PRE TEST

ID NUMBER_________________________

Your hospital is participating in the implementation of an intervention that will help better collect patient race, ethnicity and tribal affiliation. This is important because racial and ethnic disparities in healthcare are measurable differences in the range of medical services that are provided to people in the U.S. based on their race or ethnicity. 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.

This is an anonymous survey. The information we collect will not be used to evaluate your job performance. It is for research purposes only and will be used to determine and evaluate methods used in the collection of race, ethnicity and tribal affiliation data. This will not be shared with any supervisors or administration.

If you have any questions please call Nicole Katz at 505-476-3739.

Adapted from Data Collection on the Race, Ethnicity and Primary Language of Hospital Patients Survey by Health Insight 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

New Mexico Department of Health Logo

HealthInsight New Mexico

Today's Date __________________

Hospital__________________________

Gender______________________

Age Range:     18-24      25-34      35-44      45-54      55-64      65-74      75+

DEMOGRAPHICS

1. What is your position in the hospital?
   a. Registration Staff
   b. Nurse
   c. Physician
   d. Other-Please List _____________________



2. What is your ethnicity?
   a. Hispanic/Latino
   b. Non-Hispanic/Non-Latino
   c. Do not know
   d. Declined



3. What is your race? Please circle all that apply.
   a. White
   b. Black/African American
   c. Alaska Native/Native American
   d. Asian/Pacific Islander
   e. Do not know
   f. Declined



4. What is your tribal identification? Please circle all that apply.
   a. Jicarilla Apache Nation
   b. Mescalero Apache Nation
   c. Acoma Pueblo
   d. Cochiti Pueblo
   e. Isleta Pueblo
   f. Jemez Pueblo
   g. Laguna Pueblo
   h. Nambe Pueblo
   i. Picuris Pueblo
   j. Pojoaque Pueblo
   k. Ohkay Owingeh Pueblo
   l. Sandia Pueblo
   m. Santa Ana Pueblo
   n. Santa Clara Pueblo
   o. Kewa/Santo Domingo Pueblo
   p. Taos Pueblo
   q. Tesuque Pueblo
   r. Zia Pueblo
   s. Zuni Pueblo
   t. New Mexico Navajo Nation
   u. Other Tribal Affiliation- Please List ______________
   v. Unknown
   w. No tribal affiliation



5. What is your main tribe?
   a. Jicarilla Apache Nation
   b. Mescalero Apache Nation
   c. Acoma Pueblo
   d. Cochiti Pueblo
   e. Isleta Pueblo
   f. Jemez Pueblo
   g. Laguna Pueblo
   h. Nambe Pueblo
   i. Picuris Pueblo
   j. Pojoaque Pueblo
   k. Ohkay Owingeh Pueblo
   l. Sandia Pueblo
   m. Santa Ana Pueblo
   n. Santa Clara Pueblo
   o. Kewa/Santo Domingo Pueblo
   p. Taos Pueblo
   q. Tesuque Pueblo
   r. Zia Pueblo
   s. Zuni Pueblo
   t. New Mexico Navajo Nation
   u. Other Tribal Affiliation- Please List ______________
   v. Unknown
   w. No tribal affiliation

ATTITUDES:

Please circle the attitude which most identifies with your feelings towards each statement.

1-Strongly Agree; 2-Agree; 3-Neutral; 4-Disagree; 5-Strongly Disagree

I think race/ethnicity is an important aspect of healthcare	1 2 3 4 5
I think a person's race/ethnicity can affect their quality of healthcare	1 2 3 4 5
To determine a patient's race/ethnicity I observe the patient's physical characteristics.	1 2 3 4 5
I think talking about race/ethnicity is uncomfortable	1 2 3 4 5
I can tell a person's race/ethnicity by looking at them	1 2 3 4 5
I understand the meaning of the term "race"	1 2 3 4 5
I understand the meaning of the term "ethnicity"	1 2 3 4 5
I understand the meaning of the term "tribal affiliation"	1 2 3 4 5
I think my role in race/ethnicity/ tribal affiliation data collection is important	1 2 3 4 5

RACE/ETHNICITY POLICY:

1. 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)?
   a. Yes
   b. No
   c. Do not know



2. Does your hospital collect information on the ethnicity of patients (this would involve classifying patients as Hispanic/Latino, or non-Hispanic/non-Latino)?
   a. Yes
   b. No
   c. Do not know



3. Does your hospital collect information on the tribal affiliation of patients?
   a. Yes
   b. No
   c. Do not know



4. Is patient race/ethnicity/tribal affiliation typically collected at the point of patient registration?
   a. Yes (Go to question 6)
   b. No (Go to question 5)
   c. Do not know (Go to question 6)



5. If no, when is patient race/ethnicity/tribal affiliation collected?
   
   ____________________________________________



6. Does your hospital collect information on patient's primary language if it is other than English (such as Spanish, Chinese, German, Haitian Creole, etc)?
   a. Yes
   b. No
   c. Do not know



7. How do you primarily collect patient race/ethnicity/tribal affiliation?
   a. Verbally ask the patient
   b. Patient fills out this information on a form
   c. The registration staff observes the patient's physical characteristics
   d. The hospital does not collect this information
   



8. The following list identifies potential barriers to the collection of race/ethnicity/tribal affiliation data. Identify the barriers which affect you and your organization. Please mark all that apply and rank your selected barriers from smallest to largest barrier on the line next to each letter. (1=smallest barrier, 10=largest barrier)
   ___ a. Confusion about race/ethnicity categories
   ___ b. Reluctance of staff to ask this type of information
   ___ c. Reluctance of patients to provide this type of information
   ___ d. Concerns that collection of these data may expose the hospital to legal liability
   ___ e. Lack of funding to support the collection of these data
   ___ f. Limitations of health information technology system to capture this type of data
   ___ g. No demonstrated need to collect these data
   ___ h. Lack of agreement of executive leadership on the need to collect these data
   ___ i. Lack of staff time to collect these data
   ___ j. Other _________________________



9. What is the highest level of education you have completed?
   a. Less than high school
   b. High School Diploma/GED
   c. Some college
   d. Bachelor's Degree
   e. Master’s Degree or higher
   f. Declined

Adapted from Data Collection on the Race, Ethnicity and Primary Language of Hospital Patients Survey by Health Insight 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