Survey on Race and Ethnicity Data Collection

Hospital_________________________

Title____________________________

Date_________________________

Mode of Administration_________________________

Introduction:

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 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.

1. What percentage of non-white patients are admitted to your hospital?
   a. 0-20%
   b. 21-40%
   c. 41-60%
   d. 61-80%
   e. 81-100%
   f. Do not know



2. Are race and ethnicity collected as a single variable or single entity in your hospital?
   a. Yes
   b. No
   c. Do not know



3. 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 (Go To Question 4)
   b. No (Go to Question 5)
   c. Do not know (Go to Question 5)



4. Can patients choose more than one race category?
   a. Yes
   b. No
   c. Do not know



5. 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



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



7. Does your hospital use the Office of Budget and Management (OMB) 1997 guidelines to collect patient race/ethnicity/tribal affiliation data?
   a. Yes
   b. No
   c. Do not know



8. Is patient race/ethnicity/tribal affiliation typically collected at the point or patient registration?
   a. Yes (Go to question 10)
   b. No (Go to question 9)
   c. Do not know (Go to question 10)



9. When is patient race/ethnicity/tribal affiliation collected?
   
   ____________________________________________________________________



10. 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?
    a. Point of registration
    b. Medical chart
    c. Mother's worksheet provided by the New Mexico Department of Health, Bureau of Vital Records and Health Statistics
    d. Worksheet developed by the hospital
    e. Observation of the patient's physical characteristics
    f. Do not know
    g. Other__________________________________________________



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



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



13. How does your hospital 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 physical characteristics of the patient
    d. The hospital does not collect this information
    e. Do not know



14. Are there guidelines at your institution to ensure the registration staff collects race/ethnicity/tribal affiliation data from patients?
    a. Yes (Go to question 15)
    b. No (Go to question 16)
    c. Do not know (Go to question 16)



15. Are those guidelines around race/ethnicity/tribal affiliation collection enforced?
    a. Yes
    b. No
    c. Do not know



16. Below is a list of potential barriers to the collection of race/ethnicity/tribal affiliation data. For each statement circle 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)
    a. Confusion about race/ethnicity categories Y     N     DK
    b. Reluctance of staff to ask this type of information Y     N     DK
    c. Reluctance of patients to provide this type of information Y     N     DK
    d. Concerns that collection of this data may expose the hospital to legal liability Y     N     DK
    e. Lack of funding to support the collection of this data Y     N     DK
    e. Limitations of health information technology system to capture this type of data Y     N     DK
    g. No demonstrated need to collect this data Y     N     DK
    h. Lack of agreement of executive leadership on the need to collect this data Y     N     DK
    i. Lack of staff time to collect this data Y     N     DK
    j. Other barriers_________________________



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



18. Does your hospital employ interpreters (either full-time or part-time)?
    a. Yes
    b. No
    c. Do not know



19. Can you provide contact information of any other staff members at your institution that would be able to provide information regarding the topics in this survey?
    
    Name______________________________________________
    
    Contact Information__________________________________________________

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 NMMRA 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