Crosswalk - Hospital Survey

Crosswalk for Changes to
Evaluation of the CMS Network of Quality Improvement and Innovation Contractors Program (NQIIC) (CMS-10769)
Appendix B Hospital Survey Questions
#
Question Used in Pretest
Recommendation/Decision
Reason
1 Over the last 12 months, did your facility work on
• Change timeframe to last 6
• Overlap with HQIC
improving processes or protocols used to increase the
months
Period of Performance
quality and safety of patient care with any of these
• Recommend: underline “your
• Some interviewees
aims?
facility”
didn’t recognize the
term “stewardship”
•
Change
“any
of
these”
to
“either
Select all that apply
and/or “HACs”
of the two items”
a. Responding to the opioid crisis, including
• A – Revise to just say
increasing stewardship of opioid use
“Responding to the opioid crisis”
b. Reducing hospital acquired conditions (HACs)
•
BRemove “HACs” and include
or adverse events, such as infections caused by
“infections”
after “conditions”
urinary catheters or central lines

c. Neither of these
1.1 Did you work on other quality improvements for
your hospital? [Open ended]
[DO NOT READ]

a. COVID-19
NA. No other quality improvements were worked
on

2 Does your hospital publicly report on its website its
patient safety record, or the number of patients who
experience harmful events or HACS [pronounced
hacks]?
a. Yes
b. No

• Add “Over the last 6 months” to As suggested by pretest
the beginning of the sentence
• Ask as an open-ended question,
but interviewer will have access
to a close ended list of response
items and should record
responses, including typing in any
items that are not on the list. The
interviewer should also note
anything that is a HAC and
follow skip pattern [as if they said
yes to 1B]
• Remove “publicly report”
• Remove “HACS”
• Revise to read, “Does your
hospital post its patient safety
record or the number of patients
who experience harmful events
on its website?”

Recommended Revised Question
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
Over the last 6 months, did you work on
other quality improvements for your
hospital? [Open ended]
[DO NOT READ BUT RECORD
RESPONSES, INCLUDING ANY
RESPONSES THAT ARE NOT
INCLUDED IN THE LIST. 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
Does
your hospital post its patient safety
• Some respondents
record or the number of patients who
commented that
“Publicly report” means experience harmful events on its website?
reporting to a
a. Yes
government agency
b. No
• Some respondents did
not understand the term
“HACs”

1

#
Question Used in Pretest
3 Now I’m going to read a list of programs, policies,
agencies, or sources 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.

•
•
•

Select all that apply
a. Resources from the Hospital Quality
Improvement Contractor Program or [INSERT
HQIC NAME FOR HOSPITAL]
b. CMS COVID-19 StAT (Standards, Approaches
and Tactics) Learning Series
c. Reporting to NHSN or HHS Protect
d. State hospital association-sponsored effort
e. NAPH-NPSF Patient Safety Initiative
f. Other regional, state, or local initiative
(specify)
g. Hospital system-level initiative

•

•
•
•

•

3.1 Are there any other sources of information you used
when working on improving the quality of care at
your facility?
Record answer choice #1
Record answer choice #2
Record answer choice #3
NA. There are no other sources of information

5 Have you ever heard of [HQIC Name or HQIC
contact person]?
a. Yes
b. No

Recommendation/Decision
Reason
As
suggested
by pretest
Include time frame “over the last
6 months” at the end of the
sentence
Change “sources” to “resources”
B- use “COVID-19 StAT
Learning Series for Hospitals" to
refer to the training provided by
CMS.
C - Remove “reporting”, and
separate into two separate
response items
- NHSN Report
- HHS Protect Reports
D – Type in name of the state
E – Add new name of
organization
G – Change “hospital systemlevel initiative” to “Programs,
policies, and resources from your
own hospital system”
Add “peers and/or other
hospitals” as a response item

• Underline “sources”
• If interviewee responds with a
“source” interviewer should
probe to see what resources were
used/what specifically did they
use?

