Before your meeting with a practice coach on ___________________________________, please complete:
 Sections A, B, C
 Section D (Excluding #91-100)
 Sections E, F, G, H, I
 Payment Forms
Prince George Division of Family Practice – Physician Assessment
Section A: Physician Information
Demographics:
1. Last Name: _______________________________________ First Name(s): ____________________________________________
2. Age:
25-34 
35-44 
45-54 
55-64 
65+ 
3. Gender: Male  Female 
4. Years in Practice: _______
5. Medical School Attended: ___________________________________________________________________________________
6. Place of Residency Training: __________________________________________________________________________________
7. Are you a CCFP Member? Certificant  Fellow  Non-Member 
BOTH Certificant & Fellow 
8. *PSP* Do you have any additional training (e.g. CFPC-EM, enhanced OB, enhanced palliative, GP-anaesthesia, etc?) Yes  No 
If yes, please specify:_____________________________________________________________________________________
9. Estimated years until retirement:
1-2 
3-4
5-9 
10+ 
n/a (Retired) 
10. The primary language in which you practice medicine: English  French  Other  (Specify: __________________________)
11. Do you speak a secondary language fluently enough for patient care? Yes  No 
Which language(s):_______________________________________________________________________________________
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Section A: Physician Information – Continued
Your current satisfaction levels: This section is meant to be a snapshot of your satisfaction with your practice, work life, and life
outside of work. Please think of your life over the last year.
12. How satisfied are you with your professional life? (1 = very dissatisfied, 3 = neutral, 5 = very satisfied)
In your primary care office?
1  2  3  4  5  N/A 
In medical practice outside of the office? (e.g. sessional work, ER, WIC, MOCAP call)
1  2  3  4  5  N/A 
13. How satisfied are you with the care you are able to provide your patients? (1 = very dissatisfied, 3 = neutral, 5 = very satisfied)
1  2  3  4  5  N/A 
14. How satisfied are you with your life outside of work? (1 = very dissatisfied, 3 = neutral, 5 = very satisfied)
The amount of time available?
1  2  3  4  5  N/A 
The quality of time available? (e.g. pager on…)
1  2  3  4  5  N/A 
15. How satisfied are you with the financial remuneration you receive for your office/primary care practice?
1  2  3  4  5  N/A 
Comments on Q 12-15?
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
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Section A: Physician Information – Continued
Your current work life: This section is meant to be a snapshot of your current practice/work life. Please think of what you have
done over the last year. If you have taken any recent lengthy periods away from practice (e.g. maternity leave, sabbatical), please
focus on the time that you spent working, but make note of the time away from practice in Prince George in Question 32.
16. Do you currently practice office-based primary care medicine?
Yes  Continue to Question 17
No, I stopped practicing office-based primary care medicine in
(year)  Skip ahead to Question 38 (page 6)
No, I never practiced office based primary care medicine.  Skip ahead to Question 38 (page 6)
17. Where do you practice primary care medicine?
Please do NOT include After-Hours/Walk-In Clinic, ER or other specialty here. Enter those into Question 38 & 39.
Your own office  Other private offices (i.e. locums)  CINHS  UPC Clinic  Other  (Specify:________________)
18. *PSP* Please check off times that you are routinely scheduled to see patients in your office. If you work regularly at more than
one site (in Question 17), please clarify which site.
Morning office
Monday
Tuesday
Wednesday
Thursday
Friday





Location/Site
Afternoon office
Location/Site
Please elaborate if not standard
am/pm booking pattern





19. *PSP* Do you generally stay in the office after seeing your last scheduled patient? Yes  No 
If yes, how long? <30 min  30-60 min  60-90 min  90-120 min  2-3 hours  >3 hours 
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Section A: Physician Information – Continued
20. In an average week, how many hours do you practice primary care at the site(s) in Question 17? (If paperwork or practice
management is done at home after the work day, please also include that time.)
Note: Other types of non-primary care work will be explored in later questions. (e.g. meetings, sessions, Committees)
Specify Site:
Specify Site:
Specify Site:
Time in direct patient contact (i.e. appointments):
Time spent charting (if done separately in a chunk of time
after your last appointment):
Time spent doing direct patient-related paperwork
(reviewing labs, consults, imaging reports, etc.):
Time spent doing 3rd party paperwork/ forms/etc.:
Time spent doing panel or practice management
(e.g. audits, recalls, etc.):
hours
hours
hours
hours
hours
hours
hours
hours
hours
hours
hours
hours
hours
hours
hours
21. *PSP* In an average week, how many hours do you spend out of office on work related to your main practice/patient population?
(e.g. inpatient rounding, nursing home visits, surgical assists, etc.)
