Form 0920-24FI In-Depth Assessment – Exploratory Assessment Partner Int

Form Approved

OMB No. 0920-XXXX

Exp. Date xx/xx/20xx

In-Depth Assessment – Exploratory Assessment Partner Interview Guide – Clinical Quality Measure – WISEWOMAN

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Exploratory Assessment

Partner Interview Guide

Date of Interview
Interviewer
Notetaker
Organization Name
Organization Type
State
Organization City		Zip Code
Cooperative Agreement	☐ WISEWOMAN
Strategy	Strategy 1: Track and Monitor Clinical Measures
Interviewee Name(s)
Interviewee Role(s) or Title(s)

Introduction

Thank you for taking the time to participate in this interview. My name is <Insert name> and I am with the Deloitte evaluation team. Our team is working with the CDC Division for Heart Disease and Stroke Prevention to evaluate the <Insert Cooperative Agreement>. As part of the larger evaluation, we are seeking to learn more about the effectiveness of Strategy 1: Track and Monitor Clinical Measures at the site level and gain insights on sustainability and program replicability. The information you share will provide valuable insights on approaches for promoting use of electronic health records and health information technology, and standardized processes or tools for Clinical Quality Measurement and help us understand which approaches seem to work well in specific contexts.

This interview is expected to take no longer than 90 minutes. Your participation in this interview is completely voluntary. You may choose not to respond to questions at any time and it will not in any way impact the funding or technical assistance to your organizations receive from CDC. All information will be kept secure and any personally identifiable information will be removed when results are aggregated for analysis.

During this interview we will be referencing back to information gathered during the Evaluability Assessment interviews to further understand how things may have changed or remained the same since <September 2024 through September 2025>. If you did not participate in the Evaluability Assessment or were not yet with <partner organization> we understand that you may not be able to speak to everything that is referenced. We still value your input and are interested in learning about what is currently happening at your organization.

If at any time during the interview you are not clear about what we are asking, be sure to let me know. Please answer questions based on your own knowledge and experience. We appreciate your candid answers and hope that today’s interview can be a conversation among participants. Please let us know when things your colleagues are saying resonate with your experience or when your experience has been different.

Do you consent to this interview?

☐ Yes

☐ No

With your permission, we would like to record this interview for transcription purposes.

Do we have your permission to record?

☐ Yes

☐ No

Do you have any questions or concerns before we start the interview?

Background

Thank you again for agreeing to participate in this interview. For reference, for today’s interview we will be talking about Strategy 1, which is defined as

Track and monitor clinical measures shown to improve health and wellness, health care quality, and identify patients at risk of and with CVD, particularly hypertension.

We will discuss the following sub-strategies under Strategy 1: 

 

[Interviewer Note: Only describe the relevant sub-strategies for which the recipient organization has self-nominated]

1A: Provide cardiovascular disease (CVD) risk assessment to under- and uninsured participants in the priority age range of 35- 64 years during the baseline, follow-up, and reassessment office visits, as appropriate. 

 

1B: Use electronic health record (EHR) and health information technology (HIT) data to query, monitor, and track clinical and social services and support needs data for improved identification, management, referrals, treatment, and outcomes of those at risk of CVD, particularly hypertension.  

 

1C: Use standardized procedures to identify social services and support needs of participants and monitor and assess the referral and utilization of those services, such as food assistance, transportation, housing, childcare, etc. 

 

1D: Use metrics from program data to guide quality improvement activities, e.g., Plan Do Study Act (PDSA) cycles, participant and partner feedback, etc., to increase program enrollment, retention, and referrals to additional services. 

 

1E: Use EHR, HIT or program data to identify health care disparities and address health outcomes within their WISEWOMAN population. 

I’d like to start with some questions to understand the work <name of partner organization> is doing to support patients at risk of or with CVD, and also understand your role within the organization.

1. During the Evaluability Assessment it was shared that you <personal role in relation to supporting strategy approaches>. Is this still true or has this changed since we last spoke?

Probes:

• How long have you been working with <organization name>?

• How long have you been in this role?

• Can you tell me about your role in relation to developing, modifying, enhancing, or otherwise supporting EHRs and/or CQM-related efforts (i.e., CVD risk assessment, program metric data) within your organization?

• How many years have you been working on CQM-related work within your organization?

