Form G e) Clinical staff self-administered baseline surveys

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.

HEALTH WORKER BASELINE SURVEY

Item	Question	Response options	Skip pattern
000	Dear Provider, 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 will receive training on teamwork and communication tools and strategies through this project. This baseline survey is a tool to help assess the skills you already have. We will not identify your name or the name of your hospital in any reports or publications that uses 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.
000a	Staff ID Provided by AIM Team Lead	______ [Staff ID]
1	What is your staff position in this hospital? [Please select ONE answer that best describes your position.]	ObGyn Attending Physician 0 ObGyn Resident 1 ObGyn Hospitalist 2 Registered Nurse 3 Certified Nurse-Midwife 4 Midwife 5 Physician Assistant 6 Nurse Practitioner 7 Other (specify) -77 ______ [Specify; free text]
2	In total, how many years of experience in obstetric practice do you have? [Please estimate if you do not know the exact number of years.]	______ [Number of years]
3	How many years and months have you worked in this hospital? [For example, if 1 year and 6 months, please enter “1” for Number of years and “6” for Number of months].	______ [Number of years] ______ [Number of months]
4	Typically, how many hours per work do you work in this hospital? [Please estimate based on hours worked last week.]	______ [Number of hours]
5	Did you receive training on teamwork and communication aspects in clinical practice, for example, TeamSTEPPS training(s)?	Yes 1 No 0 Don’t remember -88
6	Would you like to receive (more) such training in the future ?	Yes 1 No 0 Don’t know -88
7	Are you familiar with any of the following teamwork and communication tools and strategies?
7a	Call out	Yes 1 No 0	Skip question 8a
7b	Check back	Yes 1 No 0	Skip question 8b
7c	SBAR	Yes 1 No 0	Skip question 8c
7d	Handoffs or “I PASS the BATON”	Yes 1 No 0	Skip question 8d
7e	Two-challenge rule	Yes 1 No 0	Skip question 8e
7f	Power Words (e.g., concerned, uncomfortable, safety issue)	Yes 1 No 0	Skip question 8f
7g	Briefs	Yes 1 No 0	Skip question 8g
7h	Huddles	Yes 1 No 0	Skip question 8h
7i	Debriefs	Yes 1 No 0	Skip question 8i
7j	DESCR Script	Yes 1 No 0	Skip question 8j
8	Which of the following teamwork and communication tools and strategies are you currently using in your practice?
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	How frequently are you using any of these tools and strategies in your practice?	Never 0 Rarely 1 Inconsistently 2 Consistently 3
10	How frequently are other clinicians in your unit using any of these tools and strategies in clinical practice?	Never 0 Rarely 1 Inconsistently 2 Consistently 3
11	How frequently are you using any of these tools and strategies when your patients’ family members are present?	Never 0 Rarely 1 Inconsistently 2 Consistently 3
12	How frequently are other clinicians in your unit using any of these tools and strategies when your patients’ family members are present?	Never 0 Rarely 1 Inconsistently 2 Consistently 3
13	Does your unit have a “stop the line” policy where unit 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 15 Skip to question 15
14	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
SPPCI-II Training Assessment – RESULTS [Mayo High Performance Teamwork Scale] Please think about your unit’s work over the past year. Please rate your unit’s work as a team by checking the box that corresponds to your level of agreement with the statements below. Please answer every question and select only one response for each question. Please rate conservatively as most teams do not consistently demonstrate the qualities described in the scale.
15	Our unit has a clinical team leader clearly recognized by all team members.	Never 0 Rarely 1 Inconsistently 2 Consistently 3
16	The clinical team leader assures maintenance of an appropriate balance between command authority and team member participation.	Never 0 Rarely 1 Inconsistently 2 Consistently 3
17	Each team member demonstrates a clear understanding of his or her role.	Never 0 Rarely 1 Inconsistently 2 Consistently 3
18	Our team prompts each other to attend to all significant clinical indicators throughout procedures or interventions.	Never 0 Rarely 1 Inconsistently 2 Consistently 3
19	When team members are actively involved with the patient, they verbalize their activities aloud.	Never 0 Rarely 1 Inconsistently 2 Consistently 3
