Attachment 16

ATTACHMENT 16

Survey of Bureau of Primary Health Care (BPHC) Staff to Assess Factors that Contribute to Successful Dissemination of Planned Cancer Screening

______________________________________________________________________________

OMB # 0925-0046-16 a

Exp. Date: 10/31/2006

Cancer Collaborative Study

HEALTH CENTER DIRECTOR Inventory

Instructions

This inventory asks for your opinions about activities related to cancer screening and follow-up in your clinic. It will take about 20 minutes to complete.

Marking your answers

A few items ask you to write in a number. For the other items, mark your answer by circling the corresponding number.

Moving through the questionnaire

You are sometimes told to skip over some questions (you will see GO TO instructions). If there is no instruction next to the number you circled, simply move to the next item.

Director Inventory

I. introduction

1. Did you ever participate in any HRSA Health Disparities Collaborative prior to 2005?

Yes 1

No 2 Don’t Know 8

(GO TO Q3)

2. Did you participate in the HRSA Health Disparities Cancer Collaborative anytime from 2002 through 2004?

Yes 1

Would you say regarding implementation of the Cancer Collaborative

that your organization is:

____Mostly in the planning stage

____Mostly in the early implementation stage

____Now receiving usable data on implementation activities

No 2

Don’t Know 8

3. Have you ever participated, either formally or informally, in quality improvement activities at your health center?

Yes 1

No 2

Don’t Know 8

(IF NO, THEN SKIP QUESTION 4)

4. How often do members of your health center engage in the following activities to improve cancer screening and follow-up?

	Not at all	Rarely	Some-times	Often	Don’t Know
Conference calls with experts outside your health center	1	2	3	4	8
E-mail (listserv) discussions with experts outside your health center	1	2	3	4	8
Visits from/to other health centers	1	2	3	4	8
Ongoing measurement of clinical performance at your center	1	2	3	4	8

II. CLINIC PROCESSES

1. How often does your health center connect patients with available community resources for cancer screening?

Not at all 1

Rarely 2

Sometimes 3

Often 4

Don’t know 8

		Strongly disagree	Disagree	Neither agree nor disagree	Agree	Strongly agree	Don’t Know
2.	The available community resources for cancer screening are adequate for your patient population	1	2	3	4	5	8

3. Does your health center have clinical guidelines available to health care providers (physicians, physician assistants, nurse practitioners) for cancer screening?

Yes 1

No 2 Don’t Know 8

(GO TO Q4)

If yes, are these guidelines available to health care providers…

Yes No Don’t Know

1. In writing in the room where they see patients? 1 2 8

2. On-line in the room where they see patients? 1 2 8

3. On-line at some other location than where they routinely see patients? 1 2 8

3. Is someone at your health center instructed to document self-management goal setting among patients (including (1) asking about cancer screening, (2) sharing information about cancer screening, and (3) identifying a plan)?

Yes 1

No 2

Don’t Know 8

At the start of the following questions, an approach to providing care is described in bold. PLEASE DESCRIBE YOUR LEVEL OF AGREEMENT OR DISAGREEMENT WITH THE FOLLOWING STATEMENTS.

5. Providing formal assessment of patient self-management (i.e., tracking whether patients meet their specified goals)…

	Strongly disagree	Disagree	Neither agree nor disagree	Agree	Strongly agree	Don’t know
a. is useful when providing general medical care.	1	2	3	4	5	8
b. is useful when providing cancer screening and follow-up.	1	2	3	4	5	8
c. has been improved among our health care providers and staff because of the organization's efforts to educate them about it	1	2	3	4	5	8
d. has been implemented in our health care organization.	1	2	3	4	5	8
e. has been supported by adequate resources from our health care organization.	1	2	3	4	5	8

6. Initiating or maintaining programs to increase patient self-management skills…

	Strongly disagree	Disagree	Neither agree nor disagree	Agree	Strongly agree	Don’t know
a. is useful when providing general medical care.	1	2	3	4	5	8
b. is useful when providing cancer screening and follow-up.	1	2	3	4	5	8
c. has been improved among our health care providers and staff because of the organization's efforts to educate them about it	1	2	3	4	5	8
d. has been implemented in our health care organization.	1	2	3	4	5	8
e. has been supported by adequate resources from our health care organization.	1	2	3	4	5	8

7. Providing clinical guidelines to patients…

	Strongly disagree	Disagree	Neither agree nor disagree	Agree	Strongly agree	Don’t know
a. is useful when providing general medical care.	1	2	3	4	5	8
b. is useful when providing cancer screening and follow-up.	1	2	3	4	5	8
c. has been improved among our health care providers and staff because of the organization's efforts to educate them about it	1	2	3	4	5	8
d. has been implemented in our health care organization.	1	2	3	4	5	8
e. has been supported by adequate resources from our health care organization.	1	2	3	4	5	8

8. Providing clinical guidelines to health care providers (physicians, physician assistants, nurse practitioners) through reminders…

	Strongly disagree	Disagree	Neither agree nor disagree	Agree	Strongly agree	Don’t know
a. is useful when providing general medical care.	1	2	3	4	5	8
b. is useful when providing cancer screening and follow-up.	1	2	3	4	5	8
c. has been improved among our health care providers and staff because of the organization's efforts to educate them about it	1	2	3	4	5	8
d. has been implemented in our health care organization.	1	2	3	4	5	8
e. has been supported by adequate resources from our health care organization.	1	2	3	4	5	8

9. Changing responsibilities of health care providers (physicians, physician assistants, nurse practitioners) and staff in the clinic to enable them to function more like a team…

	Strongly disagree	Disagree	Neither agree nor disagree	Agree	Strongly agree	Don’t know
a. is useful when providing general medical care.	1	2	3	4	5	8
b. is useful when providing cancer screening and follow-up.	1	2	3	4	5	8
c. has been improved among our health care providers and staff because of the organization's efforts to educate them about it	1	2	3	4	5	8
d. has been implemented in our health care organization.	1	2	3	4	5	8
e. has been supported by adequate resources from our health care organization.	1	2	3	4	5	8

10. Providing written feedback reports or data to health care providers (physicians, physician assistants, nurse practitioners) regarding their performance…

	Strongly disagree	Disagree	Neither agree nor disagree	Agree	Strongly agree	Don’t know
a. is useful when providing general medical care.	1	2	3	4	5	8
b. is useful when providing cancer screening and follow-up.	1	2	3	4	5	8
c. has been implemented in our health care organization.	1	2	3	4	5	8
d. has been supported by adequate resources from our health care organization.	1	2	3	4	5	8

11. Providing written feedback reports or data to clinic teams regarding their performance…

	Strongly disagree	Disagree	Neither agree nor disagree	Agree	Strongly agree	Don’t know
a. is useful when providing general medical care.	1	2	3	4	5	8
b. is useful when providing cancer screening and follow-up.	1	2	3	4	5	8
c. has been implemented in our health care organization.	1	2	3	4	5	8
d. has been supported by adequate resources from our health care organization.	1	2	3	4	5	8

III. MANAGEMENT STRATEGIES

1. In the last 12 months did your health center use measures of either patient satisfaction or clinical performance, or both, to do any of the following? (PLEASE RESPOND TO EACH ITEM.)

	Yes, used both patient satisfaction and clinical performance measures	Yes, but used only patient satisfaction measures	Yes, but used only performance measures	No, used neither	Don’t know
a. Pay health care provider bonuses	1	2	3	4	8
b. Adjust salary or base pay	1	2	3	4	8
c. Implement a quality improvement initiative	1	2	3	4	8
d. Have general discussions at practice meetings	1	2	3	4	8

2. In the past 12 months, did your health center compare its data on quality of care to data from other centers?

Yes 1

No 2

Don’t Know 8

3. How much does your center use each of the following strategies to ensure high quality care is delivered to primary care patients?

	Not at all	A little	Some	A lot	Don’t know
a. Health care providers’ informal monitoring of each others’ practice patterns	1	2	3	4	8
b. Chart reviews	1	2	3	4	8
c. Health care provider peer review of selected cases	1	2	3	4	8
d. Discussion of clinical guidelines at center or team meetings.	1	2	3	4	8
e. Statistical reports of practice patterns	1	2	3	4	8
f. Morbidity or mortality conferences	1	2	3	4	8
g. External medical record audits (e.g., by representatives of the state or a health plan)	1	2	3	4	8

IV. COMMUNITY OUTREACH

1. Does your organization have staff or resources allocated to ensure health care providers and patients make use of community cancer resources?

Yes 1

No 2

Don’t Know 8

2. Does your organization make available a list of identified community cancer resources in an accessible format?

Yes 1

No 2

Don’t Know 8

3. Have you set up informal or contractual agreements with the following organizations?

	Yes	No	Don’t Know
a. Public health department?	1	2	8
b. Radiology department?	1	2	8
c. Gastroenterology practice?	1	2	8
d. Community oncology practice?	1	2	8
e. Cancer center?	1	2	8
f. Academic medical center?	1	2	8
g. Cancer survivorship support group?	1	2	8

V. INFORMATION SYSTEMS

FOR PURPOSES OF THIS SECTION, THE TERM “INFORMATION SYSTEMS” CAN REFER TO A COMPUTER SYSTEM OR ELECTRONIC MEDICAL RECORD, BUT DOES NOT NEED TO DO SO.

Quality performance reports may include rates of the delivery of clinical services, such as a screening test, at the health center level.

1. In the past 12 months, did you receive any reports about the rates of delivery of clinical services at the health center level?

Yes 1

No 2 Don’t Know 8

(GO TO Q3)

2. Does your health center’s information system have any capacity to measure cancer screening or follow-up?

Yes 1

No 2 Don’t Know 8

(GO TO SECTION VI)

3. In the past 12 months, did you receive any reports from the information system about rates of…

a. Screening mammography?

