All Worksheets for Implementing PPIP

Readiness Survey

Circle the number that best indicates the extent to which you agree or disagree with each statement.

(1 = Very much; 7 = Not at all)

1. Prevention is an important aspect of the care we provide in this practice.

1 2 3 4 5 6 7

2. We think prevention should be more strongly emphasized in our practice.

1 2 3 4 5 6 7

3. Someone in our practice has the vision, leadership, and authority to make prevention happen here.

1 2 3 4 5 6 7

4. We have adequate time to do one-on-one patient education or patient counseling.

1 2 3 4 5 6 7

5. Nurses in our practice regard patient education as one of their main tasks.

1 2 3 4 5 6 7

6. Physicians in our practice regard patient education as one of their main tasks.

1 2 3 4 5 6 7

7. Our practice is willing to allocate resources (time, training, personnel, and space) to implement a comprehensive program to deliver clinical preventive services.

1 2 3 4 5 6 7

8. Internal communication is strong among staff and physicians in our practice.

1 2 3 4 5 6 7

9. A sense of teamwork exists among staff members and physicians in our practice.

1 2 3 4 5 6 7

10. Our practice has already implemented, or has tried to implement, specific programs for prevention (e.g., cancer prevention programs, smoking cessation, and diabetes education).

1 2 3 4 5 6 7

11. Our practice has effective referral mechanisms for patients to receive any screening tests not provided in our office (e.g., mammography and lab).

1 2 3 4 5 6 7

12. We have effective referral mechanisms for patients to receive behavior change counseling.

1 2 3 4 5 6 7

13. We follow up on patients referred to other services (e.g., record test results on charts).

1 2 3 4 5 6 7

14. We can allow adequate planning time to incorporate prevention into our practice.

1 2 3 4 5 6 7

15. We have a quality assurance system in place to assess and improve service delivery (e.g., Continuous Quality Improvement [CQI]; Total Quality Management [TQMI]).

1 2 3 4 5 6 7

16. We have a system in place to report the percentage of eligible patients who are receiving the screening tests they need (e.g., Pap smears and immunizations).

1 2 3 4 5 6 7

Source: Readiness to put prevention in your practice. Texas Medicine 92(12):35,1996.

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Worksheet for Assessing Organizational Climate

What are the values, attitudes, and beliefs of our staff about prevention?

_____________________________________________________________________

What are the values, attitudes, and beliefs of our patients about prevention?

_____________________________________________________________________

What kinds of preventive services do we aspire to provide all of our patients?

_____________________________________________________________________

What is the difference between what we aspire to provide and what we currently provide?

_____________________________________________________________________

Do we perceive a need to change?

_____________________________________________________________________

Are we ready to make a change?

_____________________________________________________________________

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Worksheet for Assessing Current Preventive Services

Preventive Services Provided

What preventive care do we currently provide our patients?

_____________________________________________________________________

Do we provide preventive services for which each patient is eligible?

_____________________________________________________________________

What services are we documenting?

_____________________________________________________________________

Existing Systems for Providing Preventive Services

What policies and procedures do we have in place for providing preventive services?

_____________________________________________________________________

What forms and systems are we using?

_____________________________________________________________________

How does our current physical environment support or inhibit our delivery of preventive services?

_____________________________________________________________________

What preventive services delivery systems have worked? Why?

_____________________________________________________________________

What preventive services delivery systems have not worked? Why?

_____________________________________________________________________

What can we do differently?

_____________________________________________________________________

Will the PPIP system duplicate the work we are already doing?

_____________________________________________________________________

Staff Roles

What functions do staff currently serve in the provision of preventive care?

_____________________________________________________________________

Who is documenting the delivery of preventive services?

_____________________________________________________________________

Patient Flow

How does our current patient flow support or inhibit our delivery of preventive services?

_____________________________________________________________________

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Worksheet for Assessing Current Individual and Group Systems

How are people working together?

_____________________________________________________________________

Do people like working here?

_____________________________________________________________________

What do patients say about our clinical setting?

_____________________________________________________________________

What kinds of preventive services do we aspire to provide all of our patients?

_____________________________________________________________________

What is the difference between what we aspire to provide and what we currently provide?

_____________________________________________________________________

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Worksheet for Developing an Implementation Plan

When should we start implementation?

_____________________________________________________________________

How should we start implementation?

_____________________________________________________________________

Who will our initial target population be? (Remember to start small!)

_____________________________________________________________________

With what services/materials should we start? Which should we add later?

_____________________________________________________________________

How will we know when we are ready to expand our services?

_____________________________________________________________________

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Worksheet for Designing an Evaluation Process

How will we review our progress?

_____________________________________________________________________

How often will we meet to reflect on our direction?

_____________________________________________________________________

How will we know if we have been successful?

_____________________________________________________________________

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Worksheet for Delegating PPIP Functions Among Staff

For each question, consider the following:

Who would be the best person to fill this role in your clinical setting? Why?
Who would be the best person to supervise and/or follow up?

Clinical Flow

Who will put the PPIP tools in the client's chart the day before the visit? (see Chapter 6 for PPIP materials.)

_____________________________________________________________________

Who will prescreen the patient's chart the day before the visit?

_____________________________________________________________________

Who will conduct and review the health risk profile (HRP) and initiate the preventive care flow sheet for each patient? (see Chapter 6 for a description of HRPs and preventive care flow sheets.)

_____________________________________________________________________

Who will be responsible for ordering screening tests?

_____________________________________________________________________

Who will be responsible for reviewing the appropriate health guides with the patient and for counseling the patient on identified risk factors? (see Chapter 6 for a description of PPIP health guides.)

_____________________________________________________________________

Chart Audits

Who will conduct chart audits to assess the quality of preventive services?

_____________________________________________________________________

Who will analyze the chart audit results and present them to the staff?

_____________________________________________________________________

Staff Training

Who will arrange for staff training?

_____________________________________________________________________

Who will conduct staff training?

_____________________________________________________________________

What will we do if we need technical support?

_____________________________________________________________________

Additional Functions

Who will be responsible for designing and ordering materials?

_____________________________________________________________________

What are some additional functions, and who will perform them?

_____________________________________________________________________

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Worksheet for Evaluating Your PPIP System

Goals

Are we functioning in alignment with our greater purpose? Our vision?

_____________________________________________________________________

Do we need to reevaluate our goals?

_____________________________________________________________________

What is working well? Why?

_____________________________________________________________________

What is not working? Why?

_____________________________________________________________________

What can be done differently?

_____________________________________________________________________

Are we providing the services we said we want to provide?

_____________________________________________________________________

Should we reevaluate the services we offer?

_____________________________________________________________________

Materials

How do the PPIP materials fit our needs?

_____________________________________________________________________

Should we modify any of the PPIP materials?

_____________________________________________________________________

Documentation

Are we documenting the services we provide?

_____________________________________________________________________

Staff Performance and Satisfaction

How are the staff performing their functions?

_____________________________________________________________________

Are staff stepping in where needed?

_____________________________________________________________________

Are staff working together as a team?

_____________________________________________________________________

Are all staff contributing suggestions?

_____________________________________________________________________

How do staff members feel about their work?

_____________________________________________________________________

Do staff members feel supported and heard?

_____________________________________________________________________

Patients

How are our patients responding to the change?

_____________________________________________________________________

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