Form #3 Form #3 Workflow Toolkit Activities and Perspectives Observation

A

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

ttachment C: Workflow Toolkit Activities and Perspectives Observation Log

Clinic Name: ________________________ Practice Facilitator: _______________________

Practice staff names: _________________________________________________________

Visit Date: __________________________ Time period covered: ______________________

This form will help the study team keep a record of clinic activities related to the Workflow toolkit during regularly scheduled PERC/Practice Facilitator visits, and should be completed at each visit. If you have questions about using this form, contact LeAnn Michaels at (503) 494-1583.

Current workflow and toolkit evaluation goals

C

Public reporting burden for this collection of information is estimated to average 120 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.

urrent activities and topics

No.	Activity	Outcome	Facilitation intensity (circle one)
1	Example: Observed as clinic tried to use toolkit to learn about workflow during EPIC installation, especially tracking lab values.	Example: Clinic Study Team could not find what they wanted and asked the PERC for assistance in finding the information they were seeking.	H igh Medium Low
2			High Medium Low
3			High Medium Low
4			High Medium Low

Current activities and topics (continued)

No.	Activity	Outcome	Facilitation intensity (circle one)
5			High Medium Low
6			High Medium Low

Add additional rows as needed to include all observed workflow assessment activities

Reflections

Reflection Type	Clinic Reflection	Next Steps
Facilitators of workflow success
Barriers of workflow success
Overall implementation

Other notes: