Form 6 Attachment E: ICU/Non-ICU Team Checkup Tool

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

Attachment E: ICU/Non-ICU Team Checkup Tool

TEAM CHECK-UP TOOL – ICU/NON-ICU

Please answer the following questions with respect to the past month.
1. ICU: Please estimate what percentage of all patients received daily decolonization with chlorhexidine treatments in the past month. Non-ICU: Please estimate what percentage of targeted patients with central-lines or lumbar drains received daily decolonization with chlorhexidine treatments in the past month.	 <25%  25-50%  51-75%  >75%  N/A
2. ICU: Please estimate what percentage of all patients received 5 days of treatment with intranasal mupirocin or iodophor for MRSA decolonization in the past month. Non-ICU: Please estimate what percentage of targeted patients with central-lines or lumbar drains received 5 days of treatment with intranasal mupirocin or iodophor for MRSA decolonization in the past month.	 <25%  25-50%  51-75%  >75%  N/A
3. Please estimate what percentage of all patients known to have MRSA colonization or infection were placed on contact isolation precautions in the past month.	 <25%  25-50%  51-75%  >75%  N/A
4. Please estimate what percentage of patients who had central-lines inserted in the past month received the elements of the CLABSI prevention central-line insertion bundle.	 <25%  25-50%  51-75%  >75%  N/A
5. Please estimate what percentage of patients with a central-line inserted received the elements of the CLABSI prevention central-line maintenance bundle in the past month.	 <25%  25-50%  51-75%  >75%  N/A
6. Please estimate what percentage of high-touch surfaces in the patient care rooms were adequately cleaned and disinfected both daily and for terminal cleaning in the past month (estimate based on your standard assessment of cleaning procedures).	 <25%  25-50%  51-75%  >75%  N/A
Public reporting burden for the collection of information is estimated to average 10 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, 5600 Fishers Lane, MS 0741A, Rockville, MD 20857. 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.
7. Please estimate the percentage of hand hygiene compliance among healthcare personnel on the unit in the past month (estimate based on your standard assessment of hand hygiene).	 <25%  25-50%  51-75%  >75%  N/A
8. Please indicate the CUSP activities in which your team participated in the past month by checking all that apply:	 CUSP meeting: Frequency  Once  Twice  Identify how patients may be harmed in your unit (SSA)  Senior Executive Walk Rounds  A morning briefing or huddle to discuss the patients  Multidisciplinary rounding stating specific goals for the patient that day (Daily Goals)  Learning from defects or adverse events
9. In the past month, which of the following methods did your team implement to educate the staff on your unit on MRSA prevention evidence-based practice? (Check all that apply.)	Members of the staff attended:  Internal seminar  IP visit/ talk/ report  MRSA Project webinar  In-services/demos  Other: _____________________ CUSP Team members:  Developed a new written policy  Posted evidence-based guidelines  Other: _____________________
10. How many times did the AHRQ Safety Program for MRSA Prevention team meet with your senior executive that adopted your unit, or reviewed your MRSA data with the senior executive or senior leadership (c-Suite) in the past month?	 None  Once  Twice  More than twice  No Senior Executive
11. Was the MRSA performance data (Infection Control Report) reviewed with the CUSP team during the past month?	 Yes  No
12. How many times did your team share your MRSA prevention performance results broadly with your unit’s staff in the past month?	 None  Once  Twice  More than twice  Continuous sharing of data (bulletin boards, online portals, etc.) If none, please go to question 14.
13. If AHRQ Safety Program for MRSA Prevention data were shared with your unit’s staff in the past month, please indicate how the data were provided by checking all that apply:	 Verbal Report  Poster  N/A  Written Report  Continuous sharing of data (bulletin boards, online portals, etc.)  Other:___________
14. How many people from your quality improvement team permanently left your organization or unit in the past month?	_____ (# of people who left)
15. Indicate how many people joined the quality improvement team in the past month.	_____ (# of people who joined the team)
16. Has there been any disruptive event in your unit that has distracted staff from this work (e.g., emergency response; re-organization; death of staff; sentinel event; accreditation, etc.) in the past month?	 Yes  No
17. If Yes to Q16, please identify the event that distracted staff from this work. (e.g., emergency response; re-organization; death of staff; sentinel event; accreditation, etc.).
18. In the past month, did any of the following significantly slow your team’s progress? Please check all that apply.
 Insufficient knowledge of evidence supporting interventions  Lack of team member consensus regarding goals  Not enough time to complete all the tasks for this project.  Lack of quality improvement skills  Not enough buy-in from other physician staff in your area  Not enough buy-in from other nursing staff in your area  Not enough buy-in from other staff members in your area  Burden of data collection  Not enough leadership support from executives  Other, if applicable (identify): ____________________________________