Form CMS-10769 HQIIC Hospital Survey

OMB No. 0938-xxxx
Expires xx/xx, 20xx
Appendix B: HQIC Hospital 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 hospital facilities and the types of resources that are helpful in
this area. We’re conducting a [15-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 HQIC facilities] works most closely with
[INSERT NAME OF LOCAL QIN-QIO] and / [for non-HQIC facilities] who is most
knowledgeable about the quality improvement activities your hospital has been working on. If
your hospital is part of a larger medical care system, we’ would 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 & Medicaid Services, or CMS, to learn
about quality improvements in hospital facilities and the types of resources that are helpful in
this area. We scheduled this time to conduct a [15-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?
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 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 & Medicaid Services, or CMS, to learn
about quality improvements in hospital facilities and the types of resources that are helpful in
this area. We scheduled this time to conduct a [15-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 & Medicaid Services, or CMS, to learn
about quality improvements in hospital 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. 
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
hospital?
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 been in this role? [Open ended]
[Record years and months]
Not sure (approximately how long?)
Quality Improvement Initiatives for the Last 12 Months
1. Over the last 6 months, did your facility work on improving processes or protocols used to
increase the quality and safety of patient care with either of these two aims?
Select all that apply
a. Responding to the opioid crisis
b. Reducing hospital acquired conditions, infections, or adverse events, such as infections
caused by urinary catheters or central lines
c. Neither of these
1.1 [IF Q1a AND Q1b = NO OR Q1c = YES] Over the last 6 months, did you work on other
quality improvements for your hospital? [Open ended]
[DO NOT READ BUT RECORD RESPONSES. ANY RESPONSES THAT ARE
CONSIDERED A HAC SHOULD FOLLOW THE SKIP PATTERN FOR 1B]
a. COVID-19
NA. No other quality improvements were worked on

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2. Does your hospital post its patient safety record or the number of patients who experience
harmful events on its website?
a. Yes
b. No
Use of HQIC Resources
3. Now I’m going to read a list of programs, policies, agencies, or resources that you may have
used in improving the quality of care at your facility. As I read each one, please tell me if you
recall working with or using this resource over the last 6 months.
Select all that apply
a. Resources from the Hospital Quality Improvement Contractor Program or [INSERT
HQIC NAME FOR HOSPITAL]
b. CMS COVID-19 StAT Learning Series for Hospitals
c. NHSN Report
d. HHS Protect
e. [INSERT STATE] hospital association-sponsored effort
f. National Association of Public Hospitals (NAPH) or America’s Essential Hospitals
(AEH)
g. Other regional, state, or local initiative (specify)
h. Programs, policies, and resources from your own hospital system
i. Peers and/or other hospitals
j. None of the above [DO NOT READ]
3.1 Are there any other sources of information you used when working on improving the quality
of care at your facility? [PROBE TO SEE WHAT SPECIFIC RESOURCES WERE USED
FOR EACH SOURCE]
Record answer choice #1
Record answer choice #2
Record answer choice #3
NA. There are no other sources of information
4. What would you consider the sources of information, guidance or assistance that had the
most impact on your facility’s effort to INSERT GOAL 1a ‘address the opioid crisis; GOAL
1b ‘reduce hospital acquired conditions, infections, and adverse events’; GOAL 1c ‘work on
this quality improvement’ [Open ended]
IF Q3a = YES, SKIP TO Q7]

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Check on Use of HQIC
[ASK Q5 AND Q6 IF Q3a = NO]
5. Before this survey, had you ever heard of the Hospital Quality Improvement Contractor
Program, otherwise referred to as HQIC?
a. Yes
b. No
6. The name of your HQIC is [HQIC Name OR HQIC Contact Person if available], have you
ever heard of them? [CONFIRM CONTACT PERSON IS INCLUDED IN CONTACT
LIST]
a. Yes
b. No
IF RESPONDENT IS UNAWARE OF HQICs (Q3a = NO, and Q5 = NO, and Q6 = NO), THEN
SKIP TO Q19
Engagement with HQIC
[QUESTIONS 7-8 ARE ASKED IN A LOOP FOR WORK TOWARD EACH GOAL IN Q1
THAT THE RESPONDENT CONFIRMS WORKING ON]
[ASK Q7 AND Q8 IF RESPONDENT USES OR IS AWARE OF HQICs (i.e., Q3a OR Q5 OR
Q6 = YES]
7. How would you describe your facility’s level of engagement with [INSERT HQIC ID FOR
HOSPITAL] for work on [INSERT FOR GOAL 1a ‘addressing the opioid crisis’; FOR
GOAL 1b ‘reducing hospital acquired conditions, infections, and adverse events’; GOAL 1c
‘Insert open ended answer’]? Would you say you were…
a.
b.
c.
d.

