Survey on Race and Ethnicity Data Collection

ID___________________________________________________________

Survey on Race and Ethnicity Data Collection

Hospital________________________________________________

Title_____________________________________________

Date_____________________

Mode of Administration_____________________________________________

Gender________________

Introduction:

Hello my name is _YOUR NAME_ from the Health Insight. Your hospital is participating in the implementation of a program to improve the collection of patient race, ethnicity and tribal affiliation. This is important because there are measurable differences between racial and ethnic groups in healthcare. One way to effectively address and reduce racial and ethnic disparities in healthcare is to collect and track patient data by race, ethnicity and primary language, evaluate any disparities in treatment that are found, and design interventions that will appropriately and consistently increase quality. If you have any questions, please call Nicole Katz at 505-476-3739 or 505-222-8613.

I have a short survey that will only take five to ten minutes of your time regarding your hospitals' collection of this data. This survey is confidential and individual hospital responses will not be reported or published. Only aggregated data will be used. Are you ready to begin?

Do you consider yourself Hispanic or Latino?
1. Yes
2. No
3. Declined

Which category or categories best describe your race?
1. American Indian or Alaska Native (Go to Question 3)
2. Asian (Go to Question 4)
3. Black or African American (Go to Question 4)
4. Native Hawaiian or Other Pacific Islander (Go to Question 4)
5. White (Go to Question 4)
6. Declined (Go to Question 4)
7. Other Race (Go to Question 4)

What is (are) your tribe(s) or pueblo(s)?
1. Acoma Pueblo
2. Cochiti Pueblo
3. Isleta Pueblo
4. Jemez Pueblo
5. Jicarilla Apache Nation
6. Kewa/Santo Domingo Pueblo
7. Laguna Pueblo
8. Mescalero Apache Nation
9. Nambe Pueblo
10. Navajo Nation
11. Ohkay Owingeh Pueblo
12. Picuris Pueblo
13. Pojoaque Pueblo
14. San Felipe Pueblo
15. San Ildefonso Pueblo
16. Sandia Pueblo
17. Santa Ana Pueblo
18. Santa Clara Pueblo
19. Taos Pueblo
20. Tesuque Pueblo
21. Zia Pueblo
22. Zuni Pueblo
23. Other Tribal Affiliation
24. Declined

How does your hospital define an 'inpatient' admission? _______________________________________________________________

Are you familiar with the section of the New Mexico Administration Code (NMAC 7.1.4 Data Reporting Requirements for Health Care Facilities) which requires all non-federal New Mexico Hospitals to submit inpatient discharge data to the state in a standardized way?
1. Yes
2. No
3. Do not know

Are you familiar with the Office of Budget and Management (OMB) 1997 guidelines to collect patient race/ethnicity/tribal affiliation data?
1. Yes
2. No
3. Do not know

Does your hospital collect information on the race of patients? This would generally involve classifying patients as White, Black/African American, American Indian or Alaska Native, Asian and Native Hawaiian or other Pacific Islander, etc.
1. Yes
2. No
3. Do not know

Does your hospital collect information on the ethnicity of patients? This would involve classifying patients as Hispanic/Latino, or non-Hispanic/non-Latino.
1. Yes
2. No
3. Do not know

Are race and ethnicity collected separately in your hospital?
1. Yes
2. No
3. Do not know

Can patients choose more than one race category?
1. Yes
2. No
3. Do not know

Does your hospital collect information on the tribal affiliation of patients?
1. Yes
2. No
3. Do not know

Is patient race/ethnicity/tribal affiliation typically collected at the point of patient registration?
1. Yes (Go to question 14)
2. No (Go to question 13)
3. Do not know (Go to question 14)

When is patient race/ethnicity/tribal affiliation collected? _____________________________________________________________________

How does your hospital primarily collect patient race/ethnicity/tribal affiliation?
1. Verbally ask the patient
2. Patient fills out this information on a form
3. The registration staff observes the physical characteristics of the patient
4. The hospital does not collect this information
5. Do not know

Are there guidelines at your institution to ensure the registration staff collects race/ethnicity/tribal affiliation data from patients?
1. Yes (Go to question 16)
2. No (Go to question 17)
3. Do not know (Go to question 17)

Are those guidelines regarding race/ethnicity/tribal affiliation collection monitored?
1. Yes
2. No
3. Do not know

Does your hospital use race/ethnicity/tribal affiliation data to assess and compare quality of care among patients of different population groups?
1. Yes
2. No
3. Do not know

Does your hospital use race/ethnicity/tribal affiliation data to assess and compare utilization of health services among patients of different population groups?
1. Yes
2. No
3. Do not know

What percentage of non-white patients are admitted to your hospital?
1. 0-20%
2. 21-40%
3. 41-60%
4. 61-80%
5. 81-100%
6. Do not know

I am going to read a list of potential barriers to the collection of race/ethnicity/tribal affiliation data. For each statement respond yes if it is a potential barrier in your hospital; no if it is not a potential barrier in your hospital or don't know if you do not know or are not sure. (Y=Yes; N=No; DK=Don't Know)
1. Confusion about race/ethnicity/tribal affiliation categories Y N DK
2. Reluctance of staff to ask this type of information Y N DK
3. Reluctance of patients to provide this type of information Y N DK
4. Concerns that collection of this data may expose the hospital to legal liability Y N DK
5. Lack of funding to support the collection of this data Y N DK
6. Limitations of health information technology system to capture this type of data Y N DK
7. No demonstrated need to collect this data Y N DK
8. Lack of agreement of executive leadership on the need to collect this data Y N DK
9. Lack of staff time to collect this data Y N DK
10. Other barriers_________________________________

Does your hospital collect information on patients' primary language?
1. Yes
2. No
3. Do not know

Does your hospital employ interpreters (either full-time or part-time)?
1. Yes
2. No
3. Do not know

Does your hospital have a labor/delivery department?
1. Yes (Go to question 20)
2. No (Go to question 21)
3. Do not know (Go to question 21)

When the hospital registers a birth with the New Mexico Department of Health, Bureau of Vital Records and Health Statistics, what is the primary source of the mother's race/ethnicity/tribal affiliation?
1. Point of registration
2. Medical chart
3. Mother's worksheet provided by the New Mexico Department of Health, Bureau of Vital Records and Health Statistics
4. Worksheet developed by the hospital
5. Observation of the mother's physical characteristics
6. Do not know
7. Other___________________________________________

Have there been any changes in administrative leadership positions within the last year?
1. Yes, List Positions__________________________________
2. No
3. Do not know

BASED ON SAMPLE REPORT CARD: It is possible to prepare progress report cards for individual hospitals based on the discharge data submitted, similar to this one. This would only be shown to the submitting hospital and not shared with other facilities or compared to other facilities. Would this be useful to you?
1. Yes
2. No
3. Do not know

That concludes the survey. Thank you for your time.

Adapted from Data Collection on the Race, Ethnicity and Primary Language of Hospital Patients Survey by HealthInsight New Mexico and the Robert Wood Johnson Foundation's Race, Ethnicity and Language of Patients: Hospital Practices Regarding Collection of Information to Address Disparities in Health Care

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Survey on Race and Ethnicity Data Collection