Form 8 Attachment G: LTC Team Checkup Tool

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

Attachment G: Team Checkup Tool

TEAM CHECK-UP TOOL – Long-Term Care (LTC)

Please answer the following questions with respect to the past month only: This survey will take 10 minutes or less to complete.
1. Please estimate what percentage of all residents in the facility utilized chlorhexidine for any bed bath or shower in the past month.	 <25%  25-50%  51-75%  >75%  N/A
2. Please estimate what percentage of all residents in the facility, over the past month, received nasal decolonization treatment with intranasal mupirocin or iodophor.	 <25%  25-50%  51-75%  >75%  N/A
3. Please estimate what percentage of all residents in the facility 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 all residents in the facility known to have MRSA colonization or infection were placed on enhanced barrier precautions in the past month.	 <25%  25-50%  51-75%  >75%  N/A
5. Please estimate what percentage of residents in the facility with a central-line (CL) inserted received the elements of the CLABSI prevention central-line maintenance bundle (e.g. scrubbing the hub before CL access; using sterile devices for CL access; replacing CL dressings that are wet, soiled, or loose; sterile process for dressing changes; regularly changing administration sets; daily assessment for line necessity and prompt CL removal when feasible) in the past month.	 <25%  25-50%  51-75%  >75%  N/A
6. Please estimate what percentage of high-touch surfaces in the resident rooms were adequately cleaned and disinfected in the past month (estimate based on your standard assessment of cleaning procedures).	 <25%  25-50%  51-75%  >75%  N/A
7. Please estimate the percentage of hand hygiene compliance among healthcare personnel on the facility in the past month (estimate based on your standard assessment of hand hygiene).	 <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.
8. Please estimate the percentage of compliance with proper use of personal protective equipment (PPE) among healthcare personnel for patients on either contact isolation precautions or enhanced barrier precautions in the facility in the past month (estimate based on your standard assessment of PPE compliance).	 <25%  25-50%  51-75%  >75%  N/A
9. 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 facility (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
10. In the past month, which of the following methods did your team implement to educate the staff on your facility 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
11. How many times did the AHRQ Safety Program for MRSA Prevention team meet with your senior executive, or review 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
12. Was the MRSA performance data reviewed with the CUSP team during the past month?	 Yes  No
13. How many times did your team share your MRSA prevention performance results broadly with your facility’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.
14. If AHRQ Safety Program for MRSA Prevention data were shared with your facility’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:___________
15. How many members of your CUSP team or leadership (DON, Administrator, etc.) permanently left your facility in the past month?	_____ (# of people who left)
16. Indicate how many people joined the CUSP team in the past month.	_____ (# of people who joined the team)
17. Has there been any disruptive event in your facility 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
18. 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.).
19. 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): ____________________________________