Program Description and Confidentiality Statement

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We are eager to hear from you about your recent hospital transfer experience and appreciate your honest feedback.  Your responses are protected and confidential.  They will be used to help improve the transfer process for others.  
Smooth Transitions is a statewide quality improvement effort under the Foundation for Health Care Quality.  The program’s mission is to improve hospital transfers from planned community-based births (birth center or home) to promote greater patient safety and satisfaction.  The goals of Smooth Transitions are to: 

1.  Improve the safety and efficiency of the transfer process through the establishment of system-wide protocols. 
2.  Collect and analyze transfer outcome data for the purpose of quality improvement. 
3.  Build greater collaboration between community-based midwives, EMS, and hospital care team. 
4.  Enhance the patient experience of care when transfers occur. 

While you fill out this survey, your responses will be saved so you can come back to it.  It takes about 17 minutes to complete the survey.     Thank you!

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* 1. How old are you?

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* 2. How do you describe your ethnicity/race?  Check all that apply.

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* 3. How do you classify your economic status?

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* 4. Do you self-identify with one or more of the following groups?

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

Date

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* 6. Name of receiving facility and city

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

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

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

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* 11. These responses describe your discussions with the hospital-based doctor/midwife/nurse that had the biggest impact on your experience. 

Please tell us about decision making with this person during the transfer process?

  Completely Disagree Strongly Disagree Somewhat Disagree Somewhat Agree Strongly Agree Completely Agree N/A
This person asked me how involved in decision making I wanted to be.
This person told me that there were different options for my maternity care.
This person explained the advantages/disadvantages of the maternity care options.
This person helped me understand all the different information.
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.
This person respected my choices.

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* 12. Again, these responses refer to your interactions with the hospital-based doctor/midwife/nurse that 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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* 13.  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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* 14. CONTENT WARNING: MEDICAL ABUSE.  Did you experience any of the following?  

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

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* 16. Do you have any comments about the interactions between the hospital providers/staff and your family/support team during the course of care?

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

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* 18. 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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* 19. Do you feel you and/or your baby were well received by the hospital provider and staff?

poorly received well received
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i We adjusted the number you entered based on the slider’s scale.

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

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* 22. What went well during your transfer process?  And how can this experience help inform future transfers?

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* 23. In addition to this survey, I had an opportunity to provide feedback on the transfer experience....(please check all that apply).

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

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* 25. We would like to identify some resource needs that patients may have after any emotionally difficult experience with a transfer, especially brought on by interactions with the hospital care providers.  If you were to or did have a difficult patient experience, how would you cope with or handle the situation?  Please check all that apply.

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

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* 27. Thank you again for completing this survey.  Your responses will be used to improve future transfers.  In appreciation for your time spent, we'd like to give you a gift.  Please email the Smooth Transitions program coordinator at smoothtransitions@qualityhealth.org and they will send you an electronic gift code.  Just to be clear, do not leave your email in the box below, you have to send an email to the program coordinator in order to receive your gift.  

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