Form #1 Form #1 Readiness Assessment Survey

Attachment B

Readiness Assessment Survey

R

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

eadiness Assessment Survey

Is Your Organization Ready for this TeamSTEPPS module?

Answering these questions can help your institution understand its level of readiness to implement the TeamSTEPPS module to improve the safety of patients with limited English proficiency. You may find it helpful to have a colleague review your responses or to answer the questions with a larger group (e.g., senior leaders including patient safety officer(s), leaders of the unit(s) where you plan to implement the module, leaders in interpreter services, and motivated frontline staff).

Does your institution have patients with limited English proficiency?

Y es No

Are key leaders in your institution committed to providing excellent care to all patients regardless of race, ethnicity, country of origin, or language spoken?

Y es No

Does your institution have a system for care team members to access an interpreter for patients with limited English proficiency?

Y es No

Will your institution allow time for at least two persons to attend training as master-trainers (30 minutes of pre-work, 4.5 hours of training, plus travel), and customize the course (4 to 8 hours)?

Y es No

Will your institution allow time for all staff in at least one unit to attend training, along with some of the hospital’s interpreters (1 hour, plus 10-20 minutes to evaluate the course)?

Y es No

If needed, would key leaders in your institution consider making system changes or allocating additional resources to improve care for patients with limited English proficiency?

Y es No

If you answered “no” to any of the questions above, your institution may not be ready to implement the TeamSTEPPS module to improve the safety of patients with limited English proficiency. Please refer to the accompanying Hospital Guide for steps you and your institution can take to increase your organization’s readiness.

Public reporting burden for this collection of information is estimated to average 5 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.