Attachment C -- Patient Safety and Infection Prevention Catalogue

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

HEALTHCARE ASSOCIATED INFECTIONS (HAI) PROJECT:

PATIENT SAFETY AND INFECTION PREVENTION CATALOGUE

Thank you for agreeing to complete this catalogue on patient safety and 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 process of care. 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 the collection of information is estimated to average 60 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:

Training and Education

Please list the training and education that has been conducted in your hospital in the last 12 months that addresses patient safety and reduction of HAIs.

1.1

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

2. Please provide your opinion on how useful the training and education (listed above) are for improving patient safety and infection prevention knowledge and practices at your hospital. We welcome your thoughts on how the training and education do or do not improve their understanding of patient safety and infection prevention and reduction.

SECTION 2:

Hospital Improvements

Please list organizational changes that have been made in the last 12 months in your hospital to improve patient safety and infection prevention. 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 and Monitoring Tools for Reducing HAIs

Please list the surveillance and monitoring tools you have used in the last 12 months including national surveys, national surveillance systems, and research projects focused on patient safety, particularly preventing HAIs. Please list any regular meetings and activities focused on patient safety and HAIs. We have provided some sample common tools which you may have implemented in your hospital.

3.1

Survey, monitoring tool, or other change	Date instituted
Hospital Survey on Patient Safety Culture (HSOPSC)
National Healthcare Safety Network (NHSN) for reporting rates

2. Please provide your opinion on how useful these surveillance and monitoring tools are for improving patient safety and reducing HAIs at your hospital. We welcome your thoughts on how the tools do or do not improve the facility’s ability to improve patient safety and reduce HAIs.

SECTION 4:

Printed or Electronic Materials to Improve Patient Safety and Reduce HAIs

Please list printed or electronic materials focused on improving patient safety and preventing HAIs you have used in the last 12 months. Some examples include: reminders, wall charts, online alerts, etc.

4.1

Printed or electronic materials to improve patient safety and support reductions in HAIs	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

2. Please provide your opinion on how useful these materials are for improving patient safety and infection prevention knowledge and practices at your hospital. We welcome your thoughts on how the materials do or do not improve their understanding of patient safety and infection prevention and reduction.

SECTION 5:

Other Activities

Please list anything else your hospital has done in the last 12 months that you believe is relevant for improving patient safety and addressing aspects of infection 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 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. _________________________________________________________________________________

_________________________________________________________________________________

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. _________________________________________________________________________________

__________________________________________________________________________________

3. Please provide your opinion on how well your facility 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.)