The Centers for Medicare & Medicaid Services, or CMS, is conducting this survey to learn about the resources you find helpful for improving the quality of care you provide your patients.
This survey is voluntary, and you may stop participating in the survey at any time. Neither your name, nor the name of your business, will ever appear in any reports prepared from the findings of this survey. Your responses will remain private and will not in any way affect your business’s relationship with CMS.
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 information collection is 0938-1424 (Expires xx/xx/20xx). The time required to complete this information collection is estimated to average 15 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, 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 or concerns regarding where to submit your documents, please contact [List Program Specific Contact].
Click next to begin.
S1. In what state or territory do you currently work? If you work within a large network of facilities, please use the healthcare facility where you are primarily located.
[Drop down of all 50 states, plus District of Columbia and territories]
S2. Which of the following best describes your specific occupation within the healthcare facility you primarily work? Please select one.
Medical Doctor (MD, DO, DPM; including PCPs and Specialists)
Nurse Practitioner
Physician Assistant
Registered Nurse
Medical Assistant or Technician
Office/Practice Manager
Quality Oversight
Other (Specify) [Open-text box]
S3. In what healthcare setting do you primarily work? Please select one.
In-patient hospital setting
Outpatient hospital clinic, physician office, or group practice
Nursing home, skilled nursing rehabilitation center, or other long-term care facility
Urgent care center
Community health center
Home health agency
Other rehabilitation setting
Other (Specify) [Open-text box]
[If S3= “In-patient hospital setting” OR “Nursing home, skilled nursing rehabilitation center, or other long-term care facility”, STOP SURVEY. ELSE PROCEED TO S4]
STOP SURVEY: Thank you for your time and for sharing your responses. For this effort, we are only collecting data from respondents working primarily in other settings, but we appreciate your willingness to complete this survey. If you have questions or believe you got this message by error, please contact [email protected]
Please click ‘Next’ to exit the survey
S4. Approximately how many healthcare providers are employed at the facility in which you primarily work?
[0 to 5000]
S5. Is the healthcare facility where you primarily work part of a network of practices or facilities?
Yes
No
S6. How many years have you worked in the field of healthcare?
[0 to 99]
S7. How many years have you been in your current position at the healthcare facility in which you primarily work?
[0 to 99]
In the last 12 months, when your facility tried to improve quality of care, how willing was your facility 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.”
1 – Very unwilling to adopt
2
3
4
5 – Very willing to adopt
Not Applicable or Don’t Know
In the last 12 months, what were the top three sources of influence on your facility’s ability to improve quality of care (e.g., organizations, professional associations, federal or state programs, online resources, internal staff or consultants, etc.)
Please list the specific sources:
[Open response 1]
[Open response 2]
[Open response 3]
In the last 12 months, do you recall your facility working with or using any resources provided by [Insert Partnership for Community Health name], [Insert local QIO name], or a Quality Improvement Organization (QIO)?
(3-1) [Insert Partnership for Community Health name] |
a. Yes |
b. No |
c. Previously, but not in the last 12 months
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d. Not sure |
(3-2) [Insert QIO name] |
a. Yes |
b. No |
c. Previously, but not in the last 12 months
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d. Not sure |
(3-3) Quality Improvement Organization (QIO) |
a. Yes |
b. No |
c. Previously, but not in the last 12 months |
d. Not sure |
3A. [Asked if Q3-1 AND Q3-2 AND Q3-3= b, c, or d] Which best describes the reason(s) why your facility did not work with [Insert Partnership for Community Health name] or [QIO name] or use resources provided by these organizations in the last 12 months?
(Select all that apply) [Answer Choices Randomized, but option ‘a’ is always first and ‘h’ and ‘i’ are last]
We were not aware of these organizations and their resources
No such opportunity presented itself
The resources offered seemed redundant with other efforts we were involved in
We had all the support needed within this facility
We had already received support from another government program or resource
The assistance provided didn’t seem to be helpful or worth the effort
We didn’t have enough time to participate in this effort
Other [open text]
Not Applicable or Don’t Know
3B. [Asked if Q3-1 AND Q3-2 AND Q3-3= ‘b’, ‘c’, or ‘d’; AND if Q3A ‘a’ is not selected] Do you know how to contact [Insert Partnership for Community Health name] or [QIO name] if you wanted help or advice for improving the quality of care at your facility?
