Form CMS-10272 HLQAT Instrument

CMS08_PRA_080728

CMS Page 13 of 13

Hospital Leadership and Quality

Assessment Tool©

Final Draft 4-10-08—Not for Circulation

This questionnaire may not be used or

cited without permission

This document includes the draft Hospital Leadership and Quality Assessment Tool©. This draft survey is designed to assess the perceptions of Board members and hospital leadership about important areas of clinical quality improvement in their hospitals.

The survey was developed by the University of Iowa, Department of Health Management and Policy, and the Oklahoma Foundation for Medical Quality. The survey has been pretested with participants representing various levels of hospital leadership.

This questionnaire should not be used or cited by any individual or organization for any purpose without written permission. If you have any questions about the document, please contact either of the following:

Barry R. Greene, Ph.D. Shannon Archer, RN, CPHQ

Professor and Head HI QIOSC

Dept. of Health Management & Policy Oklahoma Foundation for Medical

College of Public Health Quality

University of Iowa 14000 Quail Springs Parkway

E212 GH Oklahoma City, OK

Iowa City, IA 52242-1008 sarcher@okqio.sdps.org

barry-greene@uiowa.edu 405-840-2891, ext. 294

Phone: 319-384-5135

Fax: 319-384-5125

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-XXXX. The time required to complete this information collection is estimated to average ( XX hours) or (XX 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.

Hospital Leadership and Quality Assessment Tool©

SURVEY INSTRUCTIONS

In this survey, the term hospital leadership refers to the Chief Executive Officer/top executive, the Chief Medical Officer/top physician leader, the Chief Financial Officer/top finance executive, the Chief Nursing Officer/top nursing leader, and other senior executive leaders and directors.

Hospitals differ in their organizational structure. Please answer the survey questions from your individual perspective, given your position in your hospital organization.

SECTION A: Your Board

1. The term Board refers to your hospital’s Governing Board or Board of Trustees. If your hospital operates under only a systemwide Board, or if you are more familiar with the systemwide Board, please answer about your systemwide Board. For questions that specifically refer to Board activities, indicate which Board you will be thinking about in the survey. (Mark only one)

a. Hospital Board

b. Systemwide Board

SECTION B: Knowledge Seeking

1. During the past 12 months, how often did hospital leadership seek input about quality and patient safety issues by doing the following activities?

	Not in the past 12 months 	Once or twice in the past 12 months 	Several times in the past 12 months 	Monthly 	More than once a month 	Does Not Apply or Don’t Know 
Conducting community focus groups	1	2	3	4	5	9
Reviewing patient satisfaction data/complaints	1	2	3	4	5	9
Inviting patients/family members to attend Board meetings	1	2	3	4	5	9
Encouraging the sharing of patients’ stories about their experiences in the hospital (in-person stories, letters, or both)	1	2	3	4	5	9
Surveying employees about clinical quality improvement and/or patient safety	1	2	3	4	5	9
Other (Please specify): _____________________________	1	2	3	4	5	9

SECTION B: Knowledge Seeking (continued)

2. During the past 12 months, how often did hospital leadership review the following items?

	Not in the past 12 months 	Once or twice in the past 12 months 	Several times in the past 12 months 	Monthly 	More than once a month 	Does Not Apply or Don’t Know 
Updates on major clinical quality improvement initiatives	1	2	3	4	5	9
Progress toward clinical quality goals	1	2	3	4	5	9
Clinical quality indicators/data	1	2	3	4	5	9
Patient safety data	1	2	3	4	5	9
Risk management issues	1	2	3	4	5	9
Budget information	1	2	3	4	5	9
Employee satisfaction data (e.g., staff turnover)	1	2	3	4	5	9
Physician profiling data (i.e., comparative physician-level data on quality)	1	2	3	4	5	9

3a. During the past 12 months, did any senior executive leaders in this hospital participate in executive walk rounds to discuss quality and safety of care with staff, patients, or families?

