Form
Approved
OMB No. 0935-XXXX
Exp. Date XX/XX/20XX
Implementation Assessment Questionnaire
1. What is the composition of your team?
a. Is membership changing? If so, how?
2. Which nursing units and hospital departments are actively engaged?
3. Does your team have a routine for meeting? Please describe.
4. Is the team momentum increasing, decreasing, or remaining the same?
5. What factors are affecting your momentum?
Public reporting burden for this collection of information is estimated to average XX 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.
6. Currently, what are the major barriers you face?
7. Have you had a kick-off? If so, please describe.
8. Have you completed a Discovery and Action Dialogue?
9. How are PD and Lean being integrated and differentiated in your work so far?
10. How is MRSA data shared with other key personnel?
11. What other methods (formal or informal) are you using to measure your impact?
12. Are leaders exposed to the MRSA prevention work of front line staff? How?
13. How you do connect with hospital leadership?
a. How does hospital leadership connect with you?
14. What other information do you feel is important to share so that we can get an accurate idea of your hospital’s status?
15. Have there been any surprises along the way?
| File Type | application/msword |
| Author | Shawn Hoke |
| Last Modified By | Shawn Hoke |
| File Modified | 2010-01-11 |
| File Created | 2010-01-11 |