20	Team members repeat back or paraphrase instructions and clarifications to indicate that they heard them correctly.	Never 0 Rarely 1 Inconsistently 2 Consistently 3
21	Team members refer to established protocols and checklists for specific procedure/intervention.	Never 0 Rarely 1 Inconsistently 2 Consistently 3
22	All members of the team are appropriately involved and participate in patient care.	Never 0 Rarely 1 Inconsistently 2 Consistently 3
23	Disagreements or conflicts among team members are addressed without a loss of situation awareness.	Never 0 Rarely 1 Inconsistently 2 Consistently 3
24	When appropriate, roles are shifted to address urgent or emergent events.	Never 0 Rarely 1 Inconsistently 2 Consistently 3
25	When directions are unclear, team members acknowledge their lack of understanding and ask for repetition and clarification.	Never 0 Rarely 1 Inconsistently 2 Consistently 3
26	Team members acknowledge—in a positive manner—statements directed at avoiding or containing errors or seeking clarification.	Never 0 Rarely 1 Inconsistently 2 Consistently 3
27	Team members call attention to actions that they feel could cause errors or complications.	Never 0 Rarely 1 Inconsistently 2 Consistently 3
28	Team members respond to potential errors or complications with procedures that avoid the error or complication.	Never 0 Rarely 1 Inconsistently 2 Consistently 3
29	When statements directed at avoiding or containing errors or complications do not elicit a response to avoid or contain the error, team members persist in seeking a response.	Never 0 Rarely 1 Inconsistently 2 Consistently 3
30	Team members ask each other for assistance prior to or during periods of task overload.	Never 0 Rarely 1 Inconsistently 2 Consistently 3
31	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
AIM Bundle Implementation – Knowledge [Adapted from CUSP Team Check-up Tool] Please check the box that corresponds to your level of agreement with the statements below. Please answer every question and select only one response for each question.
32	All clinical staff in our unit know what AIM bundle(s) is(are) being implemented in our unit.	Strongly agree 4 Agree 3 Neither agree nor disagree 2 Disagree 1 Strongly disagree 0
33	Any five randomly selected clinical staff in our unit could list at least two components of the AIM bundle(s) being implemented in this hospital.	Strongly agree 4 Agree 3 Neither agree nor disagree 2 Disagree 1 Strongly disagree 0
AIM Bundle implementation – Attitudes/Beliefs/Behaviors [Adapted from CUSP Team Check-up Tool]
34	We have good ownership for AIM bundle implementation from physician staff in this unit.	Strongly agree 4 Agree 3 Neither agree nor disagree 2 Disagree 1 Strongly disagree 0
35	We have good ownership for AIM bundle implementation from nursing staff in this unit.	Strongly agree 4 Agree 3 Neither agree nor disagree 2 Disagree 1 Strongly disagree 0
36	At this time, unit staff are confused about how to proceed with the implementation of the AIM bundle(s).	Strongly agree 4 Agree 3 Neither agree nor disagree 2 Disagree 1 Strongly disagree 0
37	At this time, there are protocols in our unit to ensure that we adequately implement the AIM bundle(s).	Strongly agree 4 Agree 3 Neither agree nor disagree 2 Disagree 1 Strongly disagree 0
38	Our quality improvement team meets regularly to review progress with AIM bundle(s) implementation.	Strongly agree 4 Agree 3 Neither agree nor disagree 2 Disagree 1 Strongly disagree 0
39	Unit staff do not believe that perinatal safety is an issue for this unit.	Strongly agree 4 Agree 3 Neither agree nor disagree 2 Disagree 1 Strongly disagree 0
40	A junior staff member feels comfortable questioning a more senior staff member who is not using a unit-developed safety tool or following a unit-developed safety process or procedure for the implementation of the AIM bundle(s).	Strongly agree 4 Agree 3 Neither agree nor disagree 2 Disagree 1 Strongly disagree 0
AIM Bundle Implementation – Resources
41	Unit leadership (managers, physicians, opinion leaders) is stable (i.e., there is low turnover).	Strongly agree 4 Agree 3 Neither agree nor disagree 2 Disagree 1 Strongly disagree 0
42	To my knowledge, data collection and reporting for the AIM program have not been a burden for staff in our unit.	Strongly agree 4 Agree 3 Neither agree nor disagree 2 Disagree 1 Strongly disagree 0
AIM Bundle Implementation – Results
43	Considering your work to implement the AIM bundle(s) using teamwork and communication strategies over the last 12 months, 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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