None  <1 hour  1-3 hours  3-5 hours  5-8 hours  >8 hours 
22. *PSP* Do you have active hospital privileges? Yes  No 
23. Do you do inpatient care? Yes  No 
Are you in a weekend call group? Yes  No 
Frequency of call weekends: 1 in _______
24. Are you a member of the In-Patient Care call group (formerly Doctor of the Day)? Yes  No 
25. Do you do nursing home care? Yes  No 
If yes, how is your call set up for weekends?
Solo  Shared with Partners  Call Group  Other  (Specify: ______________________)
How many patients do you currently have in nursing homes? None  1-2  3-5  6-10  11-15  >15 
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Section A: Physician Information – Continued
26. Do you do obstetrics?
*PSP* Yes  No 
If yes, how is your call set up for:
weekdays? Solo  Shared with Partners  Call Group  Other  (Specify: ____________________)
weekends? Solo  Shared with Partners  Call Group  Other  (Specify: ____________________)
How many deliveries per year? <10 
10-19 
20-29 
30-39 
>40 
Do you accept prenatal/obstetric referrals from other practices? Yes  No 
27. Do you do palliative care? Yes, including hospice admissions.  Yes, but no hospice admissions.  No 
*PSP* If yes, are you confident in supporting all patients and families in end-of-life care? Yes  No  Somewhat 
In what areas might you need support? _________________________________________________
28. Do you do procedures (lumps and bumps, IUD insertions, etc.)?
Yes, only using my office. 
Yes, only using ambulatory care at UHNBC. 
No, I do not do procedures. 
Yes, using both locations.
29. Do you do locums? True locums  Just to “help out a colleague”  Both  Neither 
30. How much of your primary care office work is:
Fee-for-Service _______%
Alternative Payment Plan _______% (i.e. sessions at CINHS, UPC, but still doing primary care medicine)
31. In an average year, do you regularly take any lengthy time away from practicing primary care in Prince George? (e.g. 2 months
on/2 months off, working only every third week, etc.) Yes  No 
If yes, please explain: ______________________________________________________________________________
32. Have you taken any significant time off in the last 3 years? (e.g. maternity leave, sabbatical, etc.) Yes  No 
If yes, please explain: ______________________________________________________________________________
33. Do you anticipate taking any significant time off in the next 3 years, ? (e.g. mat leave, sabbatical, etc.) Yes  No  Unsure 
Do you have plans of cutting back in your office work, moving, or retiring in the next 3 years? Yes  No  Unsure 
If yes, please explain: ______________________________________________________________________________
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Section A: Physician Information – Continued
34. Are you currently in the process of trying to, or within the next year planning to: (Check all that apply.)
Recruit another physician to work in your office
Merge your practice/office with another existing practice/office
Find a replacement (e.g. to move or retire)
Find a long-term locum (e.g. for a maternity leave, sabbatical)
Find short term locum coverage for holidays, CME, etc
Other: specify
Other: specify
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
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
35. Are you interested in trying to increase capacity in your office? Yes  No  Unsure 
36. Are you interested in trying to increase efficiency in your office? Yes  No  Unsure 
37. Do you have a “vision” of changing the way you practice primary care medicine in the future? (For example, this might involve
moving from Fee-for-Service to Alternative Payment Plan, moving from a solo to group practice, or focusing your practice on a
sub-specialty or a specific patient population.) Yes  No  Unsure 
Please elaborate: _______________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
38. Do you practice in any other clinical setting, including after-hours/walk-in clinic? *PSP* Yes  No 
If yes, how many hours, shifts or sessions do you spend doing other clinical work in the average month, for the following?
Emergency Room
GP anaesthesia
GP referrals (e.g. vasectomies)
MOCAP call (e.g. IPC, sexual assault, psychiatry, trauma, etc.)
Specify:______________________________________
Specify:______________________________________
Specify:______________________________________
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Check all that apply*PSP*
Amount of Time
# shifts/mo:
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# hours/mo:
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# hours/mo:
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# shifts/mo:
# shifts/mo:
# shifts/mo:
6
Question 38, continued
*PSP* Nechako After Hours Clinic (WIC)
Sessionals (e.g. oncology, palliative, geriatrics, detox, psychiatry, women’s
health clinic, etc.) Specify:______________________________________
Specify:______________________________________
Specify:______________________________________
Surgical assists (for patients not in your practice)
Private medical services (e.g. botox, laser treatments)
Worker’s Compensation Board (WCB)
Other (e.g. Corrections/Forensics, Occupational Health, etc.)
Specify:______________________________________
Specify:______________________________________
Check all that apply*PSP*
Amount of Time
# shifts/mo:




# shifts/mo:
# shifts/mo:
# shifts/mo:

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
# hours/mo:
# hours/mo:
# hours/mo:

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# hours/mo:
# hours/mo:
39. *PSP* How many hours do you spend doing non-clinical work (paid or unpaid) in the average month for the following?
Administrative Position (e.g. Department Head)
Board Position (e.g. AIHS, PGDFP, NMS, etc.)
