TeamSTEPPS® Instructor Manual: Site Assessment Profile

The following items provide an operational profile of your hospital or department.
Please provide information on as many items that are applicable
.

1.1 Name of medical facility:  _______________________________________________________________

1.2 Date this survey completed:  _____________________________________________________________

1.3 Number of licensed inpatient beds:  ______________________________________________________

1.4a Number of inpatient admissions for last fiscal year:  ________________________________________

1.4b Number of occupied bed days for last fiscal year:  ____________________________________________

1.4c Annual census of your department:  __________________________________________________________

1.5 Number of outpatient visits per year for last fiscal year:  __________________________________

1.6 Staff Profile: Check if for hospital wide  __________  or department  __________

 

Complete for Civilian Facilities:

Number of PositionsFilledVacant
Physicians  
Nurses  
Others  

 

Complete for DoD Facilities:

Number of PositionsFilledVacant
Physicians - Military  
Physicians - Civil Service  
Nurses - Military  
Nurses - Civil Service  
Contract Staff  
Enlisted Staff  
GS Staff  
Others  

 

1.7 Organization of services (check all that apply)

 % of PopulationInpt.Outpt.Other Areas Not Listed%
ED     
OR     
ICU     
L&D     
Med/Surg     
Pediatrics     
Ambulatory Care     
Psychiatry     

 

1.8 Support Services (check all that apply)

AdmittingFinanceMaterials ManagementRadiology
Central ProcessingHousekeepingPastoral ServiceRespiratory Therapy
Clinical LaboratoriesHuman ResourcesPatient AdvocateSocial Service
Consulting ServicesInformation SystemsPharmacyTransport Service
Dietary/NutritionLaundryPT/OTOther

 

1.9 Are there impending changes or initiatives that your facility is expecting in the next 12 months? (Check all that apply)

Change in or absence of executive leaderPlant Renovations
Change in or absence of Medical DirectorRegulatory agency site visit (e.g., JCAHO)
Change in or absence of Nursing DirectorHospital-wide mandatory training
New patient care servicesMajor research efforts
DeploymentMajor readiness exercise
Union contract renewalOther

 

1.10 Overall Vision for the institution (May provide Mission, Vision and Values):
        ________________________________________________________________________
        ________________________________________________________________________
        ________________________________________________________________________
 

1.11 What are the facility's strategic goals?
        ________________________________________________________________________
        ________________________________________________________________________
        ________________________________________________________________________
 

1.12   Has a Medical Team Training initiative ever been conducted in your organization?
Yes or No. If yes, what was the impact and are teams still functional (list departments)?

        ________________________________________________________________________
        ________________________________________________________________________
        ________________________________________________________________________
        ________________________________________________________________________
        ________________________________________________________________________
 

1.13 What clinical and safety measures are you currently tracking (Include FMEA indicators)?
        ________________________________________________________________________
        ________________________________________________________________________
        ________________________________________________________________________
        ________________________________________________________________________
 

1.14 Patient Satisfaction Surveys:

1.14a What patient satisfaction tool does your site currently use?
  ________________________________________________________________________
1.14b What do patients report being most satisfied with?
  ________________________________________________________________________   ________________________________________________________________________   ________________________________________________________________________
1.14c What do patients report being least satisfied with?
  ________________________________________________________________________   ________________________________________________________________________   ________________________________________________________________________
1.14d Please provide most recent reported measures:
  ________________________________________________________________________   ________________________________________________________________________   ________________________________________________________________________

1.15 Staff Satisfaction Surveys:

1.15a What tool do you currently use to assess staff satisfaction?
  ________________________________________________________________________
1.15b What do staff report as being the most satisfying part of their job?
  ________________________________________________________________________   ________________________________________________________________________   ________________________________________________________________________
1.15c What do staff report as being least satisfied with?
  ________________________________________________________________________   ________________________________________________________________________   ________________________________________________________________________
1.15d Please provide most recent reported measures:
  ________________________________________________________________________   ________________________________________________________________________   ________________________________________________________________________

Current as of March 2013
Internet Citation: TeamSTEPPS® Instructor Manual: Site Assessment Profile. March 2013. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/education/curriculum-tools/teamstepps/instructor/reference/assesspfl.html