Healthcare Administrator Cardiac Rehabilitation Attitudes Scale 
(by healthcare administrators, we are referring to those in charge of planning, directing, and coordinating health services; see PACRR for scale assessing attitudes in healthcare providers or clinicians)

There are now numerous publications where healthcare administrator attitudes toward CR are assessed (see below; see also: https://globalcardiacrehab.com/Validated-CR-Surveys). Given healthcare administrators are often responsible for resourcing CR appropriately, knowing their attitudes and where they could be improved is key.


We have recently more formally developed a scale, which is shown below. I would be delighted if you wanted to use it in your research. Kindly email me to let me know. I would also be delighted to share any outputs of your work with the HACRA on this website, and/or to collaborate with you to attempt to mitigate identified issues that block CR use.

If you use the scale, ensure this citation appears on surveys, publications and presentations: Chaves, G.S.S., Ghisi, G.L.M.G., Britto, R.R., Servio, T.C., Cribbie, R., Pack, Q., & Grace S.L. (2020). Healthcare administrators’ cardiac rehabilitation attitudes (HACRA) in North and South America, & the development of a scale to assess them. Heart, Lung & Circulation;29(7):e111-120. July.

If you wish to translate the scale to another language: Please reach out as there may be others working on translations or available translations to which I could point you. If not, there are best practices for translation, cross-cultural adaptation and validation that should be used; I could point you to some resources if requested. Ultimately, I could post your translation to this website as well, giving you credit if you are agreeable, in case others wish to use it.

PROPOSED SCALE (to be psychometrically tested): HACRA-R
(scoring information etc. at bottom)

Instructions: Cardiac rehabilitation (CR) is an established outpatient chronic disease management model of care for secondary prevention. These programs offer risk factor management, structured exercise, patient education, and lifestyle counselling. The purpose of this survey is to understand your attitudes towards, and perceptions of CR.

 Please rate the following: (check  one box per row)

  Extremely Important Important Neutral Not very important Definitely not important at all
1.     Your perceptions of the importance of CR for patients’ outpatient care
2.     Your perception of your institution’s view of the importance of CR for patients’ outpatient care
3.     Your perceptions of the role of CR programs in reducing patient hospital re-admissions
4.     Your perceptions of the role of CR programs in reducing patient hospital length of stay
5.     Your perceptions of the value of CR for treating patients in your jurisdiction with other cardiovascular conditions (e.g., stroke) or chronic diseases (e.g., diabetes)


Please indicate how much you agree or disagree with the following statements regarding cardiac rehabilitation (CR) programs:

(check  one box per row)

  Strongly Agree Agree  Neutral Disagree Strongly Disagree N/A - I don’t know
6.   There should be financial incentives from government to promote CR delivery at health care institutions
7.   Government should not cover CR services for cardiac patients post-hospitalization*
8.   I am skeptical about the benefits of CR programs*
9.       The closest available CR program is of good quality
10.    Scarce healthcare dollars should not be spent on outpatient care at the expense of acute care*
11.    Hospital space is too expensive to be used to run a CR program*
12.    CR programs promote sustained behavioural changes that improve health outcomes
13.    If/when we make budget reductions, if it were my decision, CR programs are/would be one of the first programs to be cut-back*
14.    Patients and their families should be responsible for their own health behaviour changes and risk reduction self-management post-hospitalization*
15.    The government should provide more funding for CR programs and/or ensure more private health insurance coverage for CR
16.    If it were my decision, CR programs would continue to be resourced (e.g., staff, space) at current levels
17.    Physicians and nurses on inpatient cardiac units have other more important clinical duties than to refer patients to CR*
18.    It is a hospital’s responsibility to provide all eligible inpatients with the information they need to begin an outpatient CR program.
19.    It is a hospital’s responsibility to ensure CR programs have all the information they need so their patients can start CR (i.e., referral order, discharge summary)
20.    Cardiac administrators’ have a responsibility to ensure that policies to promote systematic referral of indicated cardiac inpatients to CR are in place at hospitals
21.    It is the cardiac administrators’ responsibility to ensure applicable hospital staff are trained and encouraged to systematically refer indicated cardiac inpatients to CR
22.    All inpatient cardiac care providers should be aware of common patient barriers to CR participation, and have the knowledge to address with patients how they can be overcome
23.    I do not have enough time to promote/ensure CR referral and/or delivery in my institution
24.    My colleagues would consider me a champion of CR delivery
25.    Inpatient cardiac units need to track the flow of their patients to outpatient CR
26.    Inpatient cardiac units need to ensure all patients (regardless of sex, socioeconomic status or other such factors) are referred to CR equitably
27.    CR programs within my jurisdiction (should) work together as a network to ensure all patients get the care they need
28.    It is a healthcare administrators’ responsibility to work towards ensuring there is sufficient CR capacity for all patients in need
29.    Inpatient and outpatient cardiac care teams should collaborate to ensure the best care transitions for patients
30.    I am familiar with how long cardiac patients in my jurisdiction have to wait to start CR
31.    It is the cardiac administrators’ responsibility to ensure CR programs are properly resourced to provide comprehensive care (i.e., all aspects of cardiac secondary prevention, including tobacco cessation interventions and stress management)
32.    It is important that the inpatient cardiac healthcare providers that report to me are aware of the CR services to which they are referring their patients, and of the follow-up they will receive post-discharge
33.    In my interactions with physicians, I promote the value of CR for patients
34.    I promote CR to those under my purview and others beyond as well
35.    I ensure we are not overly reliant on physicians in ensuring cardiac patients access CR (e.g., supporting admin staff to collate referral documentation, supporting nurses to describe CR services to patients)
36.    Many patients are not interested in attending CR, so I do not worry about promoting CR delivery*
37.    It is clear in the health system who should refer patients to CR
38.    Those responsible for referring patients to CR are incentivized appropriately to do so
  1. Please provide below any further comments or thoughts on provision of cardiac rehabilitation:


N/A: Not applicable; CR: Cardiac Rehabilitation

* Reverse-scored items.

SCORING: From left to right, response options are scored from 5 to 1, such that higher scores reflect more positive CR attitudes.


Grace SL, Scarcello S, Newton J, O'Neill B, Kingsbury K, Rivera T, & Chessex C. How do hospital administrators perceive cardiac rehabilitation in a publicly-funded health care system? BMC Health Serv Res 2013 Mar 28;13:120. doi: 10.1186/1472-6963-13-120.

Ghisi GLM, Britto R, Servio TC, Anchique Santos C, Fernandez R, Rivas-Estany E, Santibanez C, Gonzalez G, Burdiat G, Lopez-Jimenez F., Herdy AH & Grace SL. Perceptions of Cardiology Administrators About Cardiac Rehabilitation in South America and the Caribbean. J Cardiopulm Rehabil Prev 2017 Jul;37(4):268-273.

Servio, T.C., Ghisi, G.L.M., da Silva, L.P., Silva, L.D.N., Lima, M.M.O., Gomes, D.A., Britto, R.R., & Grace, S.L. (2019). Barriers to cardiac rehabilitation delivery in a low-resource setting from the perspective of healthcare administrators, rehabilitation providers and cardiac patients. BMC Health Services Research;19: September. https://rdcu.be/bP9VR