Post-Training Infection Prevention and Safety Assessment

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	              	Form Approved
		OMB No. 0935-XXXX
		Exp. Date XX/XX/20XX
HEALTHCARE ASSOCIATED INFECTIONS (HAI) PROJECT: 
POST-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 45 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 45 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:
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
1.1	I always clean my hands before and after
	contact with every patient.






1.2	I keep abreast of advances in patient
	safety through print and electronic
	media.






1.3	Our team has a well-functioning 
	interdisciplinary team approach to patient 
	safety.






1.4	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.









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

	Yes
	No	
	


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

	Yes
	No



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

	Yes
	No



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

	Yes
	No

SECTION 2:
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.

2.I   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
2.2	My facility mandates the use of 	standardized checklists to reduce 	healthcare associated infections.






2.3	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.






2.4	My unit continually improves its use of 
	information to monitor quality of patient 	care.






2.5	Healthcare associated infections most 	often occur due to human factors.






2.6	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.






2.7	The operator only needs to wear sterile 
	mask and gloves during a chest tube 	insertion.






2.8	It is important to restrain patient upper 	limbs during chest tube insertions.






2.9	Staff assisting at a central venous 	catheter 	(CVC) insertion are the ones responsible 	for ensuring that the draped field stays 	sterile.






2.10	Minimizing CVC manipulation is one of 
	the most important daily management 
	practices to prevent infections.






2.11	Nurse-to-patient ratio and specialized line 
	teams are key strategies to reduce blood 
	stream infection (BSI) from indwelling 
	catheters.






2.12	Late-onset pneumonia (> 96 hours after 
	intubation or ICU admission) is evidence 
	of a healthcare associated infection.






2.13	Elevating the head of the bed will decrease	 a patient’s risk of acquiring ventilator-
	associated pneumonia (VAP).







2.14	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 3
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.
















If you did not participate in the HAI tool(s) training, you may stop here.  



Thank you very much for completing this assessment.



Please return this form to:



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

Section 4:  
Putting Training into Practice

Please provide your input regarding any changes in practices since you have taken this training.

    4.1 I have changed practices since I went through this training. These are the three (3) most important changes I have made:

	1. ____________________________________________________________________

	2. ____________________________________________________________________

	3. ____________________________________________________________________


    4.2 Please describe what you did to make these actionable changes after training.

	____________________________________________________________________

	____________________________________________________________________

	____________________________________________________________________

    4.3 Our facility has implemented changes to improve infection prevention and patient safety in the past 6 months. These are the three most important changes that have been made:

	1. ____________________________________________________________________

	2. ____________________________________________________________________

	3. ____________________________________________________________________

    4.4 What 3 specific daily work practices (that are not already being done) could be instituted at your facility to improve infection prevention and patient safety and reduce risk of complications?

	1. ____________________________________________________________________

	2. ____________________________________________________________________

	3. ____________________________________________________________________




Thank you very much for completing this assessment.


Please return this form to:



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