AIM/ MSPQC Baseline Survey

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* 1. It is important to designate an unit-based Labor and Delivery staff member (OB Provider, Staff RN, or Charge RN) to complete the AIM Baseline Survey. It is recommended the designee is directly involved in obstetric patient care.

Name of Birth Facility

Labor and Delivery Survey Designee

Position

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* 2. Please provide the names and emails of core team members who may work on the AIM initiative.

Labor and Delivery Nurse Manager

Physician/CNM Champion

Post partum Nurse Manager

Nurse Educator

Other/Additional

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* 3. What was the last quality improvement (QI) project that the OB department attempted?

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* 4. What worked well in the past OB specific QI efforts?

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* 5. What barriers have been identified in past OB specific QI efforts?

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* 6. Does your birth facility have a multidisciplinary perinatal quality committee?

Yes (Complete Question 8)

No (Skip to Question 9)

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* 7. Please answer the following questions about your perinatal quality committee (PQC):

	Yes	No	Unsure
Does your PQC meet at least monthly?	Does your PQC meet at least monthly? Yes	Does your PQC meet at least monthly? No	Does your PQC meet at least monthly? Unsure
Has your PQC been in place and meeting regularly for at least 1 year?	Has your PQC been in place and meeting regularly for at least 1 year? Yes	Has your PQC been in place and meeting regularly for at least 1 year? No	Has your PQC been in place and meeting regularly for at least 1 year? Unsure
Does your PQC utilize Plan-Do-Study-Act or other similar QI strategies?	Does your PQC utilize Plan-Do-Study-Act or other similar QI strategies? Yes	Does your PQC utilize Plan-Do-Study-Act or other similar QI strategies? No	Does your PQC utilize Plan-Do-Study-Act or other similar QI strategies? Unsure
Does your hospital use HEALTH STREAM for staff education?	Does your hospital use HEALTH STREAM for staff education? Yes	Does your hospital use HEALTH STREAM for staff education? No	Does your hospital use HEALTH STREAM for staff education? Unsure

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* 8. Following a challenging OB case, is there a formal process for 'lessons learned' to be addressed and shared with the patient, family and staff? ( Established policy or written guidelines in place)

	Yes	No
Patient and Family	Patient and Family Yes	Patient and Family No
Staff (OB, CNM, RN)	Staff (OB, CNM, RN) Yes	Staff (OB, CNM, RN) No

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* 9. Please answer if your facility has the following practices in place for the management of OBSTETRIC HEMORRHAGE

	Yes	No	In Development
Written obstetric hemorrhage practice policy/guidelines	Written obstetric hemorrhage practice policy/guidelines Yes	Written obstetric hemorrhage practice policy/guidelines No	Written obstetric hemorrhage practice policy/guidelines In Development
Massive Transfusion Protocol	Massive Transfusion Protocol Yes	Massive Transfusion Protocol No	Massive Transfusion Protocol In Development
Obstetric Hemorrhage Kit/Cart available on units	Obstetric Hemorrhage Kit/Cart available on units Yes	Obstetric Hemorrhage Kit/Cart available on units No	Obstetric Hemorrhage Kit/Cart available on units In Development
Obstetric hemorrhage risk assessment guidelines	Obstetric hemorrhage risk assessment guidelines Yes	Obstetric hemorrhage risk assessment guidelines No	Obstetric hemorrhage risk assessment guidelines In Development
Obstetric hemorrhage simulation drills	Obstetric hemorrhage simulation drills Yes	Obstetric hemorrhage simulation drills No	Obstetric hemorrhage simulation drills In Development
Obstetric hemorrhage education for all nursing staff	Obstetric hemorrhage education for all nursing staff Yes	Obstetric hemorrhage education for all nursing staff No	Obstetric hemorrhage education for all nursing staff In Development
Obstetric hemorrhage education for all phycisian/CNM staff	Obstetric hemorrhage education for all phycisian/CNM staff Yes	Obstetric hemorrhage education for all phycisian/CNM staff No	Obstetric hemorrhage education for all phycisian/CNM staff In Development
Measured quantification of blood loss (weights, graded drapes etc.)	Measured quantification of blood loss (weights, graded drapes etc.) Yes	Measured quantification of blood loss (weights, graded drapes etc.) No	Measured quantification of blood loss (weights, graded drapes etc.) In Development

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* 10. Does the OB Department have standardized processes (i.e.order sets, unit policies, practice protocols)for the following obstetric emergencies/risk factors? Select all that apply.

	Yes	No
Severe Hypertension/Preeclampsia	Severe Hypertension/Preeclampsia Yes	Severe Hypertension/Preeclampsia No
Venous Thromboembolism Prevention	Venous Thromboembolism Prevention Yes	Venous Thromboembolism Prevention No

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* 11. How often are the obstetric emergency policies and protocols reviewed and updated?

