CMS-10550 Standardized Hospital National Provider Survey

Attachment XIII. — Standardized Hospital National Provider Survey

Hospital National Provider Survey for the

National Impact Assessment of CMS Quality and Efficiency Measures

Version 2.0

October 1, 2014

ACKNOWLEDGMENTS

This survey is being developed/prepared under contract to the

Centers for Medicare & Medicaid Services (CMS) by

Health Services Advisory Group, Inc. (HSAG) and

The RAND Corporation

1776 Main Street

Santa Monica, CA 90401

The survey may not be circulated or used without permission from CMS, HSAG, and the RAND Corporation. All questions related to the development or use of this survey should be sent to Beverly Weidmer of the RAND Corporation at Beverly_Weidmer@rand.org or Kyle Campbell of HSAG at kcampbell@hsag.com.

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-NEW. The time required to complete this information collection is estimated to average 40 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.

DEFINITION OF KEY TERMS IN THIS SURVEY

CMS quality and efficiency measures: Measures of clinical processes and outcomes, patient experience with care, patient safety, resource use or cost of care, and structural measures (such as hospital’s use of clinical database registries). These measures are reported by hospitals to the Centers for Medicare & Medicaid Services (CMS) and information on the measures can be found at https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/HospitalQualityInits/HospitalRHQDAPU.html and at https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/HospitalQualityInits/HospitalOutpatientQualityReportingProgram.html.

Measures address care provided in the inpatient and outpatient settings, including emergency department services, observation services, outpatient surgical services, lab tests, and X-rays.

Accountable Care Organizations (ACO): ACOs are networks of healthcare providers and organizations (usually hospitals and ambulatory care physician groups, and possibly including nursing homes, home health, and hospice organizations) that agree to take some financial responsibility for reducing the costs and improving the quality of care for a defined patient population.

Clinical decision support (CDS): CDS encompasses a variety of tools to enhance decision-making in the clinical workflow. These tools include computerized alerts and reminders to care providers and patients; clinical guidelines; condition-specific order sets; focused patient data reports and summaries; documentation templates; diagnostic support; and contextually relevant reference information, among other tools.”¹

Culture of safety: Organizations with a positive safety culture are characterized by communications founded on mutual trust, by shared perceptions of the importance of safety, and by confidence in the efficacy of preventive measures.

Integrated Delivery System (IDS): An IDS is an integrated network of healthcare providers and organizations such as hospital, primary and specialty care, nursing home, rehabilitation, home health care, and hospice that provides or arranges to provide a coordinated continuum of services to a defined population. It may own or be closely aligned with an insurance product, usually a form of managed care.

Lean/Six Sigma Engineering: Redesign or re-engineering concepts that were originally developed to increase the efficiency of production and reduction of errors within manufacturing companies. Lean/Six Sigma has been adopted by healthcare organizations to identify problems or inefficiencies and take actions to address these issues. “Lean” and “Six Sigma” emphasize focusing on customer satisfaction, problem solving and elimination of waste, and involving employees in identifying and resolving the problem.

Learning Organization: An organization that encourages and supports continuous employee learning, critical thinking, and risk-taking with new ideas.

Plan, Do, Study Improvement Cycles (PDSA): PDSA is a tool that is used for accelerating quality improvement that involves developing a plan to test the change (Plan), carrying out the test (Do), observing and learning from the consequences (Study), and determining what modifications should be made to the test (Act).

Situation Background Assessment Recommendation (SBAR): SBAR is a standardized way of communicating that promotes patient safety by helping individuals communicate with each other with a shared set of expectations. Staff and physicians can use SBAR to share patient information in a concise and structured format.

YOUR HOSPITAL’S EXPERIENCE WITH CMS MEASURES

1. In the last 12 months, has your hospital’s performance on CMS measures...

¹ Improved across the board on all measures

² Improved on some measures but not on others

³ Approximately stayed the same

⁴ Declined on some measures but not on others

⁵ Declined across the board on all measures

2. In your opinion, how well does your hospital’s performance on the CMS measures reflect the improvements in care that your hospital makes?

