SHC Practice Assessment Survey: DRIVE Diabetes Quality and Equity

By answering questions below about your practice site, current clinical approaches to diabetes, and challenges you face, you will be better able to develop and implement a relevant QI activity.

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* 1. Your profession/role in the practice:

Physician

Resident

Physician assistant

Pharmacist

Nurse practitioner

Nurse

Medical assistant

Practice manager

Front desk/administrative staff

Diabetes educator

Patient navigator

Social worker

Behavioral healthcare provider

Community health worker

Other (please specify)

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* 2. Practice address (city):

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* 3. Practice address (state):

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* 4. Practice address (zip code):

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* 5. Practice type. Check all that apply:

Family practice

General internal medicine

Pediatrics

Geriatrics

Multi-specialty

Endocrinology

Other (please specify)

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* 6. Number of health care providers at your practice location:

	None	1 to 2	3 to 5	6 to 10	More than 10
Physicians	Physicians None	Physicians 1 to 2	Physicians 3 to 5	Physicians 6 to 10	Physicians More than 10
Residents	Residents None	Residents 1 to 2	Residents 3 to 5	Residents 6 to 10	Residents More than 10
Physician assistants	Physician assistants None	Physician assistants 1 to 2	Physician assistants 3 to 5	Physician assistants 6 to 10	Physician assistants More than 10
Nurse practitioners	Nurse practitioners None	Nurse practitioners 1 to 2	Nurse practitioners 3 to 5	Nurse practitioners 6 to 10	Nurse practitioners More than 10
Nurses	Nurses None	Nurses 1 to 2	Nurses 3 to 5	Nurses 6 to 10	Nurses More than 10
Pharmacists	Pharmacists None	Pharmacists 1 to 2	Pharmacists 3 to 5	Pharmacists 6 to 10	Pharmacists More than 10
Medical assistants	Medical assistants None	Medical assistants 1 to 2	Medical assistants 3 to 5	Medical assistants 6 to 10	Medical assistants More than 10
LPNs	LPNs None	LPNs 1 to 2	LPNs 3 to 5	LPNs 6 to 10	LPNs More than 10
Practice managers	Practice managers None	Practice managers 1 to 2	Practice managers 3 to 5	Practice managers 6 to 10	Practice managers More than 10
Front desk staff/receptionists	Front desk staff/receptionists None	Front desk staff/receptionists 1 to 2	Front desk staff/receptionists 3 to 5	Front desk staff/receptionists 6 to 10	Front desk staff/receptionists More than 10
Social workers	Social workers None	Social workers 1 to 2	Social workers 3 to 5	Social workers 6 to 10	Social workers More than 10
Patient navigators	Patient navigators None	Patient navigators 1 to 2	Patient navigators 3 to 5	Patient navigators 6 to 10	Patient navigators More than 10
Behavioral healthcare provider	Behavioral healthcare provider None	Behavioral healthcare provider 1 to 2	Behavioral healthcare provider 3 to 5	Behavioral healthcare provider 6 to 10	Behavioral healthcare provider More than 10
Diabetes educators	Diabetes educators None	Diabetes educators 1 to 2	Diabetes educators 3 to 5	Diabetes educators 6 to 10	Diabetes educators More than 10
Community health worker	Community health worker None	Community health worker 1 to 2	Community health worker 3 to 5	Community health worker 6 to 10	Community health worker More than 10

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* 7. Practice setting:

Independent physician-owned practice.

Hospital- or health system-owned practice.

Academic medical center/residency program

Federally qualified health center

Other (please specify)

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* 8. Estimated number of patients at practice site annually (panel size):

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* 9. How does your practice approach community engagement? Check all that apply:

The health system of which we are a part leads community engagement activities.

We have compiled a list of contacts in the community who can provide social services or other supports for our patients.

We have a patient/family/community advisory group that meets with us regularly to help us understand community needs.

We have a staff person that has the responsibility for connecting our patients in the community to other service providers and supports (e.g., patient navigator).

People from our practice routinely speak at community events and health fairs, educating the community about health issues and services.

Other (please specify)

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* 10. Indicate the quality improvement experience of your practice's staff:

Rarely implements QI projects
1

Commonly implements QI projects
5

Rarely implements QI projects
1

Commonly implements QI projects
5

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* 11. What quality improvement (QI) resources does your practice have? Check all that apply:

External QI experts support staff (e.g., QIO).

EHR can be used for QI (e.g., identifying patient population for projects; addition of reminders to EHR).

Strong relationship with IT department to help run reports and add reminders, etc.

Strong leadership support for QI at practice site.

There are practice staff with implementation of QI programs as part of their job.

QI is required of practice for reimbursement (e.g., value-based payment programs).

QI is required to meet professional qualifications (e.g., ACGME requirements in residency programs; part IV requirements in medical boards).

Practice ownership, such as the health system, provide support for QI.

