Interim Feedback Forms Evaluation of a Learning Collaborative's Process and Effectiveness to Reduce Health Care Disparities Among Minority Populations Note: Feedback form draws heavily on Van de Ven and Ferry (1980), with permission from the authors. Interim Feedback on the Collaborative's Value and Structure from Organizations Participating in the National Health Plan Collaborative to Reduce DisparitiesSponsored by: Agency for Health Care Research and Quality (AHRQ)Conducted by: Mathematica Policy Research, Inc.Organization Label Here(Name, Address, Telephone)About This RequestThe National Health Plan Collaborative involves many organizations working together to reduce disparities. To understand how the collaborative functions, we are requesting feedback on your organization's general perceptions of the collaborative to date and the relationships between collaborative participants. There are no right or wrong answers. Individual responses to this request will be kept completely confidential and will only be reviewed by researchers at Mathematica Policy Research, Inc. (MPR). Findings will be reported in de-identified form. If you have any questions about this request, please call Marsha Gold or Erin Taylor at 202-484-9220. Please be sure to answer every question and mark your answers clearly. Please return your completed questionnaire in the postage-paid envelope provided by Friday, December 16, 2005.Completed by: _______________________________ Title: ________________________________Organization: _____________________________________________________________________Address: ________________________________________________________________________Telephone: (| | | |)-| | | |-| | | | | | (Area - Code Number)Date of Completion: | | | / | | | /| 2| 0| 0| 5| (Month/Day/Year)Prepared by Mathematica Policy Research, Inc.When answering questions 1 through 9, please think about the last 6 months of the collaborative with regard to disparities. QuestionsMark (X) one box for each rowNot at AllImportantA LittleImportantSomewhatImportantVeryImportantCrucial1. Overall, how important was the collaborative in attaining the goals of your organization?___1___2___3 QuestionsMark (X) one box for each rowNo ExtentA LittleExtentSomeExtentConsiderableExtentA GreatExtent2. To what extent has the collaborative carried out its responsibilities and commitments?___1___2___3___4___53. To what extent has your organization carried out its responsibilities and commitments to the collaborative?___1___2___3___4___54. To what extent do you feel the relationship between your organization and the collaborative is productive?___1 5. To what extent is the time and effort spent in developing and maintaining the relationship with the collaborative worthwhile?___1___2___3___4___56. Overall, to what extent are you satisfied with the relationship between your organization and the collaborative? 7. To what extent has your organization changed or influenced the activities of the collaborative?___1___2___3___4___58. To what extent has the collaborative changed or influenced the activities of your organization? 9. Are the payoffs of the collaborative for your organization reasonable relative to your contribution?___1___2___3___4___5In questions 10 through 17, we are interested in your organization's experience with other organizations in the collaborative. For each question, please leave blank the rating of your own organization.10. In general, prior to the start of your organization's participation in the collaborative...OrganizationWere you and your team personally acquainted with the key people from the collaborative organizations listed below?IF YES: To what extent did your organization have an effective working relationship with each of these organizations prior to the start of the collaborative?YesNoTo No orLittle ExtentTo SomeExtentConsiderableExtentAetna___1___0___1___2___3CIGNA___1___0___1___2___3Harvard Pilgrim___1___0___1___2___3HealthPartners___1___0___1___2___3Highmark Kaiser Permanente___1___0___1___2___3UnitedHealth Group___1___0___1___2___3CHCS___1___0___1___2___3IHI___1___0___1___2___3AHRQ___1___0___1___2___311. During the past six months—outside of formal collaborative meetings—how frequently have people from your organization who are involved in the collaborative communicated or been in contact with people in