CME lectures (e.g. noon or evening rounds, small groups)
Hospital committees
Meetings, unpaid (e.g. Departmental, Staff, UBC/UNBC )
Teaching
Other (e.g. sports team doctor, PARTY program volunteering, etc.)
Specify: ________________________________________
Specify: ________________________________________
Specify: ________________________________________
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Amount of Time
# hours/month:
# hours/month:
# hours/month:
# hours/month:
# hours/month:
(see Questions 36-38)
# hours/month:
# hours/month:
# hours/month:
7
Section A: Physician Information - Continued
Teaching: Northern Medical Program/UBC Family Practice Residency
40. Do you have learners in your primary care office? Yes – fill out below. No 
Type: Residents  Medical Students  Nurse Practitioner 
Time: For residents:
Family Medicine block  Native Health block  Elective time 
Time: For medical students: 1 term/yr  2 terms/yr  Elective (i.e. full time) Students 
Time: For NP students:
Describe the amount of time they spend in the office: _____________________________
41. Do you supervise learners in any other clinical location? (e.g. palliative care, geriatrics, ER) Yes – fill out below. No 
Type: Residents  Medical Students  Nurse Practitioner 
Where? _______________________________________________________________________________________________
What amount of time? ___________________________________________________________________________________
42. Do you teach at UNBC or on 5th floor? (e.g. lectures, Problem Based Learning sessions, preceptoring exams, etc.)
Yes  (Specify: _______ hours/year) No 
43. Do you have a faculty position? Yes  (Specify Position: _________________________) No 
44. Do you spend time on research? Yes  No 
45. In the last year, how many weeks did you take off for recreation? _______ weeks
46. In the last year, how many days did you take off for CME activities? _______ days
Between BCMA and REAP, how much of your CME activities were reimbursed?
0-20% 
21-40% 
41-60% 
61-80% 
81%-99% 
Prince George Version 1.5 July 2011
100% 
8
Section B: Office Information
This section refers to your primary care office, whether it is a private practice, or a clinic such as
CINHS or UPC. If you are a locum or do not do office-based medicine, skip ahead to Section E (page 23).
47. *PSP* How many physicians work in your office space?
1 (i.e. only you; skip to Q50) 
2
3
LOCUM only? 
>3  (Specify: ______)
48. If more than one physician works in your office space:
Who do you usually share with? List names:____________________________________________________
Do you share: space  staff  common expenses/overhead  *PSP* patients 
49. Do the patients have an official "main provider” documented in the chart? Yes  No 
If no official main provider, what proportion of patients have an “unofficial” main provider? (i.e. patients often
request specific doctor) (Hint: ask your MOA) 0-20%  21-40%  41-60%  61-80%  81-100% 
If you do not share patients, do you cross-cover for office appointments? Yes  No  Inpatient care? Yes  No 
50. In an average week:
What are your office’s “telephone hours”? (i.e. when the patient line is answered e.g. 8am-4pm)_______________________
Is there any time Monday to Friday, during standard office hours, that your office is closed? Yes  No 
If yes, please elaborate: ___________________________________________________________________
How many hours per week is your office open with one or more physicians seeing patients? _______ hours
What is the total number of “physician hours” per week? (For example, if you see patients 30 hours, and your partner
sees patients 25 hours, overlapping in time with you, the number of “physician hours” is 55.) _______ hours
If you have another primary care provider (i.e. nurse practitioner), how many hours are they available per week?
_______ hours
51. *PSP* How many administrative staff do you have? (MOA, transcriptionist, office manager, file clerk, etc.)
1  2  3  4  Other _______
What is the # of administrative staff FTEs per physician FTE? (e.g. 1MOA : 1MD, 2Staff : 1MD) ________________________
52. *PSP* Do you have multidisciplinary team members associated with your clinic?
Yes, check all below that apply or No 
Nurse Practitioner  LPN RN  Dietician  Social Worker  Integrated Health Team for Seniors 
Addictions Counsellor  Spiritual Elder/Counsellor  Other  (Specify: _________________________________)
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Section B: Office Information – Continued
53. *PSP* Would you benefit from having additional access to multidisciplinary care team members in your practice? Yes  No 
If yes, which ones? NP LPN RN Dietician SW IHTS Counsellor Other (Specify: _______________)
If yes, do you have room in your office to accommodate additional staff? Yes  No 
54. *PSP* As a physician, do you think you perform tasks daily that could be done effectively and safely by non-physician staff or
patients? Yes  No  If yes, give an example? ___________________________________________________________
55. *PSP* Are you aware of the following GPSC incentive payment programs? Please select the programs that you are familiar with,
and whether or not you routinely bill them (when applicable).
Familiar with?
Routinely billed?