¹ Very well

² Somewhat well

³ Not well at all

3. Thinking about the full list of CMS hospital measures, do you think the CMS measures are clinically important?

¹ Yes

² Mostly yes

³ Mostly no

⁴ No

4. Do you think hospitals should be held responsible for performance on the CMS measures?

¹ Yes

² Mostly yes

³ Mostly no

⁴ No

5. Have you experienced difficulties with improving performance on any of the CMS measures?

¹ Yes on many of the measures

² Yes on some of the measures

³ No  If “No,” go to question 8

6. Based on your hospital’s experience, is it more difficult to improve on certain types of measures than on others? Such as….

(Mark one in each row)

1. Clinical process measures (for example: Thrombolytic Yes No

Therapy for patients with stroke [STK-4])

2. Patient outcomes measures (for example: Acute Yes No

Myocardial Infarction (AMI) 30-Day Mortality Rate (MORT-30-AMI)
or Hospital-Level Risk-Standardized Complication Rate (RSCR)
following Elective Primary Total Hip Arthroplasty (THA) and Total
Knee Arthroplasty (TKA))

3. Resource use measures (for example: OP-13: Cardiac Imaging Yes No

for Preoperative Risk Assessment for Non-Cardiac Low-Risk Surgery)

4. Patient Experience measures (for example: HCAHPS Survey results) Yes No

5. Patient Safety measures (for example: Central-Line Associated Yes No

Bloodstream Infection (CLABSI))

6. Hospital Acquired Conditions (for example: foreign object retained Yes No
   after surgery, air embolism, stage III and IV pressure ulcers, catheter-
   associated urinary tract infection [UTI], vascular catheter-associated
   infection, surgical site infection, deep vein thrombosis
   [DVT]/pulmonary embolism [PE])

7. Measures of hospital readmission within 30 days from hospital Yes No
   discharge, for Acute Myocardial Infarction (AMI), Heart Failure
   (HF) and Pneumonia (PN)

7. Have any of the following contributed to your hospital’s difficulties with improving performance on the CMS measures?

(Mark one in each row)

1. Difficulty identifying improvement strategies Yes No

2. Difficulty implementing improvement strategies Yes No

3. Difficulty identifying processes of care that lead to Yes No

improved patient outcomes

4. Difficulty getting front-line clinicians to change behavior to improve Yes No

performance

5. Insufficient resources (e.g., staffing, tools, training) Yes No

6. Inadequate Health Information Technology (IT) resources and Yes No

capabilities (e.g., clinical decision support or longitudinal tracking of

outcomes)

7. Staff turnover Yes No

8. Lack of senior leadership support Yes No

9. Lack of sufficient support from physicians or other clinical staff Yes No

10. Lack of sufficient time for physicians or
    other clinical staff to participate Yes No

11. Difficulty with coding or documentation (e.g., lack of consistency Yes No

across staff, insufficient documentation)

12. Lack of training on improvement processes Yes No

13. A difficult patient mix (i.e., low socioeconomic status,
    clinically complex) Yes No

14. Culture that does not support improvement efforts Yes No

15. Other reason (please specify: _______________________________) Yes No

INNOVATIONS IN THE DELIVERY OF CARE

8. We are interested in understanding what changes your hospital has made in the way care is being delivered to improve its quality performance. Has your hospital made any of the following changes in order to improve performance on the CMS measures?

Type of Change or Innovation	Has this change or innovation been made in your hospital?	If change was made, has it helped improve your hospital’s performance on one or more CMS measures?
a. Adopted practices to become a “learning organization.”	☐Yes ☐No	☐Yes, definitely ☐Yes, somewhat ☐No ☐Don’t know/Not sure
b. Implemented a “culture of safety.”	☐Yes ☐No	☐Yes, definitely ☐Yes, somewhat ☐No ☐Don’t know/Not sure
c. Implemented an electronic health record (EHR).	☐Yes ☐No	☐Yes, definitely ☐Yes, somewhat ☐No ☐Don’t know/Not sure
d. Implemented electronic tools to support frontline clinical staff, such as clinical decision support, condition-specific electronic alerts, or automated prompts.	☐Yes ☐No	☐Yes, definitely ☐Yes, somewhat ☐No ☐Don’t know/Not sure
e. Implemented risk prediction tools to identify and manage high-risk patients.	☐Yes ☐No	☐Yes, definitely ☐Yes, somewhat ☐No ☐Don’t know/Not sure
f. Implemented an electronic health information system that shares key patient information with providers in the community (e.g., nursing homes and ambulatory care providers).	☐Yes ☐No	☐Yes, definitely ☐Yes, somewhat ☐No ☐Don’t know/Not sure
g. Implemented standardized care protocols or checklists.	☐Yes ☐No	☐Yes, definitely ☐Yes, somewhat ☐No ☐Don’t know/Not sure
h. Implemented appropriateness criteria to guide physician decision making for selected procedures, imaging studies, or tests.	☐Yes ☐No	☐Yes, definitely ☐Yes, somewhat ☐No ☐Don’t know/Not sure

