Form #3 Form #3 Key informant interviews with staff

K

Form Approved
OMB No. 0935-XXXX
Exp. Date XX/XX/20XX

ey Informant Interview for Staff and Providers

Date:

Name:

Practice location:

Role in practice:

Role in intervention:

Use/exposure to Toolkit: Y N

1. Tell me about your experience and involvement with the (practice coaching) intervention?
   
   

2. What challenges has your organization/practice encountering with implementing the CCM?

   1. With point of care decision supports?

   2. With clinical information systems?

   3. With self-management support?

   4. With delivery system design?

   5. With health system organization?

   6. With community linkages?

3. What if any changes do you believe resulted from the practice coaching intervention?

   1. With point of care decision supports?

   2. With clinical information systems?

   3. With self-management support?

   4. With delivery system design?

   5. With health system organization?

   6. With community linkages?

   7. With quality of care for (index condition)?

   8. With organizational capacity for change?

      1. Organizational will for change?

      2. Organizational capacity and skill in the conduct of change processes?

   9. Other change? Please give an example.

4. How sustainable do believe these changes are? 1 year or less, or greater than a year?

   1. If you believe the changes will only be sustained short-term, why?

   2. What would need to happen to make them long-term changes?

Public reporting burden for this collection of information is estimated to average 60 minutes per response, the estimated time required to complete the survey. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: AHRQ Reports Clearance Officer Attention: PRA, Paperwork Reduction Project (0935-XXXX) AHRQ, 540 Gaither Road, Room # 5036, Rockville, MD 20850.

5. How important are these changes to your practice/organization? Not at all, some what, very important? Please explain.

6. On a scale of 1 to 10 with 1 being not at all effective, and 10 being very effective, what rating would you rate the (intervention)? If not a 10, in your opinion, what would it take to make the intervention a “10”?

7. (if applicable) On a scale of 1 to 10, how would you rate the Toolkit? if applicable) What would be needed to make it a 10?

8. What do you believe were the most effective aspects of the intervention? Least effective?

9. What factors facilitated implementation of the intervention? What factors impeded it?

   1. At the system level?

   2. Organization level?

   3. Practice level?

   4. Provider level?

   5. Staff level?

   6. Patient level?

   7. Other?

10. How is this (intervention) the same or different from other quality improvement interventions you’ve participated in here such as the (collaboratives)?

    1. In process?

    2. In relevance to practice needs?

    3. In ease of use?

    4. In staff/provider satisfaction?

    5. Other?

11. What recommendations do you have for improving the intervention?