CMS-10776 Collaborator Survey Nursing Home

DRAFT IPRO Improve Nursing Home Quality Collaborator Feedback Survey (2021)
Your Opinion Matters

We would appreciate if you would take a few minutes to complete the following questionnaire
regarding your experience working with IPRO. Your responses will be kept private to the extent
provided by law. Information provided by you is voluntary and your decision whether or not to
participate in this survey will not affect Medicare/Medicaid reimbursements to your organization.
Thank you for your feedback.
This survey is for people who are involved with the IPRO Nursing Homes Program. The IPRO Nursing Home Quality Improvement
Program, as part of the Quality Innovation Network-Quality Improvement Organization (QIN-QIO) contract with the Centers for Medicare
& Medicaid Services (CMS), works with Nursing Homes in New York to improve the quality of care they provide to Medicare
beneficiaries through improved clinical and organizational work processes.
Please click on the "Next" button below and after each question. Please click "Done" at the end of the survey to capture your responses.

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DRAFT IPRO Improve Nursing Home Quality Collaborator Feedback Survey (2021)
Section 1: Information About You

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

Nurse Leadership

Executive Director

Department Head (please specify department)

Other (please specify)

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DRAFT IPRO Improve Nursing Home Quality Collaborator Feedback Survey (2021)
Section 1: Information About You

2. How long have you, the respondent (not your organization), been working with IPRO? If multiple people are
responding jointly to this questionnaire, the respondent with the longest working history with IPRO should
select the appropriate answer. (Check only one box).
Less than 12 months
Between 12-24 months
More than 24 months

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DRAFT IPRO Improve Nursing Home Quality Collaborator Feedback Survey (2021)
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.
3. My overall impression of my organization's working relationship with IPRO is positive.
Strongly Disagree

Disagree

Slightly Disagree

Slightly Agree

Agree

Strongly Agree

N/A

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DRAFT IPRO Improve Nursing Home Quality Collaborator Feedback Survey (2021)
Section 2: Overall Impression

* 4. You rated IPRO unfavorably for the question, "My overall impression of my organization's working
relationship with IPRO is positive." Please explain how we can improve in this area.

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DRAFT IPRO Improve Nursing Home Quality Collaborator Feedback Survey (2021)
Section 2: Overall Impression

5. When contacting IPRO, I can easily reach an appropriate person to assist me.
Strongly Disagree

Disagree

Slightly Disagree

Slightly Agree

Agree

Strongly Agree

N/A

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DRAFT IPRO Improve Nursing Home Quality Collaborator Feedback Survey (2021)
Section 2: Overall Impression

* 6. You rated IPRO unfavorably for the question, "When contacting IPRO, I can easily reach an appropriate
person to assist me." Please explain how we can improve in this area.

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DRAFT IPRO Improve Nursing Home Quality Collaborator Feedback Survey (2021)
Section 2: Overall Impression

7. IPRO staff is responsive in following up with questions or issues I have.
Strongly Disagree

Disagree

Slightly Disagree

Slightly Agree

Agree

Strongly Agree

N/A

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DRAFT IPRO Improve Nursing Home Quality Collaborator Feedback Survey (2021)
Section 2: Overall Impression

* 8. You rated IPRO unfavorably for the question, "IPRO staff is responsive in following up with questions or
issues I have." Please explain how we can improve in this area.

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DRAFT IPRO Improve Nursing Home Quality Collaborator Feedback Survey (2021)
Section 2: Overall Impression

9. I am treated respectfully and with courtesy by IPRO staff.
Strongly Disagree

Disagree

Slightly Disagree

Slightly Agree

Agree

Strongly Agree

N/A

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DRAFT IPRO Improve Nursing Home Quality Collaborator Feedback Survey (2021)
Section 2: Overall Impression

* 10. You rated IPRO unfavorably for the question, "I am treated respectfully and with courtesy by IPRO staff."
Please explain how we can improve in this area.

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DRAFT IPRO Improve Nursing Home Quality Collaborator Feedback Survey (2021)
Section 3: IPRO Nursing Home Quality Improvement Activities

The IPRO Nursing Home Quality Improvement Program, as part of the Quality Innovation NetworkQuality Improvement Organization (QIN-QIO) contract with the Centers for Medicare & Medicaid
Services (CMS), works with Nursing Homes in New York to improve healthcare-acquired conditions
and the quality of care they provide to Medicare beneficiaries through improved clinical and
organizational work processes.

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DRAFT IPRO Improve Nursing Home Quality Collaborator Feedback Survey (2021)
Section 3: IPRO Nursing Home Quality Improvement Activities

11. IPRO's communication, quality improvement tools and materials are useful resources.
Strongly Disagree

Disagree

Slightly Disagree

Slightly Agree

Agree

Strongly Agree

N/A

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DRAFT IPRO Improve Nursing Home Quality Collaborator Feedback Survey (2021)
Section 3: IPRO Nursing Home Quality Improvement Activities

* 12. You rated IPRO unfavorably for the question, "IPRO's communication, quality improvement tools and
materials are useful resources for my quality improvement program." Please explain how we can improve in
this area.

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DRAFT IPRO Improve Nursing Home Quality Collaborator Feedback Survey (2021)
Section 4: Comments

13. Please use the following area to provide your feedback on a) recommendations on how IPRO could
improve customer service to your organization, and, b) any examples of exceptional customer service and
support received from our IPRO staff.

14. 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)

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15. 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 Improve Nursing Home Quality Collaborator Feedback Survey (2021)
Section 4: Comments

Thank you for completing this survey.
PRA Disclosure Statement: 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 voluntary information collection is TBD. The expiration date is TBD.
The purpose of this voluntary information collection request is to collect feedback about the Nursing
Home Quality Program. The end goal of this effort is to collect actionable data to help improve the
overall customer experience. The time required to complete this voluntary information collection is
estimated to average 10 minutes per response, including the time to review instructions 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, please write to: CMS, 7500 Security Boulevard,
Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. ****CMS
Disclosure**** 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 about the survey please contact [email protected].

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