER OF IMPORTANCE]
a.
b.
c.
d.

Response category 1
Response category 2
Response category 3
Other [open ended]

3. [If Q1 = NO] Which of these statements describe the reasons why your facility didn’t change
any processes or protocols to prevent infection during the COVID-19 pandemic. Would you
say it’s because…
[Select all that apply]

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a.
b.
c.
d.

Our processes and protocols were already effective
We were in a green zone, and no cases of COVID-19 were reported
We didn’t have the resources needed to make changes
Other [Open ended]

4. I’m going to read a list of programs, agencies, or resources that you may have used over the
past 18 months to improve the quality of care to residents at your facility. As I read each one,
please tell me if you recall working with or using this resource over the last 18 months or
since the beginning of the COVID-19 pandemic.
a. Project ECHO [IF RESPONDENT ANSWERS ‘NO’ PROVIDE ADDITIONAL
INFORMATION TO CLARIFY: AHRQ’s (pronounced “ARK”) National Nursing Home
COVID-19 Coordinating Center or AHRQ’s National Nursing Home COVID-19 Action
Network”]
b. The Quality Improvement Organization (QIO) Program, or QIOs, also known as [QIO
Name] in your area
c. CDC
d. [TYPE IN NAME FOR STATE DEPARTMENT OF HEALTH]
e. CMS targeted COVID-19 training [IF RESPONDENT ANSWERS ‘NO’ PROVIDE
ADDITIONAL INFORMATION TO CLARIFY: Scenario-based Training also known as
the CMS Targeted COVID-19 Training for Nursing Homes (online modules for frontline
staff and nursing home management)]
f. AHCA (American Health Care Association) or [TYPE IN NAME OF STATE] chapter of
AHCA
g. Peers and/or other facilities
h. Local departments of health (city/county)
i. None of the above [DO NOT READ]
Are there any other sources of information you used when working on preventing and
controlling the spread of COVID-19?
Record response #1
Record response #2
Record response #3
NA. No additional sources of information
5. You mentioned that you use [INSERT ANSWERS FROM Q4]. what would you consider the
sources of information, guidance, or assistance that had the most impact on your facility’s
ability to prevent and control the spread of COVID-19? [Open ended]
[IF Q4b = YES, SKIP TO Q8]
QIN-QIO Engagement for non-QIO Nursing Homes [If Q4b = No]
6. Before this survey, had you ever heard of Quality Improvement Organizations, otherwise
referred to as QIOs?
a. Yes
b. No

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7. The name of your QIO is [QIO Name OR QIO Contact Person if available], have you ever
heard of them? [CONFIRM CONTACT PERSON IS INCLUDED IN CONTACT LIST]
a. Yes
b. No
[IF Q4b AND Q6 AND Q7 = NO, SKIP TO Q22]
[IF Q4b, Q6 OR Q7 = YES, GO TO Q8]
8. How would you describe your level of engagement with [QIO Name or ‘the QIO that serves
your area’] while you were working to prevent and control the spread of respiratory
infections like COVID-19? Would you say you were…
a.
b.
c.
d.

Fully engaged with [QIO name or ‘the QIO that serves your area’] [GO TO Q10]
Moderately engaged with [QIO name or ‘the QIO that serves your area’] [GO TO Q10]
Minimally engaged with [QIO name or ‘the QIO that serves your area’] [GO TO Q9]
Not at all engaged with [QIO name or ‘the QIO that serves your area’] [GO TO Q9]

[Show 8.1 If Q4b = No AND Q6 = Yes OR Q7 = Yes AND Q8 != d]
8.1 You said before you were not working with [QIO Name] but answered that you were
engaged with them. Do you want to change your response that you are working with them?
a. Yes [Set 4b = Yes, continue as normal]
b. No [Answer Q9, skip to 22]
9. [IF Q8 = c or d] Which best describes the reason(s) why this facility was not fully engaged

with [QIO Name or ‘the QIO that serves your area’] while you were working to prevent and
control the spread of COVID-19? Would you say this is because…
[Enter all that apply]

a.
b.
c.
d.
e.
f.

I don’t recall ever being contacted by [QIO name or ‘the QIO that serves your area’]
The resources seemed similar to or overlapped with other efforts we are involved in
We had all the support needed within this facility
The assistance available didn’t seem to be helpful or worth the effort
We didn’t have enough time to participate in another effort
The quality of resources or assistance from [QIO Name or ‘the QIO that serves your
area’] was sub-optimal
g. We could not find a convenient time to schedule meetings
h. Other [Open ended]

10. To the best of your knowledge did your interactions with [QIO Name or ‘the QIO that serves
your area’] result in any improvements to the processes or protocols your facility uses to
prevent COVID-19 infection, or infection control in general?
a. Yes [GO TO Q11]
b. No [IF Q8 = c OR d (minimally or not engaged), GO TO Q13; ELSE GO TO Q12]

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11. [IF Q10 = YES] Please describe what improved as a result of the interactions with [QIO
Name or ‘the QIO that serves your area.’] (PROBE)
a.
b.
c.
d.

