Smooth Transitions is a statewide quality improvement initiative at the Foundation for Health Care Quality with the mission to improve hospital transfers from planned community-based births (birth center or home) to promote greater patient safety and satisfaction.  We are eager to hear from you about your recent hospital transfer experience and appreciate your honest feedback.  Your responses will be used to help improve the transfer process for others.  Information you provide through this survey may be shared during meetings of community midwives, hospital providers and staff, and EMS personnel for quality improvement at hospitals participating in the Smooth Transitions Quality Improvement Program. In addition, selected quotes may be included in presentations to promote the program and in publications about Smooth Transitions.

It takes about 15-20 minutes to complete the survey and you will be compensated for your time.  Once you start, your responses will be saved so you can come back to it later.    Thank you!

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* 1. What was the date of your hospital transfer?

Date

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* 2. Name of the hospital you transferred to and city where it's located

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* 3. Why were you or your baby transferred to the hospital?

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* 4. Was your transfer.....

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* 6. Did you have a labor doula present with you during your transfer to the hospital?

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* 7. Select the type of hospital provider involved in your and/or your baby's care.  You can select multiple providers.

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* 8. How involved were you in decision-making once you transferred to the hospital?  In responding to the statements below, please describe your discussions with the hospital-based doctor/midwife/nurse who had the greatest impact on your experience. 

  Completely Disagree Strongly Disagree Somewhat Disagree Somewhat Agree Strongly Agree Completely Agree N/A
I was asked how involved in decision making I wanted to be.
I was told me there were different options for my care.
The advantages/disadvantages of the care options were explained to me.
I was given enough time to thoroughly consider the different care options.
I was able to choose what I considered to be the best care options.
My choices were respected.

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* 9. Again, these responses refer to your interactions with the hospital-based doctor/midwife/nurse who had the biggest impact on your experience.  

Overall, while making decisions about my care in the transfer:

  Strongly Disagree Disagree Somewhat Disagree Somewhat Agree Agree Strongly Agree N/A
I felt comfortable asking questions. 
I felt comfortable declining care that was offered. 
I felt comfortable accepting the options for care that this person recommended.
I chose the care options that I received. 
My personal preferences were respected.  
My cultural preferences were respected.  

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* 10. The following responses refer to interactions with the same person from questions 9 and 10.  If not applicable to your experience, you may indicate this by selecting N/A. 

During my transfer, I felt like I was treated poorly by this person because of:

  Strongly Disagree Disagree Somewhat Disagree Somewhat Agree Agree Strongly Agree N/A
My race, ethnicity, cultural background or language.
My sexual orientation and/or gender identity.
My type of health insurance or lack of health insurance.
A difference of opinion with my caregivers about the right care for myself or my baby.
I felt pushed into accepting the options this person suggested.

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* 11. TRIGGER WARNING: MEDICAL ABUSE.  Did you experience any of the following?

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* 12. Do you have any comments about the interactions between the hospital providers/staff and yourself during the course of care?

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* 13. Do you have any comments (positive or negative) about the interactions between the hospital providers/staff and your family/support team?

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* 14. Please check all the outcomes and/or procedures that occurred in your care at the hospital.

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* 15. How do you feel about the quality of care you and/or your baby received at the hospital?

low quality of care high quality of care
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i We adjusted the number you entered based on the slider’s scale.

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* 16. How welcomed did you feel by the hospital providers and staff?

unwelcomed, cold welcomed, warm, caring
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i We adjusted the number you entered based on the slider’s scale.

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* 17. Do you feel your community midwife prepared you well for the care you received in the hospital?

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* 18. Overall, how was your transfer handled by your community midwife?

not handled well handled very well
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i We adjusted the number you entered based on the slider’s scale.

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* 19. What could have been improved about your transfer experience and/or your hospital stay?

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* 20. What went well during your transfer experience and/or hospital stay?

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* 21. How do you feel about being given the opportunity to provide feedback on your experience through this survey?

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* 22. Do you have any recommendations on how to improve this survey?

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