Web-Based Data Collection Tool Question Pool

Attachment B3: Cross-Cutting Questions for Web-Based Data Collection Tool OMB No. 0906-XXXX
Exp. Date XX/XX/20XX

Web-Based Data Collection Tool Question Pool

Note to Reviewers: Prior to administration, the tool will be tailored to each grantee based on the strategies and activities they are implementing, so grantees will only see and answer questions that apply to their grant program. We estimate 30 minutes will be needed to complete the entire web-based data collection tool.

Attachment B3. Web-Based Data Collection Tool - Cross-Cutting Questions

Public Burden Statement: This is a new Information Collection Request (ICR) requesting approval to collect data for a portfolio-wide evaluation of Maternal Health (MH) programs funded by the Health Resources and Services Administration. 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. The OMB control number for this information collection is 0906-XXXX and it is valid until XX/XX/202X. This information collection is voluntary. Public reporting burden for this collection of information is estimated to average 1 hour per response, including the time for reviewing instructions, searching existing data sources, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to HRSA Reports Clearance Officer, 5600 Fishers Lane, Room 14N136B, Rockville, Maryland, 20857 or [email protected].

[THIS IS THE WELCOME MESSAGE THAT ALL GRANTEES WILL BE SHOWN BEFORE THEY BEGIN ANSWERING QUESTIONS.]

Welcome to the Maternal Health Portfolio Evaluation web-based data collection tool!

This is the annual data collection survey for the Health Resources and Services Administration’s (HRSA) Maternal Health Portfolio project. Please answer every question in this form. If the answer is zero, please insert “0” in the text box. We estimate that it will take 30 minutes or less for you to complete this form.

You may contact [email address of contracted evaluator] with any questions or technical difficulties. For questions regarding your grant program, please contact your HRSA project officer.

The reporting period for this survey is: [completed by evaluator each year]. This will appear on each screen of the survey.

Section A: Establishing and Strengthening
Partnerships and State Capacity

The following questions ask about the [taskforce/workgroup/network/partnership] that is part of your [State MHI/AIM/AIM-CCI/Supporting MHI] grant program.

A.1. How many [taskforce/workgroup/network/partner] meetings were held during the reporting period? [numeric response only]

A.2. How many of each of the following products or solutions were developed as a result of the [taskforce/workgroup/network/partnership] during the reporting period (e.g., strategic plan, policy change)? If none, enter “0”. [numeric response only]

	Policy Change (i.e., any formal policy at any level, including the state, local, organizational, or team level.)
	New Billing Codes
	Other, please specify: ____

A.2a. [ASKED ONLY IF POLICY CHANGE WAS >0 FOR A.2] Please describe each policy change that occurred as a result of the [taskforce/workgroup/network/ partnership] (e.g., legislation for state recommendations on maternity care evaluations for maternal hypertension) during the reporting period. [open text box]

A.2b. [ASKED ONLY IF BILLING CODES WAS >0 FOR A.2] Please describe each new billing code developed as a result of the [taskforce/workgroup/network/ partnership] (e.g., new codes to reimburse for community health workers) during the reporting period. You do not need to provide the actual code, just describe what it covers. [open text box]

A.2c. [ASKED ONLY IF OTHER, PLEASE SPECIFY WAS >0 FOR A.2] Please describe each other product or solution developed as a result of the [taskforce/workgroup/network/ partnership] (e.g., new codes to reimburse for community health workers) during the reporting period. [open text box]

A.3. Was additional funding secured through the [taskforce/workgroup/network/partnership] to address maternal morbidity and severe maternal mortality during the reporting period? Y/N

A.3a. [IF A.3 = YES] How much additional funding was secured through the [taskforce/workgroup/network/partnership]? [numeric response only]

A.3b. [If A.3 = YES] What is the source of funding? [open text box]

Section B: Workforce Training and Expanding the
Maternal Health Workforce

The following questions ask about workforce training efforts.

