Form 1 Attachment C – Partner Hospital Champion Survey

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

Evaluating the Implementation of PCOR to

Increase Referral, Enrollment, and Retention through

Automatic Referral to Cardiac Rehabilitation (CR) with Care Coordination

Attachment C

Partner Hospital Champion Survey

Version: January 8, 2020

Public reporting burden for this collection of information is estimated to average 45 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.

1. Purpose of this tool

We will conduct online surveys of CR Champions at all 125 Partner Hospitals (one Champion per hospital). Champions in each cohort will complete two surveys, one mid-way through, and the other at the end of, the 12-month implementation period. Both surveys will capture the status of implementation and the effectiveness of the training and technical assistance received. The first survey will determine the context in which the hospital operates and ask about Champions’ confidence in implementing automatic referral with care coordination given their experience in the first six months of the cohort. The second survey will focus on facilitators and barriers to implementing automatic referral with care coordination.

2. Administration

The first survey will be conducted seven months after the start of implementation and the second at the end of the 12-month implementation period. Surveys will be sent to the email address of each hospital’s CR Champion, which will be collected when the hospital registers for TAKEheart. Champions are expected to be active participants in TAKEheart, so the TA Providers should be able to provide alternative email addresses if, for example, the Champion is replaced by another person.

The surveys will not be anonymous; the results will be linkable to other data including webinar participation, Action Plans, and whether the hospital got direct technical assistance.

Partner Hospitals will have agreed to participate in the evaluation. Therefore, this survey will take up to 45 minutes to complete.

3. Informed consent

The email invitation to perform the survey will include the informed consent, which is as follows.

This survey is part of an evaluation of the assistance given to selected hospitals to increase referrals to cardiac rehabilitation in a project known as TAKEheart. The assistance, and the evaluation, are funded by the Agency for Healthcare Research and Quality (AHRQ).

The TAKEheart hospitals will do two things to increase referrals to cardiac rehabilitation: one, implement an automatic referral system which identifies patients who are eligible for cardiac rehabilitation, and two, hire or assign a care coordinator to follow up with those patients. You were selected to participate in this survey because, as your hospital’s cardiac rehabilitation “champion,” you are most knowledgeable about how your hospital is implementing automatic referral with care coordination.

Your participation is voluntary. You may choose not to answer questions with no penalty. We will write a report for AHRQ that summarizes what we learned from the survey and other sources. The report will be used to

[For cohort 1] …improve tools and support provided to a second set of hospitals which will implement an automatic referral with care coordinator and improve the resources which will be made available online for other hospitals to use.

[For cohort 2] …improve the resources which will be made available online for other hospitals to use.

The reports will not identify the hospitals or the people who answered the survey. However, there is a small chance that you could be recognized. We will be sure to keep the information that you share private.

If you have questions about the project, contact Cynthia Klein, TAKEheart Project Director, at 404-946-6310, or by email at Cynthia_Klein@abtassoc.com.

4. Data collection tool: Survey of Partner Hospital Champions

Note: The following section will be formatted as a survey , in the survey administration system, for administration. Text in italics indicates instructions for creating the survey. Text in Small Caps indicates instructions to the respondent.

Organization name: [Required question. A dropdown box with names of all hospitals in the cohort. It should have search functionality.]

1. Context

Do you have clinical training?

• Cardiologist/Cardiac surgeon

• MD, DO

• PhD

• RN/PA/NP with a focus on cardiology

• RN/PA/NP without a focus on cardiology

• PT/OT, EP

• Other, Please specify: _____________________________

• No clinical training

What is your role in [your hospital]? Is it clinical, administrative, or both?

• Cardiologist (providing clinical services)

• Other clinical role (e.g., RN, PA, NP, PT/OT, Exercise Physiologist)

• Quality Improvement

• IT staff

• Management

• Other, Please specify: __________________________

Did your hospital have prior experience customizing an EMR?

• Yes, the cardiology department has customized the EMR

• Yes, both the cardiology department and other departments have customized the EMR

• Yes, only non-cardiology departments have customized the EMR

• No

Is the cardiology department represented in hospital administration?

Is your hospital an academic medical center or community hospital? [select one]

• Academic medical center

• Community hospital

Are cardiac rehabilitation referral performance measures currently collected and reported? y/n

Number of cardiologists (FTE in clinical capacity v research) [#]

Number of cardiac surgeons (FTE in clinical capacity v research) [#]

2. Participation in TAKEheart

Month 7 survey only: How did you personally hear about TAKEheart?

• AHA Website

• AHA Health Forum marketing email

• AHA Allied Associates

• Quality ListServe

• AHRQ Website

• AACVPR conference (September 2019)

• Twitter or other social media

• A colleague in your hospital

• A colleague in a different hospital

• Other

Month 7 survey only: How were you identified to be cardiac rehabilitation Champion?

