Form 4 Participant Experience Survey - Improving Antibiotic Use

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

Attachment D: Participant Experience Survey—Antibiotic Use Cohort

Brick and Mortar Practices

Participant Experience Survey

Improving Antibiotic Use Cohort

Brick-and-Mortar Practices

Thank you for your participation in the AHRQ Safety Program for Improving Antibiotic Use in Telemedicine (“the Safety Program”). The following questions pertain to your experience implementing the AHRQ Safety Program for Telemedicine: Improving Antibiotic Use (“the Safety Program”)

1. What is the most important change you implemented to achieve your antibiotic stewardship goals? (open-ended response)

2. What did you or your practice measure to determine whether your antibiotic stewardship goals were met? (open-ended response)

3. How did you or your practice ensure adequate support to implement the Safety Program? (open-ended response)

4. How did clinicians within your practice support implementation of the Safety Program? (open-ended response)

5. Are members of your practice aware of the Four Moments of Antibiotic Decision Making?

☐ Yes ☐ No

6. Have clinicians been incorporating the Four Moments of Antibiotic Decision Making into their daily clinical practice?

☐ Yes (please explain why:_________________)

☐ No (please explain why not:______________)

7. How did non-clinician staff within your practice support implementation of the Safety Program? (open-ended response)

8. In addition to the Four Moments Framework, did you implement any other processes or procedures to support your antibiotic stewardship goals? (open-ended response)

9. What barriers did you experience while implementing the Safety Program in your practice? (Please select all that apply)

☐ Health system-level barriers (Please give a specific example:________________)

☐ Practice-level barriers (e.g., leadership not invested in the program) (Please give a specific example:__________________________________________________­­­_)

☐ Hesitation among colleagues (Please give a specific example:_______________)

☐ Resistance among patients (Please give a specific example:________________)

☐ Other (please specify and provide a specific example:______________________)

10. What changes have you or your practice made to ensure proper antibiotic prescribing practices are sustained? (open-ended response)

11. Which of the following content areas included in the Safety Program were helpful to your daily practice? (Select all that apply)

☐ Sinusitis

☐ Ear pain

☐ Influenza

☐ Acute bronchitis/chest cold

☐ Symptomatic treatment of upper respiratory tract infections

☐ Urinary tract infections

☐ Cellulitis

☐ Sexually transmitted infections

☐ Antibiotic allergy assessment

☐ Pharyngitis/sore throat

☐ COVID-19

☐ RSV

☐ Potential harms of antibiotics

☐ Other (please specify)

12. Were there specific tools or resources in the Safety Program that you found particularly helpful? Please list these.(open-ended response)

13. What additional content would have been helpful to include in the Safety Program? (open-ended response)

Public reporting burden for this collection of information is estimated to average 20 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-XXXX) AHRQ, 540 Gaither Road, Room # 5036, Rockville, MD 20850.