Acute Care Discharge Conference Fee (14017)


Community Patient Conferencing Incentive Payments (14016)
Complex Patient Care Incentive Payments (14033, 14039)
Condition Based Incentive Payments Diabetes (14050), CHF (14051), hypertension
(14052) &/or COPD (14053)






Facility Patient Conferencing Incentive Payments (14015)


Family Physician Obstetrical Premium Payments (14004, 14005, 14008, 14009)
Maternity Care Network Initiative Payment (14010)




Prevention Incentive Payments (14034 CV Risk Assess, will be 14066 as of Jan 1, 2011)


Mental Health Patient Care Incentive Payments (14043, 14044, 14045, 14046, 14047,
14048, 14049)
End of Life Incentive Payments (14063, 14069)
Telephone advice with a specialist/GP with specialty training (14018, 14021/22/23)
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56. Do you subscribe to Pharmanet (through an application like Medinet) for access to patient prescription records? Yes  No 
57. *PSP* How many patients do you see in an average 3 hour stretch? _______ patients
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Section B: Office Information – Continued
58. How frequently are your appointments booked? (e.g. q10min, 4/hour, etc.) _______________________________________
59. *PSP* How many different types of appointment time blocks are there in your schedule? (e.g. PAP, Complete Physical, etc.)
1-2 
3-4  5-6  >7 
60. Do you practice:
“Advanced Access" (encouraging 40%+ of same-day appointments) 
or Traditional booking (appointments booked far in advance) 
61. *PSP* Looking at an average work day, if a patient called at 8am, when is the third next available appointment they could book
with a primary care provider (in business days)?
Today  1 day  2 days  3 days  4-5 days  6-10 days  11-15 days  >15 days (i.e. 3weeks) 
62. What percentage of appointments is scheduled within 36 hours of the patient phone call? (i.e. same day or next day
appointments) 0-20%  21-40%  41-60%  61-80%  81-100% 
63. *PSP* On average, how long does it take for a patient, from the time they come in, until they leave, to complete the visit process?
(i.e., Cycle Time)
<15 min  < 20 min  < 30 min  <45 min  >1 hour 
64. Does your office have a process to measure patient cycle time (i.e. time from patient sign-in to departure)? Yes  No 
If yes, do you use it regularly? Yes  No  Unsure 
65. *PSP* How often do you feel rushed when seeing patients?
Never  Rarely  Half the Time  Frequently  Almost Always 
66. *PSP* Do you check ahead in your daysheet/appointment list with the intention of preparing for appointments, tracking down
results, anticipating difficult visits/patient, etc.?
Never  Rarely  Half the Time  Frequently  Almost Always 
67. *PSP* Do you generally start and end your primary practice office as scheduled?
Start on time?: Yes  No 
End on time?: Yes  No 
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Section B: Office Information – Continued
68. *PSP* Do you have a mechanism in place to get office staff and physician opinions and ideas about patient flow, task distribution,
office routines, etc.? Yes  (Elaborate:_________________________________________) No 
69. *PSP* Do you have staff policies, procedures, and job descriptions? Yes  No 
70. Have you ever organized a group office visit? *PSP* Yes  No 
Do you continue to do group visits, or plan to do group office visits in the future? Yes  No  Unsure 
Where? __________________________________________ Frequency? _____________________________________
What type? _____________________________________________________________________________________
Do you use a facilitator from Northern Health? Yes  No 
If no, from where? __________________________
71. How is after-hours care provided to your patients? After-hours phone line  Referral to the After-Hours Clinic  Both 
Other  (Please elaborate: ___________________________________________________)
72. Are you taking on new patients with the intention of becoming their primary care provider (i.e. complete, long-term patient care,
not simple transient visits/WIC follow-ups/obstetrics, etc.)?
*PSP* Yes  No  Only in specific circumstances (e.g. family of current patients, patients met at WIC, etc.) 
If yes, or only in specific circumstances, approximately how many new patients do you (or your office, if you share
patients) take on, in the average month? _______ patients
If no, what is preventing/deterring you from taking on more patients? _________________________________________
_____________________________________________________________________________________________
73. Do you see patients in your office that you do not intend to take on/begin a primary care relationship with? For example,
prenatal referrals, follow-ups from the ER or WIC, or out-of-town family members of patients? Yes  No 
If yes, what proportion of your appointments do you think these people represent in an average week?
0-1%  2-3%  3-5%  5-10%  10-20%  20-30%  >30% 
74. Do you accept new nursing home patients? (i.e. not previously your own patient)
Yes  No, but I am willing to.  No, and I am not interested. 
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12
Section C: Electronic Medical Records
75. *PSP* Does your office have an EMR? Yes  (Specify which one: ____________________)
No  (Skip to Question 87, p.17)
Current EMR Users/EMR Implemented in your Office
76. What year did you start using an EMR? _______
77. When you first implemented an EMR in your office, what was your biggest challenge (i.e. physician based)?
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
78. When you first implemented an EMR in your office, what was your staff member(s)’s biggest challenge?
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
79. *PSP* To what extent do you use your EMR (check all that apply)?