the organizations listed below? OrganizationMark (X) one box for each rowNot at All1-2 TimesMonthlyWeeklyDailyAetna___1___2___3___4___5CIGNA___1___2___3___4___5Harvard Pilgrim___1___2___3___4___5HealthPartners___1___2___3___4___5Highmark___1___2 Kaiser Permanente___1___2___3___4___5UnitedHealth Group___1___2___3___4___5CHCS___1___2___3___4___5IHI___1___2___3___4___5AHRQ___1___2___3___4___512. Overall, how important was each organization's work through the collaborative in attaining the goals of your organization with respect to disparities? OrganizationMark (X) one box for each rowNot at AllImportantSomewhatImportantModeratelyImportantVeryImportantCrucialAetna___1___2___3___4___5CIGNA___1___2___3___4___5Harvard Pilgrim___1___2___3___4___5HealthPartners___1___2___3___4___5Highmark___1___2 Kaiser Permanente___1___2___3___4___5UnitedHealth Group___1___2___3___4___5CHCS___1___2___3___4___5IHI___1___2___3___4___5AHRQ___1___2___3___4___513. To what extent has each organization carried out its responsibilities and commitments involving disparities in regard to the collaborative during the past six months? OrganizationMark (X) one box for each rowTo No Little ExtentTo a Little ExtentTo SomeExtentConsiderableExtentAetna___1___2___3___4CIGNA___1___2___3___4Harvard Pilgrim___1___2___3___4HealthPartners___1___2___3___4Highmark___1 Kaiser Permanente___1___2___3___4UnitedHealth Group___1___2___3___4CHCS___1___2___3___4IHI___1___2___3___4AHRQ___1___2___3___414. To what extent do you feel the relationship between your organization and each of the other organizations with respect to disparities is productive? OrganizationMark (X) one box for each rowTo No Little ExtentTo a Little ExtentTo SomeExtentConsiderableExtentAetna___1___2___3___4CIGNA___1___2___3___4Harvard Pilgrim___1___2___3___4HealthPartners___1___2___3___4Highmark___1 Kaiser Permanente___1___2___3___4UnitedHealth Group___1___2___3___4CHCS___1___2___3___4IHI___1___2___3___4AHRQ___1___2___3___415. During the past six months, to what extent has your organization changed or influenced the activities of each of these other organizations with respect to disparities? OrganizationMark (X) one box for each rowTo No Little ExtentTo a Little ExtentTo SomeExtentConsiderableExtentCannot AssessAetna___1___2___3___4___5CIGNA___1___2___3___4___5Harvard Pilgrim___1___2___3___4___5HealthPartners___1___2___3___4___5Highmark___1___2 Kaiser Permanente___1___2___3___4___5UnitedHealth Group___1___2___3___4___5CHCS___1___2___3___4___5IHI___1___2___3___4___5AHRQ___1___2___3___4___516. During the past six months, to what extent has each of these other organizations changed or influenced the activities of your organization with respect to disparities? OrganizationMark (X) one box for each rowTo No Little ExtentTo a Little ExtentTo SomeExtentConsiderableExtentAetna___1___2___3___4CIGNA___1___2___3___4Harvard Pilgrim___1___2___3___4HealthPartners___1___2___3___4Highmark___1 Kaiser Permanente___1___2___3___4UnitedHealth Group___1___2___3___4CHCS___1___2___3___4IHI___1___2___3___4AHRQ___1___2___3___417. Which organizations provide good ideas for dealing with disparities at meetings of the collaborative? OrganizationMark (X) one box for each rowNo Good IdeasSome Good IdeasMany Good IdeasAetna___1___2___3CIGNA___1___2___3Harvard Pilgrim___1___2___3HealthPartners___1___2___3Highmark___1 Kaiser Permanente___1___2___3UnitedHealth Group___1___2___3CHCS___1___2___3IHI___1___2___3AHRQ___1___2___318. Please use the space below to indicate anything else you want to add relative to the questions above. Thank you for completing this request for feedback. Please return your completed questionnaire in the self-addressed, stamped envelope by Friday, December 16, 2005. If you do not have the return envelope, please mail to:Mathematica Policy Research, Inc.600 Maryland Avenue, S.W., Suite 550Washington, DC 20024-2512or Fax to 202-863-1763Attn: Erin TaylorPrepared by Mathematica Policy Research, Inc.Return to Document Current as of December 2007 Internet Citation: Interim Feedback Forms: Evaluation of a Learning Collaborative's Process and Effectiveness to Reduce Health Care Disparities Among Minority Populations. December 2007. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/research/findings/final-reports/learning/form.html
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