Form 0990 Clinician Interview Guide

Appendix E:
Topic Guide for Qualitative Interviews
with RBH Clinicians

Form Approved OMB no. 0990-xxxx (Exp. Date XX/XX/XX11)

Topic Guide for Qualitative Interviews
with RBH Clinicians

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0990- . The time required to complete this information collection is estimated to average 50 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate or suggestions for improving this form, please write to: U.S. Department of Health & Human Services, OS/OCIO/PRA, 200 Independence Ave., S.W., Suite 537-H, Washington D.C. 20201, Attention: PRA Reports Clearance Officer.

Clinician Interview Guide

1. Background

Attendings, OB/GYN Residents, MWs

1.1 Before we begin, please tell me a little bit about your work history and what you do in your current position as [Position Title]. How long have you been in this position? Who supervises you, and who or how many people do you supervise? Do you work on a team?

1.2 Are you aware of CURE's activities at RBH through 2007? Can you describe activities CURE was doing or supporting at RBH through 2007? (Topics to probe: quality assurance; education, mentoring, or training; management/administration responsibilities; other)

1.3 Were you personally involved in any of CURE's work at RBH? When? Do you know who (else) was involved or responsible?

1.4 Are you aware of IMC's activities at RBH through 2007? Can you describe activities IMC has been doing or supporting at RBH through 2007? (Probe: quality assurance; education, mentoring, or training activities; management/administration responsibilities; other)

1.5 Have you been personally involved in any of IMC's work? When? Do you know who (else) has been involved or responsible?

1.6 Are you aware if any of these activities had been started at RBH before the IMC or CURE projects started? If so, would you say IMC or CURE have improved them, or not?

2. Training Content

Attendings, OB/GYN Residents, MWs

2.1 What kinds of training or education did you have for your job, before you started working at RBH? Where and when? Have you had any other outside training while working at RBH?

2.2 Have you been involved in training or education at RBH? Could you describe the training sessions or courses you took with IMC or CURE, up to the end of 2007? (Probe: clinical, management, or other IMC or CURE training courses; residency training, refresher training, ToT; barriers to participating in training or education at RBH)

2.3 Would you say that any of the clinical courses or other training activities provided by IMC or IMC trained trainers have been useful to you on the job? Which ones? Would you say that any of them were not useful to you on the job? Which ones? (Probe: motivation, personal learning or changes in practice; RBH benefits or changes in practice e.g. quality of care, infection prevention, record-keeping, diagnosis, treatment, or patient outcomes)

2.4 Have you been involved with other educational opportunities at RBH, such as being mentored? Counting only participation before the end of 2007, could you describe any other on–the-job education or mentoring you've had with IMC or CURE?

2.5 Would you say mentoring or other education outside of formal sessions or courses has been useful to you on the job? Would you say any of it was not useful to you on the job? Please describe specific examples. (Probe: personal learning or changes in practice; RBH benefits or changes in practice e.g. quality of care, records, patient outcomes, other)

2.6 Can you identify any areas or topics you consider important for improving quality of care and patient outcomes at RBH that were not covered in IMC or CURE training, education, and mentoring before the end of 2007?

3. Training Program and Systems

Attendings, OB/GYN Residents, Midwives

3.1 Think about working at RBH 4 or 5 years ago. Can you describe the training system or program that was in place at that time at RBH? (Probe: decision-making roles of MoPH, RBH management, person's unit/supervisor, and/or the person; content/utility of courses)

3.2 Think about training activities at RBH since that time, through the end of 2007. Do you feel that overall you understand the goals and structure of training activities? What would you say the main goals of training and education are, and where do they come from? (Probe: who decides; long-term vs short-term refresher, focus on learner outcomes)

3.3 When you consider RBH training in general in recent years, have you found it useful?

3.3.1 Can you describe specific changes management/administration has made to support or encourage training at RBH? Think about staffing, equipment, supplies, staff schedules or incentives, for example.

3.3.2 Can you describe evidence-based practices that have started or been improved or strengthened linked to training in evidence-based clinical decisions at RBH? Think about patient diagnosis and treatment, for example.

3.3.3 Can you describe any practices at RBH that have been changed through support of IMC or CURE training or education, to make them more culturally appropriate?

3.3.4 Can you describe any changes to the hospital's capacity to provide better patient care that were started or improved through training and education by IMC or CURE?