Record response #1
Record response #2
Record response #3
Other [GO TO Q13]

12. [IF Q1 = YES AND Q10 = NO and Q8 = a or b] You said earlier that your interactions with
[QIO Name or ‘the QIO that serves your area.’] did not result in any improvements to the
processes or protocols you facility uses to prevent COVID-19 infection, or infection control
in general? Which response(s) best describes why that was the case?
[Select all that apply]
a. Our facility already made changes needed before we began working with [QIO Name or
‘the QIO that serves your area’]
b. The resources from [QIO Name or ‘the QIO that serves your area’] seemed similar to or
overlapped with other efforts we are involved in
c. We had all the support needed within this facility
d. The assistance available didn’t seem to be helpful or worth the effort
e. We didn’t have time to implement the changes the [QIO Name or ‘the QIO that serves
your area’] recommended
f. The quality of resources or assistance from [QIO Name or ‘the QIO that serves your
area’] was sub-optimal
g. We could not find a convenient time to schedule meetings
h. Other [Open ended]
13. If I asked you to describe in just a few words the CMS Quality Improvement Program, or
QIO, also known as [QIO Name], what’s the first thing that comes to mind? (DO NOT
NEED TO PROBE) [Open ended]
Satisfaction with the QIN-QIO for QIO Nursing Homes
We want to ask some questions about your interaction with [QIO Name or ‘the QIO that serves
your area.’]
14. [If > year; “In the last twelve months” If < year; “Since [INSERT DATE]”] Overall, how
satisfied are you with the amount of contact between your facility and [QIO Name or ‘the
QIO that serves your area’]? Would you say you are…
a.
b.
c.
d.
e.
f.

Very Satisfied
Somewhat Satisfied
Neither Satisfied or Dissatisfied
Very Dissatisfied
Don’t Know/Not Sure [DO NOT READ]
Decline to answer [DO NOT READ]

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15. Have you or someone in your facility ever had the occasion to initiate the interaction with
[QIO Name or ‘the QIO that serves your area’], such as when you needed questions
answered or assistance with an issue?
a. Yes
b. No
16. [IF Q15 = Y] Overall, how satisfied are you with the timeliness of [QIO Name or ‘the QIO
that serves your area’] response to your question or request for assistance? Would you say
you are…
a.
b.
c.
d.
e.
g.
h.

Very Satisfied
Somewhat Satisfied
Neither Satisfied or Dissatisfied
Somewhat Dissatisfied
Very Dissatisfied
Don’t Know/Not Sure [DO NOT READ]
Decline to Answer [DO NOT READ]

17. Thinking about all interactions with [QIO Name or ‘the QIO that serves your area,’], overall,
how satisfied are you with your relationship with [QIO Name or ‘the QIO that serves your
area,’]? Would you say you are…
a.
b.
c.
d.
e.
i.
j.

Very Satisfied
Somewhat Satisfied
Neither Satisfied or Dissatisfied
Somewhat Dissatisfied
Very Dissatisfied
Don’t Know/Not Sure [DO NOT READ]
Decline to Answer [DO NOT READ]

Satisfaction with the QIN-QIO for QIO Nursing Homes
Please indicate your level of agreement with the following statements about the information
and assistance provided by [QIO Name or ‘the QIO that serves your area,’].
18. The assistance we received from [QIO Name or ‘the QIO that serves your area,’] was key to
the efficient implementation of our protocols to prevent and control COVID-19
infection. Would you say you…
a.
b.
c.
d.
e.
f.
g.

Strongly Agree
Somewhat Agree
Neither Agree or Disagree
Somewhat Disagree
Strongly Disagree
Don’t Know/Not Sure [DO NOT READ]
Decline to Answer [DO NOT READ]

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19. The service we received from [QIO Name or ‘the QIO that serves your area,’] was worth the
time or effort required on the part of our staff. Would you say you…
a.
b.
c.
d.
e.
f.
g.

Strongly Agree
Somewhat Agree
Neither Agree or Disagree
Somewhat Disagree
Strongly Disagree
Don’t Know/Not Sure
Decline to Answer

20. Our organization has benefited from having received services from this [QIO Name or ‘the
QIO that serves your area,’]. Would you say you…
a.
b.
c.
d.
e.
h.
i.

Strongly Agree
Somewhat Agree
Neither Agree or Disagree
Somewhat Disagree
Strongly Disagree
Don’t Know/Not Sure [DO NOT READ]
Decline to Answer [DO NOT READ]

21. [IF Q16, Q17, Q18, Q19 or Q20 = d or e] Please tell me what [QIO Name or ‘the QIO that
serves your area’] could have done better. [Open ended]
22. At this point, what quality improvement areas are you most in need of for additional
assistance? [Open ended] [RECORD ANY RESPONSES INCLUDED IN THE LIST (a-j)
BELOW BUT DO NOT READ]
a. Activities and Daily Living (ADL) [DO NOT READ]
• Bladder and bowel control
• Patient mobility
• Weight loss
b. Behavioral Health [DO NOT READ]
• Antipsychotic medication use
• Depression/anxiety
• Opioid misuse
c. Chronic Disease Management [DO NOT READ]
• Blood pressure control
• Cholesterol management
• Dementia care
• Diabetic management
• Pain management
• Smoking cessation
d. COVID-19 Response [DO NOT READ]
e. Education/Training [DO NOT READ]

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f. Nursing Home Quality [DO NOT READ]
• Patient satisfaction
• Resources
g. Patient Safety [DO NOT READ]
• Abx stewardship
• ADEs
• CDI
• Falls
• Infection control (UTIs)
• Pressure ulcers
• Wound care
h. Quality of Care Coordination [DO NOT READ]
• ED visits
• Readmissions
• Hospital admissions/re-hospitalizations
i. Staff Retention/Recruiting [DO NOT READ]
j. Other [DO NOT READ]
NA. No quality improvement areas are in need of additional assistance
Final Thank You
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 20 minutes,
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 Dr. Nancy Sonnenfeld at 410-786-1294.

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