Form 1 Appendix A: Baseline Practice Assessment

Collection of Information for: Agency for Healthcare Research and Quality’s (AHRQ) Guide to Improving Patient Safety in Primary Care Settings by Engaging Patients and Families – Evaluation

Appendix A_ Baseline_Assessment_rev_20161031

Attachment A: Baseline Practice Assessment

OMB: 0935-0235

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Appendix A - Baseline Practice Assessment





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Form Approved
OMB No.
xxxx-xxxx
Exp. Date xx/xx/xxxx







Application for Participation in Guide to Improve Patient Safety in Primary Care Settings by Engaging Patients and Families

Thank you for agreeing to implement the Guide to Improving Patient Safety in Primary Care Settings by Engaging Patients and Families (the Guide). The Guide is being developed by a team led by the MedStar Health Research Institute and the project is funded by the Agency for Healthcare Research and Quality (AHRQ).

The following assessment should be completed by one member of the practice staff. The information provided will remain confidential. The assessment will take approximately 60 minutes to complete.

Please complete this form by answering all of the questions on the survey.

General Information About Your Practice

Practice Name


Location (City, State)


Select one:

Urban

Inner City

Rural

Suburban

Other (Specify)


Contact Person


Medical Director


Number of

Physicians

__________


Nurse Practitioners

__________


Nurses

__________


Medical Assistants

__________


Pharmacists

__________


Social Workers

__________


Case Managers

Other Practice Staff


__________


Other (specify)

__________




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Public reporting burden for this collection of information is estimated to average 90 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 (0935-0179) AHRQ, 5600 Fishers Lane, Mail Stop Number 07W41A, Rockville MD 20857

















Total Number of Patients Served by Practice


Payer Mix (Indicate % of Patients)

Self-Pay

Medicare

Medicaid

Private Insurance

Uninsured

Other

_________%

_________%

_________%

_________%

_________%

_________%

Race (indicate % of patients)

White

Black or African American

American Indian or Alaska Native

Asian

Native Hawaiian or Other Pacific Islander

_________%

_________%

_________%

_________%

_________%

_________%

Ethnicity (indicate % of patients)

Hispanic or Latino

Not Hispanic or Latino

_________%

_________%



Information about Patient Safety and Quality Improvement Activities of the Practice


Yes

No

Does your practice routinely conduct a patient safety culture survey?




  • Please specify which survey you use: _____________

  • Date of the last survey ________

Is your practice part of a larger healthcare system?



Please indicate which health system you are affiliated with:

________________

Is your practice currently part of the Patient Centered Medical Home initiative?

Is your practice currently part of the Center for Medicare & Medicaid Innovation (CMMI) Transforming Clinical Practice Initiative?

Is your practice currently working on any other practice improvement strategies?

Does your practice have or use the services of a practice facilitator?



Experience with Using the Guide Interventions


Yes

No

Does your practice currently use Teach-back?



Please specify how long you have been using teach-back. _________

Does your practice currently use any of the approaches below?




Questions are the Answer


Ask Me 3


Patient Decision Aids


Shared Decision Making


Patient’s Toolkit for Diagnosis


Teach-back

Medication Lists for Patients/Families

Does your practice currently use materials and/or approaches to support medication management?



Does your practice currently use a process of warm hand-off?



Please specify how long you have been using warm handoff. ___________




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The assessment will be completed by one practice member (e.g. by the practice champion) and completed on paper and the results entered into a REDCap® form by the contractor. It is anticipated that the collection of the information to respond to the assessment will take approximately 60-minutes. This assessment will be completed at baseline only.



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