As suggested by pretest

Interviewer should confirm that the As suggested by pretest
contact person is included in the list

Recommended Revised Question
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. COVID-19 StAT Learning Series for
Hospitals
c. NHSN Report
d. HHS Protect
e. [TYPE IN NAME OF 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
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
Have you ever heard of [HQIC Name or
HQIC contact person]? [CONFIRM
CONTACT PERSON IS INCLUDED IN
CONTACT LIST]
a. Yes
b. No

2

#
Question Used in Pretest
6 How would you describe your facility’s level of
engagement with [INSERT HQIC NAME FOR
HOSPITAL] for work on [INSERT FOR GOAL 1a
‘addressing the opioid crisis’; FOR GOAL 1b
‘reducing HACs and adverse events’;GOAL 1c
‘Insert open ended answer’]? Would you say you
were…
a.
b.
c.
d.

Fully engaged
Moderately engaged
Minimally engaged
Not at all engaged

Recommendation/Decision
Reason
As
suggested
by pretest
• Change HQIC name for hospital
to Hospital ID [interviewer would
have list of Ids to reference]
• Spell out HACs and include
“infections” after “conditions” so
it reads, “Reducing hospital
acquired conditions, infections,
and adverse events.”

Recommended Revised Question
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
Moderately engaged
Minimally engaged
Not at all engaged

3

#
Question Used in Pretest
Recommendation/Decision
Reason
7 Which of these statements describe the reasons why • Change HQIC name for hospital As suggested by pretest
this hospital was not fully engaged with the
to Hospital ID [interviewer would
[INSERT HQIC NAME FOR HOSPITAL] for work
have list of Ids to reference]
on [INSERT GOAL 1a ‘addressing the opioid crisis; • Spell out HACs and include
GOAL 1b ‘reducing HACs and adverse events’;
“infections” after “conditions” so
GOAL 1c ‘this quality improvement’]?
it reads, “Reducing hospital
acquired
conditions, infections,
Select all that apply.
and adverse events.”
a. [FOR GOAL 1a] The population served by our
• A – Replace “in” with “with”
hospital did not have issues in opioid misuse
• B – Remove “stewardship”
b. [FOR GOAL 1a] The hospital did not need to
improve opioid stewardship because there were • Rework H, I, J to be sentences
already effective protocols in place
c. [FOR GOAL 1b] No improvement was needed
because the hospital sustains zero rates of harm
d. We were overwhelmed by the COVID-19

pandemic and did not have resources for
improvements in other areas [HIDE IF
1.1a=TRUE]

e. The hospital did not need the support of
[INSERT HQIC NAME FOR HOSPITAL]
f. We had all the improvement support needed
within this hospital or health system
g .We preferred to work with another organization
outside the hospital
h. Management decision
i. Sub-optimal quality of resources or
programming by [INSERT HQIC NAME FOR
HOSPITAL]
j. Inconvenient scheduling of learning events by
[INSERT HQIC NAME FOR HOSPITAL]
k. My hospital has not been in the program long
enough to assess work with [INSERT HQIC
NAME FOR HOSPITAL] (SHOW IF
enrollment <= 4 months)
l. Other [specify]:

Recommended Revised Question
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.
a. {FOR GOAL 1a] The population
served by our hospital did not have
issues with opioid misuse
b. [FOR GOAL 1a] The hospital did not
need to improve the way it addressed
opioids because there were already
effective protocols in place
h. My hospital made a management
decision not to participate
I. The quality of resources or
programming provided by [INSERT
HQIC NAME FOR HOSPITAL] was
sub-optimal
j. Learning events scheduled by
[INSERT HQIC NAME FOR
HOSPITAL] were inconvenient

4

#
Question Used in Pretest
Recommendation/Decision
Reason
8 Off the top of your head, what would you consider
As
suggested
by pretest
• Move this question so it follows
the sources of information, guidance or assistance
Q3
that had the most impact on your facility’s effort to
• Remove “Off the top of your
INSERT GOAL 1a ‘address the opioid crisis; GOAL
head”
1b ‘reduce HACs and adverse events’; GOAL 1c
• Spell out HAC, include
‘work on this quality improvement’ [Open ended]
“infections” after “conditions”
• If interviewee responds with a
“source” interviewer should
probe to see what resources were
used/what specifically did they
use?
As suggested by pretest
11 How satisfied are you with the amount of contact
• Change question to Likert scale
between your facility and [HQIC NAME FOR
so it reads, “Overall, how
HOSPITAL]? Would you say the amount of contact
satisfied are you with the amount
is …
of contact between your facility
and [HQIC NAME FOR
a. Not enough
HOSPITAL]?
b. Just about right
• Add:
c. Too much
- Don’t know/not sure
- Declined to answer
13 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.