• Self-identification

• Champion role is directly associated with existing duties so identified by job description

• Appointed by leadership

Month 12 survey only: Were the Champion in [specify month for specific cohort] or have you become the Champion since then?

Month 12 survey only and if the Champion has changed: How were you identified to be cardiac rehabilitation Champion?

• Self-identification

• Champion role is directly associated with existing duties so identified by job description

• Appointed by leadership

Approximately how much of your time is spent on activities related to automatic referral with care coordination?

• Present as a continuous scale, from “very little of my time” at <10%, “about half my time”, and “almost all my time” at 90%.

Month 7 survey only: Were you actively involved in the decision to participate in TAKEheart? y/n

Month 7 survey only: Which other key personnel, if any, were involved in the decision to participate in TAKEheart? Check all that apply.

• Cardiologist in administrative role

• Cardiologist not in administrative role

• Other medical doctor

• CR registered nurse

• Physical therapist

• Other clinical staff

• Chief Quality Officer

• Other Quality Improvement staff

• Information Technology/Informatics staff

• Hospital or health system management

• CR facility associated with hospital

• Media or public relations specialist

• Other

• Don’t know

Month 7 survey only: How would you describe your hospital’s motivation to participate in TAKEheart? [Likert: “did not change at all” through “changed a great deal”]

• Improve cardiac rehabilitation for quality or performance measurement

• Month 7 survey only: if prior answer is “did not change at all”, ask: Prior to choosing to participate in TAKEheart, did your hospital know its cardiac rehabilitation rate?

• Month 7 survey only, if prior answer is Yes: Did your hospital’s data on cardiac rehabilitation have data by sub-populations, such as males/females or by race?

• Increase utilization of cardiac rehabilitation program(s) in your health system

• Prepare for planned acquisition or affiliation with cardiac rehabilitation program(s)

• Improve patient satisfaction

• Decrease disparities across patient populations (e.g., sex, race)

• Improve patient outcomes relevant to patient (e.g., improved cardiac health)

• Improve patient outcomes relevant to hospital (e.g., decreased readmissions)

• Other, please describe

• Don’t know

Both surveys: If your hospital has a governance team to manage TAKEheart, please indicate all personnel who participate.

• There is not a governance team to manage TAKEheart

• CEO office staff

• CMO office staff

• Cardiology Department management

• Cardiologists not in administrative roles

• Other clinicians not in administrative roles

• CIO office staff

• Other IT or Informatics staff

• CQI office staff

• Other quality improvement or performance management staff

• Other

3. Cardiac rehabilitation programs

How many cardiac rehabilitation programs does your hospital refer to?

• 1

• 2-5

• 6 or more

Are any of the cardiac rehabilitation programs your hospital refers to owned by the same corporate entity which owns your hospital? y/n

Have you added or changed the cardiac rehabilitation programs your hospital refers to:

• to meet an anticipated increase in patient volume y/n

• to meet an experienced increase in patient volume y/n

Have you added or changed the cardiac rehabilitation programs your hospital refers to so your patients would have access to cardiac rehabilitation:

• on evening or weekend hours? y/n/already had CR program with this characteristic

• using an open-gym model? y/n

• using monitored home-based CR? y/n

• certified by AACVPR? y/n

• other: _______________________

Have you added or changed the cardiac rehabilitation programs your hospital refers because the cardiologists wanted more or different options?

Hospitals prepare their staff to use the automatic referral system in many different ways. Has your hospital’s provided cardiologists and cardiac surgeons on:

• the importance of cardiac rehabilitation? y/n

• methods of payment for cardiac rehabilitation? y/n

• cardiac rehabilitation programs available to your patients? y/n

• show the value and utility of automatic referral with care coordination? y/n

• the planned implementation of automatic referral with care coordination? y/nhow to

Have cardiologists changed their referral patterns, by

• referring a larger proportion of their eligible patients to cardiac rehabilitation?

• yes, all cardiologists

• mostly, except for a minority of cardiologists

• somewhat, some cardiologists

• not really, only a few cardiologists

• no

• referring all eligible patients at similar rates, regardless of patient characteristics such as gender, race, or socio-economic status?

• yes, all cardiologists

• mostly, except for a minority of cardiologists

• somewhat, some cardiologists

• not really, only a few cardiologists

• not applicable, patients were consistently referred at similar rates prior to TAKEheart

• no

Month 12 survey: Do cardiologists seem to take responsibility for encouraging patients to participate in cardiac rehabilitation more than they did prior to TAKEheart?

