Form #1 Form #1 Staff interview - implementing sites

“Assessing Organizational Responses to AHRQ’s Health Literacy Tools for Pharmacy”

Attachment B

Pharmacy Staff Interview Protocol

Implementing Sites

Module 1- Basic information about the pharmacy

[

Form Approved
OMB No. 0935-XXXX
Exp. Date XX/XX/20XX

Key informants and pharmacy staff]

1. Pharmacy name

2. Key informant name

3. What is your position at this pharmacy?

4. How long have you been in this position?

5. Have you held any other positions at this pharmacy? Which ones?
   
   

[Key informants only]

I’d like to get a better understanding of your pharmacy.

6. How many pharmacy staff members does this pharmacy have?

7. What is the staffing mix at this pharmacy

Probe: FTE pharmacist, technicians, and clerks

8. Approximately how many patients do you have in your system?

9. What are your hours of operation?

10. About how many scripts do you fill per day?

11. What can you share with me about the population that you serve? For example, can you estimate what percent of your patients are in each of these groups?

• Low-income

• Over age 65

• Rural

• Native English speakers

- African American

- American Indian/Alaskan Native

- Latinos

• Low education/literacy

12. Are patients routinely counseled or asked if they would like counseling?

13. What documents could we review to get a better understanding of this pharmacy’s organization, business model, or client base?

14. Has your pharmacy ever implemented quality improvement initiatives in the past?

• What was the focus of those QI initiatives?

• How were those QI projects selected?

• What was your experience with those QI initiatives? (Were they successful? Why or why not?)

• What are your current QI priorities?

Public reporting burden for this collection of information is estimated to average 60 minutes per response, the estimated time required to complete the survey. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: AHRQ Reports Clearance Officer Attention: PRA, Paperwork Reduction Project (0935-XXXX) AHRQ, 540 Gaither Road, Room # 5036, Rockville, MD 20850.

Module 2 – Perception prior to implementation

15. When did you first hear about the issue of health literacy?

16. a. [RECRUITED PHARMACIES ONLY] Before we recruited your pharmacy for this study, had you heard about AHRQ’s health literacy tools for pharmacists?

If yes, PROBE: Where did you first hear about these tools?

PROBE: Have you also received announcements about these tools from e-mails or newsletters from a pharmacy association? Which one? Probe on distribution efforts:

• NACDS Practice Memo

• [insert distribution mechanism]

• [insert distribution mechanism]

• [insert distribution mechanism]

• Mailing with copy of Assessment Tool enclosed

• AHRQ website

• Conducted an internet search

• Other [please specify]

PROBE: Did you go to or link to the Pharmacy Health Literacy Center website? Was it helpful? How did it influence your decision to follow through or not with using the tools?

16. b. [NON-RECRUITED PHARMACIES] When and how did you hear about AHRQ’s health literacy tools for pharmacy?

PROBE: Did you hear about these tools from e-mails or newsletters from a pharmacy association? Which one? Probe on distribution efforts:

• NACDS Practice Memo

• [insert distribution mechanism]

• [insert distribution mechanism]

• [insert distribution mechanism]

• Mailing with copy of Assessment Tool enclosed

• AHRQ website

• Other [please specify]

PROBE: Did you go to or link to the Pharmacy Health Literacy Support Center website? Was it helpful? How did it influence your decision to follow through or not with using the tools?

17. Did you hear about AHRQ’s health literacy tools from any other source?

PROBE: Have you had any conversations with your peers about these tools? What were the main messages that you got from those conversations?

18. What was your initial response to these tools?

FOR QUESTIONS 19- 23, PROBE FOR EACH TOOL:

• Assessment Tool & User’s Guide (and its 4 parts)?

1. Assessment Tour of Pharmacy,

2. Survey of Pharmacy Staff,

3. Pharmacy Patient Focus Groups,

IV) Using Assessment Results

• Training Program?

• How to Create a Pill Card

• Telephone Reminder
  
  

19. When you first learned about (TOOL NAME), was it clear how it might be helpful to a pharmacist wanting to improve health literacy practices?

20. When you first learned about (TOOL NAME), did it seem to be compatible with your pharmacy’s norms, values, and needs?

    1. How well did it appear to fit with your quality improvement (QI) priorities?

    2. How well did it appear to fit in with your work flow?

    3. How well did it appear to fit in with your mission statement or values as a pharmacy?

21. When you first learned about (TOOL NAME), was it clear to you how to use it or how it could be used in your pharmacy?

22. How simple or difficult/burdensome did it seem that (tool name) would be to implement/use?

1. Did any part of the tools feel like a burden? Which ones, and why? Do you think they could be broken down into manageable parts so you could implement them one piece at a time?

2. Did it seem like you could try the tools out before fully implementing them in the pharmacy?

23. Do you feel like you had the necessary resources (staffing, space, other) to use [insert tool name]
    
    

Key informants only

24. How far has your pharmacy gone in deciding to implement the tool(s) and implementing it?

INTERVIEWER: Circle stage of adoption on the Innovation-Decision Process diagram below. If there the stage of adoption is different for the different tools, please so indicate.

