Form 14 Calibrate Dx: Diagnostic Calibration Debrief Tool

Attachment P - Calibrate Dx Survey

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

Calibrate Dx: Diagnostic Calibration Debrief Tool
(derived from Appendix A of Calibrate Dx)

Instructions: Please complete the following items once per quarter after you have completed a review of 3-5 cases and debriefed with a peer. It should take no longer than 30 minutes to complete.

1. Case Review Plan

1A. Describe your focus of calibration (e.g., diagnosis-specific situations, undifferentiated presentations, unexpected trajectories, diagnostic test interpretation, high-risk situations, your organization’s priorities, high-risk patient populations) Free response (1-3 sentences)

1B. Processes evaluated (check all that apply)

• Patient-provider interactions

• Test performance and interpretation

• Followup and tracking

• Consultations and referrals

• Patient factors

• Other: ____________________

1C. Outcomes evaluated (check all that apply)

• Effectiveness

• Timeliness

• Efficiency

• Safety

• Patient-centeredness

• Equity

1D. Data sources evaluated (e.g., personal “remind-me” list, electronic health record query)

Free response (1 sentence)

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].

1E. Case review tool(s) used (check all that apply)

• Revised Safer Dx

• Fishbone Diagram

• Other: _______________

• No specific tool used

1F. Calibration questions considered (e.g., Was the differential diagnosis sufficiently broad? Could I have made a correct diagnosis sooner? Did I communicate the diagnosis to the patient effectively and in a timely manner? See Table 3 in the Calibrate Dx Guide for additional examples)

• Fill in the blank option 1 (free response 1 sentence)

• Fill in the blank option 2 (free response 1 sentence)

• Fill in the blank option 2 (free response 1 sentence)

1G. Write a summary assessment after reviewing your cases. Consider the following questions as you reflect on your diagnostic performance: What did you learn from your case reviews? What, if anything, surprised you? How did you manage uncertainty in the diagnostic process? What will you repeat in similar cases in the future? What will you do differently in similar cases in the future? Free response (3-5 sentences)

1H. What is one take-home message from this activity? Free response (1 sentence)

1I. Describe any changes to your self-reflection after debriefing with your peer. Free response (1-3 sentences)

1J. Describe one or more actions that you will take in response to this activity (e.g., plans for sharing, discussion, new initiatives) free response (1-3 sentences)

Implementation Information:

2A. How many of your own cases did you review? (integer range 0-99)

2B. For how many of your own cases did you use Revised Safer Dx to review? (integer range 0-99)

2C. [if 2B = 1 or more] For cases in which you used Revised Safer Dx, what was the mean score on item 13. “In conclusion, based on all the above questions, the episode of care under review has a missed opportunity to make a correct and timely diagnosis”? (integer range 0-7)

Time spent on review:

2D. Before meeting with your peer, approximately how many hours did you spend reviewing and reflecting on your own cases? (integer range 0-99)

2E. Before meeting with your peer(s), approximately how long did you spend reviewing their cases?

• I did not spend any time reviewing their cases

• less than 15 minutes

• 15 to 30 minutes

• 30 to 60 minutes

• More than 1 hour

2F. How long did you spend in meetings with peers, discussing either your cases or theirs?

• I did not meet with my peer

• less than 15 minutes

• 15 to 30 minutes

• 31 to 60 minutes

• 61-120 minutes

• More than 120 minutes