Other (please specify)

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* 12. What priorities for quality improvement, in general, does your practice have? Check up to three:

Enhance team-based care.

Improve work flow so as to create efficiencies in the practice.

Increase knowledge and implementation of motivational interviewing and shared decision-making.

Increase staff knowledge of QI approaches.

Meet performance improvement requirements for reimbursement or value-based payment.

Meet performance improvement requirements for professionalism.

Improve linkages with community representatives or services.

Improve care coordination with specialists.

Reduce provider burn-out.

Improve health equity.

Address health literacy.

Understand health status and needs of patient population.

Understand health status and needs of surrounding community.

Other (please specify)

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* 13. What barriers, if any, does your practice face with QI activities? Check all that apply:

Lack of time.

Lack of leadership prioritization.

Lack of staff.

Staff burn-out.

Staff turn-over.

Lack of knowledge about quality improvement.

Lack of resources to collect EHR data.

Other (please specify)

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* 14. Estimated patient demographics:

	Greater than 50%	25 to 50%	10 to 25%	Less than 10%
White, non-Hispanic	White, non-Hispanic Greater than 50%	White, non-Hispanic 25 to 50%	White, non-Hispanic 10 to 25%	White, non-Hispanic Less than 10%
African American or Black	African American or Black Greater than 50%	African American or Black 25 to 50%	African American or Black 10 to 25%	African American or Black Less than 10%
Hispanic or Latino	Hispanic or Latino Greater than 50%	Hispanic or Latino 25 to 50%	Hispanic or Latino 10 to 25%	Hispanic or Latino Less than 10%
Asian	Asian Greater than 50%	Asian 25 to 50%	Asian 10 to 25%	Asian Less than 10%
American Indian/Native American	American Indian/Native American Greater than 50%	American Indian/Native American 25 to 50%	American Indian/Native American 10 to 25%	American Indian/Native American Less than 10%
Native Hawaiian/Pacific Islander	Native Hawaiian/Pacific Islander Greater than 50%	Native Hawaiian/Pacific Islander 25 to 50%	Native Hawaiian/Pacific Islander 10 to 25%	Native Hawaiian/Pacific Islander Less than 10%
Medicare recipient	Medicare recipient Greater than 50%	Medicare recipient 25 to 50%	Medicare recipient 10 to 25%	Medicare recipient Less than 10%
Medicaid recipient	Medicaid recipient Greater than 50%	Medicaid recipient 25 to 50%	Medicaid recipient 10 to 25%	Medicaid recipient Less than 10%
Uninsured	Uninsured Greater than 50%	Uninsured 25 to 50%	Uninsured 10 to 25%	Uninsured Less than 10%
Primary language is English	Primary language is English Greater than 50%	Primary language is English 25 to 50%	Primary language is English 10 to 25%	Primary language is English Less than 10%
Immigrant	Immigrant Greater than 50%	Immigrant 25 to 50%	Immigrant 10 to 25%	Immigrant Less than 10%

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* 15. How often does your practice perform the following in managing your patient population with diabetes?

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* 16. What barriers to diabetes management does your practice face?

	Check all that apply.	Check top two.
Patient medication taking.	Patient medication taking. Check all that apply.	Patient medication taking. Check top two.
Costs of medications for patients.	Costs of medications for patients. Check all that apply.	Costs of medications for patients. Check top two.
Providing or accessing patient education.	Providing or accessing patient education. Check all that apply.	Providing or accessing patient education. Check top two.
Lack of time per patient visit.	Lack of time per patient visit. Check all that apply.	Lack of time per patient visit. Check top two.
CGM use or access.	CGM use or access. Check all that apply.	CGM use or access. Check top two.
Meeting patient social needs such as transportation, healthy food access, etc.	Meeting patient social needs such as transportation, healthy food access, etc. Check all that apply.	Meeting patient social needs such as transportation, healthy food access, etc. Check top two.
Patient health literacy and numeracy.	Patient health literacy and numeracy. Check all that apply.	Patient health literacy and numeracy. Check top two.
Use of insulin.	Use of insulin. Check all that apply.	Use of insulin. Check top two.

Other (please specify)

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* 17. What support would you like to enhance your diabetes care and outcomes?

Participation in a coaching call.

Educational resources for patients.

Educational resources for the clinical team.

Development of DSME training.

Community engagement.

Implicit bias training.

Resources for responding to social determinants of health.

