Form #5 Form #5 Infection Prevention and Patient Safety Activity Catalog

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

HEALTHCARE ASSOCIATED INFECTIONS (HAI) PROJECT:

INFECTION PREVENTION AND PATIENT SAFETY ACTIVITIES CATALOGUE

Thank you for agreeing to complete this catalogue on infection prevention training, education and other activities at your facility for the past 12 months. This is 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 60 minutes to complete this form. You may need to consult someone else for specific information you need. All the answers you give are CONFIDENTIAL. 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:

Name and location of this site:
(ADD CODING FOR SUB-SITES HERE)

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 60 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:

Training and Education

Please list the training and education that has been conducted in your facility in the last 12 months that addresses patient safety and reduction of healthcare associated infections (HAI).

Course title	Frequency	Target population (worker types trained)	Approximate number trained
e.g., New-employee orientation	Every other Monday	Nurses Therapists	143
e.g., Brown bag presentation on MRSA	Annually	All clinical staff	110

Please estimate the amount of this training targeted to high-risk settings:

All

Most

Some

None

SECTION 2:

Facility Improvements

Please list organizational changes that have been made in the last 12 months in your facility to improve infection prevention and patient safety. Some examples of improvements include: implementation of standard operating procedures (SOP), protocols or checklists for certain procedures; increased and/or specific monitoring systems; additional budget allotment for equipment, supplies, or staffing; designation of specific teams or champions; and policy changes.

Facility change made	Date instituted	Location of change (overall or list specific unit)
e.g., Checklist for chest tube insertions	04/28/2007	ICU, ED
e.g., Alcohol hand sanitizer introduced	01/2007	Facility-wide

SECTION 3:

Surveillance, Monitoring and Evaluation of Improvements in HAI

Please list the surveillance, data collection, and monitoring tools you have used in the last 12 months including national surveys, national surveillance systems, and research projects focused on preventing HAI. Please list any regular review meetings focused on HAI or other data-use activities. We have provided some sample common tools which you may have implemented in your facility.

Survey, research, routine data collection or other change	Date instituted
Hospital Survey on Patient Safety Culture (HSOPSC)
National Healthcare Safety Network (NHSN) for reporting rates
Surveillance for specific HAI type (Please list all that apply)

SECTION 4:

Printed or Electronic Materials to Support Reductions in HAI

Please list materials and media focused on preventing HAI you have used in the last 12 months. Some examples include: reminders, wall charts, online alerts, etc.

Printed or electronic materials to support reductions in HAI	Date instituted	Location of change (overall or list specific unit)
e.g., Posting infection rate charts in units involved	05/29/2007	ICU, ED
e.g., Hand washing screen-savers on all PCs	01/02/2007	Facility-wide

SECTION 5:

Other Activities

Please list anything else your facility has done in the last 12 months that you feel is relevant in addressing aspects of HAI prevention.

Other activities	Date instituted	Location of change (overall or list specific unit)
e.g., Bi-weekly interdisciplinary team meetings to discuss and reduce barriers to effective aseptic techniques in procedures	02/10/2007	All ICUs

SECTION 6:

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.

Thank you very much for completing this assessment.

Please return this form to:

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