Type of change or innovation	Has this change or innovation been made in your hospital?	If change was made, has it helped improve your hospital’s performance on one or more CMS measures?
i. Implemented a post-discharge continuity of care program to prevent readmissions.	☐Yes ☐No	☐Yes, definitely ☐Yes, somewhat ☐No ☐Don’t know/Not sure
j. Developed a system for tracking patient outcomes.	☐Yes ☐No	☐Yes, definitely ☐Yes, somewhat ☐No ☐Don’t know/Not sure
k. Adopted care redesign/re-engineering (e.g., Deming/ Lean Engineering, Six Sigma, Plan, Do, Study, Act (PDSA) improvement cycles).	☐Yes ☐No	☐Yes, definitely ☐Yes, somewhat ☐No ☐Don’t know/Not sure
l. Provided training to physicians and/or nurses on quality improvement strategies.	☐Yes ☐No	☐Yes, definitely ☐Yes, somewhat ☐No ☐Don’t know/Not sure
m. Provided routine feedback on your hospital’s performance on CMS measures to physicians and other clinical staff.	☐Yes ☐No	☐Yes, definitely ☐Yes, somewhat ☐No ☐Don’t know/Not sure
n. Used performance on CMS measures as a basis for determining pay for physicians or other clinical staff.	☐Yes ☐No	☐Yes, definitely ☐Yes, somewhat ☐No ☐Don’t know/Not sure
o. Implemented an internal incentive or bonus program for senior leaders and/or senior management based on performance on CMS measures.	☐Yes ☐No	☐Yes, definitely ☐Yes, somewhat ☐No ☐Don’t know/Not sure
p. Gave hospital staff awards or other special recognition tied to quality performance.	☐Yes ☐No	☐Yes, definitely ☐Yes, somewhat ☐No ☐Don’t know/Not sure

Type of change or innovation	Has this change or innovation been made in your hospital?	If change was made, has it helped improve your hospital’s performance on one or more CMS measures?
q. Increased the number of staff dedicated to quality improvement or quality management. ☐Yes ☐No	☐Yes ☐No	☐Yes, definitely ☐Yes, somewhat ☐No ☐Don’t know/Not sure
r. Identified Physician/Nurse champions for quality improvement initiatives or projects.	☐Yes ☐No	☐Yes, definitely ☐Yes, somewhat ☐No ☐Don’t know/Not sure
s. Implemented quality improvement initiatives targeted to specific CMS measures.	☐Yes ☐No	☐Yes, definitely ☐Yes, somewhat ☐No ☐Don’t know/Not sure
t. Obtained technical assistance from CMS (i.e., a CMS Quality Improvement Organization) or from private organizations (e.g., quality improvement collaboratives, consulting firms) in collecting and reporting performance measures.	☐Yes ☐No	☐Yes, definitely ☐Yes, somewhat ☐No ☐Don’t know/Not sure
u. Implemented interdisciplinary rounds or team “huddles” or formation of multi-specialty patient care teams.	☐Yes ☐No	☐Yes, definitely ☐Yes, somewhat ☐No ☐Don’t know/Not sure
v. Implemented or changed communication protocols to support or improve collaboration among clinicians and staff (i.e., Situation Background Assessment Recommendation (SBAR), hand off or paging protocols, etc.)	☐Yes ☐No	☐Yes, definitely ☐Yes, somewhat ☐No ☐Don’t know/Not sure
w. Implemented changes to how nursing staff is deployed (e.g., change in staffing levels or work hours, use of contract or contingent staff)	☐Yes ☐No	☐Yes, definitely ☐Yes, somewhat ☐No ☐Don’t know/Not sure
x. Other change or innovation. Please specify: __________________________	☐Yes ☐No	☐Yes, definitely ☐Yes, somewhat ☐No ☐Don’t know/Not sure

9. Have the changes your hospital has made in response to the CMS measures led to improvements in areas of care not measured by CMS?

