Form #1 Form #1 Pre-Training Infection Prevention and Safety Assessment

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

HEALTHCARE ASSOCIATED INFECTIONS (HAI) PROJECT:

PRE-TRAINING INFECTION PREVENTION AND PATIENT SAFETY ASSESSMENT

Thank you for agreeing to answer some questions about infection prevention at your facility and in your work as part of a project to identify factors associated with the implementation of training that can assist facilities in successfully preventing infections associated with the process of care and sustaining these reductions. It will take approximately 30 minutes to answer these questions. All the answers you give will be handled CONFIDENTIALLY. 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:

NOTE: Contractors may prepopulate this line

This site’s name and location: What is your position at this facility? (Please mark one.)
(facility and unit, if applicable)

(ADD CODING FOR SUB-SITES HERE IF DESIRED)

Nurse Pharmacist

Physician (attending/staff) Healthcare aide

Resident/intern Hospital administration

Physician assistant Risk manager

Respiratory therapist Patient safety/quality officer

Other, specify:

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 this collection of information is estimated to average 30 minutes per response, the estimated time required to complete the survey. 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.

SECTION 1:

General Work Environment

Please think about the last 12 months (or whatever shorter period is applicable for you) and respond to these statements, selecting one (1) response for each statement below.

NOTE: Please check ‘Not applicable’ if you do not have experience in the area or do not have an opinion.

	Strongly agree (5)	Agree (4)	Somewhat agree (3)	Disagree (2)	Strongly disagree (1)	Not applicable
1.1 My team has established a culture of patient safety.
1.2 I have a supportive work-team environment that enhances patient safety.
1.3 My supervisor(s) ensure that we have adequate staffing coverage to reduce staff fatigue and overwork.
1.4 This facility does a good job of establishing a culture of patient safety with new employee training.
1.5 The safety culture in my team supports staff members acknowledging adverse events.
1.6 Our facility has been able to sustain the gains we have made in improving patient safety.
1.7 There are ongoing training and refresher courses for all types of staff to decrease complacency and increase adherence to patient safety practices.
1.8 The management in my facility allocates adequate resources (staff, equipment, supplies, etc.) to support patient safety initiatives.
1.9 Our facility monitors infection and complication rates to continue to improve patient safety.
1.10 I believe my facility is not doing enough to improve patient safety and prevent healthcare associated infections.
1.11 We have an active continuing education program focused on patient safety issues.

SECTION 2:

Attitudes about Patient Safety and Reducing Healthcare Associated Infections

Please think about the last 12 months (or whatever shorter period is applicable for you) and respond to these statements, selecting one (1) response for each statement below.

NOTE: Please check ‘Not applicable’ if you do not have experience in the area or do not have an opinion.

	Strongly agree (5)	Agree (4)	Somewhat agree (3)	Disagree (2)	Strongly disagree (1)	Not applicable
2.1 I always clean my hands before and after contact with every patient.
2.2 I keep abreast of advances in patient safety through print and electronic media.
2.3 Our team has a well-functioning interdisciplinary team approach to patient safety.
2.4 There are practical things I can do during my daily work routine – no matter what my job - that help prevent healthcare associated infections in my facility.

2.5 I am aware of Joint Commission mandated training on patient safety topics.

Yes

No

2.6 I am familiar with CDC guidelines and recommendations on healthcare associated infections.

Yes

No

2.7 I know about and/or work with organizations or associations concerned with infection prevention.

Yes

No

2.8 I am up to date with my own preventive health care including immunizations (flu, pneumonia, etc.) and TB testing.

Yes

No

SECTION 3:

Work Practices which Prevent Healthcare Associated Infections

Please think about the last 12 months (or whatever shorter period is applicable for you) and respond to these statements, selecting one (1) response for each statement below. If you are not in a clinical position, please skip to SECTION 4.

NOTE: Please check ‘Not applicable’ if you do not have experience in the area or do not have an opinion.

3 .1 I estimate that I clean my hands before and after contact with every patient approximately %

of the time during my usual workday.

	Strongly agree (5)	Agree (4)	Somewhat agree (3)	Disagree (2)	Strongly disagree (1)	Not applicable
3.2 My facility mandates the use of standardized checklists to reduce healthcare associated infections.
3.3 I am comfortable asking a physician or resident to stop a central line insertion if I recognize a break in sterile technique or other situation which will harm the patient.
3.4 My unit continually improves its use of information to monitor quality of patient care.
3.5 Healthcare associated infections most often occur due to human factors.
3.6 In procedures for chest tube insertions on our unit, wide draping (head to waist for an adult patient) is always practiced to reduce risk of infection.
3.7 The operator only needs to wear sterile mask and gloves during a chest tube insertion.
3.8 It is important to restrain patient upper limbs during chest tube insertions.
3.9 Staff assisting at a central venous catheter (CVC) insertion are the ones responsible for ensuring that the draped field stays sterile.
3.10 Minimizing CVC manipulation is one of the most important daily management practices to prevent infections.
3.11 Nurse-to-patient ratio and specialized line teams are key strategies to reduce blood stream infection (BSI) from indwelling catheters.
3.12 Late-onset pneumonia (> 96 hours after intubation or ICU admission) is evidence of a healthcare associated infection.
3.13 Elevating the head of the bed will decrease a patient’s risk of acquiring ventilator- associated pneumonia (VAP).

3 .14 No matter how busy it is or how urgent the situation, I estimate that I am able to follow standard operating

procedures (SOP) % of the time during my usual work day.

SECTION 4:

Patient-Safety-Related Training and Conferences Attended

Please provide a list of the various trainings (in person, online, self-study) and conferences you have participated in during the last 12 months (or whatever shorter period is applicable for you) which have promoted and enhanced your knowledge of patient safety and practices to prevent healthcare associated infections. Please provide the information you remember; a best-guess estimate is fine.

Training, conference or seminar title	Duration (in hours)	Training Method
e.g., Continuing Education Seminar on Patient Safety	2 hours	Web-based Seminar

SECTION 5:

Additional Comments and Perspectives on Infection Prevention and Patient Safety

Please provide your opinion on how well your facility addresses infection prevention and patient safety. We welcome your thoughts about successes achieved, barriers, and investments made in infection prevention and patient safety.

Thank you very much for completing this assessment.

Please return this form to:

(NOTE: Leave blank for each individual facility to insert name.)