Attachment D -- Post-Survey Evaluation

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

OPS Web-based Evaluation

This evaluation is for the purpose of obtaining medical office reflection on the survey process, including barriers encountered in completing the survey and ways to improve survey administration, and office perceptions of the value and potential uses of the survey and the comparative data provided. Please answer questions with the overall office in mind.

This survey will take approximately 15 minutes.

Reflections on Process/Barriers

1. Please indicate your role in the office:

o clinician o practice manager o other_____________________________________

2. How long have you been with this medical office? o < 5 years o 6-10 years o >11 years

3. Please describe the overall enthusiasm of the clinicians (MDs, NPs, PAs) during the survey process:

o very enthusiastic o somewhat enthusiastic o not enthusiastic o resistant

4. Please describe the overall enthusiasm of the staff during the survey process:

o very enthusiastic o somewhat enthusiastic o not enthusiastic o resistant

5. Any comments you would like to share about the interest in the survey – yours, or that you heard from other participants?

6. Did you and/or others perceive any of these barriers to participating in the survey process? (Check all that apply.)

• We were not given adequate advance notification of the survey.

• We were not given adequate time to complete the survey.

• We were concerned that there may not be sufficient protection of our identity/that confidentiality would not be maintained.

• We had some difficulty understanding all of the questions.

• Not all of the questions were relevant to our clinic. (Please list these questions below.)

• Other (Please share other barriers here.)

Public reporting burden for this collection of information is estimated to average 15 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, 540 Gaither Road, Room # 5036, Rockville, MD 20850.

7. Were the orientation and instructions for the patient safety survey adequate?

o adequate o OK, but could have been improved o not adequate o no opinion

Please provide suggestions for how the orientation and instructions could be improved.

8. Were there any additional questions/statements that you would like to have seen included?

o yes o no

If yes, please share those here.

Perceptions of value/potential uses of the survey

The Survey was divided into six main sections (A - F). Please refer to the attached copy of the survey here and rate how important/relevant you think the following sections were to your office:

9. List of Patient Safety and Quality Issues

o very important o somewhat important o not important o no opinion

10. Patient Care Coordination With Other Settings

o very important o somewhat important o not important o no opinion

11. Working in Your Medical Office

o very important o somewhat important o not important o no opinion

12. Communication and Follow-up

o very important o somewhat important o not important o no opinion

13. Owner/Managing Partnership/Leadership Support

o very important o somewhat important o not important o no opinion

14. Your Medical Office

o very important o somewhat important o not important o no opinion

15. Do you plan to use the results of the survey within your office?

o yes o no

If “yes” please give an example of how you plan to use the results of the survey within your office.

If “no” please provide an explanation of why you would not use the results within your office.

16. Do you see a benefit from having your office participate in the Survey?

o yes o no

If “yes” please give example(s) of a benefit to your office.

If “no” please help us to understand why the survey is not of benefit to the office.

17. What advice or feedback would you like to provide to the project team regarding the use of this patient survey in a medical office such as yours?

18. Did you or others feel you received adequate feedback about the results of the survey?

o yes o no

19. Do you think your office would want to participate in further group discussion about the survey results?

o yes o no

20. Do you think your office would be interested in completing SOPS in the future?

o yes o no

21. How often do you think SOPS should be administered?

o once a year o every two years o no opinion o other _______________­­­­­­­­­­­­­­­___________________

22. Your input is very valuable to us. Do you have any additional comments or suggestions for us about the survey or how it is administered?

Thank you for taking the time to complete this online evaluation. We realize that you are very busy and appreciate your support of primary care research efforts.

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