Crosswalk of Nursing Home Survey

Crosswalk for Changes to
Evaluation of the CMS Network of Quality Improvement and Innovation Contractors Program (NQIIC) (CMS-10769)

Appendix A Nursing Home Survey Questions

Old #	New #	Question Used in Pretests	Recommendation/ Decision	Reason	Recommended Revised Question
S1	S1	Are you the best person at [FACILITY NAME] to complete this survey?   Yes  No   DK   Refused   [IF S1 = NO, ASK S2; IF S1 = Yes, PROCEED TO S4]	Skip logic adjusted to reflect DK and Refused options	As recommended by the pretest.	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	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 or DK, ASK S3]	Skip logic adjusted to reflect Refused option	As recommended by the pretest.	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]
S6	S6	How long have you worked at this facility regardless of role? [Record years and months] Not sure (approximately how long?)	Adjusted language to assess time in specific role Adjust response option to open-text	As recommended by the pretest.	How long have you been in this role at your current facility?
	S7	New question	Add question to ensure permission to record responses	As recommended by the pretest.	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
1	1	Since March 2020, has your facility changed or developed new processes or protocols to prevent and control the spread of COVID-19 infection? Yes [GO TO Q2] No [SKIP TO Q3]	Changed timeframe Changed question to focus on supportiveness of leadership when a change was made, rather than if a change was made Removed specific aims (opioid and hospital acquired conditions) from question and response options Add response options on a scale	Adjusting to reflect post-Covid years and to better assess general quality improvement culture. As recommended by the pretest.	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]
2		[If Q1 = YES] During the first 6 months of COVID-19, what would you consider the top two or three changes you made to your processes or protocols to respond to the pandemic? (PROBE) [DO NOT NEED TO BE IN ORDER OF IMPORTANCE] Response category 1 Response category 2 Response category 3 Other [open ended]	Remove question	Ensure that all questions reflect post-Covid priorities and minimize recall error for responses related to early covid period.	None.
	2	New question	Add question to assess staff willingness to adopt new practices or policies for quality improvement	Added to better assess general quality improvement culture.	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
3		[If Q1 = NO] Which of these statements describe the reasons why your facility didn’t change any processes or protocols to prevent infection during the COVID-19 pandemic. Would you say it’s because… [Select all that apply] Our processes and protocols were already effective We were in a green zone, and no cases of COVID-19 were reported We didn’t have the resources needed to make changes Other [Open ended]	Remove question	Question no longer relevant, based on removal of previous questions.	None.
4		I’m going to read a list of programs, agencies, or resources that you may have used over the past 18 months to improve the quality of care to residents at your facility. As I read each one, please tell me if you recall working with or using this resource over the last 18 months or since the beginning of the COVID-19 pandemic. Project ECHO [IF RESPONDENT ANSWERS ‘NO’ PROVIDE ADDITIONAL INFORMATION TO CLARIFY: AHRQ’s (pronounced “ARK”) National Nursing Home COVID-19 Coordinating Center or AHRQ’s National Nursing Home COVID-19 Action Network”] The Quality Improvement Organization (QIO) Program, or QIOs, also known as [QIO Name] in your area CDC [TYPE IN NAME FOR STATE DEPARTMENT OF HEALTH] CMS targeted COVID-19 training [IF RESPONDENT ANSWERS ‘NO’ PROVIDE ADDITIONAL INFORMATION TO CLARIFY: Scenario-based Training also known as the CMS Targeted COVID-19 Training for Nursing Homes (online modules for frontline staff and nursing home management)] AHCA (American Health Care Association) or [TYPE IN NAME OF STATE] chapter of AHCA Peers and/or other facilities Local departments of health (city/county) None of the above [DO NOT READ] Are there any other sources of information you used when working on preventing and controlling the spread of COVID-19? Record response #1 Record response #2 Record response #3 NA. No additional sources of information	Remove question	Question no longer necessary for data needs, remove to reduce burden.	None.
	3	New question	Add question to assess facility priorities	Per change in CMS priorities.	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	New question	Add question to understand what might be preventing changes for quality improvement within an organization	As recommended by the pretest.	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]
5	4	You mentioned that you use [INSERT ANSWERS FROM Q4]. what would you consider the sources of information, guidance, or assistance that had the most impact on your facility’s ability to prevent and control the spread of COVID-19? [Open ended]	Add explanation of open-ended response Add time period Remove specific insertion of goals Adjust wording to reflect top sources influence on general quality improvement	As recommended by the pretest.	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.)? [Open ended]
6		Before this survey, had you ever heard of Quality Improvement Organizations, otherwise referred to as QIOs? Yes No	Remove question	Question no longer necessary for data needs, remove to reduce burden.	None.