3.4 Think about the training for residents at RBH four or five years ago to 2007. Have there been important changes in the training program over that time? (Probe: changes in content, structure, or standards; good/bad effects of changes; who makes decisions about changes; management or MoPH support or lack of support for training program changes)

3.5 Can you identify any aspects of RBH training you consider important for improving quality of care and patient outcomes at RBH that should have been included in IMC or CURE activities by the end of 2007, but were not? Would you say most RBH staff are satisfied with RBH training, or are there specific changes many people still want to see?

4. Training of Trainers Content and Systems

Attendings

4.1. Have you been involved in providing any training at RBH? Counting only training to the end of 2007, could you describe the training sessions or courses you led for RBH staff? (Probe: training to be a trainer received outside RBH; RBH training preparation, support)

4.1.1 Have you been involved with other educational or mentoring opportunities at RBH? (Probe: knowledge, skills, or tools personally gained)

4.1.2 In general, would you say most of the trainers working in the training program at RBH are well-prepared and capable? Please explain.

4.2 Can you describe ways that the training program has improved RBH? (Probe: value to trainers, participants, management; quality of care or patient outcomes, feedback opportunities or how feedback is used; barriers to further improvements if needed)

4.2.1 Are there other areas or topics important for improving RBH patient outcomes that haven't yet been covered in training, education, or support for the RBH training program?

4.3 Can you describe the roles and responsibilities of RBH management and MoPH decision-makers in providing training, education, or support for the RBH training program?

5. Quality of Care

Attendings, OB/GYN Residents, MWs

5.1 Think back four or five years. Can you describe any problems with quality of care that existed at RBH at that time? (Probe: patient care and outcomes; internal management)

5.2 Considering all activities of IMC since 2003 and CURE since 2005, can you describe any improvements to RBH quality of patient care because of IMC or CURE, or both? (Probe: patient care standards/practices; diagnosis/treatment procedures; internal management; patient discharge, follow-up, referrals, and/or outcomes)

5.2.1 Can you describe any ways that you feel your responsibilities are related to improving RBH quality of care according to guidelines and standards?

5.2.2 Have you participated in IMC or CURE activities to improve or add new maternal and newborn guidelines and standards at RBH? Which ones?

5.2.3 As part of your own participation in IMC/CURE programs, have you yourself adopted the use of new tools or resources? Which new or improved tools or resources do you currently use that were started through IMC or CURE training or mentoring?

5.3 Considering the situation at the beginning of 2008, what would you describe as the main barriers to further change or improvements? (Probe: cost; time or competing priorities; community demand factors; competency/skills; language; staffing, equipment, supplies or logistics; general political or economic issues)

5.3.1 Do systems or procedures work at RBH to reward quality performance and correct staff who aren't meeting standards or guidelines? From your point of view, would you say IMC or CURE have strengthened quality assurance systems at RBH, ignored these issues, or tried but not made much difference?

5.3.2 Can you describe a case or a time when you think actions following a mistake were fair, and helpful? Can you describe a case or a time when you think actions following a mistake were not fair, or not helpful?

5.3.3 What would you say is the purpose of the morning meetings? Would you say that they help improve quality performance or quality of care a great deal, somewhat, or very little?

5.3.4 What would you say is the purpose of the review committees? Would you say that they help improve quality performance or quality of care at RBH a great deal, somewhat, or very little?

5.3.5 What role does RBH management play in quality assurance in clinical areas? What would your responsibility be if you noticed, or if someone reported to you, a behavior or practice at RBH that was outside the standards and guidelines

5.4 Considering all activities of IMC since 2003 and CURE since 2005, can you describe areas of RBH quality assurance and quality of patient care that you feel should have improved but have not improved, or have gotten worse? (Probe: most significant challenges to most-needed changes in clinicians, RBH management, community practices)

5.4.1 In your opinion, over the past 4 or 5 years, what has really helped changes happen?

5.4.2 What else, if anything, needs to be done to strengthen accountability at RBH?

7. RBH Services and Information Systems

Attendings, OB/GYN Residents, Midwives

7.1 Can you describe the referral systems or other connections RBH has in place with other facilities or service providers? Have these changed or stayed about the same over the last 4 or 5 years? (Probe: patient outcomes, RBH statistics or reputation, transportation)

7.1.1 Can you think of any efforts IMC or CURE have made to help RBH with referrals or to reduce problems with referrals?

7.1.2 Would you say referrals in and out of RBH generally work well to ensure quality care for patients, or do you think there may be some problems?

7.1.3 What changes to any part of the referral systems might be helpful? Who is responsible, and what do you think needs to happen for improvements to occur?

