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Data Collection Instruments

The following is a list of data collection instruments used in the initial evaluation. The documents are all free, downloadable PDF files. To view them, you must have Adobe Acrobat Reader 4.0 or above installed on your computer.

Health Care Organization Surveys

• Survey for Senior Leadership
• Survey for Quality Management Director(s)
• Survey for Breakthrough Series (BTS) Team Members, Wave 1
• Survey for Breakthrough Series (BTS) Team Members, Wave 2
• Survey for Key Players
• Organization Characteristics Survey for ICICE Contact

Patient Telephone Surveys

• Baseline Interview for Diabetes Patients
• Baseline Interview for Congestive Heart Failure Patients
• Baseline Interview for Depression Patients
  
• Asthma Surveys:
  • Baseline Interview: Adult Asthma Patients (Age 18+)
  • Baseline Interview for Adolescent Asthma Patients Ages 12-17
  • Baseline Interview: Parent of Adolescent with Asthma (12-17)
  • Baseline Interview: Parent of Child with Asthma (Age 2-11)
• Follow-Up Interview for Diabetes Patients
  
• Follow-Up Interview for Congestive Heart Failure Patients

Patient Chart Review Tools with Guidelines