OMB No. 0938-1424
Expires xx/xx, 20xx
Introduction and Informed Consent 1
[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 hospital 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 HQIC facilities] works most closely with [INSERT NAME OF LOCAL HQIC] and / [for non-HQIC facilities] is most knowledgeable about the quality improvement activities your hospital has been working on. If your hospital is part of a larger medical care system, we would 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.
Introduction and Informed Consent 2
[READ IF CONTACTED VIA EMAIL AND ARRANGED MEETING TIME]
We’re calling you on behalf of the Centers for Medicare & Medicaid Services, or CMS, to learn about quality improvements in hospital 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. Please 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.
Introduction and Informed Consent 3
[READ IF CALLED PREVIOUSLY AND ARRANGED NEW MEETING TIME]
We’re calling back on behalf of the Centers for Medicare & Medicaid Services, or CMS, to learn about quality improvements in hospital 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.
Introduction and Informed Consent 4
[READ IF PREVIOUSLY BEGAN CONDUCTING SURVEY AND NOW CALLING TO CONTINUE SURVEY]
We’re calling back on behalf of the Centers for Medicare & Medicaid Services, or CMS, to learn about quality improvements in hospital 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. |
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 hospital?
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 this hospital? [Open ended]
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 manually 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?
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 patients at your facility. In the last 12 months, please tell me if your facility has changed or developed new processes or protocols improving this topic…
[Respond Yes or No]
Health equity, meaning reducing disparities in health and health care…for those patients with a greater social risk factor burden
Adopting a patient-centered approach
Increasing patient safety
Opioid misuse
Preventing or controlling Covid-19 infection
Other infection control (not Covid-19)
Emergency preparedness
Care transitions
Patient Family Engagement
Other
Prefer not to answer [DON’T READ]
3A. [Asked if 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)], 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 to patients (e.g. organizations, professional associations, federal programs, websites, podcasts, etc.)?
In the last 12 months, do you recall working with [HQIC name or HQIC contact person] 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 [HQIC name or HQIC contact person] or use resources provided by this organization in the last 12 months?
[Select all that apply]
a. We were not aware of this organization and its resources
b. No such opportunity presented itself
c. We had all the support needed within this facility
d. The resources offered seemed redundant with other efforts we are involved in
e. We didn’t have enough time to participate in another effort
f. We had already received support from another government program
g. The assistance available didn’t seem to be helpful or worth the effort
h. The quality of resources or assistance from [HQIC name or HQIC contact person] was sub-optimal
i. The scheduling was not convenient
j. Other
k. Prefer not to answer [DON’T READ]
5B. [Asked if Q5= b] Do you know how to contact [HQIC name or HQIC contact person] 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 Q7]
In the last 12 months, how would you describe your facility’s level of engagement with [HQIC name or HQIC contact person]? 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 [HQIC name or HQIC contact person]?
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 of the following options best describe the reasons why this facility was not more fully engaged with the [HQIC name or HQIC contact person]?
[Select all that apply]
No such opportunity presented itself
We had all the support needed within this facility
The resources seemed redundant with other efforts we were involved in
We didn’t have enough time to participate in another effort
We had already received support from another government program
The assistance provided didn’t seem to be helpful or worth the effort
The quality of resources or assistance from [HQIC name or HQIC contact person] 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 [HQIC name or HQIC contact person]?
6D. [Asked if Q6C= b] Do you know how to contact [HQIC name or HQIC contact person]?
Yes
No
Prefer not to answer [DON’T READ]
Does your facility engage in community outreach or with other service providers?
Yes
No
Prefer not to answer [DON’T READ]
7A. [Asked if Q7= a] In the last 12 months, what types of outreach has your facility used to engage with partners in the communities you serve? I’m going to read you a list of possible ways; please tell me if this applies to your facility:
[Select all that apply]
Community advisory groups
Conducting focus groups
Patient Family Engagement committees
Collaboration with community service partners
Newsletters
Webinars or Free Talks
Social Media
Other [Open ended]
Prefer not to answer [DON’T READ]
[If Q5= b, skip to Q11]
In the last 12 months, were there any changes to the processes or protocols in your facility as a result of your interactions with [HQIC name or HQIC contact person] or its resources?
Yes
No
I’m not sure
Prefer not to answer [DON’T READ]
8A. [Asked if Q8 = a] Please identify what processes or protocols changed as a result of the interactions with [HQIC name or HQIC contact person.]
[Only include response options where respondent answered ‘Yes’ in Q3.]
Adopting a patient-centered approach
Increasing patient safety
Opioid misuse
Preventing or controlling Covid-19 infection
Other infection control (not Covid-19)
Emergency preparedness
Care transitions
Patient Family Engagement
Other [Open ended]
Prefer not to answer [DON’T READ]
8B. [Asked if Q8 = b] You said that working with [HQIC name or HQIC contact person] 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 was because...
[Select all that apply]
Our facility already made changes needed before we began working with [HQIC name or HQIC contact person]
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 the [HQIC name or HQIC contact person] recommended
The quality of resources or assistance from [HQIC name or HQIC contact person] was sub-optimal
The scheduling was inconvenient
Other [Open ended]
Prefer not to answer [DON’T READ]
Thinking about all interactions with [HQIC name or HQIC contact person,] how satisfied are you with your relationship overall? Would you say you are…
Somewhat Satisfied
Neither Satisfied nor Dissatisfied
Somewhat Dissatisfied
Very Dissatisfied
Prefer not to answer [DON’T READ]
9A. [Asked if Q9= c, d e, or f] Please tell me what [HQIC name or HQIC contact person] could have done better. [Open ended]
9B. [Asked if Q9= a, b, c, or f] Please tell me in what ways [HQIC name or HQIC contact person] 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 [HQIC name or HQIC contact person]:
The assistance we received from [HQIC name or HQIC contact person] 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 patients with a greater social risk factor burden. Would you…
Somewhat Agree
Neither Agree nor Disagree
Somewhat Disagree
Strongly Disagree
Prefer not to answer [DON’T READ]
[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, 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 B: HQIC Hospital Survey Instrument |
| Subject | NQIIC Quick Program Evaluation Survey |
| Author | Centers for Medicare & Medicaid Services |
| File Modified | 0000-00-00 |
| File Created | 2024-07-25 |