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Health Equity Action Collaborative
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Name
*
First
Last
Email
*
Project Plan Information
1. Have you identified the health topic to be the focus of your project plan? (e.g., Hepatitis C Virus, Pediatric Asthma, Opioid Use in Older Adults)
Yes
No
Unsure
2. If yes, please describe your health project in a few words.
3. Have you identified a priority population you would like to develop your project plan for? (e.g., rural areas, non-native English speakers, a specific racial/ethnic group)
Yes
No
Unsure
N/A (I.e., all people)
4. If yes, please describe your priority population in a few words.
5. Does your health topic align with a Bree Collaborative Report Topic?
Yes
No
Unsure
Program Planning Tools: Please rate your current level of knowledge on the following items using a 1-5 scale. 1= Novice, 2= Advanced Beginner, 3= Competent, 4= Proficient, 5= Expert
6. Bree Collaborative Reports
One
Two
Three
Four
Five
7. Finding sources of evidence (e.g., evidence-based recommendations, promising practices, practice-based evidence) to inform your project design
One
Two
Three
Four
Five
8. Completing a root cause analysis (i.e. Fishbone diagram)
One
Two
Three
Four
Five
9. Developing a Strategic, Measurable, Ambitious, Realistic, Time-bound, Inclusive, and Equitable (SMARTIE) aim statement
One
Two
Three
Four
Five
10. Developing a logic model
One
Two
Three
Four
Five
11. Measures & Metrics use and development
One
Two
Three
Four
Five
12. Developing Plan-Do-Study-Act cycles
One
Two
Three
Four
Five
Health Equity: Please rate your current level of knowledge on health equity on the following characteristics using a 1-5 scale. 1= Novice, 2= Advanced Beginner, 3= Competent, 4= Proficient, 5= Expert
13. Disabilities
One
Two
Three
Four
Five
14. Gender
One
Two
Three
Four
Five
15. Poverty and Economic Disadvantages
One
Two
Three
Four
Five
16. Sexual Orientation
One
Two
Three
Four
Five
17. Race and ethnicity
One
Two
Three
Four
Five
18. The population of interest for your health project or that makes up the majority of your population
One
Two
Three
Four
Five
Health Equity Continued
19. Does your organization have a standard list of social determinants of health (e.g., housing, income, transportation) by which your organization is able to assess population health measures (e.g., blood sugar for a diabetic cohort stratified by race)
Yes
No
Unsure
Barriers & Facilitators
20. What barriers exist to implementing Bree clinical guidelines in your setting? (Please pick your top 3 barriers)
A. Time
B. Cost
C. Lack of business case and/or evidence economic reward
D. Lack of personnel
E. Lack of availability and credibility of data
F. Lack of Implementation metrics
G. Lack of infrastructure capacity (e.g., EHR system, broadband issues, lack of integration with behavioral health systems etc.)
H. Lack of staff or leadership buy-in
I. Lack of staff knowledge
J. Staff attitudes
K. Lack of alignment with other priorities
L. Lack of guidelines specific factors (e.g., evidence, plausibility, complexity, applicability.
M. Other priorities (Please explain)
Other priorities (Please explain)
21. What facilitators (factors that help with change) exist to implementing Bree clinical guidelines in your setting? (Please pick your top 3 barriers) (copy)
A. Time
B. Cost
C. Business case-evidence and/or economic reward
D. Sufficient personnel
E. Availability and credibility of data
F. Implementation metrics
G. Infrastructure capacity EHR system, broadband issues, lack of integration with behavioral health systems etc.)
H. Staff or leadership buy-in
I. Staff knowledge
J. Staff attitudes
K. Alignment with other priorities
L. Guidelines specific factors (e.g., evidence, plausibility, complexity, applicability)
M. Other priorities (Please explain)
Other priorities (Please explain)
General Information
22. As we engage together in the collaborative setting, are there any group agreements you would like to have? If so, please describe.
23. How do you learn most effectively? (Pick your top 3)
A. Presentation
B. Large Group Discussions (whole group_
C. Small Group Discussions (subgroup or cohort of similar stakeholders)
D. Guest Speakers
E. Zoom Polls
F. Videos
G. Podcasts
H. Other (Please explain)
Other (Please explain)
24. Which healthcare stakeholder do you most identify as?
A. Delivery Sites staff (i.e., non-clinical)
B. Health Care Professional (i.e., clinical)
C. Health Plan staff
D. Private Purchaser (i.e., employer purchaser)
E. Public Purchaser
F. Public Health staff
G. Other (Please explain)
Other (Please explain)
25. Is there anything specific you are hoping to get out of this collaborative? (Please explain)
26. Other comments & feedback
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