a2 Structural Asse a2 Structural Assessments – Cohorts 1, 2 and 3

Form Approved
OMB No. 0935-0238
Exp. Date 09/30/2020

Attachment B: Structural Assessment Form for Ambulatory Care Settings

Structural Assessment for the Ambulatory Care Setting

1. How many clinicians work in your practice (including MDs, DOs, MBBSs, NPs, & PAs)?

2. Approximately how many patients does your practice see in an average week?

3. Does your practice have regular meetings?

3a. If yes, who attends these meetings? SELECT ALL THAT APPLY

1. Clinicians

2. Nurses

3. Medical assistants

4. Front desk staff

5. Others

3b. If yes, how often do you meet?

1. more than once a week

2.  once a week

3. 2-3 times a month

4. once a month

5. less than once a month

3c. If yes, what time of the day do you meet?

1. Before clinic

2. During morning clinic hours

3. During lunch

4. During afternoon clinic hours

5. After clinic

6. Other (please specify)

4. Has your practice used a team-based approach (such as the comprehensive unit-based safety program (CUSP)) for quality improvement initiatives in the past?

3a. If yes, please describe previous initiatives that have used a team-based approach.

5. Have clinicians in your practice developed local guidelines for conditions for which antibiotics are commonly prescribed?

5a. If yes, please describe.

6. Have clinicians in your practice developed a list of conditions for which antibiotic prescriptions are discouraged?

6a. If yes, please describe.

7. Does your practice formally track antibiotic prescriptions?

7a. If yes, please describe how tracking occurs and what the data are used for.

8. Do patient satisfaction scores impact provider compensation in your practice?

8a. If so, are all clinic visits eligible for patient satisfaction scores?

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