CMS-10750 NW 2 Collaborator Survey

DRAFT IPRO ESRD Network 2 Collaborator Survey (2020)
Your Opinion Matters

The IPRO ESRD Network of New York (Network 2) would appreciate your taking a few minutes to
complete the following questionnaire regarding your experience working with us. All responses will be
kept confidential and will not be released. Information provided by you is voluntary and your decision
whether to participate or not in this survey will not affect any Medicare or Medicaid reimbursements to
your organization.
The ESRD Network of New York initiates and supports quality improvement activities, the collection
and management of data, provides community education and serves as an informational resource to
the provider, ESRD beneficiaries and regulatory communities.
This survey is for people who are involved with the IPRO ESRD Program. Please click on the "Next" button below and after each
question. Please click "Done" at the end of the survey to capture your responses.

DRAFT IPRO ESRD Network 2 Collaborator Survey (2020)
Section 1: Information About You

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1. Who contributed in responding to this survey? (Check each that applies.)
Facility Administrator

Nurse

Data Contact

Social Worker

Medical Director
Other (please specify)

DRAFT IPRO ESRD Network 2 Collaborator Survey (2020)
Section 2: Overall Impression

Please indicate the extent you agree or disagree with the following statements on a scale of 1 to 6 with
1 being "Strongly Disagree" and 6 being "Strongly Agree", by checking the appropriate box.
2. My overall impression of my organization's working relationship with Network is positive.
Strongly Disagree

Disagree

Slightly DIsagree

Slightly Agree

Agree

Strongly Agree

NA

DRAFT IPRO ESRD Network 2 Collaborator Survey (2020)
Section 2: Overall Impression

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* 3. You gave an unfavorable rating for the question, "My overall impression of my organization's working
relationship with the Network is positive." Please explain how we can improve in this area.

DRAFT IPRO ESRD Network 2 Collaborator Survey (2020)
Section 2: Overall Impression

4. When contacting the Network, I can easily reach an appropriate person to assist me.
Strongly Disagree

Disagree

Slightly Disagree

Slightly Agree

Agree

Strongly Agree

N/A

DRAFT IPRO ESRD Network 2 Collaborator Survey (2020)
Section 2: Overall Impression

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* 5. You gave an unfavorable rating for the question, "When contacting the Network, I can easily reach an
appropriate person to assist me." Please explain how we can improve in this area.

DRAFT IPRO ESRD Network 2 Collaborator Survey (2020)
Section 2: Overall Impression

6. The Network is responsive in following up with questions or issues I have.
Strong Disagree

Disagree

Slightly Disagree

Slightly Agree

Agree

Strongly Agree

N/A

DRAFT IPRO ESRD Network 2 Collaborator Survey (2020)
Section 2: Overall Impression

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* 7. You gave an unfavorable rating for the question, "The Network is responsive in following up with questions
or issues I have." Please explain how we can improve in this area.

DRAFT IPRO ESRD Network 2 Collaborator Survey (2020)
Section 2: Overall Impression

8. I am treated respectfully and with courtesy by the Network staff.
Strongly Disagree

Disagree

Slightly Disagree

Slightly Agree

Agree

Strongly Agree

N/A

DRAFT IPRO ESRD Network 2 Collaborator Survey (2020)
Section 2: Overall Impression

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* 9. You gave an unfavorable rating for the question, "I am treated respectfully and with courtesy by the Network
staff." Please explain how we can improve in this area.

DRAFT IPRO ESRD Network 2 Collaborator Survey (2020)
Section 3: Network Activities

10. What is the primary reason you have collaborated with the Network in the past year?
(Check all that apply)
Participation in Quality Improvement Activities
Information/Educational Resources
Patient Related Issues
Technical Assistance (with CROWNWeb, NHSN, etc.)
Regulatory Issues (e.g., facility openings, closures, condition for coverage questions, etc.)
Forms/Data Request/Data Issue
All of the above
Other (please specify)

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DRAFT IPRO ESRD Network 2 Collaborator Survey (2020)
Section 3: Network Activities

11. The Network’s assistance supports my organization's quality initiatives.
Strongly Disagree

Disagree

Slightly Disagree

Slightly Agree

Agree

Strongly Agree

N/A

DRAFT IPRO ESRD Network 2 Collaborator Survey (2020)
Section 3: Network Activities

* 12. You gave an unfavorable rating for the question, "The Network’s assistance supports my organization's
quality initiatives." Please explain how we can improve in this area.

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DRAFT IPRO ESRD Network 2 Collaborator Survey (2020)
Section 3: Network Activities

13. Network initiatives help my organization with patient and family engagement, and incorporating the patient
voice in facility activities.
Strongly Disagree

Disagree

Slightly Disagree

Slightly Agree

Agree

Strongly Agree

N/A

DRAFT IPRO ESRD Network 2 Collaborator Survey (2020)
Section 3: Network Activities

* 14. You gave an unfavorable rating for the question, "Network initiatives help my organization with patient and
family engagement, and incorporating the patient voice in facility activities." Please explain how we can
improve in this area.

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DRAFT IPRO ESRD Network 2 Collaborator Survey (2020)
Section 3: Network Activities

15. The educational materials provided by the Network are used by my organization as part of QI or patient
education (materials provided via email, fax, U.S. mail, website, and social media).
Strongly Disagree

Disagree

Slightly Disagree

Slightly Agree

Agree

Strongly Agree

N/A

DRAFT IPRO ESRD Network 2 Collaborator Survey (2020)
Section 3: Network Activities

* 16. You gave an unfavorable rating for the question, "The educational materials provided by the Network are
used by my organization as part of QI or patient education (materials provided via email, fax, U.S. mail,
website, and social media)." Please explain how we can improve in this area.

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DRAFT IPRO ESRD Network 2 Collaborator Survey (2020)
Section 3: Network Activities

17. Please describe information or data that the Network provides to your organization that helps you the
most (please list all that applies).

18. How can the Network provide better customer service to your facility:

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DRAFT IPRO ESRD Network 2 Collaborator Survey (2020)
Section 4: Comments

19. Please use the following area to provide any examples of exceptional customer service and support
received from our IPRO staff.

20. Would you like to be contacted by a member of the IPRO staff regarding your answers to this survey?
No
Yes (provide contact information below).

21. Please enter your contact information below (Please complete if you wish to be contacted.)
Name:
Company:
Address:
Address 2:
City/Town:
State:

-- select state --

ZIP:
Country:
Email Address:
Phone Number:

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DRAFT IPRO ESRD Network 2 Collaborator Survey (2020)
Section 4: Comments

Thank you for completing this survey.

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