[THIS SECTION WILL BE PREPOPULATED BY THE EVALUATORS WITH TRAININGS THAT HAVE ALREADY BEEN REPORTED, IF RELEVANT. RESPONDENTS CAN ADD ADDITIONAL TRAININGS IF OTHER TRAININGS HAVE BEEN INITIATED DURING THE REPORTING PERIOD.]

B.1. Please review the list of trainings and add any additional workforce trainings, including implicit bias training, that you administered or supported as part of the HRSA program during the reporting period. Please insert a row for each training.

Grantees will answer the following questions for each training entered in B.1. The end of the section is noted in red.

B.2. Did you create your own training for this project? Y/N

B.2a. [IF B.2 = YES] Please provide an explanation about why and how you created the training (optional). [open text box]

B.3. Is this training evidence-based? Y/N

B.3a. [IF B.3 = YES] Did you adapt this training for your population in any way? Y/N

B.3b. [IF B.3 = YES] How did you adapt the training? [open text box]

B.4. Please report the number of unique providers, professionals, and organizations, by type, who were trained during the reporting period. If none, enter “0”. [numeric response only]

Providers (Number of Providers by type of provider)

	Primary Care Physician
	Family Practice Physician
	Obstetrician
	Anesthesiologist
	Physician Assistant
	Nurse Practitioner
	Registered Nurse
	Certified Nurse Midwife
	Midwife (other than CNM)
	Psychiatric Nurse Specialist
	Pharmacist
	Clinical Psychologist
	Peer Provider (e.g., Community Health Worker)
	Doula
	Nursing and Medical Assistant
	Licensed Clinical Social Worker
	Substance Use Disorder Counselor
	Other Licensed Professional Counselor
	Behavioral Health Professional (not licensed)
	Other (please specify)

Professionals (Number of professionals by setting)

	National association
	Local Health Department
	State Title V MCH Program
	State Health Department (other than State Title V MCH Program)
	State Medicaid Program
	Private payers
	Maternal Mortality Review Committee liaison
	Perinatal Quality Collaborative liaison
	State policymakers
	State association of community health centers
	Tribal organizations
	Other (please specify)

Organizations (Number and type of organizations)

Organization name (please specify)

B.5. Did you measure any changes in trainees’ knowledge, beliefs, skills or behaviors? Y/N

B.5a. [IF B.5 = YES] Which of the following did you assess? Select all that apply.

• Change in knowledge

• Change in beliefs

• Change in skills

• Change in behaviors

• Other

B.5b. [FOR EACH TOPIC NOTED IN B.5a.] What types of assessments were made?

• Pre/post assessments

• Post-only assessments

• Other, please specify_________________

B.5c. [FOR EACH TOPIC ASSESSED] Please share the results from those assessments below. [open text box]

*End of Section*

Section C: Providing Technical Assistance

The following questions ask about efforts to support grantees’ or sub-awardees’ implementation of HRSA programs through technical assistance.

[Question C.1. is a Maternal and Child Health Bureau (MCHB) Performance Measure. This question will only be asked to State MHI and AIM-CCI grantees because they do not already report on this measure through other annual reporting mechanisms. The performance measures in this section are presented in a format consistent with that of OMB No. 0915-0298.]

C.1. (Tier 1) Are you providing technical assistance (TA)* though your program? Y/N

(Tier 2) To whom are you providing TA* (check all that apply)?

 Participants/ Public

 Providers/ Health Care Professionals

 Local/ Community Partners

 State/ National Partners

*Technical Assistant (TA) refers to collaborative problem solving on a range of issues, which may include program development, program evaluation, needs assessment, and policy or guideline formulation. It may include administrative services, site visitation, and review or advisory functions. TA may be a one-time or ongoing activity of brief or extended frequency.

