2020 Modality QIA Monthly Feedback Form
Please complete this survey EVERY month for the Modality Project. Please update information as needed and notify the Network of staff changes.
Please select your Facility CCN & Name:
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(You can type to search)
Please provide your FIRST & LAST Name:
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Please provide your EMAIL:
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Who is your Facility Administrator or Clinical Manager?
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(FIRST & LAST NAME)
Facility Administrator/Clinical Manager EMAIL:
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Select the Month you are providing Feedback for:
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April Question
April Question
Did you attend the AREP webinar?
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Does your facility provide education and knowledge to staff on how to effectively triage and determine appropriate actions to ensure a patient(s) with COVID -19 (or suspected of being infected with COVID-19) receives treatment in an appropriate care setting?
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Yes
No
Modality Tracking Process:
Modality Tracking Process:
1. Does your facility use a process to monitor individual steps patients need to progress through for a successful transition to HOME dialysis?
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YES
NO
If you answered "NO" to question 1 , proceed to 2 question. If you answered "YES" to question 1, proceed to question 3.
If you answered "NO" to question 1 , proceed to 2 question. If you answered "YES" to question 1, proceed to question 3.
2. Check ALL the areas where your facility has identified a challenge or barrier in assisting patients to transition through the process towards HOME dialysis in the last 2 months. Our facility has had difficulty with:
(Select ALL that apply)
3. Does your facility use a process to monitor the individual steps patients need to progress through to successfully be placed on a TRANSPLANT waiting list?
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YES
NO
If you answered "NO" to question 3 proceed to question 4. If you answered "YES" to question 3, proceed to question 5.
If you answered "NO" to question 3 proceed to question 4. If you answered "YES" to question 3, proceed to question 5.
4. Check ALL the areas where your facility has identified a challenge or barrier in assisting patients to transition through the process to successfully be placed on a TRANSPLANT waiting list in the last 2 months. Our facility has had difficulty with:
(Select ALL that apply)
5. Are you using a Health Information Exchange (HIE) or another evidence-based highly effective information transfer system to receive information relevant to positive blood cultures during the transition of care?
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(Select ALL that apply)
Home & Transplant NCC LAN Calls:
Home & Transplant NCC LAN Calls:
6. Did at least 1 staff member attend or review the NCC's HOME LAN Call?
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7. Did at least 1 staff member attend or review the NCC's TRANSPLANT LAN Call?
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8. How has your facility utilized the tools and resources provided by the NCC LAN?
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(Briefly explain)
Modality Patient Engagement:
Modality Patient Engagement:
9. Did you use the Modality QIA resources that were provided to engage your patients and staff?
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YES
NO
10. Which QIA resources did you use to engage your patients and staff this month?
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(Select ALL that apply)
11. Which of the QIA resources did your patients or staff find the MOST effective:
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12. Why was the resource(s) MOST effective?
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(Briefly explain)
13. Which of the QIA resources did your patients or staff find the LEAST effective:
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14. Why was the resource(s) LEAST effective?
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(Briefly explain)
15. Please share any questions or comments from patients or staff about this month's activity?
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16. OPTIONAL: Upload Engagement Photos
Please NO PATIENT PHOTOS... it's a HIPPA Violation! (Click Upload to attach any Picture File of your activities)
Drop your files here
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17. Have you identified any barriers in your facilities. If so, what interventions have you developed? Briefly explain.
CMS Patient & Family Engagement Questions:
CMS Patient & Family Engagement Questions:
18. Did your facility INVITE patients to Plan of Care (POC) Meeting?
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YES
NO
19. How many care plan meetings did your facility complete this month?
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(Type to select)
20. How many patients/ family members ATTENDED the care plan meetings?
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(Type to search) Note: Attended the care plan meeting may be defined as: meeting with the patient chairside in the development and assessment for the plan of care, meeting in a conference room or other area to discuss and review the plan of care, meeting virtually using a phone or webcam to discuss the plan of care with the patient/family member(s).
21. Does your facility INCLUDE patient, family member and care giver involvement in the DEVELOPMENT of the individualized Plan of Care and/or Plan of Care meetings?
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YES
NO
22. Does your facility coordinate (or provide information on) established Patient Support Groups OR new patient adjustment groups OR patient councils?
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YES
NO
23. Does your facility INCLUDE patients and/or family/caregivers in the Quality Assurance Performance Improvement (QAPI) Program and/or Governing Body of the facility?
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Note: Did you invite patients, family members and/or caregivers to participate in the Governing Body and/or QAPI meetings.
YES
NO
24. How many patients, family members and/or caregivers attended the Governing Body and/or QAPI meeting?
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(Type to search)
25. How many Facility Patient Representatives (FPRs) do you have at the facility?
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(Type to search)
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Please select "Send Me a Copy" below, to receive an email copy of your responses.
Thank you for your time!
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