Public Access Survey for 2023 & 2024 MIPS Quality ID #222: Functional Status Change for Patients with Elbow, Wrist, Hand Impairments

ADMINISTRATION GUIDELINES: 

Standardization helps insure that patients at different clinics and different settings are all responding to questions based on their own perspectives and experiences. 

Standardization seeks to minimize coaching and other external influences on patient responses. 

1. I. Background – definition of administration, why important 
2. II. Patient Instructions Prior to Answering Survey Questions 
3. III. General Guidelines for Helping Patients Who Request Assistance 
4. IV. Supplemental Instructions 
5. V. How to Handle Common Scenarios 
6. VI. Non-verbal Communication 
7. VII. Paraphrasing Instructions 
8. VIII. When to Administer FOTO Surveys 
9. IX. How Much Assistance is Too Much? 

I. Background 

What does Administration mean? 

The term “administration” in this context refers to manner in which each FOTO Intake and Status assessment is presented to the patient. 

Why is this important? 

Adhering to standards for administering FOTO measures promotes validity, reliability and responsiveness. These properties are critical to clinicians and others who expect consistency and accuracy in measurement of outcomes. Using standard procedures for survey administration allows for more accurate benchmarking of performance across clinics. 

At least as importantly, patients deserve evidence-based care informed by the highest caliber of research, and accurate outcomes measurement is a critical component of evidence-based practice. Researchers, scholars, and policymakers similarly desire measurement that produces the most meaningful & precise results. 

Insuring that all patients receive the same instructions prior to answering survey questions preserves the integrity of the assessment. It is also important that guidelines are consistently followed when patients have questions or need help in responding. Standardization seeks to minimize coaching and other external influences on patient responses. When interacting with a patient who is completing FOTO measures, clinicians and others who have the best of intentions can inadvertently bias reporting just by what they say or how they act. 

Standardization helps insure that patients at different clinics and in different settings are all responding to questions based on their own perspectives and experiences. Scores that are obtained under standardized conditions are more trustworthy and the subsequent interpretations sound. © 2015 Focus on Therapeutic Outcomes Inc. All Rights Reserved Standards of Administration Page 2 

II. Patient Instructions Prior to Answering Survey Questions 

INTAKE- These instructions will be displayed for the patient at the start of the survey. The survey administrator is advised to state or paraphrase these instructions verbally. Keep in mind the importance of tone of voice and body language. Deliver the verbal patient instructions in a manner that communicates that the assessments are valuable. 

The following assessment will ask you about difficulties you may have with certain activities. 

It’s an important part of your evaluation. It will help us: 

· understand how your condition is affecting your activities, and 

· develop treatment goals with you. 

Please answer the questions with respect to the problem for which we are seeing you. Respond based on how you have been over the past few days. 

STATUS – The guidelines are the same as for Intake. 

Please answer these questions to help us assess your progress since starting therapy. 

Remember: 

– Answer the questions with respect to the problem for which we are seeing you. 

– Respond based on how you have been over the past few days. 

III. General Guidelines for Helping Patients Who Request Assistance

Keep mind that patient self-report measures are intended to assess the patient’s perception. 

DO	DO NOT
• Follow the standardized instructions  • Re-read  • Re-emphasize  • Objectively re-state	• Interpret the question for the patient  • Tell the patient how to answer

Illustration of General Guidelines using the Fear Avoidance Beliefs question(s).
• Re-read the instructions on the computer screen (okay to paraphrase): “It’s asking you to rate how strongly you agree or disagree with this statement, ‘I should not do physical activities which might make my pain worse.’”
• Re-emphasize: “….’I should not do physical activities which (might) make my pain worse.’”
• Objectively re-state: “Mr. Smith, how strongly do you agree or disagree with this statement: “I should not do physical activities which (might) make my pain worse?’”

IV. Supplemental Instructions 

In response to patient questions or other special circumstances, the following are supplemental instructions that may be delivered verbally to the patient, in addition to the Intake and Status instructions. Remember to remind the patient of key points from the Intake and Status instructions when applicable.

• “There are no wrong answers. We want to know what YOU think.”
• “If you are asked about something you haven’t done recently, estimate how hard it would be if you tried to do it now.”
• “Keep in mind that the assessment does not know who you are. These are standardized questions. If a question does not seem to apply to you, choose the response closest to the right answer for you…or…select the ‘best fit’ answer.”
• “The computer is assessing your abilities. In order to find out what you can do, it has to find out what you cannot do.”
• “Your clinician is interested in learning more about how your condition may or may not be affecting you either physically and/or emotionally.”
• “You also will have the opportunity to respond regarding your satisfaction with your experience at this facility.” (for Status if Satisfaction not turned off.)
• “The information you give is a part of your medical record, and subject to regulations that protect health care information.”
• “This assessment usually takes about 5-10 minutes.” (Okay to say longer if you feel that will be the case. The point here is that you give the patient a time estimate.)