1. At the clinic/local team level

Yes ……………. 1

How often: ___Every Month / Every __ Months / __Don't Know

No 2

Don’t Know 8

2. At the health care provider/individual level

Yes ……………. 1

How often: ___Every Month / Every __ Months / __Don't Know

No 2

Don’t Know 8

b. Screening Pap test?

1. At the clinic/local team level

Yes ……………. 1

How often: ___Every Month / Every __ Months / __Don't Know

No 2

Don’t Know 8

2. At the health care provider/individual level

Yes ……………. 1

How often: ___Every Month / Every __ Months / __Don't Know

No 2

Don’t Know 8

c. Screening for colorectal cancer?

1. At the clinic/local team level

Yes ……………. 1

How often: ___Every Month / Every __ Months / __Don't Know

No 2

Don’t Know 8

2. At the health care provider/individual level

Yes ……………. 1

How often: ___Every Month / Every __ Months / __Don't Know

No 2

Don’t Know 8

d. Patient notification of screening test results within 30 days of any cancer screening test?

1. At the clinic/local team level

Yes ……………. 1

How often: ___Every Month / Every __ Months / __Don't Know

No 2

Don’t Know 8

2. At the health care provider/individual level

Yes ……………. 1

How often: ___Every Month / Every __ Months / __Don't Know

No 2

Don’t Know 8

e. Discussion of screening with patients?

1. At the clinic/local team level

Yes ……………. 1

How often: ___Every Month / Every __ Months / __Don't Know

No 2

Don’t Know 8

2. At the health care provider/individual level

Yes ……………. 1

How often: ___Every Month / Every __ Months / __Don't Know

No 2

Don’t Know 8

4. Our health center has been able to use reports of clinical performance to effectively design and test changes in managing the rate of:

	Strongly agree	Disagree	Neither agree nor disagree	Agree	Strongly agree	Don’t know
a. Screening mammography within the previous 2 years	1	2	3	4	5	8
b. Pap test within the previous 3 years	1	2	3	4	5	8
c. Appropriate screening for colorectal cancer	1	2	3	4	5	8
d. Notification of screening results within 30 days	1	2	3	4	5	8
e. Completion of additional diagnostic testing after abnormal screening results within appropriate time frame	1	2	3	4	5	8
f. Beginning of treatment after cancer detection within appropriate time frame	1	2	3	4	5	8
g. Documentation of self-management goal setting	1	2	3	4	5	8

5. PLEASE DESCRIBE YOUR LEVEL OF AGREEMENT OR DISAGREEMENT WITH THE FOLLOWING STATEMENTS ABOUT THE INFORMATION SYSTEM IN PLACE AT YOUR HEALTH CENTER.

	Strongly disagree	Disagree	Neither agree nor disagree	Agree	Strongly agree	Don’t know
a. The center’s information system is adequate to accommodate the size of the population eligible for cancer screening	1	2	3	4	5	8
b. The center continually tries to improve the timeliness of its data on cancer screening and follow-up	1	2	3	4	5	8
c. The center continually tries to improve the accuracy and relevance of its data on cancer screening and follow-up	1	2	3	4	5	8
d. The information system accurately documents cancer screening taking place in the clinic	1	2	3	4	5	8
e. The information system accurately documents whether appropriate diagnostic follow-up takes place after an abnormal screening result.	1	2	3	4	5	8
f. The information system accurately documents whether appropriate treatment takes place after cancer detection	1	2	3	4	5	8
g. The data gathered in the information system is used by leadership to change the health center’s activities related to cancer screening	1	2	3	4	5	8
h. The data gathered in the information system is used by health care providers to change their behavior related to cancer screening.	1	2	3	4	5	8
i. I use the data gathered in the information system to change my behavior related to cancer screening.	1	2	3	4	5	8

VI. LEADERSHIP

Senior Leadership of Health Center

For this set of questions, the senior leadership of your health center is defined as the people who are responsible for making decisions about resources and personnel across all affiliated clinics.

1. The number of members of the health center’s senior leadership who have left the organization over the past 12 months is:

|__|__|__| out of |__|__|__|

2. PLEASE DESCRIBE YOUR LEVEL OF AGREEMENT OR DISAGREEMENT WITH THE FOLLOWING STATEMENTS ABOUT SENIOR LEADERSHIP.

The senior leadership of the health center…	Strongly disagree	Disagree	Neither agree nor disagree	Agree	Strongly agree	Don’t know
a. Has demonstrated an ability to manage the changes (e.g., organizational, technological) needed to improve the quality of care and services	1	2	3	4	5	8
b. Always listens to the concerns of other members of the organization	1	2	3	4	5	8
c. Provides needed feedback to members of the organization	1	2	3	4	5	8
d. Helps members of the organization work well together	1	2	3	4	5	8
e. Provides members of the organization with a clear expectation of their roles	1	2	3	4	5	8
f. Makes sure people have the skills and knowledge to work in teams	1	2	3	4	5	8
g. Makes sure a local clinic team that does a good job gets special rewards or recognition	1	2	3	4	5	8
h. Strongly supports our work	1	2	3	4	5	8
i. Regularly reviews our progress in making change	1	2	3	4	5	8
j. Sees success in improving the quality of care as a high priority for the organization	1	2	3	4	5	8

VII. BACKGROUND INFORMATION

1. What is your current job title?

________________________________

2. How long have you worked in your current position?

|__|__| or |__|__|

Years Months

3. How long have you worked at this health center?

|__|__| or |__|__|

Years Months

4. Is your current pay affected by:

		Yes	No	Don’t Know
a.	The results of satisfaction surveys completed by your own patients?	1	2	8
b.	Specific measures of quality of care, such as screening rates for your patients?	1	2	8

5. Which of the following titles best describes your occupational background…

Physician (MD or DO) 1

Physician Assistant (PA) 2

Nurse Practitioner (NP) 3

Registered Nurse (RN) 4

Licensed Practical Nurse (LPN) 5

Other (SPECIFY) 8

6. In what year did you graduate from your school or program?

|__|__|__|__| YYYY

Year Graduated

7. In what year were you born?

|__|__|__|__| YYYY

Year Born

8. What Is your gender?

Male 1

Female 2

9. What is your race? (MARK ONE OR MORE RACES)

American Indian or Alaska Native 1

Asian 2

Black or African American 3

Native Hawaiian or Other Pacific Islander 4

White 5

10. Are you Spanish/Hispanic/Latino?

No 1

Yes, Mexican, Mexican Am., Chicano 2

Yes, Puerto Rican 3

Yes, Cuban 4

Yes, other Spanish/Hispanic/Latino 5

THANK YOU FOR COMPLETING THIS INVENTORY

OMB # 0925-0046-16 b

Exp. Date: 10/31/2006

Cancer Collaborative Study

FINANCIAL OFFICER Inventory

Instructions

This inventory asks for your opinions about functions and activities related to your health center. The answers to these questions may require the input of multiple individuals working at your health center, including the chief financial officer, the director of clinical operations, the vice-president of development, and the human resources staff. It will take about 20 minutes to complete.

Marking your answers

A few items ask you to write in a number. For the other items, mark your answer by circling the corresponding number.

Moving through the questionnaire

You are sometimes told to skip over some questions (you will see GO TO instructions). If there is no instruction next to the number you circled, simply move to the next item.

Operations Manager Inventory

I. GOVERNANCE

1. In what year did your organization open as a health center?

|__|__|__|__| YYYY

Year

2. In what year did your center begin receiving Bureau of Primary Health Care (BPHC) funding?

|__|__|__|__| YYYY

Year

3. Has your health center ever participated in any HRSA Collaborative?

Yes 1

No 2 Don’t Know 8

(GO TOQ5)

4. Did your health center specifically participate in the HRSA Health Disparities Cancer Collaborative anytime from 2002 through 2004?

Yes 1

No 2

Don’t Know 8

5. Does the health center’s Board of Directors receive updates on your center’s collaborative activities?

Yes 1

No 2

Don’t Know 8

II. STAFFING

1. Does your center have a formal or informal relationship with any hospitals (e.g., referrals for specialty care; training or residency programs; quality improvement data sharing)?

Yes 1

No 2 Don’t Know 8

(GO TO Q4)

2. How many?

_____hospitals

3. What is the nature of the relationship(s)? (SELECT ALL THAT APPLY).

a. Center refers insured patients (private and Medicare)
to hospital(s) for specialty care 1

b. Center refers uninsured patients to hospital(s)
for specialty care 2

c. Center refers Medicaid patients to hospital(s) for
specialty care 3

d. Center serves as site for training or residency
programs 4

e. Center and hospital share quality improvement data 5

f. Center is served by physicians who have clinical responsibilities

at other hospitals 6

g. Other (PLEASE DESCRIBE) 7

4. Which of the following categories best describes the availability of each of the specialists listed below to patients at your center: (1) routinely available on-site, (2) routinely available through referrals in the service area, (3) in the service area but does not routinely accept referrals, or (4) not routinely available at all? (SELECT ONLY ONE ANSWER FOR EACH SPECIALIST LISTED)

	Available on-site	Available in service area through referral	Available in service area, but does not accept referrals	Not available
a. Gastroenterologist	1	2	3	4
b. Gynecologist	1	2	3	4
c. Oncologist	1	2	3	4
d. Pulmonologist	1	2	3	4
e. General Surgeon	1	2	3	4
f. Breast Cancer Surgeon	1	2	3	4
g. Gynecologic Surgeon	1	2	3	4
e. Radiologist – general	1	2	3	4
f. Radiologist – interventional	1	2	3	4
g. Radiologist with training in breast imaging	1	2	3	4

5. How many of the following are employed by your center?

	Number	Number of FTEs
a. Physicians	______	______
b. Nurse Practitioners	______	______
c. Physician Assistants	______	______
d. Nurses (RNs, LPNs)	______	______
e. Laboratory personnel	______	______
f. Scheduler/reception	______	______

6. Have any health care administrators or clinicians left the center in the past 12 months?

Yes 1

No 2

Don’t Know 8

7. How many of each type of staff have left the center in the past 12 months?

Number

a. CEO or other administrative leader

b. Medical Director

c. Physicians

d. Nurse Practitioners

e. Physician Assistants

f. Nurses (RNs, LPNs)

g. Laboratory personnel

h. Scheduler/reception

i. Other (PLEASE SPECIFY)

8. What percent of the following personnel are paid straight salary vs. salary plus pay for performance?

	Staff	Straight salary	Salary + pay for performance	Total
a.	Physicians	_____%	_____%	_____%
b.	Physician Assistants	_____%	_____%	_____%
c.	Nurse Practitioners	_____%	_____%	_____%
d.	Registered Nurses	_____%	_____%	_____%
e.	Licensed Practical Nurses	_____%	_____%	_____%
f.	Clinical support staff (e.g., medical assistants)	_____%	_____%	_____%

9. Does your organization use “360 degree performance appraisal”? A “360 degree performance review” is defined as a system of reviewing employee performance using input from one’s superiors, peers, and subordinates; and synthesizing this input to develop a constructive plan for employee growth and development.

