Form #3 Form #3 Pharmacy staff survey

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

Health Literacy Assessment Survey of Pharmacy Staff

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.

A. Print Materials

This section assesses the accessibility of the print materials used in the pharmacy, such as prescription labels, prescription inserts, brochures, and posters to patients with limited literacy.

Many of these statements are about writing in plain language, that is, writing in a way that everyone can understand. When materials are written in plain language they:

• Use simple, everyday words.

• Organize the information so it is easy to identify the most important points.

• Are designed in a layout that has a lot of white space on the page, so the reader is not overwhelmed with words.

Please check the ONE response that most accurately describes the pharmacy today, using the following rating scale:

1. This is something the pharmacy does not appear to be doing.
2. The pharmacy is doing this but could make some improvements.
3. The pharmacy is doing this well.
N/A Not applicable

Note: The response option "N/A" should ONLY be used to indicate that the statement does not apply to you, and not to indicate disagreement with the statement.

Question	1	2	3	N/A
1. Our pharmacy uses printed materials to advise patients about our services in different parts of the hospital or clinic, such as in the medical and surgical clinics, walk-in or urgent care centers, and inpatient wards.
2. The following print materials are written in simple and clear language, avoiding the use of technical jargon and medical terms:
a. Prescription bottle labels.
b. Prescription warning labels.
3. The following print materials are designed with lots of white space to provide relief from the print:
a. Prescription bottle labels.
b. Prescription warning labels.
4. We use graphics and illustrations in the following print materials:
a. Prescription bottle labels.
b. Prescription warning labels.
5. If appropriate, these print materials are available in languages other than English:
a. Prescription bottle labels.
b. Prescription warning labels.
c. Prescription information inserts.
d. Patient education brochures.
e. Informational posters.
6. We use a print size of 12-point or higher in these print materials:
a. Prescription bottle labels.
b. Prescription warning labels.
7. Overall, these print materials are easy for adults with limited literacy skills to understand:
a. Prescription bottle labels.
b. Prescription warning labels.
c. Prescription information inserts.
d. Patient education brochures.
e. Informational posters.
8. We regularly review our printed materials to check how easy they are to read.
9. We modify materials that are too difficult to understand and make them easier for patients to read and understand.
10. We consult with hospital/clinic staff outside of the pharmacy (e.g., Patient Education Committee) for feedback on the written materials we prepare for our patients.
11. a. The clinic/hospital/pharmacy chain that we are affiliated with has guidelines for limiting the level of reading difficulty of our printed materials.
b. Our pharmacy follows these guidelines.
c. Our pharmacy has guidelines for limiting the level of reading difficulty of our printed materials.
d. Our pharmacy follows our own guidelines.
12. Our staff has received training in how to identify, prepare, and simplify materials so that they are written in plain language.

B. Clear Verbal Communication

This section assesses the communication between pharmacy staff and patients, particularly those patients with limited literacy.

Please check the ONE response that most accurately describes the pharmacy today, using the following rating scale:

1. This is something the pharmacy does not appear to be doing.
2. The pharmacy is doing this but could make some improvements.
3. The pharmacy is doing this well.
N/A Not applicable

Note: The response option "N/A" should ONLY be used to indicate that the statement does not apply to you, and not to indicate disagreement with the statement.

Question	1	2	3	N/A
13. We distribute educational materials that patients can use to help them understand and remember the information we give them.
14. We have identified the jargon that is specific to our pharmacy or services we provide and have developed an easy way to explain these words to our patients.
15. When we work with patients, we continually check that they have understood the information we give them by asking them to repeat back key points (i.e., "teach-back").
16. We have been trained to recognize non-verbal cues that may indicate a person is not understanding what is being said.
17. We offer and provide interpreters to patients for whom English is a second language.
18. Our pharmacy's leadership promotes commitment to health literacy and clear patient communication.
19. We have a space that provides some privacy if patients need to discuss confidential information.
20. If a patient asks to speak with the pharmacist, we offer counseling on the following topics:
a. The name of the medicine.
b. The purpose of the medicine (blood pressure, cholesterol, etc.).
c. The dosage form, dosage, route of administration, and duration of drug therapy.
d. Special directions and precautions for preparation, administration, and use by the patient.
e. Common severe side or adverse effects, interactions and contraindications that can happen, including how to avoid them and what the patient should do if they happen.
f. Techniques for self-monitoring drug therapy.
g. Proper storage.
h. Prescription refill information.
i. Action to be taken in the event of a missed dose.
21. I have received training on the following clear verbal communication techniques:
a. How to effectively organize the information given to patients.
b. How to communicate using simple language.
c. How to check for understanding.
22. I am confident that I can effectively educate patients about medicines and diseases when:
a. Time is limited.
b. The patient has many medications.
c. The patient has many new prescriptions.
d. There are many changes in dosage.
e. The patient has limited literacy skills.
f. The patient is in a rush.
g. The patient asks a lot of questions.
h. The patient is angry at the pharmacy staff.
i. The patient is new to the pharmacy.
j. The patient does not understand how to pay for their medication.
k. The patient can't afford their medication.
l. The patient is non-compliant.
m. The patient does not speak English proficiently.

C. Sensitivity to Literacy

This section asks questions about standard practices that your pharmacy uses in delivering its services to patients with limited literacy skills.

Please check the ONE response that most accurately describes your pharmacy today, using the following rating scale:

1. This is something the pharmacy does not appear to be doing.
2. The pharmacy is doing this but could make some improvements.
3. The pharmacy is doing this well.
N/A Not applicable

Note: The response option "N/A" should ONLY be used to indicate that the statement does not apply to you, and not to indicate disagreement with the statement.

Question	1	2	3	N/A
23. Staff or volunteers are available to help patients fill out our forms.
24. We have identified what a patient must know (e.g., about health or medicine) and the literacy skills a patient must have to make use of our services.
25. We regularly ask our patients for verbal or written feedback about the quality and effectiveness of our services.
26. Our pharmacy's policies specifically support activities and resources that help make our pharmacy accessible to people with limited literacy.
27. We are confident that we promote our pharmacy in ways that allow adults with limited literacy skills to learn about our programs and services.
28. All staff members who have direct contact with patients are aware of certain behaviors that may indicate literacy problems.
29. Our staff, including leadership, has received awareness and sensitivity training about literacy and literacy issues..
30. Our staff knows about the adult literacy resources in our community. If asked, they could tell a client where to get help to improve his or her literacy skills.

D: Personal Information

In this section you will provide some descriptive information about yourself. (**All personal information will be kept confidential)

31. What is your primary work location? Name of Pharmacy:    ____________________________

32. Are you a:
  Pharmacist, PharmD _____
  Pharmacist, RPh ____
  Pharmacy technician ____
  Other (please specify):  ____     

33. What is the highest level of school you completed?
  Elementary school___
  College graduate___
  Some high school ___
  Some graduate or professional school___
  GED or high school graduate ___
  Graduate or professional degree___
  Some college or technical school___

34.Are you Hispanic or Latino/Latina?  Yes ___     No___

35. What is your race? Please select one or more. __ American Indian or Alaska Native

__ Asian

__ Native Hawaiian or other Pacific Islander

__ Black or African American

__ White

36. Are you:   Male___      Female____

37. How old are you?  ____

Thank You!