Other (please specify)

	Rarely	Sometimes	Often	Routinely
Assess social determinants of health, such as food insecurity, housing instability, and financial barriers.	Assess social determinants of health, such as food insecurity, housing instability, and financial barriers. Rarely	Assess social determinants of health, such as food insecurity, housing instability, and financial barriers. Sometimes	Assess social determinants of health, such as food insecurity, housing instability, and financial barriers. Often	Assess social determinants of health, such as food insecurity, housing instability, and financial barriers. Routinely
Refer patients to local community resources.	Refer patients to local community resources. Rarely	Refer patients to local community resources. Sometimes	Refer patients to local community resources. Often	Refer patients to local community resources. Routinely
Provide patients with self-management support and training.	Provide patients with self-management support and training. Rarely	Provide patients with self-management support and training. Sometimes	Provide patients with self-management support and training. Often	Provide patients with self-management support and training. Routinely
Use a shared decision-making approach to developing individual treatment plans.	Use a shared decision-making approach to developing individual treatment plans. Rarely	Use a shared decision-making approach to developing individual treatment plans. Sometimes	Use a shared decision-making approach to developing individual treatment plans. Often	Use a shared decision-making approach to developing individual treatment plans. Routinely
Use motivational interviewing techniques to enhance patient engagement, adherence, and outcomes.	Use motivational interviewing techniques to enhance patient engagement, adherence, and outcomes. Rarely	Use motivational interviewing techniques to enhance patient engagement, adherence, and outcomes. Sometimes	Use motivational interviewing techniques to enhance patient engagement, adherence, and outcomes. Often	Use motivational interviewing techniques to enhance patient engagement, adherence, and outcomes. Routinely
Employ the services of a diabetes educator.	Employ the services of a diabetes educator. Rarely	Employ the services of a diabetes educator. Sometimes	Employ the services of a diabetes educator. Often	Employ the services of a diabetes educator. Routinely
Make sure your patients are up-to-date on all recommended immunizations.	Make sure your patients are up-to-date on all recommended immunizations. Rarely	Make sure your patients are up-to-date on all recommended immunizations. Sometimes	Make sure your patients are up-to-date on all recommended immunizations. Often	Make sure your patients are up-to-date on all recommended immunizations. Routinely
Assess and track co-morbid heart failure.	Assess and track co-morbid heart failure. Rarely	Assess and track co-morbid heart failure. Sometimes	Assess and track co-morbid heart failure. Often	Assess and track co-morbid heart failure. Routinely
Assess and track co-morbid chronic kidney disease.	Assess and track co-morbid chronic kidney disease. Rarely	Assess and track co-morbid chronic kidney disease. Sometimes	Assess and track co-morbid chronic kidney disease. Often	Assess and track co-morbid chronic kidney disease. Routinely
Monitor and manage blood pressure.	Monitor and manage blood pressure. Rarely	Monitor and manage blood pressure. Sometimes	Monitor and manage blood pressure. Often	Monitor and manage blood pressure. Routinely
Monitor and manage A1C.	Monitor and manage A1C. Rarely	Monitor and manage A1C. Sometimes	Monitor and manage A1C. Often	Monitor and manage A1C. Routinely
Monitor and manage lipids.	Monitor and manage lipids. Rarely	Monitor and manage lipids. Sometimes	Monitor and manage lipids. Often	Monitor and manage lipids. Routinely
Monitor and manage co-morbid depression.	Monitor and manage co-morbid depression. Rarely	Monitor and manage co-morbid depression. Sometimes	Monitor and manage co-morbid depression. Often	Monitor and manage co-morbid depression. Routinely
Monitor medication adherence.	Monitor medication adherence. Rarely	Monitor medication adherence. Sometimes	Monitor medication adherence. Often	Monitor medication adherence. Routinely
Monitor emergency department utilization.	Monitor emergency department utilization. Rarely	Monitor emergency department utilization. Sometimes	Monitor emergency department utilization. Often	Monitor emergency department utilization. Routinely
Monitor and manage obesity.	Monitor and manage obesity. Rarely	Monitor and manage obesity. Sometimes	Monitor and manage obesity. Often	Monitor and manage obesity. Routinely
Monitor and manage tobacco use.	Monitor and manage tobacco use. Rarely	Monitor and manage tobacco use. Sometimes	Monitor and manage tobacco use. Often	Monitor and manage tobacco use. Routinely
Follow the ADA standards for Diabetes Care in determining glycemic treatment.	Follow the ADA standards for Diabetes Care in determining glycemic treatment. Rarely	Follow the ADA standards for Diabetes Care in determining glycemic treatment. Sometimes	Follow the ADA standards for Diabetes Care in determining glycemic treatment. Often	Follow the ADA standards for Diabetes Care in determining glycemic treatment. Routinely
Assist patients in gaining affordable medications.	Assist patients in gaining affordable medications. Rarely	Assist patients in gaining affordable medications. Sometimes	Assist patients in gaining affordable medications. Often	Assist patients in gaining affordable medications. Routinely
Assist patients in getting CGMs.	Assist patients in getting CGMs. Rarely	Assist patients in getting CGMs. Sometimes	Assist patients in getting CGMs. Often	Assist patients in getting CGMs. Routinely
Use telehealth for patient appointments and education.	Use telehealth for patient appointments and education. Rarely	Use telehealth for patient appointments and education. Sometimes	Use telehealth for patient appointments and education. Often	Use telehealth for patient appointments and education. Routinely