Yes 1

No 2

Don’t Know 8

III. FINANCIAL INFORMATION

1. What is your center’s annual operating budget (for the most recent fiscal year)?

$ _______________

Annual Budget

Fiscal year: ___________

2. Approximately what proportion of your patients are uninsured?

%

Uninsured

3. Approximately what proportion of your patients are enrolled in private managed care plans (i.e., HMOs and PPOs)?

%

Enrolled

4. Approximately what proportion of your patients are enrolled in public managed care plans (i.e., HMOs and PPOs)?

%

Enrolled

5. What percentage of your patient revenue comes from each of the following sources?

1. Medicare %

2. Medicaid %

3. Commercial %

4. Self-pay %

5. Total = 100% %

6. Approximately how many different insurance plans does your center have contracts with?

|__|__|

Number of Plans

7. Is your center an owner of an insurance plan, alone or in conjunction with other local or regional health centers?

Yes 1

No 2 Don’t Know 8

(GO TO Q7)

If yes…

a. What is the name of that plan?

b. In what year was the plan created? |__|__|__|__| YYYY

Year

c. What percentage of your center’s patient revenue comes from this plan? _______%

Revenue Sources

8. What percentage of the operating revenues of your organization are Medicare revenue under Diagnostic Related Groups (DRGs)?

%

Revenues

9. Capitation is defined as the pre-determined lump sum payment to care for patients regardless of how many or how few services they may need. Given this definition, what percentage of the operating revenues of your organization come from capitated payment (not including DRGs)?

%

Revenues

10. For your center’s most recent fiscal year, please circle the letter of the phrase below that best reflects your center’s financial situation.

a. Operating expenses exceeded operating revenue by  25%

b. Operating expenses exceeded operating revenue by 11-24%

c. Operating expenses exceeded operating revenues by 1-10%

d. Broke even

e. Operating revenue exceeded operating expenses by 1-10%

f. Operating revenue exceeded operating expenses by 11-24%

g. Operating revenue exceeded operating expenses by  25%

VI. PATIENT DEMOGRAPHICS

1. What percentage of patients seen at your health center in the past 12 months speak a language other than English as their primary language?

%

Percent

2. What percentage of patients seen at your health center in the past 12 months are…

a. Migrant or seasonal agricultural workers?

%

Percent

b. Homeless?

%

Percent

3. How does your center collect the patient race information documented in your center’s registration database?

a. Perception of intake clerk 1

b. Patient self-report 2

c. Other (SPECIFY) 3

4. Approximately what percentage of your patients seen in the past 12 months are 50 years of age or older? (SELECT ONLY ONE).

Less than 25% 1

25-49% 2

50-74% 3

75-100% 4

VII. BACKGROUND INFORMATION

1. What is your current job title?

Job Title

2. How long have you worked in your current position?

|___|___|

Years

3. How long have you worked at this health center?

|___|___|

Years

4. In what year were you born?

|__|__|__|__| YYYY

Year

5. What is your gender?

Male 1

Female 2

6. What is your race? (MARK ONE OR MORE RACES)

American Indian or Alaska Native 1

Asian 2

Black or African American 3

Native Hawaiian or Other Pacific Islander 4

White 5

7. Are you of Hispanic or Latino origin?

Yes 1

No 2

Don’t Know 8

THANK YOU FOR COMPLETING THIS INVENTORY

OMB # 0925-0046-16 c

Exp. Date: 10/31/2006

Cancer Collaborative Study

Health care provider Inventory

Instructions

This inventory asks for your opinions about activities related to cancer screening and follow-up in your clinic. It will take about 20 minutes to complete.

Marking your answers

A few items ask you to write in a number. For the other items, mark your answer by circling the corresponding number.

Moving through the questionnaire

You are sometimes told to skip over some questions (you will see GO TO instructions). If there is no instruction next to the number you circled, simply move to the next item.

Health care provider Inventory

I. introduction

1. Did you ever participate in any HRSA Health Disparities Collaborative prior to 2005?

Yes 1

No 2 Don’t Know 8

(GO TO Q3)

2. Did you participate in the HRSA Health Disparities Cancer Collaborative anytime from 2002 through 2004?

Yes 1

Would you say regarding implementation of the Cancer Collaborative

that your organization is:

____Mostly in the planning stage

____Mostly in the early implementation stage

____Now receiving usable data on implementation activities

No 2

Don’t Know 8

3. Have you ever participated, either formally or informally, in quality improvement activities at your health center?

Yes 1

No 2

Don’t Know 8

(IF NO, THEN SKIP QUESTION 4)

II. CLINIC PROCESSES

1. Does your health center have clinical guidelines available to health care providers (physicians, physician assistants, nurse practitioners) for cancer screening?

Yes 1

No 2 Don’t Know 8

(GO TO Q4)

If yes, are these guidelines available to health care providers…

Yes No Don’t Know

4. In writing in the room where they see patients? 1 2 8

5. On-line in the room where they see patients? 1 2 8

6. On-line at some other location than where they routinely see patients? 1 2 8

2. Is someone at your health center instructed to document self-management goal setting among patients (including (1) asking about cancer screening, (2) sharing information about cancer screening, and (3) identifying a plan)?

Yes 1

No 2

Don’t Know 8

At the start of the following questions, an approach to providing care is described in bold. PLEASE DESCRIBE YOUR LEVEL OF AGREEMENT OR DISAGREEMENT WITH THE FOLLOWING STATEMENTS.

3. Providing formal assessment of patient self-management (i.e., tracking whether patients meet their specified goals)…

	Strongly disagree	Disagree	Neither agree nor disagree	Agree	Strongly agree	Don’t Know
a. is useful when providing general medical care.	1	2	3	4	5	8
b. is useful when providing cancer screening and follow-up	1	2	3	4	5	8
c. has been improved among our health care providers and staff because of the organization's efforts to educate them about it	1	2	3	4	5	8
d. has been implemented in our health care organization	1	2	3	4	5	8
e. has been supported by adequate resources from our health care organization.	1	2	3	4	5	8

4. Initiating or maintaining programs to increase patient self-management skills…

	Strongly disagree	Disagree	Neither agree nor disagree	Agree	Strongly agree	Don’t Know
a. is useful when providing general medical care.	1	2	3	4	5	8
b. is useful when providing cancer screening and follow-up	1	2	3	4	5	8
c. has been improved among our health care providers and staff because of the organization’s efforts to educate them about it	1	2	3	4	5	8
d. has been implemented in our health care organization	1	2	3	4	5	8
e. has been supported by adequate resources from our health care organization.	1	2	3	4	5	8

5. Providing clinical guidelines to patients…

	Strongly disagree	Disagree	Neither agree nor disagree	Agree	Strongly agree	Don’t Know
a. is useful when providing general medical care.	1	2	3	4	5	8
b. is useful when providing cancer screening and follow-up	1	2	3	4	5	8
c. has been improved among our health care providers and staff because of the organization’s efforts to educate them about it	1	2	3	4	5	8
d. has been implemented in our health care organization	1	2	3	4	5	8
e. has been supported by adequate resources from our health care organization.	1	2	3	4	5	8

6. Providing clinical guidelines to health care providers (physicians, physician assistants, nurse practitioners) through reminders…

	Strongly disagree	Disagree	Neither agree nor disagree	Agree	Strongly agree	Don’t Know
a. is useful when providing general medical care.	1	2	3	4	5	8
b. is useful when providing cancer screening and follow-up	1	2	3	4	5	8
c. has been improved among our health care providers and staff because of the organization’s efforts to educate them about it	1	2	3	4	5	8
d. has been implemented in our health care organization	1	2	3	4	5	8
e. has been supported by adequate resources from our health care organization.	1	2	3	4	5	8

7. Changing responsibilities of health care providers and staff in the clinic to enable them to function more like a team…

	Strongly disagree	Disagree	Neither agree nor disagree	Agree	Strongly agree	Don’t Know
a. is useful when providing general medical care.	1	2	3	4	5	8
b. is useful when providing cancer screening and follow-up	1	2	3	4	5	8
c. has been improved among our health care providers and staff because of the organization’s efforts to educate them about it	1	2	3	4	5	8
d. has been implemented in our health care organization	1	2	3	4	5	8
e. has been supported by adequate resources from our health care organization.	1	2	3	4	5	8

8. Providing written feedback reports or data to health care providers (physicians, physician assistants, nurse practitioners) regarding their performance…

	Strongly disagree	Disagree	Neither agree nor disagree	Agree	Strongly agree	Don’t Know
a. is useful when providing general medical care.	1	2	3	4	5	8
b. is useful when providing cancer screening and follow-up	1	2	3	4	5	8
c. has been implemented in our health care organization	1	2	3	4	5	8
d. has been supported by adequate resources from our health care organization.	1	2	3	4	5	8

For several of the next questions, we are interested in your local clinic team. Your local clinic team is defined as the group of individuals responsible for delivering care in the clinic. The local clinic team includes both clinicians and non-clinicians.

