Attachment D: Consent Form

Consent Form – Measurement for Performance Improvement in Physician Practices

PURPOSE: We are inviting you to participate in an interview for the Measruement for Peformance Improvement in Physician Practices exploratory study. The purpose of this interview is to discuss with you your group practice’s internal performance measurement. The information you give us will be used to help us better understand the current state of internal measurement for performance improvement.

SPONSOR: The project is being conducted in collaboration with, and funded by, the Agency for Healthcare Research and Quality (AHRQ).

RESEARCHERS: This interview is being conducted by Westat, a social science research company located in Rockville, MD with our partners at RAND.

WHAT IS INVOLVED: Participation in this research is voluntary. You will be asked to answer questions about measurement for performance improvement in your group practice. The interview will take 60 to 90 minutes.

RECORDING: This session will be audio recorded for transcription.

CONFIDENTIALITY: No one but the people involved in this research will ever see or listen to the tapes. You may talk freely about this practice. The tapes will be destroyed within 6 weeks of the end of the contract.

RISKS: There are no foreseeable risks to particpating in this study. The only cost to you is the time and effort to answer questions. You may skip any question that you do not want to answer. The information you give will be treated as confidential; no participants will be identified by name in the reports. The taped records of the interview will be destroyed within 6 weeks of the end of the contract.

BENEFITS: There are no direct benefits to you for participating in this study. However, you will be helping improve our understanding of internal measurement for performance improvement.

QUESTIONS: For questions about the project, you may call the Project Director at Westat, Denise St. Clair, and leave a message at 1-800-WESTAT1 or contact her directly at 608-318-1669. If you have any questions about your rights and welfare as a research participant, please call the Westat Human Subjects Protection Office at 1-888-920-7631. Please leave a message with your full name and a phone number including area code. Mention you are calling about AHRQ’s Measurement for Performance Improvement in Physician Practices study and someone will return your call as soon as possible.

I have read the consent form. My questions have been answered. My verbal consent recorded during the pilot interview means that I understand the information and I consent to participate in this study. I also certify that I am 18 years of age or older.

Public reporting burden for this collection of information is estimated to average 75 minutes per response, the estimated time required to complete the interview. 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, 5600 Fishers Lane, # 07W41A, Rockville, MD 20857.

Public reporting burden for this collection of information is estimated to average XX 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, 5600 Fishers Lane, # 07W41A, Rockville, MD 20857.