1 Baseline Survey

Attachment A: TeamSTEPPS Baseline Survey (DRAFT)

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

TeamSTEPPS^® Baseline Survey

Introduction

Welcome to the [PROGRAMMER INSERT: TeamSTEPPS 3.0 Trainer Program OR TeamSTEPPS for Diagnosis Improvement Course]. This survey will assess your attitude toward team structure and the four essential skills taught in TeamSTEPPS. Note that this is not an evaluation of you or your organization. Your answers will be used only as baseline data to assess the training and the implementation of TeamSTEPPS in areas of greatest need at your organization.

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is [####-####]. This information collection is to examine the degree to which the updated TeamSTEPPS program improves the team effectiveness and streamlines team communication. The time required to complete this information collection is estimated to average less than 20 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, to review and complete the information collection. This information collection is voluntary, will remain confidential, and all data will be reported only in aggregate. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: [mailing address] or [email address], Attention: Information Collections Clearance Officer.

Should you have any questions or comments about this survey or the TeamSTEPPS evaluation effort, please contact [NAME], [TITLE], at [EMAIL]. Additional information about the TeamSTEPPS program can be found at https://www.ahrq.gov/teamstepps-program/index.html.

The public reporting burden for this collection of information is estimated to average 20 minutes per response, the estimated time required to complete the survey. 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 (NUMBER and EXPIRATION DATE to BE PROVIDED)

AHRQ

540 Gaither Road, Room # 5036

Rockville, MD 20850

TeamSTEPPS Teamwork Attitudes Questionnaire

Respond to the questions below by marking the box that corresponds to your level of agreement from Strongly Agree to Strongly Disagree. Select only one response for each question.

Team Structure	Strongly Agree	Agree	Neutral	Disagree	Strongly Disagree
1. It is important to ask patients and their families for feedback regarding patient care.
2. Patients are a critical component of the care team.
3. This facility's administration influences the success of direct care teams.
4. A team's mission is of greater value than the goals of individual team members.
5. Effective team members can anticipate the needs of other team members.
6. High-performing teams in healthcare share common characteristics with high performing teams in other industries.
Leadership	Strongly Agree	Agree	Neutral	Disagree	Strongly Disagree
7. It is important for leaders to share information with team members.
8. Leaders should create informal opportunities for team members to share information.
9. Effective leaders view honest mistakes as meaningful learning opportunities.
10. It is a leader's responsibility to model appropriate team behavior.
11. It is important for leaders to take time to discuss with their team members plans for each patient.
12. Team leaders should ensure that team members help each other out when necessary.

Situation Monitoring	Strongly Agree	Agree	Neutral	Disagree	Strongly Disagree
13. Individuals can be taught how to scan the environment for important situational cues.
14. Monitoring patients provides an important contribution to effective team performance.
15. Even individuals who are not part of the direct care team should be encouraged to scan for and report changes in patient status.
16. It is important to monitor the emotional and physical status of other team members.
17. It is appropriate for one team member to offer assistance to another who may be too tired or stressed to perform a task.
18. Team members who monitor their emotional and physical status on the job are more effective.
Mutual Support	Strongly Agree	Agree	Neutral	Disagree	Strongly Disagree
19. To be effective, team members should understand the work of their fellow team members.
20. Asking for assistance from a team member is a sign that an individual does not know how to do his/her job effectively.
21. Providing assistance to team members is a sign that an individual does not have enough work to do.
22. Offering to help a fellow team member with his/her individual work tasks is an effective tool for improving team performance.
23. It is appropriate to continue to assert a patient safety concern until you are certain that it has been heard.
24. Personal conflicts between team members do not affect patient safety.

Communication	Strongly Agree	Agree	Neutral	Disagree	Strongly Disagree
25. Teams that do not communicate effectively significantly increase their risk of committing errors.
26. Poor communication is the most common cause of reported errors.
27. Adverse events may be reduced by maintaining an information exchange with patients and their families.
28. I prefer to work with team members who ask questions about information I provide.
29. It is important to have a standardized method for sharing information when handing off patients.
30. It is nearly impossible to train individuals how to be better communicators.

Participant Profile

In this section, you are being asked to provide information about yourself, your organization, and your participation in the [PROGRAMMER INSERT: TeamSTEPPS 3.0 Trainer Program OR TeamSTEPPS for Diagnosis Improvement Course]. Your personal information will not be shared with any entity. All information will be reported in aggregate.