9. Providing written feedback reports or data to local clinic teams regarding their performance…

	Strongly disagree	Disagree	Neither agree nor disagree	Agree	Strongly agree	Don’t Know
a. is useful when providing general medical care.	1	2	3	4	5	8
b. is useful when providing cancer screening and follow-up	1	2	3	4	5	8
c. has been implemented in our health care organization	1	2	3	4	5	8
d. has been supported by adequate resources from our health care organization.	1	2	3	4	5	8

iii. INFORMATION SYSTEMS

FOR PURPOSES OF THIS SECTION, THE TERM “INFORMATION SYSTEMS” CAN REFER TO A COMPUTER SYSTEM OR ELECTRONIC MEDICAL RECORD, BUT DOES NOT NEED TO DO SO.

Quality performance reports may include rates of the delivery of clinical services, such as a screening test, at either the clinic/local team or health care provider/individual level.

1. In the past 12 months, did you receive any reports about the rates of delivery of clinical services at the health center level?

	Yes	No	Don’t Know
a. At the clinic/local team level?	1	2	8
b. At the individual level regarding your own patients?	1	2	8

(IF NO FOR BOTH, GO TO Q3)

2. In the past 12 months, did you receive any reports from the information system about rates of…

a. Screening mammography?

1. At the clinic/local team level

Yes ……………. 1

How often: ___Every Month / Every __ Months / __Don't Know

No 2

Don’t Know 8

2. At the health care provider/individual level

Yes ……………. 1

How often: ___Every Month / Every __ Months / __Don't Know

No 2

Don’t Know 8

b. Screening Pap test?

1. At the clinic/local team level

Yes ……………. 1

How often: ___Every Month / Every __ Months / __Don't Know

No 2

Don’t Know 8

2. At the health care provider/individual level

Yes ……………. 1

How often: ___Every Month / Every __ Months / __Don't Know

No 2

Don’t Know 8

c. Screening for colorectal cancer?

1. At the clinic/local team level

Yes ……………. 1

How often: ___Every Month / Every __ Months / __Don't Know

No 2

Don’t Know 8

2. At the health care provider/individual level

Yes ……………. 1

How often: ___Every Month / Every __ Months / __Don't Know

No 2

Don’t Know 8

d. Patient notification of screening test results within 30 days of any cancer screening test?

1. At the clinic/local team level

Yes ……………. 1

How often: ___Every Month / Every __ Months / __Don't Know

No 2

Don’t Know 8

2. At the health care provider/individual level

Yes ……………. 1

How often: ___Every Month / Every __ Months / __Don't Know

No 2

Don’t Know 8

e. Discussion of screening with patients?

1. At the clinic/local team level

Yes ……………. 1

How often: ___Every Month / Every __ Months / __Don't Know

No 2

Don’t Know 8

2. At the health care provider/individual level

Yes ……………. 1

How often: ___Every Month / Every __ Months / __Don't Know

No 2

Don’t Know 8

4. Our clinic is using an information system (not necessarily computerized) to send prompts to health care providers (physicians, physician assistants, nurse practitioners) at the time of the patient encounter about whether their patients are eligible for cancer screening.

Yes 1

No 2

Don’t Know 8

5. Our clinic is using an information system to send correspondence or reminders to patients eligible for cancer screening.

Yes 1

No 2

Don’t Know 8

6. Our clinic is using an information system to send correspondence or reminders to patients about screening test results.

Yes 1

No 2

Don’t Know 8

Division of Responsibilities

MARK ALL MEMBERS OF THE LOCAL CLINIC WHO PARTICIPATE IN PERFORMING THE ACTIVITY. MARK CONSULTANT IF THAT IS SOMEONE WHO DOES THE ACTIVITY. MARK “NO ONE” IF NEITHER A CONSULTANT NOR ANYONE IN THE LOCAL CLINIC PERFORMS THE ACTIVITY.

	Physician	Other provider (NP, PA)	Nurse	Other staff (office, lab)	Radiology consultant	No one
7. Screening mammography
a. Generates a list of patients due for screening	1	2	3	4	5	6
b. Actively contacts patients if due for screening	1	2	3	4	5	6
c. Discusses decision to screen with patients	1	2	3	4	5	6
d. Schedules screening mammogram	1	2	3	4	5	6
e. Actively contacts patients with abnormal screening results within 30 days	1	2	3	4	5	6
f. Arranges breast procedure if necessary (including biopsy)	1	2	3	4	5	6
	Physician	Other provider (NP, PA)	Nurse	Other staff (office, lab)	OB-GYN consultant	No one
8. Screening Pap test
a. Generates a list of patients due for screening	1	2	3	4	5	6
b. Actively contacts patients if due for screening	1	2	3	4	5	6
c. Discusses decision to screen with patients	1	2	3	4	5	6
d. Schedules Pap test	1	2	3	4	5	6
e. Performs Pap test	1	2	3	4	5	6
f. Actively contacts patients with abnormal screening results within 30 days	1	2	3	4	5	6
g. Arranges gynecologic procedure if necessary (includes colposcopy)	1	2	3	4	5	6

MARK ALL MEMBERS OF THE LOCAL CLINIC WHO PARTICIPATE IN PERFORMING THE ACTIVITY. MARK CONSULTANT IF THAT IS SOMEONE WHO DOES THE ACTIVITY. MARK “NO ONE” IF NEITHER A CONSULTANT NOR ANYONE IN THE LOCAL CLINIC PERFORMS THE ACTIVITY.

	Physician	Other provider (NP, PA)	Nurse	Other staff (office, lab)	GI consultant	No one
9. Colorectal cancer screening
a. Generates a list of patients due for screening	1	2	3	4	5	6
b. Actively contacts patients if due for screening	1	2	3	4	5	6
c. Discusses screening options with patients	1	2	3	4	5	6
d. Distributes fecal occult blood tests (stool cards)	1	2	3	4	5	6
e. Schedules lower endoscopy	1	2	3	4	5	6
f. Enters fecal occult blood test results (stool cards) into tracking database.	1	2	3	4	5	6
g. Actively contacts patients with abnormal screening results within 30 days	1	2	3	4	5	6
10. All screening tests
a. Arranges referral for treatment if cancer detected	1	2	3	4	5	6

11. Please indicate whether each piece of information listed below is available in the clinic's computer system. If you answer "Yes, it is available," then please answer whether the information is up-to-date and accurate. If you answer "NO, it is not available," go to the next piece of information.

	Available in the computer system?		Up-to-date?		Accurate?
	No	Yes	Yes	No	Yes	Yes
a. Health care provider notes	2	1 	1	2	1	2
b. Clinical guidelines	2	1 	1	2	1	2
c. Reminders for screening due	2	1 	1	2	1	2
d. Mammogram results	2	1 	1	2	1	2
e. Pap test results	2	1 	1	2	1	2
f. Fecal occult blood test results	2	1 	1	2	1	2
g. Results of procedures for breast cancer detection, including biopsy	2	1 	1	2	1	2
h. Results of gynecologic procedures for cervical cancer detection, including colposcopy	2	1 	1	2	1	2
i. Results of endoscopy procedures for colorectal cancer detection	2	1 	1	2	1	2

12. In the past 12 months, results of the following have been actively delivered to you…

	Usually in a timely manner that makes a difference in clinical care	Usually too late to make a difference in clinical care	Not delivered at all
a. Mammograms	1	2	3
b. Pap tests	1	2	3
c. Fecal occult blood tests	1	2	3
d. Results of endoscopy procedures for colorectal cancer screening	1	2	3
e. Results of diagnostic procedures (including biopsy) for breast cancer after an abnormal screening test	1	2	3
f. Results of gynecologic procedures (including colposcopy) for cervical cancer diagnosis after an abnormal screening test	1	2	3
g. Results of endoscopy procedures for colorectal cancer detection after an abnormal screening test	1	2	3

13. Does your health center’s information system have any capacity to measure cancer screening or follow-up?

Yes 1

No 2 Don’t Know 8

(GO TO SECTION IV)

14. In the past 12 months, our health center has been able to use reports of clinical performance to effectively design and test changes in managing the rate of:

	Strongly disagree	Disagree	Neither agree nor disagree	Agree	Strongly agree	Don’t Know
a. Screening mammography within the previous 2 years	1	2	3	4	5	8
b. Pap test within the previous 3 years	1	2	3	4	5	8
c. Appropriate screening for colorectal cancer	1	2	3	4	5	8
d. Notification of screening results within 30 days	1	2	3	4	5	8
e. Completion of additional diagnostic testing after abnormal screening results within appropriate time frame	1	2	3	4	5	8
f. Beginning of treatment after cancer detection within appropriate time frame	1	2	3	4	5	8
g. Documentation of self-management goal setting	1	2	3	4	5	8

15. PLEASE DESCRIBE YOUR LEVEL OF AGREEMENT OR DISAGREEMENT WITH THE FOLLOWING STATEMENTS ABOUT THE INFORMATION SYSTEM IN PLACE AT YOUR HEALTH CENTER.

	Strongly disagree	Disagree	Neither agree nor disagree	Agree	Strongly agree	Don’t Know
a. The center’s information system is adequate to accommodate the size of the population eligible for cancer screening.	1	2	3	4	5	8
b. The center continually tries to improve the timeliness of its data on cancer screening and follow-up	1	2	3	4	5	8
c. The center continually tries to improve the accuracy and relevance of its data on cancer screening and follow-up	1	2	3	4	5	8
d. The information system accurately documents whether appropriate treatment takes place after cancer detection	1	2	3	4	5	8
e. The data gathered in the information system is used by leadership to change the health center’s activities related to cancer screening.	1	2	3	4	5	8
f. The data gathered in the information system is used by health care providers to change their behavior.	1	2	3	4	5	8
g. I use the data gathered in the information system to change my behavior.	1	2	3	4	5	8

IV. LEADERSHIP

Senior Leadership of Health Center

For this set of questions, the senior leadership of your health center is defined as the people who are responsible for making decisions about resources and personnel across all affiliated clinics.

