Form E AIM Team Leads training workshop

Safety Program for Perinatal Care II – Demonstration Project

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

Public reporting burden for this collection of information is estimated to average 25 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, 5600 Fishers Lane, # 07W41A, Rockville, MD 20857.

HOSPITAL BASELINE SURVEY

Item	Question	Response options	Skip pattern
000	Dear Hospital Partner, The Safety Program in Perinatal Care-II (SPPC-II) Demonstration Project, implemented jointly by the Johns Hopkins University and the Alliance for Innovation on Maternal Health (AIM) with funding from the Agency for Healthcare Research and Quality, aims to demonstrate the value of integrating teamwork and communication training with AIM maternal safety bundles for obstetric hemorrhage and severe hypertension in pregnancy. You are being asked to complete this baseline survey because your hospital’s leadership has agreed to participate in this Demonstration Project and you were identified as the AIM Team Lead for your hospital. This baseline survey is a tool to help identify the skills, processes, and infrastructure currently available at your hospital before the staff receives training on teamwork and communication tools and strategies for use in clinical obstetric practice. We will not identify your name or the name of your hospital in any reports or publications that use the information you provide. Your responses will be kept confidential to the extent permitted by law, including AHRQ’s confidentiality statute, 42 USC 299c-3(c). That law requires that information collected for research conducted or supported by AHRQ that identifies individuals or establishments be used only for the purpose for which it was supplied unless you consent to the use of the information for another purpose.
1	Enter the name of your hospital	______ [Free text]
2	What types of full-time, hospital-employed health care providers do you have on your obstetric unit?
2a	ObGyn Attending Physician	______ [Number of providers]
2b	ObGyn Resident	______ [Number of providers]
2c	ObGyn Hospitalist	______ [Number of providers]
2d	Registered Nurse	______ [Number of providers]
2e	Certified Nurse-Midwife	______ [Number of providers]
2f	Midwife	______ [Number of providers]
2g	Physician Assistant	______ [Number of providers]
2h	Nurse Practitioner	______ [Number of providers]
2i	Other clinical (specify)	______ [Specify; free text] ______ [Number of providers]
3	On average, what is number of full-time, hospital-employed health care providers per shift in your unit?	______ [Number of providers]
4	Did any of your full-time, hospital-employed health care providers receive TeamSTEPPS or similar training in the past year?	Yes 1 No 0 Don’t remember -88	Skip to question 6 Skip to question 6
5	Approximately what proportion of full-time, hospital-employed health care providers received TeamSTEPPS or similar training in the past year? Just like you do for the AIM program, please report estimate in 10% increments rounding up. For example, if you estimate that between 10% and 15% of full-time, hospital-employed health care providers received such training, please report 15%.	______ [Proportion (%)]
6	How many private providers have practice privileges at your hospital?	______ [Number of providers]
6a	ObGyn Attending Physician	______ [Number of providers]
6b	Certified Nurse-Midwife	______ [Number of providers]
6c	Certified Midwife	______ [Number of providers]
6d	Other clinical (specify)	______ [Specify; free text] ______ [Number of providers]
7	Has your hospital provided TeamSTEPPS or similar training to private providers who have privileges at your hospital in the past year?	Yes 1 No 0 Don’t remember -88
8	Are you familiar with any of the following TeamSTEPPS tools and strategies?
8a	Call out	Yes 1 No 0
8b	Check back	Yes 1 No 0
8c	SBAR	Yes 1 No 0
8d	Handoffs or “I PASS the BATON”	Yes 1 No 0
8e	Two-challenge rule	Yes 1 No 0
8f	Power Words (e.g., concerned, uncomfortable, safety issue)	Yes 1 No 0
8g	Briefs	Yes 1 No 0
8h	Huddles	Yes 1 No 0
8i	Debriefs	Yes 1 No 0
8j	DESCR Script	Yes 1 No 0
9	Which of the following TeamSTEPPS tools and strategies are currently employed in your unit?
9a	Call out	Yes 1 No 0
9b	Check back	Yes 1 No 0
9c	SBAR	Yes 1 No 0
9d	Handoffs or “I PASS the BATON”	Yes 1 No 0
9e	Two-challenge rule	Yes 1 No 0
9f	Power Words (e.g., concerned, uncomfortable, safety issue)	Yes 1 No 0
9g	Briefs	Yes 1 No 0
9h	Huddles	Yes 1 No 0
9i	Debriefs	Yes 1 No 0
9j	DESCR Script	Yes 1 No 0
10	Please indicate which of the following AIM bundle(s) or tool(s) is your hospital currently implementing?
