Institution* must provide value
Arkansas Children's Hospital Boston Medical Center Brigham and Women's Hospital Children's Hospital of Michigan Hurley Medical Center Intermountain Medical Center Levine Children's Hospital at Carolinas HealthCare System Maimonides Medical Center Mayo Clinic New York Hospital Queens Sunnybrook Hospital Trident Medical Center University of California Medical Center University of Cincinnati University of Hawaii John A Burn School of Medicine Virginia Commonwealth University Hospital Children's Hospital of Philadelphia New Hanover Lankenau Medical Center Children's Hospital Montefiore Children's Hospital Colorado University of New Mexico Hackensack UMC Mountainside Medical University of South Carolina Sparrow Hospital Johns Hopkins Baltimore Children's National DC Toledo Children's Hospital AtlantiCare Regional Medical Center Sanford Children's Hospital Gwinnett Medical Center Children's Mercy Kansas City Boston Children's Hospital North Shore Hospital Mount Auburn Hospital Bryn Mawr Hospital Beth Israel Deaconess Hospital-Milton
Date* must provide value
Today M-D-Y
Champion/Faculty SHM.I-PASS ID number* must provide value
Service / Unit Name:
Thank you for participating in the I-PASS Handoff Program. This survey is meant to be completed at the end of an inpatient rotation or period of service. The survey will ask you about your work and educational experiences and your experiences with teamwork and handoffs in particular. Results will be used to improve the quality of care and training, and for research; aggregate results may be published, but no data that would make it possible to identify individual respondents will be shared with your supervisors, program directors, or anyone other than individuals participating in this project. Protection of your confidentiality will be of the highest priority. We will be using the data obtained from this survey as part of a research study approved by the Boston Children's Hospital Institutional Review Board to understand more about patterns across institutions about handoff and teamwork education, supervision, and improvement efforts. Your willingness to complete this survey will be considered consent to participate in this research study. best guess . You are free to skip any question you would prefer not to answer, but we encourage you to answer all questions, as complete data will improve the value of the survey. 1a. Please provide the length of your most recent completed inpatient work rotation/experience (eg 4 week inpatient block or 1 week duration as ward supervisor): * must provide value
Weeks
1b. Please provide the end date of your most recent completed inpatient work rotation/experience:* must provide value
Today M-D-Y
PLEASE NOTE: Except as otherwise noted, all subsequent questions on this survey will refer to this specific inpatient experience and duration< /font> 2. Which of the following best describes the specialty / training program of your most recent inpatient experience?* must provide value
Internal medicine Surgery Pediatrics Other
Other * must provide value
3. What was the primary setting of your most recent inpatient work experience? General inpatient ward Subspecialty ward Intensive care unit (any type) Other
Other* must provide value
4. Which of the following best describes your role?
Resident physician
Subspecialty fellow
Attending physician
Medical Student
Registered nurse
Nurse practitioner
Physicians' assistant
Respiratory therapist
Physical therapist
Occupational therapist
Other
4. Which of the following best describes your role?
Attending physician
ICU Attending
Hospitalist Attending
Other Attending
Registered nurse
Nurse practitioner
Physicians' assistant
Respiratory therapist
Physical therapist
Occupational therapist
Other * must provide value
Other * must provide value
5. If you are a resident physician, what year of your residency program are you in?
Post graduate year 1 (PGY1)
PGY2
PGY3
PGY4
PGY5
PGY6
PGY7 or more
Please rate your level of agreement with the following two statements: 9. I trust that the information in the written handoff is accurate and up to date
Completely disagree Somewhat disagree Somewhat agree Completely agree N/A
10. I trust that the information in the verbal handoff is accurate and up to date
Completely disagree Somewhat disagree Somewhat agree Completely agree N/A
Problems with handoffs led to other errors or patient harm (please describe):* must provide value
21. Prepared you for questions that arose Not at all Slightly Moderately Well Very Well Extremely Well
22. Prepared you to assume responsibility Not at all Slightly Moderately Well Very Well Extremely Well
23. Prepared you to talk with patients Not at all Slightly Moderately Well Very Well Extremely Well
24. Prepared you to talk with other providers Not at all Slightly Moderately Well Very Well Extremely Well
25. Prepared you for things that might go wrong Not at all Slightly Moderately Well Very Well Extremely Well
26. Informed you of tasks Not at all Slightly Moderately Well Very Well Extremely Well
27. Prepared you for an appropriate response Not at all Slightly Moderately Well Very Well Extremely Well
28. Informed you of how stable each patient Not at all Slightly Moderately Well Very Well Extremely Well
29. Provided a shared understanding Not at all Slightly Moderately Well Very Well Extremely Well
Please keep these definitions in mind when answering the next two questions: Minor Harm- Limited clinical consequence--such as a need for more frequent monitoring or transient discomfort, without prolongation of hospitalization, significant organ dysfunction or wocfsening of clinical condition. 19. In your most recently completed rotation or period of service , estimate the number of your patients you believe experienced a minor harm as a result of a problematic handoff. (If not applicable or unable to judge, please leave question blank) Patients
20. In your most recently completed rotation or period of service , please estimate the number of your patients you believe experienced a major harm as a result of a problematic handoff. (If not applicable or unable to judge, please leave question blank) Patients
Have you completed this survey within the past 6 months? Yes
No
21. Did you receive any training over the past year about handoff skills ?
Yes No
22. If yes, rate the overall quality of training you received about handoff skills over the past year:
Poor Fair Good Very good Excellent N/A
23. Did you receive any training over the past year about teamwork skills ?
Yes No
24. If yes, rate the overall quality of training you received about teamwork skills over the past year:
Poor Fair Good Very good Excellent N/A
25. Did you receive any training over the past year about how to provide feedback on and supervise handoffs ? Yes
No
26. Rate the overall quality of training you received about providing feedback and supervising handoffs over the past year:
Poor Fair Good Very good Excellent N/A
27. How many days did you work during your last inpatient experience? * must provide value
Days
28.Did you cover any patients when working during the day?* must provide value
Yes
N/A, I did not see patients during the day
On average, approximately how many patients were you covering?* must provide value
Patients
41. How many nights did you work during your last inpatient experience? Nights
42. On average, approximately how many patients did you cover when working during the night? Patients
43. Including both days and nights, how many hours per week did you work? Hours per week
44. On average, how much sleep did you get per 24 hours over your last inpatient experience? Hours of sleep per 24 hours
29. How would you rate the overall quality
Poor Fair Good Very good Excellent
Thank you very much for completing this survey! Copyright 2015 I-PASS Institute/Boston Children's Hospital. All rights reserved. For permissions, contact ipass.institute@childrens.harvard.edu
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