Scheduling/billing 
Full charting (no paper)  Patient recall/decision making 
80. Please rank your office’s EMR usage:
EMR Function
Scheduling/Daysheet Management
Billing/Invoicing
Storage of results (lab, imaging, consults, etc.)
Lab Interface for direct download of results for:
 Phoenix/Hospital/Cerner  LifeLabs/Excelleris
Writing Consult Letters
Patient Encounter Notes
Prince George Version 1.5 July 2011
Consistently
being used
Inconsistently
used (<50%
of time)
Not currently
used, but
would like to.
Not used, and
not interested
at this time.
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13
Question 80, continued:
EMR Function
Consistently
being used
Inconsistently
used (<50%
of time)
Not currently
used, but
would like to.
Not used, and
not interested
at this time.
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Maintaining up to date Problem Lists
Maintaining up to date Chronic Medication Lists
Performing Recalls (e.g. for PAPs, 1year CT scan follow-up, etc.)
Reporting (e.g. audits, practice management, patient registries)
Messaging/Tasking Staff
Messaging Colleagues
Other: specify
Section C: Electronic Medical Records – Continued
81. Currently, how much do the following issues affect your ability, as a physician, to increase EMR capabilities into your office:
Typing skills (this assumes your typing speed is limited)
Computer navigation skills
Anticipated concerns regarding physician workflow
General training about EMR potential usage (i.e. you do
not know what you could be doing)
EMR specific training (e.g. you know about audits, but do
not know how to do one)
Other: specify
Other: specify
Prince George Version 1.5 July 2011
Not at all
Mildly
Moderately
Significantly
Very
Significantly
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14
Section C: Electronic Medical Records – Continued
82. Currently, how much do the following issues limit your administrative staff’s ability to increase EMR usage in your office?
(Ask your staff, if needed.)
Typing skills (this assumes their typing speed is limited)
Computer navigation skills
Anticipated concerns regarding physician workflow
General training about EMR potential usage (i.e. they do
not know what they could be doing)
EMR specific training (e.g. you/they know about recall
lists, but do not know how to create them)
Other: specify
Other: specify
Not at all
Mildly
Moderately
Significantly
Very
Significantly
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83. Do you still have active paper charts in your office? Yes  No 
If yes, what are they used for? Check all that apply.
Yes, paper
charts are
still used for:
Filing paper copies of current, received information (e.g. lab results,
consult letters, etc.)
Filing paper copies of current, sent information (e.g. referral letters,
faxed requisitions, etc.)
Chart Notes
For frequent access to older records (i.e. your transition to EMR was
recent enough that you often need to review the paper chart)
Other: specify
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If yes, is data also entered into the
EMR? How:
Scanned in?
Manually entered?
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Section C: Electronic Medical Records – Continued
84. Do you use voice recognition software (e.g. DragonNaturallySpeaking)?
Never  Rarely  Half the Time  Frequently  Almost Always 
85. The PGDFP will be starting a local COP (Community of Practice) this winter. This is a PITO-funded program intended to support
EMR users locally (i.e. with coaches, both MD and non-MD, hired by the PGDFP).
*PSP* Would you like to learn more about the COP program and other PITO resources? ? Yes  No 
*PSP* Would you like support in increasing use of EMR in your office? Yes  No 
What specifically would be helpful to you at this time? ___________________________________________________
86. Are you aware of the AMCARE (Aggregated Metrics for Clinical Analysis, Research and Evaluation) data registry? Yes  No 
Do you contribute to it? Yes  No, but I would like to.  No, and I am not interested at this time.  Unsure 
Please skip ahead to Section D (page 19).
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Section C: Electronic Medical Records – Continued
Paper-based Offices/No EMR
87. Have the following issues affected your decision to stay with a paper-based office system?
Cost of EMR license
Cost of Hardware (i.e. computers, monitors, etc.)
Computer set-up (i.e. difficulty in setting up and maintaining the required
network, computers, printers, etc.)
Physical office set-up (i.e. space constraints for computer/desk, etc.)
Limited physician computer navigation skills
Limited physician typing skills
Limited administrative staff computer navigation skills
Limited administrative staff typing skills
Staff Concerns (see next question for more detail)
Time lost due to interruptions to office when initiating EMR use
Anticipated concerns regarding office workflow with EMR training
Anticipated concerns regarding office workflow with an EMR in use, once
training period is finished
Anticipated concerns regarding physician workflow with an EMR in use
Anticipated difficulties in adapting current paper charts to electronic ones
Other: specify
Other: specify
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Section C: Electronic Medical Records – Continued
88. If part of the decision not to implement an EMR is due to concerns brought forward by your staff, which of the following issues
were brought forward? (If they had simply voiced a general disinclination for EMR, please ask them what their specific concern
was.)