• yes, all cardiologists

• mostly, except for a minority of cardiologists

• somewhat, some cardiologists

• not really, only a few cardiologists

• no

4. Milestones

   Milestone	For each, ask: Have you completed this milestone? y/n If yes: When did your hospital complete the milestone? [list each month of the cohort, so they can check one. Start with “before we registered for TAKEheart (before October 2019)” and “during the registration and onboarding process (October 1-Dec 31, 2019).” End with “after our participation in TAKEheart”.] If not, how confident are you that you will be able to complete the milestone by the end of your TAKEheart participation in December 2020? Note that only some milestones have barriers pre-identified. This is intentional.
   Plan to engage cardiologists. Completion = Hospital has plan in place.
   Plan to communicate benefits of CR to all hospital staff. Completion = Hospital has plan in place.
   Plan to advertise benefits of CR to patients & their families. Completion = Hospital has plan in place.
   Develop an Action Plan. Completion = Action Plan has sequencing and planned timeline for addressing & achieving milestones.	BARRIERS Please indicate which barriers you encountered, and how significant they were. [If the barrier is checked, ask how long the barrier is likely to delay the milestone: less than a month, one to three months, three months or more, will halt effort on milestone.] CR Champion did not have sufficient time CR Champion did not have sufficient resources: staff, CR Champion left project Unable to get IT to the table Other
   Plan to engage staff in developing automatic prompt (e.g., cardiologists, staff currently involved in CR). Completion = Hospital has plan in place.
   Develop specifications for EMR. Completion = Specifications are submitted to vendor or IT department.	Please indicate which barriers you encountered, and how significant they were. [If the barrier is checked, ask how long the barrier is likely to delay the milestone: less than a month, one to three months, three months or more, will halt effort on milestone. IT leadership did not support resources spending time on specifications Difficult to get cardiologists to the table Difficult to get non-cardiologist staff currently engaged in CR to the table Differences of opinion regarding design of referral (e.g., whether to have it be opt-out or opt-in)
   Launch of tested EMR with functionality desired by hospital. Completion = Tested EMR (or other automatic referral) functionality is integrated into hospital’s workflow.	Please indicate which barriers you encountered, and how significant they were. [If the barrier is checked, ask how long the barrier is likely to delay the milestone: less than a month, one to three months, three months or more, will halt effort on milestone. Hospital leadership diverted resources/funding to other projects IT leadership diverted resources/funding to other projects Testing revealed unanticipated problems with design
   Create a Care Coordinator position with a written role description (if someone is assigned PT) or job description (FT). Completion = Role/Job description is approved by HR/management.
   Develop training materials for the Care Coordinator. Completion = Training materials are approved by HR/management.
   Identify/hire Care Coordinator. If training materials have been developed, train care coordinator. Completion = Care Coordinator starts assignment to refer patients to CR.	Please indicate which barriers you encountered, and how significant they were. [If the barrier is checked, ask how long the barrier is likely to delay the milestone: less than a month, one to three months, three months or more, will halt effort on milestone. Delay on writing care coordinator role description or job description Disagreement about care coordinator responsibilities Disagreement about care coordinator background Disagreement about care coordinator pay range Hospital leadership did not want to use resources to assign a staff person to Care Coordinator duties or to hire a Care Coordinator Department leadership did not want to assign a staff person from their department to be Care Coordinator Care coordinator left position
   Map out current process from time of referral/discharge to appointment & identify patient, program, and system barriers. Completion = Hospital has determined the current referral process and identified barriers. The results are not necessarily in a written document.
   Create new workflow incorporating automatic referral. Completion = Hospital has a plan for a new workflow in place.
   Assess the hospital's CR baseline referral rate. Completion = Hospital knows the referral rate for the baseline it identified.	What method did you use? Check all that apply. registries collecting information from medical records about past referrals collecting data about patients as they become eligible for CR
   Implement system to monitor CR after participation in the TAKEheart cohort is completed (if monitoring is not embedded into EMR). Completion = Hospital has started monitoring CR referral and enrollment.
   Develop a list of CR programs available to hospital's patients. Completion = Hospital has a list of CR programs available to its patients.	If yes, Are you in a region with multiple CR programs available? If yes, Did you expand the number of CR programs you work with for TAKEheart? Did you seek out CR programs to meet specific needs of your patient population, such as evening and weekend hours or flexible scheduling/open gym?
   Develop a protocol for outpatient CR Programs to follow when a patient attends their first CR session. Completion = Hospital has a protocol for outpatient CR programs in place.
   Develop a protocol for clinician-to-clinician hand-off to inpatient/rehab CR Programs to clarify CR plan of care, improve transitions, and reduce readmissions. Completion = Hospital has a protocol for inpatient/rehab CR programs in place.