Implementation of CQM Strategies

We’d like to learn more about how partner organizations are implementing these sub-strategies. We are particularly interested in learning how things have changed since our last round of discussions in <insert time e.g., Fall 2025> during the Evaluability Assessment. We will summarize what we heard about implementation during the key informant interviews and ask you to confirm if the activities are the same or have changed.

2. We last spoke about your activities related to <support for and implementation CQM activities> during the key informant interviews for the Evaluability Assessment. Is this still true or has it changed since we last spoke?

Probes:

• What has changed in the past two years? Why did you make these changes?

• How have you expanded <activities>? What progress has been made? Tell us more about key achievements and milestones.

• Can you please share any unique or novel activities that your organization has implemented that you are particularly proud of or would like to highlight?

• [If no longer implementing the program activity] Why are you no longer implementing? What are you doing in place of the <activity>?  

For the next topic of discussion, we would like to explore the partnerships between your organization, <recipient organization>, and other partner organizations. Please think about the process of working together to implement <activities related to CQM strategies>.

3. How did the <recipient organization> support your organization in the development or enhancement of <CQM processes> to support the identification, tracking, and monitoring of patients’ clinical and social support services?

Probes:

• How did the <recipient organization> provide support for the development or enhancement of EHRs to support identification of health care disparities?

• What types of support have been most helpful to <partner organization> to develop or strengthen these <CQM activities>?

• How is the <recipient organization> helping you with respect to developing workflows/systems to create/enhance <CQM activities>?

  • Are there other partner organizations that are also helping your organization with this work?

4. Is there anything you would want to change in your collaboration to improve your partnerships with <recipient organization>? What about with other partner organizations?

Probe:

• What are the gaps in your current partnerships?

  • [If there are gaps] How does your organization plan to overcome these gaps?

Next, we’d like to discuss any new or ongoing challenges that <partner organization> is encountering when implementing <activities related to the CQM strategy> and ways that your organization has overcome these challenges or any additional support the organization may need to overcome them.

[Interviewer Note: Reference challenges and barriers mentioned in the Evaluability Assessment key informant interviews by participants, probe for new or ongoing challenges.]

5. During the key informant interviews for the Evaluability Assessment, we heard that <challenges and barriers referenced> were some of the challenges for implementing or supporting the implementation of CQM strategies. Have these challenges persisted?

[Interviewer Note: For the next question, only describe relevant sub-strategies for which the recipient organization has self-nominated.]

Probes:

• Have challenges persisted with:

  • 1A: providing CVD risk assessments?

  • 1B: integrating/aligning EHRs and HIT within provider workflows?

  • 1C: using standardized procedures?

  • 1D: using metrics from program data to guide quality improvement activities?

  • 1E: identifying health care disparities through the use of EHR, HIT, or program data?

• How did your organization resolve these challenges?

6. Have any new challenges emerged?

Probes:

• How is your organization addressing these challenges?

• What support, TA, or resources does your organization need to overcome these challenges?

7. What factors have helped to implement <activities related to tracking and monitoring clinical measures>?

Probe:

• How did these factors provide help with implementing <CQM activities>?

We’re interested in learning about changes since we last spoke related to the external or contextual factors that may support or hinder <CQM activities> such as state or organizational policies or guidelines, other initiatives, or cooperative agreements.

8. During the Evaluability Assessment it was shared that <contextual factors that support or hinder activities related to tracking and monitoring clinical measures>. Have there been any changes in these contextual factors?

Probe:

• Have there been any recent policy level or other external changes within your jurisdiction that impact your <CQM efforts>? What about changes within your organization?

Effectiveness of CQMs

The following questions are going to ask you about effective practices for implementing program strategies. We are interested in learning more about the resources and support provided to partner organizations for implementing <CQM activities>.

[Interviewer Note: Only ask questions related to the sub-strategies for which the recipient organization has self-nominated]

[Interviewer Note: For Questions 9 through 13, be familiar with the previous logic model/measures so that we can probe if there is no mention about outcomes that were going to be tracked or were previously reported, as indicated in the Evaluability Assessment/Performance Measure Monitoring/Evaluation Reports.]

9. [1A] How has the use of CVD risk assessments among the population of focus (i.e., under- and uninsured participants between the ages of 35-64 years) affected the identification of patients at risk or with CVD?

Probes:

• What types of support or resources were most helpful to your organization to ensure CVD risk assessments were being performed at all recommended office visits (i.e., baseline, follow-up, reassessment)?

• What activities were most helpful for providing CVD risk assessments during baseline, follow-up, and reassessment?

