Form #5 Form #5 Collection of Documentation Protocol

C

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

ollection of Documentation - Pre- and Post-Implementation

July 1, 2010

Purpose: To gather data on existing hospital policies, procedures, documents, and strategies related to patient and family engagement (PFE) or patient- and family-centered care (PFCC). Documents may include formal policies, reports, memos, training materials for hospital staff, or materials for patients.

Instructions: Please mark an “X” for each row under the appropriate column.

• Document available: The hospital has the document/procedure available.

• Document received: A copy of the document/procedure has been provided to AIR staff.

• PFE included: The document/procedure contains information/strategies related to PFE and PFCC.

To the extent that it is available, we will gather documentation on the following topics pre-implementation. Post-implementation, we will gather any documentation that may have changed since pre-implementation.

Topic	Document(s) Available	Document(s) Received	PFE Included
Background on organizational structure and vision
Mission statement
Strategic plan
Organizational chart
Annual reports
Other:
Other:
Other:
Other:
Policies and procedures related to Component 1 strategies
Admission procedures
Discharge procedures
Nurse change of shift
Communication tools used between patients, family members and health care team
Materials distributed to patients and families
Orientation video for patients and families
White board use
Shared care plan
Daily goal sheet
Other:
Other:
Other:
Other:
Other:
Other:
Policies and procedures related to PFE, PFCC, quality and safety
Visitation policy (e.g., open visitation, family presence during invasive procedures)
Patient- and family-activated rapid response teams
Rounds
Patient and family access to health information (e.g., library, information resource center, video)
Patient and family access to medical records
Patient advocate/navigator program
Quality improvement and patient safety programs (e.g., medication safety/reconciliation, hand hygiene, fall prevention, surgical safety)
Other:
Other:
Other:
Other:
Other:
Other:
Opportunities for patient and family member involvement at an organizational level (Component 2)
Patients and families as advisors and reviewers
Patient and family advisory council
Patients and families on quality and safety committees and teams
Other:
Other:
Other:
Other:
Other:
Other:

Public reporting burden for this collection of information is estimated to average 4 hours per response, the estimated time required to complete the collection of documentation. 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.