Form #2 Form #2 Post-Training Infection Prevention and Safety Assessment

Form Approved
OMB No. 0935-XXXX
Exp. Date XX/XX/20XX

HEALTHCARE ASSOCIATED INFECTIONS (HAI) PROJECT:

POST-TRAINING INFECTION PREVENTION AND PATIENT SAFETY ASSESSMENT

Thank you for agreeing to answer some questions about infection prevention at your facility and in your work as part of a project to identify factors associated with the implementation of training that can assist facilities in successfully preventing infections associated with the process of care and sustaining these reductions. It will take approximately 45 minutes to answer these questions. All the answers you give will be handled CONFIDENTIALLY. Individual responses will not be shared. We are requesting identification information for data-coding use only. Thank you very much for agreeing to participate in this project.

Today’s date: HAI Master Site Name:

NOTE: Contractors may prepopulate this line

This site’s name and location: What is your position at this facility? (Please mark one.)
(facility and unit, if applicable)

(ADD CODING FOR SUB-SITES HERE IF DESIRED)

Nurse Pharmacist

Physician (attending/staff) Healthcare aide

Resident/intern Hospital administration

Physician assistant Risk manager

Respiratory therapist Patient safety/quality officer

Other, specify:

1. What is your present position (title) at this institution?

2 . How long have you been in your present position? AND/OR

3 . How long have you been working at this institution? AND/OR

4 . How long have you worked in the healthcare field? AND/OR

Public reporting burden for this collection of information is estimated to average 45 minutes per response, the estimated time required to complete the survey. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: AHRQ Reports Clearance Officer Attention: PRA, Paperwork Reduction Project (0935-XXXX) AHRQ, 540 Gaither Road, Room # 5036, Rockville, MD 20850.

SECTION 1:

Attitudes about Patient Safety and Reducing Healthcare Associated Infections

Please think about the last 12 months (or whatever shorter period is applicable for you) and respond to these statements, selecting one (1) response for each statement below.

NOTE: Please check ‘Not applicable’ if you do not have experience in the area or do not have an opinion.

	Strongly agree (5)	Agree (4)	Somewhat agree (3)	Disagree (2)	Strongly disagree (1)	Not applicable
1.1 I always clean my hands before and after contact with every patient.
1.2 I keep abreast of advances in patient safety through print and electronic media.
1.3 Our team has a well-functioning interdisciplinary team approach to patient safety.
1.4 There are practical things I can do during my daily work routine – no matter what my job - that help prevent healthcare associated infections in my facility.

1.5 I am aware of Joint Commission mandated training on patient safety topics.

Yes

No

1.6 I am familiar with CDC guidelines and recommendations on healthcare associated infections.

Yes

No

1.7 I know about and/or work with organizations or associations concerned with infection prevention.

Yes

No

1.8 I am up to date with my own preventive health care including immunizations (flu, pneumonia, etc.) and TB testing.

Yes

No

SECTION 2:

Work Practices which Prevent Healthcare Associated Infections

Please think about the last 12 months (or whatever shorter period is applicable for you) and respond to these statements, selecting one (1) response for each statement below. If you are not in a clinical position, please skip to SECTION 4.

NOTE: Please check ‘Not applicable’ if you do not have experience in the area or do not have an opinion.

2.I I estimate that I clean my hands before and after contact with every patient approximately %

of the time during my usual workday.

	Strongly agree (5)	Agree (4)	Somewhat agree (3)	Disagree (2)	Strongly disagree (1)	Not applicable
2.2 My facility mandates the use of standardized checklists to reduce healthcare associated infections.
2.3 I am comfortable asking a physician or resident to stop a central line insertion if I recognize a break in sterile technique or other situation which will harm the patient.
2.4 My unit continually improves its use of information to monitor quality of patient care.
2.5 Healthcare associated infections most often occur due to human factors.
2.6 In procedures for chest tube insertions on our unit, wide draping (head to waist for an adult patient) is always practiced to reduce risk of infection.
2.7 The operator only needs to wear sterile mask and gloves during a chest tube insertion.
2.8 It is important to restrain patient upper limbs during chest tube insertions.
2.9 Staff assisting at a central venous catheter (CVC) insertion are the ones responsible for ensuring that the draped field stays sterile.
2.10 Minimizing CVC manipulation is one of the most important daily management practices to prevent infections.
2.11 Nurse-to-patient ratio and specialized line teams are key strategies to reduce blood stream infection (BSI) from indwelling catheters.
2.12 Late-onset pneumonia (> 96 hours after intubation or ICU admission) is evidence of a healthcare associated infection.
2.13 Elevating the head of the bed will decrease a patient’s risk of acquiring ventilator- associated pneumonia (VAP).

2 .14 No matter how busy it is or how urgent the situation, I estimate that I am able to follow standard operating

procedures (SOP) % of the time during my usual work day.

SECTION 3

Additional Comments and Perspectives on Infection Prevention and Patient Safety

Please provide your opinion on how well your facility addresses infection prevention and patient safety. We welcome your thoughts about successes achieved, barriers, and investments made in infection prevention and patient safety.

If you did not participate in the HAI tool(s) training, you may stop here.

Thank you very much for completing this assessment.

Please return this form to:

(NOTE: Leave blank for each individual facility to insert name.)

Section 4:

Putting Training into Practice

Please provide your input regarding any changes in practices since you have taken this training.

1. I have changed practices since I went through this training. These are the three (3) most important changes I have made:

1. ____________________________________________________________________

2. ____________________________________________________________________

3. ____________________________________________________________________

2. Please describe what you did to make these actionable changes after training.

____________________________________________________________________

____________________________________________________________________

____________________________________________________________________

3. Our facility has implemented changes to improve infection prevention and patient safety in the past 6 months. These are the three most important changes that have been made:

1. ____________________________________________________________________

2. ____________________________________________________________________

3. ____________________________________________________________________

4. What 3 specific daily work practices (that are not already being done) could be instituted at your facility to improve infection prevention and patient safety and reduce risk of complications?

1. ____________________________________________________________________

2. ____________________________________________________________________

3. ____________________________________________________________________

Thank you very much for completing this assessment.

Please return this form to:

(NOTE: Leave blank for each individual facility to insert name.)