V. Common Scenarios 

This section applies the general guidelines and other standardized wording for common scenarios. 

A patient’s function may be limited due to medical contraindications, such as post-operative rotator cuff repair: 

• Do not tell the patient which response to choose. Re-state the instructions and/or the question and/or the patient’s perception. For example, 

Patient: “I’m not supposed to raise my arm because my doctor told me not to yet. How should I answer this question about reaching a shelf at shoulder height?” 

Response: “Remember that the instructions for this questionnaire said that you are supposed to answer based on how you are presently. You said that you are not supposed to raise your arm; how do you think that applies to this question about reaching up to a shelf at shoulder height? There are no wrong answers; choose what you feel is the best-fit response.” 

• Let’s say the patient decides that even though they aren’t supposed to reach to shoulder height, that they could do it if they tried and thus they select “moderate difficulty” rather than “Unable;” that would be the correct response because it is the patient’s perception! 
• Notice that the response above only takes into account what the patient said or knows, that their doctor said they are not to raise their arm. Thus, either a clinical or non-clinical staff member can do this. 

A patient feels that certain questions are inappropriate, such as an older adult being asked about running or hopping: 

• For example, 

Patient: “I’m 80 years old, so why am I being asked if I can run?” 

Response: “The computer is assessing your abilities. In order to find out what you can do, it has to find out what you cannot do.” 

Administering optional questionnaires about psychosocial topics contain questions some patients may consider sensitive. 

• For example, 

Patient: “Why is this asking about things that are not my problem??” 

Response: “Keep in mind that the assessment does not know who you are. These are standardized questions. If a question does not seem to apply to you, choose the response closest to the right answer for you…or…select the ‘best fit’ answer.” 

Patient: “Why is it asking me about worry and distress? My problem is physical. Do you guys think I am faking it?!” 

Response: “Your clinician is interested in learning more about how your condition may or may not be 

affecting you either physically and/or emotionally.” 

A patient asks if they should respond based on their function with or without their assistive device: 

• Instruct the patient to respond based on what the patient feels would be normal function for them. For example, o Someone who has used a walker for several years might consider that their normal function means how they can walk using a walker,…or they might not! 

  • Someone who is using an assistive device short-term due to the injury/condition might consider that their normal function means how they could perform without the device. 

• Always default to affirming to the patient that their perception is correct. 

A patient is uncertain whether to respond based on their function using the affected extremity relative to the unaffected extremity 

• Re-state for the patient any relevant Intake or Status instructions with emphasis on the key words within the questionnaire being taken. For example, 

Response: “I can see that on the question you are being asked it says, ‘Using your affected arm how much difficulty do you have…?’ How much difficulty do you feel you have because of your affected arm? Remember, there are no wrong answers; however you interpret it is correct.” 

• Instruct the patient to respond based on what the patient feels would be normal function for them. 

VI. Non-verbal Communication 

Keep in mind the importance of tone of voice and body language. Deliver the verbal patient instructions in a manner that communicates that the assessments are valuable. The patient’s responses may be more thoughtful and accurate if the patient understands the assessment process is an important component of their care episode. 

VII. Paraphrasing Standardized Patient Instructions 

It is generally acceptable to paraphrase or restate the sentences. Remain true to the message and be objective. 

Often it is best to start by using the scripted sentences verbatim, and as you become more comfortable with remembering the responses, you might evolve into putting things in your own words. 

VIII. When to Administer FOTO Assessments

It is recommended that patients complete their FOTO assessments prior to the evaluation with the clinician. 

Completing the assessment post-evaluation is the preferred option only if the alternative would be not getting the assessment at all. 

IX. How Much Assistance Is Too Much? 

After delivering the Intake or Status instructions verbally, the survey administrator may wish to remain with the patient until the first functional question in order to make sure the patient is comfortable navigating the survey. Once survey setup is complete and the patient has started answering the functional survey, DO step away and let the patient know that you are available if the patient needs help. 

If the patient asks for help, follow the guidelines provided above under Supplemental Instructions and Common Scenarios. For patients who seem to need the close presence or guidance of another, see FOTO guidelines for Proxy and Recorder survey administration options. 

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