Attachment C -- Staff Interview Protocols -- Non-implementing Sites _REVISED July 2009_with Track Changes

“Assessing Organizational Responses to AHRQ’s Health Literacy Tools for Pharmacy”

Attachment C

Pharmacy Staff Interview Protocol

Non-Implementing Sites

Module 1- Basic information about the pharmacy

1. P

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

   harmacy name

2. Key informant name

3. What is your position at this pharmacy?

4. How long have you been in this position?

5. Have you held any other positions at this pharmacy? Which ones?
   
   

I’d like to get a better understanding of your pharmacy.

6. How many pharmacy staff members does this pharmacy have?

7. What is the staffing mix at this pharmacy

Probe: FTE pharmacist, technicians, and clerks

8. Approximately how many patients do you have in your system?

9. What are your hours of operation?

10. About how many scripts do you fill per day?

11. What can you share with me about the population that you serve? For example, can you estimate what percent of your patients are in each of these groups?

• Low-income

• Over age 65

• Rural

• Native English speakers

- African American

- American Indian/Alaskan Native

- Latinos

• Low education/literacy

12. Are patients routinely counseled or asked if they would like counseling?

13. What documents could we review to get a better understanding of this pharmacy’s organization, business model, or client base?

14. Has your pharmacy ever implemented quality improvement initiatives in the past?

• What was the focus of those QI initiatives?

• How were those QI projects selected?

• What was your experience with those QI initiatives? (Were they successful? Why or why not?)

• What are your current QI priorities?

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. 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.

Module 2 – Perceptions of tools

15. When and how did you first hear about AHRQ’s health literacy tools for pharmacy?
    
    

PROBE: Did you hear about these tools from e-mails or newsletters from a pharmacy association? Which ones? Probe on distribution efforts:

• NACDS Practice Memo

• [insert distribution mechanism]

• [insert distribution mechanism]

• [insert distribution mechanism]

• Mailing with copy of Assessment Tool enclosed

• Conducted an internet search

• AHRQ website

• Other [please specify]

PROBE: Did you go to or link to the Pharmacy Health Literacy Support Center website? Was it helpful? How did it influence your decision to follow through or not with using the tools?

16. Did you hear about AHRQ’s health literacy tools from any other source?

PROBE: Have you had any conversations with your peers about these tools? What were the main messages that you got from those conversations?

17. What was your initial response to these tools?

FOR QUESTIONS 19- 23, PROBE FOR EACH TOOL:

• Assessment Tool & User’s Guide (and its 4 parts)?

1. Assessment Tour of Pharmacy,

2. Survey of Pharmacy Staff,

3. Pharmacy Patient Focus Groups,

IV) Using Assessment Results

• Training Program?

• How to Create a Pill Card

• Telephone Reminder
  
  

18. “When you first learned about (tool name), how helpful did you think it would be in improving health literacy practices?” When you first learned about (TOOL NAME), was it clear how it might be helpful to a pharmacist wanting to improve health literacy practices?

19. When you first learned about (TOOL NAME), did it seem to be compatible with your pharmacy’s norms, values, and needs?

20. How well did it appear to fit with your quality improvement (QI) priorities?

21. How well did it appear to fit in with your work flow?

22. How well did it appear to fit in with your mission statement or values as a pharmacy?

24. When you first learned about (TOOL NAME), was it clear to you how to use it or how it could be used in your pharmacy?

25. How simple or difficult/burdensome did it seem that (tool name) would be to implement/use?

1. Did any part of the tools feel like a burden? Which ones, and why? Do you think they could be broken down into manageable parts so you could implement them one piece at a time?

2. Did it seem like you could try the tools out before fully implementing them in the pharmacy?
   
   

1. Do you feel like you had the necessary resources (staffing, space, other) to use [insert tool name]

27. Did you at any point consider using any of the tools?

1. [If not], what are the main reasons that you did not consider using any of the tools? [INTERVIEWER: circle knowledge stage on diagram below]

• [If yes] What were the main barriers to implementing the tools?

Key informants only

28. Did your pharmacy hold a formal meeting or discussion where a decision was made not to use the health literacy tools? [INTERVIEWER – if no – circle persuasion phase below. If yes – circle decision phase below].

INTERVIEWER: Circle stage of adoption on the Innovation-Decision Process diagram below. If there the stage of adoption is different for the different tools, please so indicate.

Knowledge stage: At this stage, the pharmacy is just reading information about health literacy and about the health literacy tools, and becoming aware of what using the tools would require. Characteristics of the pharmacy setting (e.g., experience with other QI efforts, competing demands, proportion of the population served that has low health literacy) will affect the degree of knowledge acquired at this stage.

