Form CMS-10315 Nursing Home In Need (NHIN) Survey

CENTERS FOR MEDICARE & MEDICAID SERVICES

Survey Management, Analysis, Reporting, and Technical Support

Attachment 2

Nursing Homes in Need Survey

The questionnaire that follows maps to the following reporting sub-composites:

Satisfaction with the QIO Questions C4, C6, C7, C8, 10

Value - does the provider perceive value in the QIO’s interventions?

Root Cause Analysis Question B3

Action Plan Questions B7, B8

Across All interventions and Assistance Questions D1, D2, D3, D4

Other data not rolled up into composite score but required for analysis:

Background information Questions A1, A2, A3

Current work

About Root Cause Analysis and Action Plans Questions B1, B2, B5, B6

Methods used to assist practices Questions C2, C3

Other information about the assistance/intervention

Usefulness Question C1

Frequency of contact Question C5

Ease of access Question C9

Sources of information Questions E1, E2, E3

Open ended comment Questions B4, B9, F1

NOTE: THESE SCORING PARAMETERS WILL NOT APPEAR ON THE FINAL SURVEY

SECTION A: Background Information

1. How long have you been the main contact for the QIO?

• Less than 3 months

• 3 months to less than 6 months

• 6 to 12 months

• More than 12 months

2. What is your job title? _________________________________________________________

A3. What is the size of your nursing home?

• Less than 50 beds

• 50-99 beds

• 100-199 beds

• 200 or more beds

SECTION B: Current Work with The QIO

1. Are you familiar with the root cause analysis (RCA) performed by {QIO NAME} for your facility?

• Yes

• No → Please Go to Question C1

2. Which of the following issues were addressed in the RCA? Please check all that apply.

• Management capabilities, e.g., corporate, facility and the relationship between the two

• Financial capabilities, e.g., fiscal structure and controls

• Staffing, e.g., level of staffing, skills/education, recruitment and retention

• Procedures and processes of care, e.g., adequacy, correlation between admission policy and staff capabilities

• Communication, e.g., among management and staff, and staff to staff

• Processes of care and outcomes for reducing pressure ulcers

• Processes of care and outcomes for reducing use of physical restraints

3. Did the RCA appropriately identify the key areas in which you could improve? Would you…

• Strongly Agree

• Somewhat Agree

• Neither Agree Nor Disagree

• Somewhat Disagree

• Strongly Disagree

4. Please give us your comments on the RCA

5. Are you familiar with the Action Plan to address issues in the RCA that {QIO NAME} developed for your facility?

• Yes

• No → Please Go to Question C1

6. Which of the following issues were addressed in the RCA? Please check all that apply.

• Management capabilities, e.g., corporate, facility and the relationship between the two

• Financial capabilities, e.g., fiscal structure and controls

• Staffing, e.g., level of staffing, skills/education, recruitment and retention

• Procedures and processes of care, e.g., adequacy, correlation between admission policy and staff capabilities

• Communication, e.g., among management and staff, and staff to staff

• Processes of care and outcomes for reducing pressure ulcers

• Processes of care and outcomes for reducing use of physical restraints

7. Did the Action Plan correctly identify the areas in which you most needed improvement? Would you…

• Strongly Agree

• Somewhat Agree

• Neither Agree Nor Disagree

• Somewhat Disagree

• Strongly Disagree

8. Was the Action Plan effective in improving quality at your facility? Would you…

• Strongly Agree

• Somewhat Agree

• Neither Agree Nor Disagree

• Somewhat Disagree

• Strongly Disagree

9. Please give us your comments on the Action Plan

SECTION C

This section asks about how your received assistance from your QIO and your satisfaction with the assistance.

1. Thinking about all the information you received from the QIO, {QIO NAME}, how useful was the information you received? Would you say it was …

• Very Useful

• Useful

• Somewhat Useful

• Not Useful At All

2. Through which of the following methods of communication have you received information or assistance from {QIO NAME}?

	Yes	No
Site visits		
Training workshops, seminars or conferences		
One-to-one telephone communication		
Telephone conference calls		
Email		
From the QIO’s website		
Other:		
Please describe ____________________________________

3. Of these methods, which one method do you prefer?

___________________________________________

4. Thinking about all the ways through which you received information about quality improvement projects from the QIO, how satisfied or dissatisfied were you with the way in which information was presented to you?