• What specific changes have you observed that have resulted from <above activities>?

• How has providing CVD risk assessments to the population of focus contributed to achieving <short-term outcomes identified in Evaluability Assessment and other program materials>? How has it contributed to achieving <intermediate outcomes>?

• How has the use of CVD risk assessments contributed to addressing health disparities?

10. [1B] How has the use of EHR/HIT affected identification, monitoring, and tracking of clinical and social services and support needs?

Probes:

• What types of resources or support were most helpful to your organization to develop or strengthen CQM processes?

• What activities were most helpful for:

  • Identifying patient’s needs?

  • Assessing and tracking patient’s needs?

  • Tracking referrals and utilization of services?

• What specific changes have you observed that have resulted from <above activities>?

• How has the use of <above activities> contributed to achieving <short-term outcomes identified in Evaluability Assessment and other program materials>? How have these activities contributed to achieving <intermediate outcomes>?

• How has the use of <above activities> contributed to addressing health disparities?

11. [1C] How have the use of new processes or tools implemented affected the identification of social services and support needs of patients at highest risk of CVD?

Probes:

• What types of resources or support were most helpful to your organization to develop or strengthen CQM processes?

• What activities were helpful for:

  • Identifying social services and support needs?

  • Monitoring and assessing referrals?

  • Monitoring and assessing utilization of services?

• What specific changes have you observed that have resulted from <above activities>?

• How has the use of <above activities> contributed to achieving <short-term outcomes identified in Evaluability Assessment and other program materials>? How have these activities contributed to achieving <intermediate outcomes>?

• How has the use of <above activities> contributed to addressing health disparities?

12. [1D] How has the use of metrics from program data affected quality improvement activities?

Probes:

• What types of resources or support were most helpful to your organization to develop or strengthen CQM processes?

• What activities were helpful for increasing:

  • Program enrollment?

  • Patient retention?

  • Referrals to additional services?

• What specific changes have you observed that have resulted from <above activities>?

• How has the use of <above activities> contributed to achieving <short-term outcomes identified in Evaluability Assessment and other program materials>? How have these activities contributed to achieving <intermediate outcomes>?

• How has the use of <above activities> contributed to addressing health disparities?

13. [1E] What types of resources or support were most helpful for using EHR, HIT, and program data to identify health care disparities?

Probes:

• What types of resources or support were most helpful to your organization to develop or strengthen CQM processes?

• What activities were helpful for:

  • Identifying health care disparities?

  • Addressing health outcomes?

• What specific changes have you observed that have resulted from <above activities>?

• How has the use of <above activities> contributed to achieving <short-term outcomes identified in Evaluability Assessment and other program materials>? How have these activities contributed to achieving <intermediate outcomes>?

• How has the use of <above activities> contributed to addressing health disparities?

Now we will ask you questions about reach and health outcomes. We’re interested in outcomes related to advancing health equity particularly through identifying and addressing social determinants of health (SDOH) and reducing CVD disparities.

14. We would like to learn more about how your organization is reaching the population of focus. The population of focus, as defined by <recipient organization>, are <population of focus identified>. How effective is your organization in reaching your population of focus?

Probes:

• How are <CQM activities> designed to address the specific needs <population of focus>?

• How does your organization ensure that <CQM activities> are adapted to meet the needs <population of focus>?

• What are examples of how program feedback (e.g., from quality improvement efforts, program data, evaluation data) has been incorporated to improve program implementation?

• How does your organization define reach?

  • What metrics did your organization use to measure reach?

  • What are the findings?

• How has reach amongst the <population of focus> changed?

• What are barriers that your organization encountered in reaching the population of focus?

  • What has helped your organization reach your population?

[Interviewer Note: For Question 15, be familiar with the previous logic model/measures so that we can probe if there is no mention about outcomes that were going to be tracked or were previously reported, as indicated in the Evaluability Assessment/Performance Measure Monitoring/Evaluation Reports.]

15. How do <partner’s CQM activities> contribute to patient level health outcomes?

Probes:

• How do <your CQM activities> support patients with or at risk of CVD?

• What changes in health outcomes has your organization observed or measured?

• What factors support or hinder your organization’s ability to meet patient needs?

16. How have <partner’s CQM activities> contributed to addressing drivers of health inequities?

Probes:

• What health inequity drivers have been addressed (e.g., health system and organizational level practices and policies)?

• How do <partner activities related to CQM strategy implementation> affect social services and support needs of patients within your organizations?

