Form 2 Attachment B: Survey instrument - nonparticipant

Nursing Home Survey – Nonparticipants

BLACK text is presented to respondents.

RED text is for programming.

BLUE text is for annotations within the instrument.

PRE-LOAD VARIABLES:

• Nursing Home Name – nursing home name as available in the network data and HRSA PRF data.

• Number of sessions – Number of session attendances (from Network data).

SCREEN OUT

[If a survey for the nursing home (nursing home identifier is CCN) is already completed by this participant (SUID) or another participant associated with the same nursing home, display the screen below.]

Thank you for your interest in completing this survey. Our records indicate that you, or someone else at your facility, has already completed the survey.

If you have any questions, please call the study's toll-free number at <D_800NUM>.

INTRO

Welcome to the AHRQ ECHO National Nursing Home COVID-19 Action Network Survey!

• Taking the survey is completely voluntary. You may choose not to answer any question or to end your participation at any time.

• All responses are confidential and your responses will be combined with others’ responses to report summary results.

• NORC at the University of Chicago is conducting the survey on behalf of AHRQ. Both organizations will use the data collected in this survey only for the purpose of assessing the training and mentorship offered by AHRQ to support nursing homes in responding to the COVID-19 pandemic.

Let’s get started! By clicking “Next” below, you agree to participate in this survey.

INSTRUCTIONS

• The survey will take about 5 minutes to complete on average.

• If needed you may consult with others at your facility to answer these questions.

• Please use the “Next” and “Back” buttons to navigate through the questions. Do not use your browser buttons.

• If you need to stop the survey and continue taking it at another time, please use the “Exit” button and then use your PIN to log in again so you can start where you left off.

• If you have any questions about the survey or experience any technical problems, please e-mail us at AHRQ_NHCC@NORC.org.

Q1. [All] Our records indicate that you work at [Nursing Home Name]. Is that correct?

1. Yes

2. No [GOTO EXIT]

[SPACE]

99. Prefer not to answer

Q2. [All] Which of the following options best describes your main job/role at [Nursing Home Name]?

(Select one, RANDOMIZE ORDER EXCEPT “Other”)

1. Executive Director/Administrator/Head of Administration/CEO/President

2. Director of Nursing/Nursing Supervisor/Head of Nursing

3. Director of Inservice Training/Education

4. Director of Quality

5. Other (please specify)

[SPACE]

99. Prefer not to answer

Q3. [All] To make sure our records are up to date, can you provide your name?

First Name:

Last Name:

99. Prefer not to answer

Q4. [All] The AHRQ ECHO National Nursing Home COVID-19 Action Network was a partnership between the Agency for Healthcare Research and Quality (AHRQ), the University of New Mexico's ECHO Institute, and the Institute for Healthcare Improvement (IHI). It provided free training and mentorship to nursing homes across the country to increase the implementation of evidence-based COVID-19 infection prevention and safety practices to protect residents and staff.

Are you familiar with of the AHRQ ECHO National Nursing Home COVID-19 Action Network (“Network”)?

1. Yes

2. No [GOTO Q7]

[SPACE]

77. Not Sure

99. Prefer not to answer

Q5. [IF Q3=1, 77, 99] According to our records, your facility, [Nursing Home Name] did not participate in the Network. Below are certain reasons some facilities were not able to or chose not to participate in the Network. Please think back to the period between September 2020 and April 2021.

Did any of the following reasons factor into your facility's decision not to participate in the Network?

[READ EACH ITEM AND RECORD RESPONSE]

(RANDOMIZE ORDER EXCEPT “Other”)

	Yes	No	Don’t Know	Prefer Not to Answer
We were not aware of the Network’s activities.
The Provider Relief funding (CARES Act) was not enough to participate.
The training topics were not relevant for our facility.
We were already participating in other federal COVID-19 efforts.
We had internal or corporate COVID-19 initiatives.
Our facility did not have available staff to participate.
Technology challenges or barriers at our facility
Too many COVID-19 outbreaks in our community
Too many COVID-19 cases or outbreaks in the community outside our facility
Other reasons for not participating (please specify)

Q6. [IF Q3=1, 77, 99] Thinking back to the period between September 2020 and April 2021, how did you first hear about the Network? Did you hear about it through...

[READ EACH ITEM AND RECORD RESPONSE FOR EACH] (SELECT ALL THAT APPLY; RANDOMIZE ORDER EXCEPT “Other”)

1. Press release

2. Social media posts on Twitter/Facebook/LinkedIn

3. Recruitment emails

4. Project flyers

5. Recruitment phone call

6. Our facility was not aware of the Network activities.

7. Other (please specify)

[SPACE]

77. Not sure

99. Prefer not to answer

Q7. [All] Did your facility participate in any of the following COVID-19 Quality Improvement efforts?

[READ EACH ITEM AND RECORD RESPONSE FOR EACH]

	Yes	No	N/A	Don’t Know	Prefer not to answer
CMS Targeted COVID-19 Training for Frontline Nursing Home Staff and Management
CMS-CDC Fundamentals of COVID-19 Prevention for Nursing Home Management
CMS-CDC Nursing Home Infection Preventionist Training
Health and Human Services’ Office of Assistant Secretary for Planning and Response Clinical Rounds
VA Clinical Crisis Skills Training for Community Living Centers
Initiatives facilitated by the Quality Improvement Organization (QIO) – Quality Innovation Network (QIN-QIO) in my state
Local or organizational initiatives (please specify)
My facility received information regarding care for COVID-19 patients from another source/s (please specify)
My facility did not participate in any Quality Improvement Efforts

Q8. [All] With regard to your facility’s relationship with hospitals in your service area, to what extent do you agree or disagree with the following statements? For each statement, please tell me if you strongly disagree, disagree, neither agree nor disagree, agree, or strongly agree.

[READ EACH ITEM AND RECORD RESPONSE FOR EACH]

[REPEAT AGREEMENT SCALE AS NEEDED]

	Strongly disagree	Disagree	Neither Agree nor Disagree	Agree	Strongly Agree	Don’t know
Prior to the outbreak of COVID-19, our facility had a strong relationship with one or more hospitals in our facility’s service area.
After the outbreak of COVID-19, our facility enhanced coordination and communication with one or more hospitals in our service area to address emerging challenges.
Our facility and one or more hospitals in our service area shared resources and best practices to address emerging challenges related to COVID-19.

FEEDBACK. [All] (Optional) Is there any additional information you would like to share that was not covered in the prior questions?

[INSERT OPTIONAL TEXT BOX]

END.

Please click “Next” to submit your responses to this survey.

Thank you very much for participating. We really appreciate that you shared your valuable time and opinions.

If you have any questions about your rights as a study participant, you may call the NORC Institutional Review Board, toll free at 866-309-0542. Any other questions can be directed to the study's toll-free number at <D_800NUM>.