Form 4 ATTACHMENT G – HEALTH CARE PROFESSIONAL SURVEY

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

ATTACHMENT G – HEALTH CARE PROFESSIONAL SURVEY

The following survey is for hospital health care professionals involved in the informed consent process. [insert introductory text and consent language for online survey]

SURVEY (PRE-TRAINING)

Role in Informed Consent

1. Which best describes your typical role in informed consent for tests/treatments/procedures (check all that apply):

 I am not involved in informed consent and I am unaware when or whether it is done

 I am not involved in informed consent, but I am aware when or whether it is done

 I provide information on the test/treatment/procedure, risk/benefits, and alternatives to patients for informed consent

 I conduct the informed consent discussion with patients

 I show decision aids to patients

 I obtain signatures on the consent form (paper or electronic)

 I confirm that patients have provided consent

 I am focused on informed consent for the hospital because of my safety or quality role

 Other (please describe): __________________________________________________

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.

Current Informed Consent Process

2. For tests/treatments/procedures that require informed consent, how frequently do clinicians in your unit do the following when obtaining informed consent?
   
   Check “DK” (Don’t Know) if you don’t know what clinicians do in your unit.

	Never	Sometimes	Usually	Always	DK
Assess patients’ decision-making capacity
Allocate ample time in private space
Use health literacy universal precautions
Call for qualified interpreters when conducting a consent discussion with a patient who speaks a different language
Use teach-back
Offer choices, including the option of doing nothing
Engage patients, family, and friends in the consent discussion
Elicit goals and values
Encourage questions
Use high-quality structured patient decision aids (e.g., tool to help a patient understand the benefits, harms, and risks of a procedure and make a decision )
Neutrally explain the benefits, harms, and risks of all options
Use teach-back techniques to check patient understanding
Better document the informed consent discussion
Ask patients to confirm consent immediately before test, treatment, or procedure when consent has been given in advance

2. For tests/treatments/procedures that require informed consent, how frequently do you do the following when obtaining informed consent?
   
   Check “NA” (not applicable) if the statement does not apply to your responsibilities or you don’t know what the statement is referring to.

	Never	Sometimes	Usually	Always	DK
Assess patients’ decision-making capacity
Allocate ample time in private space
Use health literacy universal precautions
Call for qualified interpreters when conducting a consent discussion with a patient who speaks a different language
Use teach-back
Offer choices, including the option of doing nothing
Engage patients, family, and friends in the consent discussion
Elicit goals and values
Encourage questions
Use high-quality structured patient decision aids (e.g., tool to help a patient understand the benefits, harms, and risks of a procedure and make a decision )
Neutrally explain the benefits, harms, and risks of all options
Use teach-back techniques to check patient understanding
Better document the informed consent discussion
Ask patients to confirm consent immediately before test, treatment, or procedure when consent has been given in advance

Informed Consent Process Overall Effectiveness

4. On a scale from 1 to 10 where 1 is the worst and 10 is the best, how well does your unit ensure patients are making an informed choice?

 1 – Worst

 2

 3

 4

 5

 6

 7

 8

 9

 10 – Best

 DK – Don’t know

4. On a scale from 1 to 10 where 1 is the worst and 10 is the best, please rate how well do you ensure patients are making an informed choice?

 1 – Worst

 2

 3

 4

 5

 6

 7

 8

 9

 10 - Best

 N/A – I’m not involved in the consent process

Teach-Back Self-Efficacy

Teach-back is a way to check that you have explained to patients what they need to know in a manner that they understand. Patient understanding is confirmed when they are able to explain it back to you in their own words.

