a1 Structural Asse Attachment A: Structural Assessment for Acute Care Setti

Form Approved
OMB No. 0935-0238
Exp. Date 09/30/2020

Attachment A: Structural Assessment Form for Acute Care Settings

STRUCTURAL ASSESSMENT

1. How many hospital beds are in your institution?

2. How many hospital beds are in your unit?

3. Has your unit used the comprehensive unit-based safety program (CUSP) for other quality improvement

initiatives before? Yes No

3a. If yes, please describe previous initiatives that have used the CUSP approach.

4. Does your institution have an existing Antibiotic Stewardship Program (ASP)? Yes No

If you answered N0 in the last question, you can stop here. If you answered Yes, please continue.

4a. Does your ASP have a physician lead? Yes No

• What percent FTE does the physician lead receive for stewardship activities? 4b. Does your ASP have a pharmacist lead? Yes No

• What percent FTE of pharmacist time is devoted towards your ASP?

4c. What are the current activities of your ASP? (Check all that apply) Developing an antibiogram

Developing educational modules

Developing local antibiotic treatment guidelines Prior-approval of select antibiotics

Post-prescription review with feedback of select antibiotics

Other (please describe)

4d. Do you report antibiotic days of therapy per 1,000 days present periodically to track antibiotic usage?

Yes No

4e. Please describe if there are other outcomes your ASP tracks.

______________________________________________________

5. Does your hospital have an Antibiotic Stewardship Committee? Yes No

6. What is the title of the person to whom your ASP reports?

Public reporting burden for this collection of information is estimated to average 12 minutes per response, the estimated time required to complete the survey. 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 (0935-0238) AHRQ, 540 Gaither Road, Room # 5036, Rockville, MD 20850.

The confidentiality of your responses is protected by Sections 944(c) and 308(d) of the Public Health Service Act [42 U.S.C. 299c-3(c) and 42 U.S.C. 242m(d)]. Information that could identify you will not be disclosed unless you have consented to that disclosure.