7	5	The name of your QIO is [QIO Name OR QIO Contact Person if available], have you ever heard of them? [CONFIRM CONTACT PERSON IS INCLUDED IN CONTACT LIST] Yes No	Add time period Adjust question to reflect working with the QIO, rather than ‘hearing’ form them Add prefer not to answer response option	Per change in CMS priorities.	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]
	5A	New question	Add question to understand what might be preventing use of QIO resources	As recommended by the pretest.	[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 since 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	New question	Add question to confirm if providers know how to contact the QIO organization	As recommended by the pretest.	[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]
8	6	How would you describe your level of engagement with [QIO Name or ‘the QIO that serves your area’] while you were working to prevent and control the spread of respiratory infections like COVID-19? Would you say you were… Fully engaged with [QIO name or ‘the QIO that serves your area’] [GO TO Q10] Moderately engaged with [QIO name or ‘the QIO that serves your area’] [GO TO Q10] Minimally engaged with [QIO name or ‘the QIO that serves your area’] [GO TO Q9] Not at all engaged with [QIO name or ‘the QIO that serves your area’] [GO TO Q9]	Add time period Remove specificity for Covid-19 Simplify response options	Priority to assess general engagement overtime instead of Covid-19, only. As recommended by the pretest.	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	New question	Add question to understand engagement over time	As recommended by the pretest.	[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]
8.1		You said before you were not working with [QIO Name] but answered that you were engaged with them. Do you want to change your response that you are working with them? Yes [Set 4b = Yes, continue as normal] No [Answer Q9, skip to 22]	Remove question	Question no longer relevant due to change in previous question changes.
9	6B	[IF Q8 = c or d] Which best describes the reason(s) why this facility was not fully engaged with [QIO Name or ‘the QIO that serves your area’] while you were working to prevent and control the spread of COVID-19? Would you say this is because… [Enter all that apply] I don’t recall ever being contacted by [QIO name or ‘the QIO that serves your area’] The resources seemed similar to or overlapped with other efforts we are involved in We had all the support needed within this facility The assistance available 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 We could not find a convenient time to schedule meetings Other [Open ended]	Add time period Remove specificity of Covid-19	Per change in CMS priorities. As recommended by the pretest.	[Asked if Q6= c or d] In the last 12 months, which best describes the reason(s) why your facility was not more 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	New question	Added to understand if providers turn to HQICs when they need additional assistance	Adjusted to better represent data priorities for survey.	[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	New question	Simplify language	Adjusted to align with changes of question 6C, per the survey data priorities.	[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]
10	7	To the best of your knowledge did your interactions with [QIO Name or ‘the QIO that serves your area’] result in any improvements to the processes or protocols your facility uses to prevent COVID-19 infection, or infection control in general? Yes [GO TO Q11] No [IF Q8 = c OR d (minimally or not engaged), GO TO Q13; ELSE GO TO Q12]	Add time period Adjust wording for readability Remove specificity for Covid-19	Per change in CMS priorities. As recommended by the pretest.	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]
11	7A	[IF Q10 = YES] Please describe what improved as a result of the interactions with [QIO Name or ‘the QIO that serves your area.’] (PROBE) Record response #1 Record response #2 Record response #3 Other [GO TO Q13]	Add time period Change response options to specific quality improvement categories	As recommended by pretest.	[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]
12	7B	[IF Q1 = YES AND Q10 = NO and Q8 = a or b] You said earlier that your interactions with [QIO Name or ‘the QIO that serves your area.’] did not result in any improvements to the processes or protocols you facility uses to prevent COVID-19 infection, or infection control in general? Which response(s) best describes why that was the case? [Select all that apply] Our facility already made changes needed before we began working with [QIO Name or ‘the QIO that serves your area’] The resources from [QIO Name or ‘the QIO that serves your area’] seemed similar to or overlapped with other efforts we are involved in We had all the support needed within this facility The assistance available didn’t seem to be helpful or worth the effort We didn’t have time to implement the changes the [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 We could not find a convenient time to schedule meetings Other [Open ended]	Change programming Remove specificity for Covid-19 Adjust response options	As recommended by pretest.	[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]
13		If I asked you to describe in just a few words the CMS Quality Improvement Program, or QIO, also known as [QIO Name], what’s the first thing that comes to mind? (DO NOT NEED TO PROBE) [Open ended]	Remove question	Per change in CMS priorities. Reduce respondent burden.	None.