(Tier 3) Implementation (populated from prior domain questions)

# CSHCN/Developmental Disabilities TA

# Autism TA

# Prenatal Care TA

# Perinatal/ Postpartum Care TA

# Maternal and Women’s Depression Screening TA

# Safe Sleep TA

# Breastfeeding TA

# Newborn Screening TA

# Genetics TA

# Quality of Well Child Visit TA

# Well Visit TA

# Injury Prevention TA

# Family Engagement TA

# Medical Home TA

# Transition TA

# Adolescent Major Depressive Disorder Screening TA

# Health Equity TA

# Adequate health insurance coverage TA

# Tobacco and eCigarette Use TA

# Oral Health TA

# Nutrition TA

# Data Research and Evaluation TA

# Other TA

(Please specify additional topics: )

(Tier 4) What are the related outcomes in the reporting year? (populated from prior questions)

# receiving TA

# TA activities

# TA activities by target audience (Local, Title V, Other state agencies,/ partners, Regional, National, International)

C.2. During this reporting period, how many of your technical assistance activities supported efforts to address health equity? If none, enter “0”. [numeric response only]

C.3. During this reporting period, how many of your technical assistance activities supported telehealth activities? If none, enter “0”. [numeric response only]

C.4. During this reporting period, how many of your technical assistance activities supported maternal safety bundle implementation? If none, enter “0”. [numeric response only]

Section D: Health Equity

The following questions ask about health equity when addressing maternal mortality and severe maternal morbidity.

D.1. Did you use Culturally and Linguistically Appropriate Services (CLAS) measures to assess whether your program activities and materials were culturally competent? Y/N

D.1a. [If D.1 = YES] Did your assessment determine that your program activities and materials were culturally competent?

• Yes

• No

• Somewhat, please explain [open text box]

D.2. Did you conduct any assessment on patient satisfaction with quality of care among patients receiving care during the reporting period? Y/N

D.2a. [If D.2 = YES] Did this assessment investigate differences in patient satisfaction with quality of care among different sub-populations (For example, can data be divided out by race/ethnicity or geography)? Y/N

D.2b. [If D.2a = YES] Please share the results from those assessments below. [open text box]

Section E: Creating and Disseminating Products

[Question E.1. is a Maternal and Child Health Bureau (MCHB) Performance Measure. This question will only be asked to State MHI, AIM-CCI, and Supporting MHI grantees because they do not already report on this measure through other annual reporting mechanisms. The performance measures in this section are presented in a format consistent with that of OMB No. 0915-0298.]

E.1. (Tier 1) Are you creating products as part of your MCHB-supported program? Y/N

(Tier 2) Indicate the categories of products that have been produced with grant support (either fully or partially) during the reporting period. Count the original completed product, not each time it is disseminated or presented.

 Books

 Book chapters

 Reports and monographs (including policy briefs, best practice reports, white papers)

 Conference presentations and posters presented

 Web-based products (website, blogs, webinars, newsletters, distance learning modules, wikis, RSS feeds, social networking sites) Excluding video/ audio products that are posted online post-production

 Audio/ Video products (podcasts, produced videos, video clips, CD-ROMs, CDs, or audio)

 Press communications (TV/ Radio interviews, newspaper interviews, public service announcements, and editorial articles)

 Newsletters (electronic or print)

 Pamphlets, brochures, or fact sheets

 Academic course development

 Distance learning modules

 Doctoral dissertations/ Master’s theses

 Other: ________________

(Tier 3) Implementation of products

# products created in each category

Section F: Maternal Health Outcomes

The following questions ask about maternal mortality and severe maternal morbidity outcomes in your program population. When possible, outcomes should be broken down by race, ethnicity, and geography.