Persuasion stage: At this stage, the pharmacy is evaluating the value proposition of the tools, and becoming persuaded of the tools’ utility or lack thereof. Perceived characteristics of the innovation will play an important role here; for example, whether it is compatible with the pharmacy’s values, whether it is easy to use, whether it is possible to try the tool before using it. The experiences and opinions of peers will play an important role in shaping the pharmacy’s perception of the tools at this stage.

Decision stage: At this stage, the pharmacy decides whether or not to try out the tools. The pharmacy’s governance structure and decision-making process will play an important role at this stage.

Implementation stage: At this stage, the pharmacy tries out the tools, encounters successes and/or challenges in implementing them, and adapts the tools as needed to local context. Technical assistance from peers and/or the AHRQ health literacy site may play an important role here.

Confirmation stage: At this stage, the pharmacy assesses the value of the tools based on the experience at the implementation stage. The tools are institutionalized – or not – based on this assessment.

Module 3 – Reasons for Not Adopting the Tools

Thank you so much for sharing with me your initial responses to the tools. I‘d like to ask a few more questions that will help me understand how you or your pharmacy decided not to implement any of the tools.

Concern or awareness of the problem of health literacy

29. When did you first hear about the issue of health literacy?
    
    

30. To what degree is health literacy an issue for the patients that you serve?
    
    

31. Have you been involved in other projects related to health literacy? [If so, tell me more?]

32. Has your staff been involved in other work related to health literacy?

Decision-making structure

33. Who typically makes decisions in your pharmacy about quality improvement efforts or other similar opportunities?
    
    

34. How are those decisions typically made?

PROBE: Does the decision-maker discuss the decision with staff?

35. Did anyone champion that the tool(s) be considered for use in your pharmacy?

36. Would deciding to use this tool(s) require upper management approval? (If so, whose?)

37. Were there any other aspects of the decision-making process that we’ve not covered that played a significant role in the decision to not use the pharmacy health literacy tools?

Compatibility with Pharmacy Mission, Values, Structure

38. Did the tools not fit in with your workflow / dispensing process?

PROBE: [if they did not fit in] How so?

39. Did the tools not fit in with your business model?

PROBE: [if they did not fit in] – Tell me more about that.

40. Did the tools not fit in with your mission or values as a pharmacy?

PROBE: [if they did not fit in] – What can you tell me about that?

41. Was cost of implementation a factor in your decision? How was that assessed?
    
    

Lack of resources

42. Was your team lacking any skills or resources needed to implement the tools

PROBE: [If yes] What would you have needed to implement the tools?

43. Is there anything else about the way your pharmacy is set up or the structure of your pharmacy that factored in to your decision not to use the pharmacy health literacy tools?
    
    

PROBE: [if yes] What can you tell me about the other things that factored into your decision?

Information gaps

44. Did you feel you got all the information you needed to make a decision about using the tools, or was anything missing?

PROBE: [if anything missing] – what information were you missing?

Expected benefits

45. Were the expected benefits (or lack thereof) part of the reason you chose not to use the tools?

46. What were the main problems that you anticipated with the tools?

Influence of Tool Characteristics on Decision

Now I’d like to hear about how the characteristics of the tools themselves influenced your decision not use them

47. Earlier you mentioned that, when you initially learned about the tools, they seemed [easy/hard] to implement. To what degree did that influence your decision about [using/not using] the tools?
    
    

48. Which aspects of the tools seemed too difficult or too much of a burden to implement?
    
    

49. You also mentioned that the tools initially appeared [compatible/not compatible] with your [mission statement/ corporate strategy/customer service values]. To what degree did that influence your decision about [using/not using] the tools?
    
    

50. Were there parts of the tools that seemed particularly hard to use on a trial basis than others? Which ones?
    
    

51. Were these tools compared with other QI opportunities in the decision to implement them?

Influence of Other Events or Factors on Decision

52. Were there other events or factors that affected your decision not to use the tools, such as…

• Not enough time due to a high volume of prescriptions?

• Turnover of pharmacy staff?

• Shortage of pharmacy staff?

• A need to focus more on generating revenue?

• Concern with preventing medication errors

• You knew of other pharmacies that were using the tools?

• You weren’t aware of any other pharmacies that were using the tools?

• A change of management

• A change in reimbursement or regulations that affect your business

• A challenge to your business such as a fire, problems with solvency, or problems with licensure?

53. Were there other initiatives or quality initiatives that your pharmacy was working on that affected your decision not to use the tools?
    
    

If so, can you please describe the initiative(s)?

54. Did you perceive the initiative(s) you were working on to be of higher value than using the health literacy tools for pharmacy? Why or why not?

55. Did anything else influence your decision not to use the tools? What else influenced your decision to not use the tools?
    
    

56. Are there any events or changes in your community that affected your willingness (or unwillingness) to implement the tools?
    
    

57. Thank you so much for sharing your perspectives about AHRQ’s new pharmacy health literacy tools. Before we end this interview, is there anything else you’d like to comment on that we didn’t talk about today?

Thank you for your time!

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