¹ Yes

² No  If “No,” go to question 11

³ Don’t know

10. Has your hospital measured or documented the actual improvements in the areas of care not measured by CMS?

¹ Yes

² No

CHALLENGES TO REPORTING THE CMS MEASURES

11. Has your hospital experienced difficulties in reporting the CMS measures?

¹ Yes

² No  If “No,” go to question 13

12. Which of the following reasons have contributed to your hospital’s difficulties in reporting CMS measures?

(Mark all that apply)

¹ Difficulty capturing the data needed for measure construction

² Difficulty extracting the data from the EHR or other data systems/registries

³ Difficulty interpreting measure specifications

⁴ Insufficient or inadequate staffing or other resources

⁵ Challenges with CMS reporting tools or interface

⁶ Other reason (please specify: _________________________________)

FACTORS ASSOCIATED WITH CHANGE IN QUALITY PERFORMANCE

13. There are many factors that influence a hospital’s decision to invest in efforts to improve its quality performance. Please rank the importance of each of the following factors in your hospital’s decision to invest in quality improvement efforts for CMS measures.

(Please rank by order of importance where 1 is the most important and 4 is the least important)

_____ a. Potential to receive financial incentives for improved performance (i.e., pay for performance)

_____ b. Threat of financial penalties for low performance (e.g., non-payment for hospital readmissions within 30 days or for hospital-acquired infections)

_____ c. Public reporting of your hospital’s performance results on the CMS Hospital Compare website

_____ d. Participation in alternative payment models (e.g., ACOs, bundled payment arrangements) where there is an opportunity for shared reward (savings) and shared financial risk

14. Many different factors may help a hospital improve their performance. Please rank the top 3 factors that have helped your hospital improve performance on some or all of the CMS measures.

Mark here if your hospital has had no improvement on any CMS measures  Go to question 15

(Rank order the 3 most important from 1-3. Assign 1 to the most important factor, 2 to the next most important factor, and 3 to the next most important factor.)

______a. Your hospital’s organizational culture

______b. Hospital leadership support and engagement

______c. Effective relationship between management and staff

______d. Having dedicated resources for quality improvement

______d. Internal incentives tied to performance on CMS measures

______f. Internal accountability for performance on CMS measures

______g. Having strong data systems

______h. Providing feedback to clinical and nursing staff on performance on CMS measures

______i. Having a system-wide focus on quality and quality improvement

______j. Networking with other hospitals and health systems to identify elements of high-performing organizations

______k. Investments in care redesign or re-engineering

______l. Investments in patient safety

______m. Other (please specify:________________________________________)

UNDESIRED EFFECTS OF CMS QUALITY MEASUREMENT PROGRAMS

The use of quality and efficiency measures may potentially result in undesired effects. The next questions ask about your hospital’s knowledge of or experience with undesired effects of the CMS measures and their use in public reporting and pay for performance. All of the responses you provide are confidential and are intended to help CMS in modifying reporting programs so as to avoid the programs’ causing undesired effects. Your candid feedback is important in helping CMS improve these programs so that they work well for providers and their patients.

15. Has your hospital observed any undesired effects stemming from using or reporting CMS measures?

¹ Yes, definitely

² Yes, somewhat

³ No

16. In your opinion, do you think any of the following has occurred in your hospital as a result of your hospital being held accountable for performance on CMS measures?

(Mark one in each row)

1. Fewer resources for quality improvement in areas of clinical Yes No

care that are not the focus of CMS performance measures

2. Focus on narrow improvement for specific measures rather Yes No

than across the board improvement in care

3. Overtreatment of patients to ensure that a measure is met Yes No

4. Increased focus on documentation or coding of data to attain
   a higher score Yes No

5. Changing coding of data or documentation to ensure that
   a measure is met Yes No

6. Avoiding sicker or more challenging patients when
   providing care Yes No

The next questions ask about other hospitals’ experience with undesired effects of the CMS measures and their use in public reporting and pay for performance.

