Form #10 Form #10 Staff Survey

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

ATTACHMENT O

STAFF SURVEY INSTRUMENT AND S

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.

OURCE OF SURVEY ITEMS

Source of item				Staff Survey Instrument
MCG			1.	How familiar are you with the term “patient- and family-centered care”?
		1		Very familiar
		2		Somewhat familiar
		3		Not very familiar
		4		Not at all familiar collaborate
		Please rate your level of agreement with the following statements.
MCG			2.	The quality of health care is improved when patients and families are involved as partners in their care.
		1		Strongly Agree
		2		Agree
		3		Disagree
		4		Strongly Disagree
MCG			3.	Health care is safer when patients and families are involved as partners in their care.
		1		Strongly Agree
		2		Agree
		3		Disagree
		4		Strongly Disagree
MCG			4.	Patient- and family-centered care makes delivery of care more challenging.
		1		Strongly Agree
		2		Agree
		3		Disagree
		4		Strongly Disagree

MCG			5.	Patient- and family-centered care is just another quality improvement initiative.
		1		Strongly Agree
		2		Agree
		3		Disagree
		4		Strongly Disagree
MCG			6.	It is important to me to partner with patients and families in their care.
		1		Strongly Agree
		2		Agree
		3		Disagree
		4		Strongly Disagree
		Please rate your level of agreement with the following statements.
MCG			7.	I am able to carry out my work in ways that support a patient- and family-centered care environment.
		1		Strongly Agree
		2		Agree
		3		Disagree
		4		Strongly Disagree
MCG			8.	I have had the opportunity in my professional practice to hear patients' stories about their health care experiences.
		1		Strongly Agree
		2		Agree
		3		Disagree
		4		Strongly Disagree

		Please rate your level of agreement with the following statements about staff in your hospital.
MCG			9.	Staff place a high value on the involvement of patients and families in health care decision-making.
		1		Strongly Agree
		2		Agree
		3		Disagree
		4		Strongly Disagree
		Staff support families' choices, in accordance with patient preference, about whether to remain with the patient during the following:
MCG			10.	Clinic visits/examinations
		1		Strongly Agree
		2		Agree
		3		Disagree
		4		Strongly Disagree
MCG			11.	Therapy/treatment
		1		Strongly Agree
		2		Agree
		3		Disagree
		4		Strongly Disagree
MCG			12.	Painful/invasive procedures
		1		Strongly Agree
		2		Agree
		3		Disagree
		4		Strongly Disagree
MCG			13.	Resuscitation
		1		Strongly Agree
		2		Agree
		3		Disagree
		4		Strongly Disagree
		Please rate your level of agreement with the following statements.
MCG			14.	Leaders of my hospital consistently convey that the patient's and family's experience of care is important to quality.
		1		Strongly Agree
		2		Agree
		3		Disagree
		4		Strongly Disagree
MCG			15.	Leaders of my hospital consistently convey that the patient's and family's experience of care is important to safety.
		1		Strongly Agree
		2		Agree
		3		Disagree
		4		Strongly Disagree
MCG			16.	Leaders of my hospital encourage patient and family collaboration in clinical care of the individual patient.
		1		Strongly Agree
		2		Agree
		3		Disagree
		4		Strongly Disagree
MCG			17.	Leaders of my hospital encourage patient and family collaboration in developing hospital policies and programs.
		1		Strongly Agree
		2		Agree
		3		Disagree
		4		Strongly Disagree
MCG			18.	Leaders of my hospital encourage patient and family collaboration in planning organizational goals.
		1		Strongly Agree
		2		Agree
		3		Disagree
		4		Strongly Disagree
MCG			19.	Leaders of my hospital encourage patient and family collaboration in facilities planning
		1		Strongly Agree
		2		Agree
		3		Disagree
		4		Strongly Disagree
MCG			20.	Leaders of my hospital support staff and physicians in the practice of patient- and family-centered care.
		1		Strongly Agree
		2		Agree
		3		Disagree
		4		Strongly Disagree
MCG			21.	Leaders of my hospital reflect the values of patient- and family-centered care.
		1		Strongly Agree
		2		Agree
		3		Disagree
		4		Strongly Disagree
		Please rate your level of agreement with the following statements.
MCG			22.	My hospital has defined quality care to include how patients and families will experience care.
		1		Strongly Agree
		2		Agree
		3		Disagree
		4		Strongly Disagree

