7 Appendix

Appendix G – Observation Tool

AHRQ – Building Diagnostic Safety Capacity

Patient and Family Engagement Resource Pilot Test Evaluation

Practice Observation Tool

The practice observation tool will be used during the practice site visit to document evidence of the PFE Resource implementation within the practice. This will be conducted by a project team member and have minimal burden on the practice and respondents. The practice observation tool is a brief checklist to audit materials and evaluate fidelity to the intended implementation of each of the resources into everyday practice. Patient-clinician interactions will be observed at the discretion of the patient, clinician, and practice. We aim to observe up to 10 patient-clinician interactions per practice for evidence of within encounter adoption of the PFE Resources.

MedStar Health Research Institute (MHRI) will conduct direct observations of patient-clinician encounters for up to 10 encounters per practice (n=200 encounters). Each encounter will engage one patient, one clinician, and one or more staff members (burden estimate based on 2 staff). Total time for the encounter burden was estimated at 20 minutes per encounter.

Recruitment Criteria

Ambulatory care practice administrators who have been exposed to the PFE Resource within their practice will be eligible to participate in the interview. MHRI team members will work with the practice champions to identify practice administrators to participate in the interviews. We will aim to recruit practice administrators in the following manner:

• Practice administrators involved in the decision making around implementation of the PFE Resource or how have had experience using the PFE Resource

Interview Goals

The goals of the interviews will be to:

• Obtain feedback on the intervention PFE Resource materials

• Obtain feedback on the barriers and facilitators encountered during implementation

• Obtain feedback on satisfaction with instructions and materials

• Obtain feedback on receptivity and enhancements to the PFE Resource materials to improve adoption and implementation

Interview Materials

• Copies of the PFE Resource

• Informed consent documents

• Documentation for Processing of Participant stipends

• Digital recorder

Location

Practice observations will be conducted within the practice that is implementing the resource.

Participant Stipends

None.

Burden Hours: 100 patients x 30 minutes per patient

Informed Consent Procedures

Participants will complete the informed consent process at the time of arrival to the interview.

Form Approved
OMB No. xxxx-xxxx
Exp. Date xx/xx/20

AHRQ – Building Diagnostic Safety Capacity

Patient and Family Engagement Resource Pilot Test Evaluation

Practice Observation Tool

PFE Resource Component	Observed	Description of Fidelity/Implementation in Practice
Patient facing poster	☐	Encounter Room Waiting Room Hallway Other: [Define]
Patient Agenda Tool – Preparation for Encounter	☐	Given at check in Given at exam room Given in waiting room Other
Patient One Minute Story	☐	Patient given one minute to speak at start of encounter Patient interrupted after [xxxx] seconds Patient not given opportunity Patient refused opportunity Family member spoke on behalf of patient Family member engaged in story telling with patient Other? [describe]
Patient Agenda Tool - Encounter	☐	MA acknowledged the Agenda Tool Clinician acknowledged the Agenda Tool Clinician used Agenda Tool in visit Other? [describe]

This survey is authorized under 42 U.S.C. 299a. The confidentiality of your responses to this survey is protected by Sections 944(c) and 308(d) of the Public Health Service Act [42 U.S.C. 299c-3(c) and 42 U.S.C. 242m(d)].  Information that could identify you will not be disclosed unless you have consented to that disclosure. Public reporting burden for this collection of information is estimated to average 20 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, Room #07W42, Rockville, MD 20857.