Yes
No
Not Applicable or Don’t Know
[If Q3-1 AND Q3-2 AND Q3-3= ‘b’ ‘c’, or ‘d’ skip to Q10]
[If Q3-1 OR Q3-2 OR Q3-3 = ‘a,’ use corresponding name in the remaining questions. If both Q3-1 and Q3-2 = ‘a,’ use Partnership for Community Health name, only. If only Q3-3 = ‘a,’ use “the QIO” for remaining questions.]
In the last 12 months, how would you describe your level of engagement with [Insert Partnership for Community Health or QIO name] in order to improve the quality of care at your facility?
Not at all engaged with [Insert Partnership for Community Health or QIO name]
Minimally engaged with [Insert Partnership for Community Health or QIO name]
Moderately engaged with [Insert Partnership for Community Health or QIO name]
Highly engaged with [Insert Partnership for Community Health or QIO name]
Not Applicable or Don’t Know
4A. [Asked if Q4 = a, b, or e] Which best describes the reason(s) why your facility was not more fully engaged with [Insert Partnership for Community Health or QIO name] since [insert date]. (Select all that apply) [Answer Choices Randomized]
No such opportunity presented itself
The resources offered seemed redundant with other efforts we were involved in
We had already received support from another government program or resource
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
Not Applicable or Don’t Know
4B. [Asked if Q4 = d or e] Do you know how to contact the [Insert Partnership for Community Health or QIO name] if you wanted help or advice for improving quality at your facility?
Yes
No
Not Applicable or Don’t Know
[IF Q4=d, SKIP to Q10]
Please provide feedback indicating how helpful you perceive [Insert Partnership for Community Health or QIO name] to be for improving the quality of care to your patients regarding the following topics in the last 12 months:
[Answer Choices Randomized]
[Allow only one response]
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a. Not at All Helpful |
b. Not Very Helpful |
c. Somewhat Helpful |
d. Very Helpful |
e. Did not work with [Insert PCH or QIO name] on this topic |
f. Don’t Know |
(5-1) Infection Control |
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(5-2) Immunization (COVID, influenza, pneumococcal vaccines) |
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(5-3) Managing chronic disease |
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(5-4) Addressing public health emergencies or natural disasters |
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(5-5) Building resiliency for your staff during public health emergencies or natural disasters |
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(5-6) Building resiliency for your patients during public health emergencies or natural disasters |
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(5-7) Communicating with members of the community |
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(5-8) Overcoming or mitigating barriers to accessing healthcare |
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(5-9) Coordination with other healthcare providers, including hospitals and skilled nursing facilities |
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(5-10) Providing satisfactory customer service |
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(5-11) Preventing or controlling opioid misuse and fatalities |
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(5-12) Other [open text] |
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5A. Please briefly state the most helpful services or resources provided by [Insert Partnership for Community Health or QIO name] [Open ended]
5B. Can you suggest how [Insert Partnership for Community Health or QIO name] could be more helpful [Open ended]
In the last 12 months, did your interactions with [Insert QIO or Partnership for Community Health name] result in any changes to the processes or protocols your facility uses?
Yes
No
6A. [Asked if Q6 = a] Please identify which (if any) processes or protocols changed as a result of the interactions with [Insert Partnership for Community Health or QIO name]
Answer Choices Randomized.
[Show only Q5-1 to Q5-12 items NE e and f]
(6- 1) Infection Control |
a. Yes |
b. No |
c. NA/Don’t Know |
(6- 2) Immunization (COVID, influenza, pneumococcal vaccines) |
a. Yes |
b. No |
c. NA/Don’t Know |
(6- 3) Managing chronic disease |
a. Yes |
b. No |
c. NA/Don’t Know |
(6- 4) Addressing national public health emergencies or natural disasters |
a. Yes |
b. No |
c. NA/Don’t Know |
(6-5) Building resiliency for your staff during public health emergencies or natural disasters |
a. Yes |
b. No |
c. NA/Don’t Know |
(6-6) Building resiliency for your patients during public health emergencies or natural disasters |
a. Yes |
b. No |
c. NA/Don’t Know |
(6-7) Communicating with members of the community |
a. Yes |
b. No |
c. NA/Don’t Know |
(6- 8) Overcoming or mitigating barriers to accessing healthcare |
a. Yes |
b. No |
c. NA/Don’t Know |
(6- 9) Coordination with other healthcare providers, including hospitals and skilled nursing facilities |
a. Yes |
b. No |
c. NA/Don’t Know |
(6- 10) Providing satisfactory customer service |
a. Yes |
b. No |
c. NA/Don’t Know |
(6- 11) Preventing or controlling opioid misuse and fatalities |
a. Yes |
b. No |
c. NA/Don’t Know |
(6-12) [include ‘other’ write-in response from above] |
a. Yes |
b. No |
c. NA/Don’t Know |
6B. [Asked if Q6= b] You indicated that working with [Insert Partnership for Community Health or QIO name] did not lead to changing any processes or procedures used by your facility.
