Form
Approved
OMB No. xxxx-xxxx
Exp.
Date xx/xx/20
Please complete the following information about your practice:
General Information About Your Practice
Practice Name |
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Mailing Address (City, State, Zip code) |
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Contact Person |
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Medical Director |
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Number of |
Physicians |
__________ |
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Nurse Practitioners |
___________ |
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Nurses |
__________ |
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Medical Assistants |
__________ |
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Pharmacists |
___________ |
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Social Workers |
__________ |
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Case Managers Other Practice Staff |
__________ __________ |
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Other (specify) |
__________ |
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Total Number of Patients Served by Practice |
________ |
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Payer Mix (Indicate % of Patients) |
Self-Pay Medicare Medicaid Private Insurance Uninsured Other |
_________% _________% _________% _________% _________% _________%
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Race (indicate % of patients)
|
White Black or African American American Indian or Alaska Native Asian Native Hawaiian or Other Pacific Islander Multiple racial categories |
_________% _________% _________% _________% _________%
_________%
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Ethnicity (indicate % of patients) |
Hispanic or Latino Not Hispanic or Latino |
_________% _________%
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Information about Previous Implementation of TeamSTEPPS® Strategies in the Setting
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Yes |
No |
Has your organization implemented/ attempted to implement a TeamSTEPPS® training course in the past?
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Please specify which TeamSTEPPS® Course you previously implemented: _________________ _________________
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Information about Patient Safety and Quality Improvement Activities of the Setting
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Yes |
No |
Does your practice routinely conduct a patient safety culture survey?
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Please specify which survey you use: ________________ Date of the last survey: _________________
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Is your practice part of a larger healthcare system?
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Please indicate which health system you are affiliated with: ___________________
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Is your practice currently working on any other practice improvement strategies? |
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Does your practice have or use the services of a practice facilitator? |
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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 60 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 |
Author | Hill, Mary A |
File Modified | 0000-00-00 |
File Created | 2023-11-12 |