1. The number of members of the health center’s senior leadership who have left the organization over the past 12 months is:

|__|__|__| out of |__|__|__|

2. PLEASE DESCRIBE YOUR LEVEL OF AGREEMENT OR DISAGREEMENT WITH THE FOLLOWING STATEMENTS ABOUT SENIOR LEADERSHIP OVERALL.

Overall, the senior leadership of the health center…	Strongly disagree	Disagree	Neither agree nor disagree	Agree	Strongly agree	Don’t Know
a. Has demonstrated an ability to manage the changes (e.g., organizational, technological) needed to improve the quality of care and services.	1	2	3	4	5	8
b. Always listens to the concerns of other members of the organization	1	2	3	4	5	8
c. Provides needed feedback to members of the organization	1	2	3	4	5	8
d. Helps members of the organization work well together	1	2	3	4	5	8
e. Provides members of the organization with a clear expectation of their roles	1	2	3	4	5	8
f. Makes sure people have the skills and knowledge to work in teams	1	2	3	4	5	8
g. Makes sure a local clinic team that does a good job gets special rewards or recognition	1	2	3	4	5	8
h. Strongly supports our work	1	2	3	4	5	8
i. Regularly reviews our progress in making change	1	2	3	4	5	8
j. Sees success in improving the quality of care as a high priority for the organization	1	2	3	4	5	8

Local Clinic Team Leadership

For this set of questions, the local leader is defined as the person who is a part of the local clinic team and most responsible for leading the team in efforts to measure and improve the quality of care.

If you consider yourself to be the local leader, please check here _____ and go to Section V.

	Strongly disagree	Disagree	Neither agree nor disagree	Agree	Strongly agree	Don’t Know
3. The local leader…
a. Possesses the functional expertise necessary for leading the local clinic team successfully	1	2	3	4	5	8
b. Always listens to the concerns of other local clinic team members	1	2	3	4	5	8
c. Provides needed feedback to other local clinic team members	1	2	3	4	5	8
d. Helps local clinic team members work well together	1	2	3	4	5	8
e. Provides local clinic team members with a clear expectation of their roles on this team	1	2	3	4	5	8

V. TEAMS

For this set of questions, your local clinic team is again defined as the group of individuals responsible for both delivering and improving the quality of care in the clinic. The local clinic team responsible for care and quality improvement may include both clinicians and non-clinicians.

1. Local Clinic Team Characteristics

	Strongly disagree	Disagree	Neither agree nor disagree	Agree	Strongly agree	Don’t Know
a. The number of people on my local clinic team is about right for the work to be accomplished	1	2	3	4	5	8
b. The members of the local clinic team work together well as a team	1	2	3	4	5	8
c. Members of my local clinic team vary widely in their knowledge, skills, and abilities	1	2	3	4	5	8
d. Members of my local clinic team have skills and abilities that complement each other	1	2	3	4	5	8
e. I generally prefer to work as part of a team	1	2	3	4	5	8
f. Our local clinic team gets the information we need to plan our work	1	2	3	4	5	8

1. Local Clinic Team Characteristics (continued)

	Strongly disagree	Disagree	Neither agree nor disagree	Agree	Strongly agree	Don’t Know
g. Our local clinic team has the authority to manage its work pretty much the way members want to	1	2	3	4	5	8
h. There is a great deal of room for initiative and judgment in the work that we do	1	2	3	4	5	8
i. The participants on our local clinic team have substantial influence in managing care and influencing others to make improvements in care	1	2	3	4	5	8
j. When our local clinic team does not know something it needed to know to do its work, there are people available to teach or help	1	2	3	4	5	8
k. There are one or more well-respected members of our staff that support our work with their time, and verbal encouragement	1	2	3	4	5	8
l. Our local clinic team is able to identify measures that were tracked on a regular basis to assess our work	1	2	3	4	5	8
m. My skills, training, and experience are fully utilized	1	2	3	4	5	8

VI. BACKGROUND INFORMATION

1. What is your current job title?

________________________________

2. How long have you worked in your current position?

|__|__| or |__|__|

Years Months

3. How long have you worked at this health center?

|__|__| or |__|__|

Years Months

4. About how many outpatients do you see in a typical week?

|__|__|__|

# of Outpatients

5. Thinking about all the work that you do, on average, approximately how many hours per week do you spend doing:

a. patient care |__|__| hours per week

b. administrative tasks |__|__| hours per week

c. teaching |__|__| hours per week

d. research-related activities |__|__| hours per week

6. Is your current pay affected by:

Don’t

Yes No Know

a. The results of satisfaction surveys completed by
your own patients? 1 2 8

b. Specific measures of quality of care, such as screening
rates for your patients? 1 2 8

7. Are you a physician?

Yes 1 (GO TO Q9)

No 2

8. Which of the following titles best describes your occupational background…

Physician (MD or DO) 1

Physician Assistant (PA) 2

Nurse Practitioner (NP) 3

Registered Nurse (RN) 4

Licensed Practical Nurse (LPN) 5

Other (SPECIFY) 8

9. In what year did you graduate from your school or program

|__|__|__|__| YYYY

Year Graduated

10. In what year were you born?

|__|__|__|__| YYYY

Year Born

11. What is your gender?

Male 1

Female 2

12. What is your race? (MARK ONE OR MORE RACES)

American Indian or Alaska Native 1

Asian 2

Black or African American 3

Native Hawaiian or Other Pacific Islander 4

White 5

13. Are you of Hispanic or Latino origin?

Yes 1

No 2

Don’t Know 8

FOR PHYSICIANS ONLY

14. In what year did you graduate from medical school?

|__|__|__|__| YYYY

Year Graduated

15. FOR ANY FIELDS LISTED BELOW THAT APPLY TO YOU, PLEASE RECORD YOUR CURRENT CLINICAL TRAINING STATUS.

	Completed residency or fellowship		Board-certified
	Yes	No	Yes	No
a. Family Practice	1	2	1	2
b. Infectious Diseases	1	2	1	2
c. Internal Medicine	1	2	1	2
d. Med/Peds	1	2	1	2
e. Ob/Gyn	1	2	1	2
f. Psychiatry	1	2	1	2
g. Other (SPECIFY)	1	2	1	2

THANK YOU FOR COMPLETING THIS INVENTORY

OMB # 0925-0046-16 d

Exp. Date: 10/31/2006

Cancer Collaborative Study

INFORMATION SYSTEMS PERSONNEL Inventory

Instructions

This inventory asks for your opinions about activities related to cancer screening and follow-up in your clinic. It will take about 20 minutes to complete.

Marking your answers

A few items ask you to write in a number. For the other items, mark your answer by circling the corresponding number.

Moving through the questionnaire

You are sometimes told to skip over some questions (you will see GO TO instructions). If there is no instruction next to the number you circled, simply move to the next item.

Information Systems Personnel Inventory

I. introduction

1. Did you ever participate in any HRSA Health Disparities Collaborative prior to 2005?

Yes 1

No 2 Don’t Know 8

(GO TO Q3)

2. Did you participate in the HRSA Health Disparities Cancer Collaborative anytime from 2002 through 2004?

Yes 1

Would you say regarding implementation of the Cancer Collaborative

that your organization is:

____Mostly in the planning stage

____Mostly in the early implementation stage

____Now receiving usable data on implementation activities

No 2

Don’t Know 8

3. Have you ever participated, either formally or informally, in quality improvement activities at your health center?

Yes 1

No 2

Don’t Know 8

(IF NO, THEN SKIP QUESTION 4)

4. How often do members of your health center engage in the following activities to improve cancer screening and follow-up?

	Not at all	Rarely	Sometimes	Often	Don’t Know
Conference calls with experts outside your health center	1	2	3	4	8
E-mail (listserv) discussions with experts outside your health center	1	2	3	4	8
Visits from/to other health centers	1	2	3	4	8
Ongoing measurement of clinical performance at your center	1	2	3	4	8

II. CLINIC PROCESSES

1. Changing responsibilities of health care providers (physicians, physician assistants, nurse practitioners) and staff in the clinic to enable them to function more like a team…

	Strongly disagree	Disagree	Neither agree nor disagree	Agree	Strongly agree	Don’t Know
a. is useful when providing general medical care.	1	2	3	4	5	8
b. is useful when providing cancer screening and follow-up	1	2	3	4	5	8
c. has been improved among our health care providers and staff because of the organization’s efforts to educate them about it	1	2	3	4	5	8
d. has been implemented in our health care organization	1	2	3	4	5	8
e. has been supported by adequate resources from our health care organization.	1	2	3	4	5	8

2. Providing written feedback reports or data to health care providers (physicians, physician assistants, nurse practitioners) regarding their performance…

	Strongly disagree	Disagree	Neither agree nor disagree	Agree	Strongly agree	Don’t Know
a. is useful when providing general medical care.	1	2	3	4	5	8
b. is useful when providing cancer screening and follow-up	1	2	3	4	5	8
c. has been implemented in our health care organization	1	2	3	4	5	8
d. has been supported by adequate resources from our health care organization.	1	2	3	4	5	8

3. Providing written feedback reports or data to clinic teams regarding their performance…

	Strongly disagree	Disagree	Neither agree nor disagree	Agree	Strongly agree	Don’t Know
a. is useful when providing general medical care.	1	2	3	4	5	8
b. is useful when providing cancer screening and follow-up	1	2	3	4	5	8
c. has been implemented in our health care organization	1	2	3	4	5	8
d. has been supported by adequate resources from our health care organization.	1	2	3	4	5	8

III. INFORMATION SYSTEMS

FOR PURPOSES OF THIS SECTION, THE TERM “INFORMATION SYSTEMS” CAN REFER TO A COMPUTER SYSTEM OR ELECTRONIC MEDICAL RECORD, BUT DOES NOT NEED TO DO SO.