4. On a scale from 1 to 10, how confident are you in your ability to use teach-back in an informed consent discussion? (1 = “not at all confident”, 10 = “very confident”)

 1 – not at all confident

 2

 3

 4

 5

 6

 7

 8

 9

 10 – very confident

 N/A – I’m not involved in the consent process

Attitudes about Informed Consent

4. To what extent do you agree or disagree with the following statements:

	Strongly Disagree	Disagree	Neither Agree Nor Disagree	Agree	Strongly Agree
Clinicians should encourage patients to talk about their values when deciding whether to consent to a test, treatment, or procedure
Clinicians are in a better position than patients to decide which tests, treatments, or procedures patients need
Clinicians should not present alternatives that are demonstrably less effective
Refusing a life-saving treatment or procedure demonstrates that the patient is not capable of making a sound decision
Clinicians are responsible for ensuring that patients understand all their options before making a decision
Getting the patient’s signature on a consent form is the most critical part of the informed consent process
Lack of patient understanding of benefits, harms, and risks of treatments is a serious patient safety problem
The informed consent process is worth the time it takes
The chief purpose of informed consent processes is to comply with regulations and be protected from lawsuits

Background Information¹

This information will help in the analysis of the survey results.

4. How long have you worked in this hospital?

    a. Less than 1 year	 d. 11 to 15 years
    b. 1 to 5 years	 e. 16 to 20 years
    c. 6 to 10 years	 f. 21 years or more

5. How long have you worked in your current hospital work area/unit?

 a. Less than 1 year	 d. 11 to 15 years
 b. 1 to 5 years	 e. 16 to 20 years
 c. 6 to 10 years	 f. 21 years or more

4. What is your staff position in this hospital? Select ONE answer that best describes your staff position.

    a. Registered Nurse	 h. Dietician
    b. Physician Assistant/Nurse Practitioner	 i. Unit Assistant/Clerk/Secretary
    c. LVN/LPN	 j. Respiratory Therapist
    d. Patient Care Asst/Hospital Aide/Care Partner	 k. Physical, Occupational, or Speech Therapist
    e. Attending/Staff Physician	 l. Technician (e.g., EKG, Lab, Radiology)
    f. Resident Physician/Physician in Training	 m. Administration/Management
    g. Pharmacist	 n. Other, please specify:

5. How long have you worked in your current specialty or profession?

    a. Less than 1 year	 d. 11 to 15 years
    b. 1 to 5 years	 e. 16 to 20 years
    c. 6 to 10 years	 f. 21 years or more

6. In your staff position, do you typically have direct interaction or contact with patients?

    a. YES, I typically have direct interaction or contact with patients.

    b. NO, I typically do NOT have direct interaction or contact with patients.

7. In which hospital unit do you primarily work?

 Surgery

 [insert other participating units ]

 [insert other participating units ]

 [insert other participating units ]

SURVEY (POST-TRAINING & IMPLEMENTATION)

Role in Informed Consent

1. Which best describes your typical role in informed consent for tests/treatments/procedures (check all that apply):

 I am not involved in informed consent and I am unaware when or whether it is done

 I am not involved in informed consent, but I am aware when or whether it is done

 I provide information on the test/treatment/procedure, risk/benefits, and alternatives to patients for informed consent

 I conduct the informed consent discussion with patients

 I show decision aids to patients

 I obtain signatures on the consent form (paper or electronic)

 I confirm that patients have provided consent

 I am focused on informed consent for the hospital because of my safety or quality role

 Other (please describe): __________________________________________________

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.

Current Informed Consent Process

2. For tests/treatments/procedures that require informed consent, how frequently do clinicians in your unit do the following when obtaining informed consent?
   
   Check “DK” (Don’t Know) if you don’t know what clinicians do in your unit.

	Never	Sometimes	Usually	Always	DK
Assess patients’ decision-making capacity
Allocate ample time in private space
Use health literacy universal precautions
Call for qualified interpreters when conducting a consent discussion with a patient who speaks a different language
Use teach-back
Offer choices, including the option of doing nothing
Engage patients, family, and friends in the consent discussion
Elicit goals and values
Encourage questions
Use high-quality structured patient decision aids (e.g., tool to help a patient understand the benefits, harms, and risks of a procedure and make a decision )
Neutrally explain the benefits, harms, and risks of all options
Use teach-back techniques to check patient understanding
Better document the informed consent discussion
Ask patients to confirm consent immediately before test, treatment, or procedure when consent has been given in advance

2. For tests/treatments/procedures that require informed consent, how frequently do you do the following when obtaining informed consent?
   
