2020 Modality QIA Monthly Feedback Form

Please select your Facility CCN & Name:*

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Please provide your FIRST & LAST Name:*

Please provide your EMAIL:*

Who is your Facility Administrator or Clinical Manager?*

(FIRST & LAST NAME)

Facility Administrator/Clinical Manager EMAIL:*

Select the Month you are providing Feedback for:*

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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?*

Yes

No

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?*

YES

NO

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)

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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?*

YES

NO

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)

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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?*

(Select ALL that apply)

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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?*

(Briefly explain)

Modality Patient Engagement:

9. Did you use the Modality QIA resources that were provided to engage your patients and staff?*

YES

NO

10. Which QIA resources did you use to engage your patients and staff this month?*

(Select ALL that apply)

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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?*

(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?*

(Briefly explain)

15. Please share any questions or comments from patients or staff about this month's activity?*

16. OPTIONAL: Upload Engagement Photos

Please NO PATIENT PHOTOS... it's a HIPPA Violation! (Click Upload to attach any Picture File of your activities)

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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:

18. Did your facility INVITE patients to Plan of Care (POC) Meeting?*

YES

NO

19. How many care plan meetings did your facility complete this month?*

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20. How many patients/ family members ATTENDED the care plan meetings?*

(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).

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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?*

YES

NO

22. Does your facility coordinate (or provide information on) established Patient Support Groups OR new patient adjustment groups OR patient councils?*

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?*

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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25. How many Facility Patient Representatives (FPRs) do you have at the facility?*

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