I-Pass Baseline Collection

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* 1. Observer (Name)

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* 2. Date of Observation

Date

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* 3. Observation Time

Time Start

Time

AM/PM

Time End

Time

AM/PM

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* 4. Type of Service

ICU

Other (please specify)

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* 5. Individuals Being Observed

Giver

Receiver

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* 6. Number of Individual Patient Handoffs Observed

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* 7. Was the situational overview provided by the provider GIVING the handoff (e.g. description of the "big picture" of what will need to be prioritized by the receivers of the handoff)

Yes

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* 8. Please Indicate the Frequency of I-Pass Mnemonic Elements Presence During Observation

	Never	Rarely	Sometimes	Usually	Always
I- Illness Severity	I- Illness Severity Never	I- Illness Severity Rarely	I- Illness Severity Sometimes	I- Illness Severity Usually	I- Illness Severity Always
P- Patient Summary	P- Patient Summary Never	P- Patient Summary Rarely	P- Patient Summary Sometimes	P- Patient Summary Usually	P- Patient Summary Always
A- Action List	A- Action List Never	A- Action List Rarely	A- Action List Sometimes	A- Action List Usually	A- Action List Always
S- Situational Awareness & Contingency Planning	S- Situational Awareness & Contingency Planning Never	S- Situational Awareness & Contingency Planning Rarely	S- Situational Awareness & Contingency Planning Sometimes	S- Situational Awareness & Contingency Planning Usually	S- Situational Awareness & Contingency Planning Always
S- Synthesis by Receiver	S- Synthesis by Receiver Never	S- Synthesis by Receiver Rarely	S- Synthesis by Receiver Sometimes	S- Synthesis by Receiver Usually	S- Synthesis by Receiver Always

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* 9. Does the GIVER actively engage the receiver to ensure a shared understanding of patients (e.g encouraged questions, considers learning style of the receiver)

Never

Rarely

Sometimes

Always

Never

Rarely

Sometimes

Always

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* 10. Does the GIVER appropriately prioritize key information, concerns, or actions

Never

Rarely

Sometimes

Always

Never

Rarely

Sometimes

Always

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* 11. How well do you know the patients whose handoff you are evaluating

Very Well

Somewhat Well

Not at All

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* 12. Rate the frequency with which the Provider who gave the handoff included the following:

	Never	Rarely	Sometimes	Usually	Always
Patient summary that includes clearly specified plan for the remainder of admission	Patient summary that includes clearly specified plan for the remainder of admission Never	Patient summary that includes clearly specified plan for the remainder of admission Rarely	Patient summary that includes clearly specified plan for the remainder of admission Sometimes	Patient summary that includes clearly specified plan for the remainder of admission Usually	Patient summary that includes clearly specified plan for the remainder of admission Always
To-do items with a clear if/than format when appropriate	To-do items with a clear if/than format when appropriate Never	To-do items with a clear if/than format when appropriate Rarely	To-do items with a clear if/than format when appropriate Sometimes	To-do items with a clear if/than format when appropriate Usually	To-do items with a clear if/than format when appropriate Always
To-do list restricted to items that should be accomplished on next shift	To-do list restricted to items that should be accomplished on next shift Never	To-do list restricted to items that should be accomplished on next shift Rarely	To-do list restricted to items that should be accomplished on next shift Sometimes	To-do list restricted to items that should be accomplished on next shift Usually	To-do list restricted to items that should be accomplished on next shift Always
High quality contingency plans with clear if/then format	High quality contingency plans with clear if/then format Never	High quality contingency plans with clear if/then format Rarely	High quality contingency plans with clear if/then format Sometimes	High quality contingency plans with clear if/then format Usually	High quality contingency plans with clear if/then format Always
Miscommunications or transfer of erroneous information	Miscommunications or transfer of erroneous information Never	Miscommunications or transfer of erroneous information Rarely	Miscommunications or transfer of erroneous information Sometimes	Miscommunications or transfer of erroneous information Usually	Miscommunications or transfer of erroneous information Always
Omissions of important information	Omissions of important information Never	Omissions of important information Rarely	Omissions of important information Sometimes	Omissions of important information Usually	Omissions of important information Always
Tangential or unrelated information	Tangential or unrelated information Never	Tangential or unrelated information Rarely	Tangential or unrelated information Sometimes	Tangential or unrelated information Usually	Tangential or unrelated information Always

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* 13. How frequently did the provider receiving the handoff do the following:

	Never	Rarely	Sometimes	Usually	Always
Verbalize a synthesis of each patient (i.e check back or read back of patient handoff)	Verbalize a synthesis of each patient (i.e check back or read back of patient handoff) Never	Verbalize a synthesis of each patient (i.e check back or read back of patient handoff) Rarely	Verbalize a synthesis of each patient (i.e check back or read back of patient handoff) Sometimes	Verbalize a synthesis of each patient (i.e check back or read back of patient handoff) Usually	Verbalize a synthesis of each patient (i.e check back or read back of patient handoff) Always
Appear focused, engaged, and demonstrate active listening skills	Appear focused, engaged, and demonstrate active listening skills Never	Appear focused, engaged, and demonstrate active listening skills Rarely	Appear focused, engaged, and demonstrate active listening skills Sometimes	Appear focused, engaged, and demonstrate active listening skills Usually	Appear focused, engaged, and demonstrate active listening skills Always

