OMB No. 0938-1424
Expires xx/xx, 20xx
[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 nursing home facilities and the types of resources that are helpful in this area. We’re conducting a 20-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 NQIIC facilities] works most closely with [INSERT NAME OF LOCAL QIN-QIO] and / [for non-NQIIC facilities] is most knowledgeable about the quality improvement activities your nursing home has been working on. If your nursing home is part of a nursing home chain, we’d 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 0938-1424.
[READ IF CONTACTED VIA EMAIL AND ARRANGED MEETING TIME]
We’re calling you on behalf of The Centers for Medicare and Medicaid Services, or CMS, to learn about quality improvements in nursing home facilities and the types of resources that are helpful in this area. We scheduled this time to conduct a 20-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. You should also 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 0938-1424.
[READ IF CALLED PREVIOUSLY AND ARRANGED NEW MEETING TIME]
We’re calling back on behalf of The Centers for Medicare and Medicaid Services, or CMS, to learn about quality improvements in nursing home facilities and the types of resources that are helpful in this area. We scheduled this time to conduct a 20-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 0938-1424.
[READ IF PREVIOUSLY BEGAN CONDUCTING SURVEY AND NOW CALLING TO CONTINUE SURVEY]
We’re calling back on behalf of The Centers for Medicare and Medicaid Services, or CMS, to learn about quality improvements in nursing home 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 0938-1424. The time required to complete this information collection is estimated to average 20 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection.
S1. Are you the best person at [FACILITY NAME] to complete this survey?
a. Yes
b. No
c. DK
d. Refused
[IF S1 = NO, DK, or Refused, 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 nursing home?
a. Yes
b. No
c. DK
d. Refused
Record Name
Record Title
Record phone number
[IF S2 = No, DK, or Refused, 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 at your current facility?
S7. This survey includes closed-ended questions with specific answer choices, as well as longer open-ended response questions. In order to help the survey go faster, I would like to record your answers to some questions where you may have longer responses. Do I have your permission to record these answers?
Yes
No
[If S7 = No, proceed by entering as much of the open-ended responses as possible, otherwise enable audio recording]
Thank you. I will now proceed with the survey questions.
In the last 12 months, when your facility tried to improve quality of care, how supportive was your leadership? Please give a response on a scale from 1 to 5, with 1 being very unsupportive and 5 being very supportive. How would you rate your leadership?
1- Very unsupportive
2
3
4
5- Very supportive
Prefer not to answer [DON’T READ]
In the last 12 months, when your facility tried to improve quality of care, how willing was your staff to adopt new practices or policies? Please give a response on a scale from 1 to 5, with 1 being very unwilling and 5 being very willing. How would you rate your staff?
1- Very unwilling to adopt
2
3
4
5-Very willing to adopt
Prefer not to answer [DON’T READ]
Now we want to better understand your facility’s priorities for quality improvement. I’m going to read a list of care topics that you may have addressed to improve the quality of care for residents at your facility. In the last 12 months, please tell me if your facility has changed or developed new processes or protocols to improve this topic…
[Respond Yes or No]
Health equity, meaning reducing disparities in health and health care…for those residents with a greater social risk factor burden
Preventing or controlling Covid-19 infection
Other Infection control (not Covid-19)
Resilience, meaning the ability to adapt and persist despite disturbances to the system, high-risk situations, or the presence of continuous stress
Emergency preparedness
Opioid misuse
Increased resident safety
Care transitions
Chronic disease self-management
Immunization (COVID, influenza, pneumococcal vaccines)
Other
Prefer not to answer [DON’T READ]
3A. [Asked if any a-i = No] With regard to the care topics that you have not addressed, namely [insert responses selected ‘no’ above (do not include the full definition for Health Equity or Resilience)], which of these statements best describe the reasons why your facility didn’t change any processes or protocols? [Select all that apply]
Our processes and protocols were already effective
Other goals were of higher priority to our facility
We didn’t have the resources needed to make changes
We were not aware of best practices for quality improvement
Other [Open ended]
Prefer not to answer [DON’T READ]
The next question will be an open-response question.
In the last 12 months, what were the top three sources of influence on your facility’s ability to improve the quality of services for residents (e.g. organizations, professional associations, federal programs, websites, podcasts, etc.)?
In the last 12 months, do you recall working with [QIO name or ‘the QIO that serves your area’] or using any resources provided by this organization?
Yes
No
Prefer not to answer [DON’T READ]
[If Q5= a or c, skip to Q6]
5A. [Asked if Q5= b] Which best describes the reason(s) why your facility did not work with [QIO name or ‘the QIO that serves your area’] or use resources provided by this organization in the last 12 months?
[Select all that apply]
We were not aware of this organization and its resources
No such opportunity presented itself
The resources offered seemed redundant with other efforts we are involved in
We had all the support needed within this facility
We had already received support from another government program
The assistance available didn’t seem to be helpful or worth the effort
We didn’t have enough time to participate in another effort
Other
Prefer not to answer [DON’T READ]
5B. [Asked if Q5= b] Do you know how to contact [QIO name or ‘the QIO that serves your area’] if you want help or advice from them on improving quality at your facility?