10a	Obstetric hemorrhage bundle	Yes 1 No 0	 Skip question 11b
10b	Severe hypertension/preeclampsia bundle	Yes 1 No 0	 Skip question 11b
10c	Maternal Early Warning Signs tool	Yes 1 No 0
10d	Severe Maternal Morbidity review form	Yes 1 No 0
10e	Other (specify)	______ [Specify; free text] Yes 1 No 0	 Skip question 11c
11a	What specific components in the obstetric hemorrhage bundle did your hospital implement to date?	______ [Specify; free text]
11b	What specific components in the severe hypertension/preeclampsia bundle did your hospital implement to date?	______ [Specify; free text]
11c	What specific components in any other AIM bundle did your hospital implement to date?	______ [Specify; free text]
12	At this time, does your unit have a multidisciplinary quality improvement committee that meets regularly?	Yes 1 No 0 Don’t know -88
13	Is there a process for regular debriefs with unit staff after major obstetric complications?	Yes 1 No 0 Don’t know -88
14	Does your unit have standardized processes (for example, order sets, unit policies, practice protocols) for the following?
14a	Obstetric hemorrhage	Yes 1 No 0 Don’t remember -88
14b	Massive transfusion	Yes 1 No 0 Don’t remember -88
14c	Severe hypertension/preeclampsia	Yes 1 No 0 Don’t remember -88
14d	Eclampsia	Yes 1 No 0 Don’t remember -88
14e	Use of Maternal Early Warning Signs	Yes 1 No 0 Don’t remember -88
14f	Review of Severe Maternal Morbidity cases	Yes 1 No 0 Don’t remember -88
14g	Review of Maternal Deaths	Yes 1 No 0 Don’t remember -88
15	To what extent are you confident that staff in your unit use such obstetric emergency order sets, policies and/or protocols in an obstetric emergency?	Not confident 0 Somewhat not confident 1 Neither confident nor not confident 2 Somewhat confident 3 Very confident 4
16a	Does your unit conduct multidisciplinary in situ (on site) clinical scenario simulation drills for obstetric emergencies?	Yes 1 No 0 Don’t remember -88	Skip to question 19 Skip to question 19
16b	How often does your unit conduct such multidisciplinary in situ (on site) clinical scenario simulation drills for obstetric emergencies?	Monthly 0 Quarterly 1 Annually 2 Other (specify) -77 ______ [Specify; free text] Don’t remember -88
16c	How many such multidisciplinary in situ (on site) clinical scenario simulation drills for obstetric emergencies have been organized in the past year?	______ [Number of drills] Don’t remember -88
17	In the past year, which of the following obstetric emergencies do these clinical scenario simulation drills focused on?
17a	Obstetric hemorrhage	Yes 1 No 0
17b	Severe hypertension/preeclampsia	Yes 1 No 0
17c	Eclamptic seizure	Yes 1 No 0
17d	Sepsis	Yes 1 No 0
17e	Emergent cesarean section	Yes 1 No 0
17f	Maternal code	Yes 1 No 0
17g	Other (specify)	______ [Specify; free text]
18	Which of the following health care providers in your unit are required to participate in the obstetric clinical scenario simulation drills?
18a	ObGyn Attending Physician	Yes 1 No 0
18b	ObGyn Resident	Yes 1 No 0
18c	ObGyn Hospitalist	Yes 1 No 0
18d	Registered Nurse	Yes 1 No 0
18e	Certified Nurse-Midwife	Yes 1 No 0
18f	Midwife	Yes 1 No 0
18g	Physician Assistant	Yes 1 No 0
18a	Nurse Practitioner	Yes 1 No 0
18b	Other clinical (specify)	______ [Specify; free text] Yes 1 No 0
19	Does your unit have a “stop the line” policy where clinical staff know that they have the responsibility and authority to stop a procedure when patient safety is a concern?	Yes 1 No 0 Don’t remember -88	 Skip to question 21  Skip to question 21
20	How confident are you that clinical staff at all levels are empowered to "stop the line"?	Not confident 0 Somewhat not confident 1 Neither confident nor not confident 2 Somewhat confident 3 Very confident 4
21	How does your unit obtain data to track unit-based outcomes?	Char review 0 Computer-generated reports 1 Both chart review and computer-generated reports 2 Other (specify) -77 ______ [Specify; free text]
22	Does your unit have difficulties reporting the required data for the AIM program in your state?	Yes 1 No 0 Don’t know -88
23	Who is responsible for this reporting?	______ [Specify position title, without names]
24	Please give your unit an overall grade on patient safety at this time.	A—Excellent 4 B—Very good 3 C—Acceptable 2 D—Poor 1 E—Failing 0
25	Considering your work to implement the AIM bundle(s) using teamwork and communication strategies over the past year, please give your unit an overall grade on implementation of the AIM bundle(s).	A—Excellent 4 B—Very good 3 C—Acceptable 2 D—Poor 1 E—Failing 0

Thank you for completing this survey.

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