Form 1 Appendix A

Appendix A: AHRQ ECHO National Nursing Home COVID-19 Action Network Best Practices Survey

Form Approved

OMB No. xxxx-xxxx

Exp. Date xx/xx/21

AHRQ ECHO National Nursing Home COVID-19 Action Network

Best Practices Survey

Email text with survey link:

Dear X,

Thank you very much for your participation in the AHRQ ECHO National Nursing Home COVID-19 Action Network (the Network). NORC, on behalf of AHRQ, is seeking your initial feedback on your experience in the Network.

Your feedback is very important to us. Please consider completing a brief 6 question follow-up survey on your experience in the Network.

All responses will be kept confidential and included as part of our assessment of participant experience and implementation of best practices. We will not share your name or attribute any responses directly to you.

Click here to start the survey: <link>

Thank you,

XXXX

Approximate start date of the Network training (month year): [TEXT BOX]

1. About how many sessions have you attended or did you attend? [select one]

1. 0 sessions

2. 1 – 5 sessions

3. 6 – 9 sessions

4. 10– 15 sessions

5. All 16 sessions

[If the respondent enters “0”, the survey skips to Q6]

2. Among the sessions that you attended, which topic areas were the most helpful [Select up to 3]

• COVID-19 prevention and best-practice safety measures to protect residents and staff

• COVID-19 screening of residents and staff

• COVID-19 testing of residents and staff

• COVID-19 vaccination of residents and staff

• Providing safe and appropriate care to residents with or recovering from COVID-19

• Staff well-being

• Resident and family well-being

• Other [text box]

3. Please indicate which, if any, of the Network’s training center resources you have found the most useful [Select up to 3]:

• Information from quality improvement experts during training sessions

• Case studies during training sessions

• Access to quality coaches between training sessions

• Ongoing technical assistance / email support outside of training sessions

• Networking / knowledge sharing with other nursing home staff

• Other [TEXT BOX]

4. As a result of participating in these sessions, did you collaborate with other nursing home staff? [Y/N]

5. Did you or your facility make any changes as a result of the Network training? [Y/N]

[If respondent selects yes, they will see 5a. to 5b. If no is selected, skip to Q6]

1. In what area(s) did the change occur? [Select all that apply]

• COVID-19 prevention and best-practice safety measures to protect residents and staff

• COVID-19 screening of residents and staff

• COVID-19 testing of residents and staff

• COVID-19 vaccination of residents and staff

• Providing safe and appropriate care to residents with or recovering from COVID-19

• Staff well-being

• Resident and family well-being

• Other [TEXT BOX]

2. Would you describe the change(s) made as major or minor? [Pop up with each of the items they selected to indicate major / minor / both response]

6. Are you willing to be contacted in the future for a short follow-up conversation on your experience? [Y/N]

[If respondent selects yes, they will see 6a.-6b. If no, the survey ends]

1. Name [TEXT FIELD]

2. Email [TEXT FIELD]

3. Phone [TEXT FIELD]

If the respondent is willing to be contacted, we will do the following for a follow-up conversation:

Welcome and Introduction

• Thank you for agreeing to speak with members of the Network team, including [insert name(s) of discussants].

• We set up this call as a follow-up to your response on the survey stating that you would be willing to speak with us re: your experience in the Network.

• With your permission, we will would like to record this session for sole purpose of making sure we do not miss anything. We would like to share with other people who are working on this project the feedback so that we can continue to identify best practices.

• Everything you say here will be kept confidential and included as part of our assessment of participant experience and implementation of best practices. We will not share your name or attribute any responses directly to you.

• Do you have any questions before we begin?

General Question regarding Experience

• Can you tell me more about your experience?

Closing

• Thank you for your time and participation in this interview. Your comments will be very helpful to this project.

Public reporting burden for this collection of information is estimated to average 25 minutes per response, including 5 minutes to complete the survey and 20 minutes for a follow-up conversation on Network experience. All information collected will be kept confidential (42 U.S.C. 299c-3(c)) and included as part of the assessment of participant experience and implementation of best practices. An individual’s name will not be shared and responses will not be attributed to a specific individual. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: AHRQ Reports Clearance Officer Attention: PRA, Paperwork Reduction Project (0935-0179) AHRQ, 5600 Fishers Lane, Mail Stop Number 07W41A, Rockville MD 20857