2020 Modality QIA Pre-Project Survey

Please select two staff members to be the Project Lead & Project Back-up. These staff members play a key part in the success of this project. The Main Responsibilities of these two individuals include: -Engaging patients and other staff members -Coordinating and Communicating with the Network -Completing Monthly Required Modalities QIA tasks -Sharing Monthly Educational and Engagement activities with patients and staff -Discussing information about Modality Options (Home and Transplant) efforts in Monthly QAPI meetings.

(Type to search. If you cannot find your facility in this drop down, you are not in this QIA)

Select
Caret IconCaret symbol
4. Have you notified your regional corporate representative that your facility has been selected to participate in the 2020 Modalities QIA?*
5. Do you have a Facility Patient Representative (FPR), Patient Subject Matter Expert (SME) or an actively engaged patient who is part of the facility's regular activities?*
6. IF you answer to Question #8 "No", will you be willing to find a patient who may be interesting becoming a Facility Patients Representative (FPR) or Patient Subject Matter Expert (SME) by January 31st?

(CMS's ultimate goal is to have at least ONE active FPR PER shift.)

Select or enter value
Caret IconCaret symbol
Select or enter value
Caret IconCaret symbol
10. Does your facility hold monthly patient engagement or educational activities related to Transplant or Home Dialysis for all patients?*
11. Do any of your patients and/or family members participate in the QAPI/QA program/ meeting?*

(Select All that Apply)

Select or enter value
Caret IconCaret symbol
13. Are you communicating monthly with Transplant Centers to track patients' status and follow up on the work up process?*
14. Has your facility collaborated with outside personnel (Transplant coordinator, Transplant recipient, Transplant nephrologist, home dialysis patient, home dialysis nurse, home dialysis advocate) to conduct Patients Engagement Ativities such as lobby days, discussion groups, or support groups?*

(Examples of collaboration activities include speaking on different topics, lobby days, providing patient education etc.) (Select ALL that Apply)

Select
Caret IconCaret symbol

(Select ALL that Apply)

Select
Caret IconCaret symbol

(Select 2 Choices)

Select or enter value
Caret IconCaret symbol

IMPORTANT: By submitting this Pre-Project Attestation Survey, I attest I have reviewed the Modalities Project Intro Webinar.

Please Select "Send Me a Copy" Below, to keep track of your Responses!

Privacy Notice|Report Abuse