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* 14. Rate the following:

	Poor	Fair	Good	Very Good	Excellent
Accuracy of Illness Severity Assessments by GIVER	Accuracy of Illness Severity Assessments by GIVER Poor	Accuracy of Illness Severity Assessments by GIVER Fair	Accuracy of Illness Severity Assessments by GIVER Good	Accuracy of Illness Severity Assessments by GIVER Very Good	Accuracy of Illness Severity Assessments by GIVER Excellent
Quality of Patient Summaries by GIVER	Quality of Patient Summaries by GIVER Poor	Quality of Patient Summaries by GIVER Fair	Quality of Patient Summaries by GIVER Good	Quality of Patient Summaries by GIVER Very Good	Quality of Patient Summaries by GIVER Excellent
Quality of synthesis by RECEIVER	Quality of synthesis by RECEIVER Poor	Quality of synthesis by RECEIVER Fair	Quality of synthesis by RECEIVER Good	Quality of synthesis by RECEIVER Very Good	Quality of synthesis by RECEIVER Excellent

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* 15. Rate the following:

	Synthesis did not occur	Insufficient length/detail and/or number of questions	Appropriate length/detail and/or number of questions	Moderately excessive length/detail and/or number of questions	Excessive length/detail and/or number of questions
What phrase listed BEST describes your impression of the appropriateness of the length and degree of detail of the syntheses by the RECEIVER	What phrase listed BEST describes your impression of the appropriateness of the length and degree of detail of the syntheses by the RECEIVER Synthesis did not occur	What phrase listed BEST describes your impression of the appropriateness of the length and degree of detail of the syntheses by the RECEIVER Insufficient length/detail and/or number of questions	What phrase listed BEST describes your impression of the appropriateness of the length and degree of detail of the syntheses by the RECEIVER Appropriate length/detail and/or number of questions	What phrase listed BEST describes your impression of the appropriateness of the length and degree of detail of the syntheses by the RECEIVER Moderately excessive length/detail and/or number of questions	What phrase listed BEST describes your impression of the appropriateness of the length and degree of detail of the syntheses by the RECEIVER Excessive length/detail and/or number of questions
What phrase listed BEST describes your impression of the appropriateness of the number of pertinent and clarifying questions asked by the RECEIVER?	What phrase listed BEST describes your impression of the appropriateness of the number of pertinent and clarifying questions asked by the RECEIVER? Synthesis did not occur	What phrase listed BEST describes your impression of the appropriateness of the number of pertinent and clarifying questions asked by the RECEIVER? Insufficient length/detail and/or number of questions	What phrase listed BEST describes your impression of the appropriateness of the number of pertinent and clarifying questions asked by the RECEIVER? Appropriate length/detail and/or number of questions	What phrase listed BEST describes your impression of the appropriateness of the number of pertinent and clarifying questions asked by the RECEIVER? Moderately excessive length/detail and/or number of questions	What phrase listed BEST describes your impression of the appropriateness of the number of pertinent and clarifying questions asked by the RECEIVER? Excessive length/detail and/or number of questions

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* 16. Indicate the phrase that BEST describes the pace of the handoff:

Very slow pace/ very inefficient

Slow pace/ inefficient

Optimally paced/ efficient

Fast/ pressure pace

Very fast/ very pressured pace

I-Pass Baseline Collection

Question Title

* 1. Observer (Name)

Question Title

* 2. Date of Observation

Question Title

* 3. Observation Time

Question Title

* 4. Type of Service

Question Title

* 5. Individuals Being Observed

Question Title

* 6. Number of Individual Patient Handoffs Observed

Question Title

* 7. Was the situational overview provided by the provider GIVING the handoff (e.g. description of the "big picture" of what will need to be prioritized by the receivers of the handoff)

Question Title

* 8. Please Indicate the Frequency of I-Pass Mnemonic Elements Presence During Observation

Question Title

* 9. Does the GIVER actively engage the receiver to ensure a shared understanding of patients (e.g encouraged questions, considers learning style of the receiver)

Question Title

* 10. Does the GIVER appropriately prioritize key information, concerns, or actions

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* 11. How well do you know the patients whose handoff you are evaluating

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* 12. Rate the frequency with which the Provider who gave the handoff included the following:

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* 13. How frequently did the provider receiving the handoff do the following:

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* 14. Rate the following:

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* 15. Rate the following:

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* 16. Indicate the phrase that BEST describes the pace of the handoff:

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* 17. What was especially effective about the handoff?

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* 18. What aspect(s) of the handoff could be improved?