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.
 
(You can type to search)
 
 
 
(FIRST & LAST NAME)
 
 
 

 

April Question

 
 
 

 

Modality Tracking Process:

 
 

If you answered "NO" to question 1 , proceed to 2 question. If you answered "YES" to question 1, proceed to question 3.

 
(Select ALL that apply)
 
 

If you answered "NO" to question 3 proceed to question 4. If you answered "YES" to question 3, proceed to question 5.

 
(Select ALL that apply)
 
(Select ALL that apply)
 

 

Home & Transplant NCC LAN Calls:

 
 
 
(Briefly explain)
 

 

Modality Patient Engagement:

 
 
(Select ALL that apply)
 
 
(Briefly explain)
 
 
 
(Briefly explain)
 
 
 
 
Please NO PATIENT PHOTOS... it's a HIPPA Violation! (Click Upload to attach any Picture File of your activities)
Drop your files here
 
 
 

 

CMS Patient & Family Engagement Questions:

 
 
(Type to select)
 
(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).
 
 
 
Note: Did you invite patients, family members and/or caregivers to participate in the Governing Body and/or QAPI meetings.
 
(Type to search)
 
(Type to search)
 

 

Please select "Send Me a Copy" below, to receive an email copy of your responses.

Thank you for your time!