Attachment B -- HIA Information Collection and Reporting Summary

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

HEALTHCARE ASSOCIATED INFECTIONS (HAI) PROJECT:

HAI INFORMATION COLLECTION AND REPORTING SUMMARY

Thank you for agreeing to complete this summary on HAI information collection and reporting. This is part of a project to identify factors associated with the process of care. It will take approximately 45 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 hospital?

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

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

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

Public reporting burden for the collection of information is estimated to average 45 minutes per response.  An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number.  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 (0935-0143), AHRQ, 540 Gaither Road, Room #5036, Rockville, MD 20850.

SECTION 1:

HAI Rate Collection and Reporting

Please list below the HAI rates that are reported by your hospital. Examples include: ventilator associated pneumonia (VAP); catheter-associated blood stream infections (CA-BSI); central line-associated blood stream infections (CLABSI); catheter-associated urinary tract infection (CAUTI) events; symptomatic urinary tract infections (SUTI); and surgical site infections (SSI) such as total hip arthroplasty and total knee arthroplasty. Please also provide information on the method of the collection and to whom the rates were reported.

1.1

HAI Rate	Collection Method	Reporting Method
e.g., Ventilator Associated Pneumonia (VAP)	National Healthcare Safety Network (NHSN)	CDC, state reporting system, patient safety officer, hospital CEO

2. Does your hospital collect and report overall rates for HAIs from aggregated rate-specific information? If so, please indicate how this overall rate is collected and how it is reported.

SECTION 2:

General Work Environment

Please think about the last 12 months (or for the period you have been employed if less than 12 months) 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
2.1 Our hospital supports a culture of patient safety.
2.2 I have a supportive work-team environment that enhances patient safety.
2.3 Our hospital ensures that we have adequate staffing coverage to reduce staff fatigue and overwork.
2.4 Our hospital does a good job of establishing a culture of patient safety with new employee training.
2.5 The safety culture in my hospital supports staff members acknowledging adverse events.
2.6 Our hospital has been able to sustain the gains we have made in improving patient safety.
2.7 There are ongoing training and refresher courses for all types of staff to decrease complacency and increase adherence to patient safety practices.
2.8 Oure hospital management allocates adequate resources (staff, supplies, etc.) to support patient safety initiatives.
2.9 Our hospital monitors infection and complication rates to continue to improve patient safety.
2.10 I believe our hospital is not doing enough to improve patient safety and prevent healthcare associated infections.
2.11 We have an active continuing education program focused on infection reduction issues.

SECTION 3:

Infection Prevention and Reduction Activities

1. In your opinion, does collecting the hospital infection rates listed in Section 1 help identify areas for targeting infection reduction? If so, please provide an example of a training, tool, or intervention that was used by your hospital. Did the training, tool, or intervention result in infection rate improvements?

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2. Do you have suggestions for infection prevention and reduction training and interventions that could be implemented at your hospital?

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3. What challenges did you encounter in implementing infection reduction initiatives in your hospital?

Was the hospital able to resolve these challenges? If so, how?

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3.4 What other lessons did you learn from implementing infection reduction initiatives?

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SECTION 4:

Additional Comments and Perspectives on Patient Safety and Infection Prevention

1. If your hospital has implemented changes to improve patient safety and infection prevention in the past 12 months, what were the 2 most important changes that have been made? (Leave blank if your hospital has not implemented changes to improve patient safety and infection prevention in the last 12 months.)

A. ________________________________________________________________________________

________________________________________________________________________________

B. _________________________________________________________________________________

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2. If your hospital has not implemented the 2 most important patient safety and infection prevention what do you think are the reasons?

A. _________________________________________________________________________________

_________________________________________________________________________________

B. _________________________________________________________________________________

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

Thank you very much for completing this assessment.

Please return this form to:

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