Quality performance reports may include rates of the delivery of clinical services, such as a screening test, at either the clinic/local team or health care provider/individual level.

1. In the past 12 months, did you receive any reports about the rates of delivery of clinical services at the health center level?

	YYes	NNo	DDon’t Know
At the clinic/local team level?	1	2	8
At the health care provider/individual level?	1	2	8

(IF NO FOR BOTH, GO TO Q3)

2. In the past 12 months, did you receive any reports from the information system about rates of…?

a. Screening mammography?

1. At the clinic/local team level

Yes ……………. 1

How often: ___Every Month / Every __ Months / __Don't Know

No 2

Don’t Know 8

2. At the health care provider/individual level

Yes ……………. 1

How often: ___Every Month / Every __ Months / __Don't Know

No 2

Don’t Know 8

b. Screening Pap test?

1. At the clinic/local team level

Yes ……………. 1

How often: ___Every Month / Every __ Months / __Don't Know

No 2

Don’t Know 8

2. At the health care provider/individual level

Yes ……………. 1

How often: ___Every Month / Every __ Months / __Don't Know

No 2

Don’t Know 8

c. Screening for colorectal cancer?

1. At the clinic/local team level

Yes ……………. 1

How often: ___Every Month / Every __ Months / __Don't Know

No 2

Don’t Know 8

2. At the health care provider/individual level

Yes ……………. 1

How often: ___Every Month / Every __ Months / __Don't Know

No 2

Don’t Know 8

d. Patient notification of screening results within 30 days of any cancer screening test?

1. At the clinic/local team level

Yes ……………. 1

How often: ___Every Month / Every __ Months / __Don't Know

No 2

Don’t Know 8

2. At the health care provider/individual level

Yes ……………. 1

How often: ___Every Month / Every __ Months / __Don't Know

No 2

Don’t Know 8

e. Discussion of screening with patients?

1. At the clinic/local team level

Yes ……………. 1

How often: ___Every Month / Every __ Months / __Don't Know

No 2

Don’t Know 8

2. At the health care provider/individual level

Yes ……………. 1

How often: ___Every Month / Every __ Months / __Don't Know

No 2

Don’t Know 8

3. Is there a computer with Internet access available at your clinic for you to use for patient care?

Yes 1

No 2 Don’t Know 8

(GO TO Q8)

4. Where is the computer?

		Yes	No	Don’t Know
a.	At the point of care (e.g., exam room)	1	2	8
b.	At your desk or a work station, away from the point of care	1	2	8

5. The information system can send prompts to health care providers (physicians, physician assistants, nurse practitioners) at the time of the patient encounter about which of their patients are eligible for cancer screening.

Yes 1

No 2

Don’t Know 8

6. The information system has the capacity to send correspondence or reminders to patients eligible for cancer screening.

Yes 1

No 2

Don’t Know 8

7. The information system has the capacity to send reminders or correspondence to patients about screening test results.

Yes 1

No 2

Don’t Know 8

8. Are you able to use an information system to systematically identify all patients due for cancer screening?

	Yes	No	Don’t know
a. By name	1	2	8
b. With contact information	1	2	8

9. Please indicate whether each piece of information listed below is available in the clinic's computer system. If you answer "Yes, it is available," then please answer whether the information is up-to-date and accurate. If you answer "NO, it is not available," go to the next piece of information.

	Available in the computer system?		Up-to-date?		Accurate?
	No	Yes	Yes	No	Yes	Yes
a. Health care provider notes	2	1 	1	2	1	2
b. Clinical guidelines	2	1 	1	2	1	2
c. Reminders for screening due	2	1 	1	2	1	2
d. Mammogram results	2	1 	1	2	1	2
e. Pap test results	2	1 	1	2	1	2
f. Fecal occult blood test results	2	1 	1	2	1	2
g. Results of procedures for breast cancer detection, including biopsy	2	1 	1	2	1	2
h. Results of gynecologic procedures for cervical cancer detection, including colposcopy	2	1 	1	2	1	2
i. Results of lower endoscopy procedures for colorectal cancer detection	2	1 	1	2	1	2

10. In the past 12 months, results of the following are actively delivered to health care providers (physicians, physician assistants, nurse practitioners):

	Usually in a timely manner that makes a difference in clinical care	Usually too late to make a difference in clinical care	Not delivered at all
Mammograms	1	2	3
Pap tests	1	2	3
Fecal occult blood tests	1	2	3
Results of lower endoscopy procedures for colorectal cancer screening	1	2	3
Results of diagnostic procedures (including biopsy) for breast cancer after an abnormal screening test	1	2	3
Results of gynecologic procedures (including colposcopy) for cervical cancer diagnosis after an abnormal screening test	1	2	3
Results of lower endoscopy procedures for colorectal cancer detection after an abnormal screening test	1	2	3

11. Does your health center’s information system have any capacity to measure cancer screening or follow-up?

Yes 1

No 2 Don’t Know 8

(GO TO SECTION IV)

12. In the past 12 months, our health center has been able to use reports of clinical performance to effectively design and test changes in managing the rate of:

	Strongly disagree	Disagree	Neither disagree nor agree	Agree	Strongly agree	Don’t know
Screening mammography within the previous 2 years	1	2	3	4	5	8
Pap test within the previous 3 years	1	2	3	4	5	8
Appropriate screening for colorectal cancer	1	2	3	4	5	8
Notification of screening results within 30 days	1	2	3	4	5	8
Completion of additional diagnostic testing after abnormal screening results within appropriate time frame	1	2	3	4	5	8
Completion of treatment after cancer detection within appropriate time frame	1	2	3	4	5	8
Documentation of shared decision-making	1	2	3	4	5	8

13. The size of the population eligible for cancer screening at our health center makes achieving a goal rate for the following measure difficult:

	Strongly disagree	Disagree	Neither disagree nor agree	Agree	Strongly agree	Don’t know
Screening mammography within the previous 2 years	1	2	3	4	5	8
Pap test within the previous 3 years	1	2	3	4	5	8
Appropriate screening for colorectal cancer	1	2	3	4	5	8
Notification of screening results within 30 days	1	2	3	4	5	8
Completion of additional diagnostic testing after abnormal screening results within appropriate time frame	1	2	3	4	5	8
Completion of treatment after cancer detection within appropriate time frame	1	2	3	4	5	8
Documentation of shared decision-making	1	2	3	4	5	8

14. PLEASE DESCRIBE YOUR LEVEL OF AGREEMENT OR DISAGREEMENT WITH THE FOLLOWING STATEMENTS ABOUT THE INFORMATION SYSTEM IN PLACE AT YOUR HEALTH CENTER.

	Strongly disagree	Disagree	Neither disagree nor agree	Agree	Strongly agree	Don’t know
The center’s information system is adequate to accommodate the size of the population eligible for cancer screening	1	2	3	4	5	8
The center continually tries to improve the timeliness of its data on cancer screening and follow-up	1	2	3	4	5	8
The center continually tries to improve the accuracy and relevance of its data on cancer screening and follow-up	1	2	3	4	5	8
Data entry does not represent a barrier to using the information system	1	2	3	4	5	8
We have adequate staff to perform the data entry required by the information system	1	2	3	4	5	8
The information system accurately documents whether appropriate treatment takes place after cancer detection The information system accurately documents whether appropriate treatment takes place after cancer detection	1	2	3	4	5	8
g. The data gathered in the information system is used by leadership to change the health center’s activities related to cancer screening.	1	2	3	4	5	8
h. The data gathered in the information system is used by health care providers to change their behavior related to cancer screening.	1	2	3	4	5	8

IV. LEADERSHIP

Senior Leadership of Health Center

For this set of questions, we are interested in the senior leadership of your health center. The senior leadership of your health center is defined as the people who are responsible for making decisions about resources and personnel across all affiliated clinics.

1. PLEASE DESCRIBE YOUR LEVEL OF AGREEMENT OR DISAGREEMENT WITH THE FOLLOWING STATEMENTS ABOUT SENIOR LEADERSHIP.

The senior leadership of the health center…	Strongly disagree	Disagree	Neither agree nor disagree	Agree	Strongly agree	Don’t know
a. Has demonstrated an ability to manage the changes (e.g., organizational, technological) needed to improve the quality of care and services.	1	2	3	4	5	8
b. Always listens to the concerns of other members of the organization	1	2	3	4	5	8
c. Provides needed feedback to members of the organization	1	2	3	4	5	8
d. Helps members of the organization in working well together	1	2	3	4	5	8
e. Provides members of the organization with a clear expectation of their roles	1	2	3	4	5	8
f. This organization makes sure people have the skills and knowledge to work in teams	1	2	3	4	5	8
g. Makes sure a local clinic team that does a good job gets special rewards or recognition	1	2	3	4	5	8
h. Senior leadership at the health center strongly supports our work	1	2	3	4	5	8
i. Senior leadership regularly reviews our progress in making change	1	2	3	4	5	8
j. Senior leadership in my organization sees success in improving the quality of care as a high priority for the organization	1	2	3	4	5	8

Local Clinic Team Leadership

For several of the next questions, we are interested in your local clinic team. Your local clinic team is defined as the group of individuals responsible for delivering care in the clinic. The local clinic team includes both clinicians and non-clinicians.

For this set of questions, the local leader is defined as the person who is a part of the local clinic team and most responsible for leading the team in efforts to measure and improve the quality of care.

