10 Measure Dx Data Collection Instrument

Attachment K - Measure Dx Organizational Self-Assessment

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

Measure Dx Data Collection Instrument

Organizational Self-Assessment (This instrument is the General

Organizational Readiness Checklist of the Measure DX tool, page 8)

Please complete this form to provide more information about your (organization); it should take no longer that 30 minutes to gather the information you need about your organization’s resources and to complete this form.

Site: [dropdown of enrolled sites] 

 

Name of person filling out this form: [text box] -> This self-assessment is to be filled out by both site champions at each site: the clinical champion and the quality improvement leader

 

Email address of person filling out this form: [text box] -> Individuals filling out the form will receive a copy of their answers

This survey is authorized under 42 U.S.C. 299a. This information collection is voluntary and 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 30 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. The data you provide will help AHRQ’s mission to produce evidence to make health care safer, higher quality, more accessible, equitable, and affordable. 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, or by email to the AHRQ MEPS Project Director at [email protected].

Organizational Self-Assessment

General Organizational Readiness Checklist

Before selecting specific diagnostic safety measurement strategies, ensure that sufficient resources and supportive mechanisms are available not only to collect information about diagnostic safety but also to respond effectively when learning opportunities are discovered. Check the following items as you develop your plan for measurement:

Clear objectives

The diagnostic safety team has identified specific motivations and expected outcomes of measurement activities that foster nonpunitive learning and improvement.

• Yes

• No

Leadership engagement

Leaders at the appropriate level of the organization have committed support to learning from diagnostic safety events.

• Yes

• No

Designated team

One or more team members are able and willing to commit time and effort to lead a diagnostic safety measurement and improvement program.

• Yes

• No

Team members have support from others at your organization who are also willing to learn in pursuit of diagnostic excellence. These could include physicians/clinicians, nursing staff, risk management/legal staff, representatives of diagnostic specialties (if available), and information technology and informatics staff (if available).

• Yes

• No

Safety culture

Your organization demonstrates commitment to safety culture (e.g., by conducting periodic surveys of safety culture,11 reviewing and learning from the findings, and implementing strategies to address findings).

• Yes

• No

Your organization has a mechanism to share learning from case review/analysis.

• Yes

• No

Quality and safety resources and infrastructure

Patient safety and quality infrastructure is available to support your efforts. This could include basic safety measurement and reporting infrastructure or resources that support more advanced data gathering and analysis.

• Yes

• No