This survey maintains respondent confidentiality. Once submitted, the survey can not be directly tied by the organization to the individual responding.

Survey Instructions
Think about the way things are done in your medical office and provide your opinions on issues that affect the overall safety and quality of the care provided to patients in your office.

In this survey, the term provider refers to physicians, physician assistants, and nurse practitioners who diagnose, treat patients, and prescribe medications. The term staff refers to all others who work in the office.

If a question does not apply to you or you don’t know the answer, please check "Does not apply or Don’t know." If you work in more than one office or location for your practice, when answering this survey answer only about the office location where you received this survey--do not answer about the entire practice. If your medical office is in a building with other medical offices, answer only about the specific medical office where you work—do not answer about any other medical offices in the building.

In this survey, think of your "unit" as the PICU work area/unit at Baltimore Memorial.

Section A: List of Patient Safety and Quality Issues

The following items describe things that can happen in medical offices that affect patient safety and quality of care. In your best estimate, how often did the following things happen in your medical office OVER THE PAST 12 MONTHS?	Daily	Weekly	Monthly	Several times in the past 12 months	Once or twice in the past 12 months	Not in the past 12 months		Does Not Apply or Don't Know
Access to Care
1. A patient was unable to get an appointment within 48 hours for an acute/serious problem
Patient Identification
2. The wrong chart/medical record was used for a patient
Charts/Medical Records
3. A patient's chart/medical record was not available when needed
4. Medical information was filed, scanned, or entered into the wrong patient's chart/medical record
Medical Equipment
5. Medical equipment was not working properly or was in need of repair or replacement
Medication
6. A pharmacy contacted our office to clarify or correct a prescription
7. A patient's medication list was not updated during his or her visit
Diagnostics & Tests
8. The results from a lab or imaging test were not available when needed
9. A critical abnormal result from a lab or imaging test was not followed up within 1 business day

Section B: Information Exchange With Other Settings

Over the past 12 months, how often has your medical office had problems exchanging accurate, complete, and timely information with:	Problems daily	Problems weekly	Problems monthly	Problems several times in the past 12 months	Problems once or twice in the past 12 months	No problems in the past 12 months		Does Not Apply or Don't Know
1. Outside labs/imaging centers?
2. Other medical offices/Outside physicians?
3. Pharmacies?
4. Hospitals?

Section C: Working in Your Medical Office

How much do you agree or disagree with the following statements?	Strongly Disagree	Disagree	Neither	Agree	Strongly Agree		Does Not Apply or Don't Know
1. When someone in this office gets really busy, others help out
2. In this office, there is a good working relationship between staff and providers
3. In this office, we often feel rushed when taking care of patients
4. This office trains staff when new processes are put into place
5. In this office, we treat each other with respect
6. We have too many patients for the number of providers in this office
7. This office makes sure staff get the on-the-job training they need
8. This office is more disorganized than it should be
9. We have good procedures for checking that work in this office was done correctly
10. Staff in this office are asked to do tasks they haven't been trained to do
11. We have enough staff to handle our patient load
12. We have problems with workflow in this office
13. This office emphasizes teamwork in taking care of patients
14. This office has too many patients to be able to handle everything effectively
15. Staff in this office follow standardized processes to get tasks done

Section D: Communication and Follow-up

How often do the following things happen in your medical office?	Never	Rarely	Sometimes	Most of the time	Always		Does Not Apply or Don't Know
1. Providers in this office are open to staff ideas about how to improve office processes
2. Staff are encouraged to express alternative viewpoints in this office
3. This office reminds patients when they need to schedule an appointment for preventive or routine care
4. Staff are afraid to ask questions when something does not seem right
5. This office documents how well our chronic care patients follow their treatment plans
6. Our office follows up when we do not receive a report we are expecting from an outside provider
7. Staff feel like their mistakes are held against them
8. Providers and staff talk openly about office problems
9. This office follows up with patients who need monitoring
10. It is difficult to voice disagreement in this office
11. In this office, we discuss ways to prevent errors from happening again
12. Staff are willing to report mistakes they observe in this office

Section E: Owner/Managing Partner/Leadership Support

A. Are you an owner, a managing partner, or in a leadership position with responsibility for making financial decisions for your medical office?		Yes › (SKIP TO SECTION F)
		No › (ANSWER ADDITIONAL ITEMS 1–4 BELOW)
How much do you agree or disagree with the following statements about the owners/managing partners/leadership of your medical office? Strongly Disagree Disagree Neither Agree Strongly Agree Does Not Apply or Don't Know 1. They aren't investing enough resources to improve the quality of care in this office 2. They overlook patient care mistakes that happen over and over 3. They place a high priority on improving patient care processes 4. They make decisions too often based on what is best for the office rather than what is best for patients

Section F: Your Medical Office

How much do you agree or disagree with the following statements?	Strongly Disagree	Disagree	Neither	Agree	Strongly Agree		Does Not Apply or Don't Know
1. When there is a problem in our office, we see if we need to change the way we do things
2. Our office processes are good at preventing mistakes that could affect patients
3. Mistakes happen more than they should in this office
4. It is just by chance that we don't make more mistakes that affect our patients
5. This office is good at changing office processes to make sure the same problems don't happen again
6. In this office, getting more work done is more important than quality of care
7. After this office makes changes to improve the patient care process, we check to see if the changes worked

Section G: Overall Ratings
 Overall Ratings on Quality
 1. Overall, how would you rate your medical office on each of the following areas of health care quality?

			Poor	Fair	Good	Very Good	Excellent
a.	Patient - centered	Is responsive to individual patient preferences, needs, and values
b.	Effective	Is based on scientific knowledge
c.	Timely	Minimizes waits and potentially harmful delays
d.	Efficient	Ensures cost-effective care (avoids waste, overuse, and misuse of services)
e.	Equitable	Provides the same quality of care to all individuals regardless of gender, race, ethnicity, socioeconomic status, language, etc.

 Overall Rating on Patient Safety
 2. Overall, how would you rate the systems and clinical processes your medical office has in place to prevent, catch, and correct problems that have the potential to affect patients?

Poor	Fair	Good	Very Good	Excellent

Section H: Background Questions
1. How long have you worked in this medical office location?
Less than 2 months
2 months to less than 1 year
1 year to less than 3 years
3 years to less than 6 years
6 years to less than 11 years
11 years or more

2. Typically, how many hours per week do you work in this medical office location?
1 to 4 hours per week
5 to 16 hours per week
17 to 24 hours per week
25 to 32 hours per week
33 to 40 hours per week
41 hours per week or more

3. What is your position in this office? Check ONE category that best applies to your job.
Physician (MD or DO)
Physician Assistant, Nurse Practitioner, Clinical Nurse Specialist, Nurse Midwife, Advanced Practice Nurse, etc.
Management (Practice Manager, Business Manager, Office Manager, Nurse Manager, Office Administrator, Lab Manager, Other Manager)
Administrative or clerical staff (Insurance Processor, Front Desk, Billing Staff, Receptionist, Referral Staff, Scheduler (appointments, surgery, etc.), Medical Records, Other administrative or clerical staff position)
Nurse (RN), Licensed Vocational Nurse (LVN), Licensed Practical Nurse (LPN)
Other clinical staff or clinical support staff (Medical Assistant, Technician (all types), Nursing Aide, Therapist (all types), Other clinical staff or clinical support staff)

Section I: Your Comments
Please feel free to write any comments you may have about patient safety or quality of care in your medical office.

THANK YOU FOR COMPLETING THIS SURVEY.

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