6 Appendix F: Team Questionnaire
Measure Dx: A Resource To Identify, Analyze, and Learn From DiagnosticSafety Events
F_Team Questionnaire 5.17
OMB: 0935-0263
Appendix F – Team Questionnaire
Form Approved
OMB No. xxxx-xxxx
Exp.
Date xx/xx/20xx
Appendix F – Team Questionnaire
Team Questionnaire
The following questions ask about the diagnostic safety team that is implementing the Measure Dx resource. This form should be completed by a member from this team who is closely involved with the team’s activities.
Questions about the team refer to the people in the organization who are directly responsible for planning and overseeing the measurement activities described in Measure Dx (this is likely to be a small group).
Questions about the project refer to all new (or anticipated) diagnostic safety activities resulting from use of Measure Dx.
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Strongly
Agree
Strongly Disagree
1. The Measure Dx project is backed up by a mandate from Senior Leadership.
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2. The Measure Dx project is in line with our organization’s key strategic goals.
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3. Our healthcare facility has a non-punitive method of investigating medical adverse events or close calls.
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4. Our TEAM has sufficient resources (support services, computer access, and data management) to meet our aims in the project.
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5. Our TEAM has sufficient time to meet our aims in the project.
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6. Our current information systems provide useful data to help us meet our aims in this project.
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7. The changes we are making are supported by the front-line clinical staff in our organization.
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8. A physician is an active participant on our TEAM.
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9. Our TEAM has strong leadership with the clout to make changes happen.
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10. Our TEAM has worked together as a team before this collaborative.
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11. Our TEAM has worked on improvement projects before.
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12. Our TEAM is familiar with measuring clinical process improvements.
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13. TEAM members understand each other’s strengths and weaknesses.
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14. There is mutual respect among TEAM members.
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15. The TEAM views problems as everyone’s responsibility rather than “someone’s fault.”
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16. The TEAM has a shared vision of how to improve.
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17. The TEAM has a good way of solving conflicts between team members.
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18. Everyone on the TEAM feels comfortable expressing their opinion.
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19. The TEAM gathers data from patients about ways to continue to improve.
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20. Our TEAM has a specific plan to spread the information learned in this project to other parts of our organization.
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This
survey is authorized under 42 U.S.C. 299a. The confidentiality of
your responses to this survey is protected by Sections 944(c) and
308(d) of the Public Health Service Act [42 U.S.C. 299c-3(c) and 42
U.S.C. 242m(d)]. Information that could identify you will not
be disclosed unless you have consented to that disclosure. Public
reporting burden for this collection of information is estimated to
average 25 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, 5600 Fishers Lane, Room #07W42,
Rockville, MD 20857.
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| File Title | VAMC Name:___________________________ |
| Author | Department of Veterans Affairs |
| File Modified | 0000-00-00 |
| File Created | 2022-10-10 |
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