SHC Practice Assessment:  Atrial Fibrillation Screening
By answering a few questions about your practice’s organization, quality improvement experience, and current approach to atrial fibrillation, as well as the impact of COVID-19, we will be able to assist you in developing a quality improvement project that suits your needs and experience.  Only one person per practice need complete the assessment, gaining the input of colleagues as necessary.  Please respond to the questions below as it relates to your specific practice location.  
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Practice name:
Your name:
Your profession/role in the practice:
Clear selection
Practice address (street):
Practice address (city):
Practice address (state):
Practice address (zip code):
Practice type:  (Check all that apply.)
Number of health care providers at your practice location.  Check one response for each row.  
1 to 2
3 to 5
6 to 10
More than 10
Physician Assistants
Nurse Practitioners
Medical Assistants
Practice Managers
Front desk staff/receptionists
Social workers
Patient navigators
Patient advisors
Practice setting.  
Clear selection
Estimated number of patients at practice site annually (panel size).
Estimated patient demographics.  Check one response for each row.
More than 50%
25 to 50%
10 to 25%
Less than 10%
White, non-hispanic
African American or black
Hispanic or Latino
American Indian or Alaskan Native
Native Hawaiian or other Pacific Islander
Medicare recipient
Medicaid recipient
Primary language is English
Indicate the quality improvement experience of your practice’s staff?  
Rarely implements QI projects
Commonly implements QI projects
Clear selection
What quality improvement (QI) resources does your practice have (check all that apply)?
What priorities for quality improvement, in general, does your practice have (check up to three)?
What barriers, if any, does your practice face to QI activities (briefly describe)?
How does your practice approach community engagement (check all that apply)?
Estimated total number of patients with AF at practice site:
Does your practice currently screen patients for undetected AF?  
Clear selection
If so, what screening method(s) do you apply (check all that apply)?
With AF screening, what patient population is or would be targeted (check all that apply)?
Briefly describe your response to the above question: "What age group and/or what score?"
Screening approach (check all that apply)
Does your practice currently track anticoagulation therapy adherence in your AF patients?  
Clear selection
Briefly describe your response to the above question.
How do or would you like to educate your patient population about AF (check all that apply)?
Currently used to educate our patients
Would like to implement so as to educate our patients
Provide print information to patients diagnosed with AF concerning risk stroke and importance of anticoagulation
Display posters in the office regarding the risks posed by AF
Use decision aids in conversations with your AF patients to help choose medications
Provide video or web-based education to patients with AF or at risk of AF
Use the patient portal to distribute education to patients about AF and its treatment
Text patients with AF about the importance of treatment/adherence
Have patient education materials in languages other than English
Use patient education materials that are at the appropriate health literacy and numeracy level
Give presentations at community events on AF
Other (please describe)
What barriers do or would you face in terms of implementing an AF screening program (check all that apply)?
What would be most useful to your practice in moving forward to implement an AF screening program (Check all that apply)?
How do you coordinate AF care with cardiology practices and/or leadership in your region/healthcare system (check all that apply)?
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