1. Date

__MM/DD/YY__ (This could possibly be automatically generated by the system.)

2. Your first and last name

3. Your email address

4. What is the name of your employer facility or organization?

___________________________________________________________________________

5. If your facility is part of a larger health care system, what is the name of that larger system?

___________________________________________________________________________

6. Which of the following best characterizes the organization in which you currently work? [Select one]

1. Academic health profession program

2. Public hospital

3. Federal government health provider

4. Community hospital

5. Children’s hospital

6. Critical access hospital

7. Outpatient clinic

8. Quality improvement organization

9. State health department

10. Hospital association

11. Patient safety center or commission

12. Risk, liability, malpractice, or other insurer

13. Long-term care facility, assisted living facility, or home health agency

14. Regional or state-based health care professional association or institution

15. Consulting practice or individual consultant

16. Other: [Fill in the blank]

7. In which state is your organization located?

[STATES will be provided in a drop-down menu]

8. How long have you served in your current role (at your current organization)?

1. 0–1 year

2. 2–5 years

3. 6–10 years

4. 11 or more years

9. What is your current role in patient care?

   1. I deliver direct patient care to inpatients.

   2. I deliver direct patient care to outpatients.

   3. I deliver direct patient care to both inpatients and outpatients.

   4. I do not deliver direct patient care.

10. What is your professional discipline? (Choose one)

    1. Physician

    2. Physician assistant

    3. Dentist

    4. Pharmacist

    5. Nurse practitioner

    6. Nurse

    7. Case manager

    8. Psychologist

    9. Human resources specialist

    10. Dietician

    11. Medical assistant

    12. Health education specialist

    13. Administrative support (in unit or organization)

    14. Quality improvement specialist

    15. Risk management specialist

    16. Other (Please specify) _______________________

11. What is your clinical specialty? (Choose one)

    1. Allergy and immunology

    2. Anesthesiology

    3. Cardiology

    4. Critical care

    5. Dermatology

    6. Endocrinology

    7. Family medicine

    8. Gastroenterology

    9. Genetic disorders

    10. Geriatric medicine

    11. Hematology

    12. Infectious disease

    13. Internal medicine

    14. Medical-surgical nursing

    15. Neonatal-perinatal

    16. Nephrology

    17. Neurology

    18. Obstetrics-gynecology

    19. Oncology

    20. Ophthalmology

    21. Orthopedics

    22. Otolaryngology

    23. Pain management

    24. Pathology

    25. Pediatrics

    26. Psychiatry

    27. Pulmonology

    28. Radiology

    29. Rheumatology

    30. Surgery

    31. Urology

    32. Women’s health

    33. None/not applicable

    34. Other (Please specify)___________________________

12. What is your prior team training experience?

    1. I have previously attended or completed a health care team training program other than TeamSTEPPS.

    2. I have previously attended or completed TeamSTEPPS training.

    3. I have NOT attended or completed TeamSTEPPS or any other health care team training program. [Skip to Q15]

13. After your prior team training experience, did you apply what you learned to your work?

    1. I applied what I learned in the training to my work.

    2. I have NOT yet applied what I learned in the training to my work.

14. What team training is your organization currently implementing?

    1. My organization is currently implementing TeamSTEPPS.

    2. My organization is currently implementing a team training intervention other than TeamSTEPPS.

    3. Don’t know/not applicable.

15. What is your age?

    1. 18–25

    2. 26–35

    3. 36–45

    4. 46–55

    5. 56–65

    6. 66 or older

16. Do you consider yourself to be of Latino or Hispanic origin?

1. Yes

2. No

17. What is your race? (Mark all that apply.) /* MULTIPLE RESPONSES PERMITTED */

1. American Indian or Alaska Native

2. Black or African American

3. Asian

4. Native Hawaiian or other Pacific Islander

5. White

/* QRACE_CODE */ Race

1. IF S3 = 1, Code Hispanic

2. IF S3 = 2 & S4 = 5, Code Non-Hispanic White

3. IF S3 = 2 & S4 = 2, Code Non-Hispanic Black

4. IF S3 = 2 & S4 = 3, Code Non-Hispanic Asian

5. IF S3 = 2 & S4 = ELSE, Code Other

18. What is your gender identity? (Mark all that apply.) /* MULTIPLE RESPONSES PERMITTED */

1. Man

2. Nonbinary

3. Woman

4. Prefer not to disclose

5. Other not listed: _____

Thank you! We look forward to seeing you at the training!