• Very Satisfied

• Somewhat Satisfied

• Neither Satisfied Nor Dissatisfied

• Somewhat Dissatisfied

• Very Dissatisfied

5. Since {DATE}, thinking about all types of interactions, how frequently have you been in contact with {QIO NAME}? Would you say about …

• Once a week or more

• Once every two weeks

• Once per month

• Less than once per month

6. Since {DATE}, how satisfied are you with the amount of contact between your organization and {QIO NAME}? Would you say you are …

• Very Satisfied

• Somewhat Satisfied

• Neither Satisfied Nor Dissatisfied

• Somewhat Dissatisfied

• Very Dissatisfied

7. Thinking about all of the times you have tried to contact the QIO, how satisfied are you with the ease of access to the QIO?

• Very Satisfied

• Somewhat Satisfied

• Neither Satisfied Nor Dissatisfied

• Somewhat Dissatisfied

• Very Dissatisfied

8. How satisfied are you with the timeliness of the QIO’s response to your question or request for assistance? Would you say you are …

• Very Satisfied

• Somewhat Satisfied

• Neither Satisfied Nor Dissatisfied

• Somewhat Dissatisfied

• Very Dissatisfied

9. Thinking about all the times you contacted the QIO, how often were you able to get through to the person you were trying to reach or to someone who could help you?

• Always

• Usually

• Sometimes

• Never

10. Thinking about all interactions with {QIO NAME}, how satisfied are you with your relationship with the QIO overall?

• Very Satisfied

• Somewhat Satisfied

• Neither Satisfied Nor Dissatisfied

• Somewhat Dissatisfied

• Very Dissatisfied

SECTION D

Please indicate your level of agreement with the following statements about the information and assistance provided by the QIO.

1. When implementing our quality improvement projects, we used the information provided by {QIO NAME}. Would you…

• Strongly Agree

• Somewhat Agree

• Neither Agree Nor Disagree

• Somewhat Disagree

• Strongly Disagree

2. The assistance we received from (QIO NAME} was worth the time and effort required on the part of our staff. Would you …

• Strongly Agree

• Somewhat Agree

• Neither Agree Nor Disagree

• Somewhat Disagree

• Strongly Disagree

D3 We were able to implement this intervention because of the assistance from {QIO NAME}? Would you…

• Strongly Agree

• Somewhat Agree

• Neither Agree Nor Disagree

• Somewhat Disagree

• Strongly Disagree

D4. In general, the assistance we received from the QIO was key to the efficient implementation of our quality improvement projects. Would you….

• Strongly Agree

• Somewhat Agree

• Neither Agree Nor Disagree

• Somewhat Disagree

• Strongly Disagree

D5 Using a scale of 1 to 10, where 1 is “The QIO did not contribute at all” and 10 is “The QIO’s contribution was indispensable,” please rate the contribution of the QIO to your quality improvement projects.

1 = The QIO did not contribute at all

10 = The QIO’s contribution was indispensable

	1	2	3	4	5	6	7	8	9	10
										

Please mark the box that corresponds to your rating

SECTION E: Sources of Information

1. Is there an organization that you would prefer to use for quality improvement assistance, rather than the QIO, {QIO NAME}?

• Yes

• No

• It would depend on cost and other factors

• I don’t know

2. What organizations or information sources do you turn to when you need information or assistance for your quality improvement initiatives?

	Yes	No
Centers for Medicare & Medicaid Services (CMS)		
CMS Nursing Home Compare		
{QIO NAME}		
MedQIC		
The Agency for Health Research and Quality (AHRQ)		
The Institute for Health Improvement (IHI)		
The American Health Quality Association (AHQA)		
The National Quality Forum		
Other membership association websites (including AMDA, AAHSA, AHCA, etc.)		
Advancing Excellence in America’s Nursing Homes campaign		
Other:		
Please describe ____________________________________

3. Of these organizations or information sources listed in the previous question, which one organization provides you with the most useful information and assistance?

_________________________________________

COMMENTS

1. Please use the space below to provide additional comments on how you view the services received from the QIO.

Thank you for completing this survey.

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