Which response(s) best describes why that was the case:
(Select all that apply) [Answer Choices Randomized]
No such opportunity presented itself
We had all the support needed within this facility
The resources seemed redundant with other resources we were using
The assistance provided didn’t seem to be helpful or worth the effort
We didn’t have time to implement the changes [Insert Partnership for Community Health or QIO name] recommended
The quality of resources or assistance from [Insert Partnership for Community Health or QIO name] was sub-optimal
The scheduling was inconvenient
Our facility already made changes needed before we began working with [Insert Partnership for Community Health or QIO name]
Other [Open ended]
Not Applicable or Don’t Know
Thinking about all interactions with [Insert Partnership for Community Health or QIO name] how satisfied are you with your relationship with the organization overall? Please give a response on a scale from 1 to 5, with 1 being very dissatisfied and 5 being very satisfied.
1- Very dissatisfied
2
3
4
5- Very satisfied
Not Applicable or Don’t Know
If your facility requested assistance from [Insert Partnership for Community Health or QIO name], how satisfied were you with the timeliness of the response? Please give a response on a scale from 1 to 5, with 1 being very dissatisfied and 5 being very satisfied.
1- Very dissatisfied
2
3
4
5- Very satisfied
Not Applicable or Don’t Know
Please indicate your level of agreement with the following statement about health equity and the information and assistance provided by [Insert Partnership for Community Health or QIO name]:
The assistance we received from [Insert Partnership for Community Health or QIO name] had an impact on our facility’s efforts to improve health equity. Health equity means addressing health disparities and ensuring that all patients have an equal opportunity to attain their full potential for health. Please give a response on a scale from 1 to 5, with 1 being strongly disagree and 5 being very satisfied.
1- Strongly disagree
2
3
4
5- Strongly Agree
Not Applicable or Don’t Know
[For respondents who answered b, c, or d to Q3-1 AND Q3-2 AND Q3-3, only]
Please indicate if your facility has changed or developed new processes or protocols for improving the following topics in the last 12 months.
(6- 1) Addressing Health Equity |
a. Yes |
b. No |
c. NA/Don’t Know |
(6- 2) Infection Control |
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(6- 3) Immunization (COVID, influenza, pneumococcal vaccines) |
a. Yes |
b. No |
c. NA/Don’t Know |
(6- 4) Managing chronic disease |
a. Yes |
b. No |
c. NA/Don’t Know |
(6- 5) Addressing national public health emergencies or natural disasters |
a. Yes |
b. No |
c. NA/Don’t Know |
(6-6) Building resiliency for your staff during public health emergencies or natural disasters |
a. Yes |
b. No |
c. NA/Don’t Know |
(6-7) Building resiliency for your patients during public health emergencies or natural disasters |
a. Yes |
b. No |
c. NA/Don’t Know |
(6-8) Communicating with members of the community |
a. Yes |
b. No |
c. NA/Don’t Know |
(6- 9) Overcoming or mitigating barriers to accessing healthcare |
a. Yes |
b. No |
c. NA/Don’t Know |
(6- 10) Coordination with other healthcare providers, including hospitals and skilled nursing facilities |
a. Yes |
b. No |
c. NA/Don’t Know |
(6- 11) Providing satisfactory customer service |
a. Yes |
b. No |
c. NA/Don’t Know |
(6- 12) Preventing or controlling opioid misuse and fatalities |
a. Yes |
b. No |
c. NA/Don’t Know |
(6-13) [include write-in response from above] |
a. Yes |
b. No |
c. NA/Don’t Know |
[Respondents that completed all questions: ‘Finally, what’] [Respondents who skipped from Q3: ‘What’] quality improvement areas are you most in need of for additional assistance? [Open ended]
Your responses have been received. Thank you for your time and for completing the survey.
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| File Modified | 0000-00-00 |
| File Created | 2024-08-03 |