7.2 About how much time each day would you say you personally spend on paperwork or records? About how much time each day do you think most (attendings, residents, midwives) spend on paperwork or records?

7.2.1 Can you describe all of the record-keeping steps you would need to perform for a mother who comes to RBH to deliver her baby?

7.2.2 What happens to the records after you complete all of your steps? Would you ever need to use these records again? Are there other RBH staff who would use these records?

7.2.3 In general, would you say that when you look at records other people have created, they are usually accurate and complete, or do you often have questions or uncertainty about those records?

7.3 What would you say are the most important records affecting the patients' quality of care and health outcomes? Have you had any extra training or education/mentoring on how to make sure those records accurate and complete?

7.3.1 Can you describe what happens to these most important records after you complete your entries? Do other RBH staff use the information in those records at that time, or later?

7.3.2 Can you describe any changes to record-keeping practices or use of records that have been led or supported by IMC or CURE? Would you say any changes have been useful?

7.3.3 Thinking about the end of 2007, would you say at that time you saw benefits from the records other people make very often, sometimes, or very rarely? Compared to 2003 or 2005, would you say other people's records were more useful, not as useful, or about the same? If there has been a change, why or how did it happen?

7.4 Can you describe the personnel or human resources system at RBH? Would you say this system has been helpful to you in your job, or not helpful? Do you think most RBH staff generally find this system to be helpful and supportive, or not? Can you describe an example of your interaction with personnel decision-making processes at RBH?

7.4.1 Can you describe any changes in personnel systems or decisions over the last four or five years because of IMC or CURE involvement?

7.4.2 How are conflicts and other differences of opinion managed or resolved when they occur among RBH staff? Can you describe an example of a conflict, over a personnel issue or clinical/operational policy, and if or how it was resolved?

7.5 Can you describe any other administrative or support systems that IMC or CURE activities at RBH up to the end of 2007 were trying to change? Were any of these activities helpful? (Probe: procurement, payroll, purchasing, pharmacy, occupational health)

8. Additional feedback

Attendings, OB/GYN Residents, Midwives

8.1 When you consider changes that have occurred at RBH through IMC and CURE programs, to the end of 2007, are there some changes that you would describe as very helpful? Can you describe key strengths or improvements at RBH as of the end of 2007 that you would say are connected to successful IMC and CURE activities at RBH? What are the activities that seemed to work best? Do you have some ideas of the reasons for their success?

8.2 When you consider changes that have occurred at RBH through IMC and CURE programs, to the end of 2007, are there some changes that you would describe as very unhelpful? Can you describe key weaknesses or failures at RBH as of the end of 2007 that you would say are connected to unsuccessful IMC and CURE activities at RBH? What are the activities that really did not seem to work well? Do you have some ideas of the reasons they did not work?

8.3 Have there been changes in community involvement in RBH decisions over the past two or three years? Would you say you or your colleagues generally would like surrounding communities to be more involved in RBH decisions, less involved, or about the same? (Probe: effects, costs/benefits of changes, what has not changed)

8.3.1 Can you describe any community engagement or health improvements that you think occurred because of CURE or IMC activities at RBH? Or that were helped or strengthened through CURE or IMC activities at RBH?

8.3.2 Considering the ways RBH clinicians and staff interact with patients and families, would you say RBH practices generally demonstrate respect for community attitudes and beliefs? What about individual patient attitudes and beliefs? Can you describe any examples of respect for patient attitudes and beliefs? Has this changed in any ways over the past several years because of IMC or CURE activities at RBH?

8.3.3 What educational or explanatory materials do staff and clinicians use when interacting with RBH patients and families? Is this different for patients who understand English, who don't understand or read English, or those who are illiterate in any language? Has this changed over the past several years because of IMC or CURE activities at RBH?

8.4 When you consider changes that have occurred at RBH through IMC and CURE programs, up until 2007, can you identify other changes or improvements that are extremely critical right now? What about changes that are extremely critical over the next few years?

8.4.1 In general, what would you say are the most important areas RBH needs to improve in order to become more effective at providing quality care for better patient outcomes?

8.4.2 Do you think those changes or improvements can happen, are possible? Do you think those changes or improvements are likely to happen or will happen? Why or why not?

8.4.3 Thinking back over the past four or five years, do you think the changes at RBH have had more positive effects than negative, not really many effects overall, or more negative effects than positive?

8.4.4 Do you expect changes that have happened since IMC and CURE became involved in projects at RBH will be permanent changes? Why or why not? Would you say most people expect the effects to be permanent, or to disappear not too long after the IMC and CURE projects end?

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