1. Yes (Go to Question 3b)

2. No (Go to Section C)

3. Don’t know (Go to Section C)

3b. During the past 12 months, how often did the following persons participate in executive walk rounds to discuss quality and safety of care with staff, patients, or families?

	Not in the past 12 months 	Once or twice in the past 12 months 	Several times in the past 12 months 	Monthly 	More than once a month 	Does Not Apply or Don’t Know 
A member of the Board	1	2	3	4	5	9
The Chief Executive Officer (CEO)/top executive	1	2	3	4	5	9
Chief Medical Officer/top physician leader	1	2	3	4	5	9
Chief Nursing Officer/top nursing leader	1	2	3	4	5	9
Other senior executive leaders	1	2	3	4	5	9

SECTION C: Goals and Priorities
To what extent do the following statements apply in this hospital?
	Not at All 	A little 	Some-what 	A moderate amount 	A lot 	Does Not Apply or Don’t Know 
This hospital’s mission or vision statement contains language that clearly supports a commitment to achieving excellence in:
Clinical quality	1	2	3	4	5	9
Patient safety	1	2	3	4	5	9
Hospital leadership actively solicits input from key departments, individuals, or experts when planning the hospital’s clinical quality improvement goals	1	2	3	4	5	9
Hospital leadership uses clinical quality information to establish clinical quality improvement goals for the hospital	1	2	3	4	5	9
Hospital leadership has an effective mechanism for establishing priorities among potential clinical quality improvement goals	1	2	3	4	5	9
Hospital leadership promotes clinical quality as a top priority	1	2	3	4	5	9
Hospital leadership promotes patient safety as a top priority	1	2	3	4	5	9
This hospital has implemented effective policies and procedures to help achieve its clinical quality improvement goals	1	2	3	4	5	9
This hospital has established measures to evaluate progress toward clinical quality improvement goals	1	2	3	4	5	9
Medical staff have an effective process for incorporating evidence-based medicine into practice standards	1	2	3	4	5	9
The by-laws and/or policies of medical staff support the use of evidence-based medicine protocols	1	2	3	4	5	9
The Board supports public reporting of this hospital’s clinical quality data	1	2	3	4	5	9

SECTION D: Communication about Clinical Quality Improvement
During the past 12 months, how often did the following discussions or communications occur in this hospital?
	Not in the past 12 months 	Once or twice in the past 12 months 	Several times in the past 12 months 	Monthly 	More than once a month 	Does not Apply or Don’t Know 
Senior executive leaders discussed hospital quality data with staff reporting to them	1	2	3	4	5	9
Physician leaders, both administrative and clinical, discussed hospital-level quality data with medical staff	1	2	3	4	5	9
Physician leaders, both administrative and clinical, discussed external clinical benchmarking (comparative) data with medical staff	1	2	3	4	5	9
Clinical leaders at the department level discussed hospital quality data with staff reporting to them	1	2	3	4	5	9
Clinical leaders at the department level discussed external benchmarking (comparative) data with staff reporting to them	1	2	3	4	5	9
Clinical leaders at the department level communicated clinical quality improvement goals to staff reporting to them	1	2	3	4	5	9

SECTION E: Collaboration

To what extent do the following statements apply in this hospital?
	Not at All 	A little 	Some-what 	A moderate amount 	A lot 	Does Not Apply or Don’t Know 
The Board and the Chief Medical Officer/top physician leader collaborate on clinical quality improvement	1	2	3	4	5	9
The Board and medical staff (other than the top physician leader) collaborate on clinical quality improvement	1	2	3	4	5	9
The Chief Medical Officer/top physician leader in this hospital collaborates with:	1	2	3	4	5	9
The Board, to address clinical quality issues concerning physician practice	1	2	3	4	5	9
Other senior executive leaders, to address clinical quality issues in this hospital	1	2	3	4	5	9
The top nursing leader, to address clinical quality issues in this hospital	1	2	3	4	5	9

