Clinical Staff Questoinnaire

Attachment E3: UCSF Clinical Staff Evaluation Questionnaire

Form Approved

OMB No: 0920-xxxx
Exp. Date: xx-xx-xxxx

Public Reporting burden of this collection of information is estimated at 5 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.  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 CDC/ATSDR Reports Clearance Officer, 1600 Clifton Road NW, MS D-74, Atlanta, GA  30333; Attn:  PRA (0920-xxxx).

Thank you for participating in this important study. Your responses to this questionnaire will be kept confidential and will not be shared outside our research and quality-improvement team.

This survey asks about your use of and experience with opioid prescribing guidance and your opinion of the effectiveness of the project to reduce falls and opioid-related adverse events in older adults (persons ages 65 and older). This should take no more than 5 minutes to complete.

If you have questions, please call Dr. Andrew Auerbach (4155021414) or email (TBD)

Tell us about yourself and your background:

							Key respondent
1	Age	 <30	 30-39	 40-49	 50-64	 65+	All
2	Gender	 Female	 Male	 Decline to say			All
3	Years in clinical practice	 0-5	 6-10	 11-15	 16-20	 > 20	All
4	Professional preparation/role	 MD/DO	 NP/PA	RPH/PharmD	 RN		All
5	I am a student, resident, or fellow	 Yes	 No				All
6	Have a DEA number	 Yes	 No	 NA
7	Unit(s) where you primarily care for patients	 15	 14	 13	 12	 11
		 10	 9	 8	 7	 6
	This section asks about your recent experiences in caring for older adult (65+) patients. In the past week….
8	… how many times did you screen a patient for possible opioid use disorder?	 0	 1-3	 4-6	 7-10	 >10	All
9	…how many times did you seek consultation to aid in pain management for your patients?	 0	 1-3	 4-6	 7-10	 >10	All
10	… how many times did you give instructions for how to use non-pharmacologic pain treatments during hospitalization?	 0	 1-3	 4-6	 7-10	 >10	All
11	… how many discharge opioid prescriptions did you write?	 0	 1-3	 4-6	 7-10	 >10	All (RN/pharmacist answer 0)
12	… how many times did you give instructions on how to taper opioids after discharge?	 0	 1-3	 4-6	 7-10	 >10	All
13	… how many times did you give instructions on non-pharmacologic pain treatments at discharge?	 0	 1-3	 4-6	 7-10	 >10	All

		SA	A	Neutral	D	SD
14	I feel confident in my ability to manage pain in hospitalized patients.
15	I feel confident in my ability to prescribe opioids in the hospital
16	I feel confident in my ability to use opioid conversion calculations in caring for my patients
17	I feel confident in my ability to identify patients at risk for opioid misuse at the time they are admitted to the hospital
18	I feel confident in my knowledge about how to avoid use of parenteral opioids for pain in hospitalized patients
19	I feel confident in my ability to transition patients from opioid-inclusive to non-opioid regimens during hospitalization
20	I feel confident in my knowledge about alternatives to opioids for pain in hospitalized patients
21	I know where to find educational or clinical guideline resources to assist me with managing my patients’ pain
22	I feel confident in my ability to instruct patients on how to taper or transition off opioid pain medications at the time of discharge
23	I feel confident in my ability to identify patients at risk for opioid misuse at the time they are being discharged from the hospital
24	I feel confident in my knowledge of non-pharmacologic approaches to aid with pain management in patients after discharge
25	Encouraging non-opioid medications for management of pain is time consuming.
26	I feel confident in my ability to counsel patients who are reluctant to avoid or reduce opioids
27	Our electronic health record helps me choose non-opioid pain regimens during hospitalization
28	Our electronic health record helps me choose non-opioid pain regimens at discharge
29	Our electronic health record makes it easier for me to teach patients about how to manage their pain after discharge
30	Our electronic health record makes it easier for me to teach patients about how to taper off opioids after discharge
31	What suggestions do you have for how UCSF Health might help you take care of your patients with pain, particularly patients >65?	(fill in)

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