Yes
No
Prefer not to answer [DON’T READ]
[If Q5=b, skip to Q10]
In the last 12 months, how would you describe your level of engagement with [QIO name or ‘the QIO that serves your area’]? Would you say you were…
Highly engaged
Moderately engaged
Minimally engaged
Not at all engaged
Prefer not to answer [DON’T READ]
6A. [Asked if Q6= c or d] You said you were [insert answer from Q6], was there a period before the last 12 months when you were more engaged with [QIO name or ‘the QIO that serves your area’]?
Yes
No
Prefer not to answer [DON’T READ]
[If Q6 is a, b, or e= skip to Q7]
6B. [Asked if Q6= c or d] In the last 12 months, which best describes the reason(s) why your facility was not fully engaged with [QIO name or ‘the QIO that serves your area’]?
[Select all that apply]
No such opportunity presented itself
We had all the support needed within this facility
The resources offered seemed redundant with other efforts we were involved in
We had already received support from another government program
The assistance provided didn’t seem to be helpful or worth the effort
We didn’t have enough time to participate in another effort
The quality of resources or assistance from [QIO name or ‘the QIO that serves your area’] was sub-optimal
The scheduling was not convenient
Other [Open ended]
Prefer not to answer [DON’T READ]
6C. [Asked if Q6= d] When you needed additional support or advice for improving quality of care at your facility, did you contact [QIO name or ‘the QIO that serves your area’]?
Yes
No
Prefer not to answer [DON’T READ]
6D. [Asked if Q6C= b] Do you know how to contact [QIO name or ‘the QIO that serves your area’]?
Yes
No
Prefer not to answer [DON’T READ]
In the last 12 months, were there any changes to the processes or protocols in your facility as a result of your interactions with [QIO Name or ‘the QIO that serves your area’] or its resources?
Yes
No
I’m not sure
Prefer not to answer [DON’T READ]
7A. [Asked if Q7 = a] In the last 12 months, what processes or protocols changed as a result of the interactions with [QIO Name or ‘the QIO that serves your area.’]
[Only include response options where respondent answered ‘Yes’ in Q3.]
[Respond Yes or No]
Preventing or controlling Covid-19 infection
Other infection control (not Covid-19)
Resilience, meaning the ability to adapt and persist despite disturbances to the system, high-risk situations, or the presence of continuous stress
Emergency preparedness
Opioid misuse
Increased resident safety
Care transitions
Chronic disease self-management
Immunization (COVID, influenza, pneumococcal vaccines)
Other [Open ended]
Prefer not to answer [DON’T READ]
7B. [Asked if Q7 = b] You said that working with [QIO name or ‘the QIO that serves your area’] did not result in any changes to your facility’s procedures or protocols. Which responses best describe why that was the case? Would you say it is because…
[Select all that apply]
Our facility already made changes needed before we began working with [QIO name or ‘the QIO that serves your area’]
We had all the support needed within this facility
The resources offered seemed redundant with other efforts we were using
We had already received support from another government program.
The assistance provided didn’t seem to be helpful or worth the effort
We didn’t have time to implement the changes [QIO name or ‘the QIO that serves your area’] recommended
The quality of resources or assistance from [QIO name or ‘the QIO that serves your area’] was sub-optimal
The scheduling was inconvenient
Other [Open ended]
Prefer not to answer [DON’T READ]
Thinking about all interactions with [QIO Name or ‘the QIO that serves your area,’] in the last 12 months, how satisfied are you with your relationship with the QIO overall? Would you say you are…
Very satisfied
Somewhat satisfied
Neither satisfied nor dissatisfied
Somewhat dissatisfied
Very dissatisfied Prefer not to answer [DON’T READ]
8A. [Asked if Q8= c, d, or e] You said you were [insert answer from Q8], was there a period prior to the last 12 months when you were more satisfied with [QIO name or ‘the QIO that serves your area’]?
Yes
No
Prefer not to answer [DON’T READ]
8B. [Asked if Q8= c, d, e, or f] Please tell me what [QIO name or ‘the QIO that serves your area’] could have done better. [Open ended]
8C. [Asked if Q8= a, b, c, or f] Please tell me in what ways [QIO name or ‘the QIO that serves your area’] has been most helpful. [Open ended]
Please indicate your level of agreement with the following statement about health equity and the information and assistance provided by the QIN-QIO:
The assistance we received from [QIO Name or ‘the QIO that serves your area,’] was significant to our facility’s efforts to improve health equity in the care setting, meaning the facility’s efforts to reduce disparities in health and health care…for those residents with a greater social risk factor burden. Would you...
Strongly agree
Somewhat agree
Neither agree nor disagree
Somewhat disagree
Strongly disagree Prefer not to answer
[All respondents] Finally, what quality improvement areas are you most in need of additional assistance? [Open ended]
Thank you for your time and for sharing your experiences. The time required to complete this information collection was estimated to average 20 minutes per response, 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 Mr. Jeff Mokry at 214-767-4021.
Thank you for your time and for sharing your experiences.
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| File Title | Appendix A: NQIIC Nursing Home Survey Instrument |
| Subject | NQIIC Quick Program Evaluation Survey |
| Author | Centers for Medicare & Medicaid Services |
| File Modified | 0000-00-00 |
| File Created | 2024-07-25 |