SECTION F: Roles and Responsibilities
How much do you agree or disagree with the following statements?
	Strongly Disagree 	Disagree 	Neither Agree nor Disagree 	Agree 	Strongly Agree 	Does Not Apply or Don’t Know 
Senior executive leaders are assigned responsibility for major clinical quality improvement initiatives	1	2	3	4	5	9
Senior executive leaders assigned responsibility to work on quality improvement initiatives have the authority to initiate actions to address gaps in clinical quality	1	2	3	4	5	9
The responsibilities of individual Board members, as these relate to hospital clinical quality, are clearly defined	1	2	3	4	5	9
New Board members are given adequate orientation regarding their clinical quality improvement responsibilities	1	2	3	4	5	9
Physician champions are identified to promote and lead new clinical quality improvement initiatives	1	2	3	4	5	9
Physician champions are supported in their role by the Chief Medical Officer/top physician leader	1	2	3	4	5	9
Clinical leaders in this hospital initiate actions to deal with quality issues in clinical practice	1	2	3	4	5	9
The following persons are effective champions for clinical quality improvement initiatives in this hospital:
Chief Executive Officer/top executive leader	1	2	3	4	5	9
Chief Medical Officer/top physician leader	1	2	3	4	5	9
Chief Financial Officer/top finance executive	1	2	3	4	5	9
Chief Nursing Officer/top nursing leader	1	2	3	4	5	9

SECTION G: Monitoring/Evaluation
During the past 12 months, how often did the following occur in this hospital?
	Not in the past 12 months 	Once or twice in the past 12 months 		Several times in the past 12 months 		Monthly 	More than once a month 	Does Not Apply or Don’t Know 
Clinical quality improvement initiatives in this hospital were evaluated to assess their effectiveness	1	2		3		4	5	9
Clinical quality improvement initiatives in this hospital were evaluated to assess their sustainability	1		2		3	4	5	9
This hospital provided medical staff with feedback on their individual performance on clinical quality indicators	1		2		3	4	5	9
This hospital provided medical staff with reports comparing their individual performance on clinical quality indicators with their peers’ performance	1		2		3	4	5	9
Hospital leadership followed up on opportunities and concerns raised during their executive walk rounds	1		2		3	4	5	9
Hospital leadership performed a cost/benefit analysis of the impact of this hospital’s clinical quality improvement initiatives	1		2		3	4	5	9
Hospital leadership evaluated improvement by comparing its clinical quality data with data from other hospitals	1		2		3	4	5	9
The Board completed a self-evaluation regarding effectiveness of Board actions to improve clinical quality	1		2		3	4	5	9
The Board has had an external evaluation of effectiveness of its actions with regard to clinical quality	1		2		3	4	5	9

SECTION H: Rewards/Compensation

How much do you agree or disagree with the following statements?
	Strongly Disagree 	Disagree 	Neither Agree nor Disagree 	Agree 	Strongly Agree 	Does Not Apply or Don’t Know 
This hospital recognizes clinical staff who demonstrate a strong commitment to clinical quality	1	2	3	4	5	9
This hospital rewards clinical staff who demonstrate a strong commitment to clinical quality	1	2	3	4	5	9
Physician performance on specific clinical quality indicators is used to make decisions regarding privileging and recredentialing	1	2	3	4	5	9
Performance expectations that support the hospital’s clinical quality goals are built into performance evaluation criteria for the following persons
a. Hospital leadership	1	2	3	4	5	9
b. Front-line clinical staff	1	2	3	4	5	9

SECTION I: Resource Support for Clinical Quality Improvement
How much do you agree or disagree with the following statements?
	Strongly Disagree 	Disagree 	Neither Agree nor Disagree 	Agree 	Strongly Agree 	Does Not Apply or Don’t Know 
Sufficient staff are available to provide care that meets the organization’s expectations for quality	1	2	3	4	5	9
This hospital’s annual operating budget includes specific funding for clinical quality improvement activities	1	2	3	4	5	9
Leaders of clinical quality improvement initiatives are able to receive sufficient funds for their improvement activities	1	2	3	4	5	9
Adequate time is dedicated/allocated to quality improvement activities in this hospital	1	2	3	4	5	9
This hospital has all the experts it needs to support clinical quality improvement	1	2	3	4	5	9