• In what ways has the reduction in SDOH barriers influenced CVD-related outcomes?

[Interviewer Note: For Question 17, be familiar with the previous logic model/measures so that we can probe if there is no mention about outcomes that were going to be tracked or were previously reported, as indicated in the Evaluability Assessment/Performance Measure Monitoring/Evaluation Reports.]

17. Have there been any measurable reductions in health disparities as a result of <partner’s activities related to CQM strategy implementation>?

Probes:

• If yes:

  • What are specific examples of how health disparities were reduced through the implementation of <CQM strategy>?

  • How do <partner activities related to CQM strategy implementation> address gaps in care for your population of focus?

• If no:

  • Are there any barriers that affect your ability to mitigate health disparities? Please describe.

  • Are there any barriers to measuring changes in health disparities?

• What additional resources are needed to address patient’s unmet SDOH needs?

18. What other outcomes, intended or unintended, have come out because of these implemented strategies?

Probe:

• [If partner reports an unintended outcome] Can you elaborate on the unintended outcome and why this may have resulted?

19. Can you tell us about any processes or outcomes that your organization has achieved as a result of these implemented strategies that you are especially proud of?

Sustainability

For the following questions, we are interested in learning more about your plans and preparation for sustaining the activities related to CQM after the completion of the cooperative agreement.

20. [1A] What steps has your organization taken to help sustain providing CVD risk assessments for patients?

Probe:

• Can you share any challenges faced in providing CVD risk assessments and how they were addressed?

21. [1B] What steps has your organization taken to help sustain tracking and monitoring clinical and social services and support needs measures for patients?

Probes:

• Can you share any challenges faced in tracking and measuring clinical and social services and support needs and how they were addressed?

• Does your organization review and update standardized quality improvement processes to ensure they remain effective and relevant? If so, how often are they reviewed?

22. [1C] What steps has your organization taken to help sustain new processes or tools to identify patient social services and support needs and monitor patient’s utilization of these services?

Probe:

• Can you share any challenges faced in using new processes or tools and how they were addressed?

23. [1D] What steps has your organization taken to help sustain use of program metric data to guide quality improvement activities to increase program enrollment, retention, and referrals to services?

Probe:

• Can you share any challenges faced in using program metric data and how they were addressed?

24. [1E] What steps has your organization taken to help sustain use of EHR, HIT, and program data to identify health care disparities and address health outcomes?

Probe:

• Can you share any challenges faced in using EHR, HIT, or program data and how they were addressed?

25. Are any modifications needed to ensure sustainability? If so, what modifications are needed?

Probe:

• What additional support, TA, or resources are needed to improve sustainability?

[Interviewer Note: Only ask the questions that align with the sub-strategy for which the recipient organization self-nominated]

26. [1A] How do you plan to proceed with <partner activities related to CVD risk assessments> after <September 2028 or date that partner is no longer engaged with WISEWOMAN>?

27. [1B/1E] How do you plan to proceed with activities related to <partner activities related to EHR/HIT/program data> after <September 2028 or date that partner is no longer engaged with WISEWOMAN>?

28. [1C] How do you plan to proceed with <activities related to standardized processes or tools> after <September 2028 or date that partner is no longer engaged with WISEWOMAN>?

29. [1D] How do you plan to proceed with <activities related to quality improvement activities> after <September 2028 or date that partner is no longer engaged with WISEWOMAN>?

30. After <September 2028 or date the partner is no longer engaged with NOFO>, are there any aspects of <CQM activities that the partner is implementing> you will not continue? Are there aspects of the program that you would like to continue but do not feel like you could sustain?

31. Aside from funding, is there any resource, tool, or any type of additional support that would be beneficial to continuing <partner activities related to CVD risk assessments, EHR/HIT/program data, standardized processes or tools, quality improvement, and CQM tracking and monitoring> after the cooperative agreement? Please explain the impact of this.

Scalability and Replicability

32. What insights can other organizations gain from your organization’s successes or challenges with <strategy implementation>?

Probes:

• Can you share any lessons learned that could be beneficial for similar programs?

• How can successful activities be replicated elsewhere? How could other organizations implement similar activities?

Close

Lastly, what questions do you have for me? Is there anything else you’d like to share?

Thank you for your time. This concludes our interview about the implementing clinical quality measures strategy for the <Insert cooperative agreement>. If you have any additional questions, please feel free to contact the Comprehensive Evaluation Team, hdsp_nofo_eval@cdc.gov.