Attachment D -- Patient safety and Infection Prevention Assessment

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

HEALTHCARE ASSOCIATED INFECTIONS (HAI) PROJECT:

PATIENT SAFETY AND INFECTION PREVENTION 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 process of care. 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 the collection of information is estimated to average 45 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, 540 Gaither Road, Room #5036, Rockville, MD 20850.

SECTION 1:

General Work Environment

Please think about the last 12 months (or for the period you have been employed if less than 12 months) 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 hospital 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 hospital 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 hospital management allocates adequate resources (staff, equipment, supplies, etc.) to support patient safety initiatives.
1.9 Our hospital monitors infection and complication rates to continue to improve patient safety.
1.10 I believe my hospital 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 the time period you have been employed if less than 12 months) 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 employment period is applicable) 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.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
3.2 My hospital 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 employment period is applicable) which have promoted and enhanced your knowledge of patient safety, particularly any training focused on prevent ion of 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

2. Please provide your opinion on how useful the training is for your work at the hospital. We welcome your thoughts on how the training did or did not improve your understanding of patient safety and infection prevention and reduction.

SECTION 5

Additional Comments and Perspectives on Patient Safety and Infection Prevention

1. If your hospital has implemented changes to improve patient safety and infection prevention in the past 12 months, what were the 2 most important changes that have been made? (Leave blank if your hospital has not implemented changes to improve patient safety and infection prevention in the last 12 months.)

A. ________________________________________________________________________________

________________________________________________________________________________

B. _________________________________________________________________________________

_________________________________________________________________________________

5.2 If your hospital has not implemented the 2 most important patient safety and infection prevention changes, what do you think are the reasons?

A. _________________________________________________________________________________

_________________________________________________________________________________

B. _________________________________________________________________________________

__________________________________________________________________________________

5.3 Do you have suggestions for infection prevention and reduction training and interventions that could be implemented at your hospital?

_________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

SECTION 5

Additional Comments and Perspectives on Patient Safety and Infection Prevention

5.4 What challenges did you encounter in implementing infection reduction initiatives in your hospital? Was the hospital able to resolve these challenges? If so, how?

_________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

5.5 What other lessons did you learn from implementing infection reduction initiatives?

____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

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

Thank you very much for completing this assessment.

Please return this form to:

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