Knowledge stage: At this stage, the pharmacy is just reading information about health literacy and about the health literacy tools, and becoming aware of what using the tools would require. Characteristics of the pharmacy setting (e.g., experience with other QI efforts, competing demands, proportion of the population served that has low health literacy) will affect the degree of knowledge acquired at this stage.

Persuasion stage: At this stage, the pharmacy is evaluating the value proposition of the tools, and becoming persuaded of the tools’ utility or lack thereof. Perceived characteristics of the innovation will play an important role here; for example, whether it is compatible with the pharmacy’s values, whether it is easy to use, whether it is possible to try the tool before using it. The experiences and opinions of peers will play an important role in shaping the pharmacy’s perception of the tools at this stage.

Decision stage: At this stage, the pharmacy decides whether or not to try out the tools. The pharmacy’s governance structure and decision-making process will play an important role at this stage.

Implementation stage: At this stage, the pharmacy tries out the tools, encounters successes and/or challenges in implementing them, and adapts the tools as needed to local context. Technical assistance from peers and/or the AHRQ health literacy site may play an important role here.

Confirmation stage: At this stage, the pharmacy assesses the value of the tools based on the experience at the implementation stage. The tools are institutionalized – or not – based on this assessment.

Module 3 – Decision-making re: tool adoption

Now I’d like to discuss the factors that played a role in your decision-making about the adoption of (one or more of the tools).

Concern or awareness of the problem of health literacy

I’d like to begin by hearing about your experience with health literacy.

25. Apart from your experience with this study, have you been involved in other work related to health literacy? [Tell me more about that]

26. To what degree is health literacy an issue for the patients that you serve?

27. To what degree did the population you serve influence your decision about [using/not using] the tools?

[Key informants only]

28. Apart from their experience with this study, has your staff been involved in other work related to health literacy?

Decision-making structure

29. Who typically makes decisions in your pharmacy about quality improvement efforts or other similar opportunities?
    
    

30. How are those decisions typically made?

PROBE: Does the decision-maker discuss the decision with staff?

31. Who, if anyone, has championed the use of the tool(s) in your pharmacy?

32. Who else did the champions of this tool have to convince? How easy or hard was it for them to do that?

33. Is there anything about how your pharmacy is managed, structured or staffed that led to your decision to use/not use the tool(s)? For example…

34. Did you have to get approval from upper management to use the tools? (If so, whose?)

Role of Pharmacy Mission, Values, Structure, Resources in decision-making

35. What role, if any, does a commitment to QI, patient-centered care, innovation or other values or goals play in decisions to adopt organizational changes in your pharmacy? Please explain.

36. What role if any do available skills, existing resources or resource constraints play in decisions to adopt organizational change?

37. Did you have outside resources to help you implement the tools, such as pharmacy students or residents, grant funding, or any other kind of outside support?

38. Was cost of implementation a factor in your decision? How was that assessed?

Expected benefits

39. Would you say this tool is directly relevant to your pharmacy’s work? How?

40. How well do the tools fit in with your existing workflow / dispensing process?

41. What was your principal motivation for adopting the tool/s?

a. What goals did you hope to accomplish? What problems did you hope to solve?

42. What do you anticipate would be the immediate benefits of using these tools?

43. What do you anticipate would be the long-term benefits of using these tools?

44. Did you expect this tool to improve key pharmacy management tasks? If so which? How?

Influence of Tool Characteristics on Decision

Now I’d like to hear about how the characteristics of the tools themselves influenced your decision to use/not use them

45. Earlier you mentioned that, when you initially learned about the tools, they seemed [easy/hard] to implement. To what degree did that influence your decision about [using/not using] the tools?
    
    

46. Were there any aspects of the [insert tool name] that you decided would be too difficult or too much of a burden to implement?
    
    

47. You also mentioned that the tools initially appeared [compatible/not compatible] with your [mission statement/ corporate strategy/customer service values]. To what degree did that influence your decision about [using/not using] the tools?
    
    

48. Were there parts of the tools that you were more willing to use on a trial basis than others? Which ones?
    
    

49. Were these tools compared with other QI opportunities in the decision to implement them?

Influence of Other Events or Factors on Decision

50. Were there other events or factors that affected your decision to use or not use the tools, such as…

• Not enough time due to a high volume of prescriptions?

• Turnover of pharmacy staff?

• Shortage of pharmacy staff?

• A need to focus more on generating revenue?

• Concern with preventing medication errors

• You knew of other pharmacies that were using the tools?

• Awareness of other pharmacies that were using the tools?

• Promotion of the use of the tools by a local, state, or national pharmacy association?

• Promotion of the use of the tools by the local pharmacy school?

• Attended a C.E. program about using the tools?

• The fact that you may have pharmacy students working there?

• A change of management

• A change in reimbursement or regulations that affect your business

• A challenge to your business such as a fire, problems with solvency, or problems with licensure?
  
