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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 Disparities

Sponsored by: Agency for Health Care Research and Quality (AHRQ)
Conducted by: Mathematica Policy Research, Inc.

Organization Label Here

(Name, Address, Telephone)



About This Request

The 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 row
Not at All
Important		A Little
Important		Somewhat
Important		Very
Important		Crucial
1. Overall, how important was the collaborative in attaining the goals of your organization?___1___2___3  

QuestionsMark (X) one box for each row
No ExtentA Little
Extent		Some
Extent		Considerable
Extent		A Great
Extent
2. To what extent has the collaborative carried out its responsibilities and commitments?___1___2___3___4___5
3. To what extent has your organization carried out its responsibilities and commitments to the collaborative?___1___2___3___4___5
4. 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___5
6. 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___5
8. 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___5

In 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 or
Little Extent		To Some
Extent		Considerable
Extent
Aetna___1___0___1___2___3
CIGNA___1___0___1___2___3
Harvard Pilgrim___1___0___1___2___3
HealthPartners___1___0___1___2___3
Highmark     
Kaiser Permanente___1___0___1___2___3
UnitedHealth Group___1___0___1___2___3
CHCS___1___0___1___2___3
IHI___1___0___1___2___3
AHRQ___1___0___1___2___3
11. 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 row
Not at All1-2 TimesMonthlyWeeklyDaily
Aetna___1___2___3___4___5
CIGNA___1___2___3___4___5
Harvard Pilgrim___1___2___3___4___5
HealthPartners___1___2___3___4___5
Highmark___1___2   
Kaiser Permanente___1___2___3___4___5
UnitedHealth Group___1___2___3___4___5
CHCS___1___2___3___4___5
IHI___1___2___3___4___5
AHRQ___1___2___3___4___5
12. 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 row
Not at All
Important		Somewhat
Important		Moderately
Important		Very
Important		Crucial
Aetna___1___2___3___4___5
CIGNA___1___2___3___4___5
Harvard Pilgrim___1___2___3___4___5
HealthPartners___1___2___3___4___5
Highmark___1___2   
Kaiser Permanente___1___2___3___4___5
UnitedHealth Group___1___2___3___4___5
CHCS___1___2___3___4___5
IHI___1___2___3___4___5
AHRQ___1___2___3___4___5
13. 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 row
To No Little ExtentTo a Little ExtentTo Some
Extent		Considerable
Extent
Aetna___1___2___3___4
CIGNA___1___2___3___4
Harvard Pilgrim___1___2___3___4
HealthPartners___1___2___3___4
Highmark___1   
Kaiser Permanente___1___2___3___4
UnitedHealth Group___1___2___3___4
CHCS___1___2___3___4
IHI___1___2___3___4
AHRQ___1___2___3___4
14. 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 row
To No Little ExtentTo a Little ExtentTo Some
Extent		Considerable
Extent
Aetna___1___2___3___4
CIGNA___1___2___3___4
Harvard Pilgrim___1___2___3___4
HealthPartners___1___2___3___4
Highmark___1   
Kaiser Permanente___1___2___3___4
UnitedHealth Group___1___2___3___4
CHCS___1___2___3___4
IHI___1___2___3___4
AHRQ___1___2___3___4
15. 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 row
To No Little ExtentTo a Little ExtentTo Some
Extent		Considerable
Extent		Cannot Assess
Aetna___1___2___3___4___5
CIGNA___1___2___3___4___5
Harvard Pilgrim___1___2___3___4___5
HealthPartners___1___2___3___4___5
Highmark___1___2   
Kaiser Permanente___1___2___3___4___5
UnitedHealth Group___1___2___3___4___5
CHCS___1___2___3___4___5
IHI___1___2___3___4___5
AHRQ___1___2___3___4___5
16. 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 row
To No Little ExtentTo a Little ExtentTo Some
Extent		Considerable
Extent
Aetna___1___2___3___4
CIGNA___1___2___3___4
Harvard Pilgrim___1___2___3___4
HealthPartners___1___2___3___4
Highmark___1   
Kaiser Permanente___1___2___3___4
UnitedHealth Group___1___2___3___4
CHCS___1___2___3___4
IHI___1___2___3___4
AHRQ___1___2___3___4
17. Which organizations provide good ideas for dealing with disparities at meetings of the collaborative?
OrganizationMark (X) one box for each row
No Good IdeasSome Good IdeasMany Good Ideas
Aetna___1___2___3
CIGNA___1___2___3
Harvard Pilgrim___1___2___3
HealthPartners___1___2___3
Highmark___1  
Kaiser Permanente___1___2___3
UnitedHealth Group___1___2___3
CHCS___1___2___3
IHI___1___2___3
AHRQ___1___2___3
18. 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 550
Washington, DC 20024-2512
or Fax to 202-863-1763

Attn: Erin Taylor

Prepared by Mathematica Policy Research, Inc.

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Page last reviewed 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://archive.ahrq.gov/research/findings/final-reports/learning/form.html