F.1. Please report the number for each outcome: [numeric response only]

Clinical Outcomes	Response
Number of pregnancy-related deaths among program population
Number of live births among program population
Number of events for each severe maternal morbidity indicator in the program population [dropdown menu of SMM indicators: Acute myocardial infarction, Aneurysm, Acute renal failure, Adult respiratory distress syndrome, Amniotic fluid embolism, Cardiac arrest/ventricular fibrillation, Conversion of cardiac rhythm, Disseminated intravascular coagulation, Eclampsia, Heart failure/arrest during surgery or procedure, Puerperal cerebrovascular disorders, Pulmonary edema / Acute heart failure, Severe anesthesia complications, Sepsis, Shock, Sickle cell disease with crisis, Air and thrombotic embolism, Blood products transfusion, Hysterectomy, Temporary tracheostomy, Ventilation]
Number of delivery hospitalizations among program population

F.1a. [If F.1 = any data] Please describe the data used to report these outcomes, including the data source(s), the time period represented by the data, and who was included in the program population. [open-text box]

F.2. Please report the number for each outcome broken down by race, if available: [numeric response only]

Clinical Outcomes	White	Black/African American	American Indian/Alaska Native	Asian	Native Hawaiian or Other Pacific Islander	Two or More Races	Other (please specify)
Number of pregnancy-related deaths among program population
Number of live births among program population
Number of events for each severe maternal morbidity indicator in the program population [dropdown menu of SMM indicators: Acute myocardial infarction, Aneurysm, Acute renal failure, Adult respiratory distress syndrome, Amniotic fluid embolism, Cardiac arrest/ventricular fibrillation, Conversion of cardiac rhythm, Disseminated intravascular coagulation, Eclampsia, Heart failure/arrest during surgery or procedure, Puerperal cerebrovascular disorders, Pulmonary edema / Acute heart failure, Severe anesthesia complications, Sepsis, Shock, Sickle cell disease with crisis, Air and thrombotic embolism, Blood products transfusion, Hysterectomy, Temporary tracheostomy, Ventilation]
Number of delivery hospitalizations among program population

F.2a. [If F.2 = any data] Please describe the data used to report these outcomes, including the data source(s), the time period represented by the data, who was included in the program population, and how race was defined and assessed. [open-text box]

F.3. Please report the number for each outcome broken down by ethnicity, if available: [numeric response only]

Clinical Outcomes	Hispanic or Latina	Not Hispanic or Latina
Number of pregnancy-related deaths among program population
Number of live births among program population
Number of events for each severe maternal morbidity indicator in the program population [dropdown menu of SMM indicators: Acute myocardial infarction, Aneurysm, Acute renal failure, Adult respiratory distress syndrome, Amniotic fluid embolism, Cardiac arrest/ventricular fibrillation, Conversion of cardiac rhythm, Disseminated intravascular coagulation, Eclampsia, Heart failure/arrest during surgery or procedure, Puerperal cerebrovascular disorders, Pulmonary edema / Acute heart failure, Severe anesthesia complications, Sepsis, Shock, Sickle cell disease with crisis, Air and thrombotic embolism, Blood products transfusion, Hysterectomy, Temporary tracheostomy, Ventilation]
Number of delivery hospitalizations among program population

F.3a. [If F.3 = any data] Please describe the data used to report these outcomes, including the data source(s), the time period represented by the data, who was included in the program population, and how ethnicity was defined and assessed. [open-text box]

F.4. Please report the number for each outcome broken down by geography, if available. [numeric response only]

Clinical Outcomes	Urban	Suburban	Rural
Number of pregnancy-related deaths among program population
Number of live births among program population
Number of events for each severe maternal morbidity indicator in the program population [dropdown menu of SMM indicators: Acute myocardial infarction, Aneurysm, Acute renal failure, Adult respiratory distress syndrome, Amniotic fluid embolism, Cardiac arrest/ventricular fibrillation, Conversion of cardiac rhythm, Disseminated intravascular coagulation, Eclampsia, Heart failure/arrest during surgery or procedure, Puerperal cerebrovascular disorders, Pulmonary edema / Acute heart failure, Severe anesthesia complications, Sepsis, Shock, Sickle cell disease with crisis, Air and thrombotic embolism, Blood products transfusion, Hysterectomy, Temporary tracheostomy, Ventilation]
Number of delivery hospitalizations among program population

F.4a. [If F.4 = any data] Please describe the data used to report these outcomes, including the data source(s), the time period represented by the data, who was included in the program population, and how geography was defined and assessed. [open-text box]

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