17. To your knowledge, have other hospitals observed any undesired effects stemming from the CMS measures and their use in public reporting and for payment/value-based purchasing?

¹ Yes, definitely

² Yes, somewhat

³ No

⁴ Don’t know

18. To your knowledge, have any of the following occurred in other hospitals as a result of being held accountable for performance on CMS measures?

(Mark one in each row)

a. Fewer resources for quality improvement in areas of clinical Yes No Don’t know care that are not the focus of CMS performance measures

b. Focus on narrow improvement for specific measures rather Yes No Don’t know than across the board improvement in care

c. Overtreatment of patients to ensure that a measure is met Yes No Don’t know

d. Increased focus on documentation or coding of data to Yes No Don’t know attain a higher score

e. Changing coding of data or documentation to ensure that Yes No Don’t know
a measure is met

f. Avoiding sicker or more challenging patients when Yes No Don’t know

providing care

PERSPECTIVES OF HOSPITAL LEADERSHIP AND OTHER STAKEHOLDERS

19. How often do meetings of your hospital’s board include a review and discussion of the hospital’s performance on the CMS measures?

(Mark one)

¹ More than four times per year

² Quarterly

³ Twice per year

⁴ Annually

⁵ Less than once per year

20. Which of the following best describes your hospital’s board?

(Mark one)

¹ Board is more engaged in financial performance issues than quality performance issues.

² Board is equally engaged in financial performance issues and quality performance issues.

³ Board is more engaged in quality performance issues than financial performance issues.

21. On a scale from 0 to 10, where 0 is not at all supportive and 10 is extremely supportive, how would you describe the hospital board of director’s support of your hospital’s efforts to improve performance on CMS measures?

0 – Not at all supportive

1

2

3

4

5

6

7

8

9

10 – Extremely supportive

22. On a scale from 0 to 10, where 0 is not at all supportive and 10 is extremely supportive, how would you describe the hospital leadership’s (e.g., the C-Suite executive management) support of your hospital’s efforts to improve performance on CMS measures?

0 – Not at all supportive

1

2

3

4

5

6

7

8

9

10 – Extremely supportive

23. On a scale from 0 to 10, where 0 is not at all and 10 is a great deal, how much does your hospital leadership promote a culture of quality?

0 – Not at all

1

2

3

4

5

6

7

8

9

10 – A great deal

24. On a scale from 0 to 10, where 0 is not at all supportive and 10 is extremely supportive, how would you describe the nursing leadership’s support of your hospital’s efforts to improve performance on CMS measures?

0 – Not at all supportive

1

2

3

4

5

6

7

8

9

10 – Extremely supportive

25. On a scale from 0 to 10, where 0 is not at all supportive and 10 is extremely supportive, how would you describe physicians’ support of your hospital’s efforts to improve performance on CMS measures?

0 – Not at all supportive

1

2

3

4

5

6

7

8

9

10 – Extremely supportive

USE OF HEALTH INFORMATION TECHNOLOGY

These next questions are about your hospital’s use of and outside provider access to Health Information Technology.

26. Does your hospital have an electronic health record (EHR)?

¹ Yes

² No  If “No,” go to question 32

27. Is your hospital’s EHR able to exchange information electronically with all departments in the hospital?

¹ Yes

² No

28. Are health providers in your community (i.e., ambulatory care physicians, nursing homes) able to access your hospital’s EHR or health information system to obtain key clinical data on patients?

¹ Yes, all key clinical data

² Yes, some key clinical data

³ No  If “No,” go to question 30

29. Which of the following types of information are health providers in your community (i.e., ambulatory care physicians, nursing homes) able to access electronically through your hospital’s EHR or health information system?

(Mark one in each row)

a. Diagnostic/treatment summary Yes No

b. Discharge instructions Yes No

c. Lab tests/Imaging results Yes No

d. Prescribed medications Yes No

30. Is your hospital able to electronically access information on patients from other providers in your community (i.e., ambulatory care physicians, nursing homes)?