  

51. What else influenced your decision to use/ not use the tools?
    
    

52. Are there any events or changes in your community that have affected your willingness to move forward with implementing the tools?
    
    

53. Did the availability of a local school of pharmacy nearby play a role in your implementation efforts?
    
    

54. Did someone in your state, such as a professional association, school of pharmacy, or licensure board, promote the use of the tools?
    
    

55. Are there state rules or regulations that have affected your implementation efforts?

Module 4 – Experience with Implementation

ASK THE FOLLOWING QUESTIONS FOR EACH TOOL IMPLEMENTED

56. What actions have you taken to date to implement the [insert tool name]?
    
    For Assessment tool PROBE:

• Who was assigned to the project?

• What was their role in the organization?

• Who conducted the assessment?

• Who participated in the assessment?

• Was participation mandatory or voluntary?

• Was a report made of the assessment results?

• Who received the report?

• Where any operational changes made as a result of the use of the assessment tool?

57. Tell me a little bit about your experience implementing [insert tool name] so far.

PROBES for all tools:

• How has it been going?

• How far have you gotten in implementing the tool?

• What’s been easy about implementing the tool?

• What’s been difficult about implementing the tool?

• How did the tool relate to or interact with your other quality improvement efforts?

For Assessment tool also PROBE:

• Did you extend or restrict the scope of the assessment tool in any way?

• Did you adjust the assessment tool to work better within your pharmacy setting?

• For example, some pharmacies don’t have a room in which to conduct a focus group – did you experience that kind of constraint?

• How did you adjust?

58. Did the tool need to be adapted to serve your needs? Which ones? How so?

59. Did you use the Pharmacy Health Literacy Center website and any of its resources?

60. Did you get any outside or additional help to implement the tool? If so, who and/or what?

61. Were there any events or resources outside your pharmacy that affected your experience implementing [insert tool name]?

PROBES:

• Were there factors related to the tool that impacted your experience implementing?

• Were there factors specific to your pharmacy or pharmacy setting that impacted your experience implementing?
  
  

62. How did your experience implementing [insert tool name] compare to your expectations of implementing this tool?

PROBE:

• Did you have any surprises when implementing the tool? Did you encounter any unexpected challenges or difficulties(e.g., with regard to time, level of effort)? How did you address them?

• Was there anything about the way your pharmacy is structured that made implementation more difficult than you originally anticipated?

• Did you need to make any changes in your pharmacy to implement the tool?

• Is there anything you wish you had known or thought about before implementing the tool?

Module 5 - Effects of Implementation

Now I’d like to talk a little bit about the effects that the tool(s) have had on you and your pharmacy so far.

63. [Ask for each tool implemented/used] Earlier you shared with me what you initially thought of the [insert tool name]. Once you began implementing the tool in your pharmacy, did your opinion of the tool change in any way?

PROBES:

• For example, did your opinion change about how helpful this tool would be? (Tell me more about that).

• What about other staff members at the pharmacy - did their opinions of the tools change in any way after you began implementing them?

• When you started implementing your first health literacy tool, did that make you more interested, less interested, or just as interested as before in using the other health literacy tools?

• As a result of exposure to the tool(s), did you develop an increased interest in any other types of QI activities? If so, what types of activities and how far have you gone in implementing them?

64. [Ask of pharmacies that implemented Assessment Tool & User’s Guide] What has been the effect or impact of the Assessment Tool & User’s Guide in your pharmacy so far?

PROBES:

• Would you say that your awareness of health literacy increased as a result of using this tool? Please elaborate.
  
  

• Would you say that other pharmacy staff’s awareness of health literacy increased as a result of using this tool?
  
  

• Has your pharmacy reorganized its work in any way as a result of using this tool? For example, have you changed any of your practices, procedures, processes, layout, or staffing as a result of using this tool?

65. [Ask of pharmacies that implemented other tools] What has been the effect or impact of the [insert tool name] in your pharmacy so far?
    
    

PROBES:

• Would you say that your awareness of health literacy increased as a result of using this tool? (tell me more about that).

• What about other staff members at the pharmacy – would you say that their awareness of health literacy increased as a result of your using this tool?

• As a result of using this tool, do you feel any differently now about persons with low health literacy? How so?

• What about other staff members at the pharmacy – as a result of using this tool, would you say that they feel any differently about persons with low health literacy? How so?

• Has your pharmacy reorganized its work in any way as a result of using this tool? For example, have you changed any of your practices, procedures, processes, layout, or staffing as a result of using this tool?

66. Are those the effects you had anticipated from using the tools? [if not], How was this different from what you had anticipated?

67. Did your use of the tools harm your pharmacy or your clients in any way that you had not anticipated?

68. Did your use of the tools benefit your pharmacy or your clients in any way that you had not anticipated?
    
    

69. Based on your experience, how would you modify the health literacy tools?
    
    

70. Based on your experience, what would be your advice to other pharmacies that would like to implement these tools?

71. Are there any other tools that you think would be helpful to have?

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