Date:
Name of Hospital:
Respondent’s Name:
Introduction
The purpose of this questionnaire is to help the University of Arizona’s Center for Rural Health answer four broad questions:
· What is the current status of Arizona’s rural and critical access hospitals in completing CHNAs?
· How are hospitals conducting CHNAs?
· Did the hospital coordinate with the other community partners, including a County Health Department?
· What types of assistance might be needed in conducting a CHNA?
Statement of Confidentiality
Personalized answers to these questions will not be made available to any individual or organization outside of the University of Arizona’s Center for Rural Health. If published, personal or hospital specific identifiers will not be used.
1. In what phase is your hospital in planning a CHNA?
☐ Not Yet Begun ☐ Just Started ☐ Almost Done ☐ Completed
- If not yet begun, please indicate when you plan to begin the process?
- If completed, has the CHNA been posted to your website?
☐ Yes ☐ No
2. Is your hospital following the IRS’ specified steps and requirements for completing a CHNA?
☐ Yes ☐ No
3. In conducting a CHNA, what resources or partnerships does your hospital intend to use: (check all that apply)
☐ Hospital, in-house staff
☐ Consulting group
☐ County Health Department
☐ University of Arizona College of Public Health
☐ Another hospital
☐ Hospital Managing Group (please identify name of group)______
SECTION 2 / BARRIERS TO YOUR HOSPITAL IN COMPLETING A CHNA4. Is a lack of financial resources a barrier to completing a CHNA?
☐ Major barrier ☐ Minor barrier ☐ No barrier
5. Is a lack of staff or trained personnel a barrier to completing a CHNA?
☐ Major barrier ☐ Minor barrier ☐ No barrier
6. Is your hospital’s ability to locate existing data a barrier to completing a CHNA?
☐ Major barrier ☐ Minor barrier ☐ No barrier
7. Is your hospital’s ability to collect new data a barrier to completing a CHNA?
☐ Major barrier ☐ Minor barrier ☐ No barrier
8. Is your hospital’s ability to interpret or analyze data a barrier to completing a CHNA?
☐ Major barrier ☐ Minor barrier ☐ No barrier
9. Are you aware of any additional barriers that might impede your hospital in completing a CHNA?
SECTION 3 / INTEREST IN RECEIVING ASSISTANCE FROM THE U OF ARIZONAAt the Center for Rural Health, we are interested in identifying ways we might be able to assist your hospital in completing a CHNA. Experts indicate that the CHNA process can be divided into six interrelated, yet distinguishable steps. Below, the six steps are briefly outlined to assess your interest in contracting with the Center to complete any or all of them. For each step, please indicate your level of interest as being high, low or none.
10. Begin needs assessment planning, including identifying goals
☐ High interest ☐ Low interest ☐ No interest
11. Work with the hospital leadership group to identify existing data
☐ High interest ☐ Low interest ☐ No interest
12. Collect new data through key informant interviews, focus groups, and surveys, analyze the data, and prepare report for the hospital.
☐ High interest ☐ Low interest ☐ No interest
13. Work with the hospital leadership group to work with community in assessing needs, presenting findings and becoming invested in action plan
☐ High interest ☐ Low interest ☐ No interest
14. Assist in developing the hospital’s action plan, including measures for monitoring progress.
☐ High interest ☐ Low interest ☐ No interest
15. Assist with documenting results and communicating them to your hospital service area population.
☐ High interest ☐ Low interest ☐ No interest
16. Would you or members of your staff be interested in attending a workshop (webinar) that addresses strategies for utilizing CHNAs to plan future services?
☐ High interest ☐ Low interest ☐ No interest
17. Is there any other way you believe that the Center for Rural Health might contribute to your hospital’s ability to complete a CHNA?
18. Do you believe that a CHNA will be a valuable resource to your hospital?
☐ Yes ☐ No
- If yes, what actions do you anticipate taking once it is complete?
QUESTIONNAIRE COMPLETE – THANK YOU!
In a few weeks, a summary report will be posted on the Center for Rural Health website. For more information please contact Joyce Hospodar or Kevin Driesen.
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