5. Training and Technical Assistance

   1. Training Modules

Which of the following Training Modules did you attend? Check all that apply.

Training Module and date	Did anyone from your hospital attend this training module?	If no: [see list below table]	If yes: [See list below table.]
1 Welcome to the TAKEheart Initiative and the Benefits of Increasing Cardiac Rehabilitation, DATE	Yes, I attended Yes, both I and others attended Yes, someone else attended but I didn’t I don’t know whether anyone attended No one attended
2 System Change: Foundations and Leadership, DATE
3 System Change: Implementation and Teamwork, DATE
4 Building and Implementing a Successful Automated CR Referral System, DATE
5 Defining the Care Coordinator Role, Hiring Criteria, and Training and Integrating a Care Coordinator
6 Accommodating Patient Needs, Improving CR Accessibility, Affordability, and Acceptability, DATE
7 Collecting and using data to Improve CR Uptake and Effectiveness, DATE
8 This is harder than I Thought: Troubleshooting a CR Referral System
9 Empowering Patients: Motivational Interviewing, Self-Management Support and Patient Follow Up
10 Home based Cardiac Rehab Programs: What Works and Why?

[If they did not attend the training:]

Please Check all the reasons your hospital didn’t attend.

• The topic did not seem relevant to our hospital’s needs.

• I did not think I would learn from the webinar.

• The time was not convenient/possible.

• I planned to attend but a conflict came up.

• I planned to attend but forgot.

• I was not allowed to attend.

• Other

[If they attended the training:]

• How useful was the information presented in the webinar in helping your hospital prepare to implement automatic referral with care coordinator? Likert

• Each webinar has a companion guide intended to help hospitals apply the information learned in the webinar. If you used the companion guide to the webinar,

• How useful was the Implementation Guide? [responses: “did not use” and Likert]

• How actionable was the Implementation Guide in helping you implement automatic referral with care coordinator? [responses: “did not use” and Likert]

• Each webinar is followed by a Partner Hospital Peer Action Group meeting, in which hospitals discuss how to apply what they learned on the webinar. If you attended the Partner Hospital Peer Action Group session discussing the webinar:

• How useful was the discussion? [responses: “did not use” and Likert]

• How actionable was what you learned in the discussion in helping you implement automatic referral with care coordinator?

• Some hospitals request additional, direct technical assistance. If you got additional, direct technical assistance on the webinar topic:

• How useful was the technical assistance? [responses: “did not use” and Likert]

• How actionable was what you learned from the technical assistance in helping you implement automatic referral with care coordinator? [responses: “did not use” and Likert]

• Did you get enough information to implement what you learned? Likert

• Did you have the resources you needed? y/n

• If not Where did you seek additional information Check all that apply

• Partner Hospital Peer Action Group members directly

• Direct contact with other TAKEheart hospitals champions not in the Partner Hospital Peer Action Group

• TAKEheart private website for Partner Hospitals (e.g., materials other Partner Hospitals posted)

• Staff at hospitals not participating in TAKEheart

• TAKEheart public website

• CRCP website

• Other: Please specify

2. Other Technical Assistance

TAKEheart has a private website on which Partner Hospitals can share materials and discuss activities. Did you use the website to:

• Upload documents for comments from other cardiac rehabilitation Champions? y/n, Likert for how useful this was

• Use documents posted by other Partner Hospitals? y/n, Likert for how useful this was

• Comment on other Partner Hospitals’ materials? y/n, Likert for how useful this was

• Participate in a group to produce documents? y/n, Likert for how useful this was

TAKEheart supports a website with cardiac rehabilitation resources that are available to all hospitals. If you used any of these resources, how useful were they to implementing automatic referral with care coordinator? didn’t use /Likert

Did you attend the American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR) in September 2019 conference?

If yes, how helpful were the sessions to implementing automatic referral with care coordinator? n/a, Likert

If you discussed implementing automatic referral with care coordinator with staff at other hospitals during the conference, how helpful were those conversations? n/a, Likert

6. Closing questions

Month 7 survey: Do you feel you know where to access information, materials, or other resources you need to implement automatic referral with care coordinator?

Month 12 survey: How satisfied with you on the progress your hospital made towards implementing automatic referral with care coordinator? Likert

Both surveys: How confident are you that your hospital will implement automatic referral with care coordinator by the end of the technical support period, [date of the end of the cohort], or within a few months after that?

• Very confident; we have completed implementation of automatic referral with care coordination

• Very confident

• Somewhat confident

• Not very confident

• Not confident; we face significant challenges to completing the automatic referral

• Not confident; we face significant challenges to filling the care coordinator role

• Not confident; we have stopped work on the project

You have completed the survey. We sincerely thank you for your time! Your feedback is essential.