Program Description and Confidentiality Statement

You have reached the old version of the Smooth Transitions surveys. Please do not fill this out. Our new surveys can be found on the Smooth Transitions website at https://www.qualityhealth.org/smoothtransitions/surveys-2/

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* 1. Date of transfer

Date

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* 2. Receiving Facility and County

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* 3. Type of Transfer

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* 4. Mode of transfer

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* 5. Receiving Provider Type

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* 6. Urgency of transfer

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* 7. What was/were the indication(s) for transfer?

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* 8. Did the community midwife notify the hospital prior to arrival?

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* 9. Did the community midwife accompany the patient to the hospital?

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* 10. Did the community midwife:

  yes no
Provide a verbal report to you, including details on current health status?
Convey a sense of urgency appropriately aligned with the clinical situation?
Provide a legible copy of relevant prenatal and labor medical records?
Answer your questions about the patient and what led to the transfer?
Use a transfer form?

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* 11. Regarding the quality and accuracy of the information the midwife provided:

  high quality and very accurate average quality and accuracy low quality and inaccurate N/A
the phone request for transfer
the verbal report upon arrival
the medical record/chart

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* 12. Please use the following scale in responding to the statements below:

  strongly agree agree undecided/neutral disagree strongly disagree
The interactions between me and the community midwife were professional.
The communication between me and the community midwife was respectful.
The midwife and I worked well together.
The hospital staff were sensitive to the psychological/emotional needs of this patient.
The hospital staff accommodated the community midwife's presence according to the patient's wishes and/or hospital's protocols.
I participated in shared decision-making with the patient to create a care plan.

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* 13. A TeamBirth "huddle" is when the community midwife, hospital provider, and nurse, talk together with the patient (and their support team) about their preferences for labor, birth, and postpartum and together agree on care plans for them and their baby, and set plans for the next check-in or step. 

Can you share information about your participation in these huddles?  Select all that apply.

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* 14. Do you feel your interactions with the patient and/or the transferring midwife were impacted by your race/ethnicity, gender identity, or disability status?

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* 15. What went well during this transfer process?

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* 16. What could have gone better during this transfer process? 

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* 17. How would you rate this transfer overall?

0 100
Clear
i We adjusted the number you entered based on the slider’s scale.

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* 18. Do you have any other comments about this transfer?

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* 19. Do you participate in the Smooth Transitions Perinatal Transfer Committee Meetings with the hospital where this transfer occurred?

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* 20. How would you describe your experience level interacting with community midwives during transfers?

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