Form 3 Attachment C: The Office Readiness Survey_Cancer Diagnos

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

Office Readiness Survey

Date

Survey No.

This tool can be used to assess your office’s readiness for quality and safety improvement.
Circle the number between 1 and 5 that most accurately describes how you feel about your office.

Practice Improvement
1. The leadership (e.g.,medical director, office manager, head nurse, or other leader)
at this office demonstrates a commitment to quality and patient safety.

Strongly
Neither Agree
Disagree Disagree nor Disagree Agree

Strongly
Agree

1

2

3

4

5

2. Communication among staff, physicians, and leadership promotes mutual respect and trust.

1

2

3

4

5

3. All staff in this office work as a team.

1

2

3

4

5

4. All staff are asked to provide input on decisions about office processes.

1

2

3

4

5

5. Monthly meetings are held, and quality of care is a regular item on the agenda.

1

2

3

4

5

6. This office has written procedures describing how to handle testing and test results.

1

2

3

4

5

7. Everyone in this office has read and follows the testing procedures.

1

2

3

4

5

8. Medical testing errors in this office do not harm patients.

1

2

3

4

5

9. Providers and staff openly discuss causes and effects of errors.

1

2

3

4

5

10. This office has systems to prevent, catch, and/or correct problems in the testing process.

1

2

3

4

5

Comments:

Quality and Safety of the Testing Process

Comments:

Public reporting burden for this collection of information is estimated to average 5 minutes per response, the estimated time required to complete the survey. An
9
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-XXX) AHRQ, 540 Gaither Road, Room # 5036, Rockville, MD 20850