Maryland Patient Safety Center Perinatal Collaborative
Team Registration Form
Please complete and email to horvathb@dfmc.org or fax to 410-712-4357 before January 19, 2007.
Hospital Name (indicate if more than one site):
Improvement Lead
First Name:
Last Name:
Title:
Email:
Direct Telephone:
Fax Number:
Direct Mailing Address:
Improvement Team Members (* = required)
Feel free to add rows, but please complete all fields to avoid delays in registration. Note: These roles are not exclusive. Please consider who the stakeholders are within your local
context and build a representative team. If you would like to discuss an alternative model, please contact Bonnie Horvath at 410-712-7431, ext. 7661, or horvathb@dfmc.org.
Collaborative Role
Executive Sponsor
(vice-president or above)*
Chief or Director of Obstetrics*
Registered Nurse*
Physician (OB)*
Director or Nurse Manager (OB)*
Patient Safety or Quality Representative
OB Resident (only if your facility has
a residency program)
Name (First and Last)
Credentials
Professional Title
Email
Collaborative Role
Name (First and Last)
Credentials
Professional Title
Perinatologist
Neonatologist
Anesthesiologist
Risk Manager
Respiratory Therapist
NICU Nurse
Nurse Midwife
IT Specialist
Tell Us About Your Perinatal/Labor and Delivery Unit
Annual birth volume:
Level of Neonatal Intensive Care Unit (NICU):
Level I
Level II
Number of NICU beds:
Level III
Other specialty beds:
Number of Labor/Delivery/Recovery and Post Partum (LDRP) rooms:
Total number of labor and delivery staff and physicians:
Staffing
What staffing model do you employ?
Private model (Physicians are part of a private practice or group)
Hospital/medical center model (Physicians are employed by the hospital or medical center)
Is an OB physician available in-house 24 hours a day, 7 days a week?
Is an anesthesiologist available in-house 24 hours a day, 7 days a week?
Is a neonatologist or perinatologist on staff?
Yes
No
Yes
Yes
No
No
Email
Are nurse midwives on staff?
Yes
No
Do your units use residents or is there a residency program?
If yes, which medical school is the program affiliated with?
Yes
No
Obstetrical Practices
Does your unit use forceps and/or vacuum extraction techniques?
Yes
Does your unit perform Vaginal Birth After Cesarean Section (VBACS)?
No
Yes
No
Other
Has your unit undergone any type of team training?
Yes
No
If yes, please describe.
Does your unit require annual competencies in labor and delivery for physicians and nurses?
If so, in what areas?
Yes
No
Which of the following tools have you incorporated into your unit practice?
SBAR
Briefings
Two-Challenge Rule
Huddles
Check-Back
Critical Events Training
Simulations
Other:
Have any changes occurred in leadership (for example, CEO, Chief of OB, Director of Nursing, etc.) in the last 3 months?
If yes, which position(s)?
Yes
No
As part of the collaborative, we will hold monthly conference calls to discuss various topics and facilitate sharing between hospitals. Please indicate which days and times
would be most convenient for your team.
Monday
A.M.
P.M.
Tuesday
A.M.
P.M.
Wednesday
A.M.
P.M.
Thursday
A.M.
P.M.
Friday
A.M.
P.M.