Fully engaged [INSERT HQIC NAME FOR HOSPITAL]
Moderately engaged [INSERT HQIC NAME FOR HOSPITAL]
Minimally engaged [INSERT HQIC NAME FOR HOSPITAL]
Not at all engaged [INSERT HQIC NAME FOR HOSPITAL]

[If Q3a = No AND Q5 = Yes OR Q6 = Yes AND Q7 != d]
7.1 You said before you were not working with [HQIC 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 Q3a = YES]
b. No
[If Q7 = c or d]
8. Which of these statements describe the reasons why this hospital was not fully engaged with
the [INSERT HQIC ID FOR HOSPITAL] for work on [INSERT GOAL 1a ‘addressing the
opioid crisis; GOAL 1b ‘reducing hospital acquired conditions, infections, and adverse
events’; GOAL 1c ‘this quality improvement’]?
Select all that apply.

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a.
b.
c.
d.
e.
f.
g.
h.
i.
j.
k.

l.

[FOR GOAL 1a] The population served by our hospital did not have issues with opioid
misuse
[FOR GOAL 1a] The hospital did not need to improve the way it addressed opioids
because there were already effective protocols in place
[FOR GOAL 1b] No improvement was needed because the hospital sustains zero rates of
harm
We were overwhelmed by the COVID-19 pandemic and did not have
resources for improvements in other areas [HIDE IF 1.1a=TRUE]
The hospital did not need the support of [INSERT HQIC NAME FOR
HOSPITAL]
We had all the improvement support needed within this hospital or health
system
We preferred to work with another organization outside the hospital
My hospital made a management decision not to participate
The quality of resources or programming provided by [INSERT HQIC NAME
FOR HOSPITAL] was sub-optimal
Learning events scheduled by [INSERT HQIC NAME FOR HOSPITAL]
were inconvenient
My hospital has not been in the program long enough to assess work with
[INSERT HQIC NAME FOR HOSPITAL] (SHOW IF enrollment <= 4
months)
Other [specify]:

We want to ask some questions about your interaction with the Hospital Quality Improvement
Contractor that serves your area.
9. Do you know how to contact someone at [HQIC NAME FOR HOSPITAL] if you wanted
help or advice from them on improving quality at your facility?
a. Yes
b. No
10. If I asked you to describe in just a few words, the CMS Quality Improvement Program, or the
HQIC Program, also known as [HQIC NAME FOR HOSPITAL], what’s the first thing that
comes to mind? [Open ended]
Satisfaction with HQIC
11. [If > year; “In the last twelve months” If < year; “Since [INSERT DATE]” how satisfied are
you with the amount of contact between your facility and [HQIC NAME FOR HOSPITAL]?
Would you say you are …
a.
b.
c.
d.
e.
f.
g.

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]

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12. Have you or someone in your facility ever had occasion to initiate the interaction with
[HQIC NAME FOR HOSPITAL], such as when you needed questions answered or
assistance with an issue?
a. Yes
b. No [GO TO Q14]
13. [IF Q12 = Y] Overall, how satisfied are you with the timeliness of [HQIC NAME FOR
HOSPITAL]’s response to your questions or requests for assistance? Would you say
you are...
a.
b.
c.
d.
e.
f.
g.

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]

14. Thinking about all interactions with [HQIC NAME FOR HOSPITAL], overall, how satisfied
are you with your relationship with [HQIC NAME FOR HOSPITAL]? Would you say
you are…
a.
b.
c.
d.
e.
f.
g.

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]

Perceived HQIC Value
Please indicate your level of agreement with the following statements about the information
and assistance provided by [HQIC NAME FOR HOSPITAL].
15. The assistance we received from [HQIC NAME FOR HOSPITAL] was key to the efficient
implementation of our quality improvement projects. 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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16. The service we received from [HQIC NAME FOR HOSPITAL] 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 [DO NOT READ]
Decline to answer [DO NOT READ]

17. Our organization has benefited from having received services from [HQIC NAME FOR
HOSPITAL]. 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]

18. [If Q13, Q14, Q15, Q16 OR Q17 = d or e] Please tell me what [HQIC NAME FOR
HOSPITAL] could have done better. [Open ended]
19. At this point, what quality improvement areas are you most in need of for additional
assistance? [Open ended]
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 15 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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