FOLLOW-UP SURVEY

ID NUMBER________________________________________________

Your hospital is participating in the implementation of an intervention that will help collect patient race, ethnicity and tribal affiliation in a more consistent and standardized way. 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, tribal affiliation 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 at the Department of Health.

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

New Mexico Department of Health logo

HealthInsight New Mexico logo

Today's Date__________________________________________

Hospital________________________________________________

Please circle your answers below.

1. Gender: Male Female



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



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



4. 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



5. Do you consider yourself Hispanic or Latino?
   a. Yes
   b. No
   c. Declined



6. 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. Other race
   f. Declined



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

If you selected multiple tribes, what is your primary affiliation? ______________________________

8. 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



9. 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



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



11. Is patient race/ethnicity/tribal affiliation typically collected at the point of patient registration?
    a. Yes (Go to question 13)
    b. No (Go to question 12)
    c. Do not know (Go to question 12)



12. If no, when is patient race/ethnicity/tribal affiliation collected? ___________________________________________



13. How do you primarily collect patient race/ethnicity/tribal affiliation? Circle all that apply
    a. Verbally ask the patient
    b. Patient fills out this information on a form
    c. The registration staff observes the patient's physical characteristics



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



15. 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 using a scale of 1 to 10 (1 = smallest barrier, 10 = largest barrier) on the line next to each letter.
    
    ___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 _________________________
    



16. Please circle the number 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
The way I collect race/ethnicity/tribal affiliation data changed because of the training	1 2 3 4 5
I can explain the importance of collecting race/ethnicity/tribal affiliation data to patients as a result of the training	1 2 3 4 5

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

New Mexico Department of Health logo