NJ AIM 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.

Hospital Name

Name

Title

Question Title

* 2. Will you be participating in NJ AIM?

Yes (see #3)

No/Undecided (please specify the reason in the text box below)

If No/Undecided, please share the reason for not participating in AIM

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* 3. If your birth facility is participating in AIM, which bundle(s) will you be implementing?

Hemorrhage

Hypertension

Hemorrhage and Hypertension

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

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

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

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* 7. Is your birth facility currently participating in or has it recently participated in QI efforts with a NJ QI program (i.e. NJ Perinatal Quality Collaborative, NJ AWHONN PPH project, Private or Not-for-profit QI organization)

Yes (Name the Program in text box below)

Name of Program

Question Title

* 8. What quality improvement projects is your facility currently working on or has worked on in the past 5 years? Select all that apply.

Breastfeeding

Maternal Hemorrhage

Severe Hypertension/Preeclampsia (Hypertensive Disorders)

Cesarean Sections (C/S)

Oxytocin Adminstration/Induction of Labor

Infections/Sepsis

Patient and Family Engagement

Simulation Drills

VTE/Amniotic Fluid Embolism (AFE)

Data Collection and Measurement

Other (please specify)

Question Title

* 9. Does the OB department have an OB provider (Physician, CNM) or a nurse leader that participates in QI projects?

	Yes	No
Physician	Physician Yes	Physician No
Certified Nurse-Midwife/Certified Midwife	Certified Nurse-Midwife/Certified Midwife Yes	Certified Nurse-Midwife/Certified Midwife No
Nurse Leader	Nurse Leader Yes	Nurse Leader No

Question Title

* 10. If your birth facility has a multidisciplinary perinatal quality committee, please identify the representatives on your committee. Select all that apply.

Nurse Adminstrator/Manager

Staff Nurse

MFM/Perinatologist

Neonatologist/Pediatrician

Quality/Safety Officer

Pharmacy

Social Work

Discharge Planning/Case Management

Other (please specify)

Question Title

* 11. Following a challenging OB case, is there a process for “lessons learned” to be addressed and shared with the patient, family and staff? (i.e. debriefing, patient care conference)

	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

Question Title

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

	Yes	No
OB Hemorrhage	OB Hemorrhage Yes	OB Hemorrhage No
Severe Hypertension/Preeclampsia	Severe Hypertension/Preeclampsia Yes	Severe Hypertension/Preeclampsia No

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* 13. Does your birth facility Emergency Department have standardized processes (i.e. order sets, unit policies, practice protocols) for obstetric emergencies?

Yes

Do not have an Emergency Department

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

Every year

Every 2 years

Every 3 years

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* 15. How often are the obstetric emergency policies and protocols (ie. order sets) used in an obstetric emergency by staff (OB, OB Resident, CNM, Staff RN)?

N/A

25%

50%

75%

100%

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

Yes

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

Yes

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

N/A

Monthly

Quarterly

Annually

Other (please specify)

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* 19. 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

Shoulder Dystocia

Other (please specify)

Question Title

* 20. Which frontline providers are required to participate in the OB clinical scenario simulation drills?

	N/A	Yes	No
OBs	OBs N/A	OBs Yes	OBs No
OB Residents	OB Residents N/A	OB Residents Yes	OB Residents No
Anesthesia	Anesthesia N/A	Anesthesia Yes	Anesthesia No
Family Practitioners	Family Practitioners N/A	Family Practitioners Yes	Family Practitioners No
Certified Nurse-Midwives	Certified Nurse-Midwives N/A	Certified Nurse-Midwives Yes	Certified Nurse-Midwives No
Perinatal Dept. Nursing Staff	Perinatal Dept. Nursing Staff N/A	Perinatal Dept. Nursing Staff Yes	Perinatal Dept. Nursing Staff No
Emergency Dept. Staff	Emergency Dept. Staff N/A	Emergency Dept. Staff Yes	Emergency Dept. Staff No

Other (please specify)

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

Chart Review

Computer generated reports

No data is collected

Other (please specify)

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

Incorrect Coding

Inadequate Documentation

Lack of Trained Staff

Time Burden

None

Other (please specify)

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

Yes

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* 25. Does your OB department staff know that they have the responsibility and authority to stop a procedure when patient safety is a concern? (i.e. TEAMSTEPPS, CUSP)

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.

Question Title

* 2. Will you be participating in NJ AIM?

Question Title

* 3. If your birth facility is participating in AIM, which bundle(s) will you be implementing?

Question Title

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

Question Title

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

Question Title

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

Question Title

* 7. Is your birth facility currently participating in or has it recently participated in QI efforts with a NJ QI program (i.e. NJ Perinatal Quality Collaborative, NJ AWHONN PPH project, Private or Not-for-profit QI organization)

Question Title

* 8. What quality improvement projects is your facility currently working on or has worked on in the past 5 years? Select all that apply.

Question Title

* 9. Does the OB department have an OB provider (Physician, CNM) or a nurse leader that participates in QI projects?

Question Title

* 10. If your birth facility has a multidisciplinary perinatal quality committee, please identify the representatives on your committee. Select all that apply.

Question Title

* 11. Following a challenging OB case, is there a process for “lessons learned” to be addressed and shared with the patient, family and staff? (i.e. debriefing, patient care conference)

Question Title

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

Question Title

* 13. Does your birth facility Emergency Department have standardized processes (i.e. order sets, unit policies, practice protocols) for obstetric emergencies?

Question Title

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

Question Title

* 15. How often are the obstetric emergency policies and protocols (ie. order sets) used in an obstetric emergency by staff (OB, OB Resident, CNM, Staff RN)?

Question Title

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

Question Title

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

Question Title

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

Question Title

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

Question Title

* 20. Which frontline providers are required to participate in the OB clinical scenario simulation drills?

Question Title

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

Question Title

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

Question Title

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

Question Title

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

Question Title

* 25. Does your OB department staff know that they have the responsibility and authority to stop a procedure when patient safety is a concern? (i.e. TEAMSTEPPS, CUSP)

Question Title

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