1 PCFDI Faculty Skill and Program Feasibility Survey

OMB No. 0915-XXXX

Expiration Date: XX/XX/201X

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PCFDI Faculty Skill & Program Feasibility Survey

Participant ID:

Part 1- Faculty Skills - Instructions: Using the Self-Assessment scale to the right, circle the number that best represents your skill level prior to the Primary Care Faculty Development Program, as well as your current skill level for each competency item listed below.

Competency Items	Self Assessment Categories
	Competency Level Prior to Receipt of PCFDI Program					Current Competency Level (based on Receipt of PCFDI Program)
Leadership	Not at all competent	Somewhat competent	Moderately competent	Highly competent			Not at all competent	Somewhat competent	Moderately competent	Highly competent
Demonstrate ability to provide clinical leadership for your residency practice’s change & improvement process	1	2	3	4			1	2	3	4
Demonstrate ability to provide educational leadership for your residency program’s change & improvement process	1	2	3	4			1	2	3	4
Apply leadership practices that support trust, collaboration & team effectiveness	1	2	3	4			1	2	3	4
Additional comments about your Leadership Skills (optional):
Change Management	Not at all competent	Somewhat competent	Moderately competent	Highly competent			Not at all competent	Somewhat competent	Moderately competent	Highly competent
Create a vision for success and assess stakeholder’s perspectives on how they can support that vision for the future	1	2	3	4			1	2	3	4
Prepare a roadmap for practice development and improvement that acknowledges what is currently known about the change process, physician resistance to change, change fatigue, and human life together	1	2	3	4			1	2	3	4
Recognize & manage own emotions, especially at high stakes, potentially threatening moments and describe personal approach for strengthening these skills  [Emotional intelligence]	1	2	3	4			1	2	3	4
Create safe space for difficult conversations in presence of hierarchical relationships	1	2	3	4			1	2	3	4
Additional comments about your Change Management Skills (optional):

Competency Items	Self Assessment Categories
	Current Competency Level (based on Receipt of PCFDI Program)					Competency Level Prior to Receipt of PCFDI Program
Teamwork	Not at all competent	Somewhat competent	Moderately competent	Highly competent			Not at all competent	Somewhat competent	Moderately competent	Highly competent
Appreciate the roles of the various members of the healthcare team and how team members can be integrated for optimal patient care	1	2	3	4			1	2	3	4
Establish team processes that support diverse professionals to work together in support of common change goals	1	2	3	4			1	2	3	4
Identify resources for ongoing team training at the local level that optimizes patient safety and quality of care	1	2	3	4			1	2	3	4
Additional Comments about your Teamwork Skills (optional):
Patient-Centeredness & PCMH Principles	Not at all competent	Somewhat competent	Moderately competent	Highly competent			Not at all competent	Somewhat competent	Moderately competent	Highly competent
Demonstrate comprehensive, coordinated care using an evidence-based personal care plan, with goals prioritized by the patient and decision-making shared with the patient	1	2	3	4			1	2	3	4
Manage patients and families with sensitivity to patients' health literacy, beliefs, customs, culture, and community.	1	2	3	4			1	2	3	4
Additional comments about your Patient-centeredness & PCMH Principles Skills (optional):
Population Management & Measurement	Not at all competent	Somewhat competent	Moderately competent	Highly competent			Not at all competent	Somewhat competent	Moderately competent	Highly competent
Utilize registries and/or other IT tools to identify and manage populations of patients within the practice.	1	2	3	4			1	2	3	4
Interpret data as a measure of patient outcomes and design strategies to target those patients whose outcomes are not improving.	1	2	3	4			1	2	3	4
Identify community resources available to the patient populations served by your residency training program and demonstrate the integration of these resources into the management of patients.	1	2	3	4			1	2	3	4
Additional comments about your Population Management & Measurement Skills (optional):

Competency Items	Self Assessment Categories
	Current Competency Level (based on Receipt of PCFDI Program)					Competency Level Prior to Receipt of PCFDI Program
Systems Thinking (Microsystems)	Not at all competent	Somewhat competent	Moderately competent	Highly competent			Not at all competent	Somewhat competent	Moderately competent	Highly competent
Understand and be able to teach basic system science	1	2	3	4			1	2	3	4
Apply system science principles to patient care design in multiple settings	1	2	3	4			1	2	3	4
Additional comments about your Systems Thinking Skills (optional):
Assessment of Competencies in the Ambulatory Setting	Not at all competent	Somewhat competent	Moderately competent	Highly competent			Not at all competent	Somewhat competent	Moderately competent	Highly competent
Design assessment systems that utilize multifaceted methods of assessment and interdisciplinary assessors for each required competency as well as the ability to assess the integration of competencies in care delivery.	1	2	3	4			1	2	3	4
Use appropriate assessment tools based on their “utility” for purpose, based on validity, reliability, educational effect, feasibility and acceptability.	1	2	3	4			1	2	3	4
Demonstrate ability to effectively perform direct observation of trainees	1	2	3	4			1	2	3	4
Train and calibrate assessors to use direct observation to enhance the utility and value of assessment.	1	2	3	4			1	2	3	4
Apply, and where necessary devise, assessment methods that connect educational outcomes with clinical outcomes	1	2	3	4			1	2	3	4
Additional comments about your Competency Assessment Skills (optional):

Part 2 – Access to Faculty Development - Instructions: Please answer the questions below by selecting or writing in the response that best reflects your situation.