Limited staff computer navigation skills
Limited staff typing skills
Staff concerns regarding additional responsibilities/knowledge base
Time lost due to interruptions to office when initiating EMR use
Anticipated concerns regarding office workflow with an EMR in use
Anticipated concerns regarding physician workflow with an EMR in use
Anticipated difficulties in adapting current paper charts to electronic one
Physical front desk set-up (i.e. space constraints for computer/desk)
Other: specify
Other: specify
No Effect on
Decision
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89. Are you aware of the AMCARE (Aggregated Metrics for Clinical Analysis, Research and Evaluation) data registry? Yes  No 
Would you be willing to contribute to it? Yes  No  Unsure 
90. The Division will be starting a local COP (Community of Practice) this winter. This is a PITO-funded program intended to support
EMR users locally (i.e. with coaches, both MD and non-MD, hired by the PGDFP).
*PSP* Would you like to learn more about the COP program, and other PITO resources? Yes  No 
*PSP* Would you like support in initiating use of EMR in your office? Yes  No 
What specifically would be helpful to you at this time? ___________________________________________________
Would you like information about MOIS (a Prince George original!) or AIHS (the not-for-profit organization supporting
MOIS)? Yes  No 
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Section D: Demographics of Your Patient Population This section involves assessing your current patient population, in
your office. The PGDFP can provide assistance to collect this information, if desired. If you and your partner(s) share the same
patient population, Questions 91 through 100 need only to be filled in by one of you, although ideally you would work together with
the coach to gather this data.
91. *PSP* How large is your patient panel? i.e. The total number of active patients (not transient patients) in your primary office:
Your best estimate/guess: 1-500  501-1000  1001-1500  1501-2000  2001-2500  2501-3000  3001+ 
Number from EMR: Active (A) patients, seen in the last ... 5 years: _______ ... 3 years: _______ ... 1 year: _______
92. Total number of transient (TR)patients seen in the last 3 years, in your office: _______
93. Patients in my office are shared (i.e. no main provider): Yes  No 
94. Does your office have consistently applied procedures for labelling charts as active, inactive, deceased, moved away, changed
doctors, or transient (e.g. seen for a WIC follow-up only, prenatal care only, etc.)? Yes  No  Unsure 
95. Age distribution: (Active patients seen in last 3 years) Fill in numbers or print report.
Age Group
0-9 years
10-19 years
20-29 years
30-39 years
40-49 years
Number of Active Patients
Age Group
50-59 years
60-69 years
70-79 years
80-89 years
90-100+ years
96. Sex distribution: (Active patients seen in last 3 years) Fill in numbers or print report.
Gender
Male
Female
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PRINTED REPORT ATTACHED 
Number of Active Patients
PRINTED REPORT ATTACHED 
Number of Active Patients
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Section D: Demographics of Your Patient Population – Continued
Disease Burden In Your Patient Population
97. Number of active Complex Care Plan-eligible patients in your practice: _______
(I.e. Patients have at least 2 of the 8 eligible diagnoses: Diabetes, Chronic Kidney Disease, CHF, Chronic Respiratory Condition,
Cerebrovascular Disease, Ischemic Heart, Chronic Neurodegenerative, Chronic Liver Disease)
*PSP* Do you have a registry, or perform regular audits (at least 2x/year), to ensure recalls/billing? Yes  No 
What percentage were billed last year? 0-24%  25-49%  50-74%  75-99%  100%  Unsure 
98. Several chronic diseases have guidelines, extra billing codes, and/or are more difficult to treat.
a) What are the number of active patients, seen in your main office within the last 3 years, with the various diagnoses below,
b) do you have a registry or perform regular audits (at least 2x/year) for recalls, and
c) how many of those eligible for extra Chronic Disease Management billing codes were billed in the last 12 months.
Include patients with multiple diagnoses in all relevant rows.
Diagnosis
Addictions
Arthritis
Axis I Mental Health (excluding
depression)
Cancer
Cerebrovascular Disease (CVA, TIA)
Chronic Pain
Chronic Kidney Disease
Congestive Heart Failure
COPD
Depression
Diabetes
HIV, Hepatitis C
Hypertension
Ischemic Heart Disease
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Number of Active
Patients
Have a registry, or Number for whom CDM Billing was done in the last
do regular audits? 12 months, if applicable
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(Bill Code: 14051)
(Bill Code: 14053)
(Bill Code: 14050)
(Bill Code: 14052)
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Question 98, continued...
Neurodegenerative Diseases
(dementia, brain injury, MS, etc.)
Palliative
Number of Active
Patients
Have a registry, or Number for whom CDM Billing was done in the last
do regular audits? 12 months, if applicable
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Bill Code: 14063
99. *PSP* Do you perform recalls for patients with chronic diseases who have not followed up within your expected timelines and/or
need guideline care?
Yes  No 
100. Do you perform recalls for any other specific reasons (e.g. repeat imaging or labs due, immunization/boosters due, etc.)?
(Please exclude PAPs from this question, as a PAP registry is effectively maintained by the BCCA.) Yes  No 
101.
*PSP* Do you use patient self-management strategies in your practice?