	Strongly disagree	Disagree	Neither agree nor disagree	Agree	Strongly agree	Don’t know
2. The local leader…
a. Possesses the functional expertise necessary for leading the local clinic team successfully.	1	2	3	4	5	8
b. Always listens to the concerns of other local clinic team members	1	2	3	4	5	8
c. Provides needed feedback to other local clinic team members	1	2	3	4	5	8
d. Helps local clinic team members in working well together	1	2	3	4	5	8
e. Provides local clinic team members with a clear expectation of their roles on this team	1	2	3	4	5	8

V. TEAMS

Again, your “local clinic team” is defined as the group of individuals responsible for delivering care in the clinic. The local clinic team includes both clinicians and non-clinicians.

1. The number of individuals on your local clinic team with whom you work regularly (excluding yourself) is:

|__|__|__|

Number

2. The number of individuals on your local clinic team who stopped working regularly with you over the past 12 months is:

|__|__|__|

Number

3. The number of members of the health center’s senior leadership who have left the organization over the past 12 months is:

|__|__|__| out of |__|__|__|

4. Local Clinic Team Characteristics

	Strongly disagree	Disagree	Neither agree nor disagree	Agree	Strongly agree	Don’t know
a. The number of people on my local clinic team is about right for the work to be accomplished	1	2	3	4	5	8
b. The members of the local clinic team work together well as a team	1	2	3	4	5	8
c. Members of my local clinic team vary widely in their knowledge, skills, and abilities	1	2	3	4	5	8
d. Members of my local clinic team have skills and abilities that complement each other	1	2	3	4	5	8
e. I generally prefer to work as part of a team	1	2	3	4	5	8
f. Our local clinic team gets the information we need to plan our work	1	2	3	4	5	8

4. Local Clinic Team Characteristics (continued)

	Strongly disagree	Disagree	Neither agree nor disagree	Agree	Strongly agree	Don’t know
g. Our local clinic team has the authority to manage its work pretty much the way members want to	1	2	3	4	5	8
h. There is a great deal of room for initiative and judgment in the work that we do	1	2	3	4	5	8
i. The participants on our local clinic team have substantial influence in managing care and influencing others to make improvements in care	1	2	3	4	5	8
j. When our local clinic team does not know something it needed to know to do its work, there are people available to teach or help	1	2	3	4	5	8
k. There are one or more well-respected members of our staff that support our work with their time, and verbal encouragement	1	2	3	4	5	8
l. Our local clinic team is able to identify measures that were tracked on a regular basis to assess our work	1	2	3	4	5	8
m. My skills, training, and experience are fully utilized	1	2	3	4	5	8

VI. BACKGROUND INFORMATION

1. What is your current job title?

________________________________

2. How long have you worked in your current position?

|__|__| or |__|__|

Years Months

3. How long have you worked at this health center?

|__|__| or |__|__|

Years Months

4. In what year were you born?

|__|__|__|__| YYYY

Year

5. What is your gender?

Male 1

Female 2

6. What is your race? (MARK ONE OR MORE RACES)

American Indian or Alaska Native 1

Asian 2

Black or African American 3

Native Hawaiian or Other Pacific Islander 4

White 5

7. Are you Spanish/Hispanic/Latino?

No 1

Yes, Mexican, Mexican Am., Chicano 2

Yes, Puerto Rican 3

Yes, Cuban 4

Yes, other Spanish/Hispanic/Latino 5

THANK YOU FOR COMPLETING THIS INVENTORY

OMB # 0925-0046-16 e

Exp. Date: 10/31/2006

Cancer Collaborative Study

GENERAL STAFF Inventory

Instructions

This inventory asks for your opinions about activities related to cancer screening and follow-up in your clinic. It will take about 20 minutes to complete.

Marking your answers

A few items ask you to write in a number. For the other items, mark your answer by circling the corresponding number.

Moving through the questionnaire

You are sometimes told to skip over some questions (you will see GO TO instructions). If there is no instruction next to the number you circled, simply move to the next item.

STAFF INVENTORY

I. INTRODUCTION

1. Did you ever participate in any HRSA Health Disparities Collaborative prior to 2005?

Yes 1

No 2 Don’t Know 8

(GO TO Q3)

2. Did you participate in the HRSA Health Disparities Cancer Collaborative anytime from 2002 through 2004?

Yes 1

Would you say regarding implementation of the Cancer Collaborative

that your organization is:

____Mostly in the planning stage

____Mostly in the early implementation stage

____Now receiving usable data on implementation activities

No 2

Don’t Know 8

3. Have you ever participated, either formally or informally, in quality improvement activities at your health center?

Yes 1

No 2

Don’t Know 8

(IF NO, THEN SKIP QUESTION 4)

4. How often do members of your health center engage in the following activities to improve cancer screening and follow-up?

	Not at all	Rarely	Some-times	Often	Don’t Know
Conference calls with experts outside your health center	1	2	3	4	8
E-mail (listserv) discussions with experts outside your health center	1	2	3	4	8
Visits from/to other health centers	1	2	3	4	8
Ongoing measurement of clinical performance at your center	1	2	3	4	8

II. CLINIC PROCESSES

1. How often does your health center connect patients with available community resources for cancer screening?

Not at all 1

Rarely 2

Sometimes 3

Often 4

Don’t Know 8

		Strongly disagree	Disagree	Neither agree nor disagree	Agree	Strongly agree	Don’t Know
2.	The available community resources for cancer screening are adequate for your patient population	1	2	3	4	5	8

3. There are many ways providers can inform patients about cancer screening choices.

How often do you or your staff…

a. Provide patients with educational materials, such as pamphlets or brochures, that are easy to read and understand?

Never 1

Rarely 2

Sometimes 3

Routinely 4

Don’t Know 8

b. Provide patients with written or online directories that provide guidance to cancer resources?

Never 1

Rarely 2

Sometimes 3

Routinely 4

Don’t Know 8

4. During acute care visits, how often are cancer screening guidelines discussed with eligible patients?

a. By you?

Never 1

Rarely 2

Sometimes 3

Routinely 4

Don’t Know 8

Not applicable 9

b. By others who work in the clinic?

Never 1

Rarely 2

Sometimes 3

Routinely 4

Don’t Know 8

5. During non-acute care visits, how often are cancer screening guidelines discussed with eligible patients?

a. By you?

Never 1

Rarely 2

Sometimes 3

Routinely 4

Don’t Know 8

Not applicable 9

b. By others who work in the clinic?

Never 1

Rarely 2

Sometimes 3

Routinely 4

Don’t Know 8

6. Is someone at your health center instructed to document self-management goal setting among patients (including (1) asking about cancer screening, (2) sharing information about cancer screening, and (3) identifying a plan)?

Yes 1

No 2

Don’t Know 8

At the start of the following questions, an approach to providing care is described in bold. PLEASE DESCRIBE YOUR LEVEL OF AGREEMENT OR DISAGREEMENT WITH THE FOLLOWING STATEMENTS.

7. Providing formal assessment of patient self-management (i.e., tracking whether patients meet their specified goals)…

	Strongly disagree	Disagree	Neither agree nor disagree	Agree	Strongly agree	Don’t know
a. is useful when providing general medical care.	1	2	3	4	5	8
b. is useful when providing cancer screening and follow-up	1	2	3	4	5	8
c. has been improved among our health care providers and staff because of the organization’s efforts to educate them about it	1	2	3	4	5	8
d. has been implemented in our health care organization	1	2	3	4	5	8
e. has been supported by adequate resources from our health care organization.	1	2	3	4	5	8

8. Initiating or maintaining programs to increase patient self-management skills…

	Strongly disagree	Disagree	Neither agree nor disagree	Agree	Strongly agree	Don’t know
a. is useful when providing general medical care.	1	2	3	4	5	8
b. is useful when providing cancer screening and follow-up	1	2	3	4	5	8
c. has been improved among our health care providers and staff because of the organization’s efforts to educate them about it	1	2	3	4	5	8
d. has been implemented in our health care organization	1	2	3	4	5	8
e. has been supported by adequate resources from our health care organization.	1	2	3	4	5	8

9. Providing clinical guidelines to patients…

	Strongly disagree	Disagree	Neither agree nor disagree	Agree	Strongly agree	Don’t know
a. is useful when providing general medical care.	1	2	3	4	5	8
b. is useful when providing cancer screening and follow-up	1	2	3	4	5	8
c. has been improved among our health care providers and staff because of the organization’s efforts to educate them about it	1	2	3	4	5	8
d. has been implemented in our health care organization	1	2	3	4	5	8
e. has been supported by adequate resources from our health care organization.	1	2	3	4	5	8

10. Changing responsibilities of staff and providers in the clinic to enable them to function more like a team…

	Strongly disagree	Disagree	Neither agree nor disagree	Agree	Strongly agree	Don’t know
a. is useful when providing general medical care.	1	2	3	4	5	8
b. is useful when providing cancer screening and follow-up	1	2	3	4	5	8
c. has been improved among our health care providers and staff because of the organization’s efforts to educate them about it	1	2	3	4	5	8
d. has been implemented in our health care organization	1	2	3	4	5	8
e. has been supported by adequate resources from our health care organization.	1	2	3	4	5	8

For several of the next questions, we are interested in your local clinic team. Your local clinic team is defined as the group of individuals responsible for delivering care in the clinic. The local clinic team includes both clinicians and non-clinicians.

11. Providing written feedback reports or data to local clinic teams regarding their performance…

	Strongly disagree	Disagree	Neither agree nor disagree	Agree	Strongly agree	Don’t know
a. is useful when providing general medical care.	1	2	3	4	5	8
b. is useful when providing cancer screening and follow-up	1	2	3	4	5	8
c. has been implemented in our health care organization	1	2	3	4	5	8
d. has been supported by adequate resources from our health care organization.	1	2	3	4	5	8

III. INFORMATION SYSTEMS

FOR PURPOSES OF THIS SECTION, THE TERM “INFORMATION SYSTEMS” CAN REFER TO A COMPUTER SYSTEM OR ELECTRONIC MEDICAL RECORD, BUT DOES NOT NEED TO DO SO.