1. In general, how difficult is it for you to free up time so you can participate in any faculty development program that you are interested in?

Not difficult at all	Somewhat Difficult	Moderately Difficult	Very Difficult	Nearly Impossible
1	2	3	4	5

2. How difficult has it been for you to free up time so you could participate in this faculty development program?

Not difficult at all	Somewhat Difficult	Moderately Difficult	Very Difficult	Nearly Impossible
1	2	3	4	5

3. Were you an active participant (helped to draft the application rather than just review or edit it) in developing the Primary Care Faculty Development Initiative (PCFDI) Pilot Project application?

1. Yes 2. No If No, How did you become involved in participating in this program?

________________________________________________________________________

Part 3 – About You - Instructions: Please answer the questions below by selecting or writing in the response that best reflects your situation.

1. In what year were you born? __ __ __ __

2. Are you Board Certified in your primary discipline? 1. Yes 2. No

3. What other specialty certifications do you have? 1. None 2. Indicate specialty certifications you have: ____________________

4. How long have you been in practice as a physician? ___ ___ Years 2. Not Applicable

5. How long have you been a faculty member in any institution? ___ ___ Years

6. How long have you been a faculty member in your current program? ___ ___ Years

7a. What is your role in the program?

1. Program Director

2. Associate Program Director

3. Medical Director

4. Other (Specify): ______________________

7b. How long have you been in this role? ___ ___ Years

Part 4 – Progress Toward Your Goals - Instructions: Please answer the questions below by selecting or writing in the response that best reflects your situation.

Learning Community		Not at all	Once in 6 Months			Once a Month				Twice a Month			Once a Week or more
How often have you met face-to-face with your interdisciplinary learning community since the April Program held in Chicago?		1	2			3				4			5
How often have you communicated by phone or e-mail with your interdisciplinary learning community since the April Program held in Chicago?		1	2			3				4			5
How often did you share or exchange materials you developed as part of this program with the other three institutions selected?		1	2			3				4			5
How often did you visit any of the other 3 institutions selected?		1	2			3				4			5
How often did you invite anyone from the other 3 institutions or from the core faculty (not including the site visit) to consult/bring expertise?		1	2			3				4			5
Practice Re-design Efforts – NOTE SCALE CHANGE	Already in place before this effort		Not at all		Very Little			Somewhat			Moderate			Fully
To what extent did you develop a high value relationship and plan with information technology support people to achieve your goals?	1		2		3			4			5			6
To what extent did you implement clinic-wide process(es) to enhance and support teamwork (e.g., briefs, huddles, debriefs)?	1		2		3			4			5			6
To what extent did you involve patients in a meaningful way in your redesign/ transformation process?	1		2		3			4			5			6
To what extent did you plan implementation of QI teams with resident, staff and faculty engagement?	1		2		3			4			5			6
To what extent did you articulate your organization's commitment to true patient-centeredness with a statement, such as one that included relationship, service, and reliability?	1		2		3			4			5			6
Did you identify a faculty member to champion professional development in team training (TeamSTEPPS)? NOTE RESPONSE CHANGE		1. Yes						2. No
Residency Education Re-design Efforts	Already in place before this effort		Not at all		Very Little			Somewhat			Moderate			Fully
To what extent did you protect resident time to engage in this work?	1		2		3			4			5			6
To what extent did you establish resident training that covers the nature and definition of systems?	1		2		3			4			5			6
To what extent did you develop and implement a system to ensure direct observation with feedback of all trainees?	1		2		3			4			5			6
Change Process	Already in place before this effort		Not at all		Very Little			Somewhat			Moderate			Fully
To what extent have you engaged key stakeholders?	1		2		3			4			5			6
To what extent did you develop a Timeline for your work?	1		2		3			4			5			6
To what extent did you develop a PCMH Roadmap for your work?	1		2		3			4			5			6
To what extent did you form a new collaborative around this work with others beyond your team? (e.g., local, regional, statewide networks)	1		2		3			4			5			6

Financial Support
Did you seek funding to support your transformation efforts?	1. Yes	2. No

a. If Yes, who did you seek funding from? __________________________

b. Did you receive any funding? 1. Yes 2. No

c. If Yes, how much: $________________

d. How did you use these funds? __________________________________

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