Very Satisfied
Somewhat Satisfied
Neither Satisfied Nor Dissatisfied
Somewhat Dissatisfied
Very Dissatisfied

• Move “overall” so it is in front of As suggested by pretest
“how”
• Add:
- Don’t know/not sure
- Declined to answer

Recommended Revised Question
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]

Overall, how satisfied are you with the
amount of contact between your facility
and [HQIC NAME FOR HOSPITAL]?
Would you say you are…
a. Very Satisfied 
b. Somewhat Satisfied 
c. Neither Satisfied or Dissatisfied
d. Somewhat Dissatisfied 
e. Very Dissatisfied
f. Don’t know/not sure
g. Declined to answer
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
Declined to answer

5

#
Question Used in Pretest
Recommendation/Decision
Reason
14 Thinking about all interactions with your HQIC, how • Move “overall” so it is in front of As suggested by pretest
satisfied are you with your relationship with your
“how”
HQIC overall?
• Add “Would you say you are...”
to the end of the sentence
a. Very Satisfied
•
Add:
b. Somewhat Satisfied
- Don’t know/not sure
c. Neither Satisfied Nor Dissatisfied
- Declined to answer
d. Somewhat Dissatisfied
e. Very Dissatisfied

15 The assistance we received from [HQIC NAME
FOR HOSPITAL] was key to the efficient
implementation of our quality improvement
projects. Would you…
a.
b.
c.
d.
e.

Strongly Agree
Somewhat Agree
Neither Agree Nor Disagree
Somewhat Disagree
Strongly Disagree

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 …
a.
b.
c.
d.
e.

Strongly Agree
Somewhat Agree
Neither Agree Nor Disagree
Somewhat Disagree
Strongly Disagree

• Add to the beginning (to be
consistent with NH Survey),
“Please indicate your level of
agreement with the following
statements about the information
and assistance provided by the
HQIC.”
• Underline the word “key”
• Revise “Would you…” to
“Would you say you…”
• Add:
- Don’t know/not sure
- Declined to answer

As suggested by pretest

• Revise “Would you…” to
“Would you say you…”
• Add:
- Don’t know/not sure
- Declined to answer

As suggested by pretest

Recommended Revised Question
Thinking about all interactions with your
HQIC, overall how satisfied are you with
your relationship with your HQIC? Would
you say you are...
a. Very Satisfied 
b. Somewhat Satisfied 
c. Neither Satisfied or Dissatisfied 
d. Somewhat Dissatisfied 
e. Very Dissatisfied
f. Don’t know/not sure
g. Declined to answer
Please indicate your level of agreement
with the following statements about the
information and assistance provided by the
HQIC.
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. Strongly Agree
b. Somewhat Agree
c. Neither Agree or Disagree
d. Somewhat Disagree
e. Strongly Disagree
f. Don’t know/not sure
g. Declined to answer
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
Declined to answer

6

#
Question Used in Pretest
17 Our organization is better off having received
services from [HQIC NAME FOR
HOSPITAL]. Would you…
a.
b.
c.
d.
e.

Strongly Agree
Somewhat Agree
Neither Agree Nor Disagree
Somewhat Disagree
Strongly Disagree

19 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

Recommendation/Decision
• Change to “Our organization has
benefited from having received
services from…”
• Revise “Would you…” to
“Would you say you…”
• Add:
- Don’t know/not sure
- Declined to answer

Reason
As suggested by pretest

• Add “at this point” at the
beginning of the sentence

As suggested by pretest

Recommended Revised Question
Our organization has benefited from
having received services from [HQIC
NAME FOR HOSPITAL]. Would you say
you…
a. Strongly Agree
b. Somewhat Agree
c. Neither Agree or Disagree
d. Somewhat Disagree
e. Strongly Disagree
f. Don’t know/not sure
g. Declined to answer
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

7