Form 1 Appendix A: Baseline Practice Assessment

Appendix A - Baseline Practice Assessment

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)	__________

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. ___________	☐

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.