Division of Responsibilities

MARK ALL MEMBERS OF THE LOCAL CLINIC WHO PARTICIPATE IN PERFORMING THE ACTIVITY. MARK CONSULTANT IF THAT IS SOMEONE WHO DOES THE ACTIVITY. MARK “NO ONE” IF NEITHER A CONSULTANT NOR ANYONE IN THE LOCAL CLINIC PERFORMS THE ACTIVITY.

	Physician	Other provider (NP, PA)	Nurse	Other staff (office, lab)	Radiology consultant	No one
Screening mammography
a. Generates a list of patients due for screening	1	2	3	4	5	6
b. Actively contacts patients if due for screening	1	2	3	4	5	6
c. Discusses decision to screen with patients	1	2	3	4	5	6
d. Schedules screening mammogram	1	2	3	4	5	6
e. Actively contacts patients with abnormal screening results within 30 days	1	2	3	4	5	6
f. Arranges breast procedure if necessary (including biopsy)	1	2	3	4	5	6
	Physician	Other provider (NP, PA)	Nurse	Other staff (office, lab)	OB-GYN consultant	No one
Screening Pap test
a. Generates a list of patients due for screening	1	2	3	4	5	6
b. Actively contacts patients if due for screening	1	2	3	4	5	6
c. Discusses decision to screen with patients	1	2	3	4	5	6
d. Schedules Pap test	1	2	3	4	5	6
e. Performs Pap test	1	2	3	4	5	6
f. Actively contacts patients with abnormal screening results within 30 days	1	2	3	4	5	6
g. Arranges gynecologic procedure if necessary (includes colposcopy)	1	2	3	4	5	6

MARK ALL MEMBERS OF THE LOCAL CLINIC WHO PARTICIPATE IN PERFORMING THE ACTIVITY. MARK CONSULTANT IF THAT IS SOMEONE WHO DOES THE ACTIVITY. MARK “NO ONE” IF NEITHER A CONSULTANT NOR ANYONE IN THE LOCAL CLINIC PERFORMS THE ACTIVITY.

	Physician	Other provider (NP, PA)	Nurse	Other staff (office, lab)	GI consultant	No one
Colorectal cancer screening
a. Generates a list of patients due for screening	1	2	3	4	5	6
b. Actively contacts patients if due for screening	1	2	3	4	5	6
c. Discusses screening options with patients	1	2	3	4	5	6
d. Distributes fecal occult blood tests (stool cards)	1	2	3	4	5	6
e. Schedules lower endoscopy	1	2	3	4	5	6
f. Enters fecal occult blood test results (stool cards) into tracking database.	1	2	3	4	5	6
g. Actively contacts patients with abnormal screening results within 30 days	1	2	3	4	5	6
12. All screening tests
a. Arranges referral for treatment if cancer detected	1	2	3	4	5	6

5. In the last 12 months, our health center has been able to use self-measurement of clinic performance to effectively design and test changes in managing the rate of:

	Strongly disagree	Disagree	Neither agree nor disagree	Agree	Strongly agree	Don’t know
a. Screening mammography within the previous 2 years	1	2	3	4	5	8
b. Pap test within the previous 3 years	1	2	3	4	5	8
c. Appropriate screening for colorectal cancer	1	2	3	4	5	8
d. Notification of screening results within 30 days	1	2	3	4	5	8
e. Completion of additional diagnostic testing after abnormal screening results within appropriate time frame	1	2	3	4	5	8
f. Beginning of treatment after cancer detection within appropriate time frame	1	2	3	4	5	8
g. Documentation of shared decision-making	1	2	3	4	5	8

6. PLEASE DESCRIBE YOUR LEVEL OF AGREEMENT OR DISAGREEMENT WITH THE FOLLOWING STATEMENTS ABOUT THE INFORMATION SYSTEM IN PLACE AT YOUR HEALTH CENTER.

	Strongly disagree	Disagree	Neither agree nor disagree	Agree	Strongly agree	Don’t know
a. The center’s information system is adequate to accommodate the size of the population eligible for cancer screening.	1	2	3	4	5	8
b. The center continually tries to improve the timeliness of its data on cancer screening and follow-up	1	2	3	4	5	8
c. The center continually tries to improve the accuracy and relevance of its data on cancer screening and follow-up	1	2	3	4	5	8
d. The information system accurately documents cancer screening taking place in the clinic	1	2	3	4	5	8
e. The information system accurately documents whether appropriate diagnostic follow-up takes place after an abnormal screening result	1	2	3	4	5	8
f. The information system accurately documents whether appropriate treatment takes place after cancer detection	1	2	3	4	5	8
g. The data gathered in the information system is used by leadership to change the health center’s activities related to cancer screening.	1	2	3	4	5	8
h. The data gathered in the information system is used by providers to change their behavior related to cancer screening.	1	2	3	4	5	8
i. I use the data gathered in the information system to change my behavior related to cancer screening.	1	2	3	4	5	8

IV. LEADERSHIP

Senior Leadership of Health Center

For this set of questions, we are interested in the senior leadership of your health center. The senior leadership of your health center is defined as the people who are responsible for making decisions about resources and personnel across all affiliated clinics.

1. The number of members of the health center’s senior leadership who have left the organization over the past 12 months is:

|__|__|__| out of |__|__|__|

2. PLEASE DESCRIBE YOUR LEVEL OF AGREEMENT OR DISAGREEMENT WITH THE FOLLOWING STATEMENTS ABOUT SENIOR LEADERSHIP.

The senior leadership of the health center…	Strongly disagree	Disagree	Neither agree nor disagree	Agree	Strongly agree	Don’t know
a. Has demonstrated an ability to manage the changes (e.g., organizational, technological) needed to improve the quality of care and services	1	2	3	4	5	8
b. Always listens to the concerns of other members of the organization	1	2	3	4	5	8
c. Provides needed feedback to members of the organization	1	2	3	4	5	8
d. Helps members of the organization work well together	1	2	3	4	5	8
e. Provides members of the organization with a clear expectation of their roles	1	2	3	4	5	8
f. Makes sure people have the skills and knowledge to work in teams	1	2	3	4	5	8
g. Makes sure a local clinic team that does a good job gets special rewards or recognition	1	2	3	4	5	8
h. Strongly supports our work	1	2	3	4	5	8
i. Regularly reviews our progress in making change	1	2	3	4	5	8
j. Sees success in improving the quality of care as a high priority for the organization	1	2	3	4	5	8

Local Clinic Team Leadership

For this set of questions, the local leader is defined as the person who is a part of the local clinic team and most responsible for leading the team in efforts to measure and improve the quality of care.

	Strongly disagree	Disagree	Neither agree nor disagree	Agree	Strongly agree	Don’t know
2. The local leader….
a. Possesses the functional expertise necessary for leading the local clinic team successfully.	1	2	3	4	8	9
b. Always listens to the concerns of other local clinic team members	1	2	3	4	8	9
c. Provides needed feedback to other local clinic team members	1	2	3	4	8	9
d. Helps local clinic team members work well together	1	2	3	4	8	9
e. Provides local clinic team members with a clear expectation of their roles on this team	1	2	3	4	8	9

V. TEAMS

For this set of questions, your local clinic team is defined as the group of individuals responsible for both delivering and improving the quality of care in the clinic. The local clinic team responsible for care and quality improvement may include both clinicians and non-clinicians.

1. The number of individuals on your local clinic team with whom you work regularly (excluding yourself) is:

|__|__|__|

Number

2. The number of individuals on your local clinic team who stopped working regularly with you over the past 12 months is:

|__|__|__|

Number

3. Local Clinic Team Characteristics

	Strongly disagree	Disagree	Neither agree nor disagree	Agree	Strongly agree	Don’t know
a. The number of people on my local clinic team is about right for the work to be accomplished	1	2	3	4	5	8
b. The members of the local clinic team work together well as a team	1	2	3	4	5	8
c. Members of my clinic team vary widely in their knowledge, skills, and abilities	1	2	3	4	5	8
d. Members of my clinic team have skills and abilities that complement each other	1	2	3	4	5	8
e. I generally prefer to work as part of a team	1	2	3	4	5	8
f. Our local clinic team gets the information we need to plan our work	1	2	3	4	5	8
g. Our local clinic team has the authority to manage its work pretty much the way members want to	1	2	3	4	5	8
h. There is a great deal of room for initiative and judgment in the work that we do	1	2	3	4	5	8

Local Clinic Team Characteristics (continued)

	Strongly disagree	Disagree	Neither agree nor disagree	Agree	Strongly agree	Don’t know
i. The participants on our local clinic team have substantial influence in managing care and influencing others to make improvements in care	1	2	3	4	5	8
j. When our local clinic team does not know something it needed to know to do its work, there are people available to teach or help	1	2	3	4	5	8
k. There are one or more well respected members of our staff that support our work with their time, and verbal encouragement	1	2	3	4	5	8
l. Our local clinic team is able to identify measures that were tracked on a regular basis to assess our work	1	2	3	4	5	8
m. My skills, training, and experience are fully utilized	1	2	3	4	5	8

VI. BACKGROUND INFORMATION

1. What is your current job title?

________________________________

2. How long have you worked in your current position?

|__|__| or |__|__|

Years Months

3. How long have you worked at this health center?

|__|__| or |__|__|

Years Months

4. In what year were you born?

|__|__|__|__| YYYY

Years

5. What is your gender?

Male 1

Female 2

6. What is your race? (MARK ONE OR MORE RACES)

American Indian or Alaska Native 1

Asian 2

Black or African American 3

Native Hawaiian or Other Pacific Islander 4

White 5

7. Are you Spanish/Hispanic/Latino?

No 1

Yes, Mexican, Mexican Am., Chicano 2

Yes, Puerto Rican 3

Yes, Cuban 4

Yes, other Spanish/Hispanic/Latino 5

THANK YOU FOR COMPLETING THIS INVENTORY

D-82