Form 5 Attachment H – Learning Community Follow-up Survey

1. Form Approved
   OMB No. 0935-XXXX
   Exp. Date XX/XX/20XX

Evaluating the Implementation of PCOR to

Increase Referral, Enrollment, and Retention through

Automatic Referral to Cardiac Rehabilitation (CR) with Care Coordination

Attachment H

Learning Community Follow-up Survey

Version: January 8, 2020

Public reporting burden for this collection of information is estimated to average 10 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-XXXX) AHRQ, 540 Gaither Road, Room # 5036, Rockville, MD 20850.

1. Purpose of this tool

The survey will capture the effectiveness of select Learning Community “Affinity Group” virtual meetings in enabling participants to implement changes or share knowledge learned in the meeting.

2. Administration

We will select ten Affinity Groups. Two months after the final virtual meeting of each, a survey will be conducted. Registration, including email address, is required for the virtual meetings. Our survey administration system will send an email to the Affinity Group participants with a link to the survey. The system can link survey responses from a single email address, enabling us to compare results to the participant’s immediate evaluation of the Affinity Group.

Learning Community participants engage in TAKEheart voluntarily and may choose to engage in the Learning Community, rather than being a Partner Hospital, due to time constraints. We must assume they will be willing to share minimal time on this survey, which will last no more than 10 minutes.

3. Informed consent

The email invitation to perform the survey will include the informed consent, which is as follows.

This survey is part of an evaluation of the assistance given to selected hospitals to increase referrals to cardiac rehabilitation in a project known as TAKEheart. The assistance, and the evaluation, are funded by the Agency for Healthcare Research and Quality (AHRQ).

You were selected to participate in this survey because the TAKEheart Learning Community is a series of virtual meetings which combine education and peer-to-peer sharing. You attended [name the meeting title] on [meeting date.] We are interested your perspective on [name the meeting title] now that some time has passed.

Your participation is voluntary. You may choose not to answer questions with no penalty. We will write a report for AHRQ that summarizes what we learned from the survey and other sources. The report will be used to improve the resources which will be made available online for other hospitals to use.

The reports will not identify the hospitals or the people who answered the survey. However, there is a small chance that you could be recognized. We will be sure to keep the information that you share private.

If you have questions about the project, contact Cynthia Klein, TAKEheart Project Director, at 404-946-6310, or by email at [email protected].

4. Data collection tool: Survey of Learning Community hospitals

Note: The following section will be formatted as a survey, in the survey administration system, for administration. Text in italics indicates instructions for creating the survey. Text in Small Caps indicates instructions to the respondent.

1. Training

Do you recall participating in [name the Affinity Group], which met on [meeting dates]?

• Yes, clearly

• Yes, somewhat

• No [skip to end]

[If yes] Were you able to apply what you learned in [name the Affinity Group] at your hospital?

• Yes

• No

To what degree has what you learned in [name the Affinity Group] directly helped your hospital implement automatic referral with care coordination?

• Helped a great deal

• Helped a moderate amount

• Helped somewhat

• Did not help much

• Did not help at all

Did you share information you learned in [name the Affinity Group] with other staff at your hospital?

• Yes

• No

[If yes] What types of staff did you share the information you learned in [name the Affinity Group] with? (Please check all that apply.)

• Clinical staff who are involved in TAKEheart

• IT staff who are involved in TAKEheart

• Quality Improvement staff who are involved in TAKEheart

• Management involved in TAKEheart

• Other staff who are involved in TAKEheart

• Staff who are not involved in TAKEheart

Did you share information you learned in [name the Affinity Group] with people who work in cardiac services but who don’t work at your hospital?

• Yes

• No

Did you seek additional information about the information you learned in [name the Affinity Group]?

• Yes

• No

Where did you seek additional information about the information you learned in [name the Affinity Group]? (Please check all that apply.)

• Colleagues in your hospital

• Colleagues not in your hospital

• Listservs or online groups (e.g., LinkedIn, Facebook)

• Social media as an individual (not in a group)

• TAKEheart website

• Million Hearts website

• AHRQ website

• Online search

• Other (Please specify): ________________________

[End] Thank for participating in the survey! Your responses will help us develop better tools to help other hospitals.