¹ Yes, for all or most patients

² Yes, for some patients

³ No

31. Does your hospital’s EHR have an interface or other tools that help with…

(Mark one in each row)

a. Medication tracking and reconciliation? Yes No

b. Evidence-based treatment or clinical decision support? Yes No

c. Collection of CMS measures? Yes No

d. Reporting of CMS measures? Yes No

e. Tracking or monitoring of quality of care Yes No

and/or patient outcomes?

32. Not including an EHR, does your hospital use any other software or electronic tools that help with...

(Mark one in each row)

a. Collection of CMS measures? Yes No

b. Reporting of CMS measures? Yes No

CHARACTERISTICS OF YOUR HOSPITAL

These next questions will help us to describe the hospitals that participate in this survey.

33. Is your hospital affiliated with a hospital system?

¹ Yes

² No

34. Is your hospital part of an integrated delivery system?²

¹ Yes

² No

35. How many competitor hospitals exist within your hospital’s service area?

¹ 0

² 1

³ 2

⁴ 3

⁵ 4

⁶ 5

⁷ 6 or more

36. Compared to your competitors, how well does your hospital perform on the CMS quality and efficiency measures?

¹ Better

² About the same

³ Worse

⁴ Don’t know

37. Do you face a shortage of physicians in your area?

¹ Yes

² No

38. Are most of the physicians who practice in your hospital employees or are they independent contractors?

¹ Most physicians are employees

² Most physicians are independent contractors

39. Do you face a shortage of nurses in your area?

¹ Yes

² No

40. Does your hospital participate in any of the following types of Accountable Care Organizations (ACOs)?

(Mark one in each row)

a. Medicare Shared Savings Program Yes No

b. Medicare Pioneer ACO Yes No

c. Medicare’s Advanced Payment Model ACO Yes No

d. Medicaid ACO Yes No

e. A private, commercially insured ACO arrangement Yes No

(within an HMO or PPO)

41. Is your hospital participating in any other type of alternative payment model that may have shared savings or shared risk (e.g., global budgets, bundled payments for selected procedures)?

¹ Yes

² No

42. Does your hospital participate in other non-CMS quality and efficiency measure reporting programs sponsored by:

(Mark one in each row)

a. Medicaid Yes No

b. The state where you hospital is located Yes No

3. Commercial insurers Yes No

4. Employer or multi-stakeholder collaboratives Yes No

43. Across your hospital’s entire book of business, approximately what percentage of your patients is comprised of…?

(Please provide your best estimate. Your estimates should add to 100%)

__________% Medicare only patients

__________% Medicaid only or Dual eligible (Medicare and Medicaid) patients

__________% Commercially-insured patients

__________% Private-pay patients

__________% Uninsured patients

RESPONDENT BACKGROUND

44. Which of the following best describes your job title or position within this hospital?

(Mark one)

¹ Chief Executive Officer

² Chief Medical Officer

³ Chief Nursing Officer

⁴ Senior leader responsible for quality of clinical care (e.g., VP for Quality)

⁵ Member of a team responsible for measuring and reporting quality of clinical care

⁶ Some other role (Please specify: ________________________________)

45. How many years have you been in your current position within this hospital?

¹ Less than one year

² One to three years

³ More than 3 years

46. Are you a physician?

¹ Yes (please specify Specialty:______________________________________)

² No

47. Did anyone else help you complete this survey?

¹ Yes

² NoThank you for completing this survey!

48. What is the job title or position of the other person or persons who helped you complete the survey?

Thank you for taking the time to complete the survey.

Please make a copy for your file and send the original back to the [VENDOR NAME] in the pre-paid envelope to:

[INSERT VENDOR ADDRESS HERE]

1 Source: http://www.healthit.gov/policy-researchers-implementers/clinical-decision-support-cds

2 An Integrated Delivery System (IDS) is a network of health care providers and organizations (i.e., hospital, primary and specialty care, rehabilitation, home health care, hospice) that provides or arranges to provide a coordinated continuum of services to a defined population. It may own or be closely aligned with an insurance product, usually a form of managed care.

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