Interviewer Data Collection Worksheet

Attachment 10a

Form Approved

OMB No: 0920-1019

Exp. Date: XX/XX/XXXX

Integrating Community Pharmacists and Clinical Sites

for Patient-Centered HIV Care

Attachment 10a Interviewer Data Collection Worksheet

Public reporting burden of this collection of information is estimated to average 30 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. 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 CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; Attn: OMB-PRA (0920-1019)

Interviewer data collection worksheet

	Changes at Pharmacy	Changes at Medical Clinic	What Worked Well	Areas for Improvement	Most Significant Change
WORK SYSTEM
Personnel preparation (education, skills, knowledge, motivation, needs)
Organizational coordination, collaboration, and communication (policies, procedures, infrastructure, marketing communications, Care Model description including – size / patients served / travel distances / targeted minorities enrolled)
Work schedule adjustments (staff changes)
Technologies and tools (documentation, forms, standing orders, equipment)
Job demand changes (workload, time pressure, protocols)
Work area adjustments (layout, noise, lighting, work station design)
PROCESS
Patient care process adjustments (medication reviews, on-call services, interventions, medication management services, action plans, biometrics conducted, screenings conducted, use of services – 24 hr access / standing orders / formulary / medication review / after hour time / medication changes / dose changes / drug therapy problems identified and resolved)
Information flow adjustments (collaborative activities, reporting methods)
Purchasing and/or billing adjustments (business models, accounting systems, metrics)
Process improvement activities (time records, meetings)
OUTCOMES
Personnel job satisfaction (including change in perception of pharmacist as part of team, employee retention
Job stress and burnout
Employee turnover
Organizational health (profitability, meeting goals, changes in cost of care, decreased waste in nursing time / rework / other)
Patient Safety (drug therapy problem identification, complexity, and outcome)
Quality of Patient Care (retention of HIV care, adherence, HIV viral load suppression, opportunistic infection, access to medications, access to information, changes in patient or caregiver knowledge, clinical effect of medication recommendations)
From all of the significant changes you described, what do you think was the most significant change of all?