			My hospital's definition for delivery of care articulates the following standards:
MCG					23.		The importance of conveying respect and preserving the dignity of each patient and family.
			1				Strongly Agree
			2				Agree
			3				Disagree
			4				Strongly Disagree
MCG					24.		Acknowledgement of the individuality, culture, capacity, and abilities of each patient and family.
			1				Strongly Agree
			2				Agree
			3				Disagree
			4				Strongly Disagree
MCG					25.		A broad definition of family.
			1				Strongly Agree
			2				Agree
			3				Disagree
			4				Strongly Disagree
MCG					26.		The importance of families to the care and comfort of patients.
			1				Strongly Agree
			2				Agree
			3				Disagree
			4				Strongly Disagree
MCG					27.		The importance of collaborating with patients and families at all levels of care.
			1				Strongly Agree
			2				Agree
			3				Disagree
			4				Strongly Disagree
				Please rate your level of agreement with the following statements.
MCG						28.		Family members are always welcome to be with the patient, in accordance with patient preference.
				1				Strongly Agree
				2				Agree
				3				Disagree
				4				Strongly Disagree
MCG						29.		Care is coordinated with patients and families across disciplines and departments.
				1				Strongly Agree
				2				Agree
				3				Disagree
				4				Strongly Disagree
MCG						30.		Policies and practices encourage patient and family involvement in decision-making regarding their health care.
				1				Strongly Agree
				2				Agree
				3				Disagree
				4				Strongly Disagree
MCG						31.		Patients and families are viewed as integral members of the health care team.
				1				Strongly Agree
				2				Agree
				3				Disagree
				4				Strongly Disagree
MCG						32.		Employees/medical staff ask patients to identify family members or other support people who will participate in care.
				1				Strongly Agree
				2				Agree
				3				Disagree
				4				Strongly Disagree
MCG						33.		Position descriptions define expectations for behaviors consistent with patient- and family- centered care concepts.
				1				Strongly Agree
				2				Agree
				3				Disagree
				4				Strongly Disagree
MCG						34.		Performance appraisals define expectations for behaviors consistent with patient- and family-centered care concepts.
				1				Strongly Agree
				2				Agree
				3				Disagree
				4				Strongly Disagree
MCG						35.		Patient- and family-centered care brings about delays in the planning process.
				1				Strongly Agree
				2				Agree
				3				Disagree
				4				Strongly Disagree
MCG						36.		In-service programs support staff in developing a patient and family centered care approach to delivering care.
				1				Strongly Agree
				2				Agree
				3				Disagree
				4				Strongly Disagree
MCG						37.		Do you have any additional comments about the practice of patient- and family-centered care within your hospital?
								_____________________________________________________________
								_____________________________________________________________
								_____________________________________________________________
								_____________________________________________________________
				PATIENT SAFETY
HSOP						38.		Please give your work area/unit in this hospital an overall grade on patient safety.
				1				Excellent
				2				Very Good
				3				Acceptable
				4				Poor
				5				Failing
				JOB SATISFACTION Please rate your level of agreement with the following statements.
AMDCS						39.		My job provides me with a sense of accomplishment.
				1				Strongly Agree
				2				Agree
				3				Disagree
				4				Strongly Disagree
AMDCS						40.		I feel good about my job.
				1				Strongly Agree
				2				Agree
				3				Disagree
				4				Strongly Disagree
AMDCS						41.		I enjoy doing the things that I do at work.
				1				Strongly Agree
				2				Agree
				3				Disagree
				4				Strongly Disagree
AMDCS						42.		My talents and skill are used in my job.
				1				Strongly Agree
				2				Agree
				3				Disagree
				4				Strongly Disagree

AMDCS			43.	My job is stimulating and challenging.
		1		Strongly Agree
		2		Agree
		3		Disagree
		4		Strongly Disagree
		ABOUT YOU
HSOP			44.	Think of your “unit” as the work area, department, or clinical area of the hospital where you spend most of your work time or provide most of your clinical services. What is your primary work area or unit in this hospital? Select ONE answer.
		1		Many different hospital units/No specific unit
		2		Medicine (non-surgical)
		3		Surgery
		4		Obstetrics
		5		Pediatrics
		6		Emergency department
		7		Intensive care unit (any type)
		8		Psychiatry/mental health
		9		Rehabilitation
		10		Pharmacy
		11		Laboratory
		12		Radiology
		13		Anesthesiology
		14		Other:
				Please specify: _______________________________________________
NEW			45.	What is your staff position in this hospital? Select ONE answer that best describes your staff position.
		1		Registered Nurse
		2		Physician Assistant/Nurse Practitioner
		3		LVN/LPN
		4		Patient Care Asst/Hospital Aide/Care Partner
		5		Attending/Staff Physician
		6		Resident Physician/Physician in Training
		7		Pharmacist
		8		Dietician
		9		Unit Assistant/Clerk/Secretary
		10		Respiratory Therapist
		11		Physical, Occupational, or Speech Therapist
		12		Technician (e.g., EKG, Lab, Radiology)
		13		Administration/Management
		14		Other:
				Please specify: _______________________________________________
NEW			46.	How many years have you worked in your current position?
		1		Less than one year
		2		1-2 years
		3		3-5 years
		4		6-10 years
		5		more than 10 years
MCG			47.	Are you of Hispanic or Latino origin or descent?
		1		No
		2		Yes
MCG			48.	What is your race? Please mark one or more.
		1		American Indian or Alaska Native
		2		Asian
		3		Native Hawaiian or other Pacific Islander
		4		Black or African American
		5		White
MCG			49.	What is your gender?
		1		Female
		2		Male
MCG			50.	What is your age?
				__________ years
Key:
MCG		Medical College of Georgia Patient and Family Centered Care Survey - Culture Survey ©2005.
AMDCS		Army Medical Department Climate Survey
HSOP		Hospital Survey on Patient Safety. Agency for Healthcare Research and Quality

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