Form CMS-10503 Structured Interview Questions for the IRF Setting

ACA §3004 Inpatient Rehabilitation Facilities (IRF) Quality Reporting Program (QRP):
Program Evaluation
STRUCTURED INTERVIEW QUESTIONS FOR THE IRF SETTING

Sample introduction: The Centers for Medicare and Medicaid Services (CMS) are seeking
input from providers, and wants to learn more about its new QRP process and how it is
impacting providers. CMS wants to stress that this information is intended to provide feedback.
All responses will be confidential and are not linked with a specific provider. Your participation
is voluntary. We have nine topics of particular interest and are interested in your thoughts.
Topics include feedback related to:
a. The measures and their importance and priority
b. Facility suggested priorities
c. Burden and feasibility (e.g., Electronic Health Records use)
1. Can you please introduce yourself and tell us what your role is?
2. Please tell me a little about your facility?
a. What type of clients do you serve
b. How does your facility compare to other providers
3. In broad terms, not restricted to the QRP indicators required by CMS, tell me about what
data (both quality data and other indicators) you look at, and how often you look at the
data?
4. In terms of all the data that you look at (not restricted to QRP indicators), tell me what
actions you take in response to that data? (ask for concrete examples of any changes in
practices that resulted from looking at data)
5. Now, narrowing the discussion to only the CMS mandated indicators, can you talk with
me about how you feel in general about the QRP measurements/indicators?
a. Are they meaningful and/or represent healthcare priorities
b. How can they be improved (specifics)
6. In terms of the CMS mandated QRP measures, talk to me about how the data is actually
collected and reported?
a. Are there mechanisms in place that allow you to verify the accuracy of the data?
b. How easy is it to comply with the CMS mandated reporting requirement?
i. Have you had to invest in new software to submit the data to CMS
ii. Do you already use electronic health records, and if so, does that make
reporting easier
iii. Is there electronic medical record data transfer as part of patient transfer
of care; care coordination
iv. How easy, or hard, is it to learn about new or revised QRP requirements
v. How easy, or hard, is it to make sure you have submitted the mandated
1

QRP data in a timely and accurate fashion
vi. Is there anything that can be changed in terms of the mechanics of
submitting data that would make the process easier for you
vii. Do you use the free software, and if so, does the data get pushed out from
a central location
7. Looking at the QRP program in the “big picture,” in your opinion or experience, what is
the overall impact of the QRP process on practice and outcomes?
a. Impact on healthcare behaviors
b. Impact on patient outcomes
c. Impact on healthcare costs and expenditures
8. Do you have any suggestions that you can provide to CMS that might improve the QRP,
including the process and/or requirements?
9. Finally, we have some technical questions related to data entry:
a. If your facility has more than one IRF ward, how do you differentiate between
them? Does the NHSN (National Healthcare Safety Network) system provide
you options (i.e., location mapping) that allows you to accurately report data?
b. Given the different needs of patients (example: acuity level), how does your
facility track these different levels of need/care, and are these reflected in data that
is submitted to CMS (i.e., IRF-PAI (Patient Assessment Instrument), NHSN)?

2