Form #7 Form #7 Pre-Training Behavior Survey

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

Improving the Safety of

Patients with Limited English Proficiency

Unit Staff Pre-Training Behavior Survey

As part of our quality improvement activities, we are conducting a brief survey about the care we provide for patients with limited English proficiency (LEP). Please answer the questions below truthfully to the best of your abilities and return the survey to ____________________________ . Your answers will be confidential. We appreciate your time and honesty.

S2. Are you an interpreter?

¹ Yes  Do not complete this questionnaire

² No

1. What language(s) do you speak very well?

   1. English

2. ¹ Yes

3. ² No

   1. Spanish

4. ¹ Yes

5. ² No

   1. Other languages (please list here) _____________________

____________________________________________________

____________________________________________________

6. About what percentage of your patients do not speak any of those languages very well?

_________%

7. For those patients who do not speak any of those languages very well, about what percentage of your encounters take place in the presence of a trained interpreter?

_________%

4. What comments do you have about why you do or do not use interpreters to communicate with LEP patients whose language you do not speak very well?

The next questions focus on some things we will cover in the TeamSTEPPS training on LEP patient safety. We’re just checking to see if you’ve used these tools before.

How many times in the past 2 months have you used the following tools with LEP patients?

5. Assertion or advocacy on behalf of an LEP patient (for example, to get an interpreter to the encounter, or to make sure the doctor or nurse explained things more clearly)

6. ¹ Never

7. ² Once

8. ³ Once to 3 times

9. ⁴ More than 5 times

5. Expressing concern or discomfort about communication involving LEP patients when there is a patient safety issue (e.g., using the CUS words: “I’m Concerned/ I’m Uncomfortable/ This is a patient Safety issue”)

6. ¹ Never

7. ² Once

8. ³ Once to 3 times

9. ⁴ More than 5 times

7. Briefs that include the interpreter (A brief is a short meeting of the care team before seeing the patient where the team leader describes team roles, goals, plans and risks).

8. ¹ Never

9. ² Once

10. ³ Once to 3 times

11. ⁴ More than 5 times

8. Creating psychological safety, for example by saying “please let me know if anything I say is not clear”. The interpreter can do this for the patient and other members of the care team can do this for the interpreter.

9. ¹ Never

10. ² Once

11. ³ Once to 3 times

12. ⁴ More than 5 times

8. Check-back with the patient (Repeating out loud what the patient said to check your understanding)

9. ¹ Never

10. ² Once

11. ³ Once to 3 times

12. ⁴ More than 5 times

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.

3