Yes, >half the time.  Yes, <half the time.  No 
a. *PSP* “We ask patients if they want or need to bring family members, friends, Elders, or other spokespersons to their
appointments, especially for appointments concerning diagnoses and treatments.”
 We do this consistently
 We are doing this, but we could make some improvements
 We are not doing this and should consider it for future implementation
 Not applicable or we do not have the resources in our community to do this.
b. *PSP* Patient understanding is vital to successful self-management. “To check for understanding, we ask patients to
describe to us, in their own words, the instructions we have just given them (known as the “teach back” method).”
 We do this consistently
 We are doing this, but we could make some improvements
 We are not doing this and should consider it for future implementation
 Not applicable or we do not have the resources in our community to do this.
102. *PSP* To ensure that your patients receive care that is appropriate, do you generally follow the most recent clinical
guidelines for the conditions listed below? (Check all that apply)
 CHF
 Diabetes  CKD  HTN  COPD  Depression  Palliative  Other (specify:_______________)
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Section D: Demographics of Your Patient Population – Continued
103.
*PSP* Are you confident in identifying and managing all patients with mental health conditions? Yes  No  Somewhat 
In what areas might you need support? _________________________________________________
104. *PSP* Do you have a method set up in your office to get feedback from patients, about any aspect of the patient experience?
(e.g. patient surveys) Yes  (Specify: _________________________________________________________) No  Unsure 
105. In an average week, how many After-Hours Clinic visit reports do you get? (i.e. from your patients attending the Nechako
Clinic)
*PSP* Please estimate: _______ reports/week
If able, Audit result: _______ reports last week
106. Would you like us to find and provide to you a summary of how many of your patients attended the ER in the last month, by
Triage Level? Yes  No 
107.
*PSP* Do you feel that you have adequate access to specialist support? (1 = low, 5 = good)
Emergent
Urgent
Elective
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2
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Section E: Attachment Initiative As described at the Nov 3, 2010 Division Quarterly Meeting, the current major focus of the
PG Division of Family Practice is the Attachment Initiative. The purpose of this initiative is described in detail on the Division
website, but in summary, the goal is to find a Primary Care Home for every person in Prince George who either wants or needs one.
This involves both planning how to increase capacity in Prince George, and deciding how to compensate practitioners for the
patients that they already have and/or agree to take on. Increasing capacity will likely include development of a Multidisciplinary
Clinic, which would become a permanent home for some patients, and be a transient home for others, with an eventual plan to
finding them independent primary care practitioners.
The following questions are intended to get a preliminary sense of Division Members’ opinions about capacity, manpower, and
compensation.
108. Do you think that you might be interested in working at a Multidisciplinary Clinic in the future? (Likely with sessional
payment; the team would potentially include such allied health professionals as a social worker, addictions counsellor, and nurse
practitioner.) Yes  No  Unsure 
109. Once the Attachment Initiative is underway, do you anticipate that you or your office will agree to take on new patients from
the Multidisciplinary Clinic? Yes  No  Unsure 
If yes, how many do you think you or your office would be able to take on per month? <1  1  2  >2 
If no or unsure, what would make it attractive enough for you to change your mind? Please elaborate:
______________________________________________________________________________________________________
______________________________________________________________________________________________________
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110. Certain patient characteristics and/or diseases are often considered to be more complex, requiring more time and effort
from a primary care physician. The attachment initiative may attempt to value relative patient complexity into a compensation
plan. Several chronic diseases are listed below, please score them in terms of their level of complexity/difficulty in providing
care. For comparison, a few acute/chronic conditions that might be considered “easy” are also included.
If there are any “very complex” diagnoses that you think ought to be included here, please add them in at the end.
Condition
Addictions
Asthma
Axis I Mental Health Diagnoses
Axis II Mental Health (Personality Disorders)
Cancer
Cardiac Disease
Chronic Non-Inflammatory Bowel Complaints
Chronic Pain
Chronic Kidney Disease
Congestive Heart Failure
COPD
Diabetes
Dialysis (HD or PD; with respect to dealing with any
other health issues in these complex patients)
Fatigue NYD
Headaches (Chronic, Non-malignant)
HIV, Hepatitis C
Hypertension
Injured Ankle
Neurodegenerative Diseases (brain injury, stroke,
developmental disorders, dementia, etc.)
Pharyngitis, infectious
Rheumatoid Arthritis
Other: specify
Other: specify
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Not Difficult
(1)
Average
Office Visit (2)
Mildly
Complex (3)
Moderately
Complex (4)
Very Difficult/
Complex (5)
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24
Section F: Practice Support Modules If you do not practice office-based primary care medicine, please skip to Section H.
111. Which of the following PSP modules have you completed? Have you put it into practice/applied it in your office? If you have
not completed and/or not applied a module, are you interested in doing so?
PSP Module
Group Medical Visits
Advanced Access
Mental Health
Patient Self Management
Chronic Disease Management
Palliative Care (not yet released)
112.
Completed?
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n/a
Applied to Practice?