Every year

Every 2 years

Every 3 years

As needed or no set frequency

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* 12. How often are these order sets and practice protocols used in an obstetric emergency by staff (OB, OB Resident, CNM, Staff RN)?

N/A

25% of obstetric emergencies

50% of obstetric emergencies

75% of obstetric emergencies

100% of obstetric emergences

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* 13. Does your birth facility have a policy for notification and response to maternal early warning signs?

Yes

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* 14. Does your birth facility conduct regular multidisciplinary in situ (on site) clinical scenario simulation drills for OB emergencies?

Yes

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* 15. How often does the OB department conduct clinical scenario simulation drills?

N/A

Monthly

Quarterly

Annually

Other (please specify)

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* 16. What obstetric emergencies do these clinical scenario simulation drills focus on? Select all that apply.

N/A

OB Hemorrhage

Severe Hypertension/Preeclampsia

Eclamptic Seizure

Sepsis

Emergent Cesarean Section

Maternal Code

Other (please specify)

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* 17. How does the OB department obtain data to track unit-based outcomes? Select all that apply.

Chart Review

Computer generated reports

Other (please specify)

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* 18. What type of data measures does the OB department track? Select all that apply.

Process measure-frequency of performing a diagnostic test or treatment related to an outcome (i.e. rate of antibiotic prophylaxis at Cesarean birth, rate of obstetric hemorrhage risk assessment on L&D admission)

Structure measure-identify information about policies, equipment, and staff that are relevant to the QI project and are often noted once when the task is completed (i.e. annual policy review, staff training sessions)

Outcome measures-examines the impact on patient's health and well-being (i.e. severe maternal morbidity and mortality rates)

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* 19. What data collection challenges exist in your birth facility? Select all that apply.

Incorrect Coding

Inadequate Documentation

Lack of Trained Staff

Time Burden

Inadequate reporting and sharing

None

Other (please specify)

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* 20. Has your birth facility participated in a formal 'culture of safety' assessment within the last 2 years?

Yes

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* 21. Does your OB department have a 'stop the line' policy where staff know that they have the responsibility and authority to stop a procedure when patient safety is a concern?

Yes

Question Title

* 1. It is important to designate an unit-based Labor and Delivery staff member (OB Provider, Staff RN, or Charge RN) to complete the AIM Baseline Survey. It is recommended the designee is directly involved in obstetric patient care.

Question Title

* 2. Please provide the names and emails of core team members who may work on the AIM initiative.

Question Title

* 3. What was the last quality improvement (QI) project that the OB department attempted?

Question Title

* 4. What worked well in the past OB specific QI efforts?

Question Title

* 5. What barriers have been identified in past OB specific QI efforts?

Question Title

* 6. Does your birth facility have a multidisciplinary perinatal quality committee?

Question Title

* 7. Please answer the following questions about your perinatal quality committee (PQC):

Question Title

* 8. Following a challenging OB case, is there a formal process for 'lessons learned' to be addressed and shared with the patient, family and staff? ( Established policy or written guidelines in place)

Question Title

* 9. Please answer if your facility has the following practices in place for the management of OBSTETRIC HEMORRHAGE

Question Title

* 10. Does the OB Department have standardized processes (i.e.order sets, unit policies, practice protocols)for the following obstetric emergencies/risk factors? Select all that apply.

Question Title

* 11. How often are the obstetric emergency policies and protocols reviewed and updated?

Question Title

* 12. How often are these order sets and practice protocols used in an obstetric emergency by staff (OB, OB Resident, CNM, Staff RN)?

Question Title

* 13. Does your birth facility have a policy for notification and response to maternal early warning signs?

Question Title

* 14. Does your birth facility conduct regular multidisciplinary in situ (on site) clinical scenario simulation drills for OB emergencies?

Question Title

* 15. How often does the OB department conduct clinical scenario simulation drills?

Question Title

* 16. What obstetric emergencies do these clinical scenario simulation drills focus on? Select all that apply.

Question Title

* 17. How does the OB department obtain data to track unit-based outcomes? Select all that apply.

Question Title

* 18. What type of data measures does the OB department track? Select all that apply.

Question Title

* 19. What data collection challenges exist in your birth facility? Select all that apply.

Question Title

* 20. Has your birth facility participated in a formal 'culture of safety' assessment within the last 2 years?

Question Title

* 21. Does your OB department have a 'stop the line' policy where staff know that they have the responsibility and authority to stop a procedure when patient safety is a concern?

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* 22. What do you see as the greatest need to improve OB specific QI efforts in your birth facility?