AK Birth Transfer Initiative: Receiving Provider Survey

You are invited to participate in this brief survey because you were identified as the receiving provider during a recent transfer from a planned community (home or birth center) birth. As part of the evaluation of the Alaska Birth Transfer Initiative, all transferring providers, receiving providers, registered nurses, clients, and emergency medical personnel (for emergent transports) who were involved in a transfer/transport in participating regions will be asked to complete an evaluation survey that asks about experiences with the transfer process. The Alaska Birth Transfer Initiative seeks to improve the transfer/transport process, to enhance collaboration among community and hospital-based birth providers and staff, and to improve the patient experience during transfers.

Your responses to this survey will remain anonymous. Your participation in this survey is entirely voluntary and you may leave the survey at any time. Please do not provide any information in the comments that could potentially identify a client. We look forward to hearing about your recent birth transfer/transport experience and appreciate your honest feedback.

Please contact Katy Krings at katy.krings@alaska.gov or 907-269-3418 if you have any questions or concerns about this survey.

Question Title

* 1. What is your occupation/profession?

Certified Nurse Midwife

Physician (OB/GYN or MFM)

Physician (Neonatologist/Pediatrician)

Physician (Family Practice)

Nurse Practitioner

Physician Assistant

Other (please specify)

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* 2. What was the occupation of the transferring provider?

Certified Nurse Midwife

Certified Direct Entry Midwife

Physician

Physician Assistant

Nurse Practitioner

Unknown

Other (please specify)

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* 3. In which region/community did the transfer occur?

Anchorage

Matanuska-Susitna

Interior Region

Gulf Coast Region

Northern Region

Southeast Region

Southwest Region

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* 4. What was the month and year of the transfer (MM/YYYY)?

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* 5. Where was the client transferred from?

Home

Birth Center

Unknown

Other (please specify)

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* 6. What type of transfer was it?

Maternal

Neonatal

Both

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* 7. When did the transfer occur?

Prior to labor

During labor

After birth

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* 8. What were the reasons for the transfer? Check all that apply.

Prolonged labor/need for augmentation

Hypertension

Malpresentation

Maternal exhaustion

Pain management

Maternal fever

Meconium-stained amniotic fluid

Abnormal fetal heart rate

Prolonged rupture of membranes

Maternal choice/no medical indication

Postpartum hemorrhage

Need for complex suturing

Retained placenta

Maternal infection

Newborn respiratory problems

Abnormal newborn physical exam

Other (please specify)

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* 9. Was this an emergent transfer/transport?

Yes, emergent transport

No, non-emergent transfer of care

Comment

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* 10. What was the mode of transport?

By car

By ambulance

By flight

Unknown

Comment

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* 11. Did the transferring provider notify the hospital prior to arrival?

Yes

Unknown

Comment

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* 12. Did the transferring provider accompany the client to the hospital?

Yes

Unknown

If no, please explain why.

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* 13. Upon arrival at the hospital, did the transferring provider...

	Yes	No	Unknown
Provide a verbal report to the receiving provider?	Provide a verbal report to the receiving provider? Yes	Provide a verbal report to the receiving provider? No	Provide a verbal report to the receiving provider? Unknown
Provide a legible copy of the client's relevant medical history?	Provide a legible copy of the client's relevant medical history? Yes	Provide a legible copy of the client's relevant medical history? No	Provide a legible copy of the client's relevant medical history? Unknown
Answer questions about the client's medical and labor history?	Answer questions about the client's medical and labor history? Yes	Answer questions about the client's medical and labor history? No	Answer questions about the client's medical and labor history? Unknown
Use a transfer form to share pertinent medical information?	Use a transfer form to share pertinent medical information? Yes	Use a transfer form to share pertinent medical information? No	Use a transfer form to share pertinent medical information? Unknown
Act appropriately according to their scope of practice and privileges at the hospital?	Act appropriately according to their scope of practice and privileges at the hospital? Yes	Act appropriately according to their scope of practice and privileges at the hospital? No	Act appropriately according to their scope of practice and privileges at the hospital? Unknown

Comment

Question Title

* 14. Please respond to the following statements about your interactions with the transferring provider during this transfer.

	Strongly agree	Agree	Neutral	Disagree	Strongly disagree
The interactions with the transferring provider were respectful and professional	The interactions with the transferring provider were respectful and professional Strongly agree	The interactions with the transferring provider were respectful and professional Agree	The interactions with the transferring provider were respectful and professional Neutral	The interactions with the transferring provider were respectful and professional Disagree	The interactions with the transferring provider were respectful and professional Strongly disagree
The transferring provider and I worked well together	The transferring provider and I worked well together Strongly agree	The transferring provider and I worked well together Agree	The transferring provider and I worked well together Neutral	The transferring provider and I worked well together Disagree	The transferring provider and I worked well together Strongly disagree
I accommodated the transferring provider according to the client's wishes	I accommodated the transferring provider according to the client's wishes Strongly agree	I accommodated the transferring provider according to the client's wishes Agree	I accommodated the transferring provider according to the client's wishes Neutral	I accommodated the transferring provider according to the client's wishes Disagree	I accommodated the transferring provider according to the client's wishes Strongly disagree
I developed a plan for post-discharge care with the transferring provider	I developed a plan for post-discharge care with the transferring provider Strongly agree	I developed a plan for post-discharge care with the transferring provider Agree	I developed a plan for post-discharge care with the transferring provider Neutral	I developed a plan for post-discharge care with the transferring provider Disagree	I developed a plan for post-discharge care with the transferring provider Strongly disagree

Comments

AK Birth Transfer Initiative: Receiving Provider Survey

Question Title

* 1. What is your occupation/profession?

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* 2. What was the occupation of the transferring provider?

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* 3. In which region/community did the transfer occur?

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* 4. What was the month and year of the transfer (MM/YYYY)?

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* 5. Where was the client transferred from?

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* 6. What type of transfer was it?

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* 7. When did the transfer occur?

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* 8. What were the reasons for the transfer? Check all that apply.

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* 9. Was this an emergent transfer/transport?

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* 10. What was the mode of transport?

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* 11. Did the transferring provider notify the hospital prior to arrival?

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* 12. Did the transferring provider accompany the client to the hospital?

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* 13. Upon arrival at the hospital, did the transferring provider...

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* 14. Please respond to the following statements about your interactions with the transferring provider during this transfer.

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* 15. What went well during this transfer?

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* 16. What didn't go well doing this transfer?

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* 17. Please provide any additional comments for the AK Birth Transfer Initiative Advisory Committee.