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n/a
Interested in future?
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Would your interest in engaging in practice improvement work be increased if it were:
Delivered through the Division? Yes  No  Unsure 
More tailored to your specific practice needs? Yes  No  Unsure 
More tailored to your schedule? Yes  No  Unsure 
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*PSP* Section G: PSP Questionnaire Closing Questions
Name: __________________________________
These questions are copied directly from the PSP survey, from the final section entitled “Taking Stock...”. Your hand-written
responses will be sent “as-is” to PSP. If you are not applying for the PSP funding, then you do not need to fill out these questions,
but are certainly welcome to. Please reflect on the following questions:
113.
*PSP* What are you most proud of about your practice?
114.
*PSP* What insights into your practice did you gain from this assessment?
115.
*PSP* Do you see an immediate and obvious change that you can easily make? Describe.
116.
*PSP* Do you see some longer-term changes that you’d like to make over the next year or two? Describe.
117.
*PSP* What have you changed successfully in your practice in the last six months?
118.
*PSP* What additional resources could you use to help you manage your patients?
119.
*PSP* What makes my practice different from someone else’s practice?
120.
*PSP* I would like to learn more about...
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Section H: The Innovation Development Commons: The Innovation Development Commons (IDC) is a joint initiative
between Northern Health and UNBC. It brings the academic resources of UNBC, the Northern Medical Program and NH together
with the experience of front line health care providers (i.e. you!) and administrators. They are planning to set up “think tanks” in
communities across the northern health authorities, with the goal of improving access to and quality of primary health care in
Northern BC. Your answers will be forwarded to the IDC anonymously, except Q 121 for which your name will be attached.
121. Would you be interested in participating in a “think tank” session to discuss innovative and practical ideas and potential
solutions to the issues, barriers and gaps identified by yourself and other health care providers? (Note: Your answer will be
forwarded non-anonymously to the IDC)
Yes  No  Not sure  Decline to answer 
122.
Which of the following might be determining factors for your participation or non-participation?
Content?
Yes  No  Not sure 
(If yes or not sure, please comment below)
Format?
Yes  No  Not sure 
(If yes or not sure, please comment below)
Length?
Yes  No  Not sure 
(If yes or not sure, please comment below)
Remuneration?
Yes  No  Not sure 
(If yes or not sure, please comment below)
Expected outcomes? Yes  No  Not sure 
(If yes or not sure, please comment below)
Comments: ____________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
123. Who do you know who is doing good work in Primary Health Care that IDC could invite to present and participate at a future
“think tank” session? _______________________________________________________________________________________
________________________________________________________________________________________________________
124. Is there one other person (either a physician outside of Prince George, or another health professional in Northern BC) that
you would recommend IDC contact regarding participation in these “think tanks”? _____________________________________
________________________________________________________________________________________________________
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Section I: How Can the Division Help You?
125.
Are you currently a member of the PGDFP?
Yes  No, but I’m interested in joining.  No, and I’m not interested at this time. 
126.
How confident are you that the PGDFP will represent your interests?
Not Confident  Somewhat Confident  Very Confident  Unsure 
Why? _______________________________________________________________________________________________
_______________________________________________________________________________________________
127. Below are ways that the Division is considering trying to support its members. The method with which this will be done, or in
some cases, whether it can be done, is not yet clear. We would like your feedback about the teaching/support that would help
you.
Check all that apply. I would like support/teaching…
In completing of this survey
About incentive billing (e.g. Mental Health Care, Complex Care, Obstetrical
Premium Payments, Community Patient Conferencing Billing, etc.)
About AMCARE
For continuing education for my MOAs
In “exit planning” (i.e. to retire or find a replacement)
To find locums
To find a partner (i.e. recruiting new physician to Prince George)
With initiating or optimizing EMR usage
With changing from solo to group practice (i.e. merging your practice with one
currently in existence)
With administrative continuing education (e.g. business strategies)
With incorporating a nurse practitioner or physician assistant into your office
With incorporating a multidisciplinary team member (SW, LPN, RN, dietician, etc.)
Other: specify
Other: specify
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Section I: How Can the Division Help You? – Continued
128.
Are you willing and able to coach other physicians? Yes  No  Unsure 
If yes, are there any particular areas that you would feel most comfortable coaching, either one-to-one or in small
groups? For example: a particular PSP module, general or specific EMR use, new billing codes, or even an idiosyncratic
topic such as “I just merged my solo practice into a group practice: tips and things to avoid, to stop you from pulling out
your hair!” 
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
129. Is your MOA (preferably in an office that currently uses MOIS) interested in coaching other MOAs? The wage for this
coaching would be paid by the Division, and it is meant to be time outside of what is usually spent working in your office.
Yes  No  Unsure  If yes or unsure, name: __________________________________________________
Is there a specific topic that she/he would be most interested in coaching? For example: billing, MOIS functions, etc.
_____________________________________________________________________________________________
Thank you for your time!
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