Form E AIM Team Leads training workshop

Safety Program in Perinatal Care (SPPC)-II Demonstration Project

Attachment E - AIM TEAM LEAD self-administered baseline survey

AIM Team Lead self-administered baseline surveys

OMB: 0935-0246

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Safety Program for Perinatal Care II – Demonstration Project



Shape1

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


















Shape2

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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