   Check “NA” (not applicable) if the statement does not apply to your responsibilities or you don’t know what the statement is referring to.

	Never	Sometimes	Usually	Always	DK
Assess patients’ decision-making capacity
Allocate ample time in private space
Use health literacy universal precautions
Call for qualified interpreters when conducting a consent discussion with a patient who speaks a different language
Use teach-back
Offer choices, including the option of doing nothing
Engage patients, family, and friends in the consent discussion
Elicit goals and values
Encourage questions
Use high-quality structured patient decision aids (e.g., tool to help a patient understand the benefits, harms, and risks of a procedure and make a decision )
Neutrally explain the benefits, harms, and risks of all options
Use teach-back techniques to check patient understanding
Better document the informed consent discussion
Ask patients to confirm consent immediately before test, treatment, or procedure when consent has been given in advance

Informed Consent Process Overall Effectiveness

2. On a scale from 1 to 10 where 1 is the worst and 10 is the best, how well does your unit ensure patients are making an informed choice?

 1 – Worst

 2

 3

 4

 5

 6

 7

 8

 9

 10 – Best

 DK – Don’t know

2. On a scale from 1 to 10 where 1 is the worst and 10 is the best, please rate how well do you ensure patients are making an informed choice?

 1 – Worst

 2

 3

 4

 5

 6

 7

 8

 9

 10 - Best

 N/A – I’m not involved in the consent process

Teach-Back Self-Efficacy

Teach-back is a way to check that you have explained to patients what they need to know in a manner that they understand. Patient understanding is confirmed when they are able to explain it back to you in their own words.

2. On a scale from 1 to 10, how confident are you in your ability to use teach-back in an informed consent discussion? (1 = “not at all confident”, 10 = “very confident”)

 1 – not at all confident

 2

 3

 4

 5

 6

 7

 8

 9

 10 – very confident

 N/A – I’m not involved in the consent process

Attitudes about Informed Consent

2. To what extent do you agree or disagree with the following statements:

	Strongly Disagree	Disagree	Neither Agree Nor Disagree	Agree	Strongly Agree
Clinicians should encourage patients to talk about their values when deciding whether to consent to a test, treatment, or procedure
Clinicians are in a better position than patients to decide which tests, treatments, or procedures patients need
Clinicians should not present alternatives that are demonstrably less effective
Refusing a life-saving treatment or procedure demonstrates that the patient is not capable of making a sound decision
Clinicians are responsible for ensuring that patients understand all their options before making a decision
Getting the patient’s signature on a consent form is the most critical part of the informed consent process
Lack of patient understanding of benefits, harms, and risks of treatments is a serious patient safety problem
The informed consent process is worth the time it takes
The chief purpose of informed consent processes is to comply with regulations and be protected from lawsuits

Training and Implementing Improvements

7. What was your role in improving informed consent in your hospital with respect to the training? [Check all that apply]

 None

 Completed the online training

 Made changes to my informed consent approach

 Participated on a team to make changes

 Championed changes in my unit

 Championed changes across the hospital

 Other (please describe): ____________________________________

7. How useful did you find each section of the training?

	Not at all useful	Slightly Useful	Some-what Useful	Very Useful	Extremely Useful
Section 1: Principles of Informed Consent
Section 2: Strategies for Clear Communication
Strategy 1: Prepare for the Informed Consent Discussion
Strategy 2: Use Health Literacy Universal Precautions
Strategy 3: Remove Language Barriers
Strategy 4: Use Teach-Back
Section 3: Strategies for Presenting Choices
Strategy 5: Offer Choices
Strategy 6: Engage the Patient and Their Family and Friends
Strategy 7: Elicit Goals and Values
Strategy 8: Encourage Questions
Strategy 9: Show High Quality Decision Aids
Strategy 10: Explain Benefits, Harms, and Risks of All Options
Section 4: Documenting and Confirming Informed Consent as Part of a Team

9a. Can you explain the reason for your ratings?

