HSAG HQIC Partnership Questionnaire

Hospital Information

Welcome to the Health Services Advisory Group Hospital Quality Improvement Contract (HSAG HQIC) partnership. Completing this short, two-minute questionnaire will help HSAG HQIC support your hospital and achieve Centers for Medicare & Medicaid Services (CMS) goals to customize intervention opportunities and technical assistance to support your hospital and community during the COVID-19 pandemic.

Please answer the following questions for each individual hospital. This questionnaire should be completed by the person most knowledgeable about your hospital’s quality and safety practices and measures, such as a quality leader, patient safety officer, or clinical administrative leader.

If you have any questions regarding this questionnaire, please email hospitalquality@hsag.com.

Question Title

* 1. Facility Information

Hospital Name *

Hospital CMS Certification Number (CCN), if known

City/Town *

State *

Question Title

* 2. Person Completing This Questionnaire

First Name *

Last Name *

Job Title *

Email Address

Phone Number