SECTION J: Education and Training

1. To what extent are the following persons provided with formal education and training in clinical quality improvement?
	Not at All 	A little 	Some-what 	A moderate amount 	A lot 	Does Not Apply or Don’t Know 
Board members	1	2	3	4	5	9
Chief Executive Officer/top executive	1	2	3	4	5	9
Chief Medical Officer/top physician leader	1	2	3	4	5	9
Chief Nursing Officer/top nursing leader	1	2	3	4	5	9
Other senior executive leaders	1	2	3	4	5	9
Other physician leaders (administrative or clinical)	1	2	3	4	5	9

SECTION K: Nonpunitive Culture

How much do you agree or disagree with the following statements?
	Strongly Disagree 	Disagree 	Neither Agree nor Disagree 	Agree 	Strongly Agree 	Does Not Apply or Don’t Know 
In this hospital, patient care errors made by staff are dealt with in a just (fair and reasonable) manner	1	2	3	4	5	9
This hospital supports a nonpunitive response to staff errors in the following ways:
Policies outline how staff errors are investigated and handled	1	2	3	4	5	9
Patient care errors are disclosed to patients and families	1	2	3	4	5	9
Errors (not due to outright negligence or criminal intent) are viewed as opportunities for staff education and performance improvement	1	2	3	4	5	9

SECTION L: Public Reporting/Transparency

1. This hospital shares its clinical performance data in the following ways (e.g., data for quality

of care provided to patients with heart attack, heart failure, pneumonia):

	Yes 	No 	Does Not Apply or Don’t Know 
Submits data for the CMS Hospital Compare web site	1	2	9
Participates in State hospital public reporting activities	1	2	9
Posts the data on the hospital’s public web site (Internet)	1	2	9
Posts the data on the hospital’s intranet (internal web site)	1	2	9
Includes the data in Board reports	1	2	9
Presents the data at hospital department meetings	1	2	9
Makes the data available to hospital staff	1	2	9

SECTION M: Clinical Management Tools and Techniques and Processes

To facilitate and/or coordinate the safety and quality of patient care between caregivers, this hospital uses:

	Not at All 	A little 		Some-what 	A moderate amount 	A lot 	Does Not Apply or Don’t Know 
Clinical tools
Clinical guidelines (protocols)	1	2		3	4	5	9
Clinical pathways Clinical	1	2		3	4	5	9
Standing orders	1	2		3	4	5	9
Preprinted or computer-generated order sets	1	2		3	4	5	9
Preprinted or computer-generated diagnosis specific discharge instructions	1	2		3	4	5	9
Benchmarking (comparative analysis on clinical performance)	1	2		3	4	5	9
Other (Please specify): _____________________	1	2		3	4	5	9
2. Clinical techniques and processes
Team clinical rounds at the bedside	1	2	3		4	5	9
Multidisciplinary integrated progress notes	1	2	3		4	5	9
Concurrent review of quality indicators by case managers	1	2	3		4	5	9
Rapid response teams	1	2	3		4	5	9
Other (Please specify): _______________________________	1	2	3		4	5	9

SECTION N: Overall Quality Ratings

1. How much do you agree or disagree that this hospital devotes adequate resources to quality improvement? (Mark one)

a. Strongly disagree

b. Disagree

c. Neither Agree Nor Disagree

d. Agree

e. Strongly agree

2. To what extent do you think there is a commitment to quality throughout the organization? (Mark one)

a. Not at all

b. A little

c. Somewhat

d. A moderate amount

e. A lot

3. To what extent do you think that quality improvement in your hospital is a success? (Mark one)

a. Not at all

b. A little

c. Somewhat

d. A moderate amount

e. A lot

Section O: Your Comments

P

lease feel free to write any comments you may have about clinical quality improvement in your hospital.

Thank you for your participation!