14		[If > year; “In the last twelve months” If < year; “Since [INSERT DATE]”] Overall, how satisfied are you with the amount of contact between your facility and [QIO Name or ‘the QIO that serves your area’]? Would you say you are… Very Satisfied Somewhat Satisfied Neither Satisfied or Dissatisfied Very Dissatisfied Don’t Know/Not Sure [DO NOT READ] Decline to answer [DO NOT READ]	Remove question	Per change in CMS priorities. Reduce respondent burden.	None.
15		Have you or someone in your facility ever had the occasion to initiate the interaction with [QIO Name or ‘the QIO that serves your area’], such as when you needed questions answered or assistance with an issue? Yes No	Remove question	Per change in CMS priorities. Reduce respondent burden.	None.
16		[IF Q15 = Y] Overall, how satisfied are you with the timeliness of [QIO Name or ‘the QIO that serves your area’] response to your question or request for assistance? Would you say you are… Very Satisfied  Somewhat Satisfied  Neither Satisfied or Dissatisfied  Somewhat Dissatisfied  Very Dissatisfied  Don’t Know/Not Sure [DO NOT READ] Decline to Answer [DO NOT READ]	Remove question	Per change in CMS priorities. Reduce respondent burden.	None.
17	8	Thinking about all interactions with [QIO Name or ‘the QIO that serves your area,’], overall, how satisfied are you with your relationship with [QIO Name or ‘the QIO that serves your area,’]? Would you say you are…  Very Satisfied  Somewhat Satisfied  Neither Satisfied or Dissatisfied  Somewhat Dissatisfied  Very Dissatisfied  Don’t Know/Not Sure [DO NOT READ] Decline to Answer [DO NOT READ]	Moved word “overall” for better flow Adjusted last two response options to one: “prefer not to answer”	As recommended by pretest.	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	New question	Add question to understand prior satisfaction	As recommended by pretest.	[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]
21	8B	[IF Q16, Q17, Q18, Q19 or Q20 = d or e] Please tell me what [QIO Name or ‘the QIO that serves your area’] could have done better. [Open ended]	Move question for better survey flow	Per CMS priorities.	[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	New question	Add question to understand how QIO has been most helpful	Per CMS priorities.	[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
18	9	The assistance we received from [QIO Name or ‘the QIO that serves your area,’] was key to the efficient implementation of our protocols to prevent and control COVID-19 infection. Would you say you… Strongly Agree Somewhat Agree Neither Agree or Disagree  Somewhat Disagree  Strongly Disagree  Don’t Know/Not Sure [DO NOT READ] Decline to Answer [DO NOT READ]	Added introduction to statement Changed word ‘key’ to ‘significant’ Adjusted question focus from Covid-19 implementation to health equity efforts Simplified last two response options to ‘prefer not to answer’	Per change in CMS priorities.	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 [DON’T READ]
19		The service we received from [QIO Name or ‘the QIO that serves your area,’] was worth the time or effort required on the part of our staff. Would you say you…  Strongly Agree Somewhat Agree Neither Agree or Disagree  Somewhat Disagree  Strongly Disagree Don’t Know/Not Sure Decline to Answer	Remove question	Per change in CMS priorities. Reduce respondent burden.	None.
20		Our organization has benefited from having received services from this [QIO Name or ‘the QIO that serves your area,’]. Would you say you… Strongly Agree Somewhat Agree Neither Agree or Disagree  Somewhat Disagree  Strongly Disagree  Don’t Know/Not Sure [DO NOT READ] Decline to Answer [DO NOT READ]	Remove question	Per change in CMS priorities. Reduce respondent burden.	None.
22	10	At this point, what quality improvement areas are you most in need of for additional assistance? [Open ended] [RECORD ANY RESPONSES INCLUDED IN THE LIST (a-j) BELOW BUT DO NOT READ] Activities and Daily Living (ADL) [DO NOT READ] Bladder and bowel control Patient mobility Weight loss Behavioral Health [DO NOT READ] Antipsychotic medication use Depression/anxiety Opioid misuse Chronic Disease Management [DO NOT READ] Blood pressure control Cholesterol management Dementia care Diabetic management Pain management Smoking cessation COVID-19 Response [DO NOT READ] Education/Training [DO NOT READ] Nursing Home Quality [DO NOT READ] Patient satisfaction Resources Patient Safety [DO NOT READ] Abx stewardship ADEs CDI Falls Infection control (UTIs) Pressure ulcers Wound care Quality of Care Coordination [DO NOT READ] ED visits Readmissions Hospital admissions/re-hospitalizations Staff Retention/Recruiting [DO NOT READ] Other [DO NOT READ] NA. No quality improvement areas are in need of additional assistance	Simplify question wording Remove programming to record specific responses—record all responses	As recommended by pretest.	[All respondents] Finally, what quality improvement areas are you most in need of additional assistance? [Open ended]

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