_________________________________________________________________________________

7. What motivated you to improve your informed consent practices? [Check all that apply]

 It was apparent informed consent practices could be improved

 Data supported the need for improvements to our informed consent practices

 Patients seemed to respond well to the changes in our approach to informed consent

 I came to recognize how the changes were an improvement over our previous approach

 Hospital/unit leaders made it clear that improving our informed consent practices was a priority

 Improving my informed consent practices was a priority for me

 My colleagues were going through similar improvements in their informed consent practices

 Other (please specify): ________________________________________________

7. What made it easier to improve your informed consent practices? [Check all that apply]

 There was support from hospital leadership (e.g., policies were clarified, expectations for informed consent were made clear, libraries of high-quality decision aids were provided, adequate interpreter services were made available)

 There was support from unit leadership (e.g., workflow changes, team responsibilities clarified)

 I had sufficient time to improve my informed consent practices

 The changes to improve our informed consent processes were simple enough to make and integrate into our routines

 There was additional training or other reinforcement of material after I completed the online module

 I was incentivized to improve my informed consent practices

If so, how: _________________________________________________

 I was recognized for improving my informed consent practices

If so, how: _________________________________________________

 I was held accountable for changes in my informed consent practices (e.g., observation of informed consent discussions, audit of documentation)

 Other (please specify): ________________________________________________

7. To what do you attribute difficulties with changing informed consent in your unit? Check all that apply.

 Electronic health record issues

 Staff turnover, shortages or limited availability

 Competing priorities

 Lack of accountability

 Lack of resources

 Lack of time for informed consent discussions

 Lack of non-patient care time for training and making improvements

 Lack of leadership support

 Issues related to teamwork and communication among team members

 Resistance from certain team members on the unit for improving the process

 Implementing proposed changes took too much time

 Lack of champion/lead

 Other (please specify): ________________________________________________

Background Information²

This information will help in the analysis of the survey results.

7. How long have you worked in this hospital?

    a. Less than 1 year	 d. 11 to 15 years
    b. 1 to 5 years	 e. 16 to 20 years
    c. 6 to 10 years	 f. 21 years or more

8. How long have you worked in your current hospital work area/unit?

    a. Less than 1 year	 d. 11 to 15 years
    b. 1 to 5 years	 e. 16 to 20 years
    c. 6 to 10 years	 f. 21 years or more

9. What is your staff position in this hospital? Select ONE answer that best describes your staff position.

 a. Registered Nurse	 h. Dietician
 b. Physician Assistant/Nurse Practitioner	 i. Unit Assistant/Clerk/Secretary
 c. LVN/LPN	 j. Respiratory Therapist
 d. Patient Care Asst/Hospital Aide/Care Partner	 k. Physical, Occupational, or Speech Therapist
 e. Attending/Staff Physician	 l. Technician (e.g., EKG, Lab, Radiology)
 f. Resident Physician/Physician in Training	 m. Administration/Management
 g. Pharmacist	 n. Other, please specify:

7. How long have you worked in your current specialty or profession?

   a. Less than 1 year	 d. 11 to 15 years
    b. 1 to 5 years	 e. 16 to 20 years
    c. 6 to 10 years	 f. 21 years or more

8. In your staff position, do you typically have direct interaction or contact with patients?

    a. YES, I typically have direct interaction or contact with patients.

    b. NO, I typically do NOT have direct interaction or contact with patients.

9. In which hospital unit do you primarily work?

 Surgery

 [insert other units potentially participating]

 [insert other units potentially participating]

 [insert other units potentially participating]

1 Questions taken from the AHRQ Hospital Survey on Patient Safety

2 Questions taken from the AHRQ Hospital Survey on Patient Safety

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