I-PASS Initial Assessment (Coverys)

I-PASS Implementation - Initial Assessment (Coverys)

Respondent Contact Information

Current State of Handoffs & Patient Safety

Quality Improvement (QI) Environment & Team Structure

Organizational Context

Technology Solutions for Handoff Communication

Overall Safety Goals & Organizational Strategy

Thank you for expressing interest in implementing the I-PASS handoff methodology at your organization, in partnership with Coverys and the I-PASS Institute. Please respond to the questions below, providing as much context in the free text responses to support your answers as possible. This survey should take 25-30 minutes to complete. Responses are confidential and will be used for evaluation purposes only.

You will be asked to respond to a series of statements across five categories. It may be necessary to gather input from other leaders and subject-matter experts in your organization before submitting your responses. Please note that you may save responses and continue within 30 days using the button at the end of the survey.

Please complete the fields below before beginning this survey.

Hospital Name(Required)

Number of Beds at Hospital(Required)

Number of Clinical Employees(Required)

Name of Respondent(Required)

First Last

Respondent Title within Organization(Required)

Respondent Email(Required)

Respondent Phone Number(Required)

How would you describe your institution?(Required)

Community Hospital

Academic Medical Center

Pediatric Hospital (free-standing)

Tertiary Care Facility

Other (please specify)

Other Institution Type

Did other individuals contribute to the responses in this survey?(Required)

Yes

Other Contributor Information

If other individuals contributed to the responses submitted in this assessment, please list their names with titles in parentheses. Example: John Smith (CEO)

Please respond to the statements below regarding the current state of handoff communication within your organization.(Required)

Current State of Handoffs - Free Response(Required)

Please use this section to expand on your responses to the above statements relative to the current state of handoffs at your organization.

My organization has a structured Quality Improvement and/or Patient Saftey department that has:(Required)

Please respond select a response to each statement provided.

QI Environment - Free Response(Required)

Please use this section to expand on your responses to the above statements relative to the QI environment at your organization.

To implement change, my organization operates most effectively through:(Required)

The following elements are present within my organization to support the implementation of I-PASS:(Required)

	Strongly disagree	Disagree	Neutral	Agree	Strongly agree	Unknown
Support from administrative/business service lines: QI, Patient Safety or Risk Mgmt.; IT or IS; Education or Training
Support from clinical service lines: Nursing, Medicine, Surgery, Ambulatory care
Prioritization of improved handoff communication as a QI effort
Presence of support from executive leadership
Presence of funding/resources
Readiness to adopt a written handoff tool
A culture that supports iterative process improvement and change management
Presence of end user community support

The following barriers are present within my organization and could negatively impact implementation of I-PASS:(Required)

	Strongly disagree	Disagree	Neutral	Agree	Strongly agree	Unknown
Lack of support from administrative/business service lines: QI, Patient Safety or Risk Mgmt.; IT or IS; Education or Training
Lack of support from clinical service lines: Nursing, Medicine, Surgery, Ambulatory care
Lack of funding/resources
Prioritization of other QI efforts not related to handoff communication
Lack of support from executive leadership
Overall culture that is resistant to change
Lack of support from end-user community
Lack of interest or support to adopt a standard written handoff tool

Organizational Context - Free Response(Required)

Please use this section to expand on your responses to the above statements relative to your organizational context.

What electronic medical record system(s) is/are currently in use at your organization?(Required)

Please respond to the statements below regarding technology solutions for handoff communication within your organization.(Required)

	Strongly disagree	Disagree	Neutral	Agree	Strongly agree	Unknown
We do not anticipate significant changes or upgrades to our hospital EMR system(s) in the next 24-36 months.
Our organization has no large-scale IT/IS priorities in the next 24-36 months that would compete for resources required as part of an I-PASS implementation.

Technology Solutions for Handoff Communication - Free Response(Required)

Please use this section to expand on your responses to the above statements relative to your organization's technology solutions for handoff communication.

Strongly disagree

Strongly agree

Clinicians at my institution use a structured approach to verbal handoff communication.

Clinicians at my institution use a structured approach to written handoff communication.

High-quality handoffs between clinicians occur consistently at my organization.

Clinicians at my institution are satisfied with the quality of handoffs they provide and receive, indicated through AHRQ Culture of Safety surveys or similar surveys.

My organization is rated highly on handoff communication-related safety scores from third-party institutions.

Please respond to the statements below regarding the overall goals for patient safety within your organization.(Required)

	Strongly disagree	Disagree	Neutral	Agree	Strongly agree	Unknown
My organization is currently engaged in a High-Reliability Organizing journey
My organization has set and communicate clear goals related to patient safety (e.g. Zero Preventable Harm)
My organization has a standard definition for harm that is well-understood by all team members and clinicians.
According to our serious safety event reporting system (e.g. Midas) our organization has a lower than average incidence rate of handoff-related communication failures.
Employees in my organization report positive perceptions of the leadership team.
My organization regularly reviews safety data for opportunities for improvement

Overall Safety Goals & Organizational Strategy - Free Text(Required)

Please use this section to expand on your responses to the above statements relative to your organization's overall safety goals.

	Strongly disagree	Disagree	Neutral	Agree	Strongly agree	Unknown
Consensus building
Top-down decision making
A combination of consensus building and top-down decisions