Form #8 Form #8 NH Leadership Post-Implementation Questionnaire

The Study of the Use of Nursing Home Antibiograms

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

Nursing Home Leadership Post-Implementation Questionnaire

Statement of Informed Consent: I am a researcher with Abt Associates and I would like to ask you a few questions about your experience with the antibiogram program in the <facility name>. All data gathered from the three participating nursing homes these through the administrative interviews will be aggregated; no direct quotes will be attributed to individual respondents, and only the Abt research team will have access to the data. The name of your facility will not be identified in any report, publication, or presentation that may result from the findings obtained from this study. Your participation in the survey is voluntary and you may refuse to answer any question. No penalty or loss to you or to the patients you treat will result from refusal to participate or from survey discontinuation at any time. Your responses will be kept confidential to the extent permitted by law, including AHRQ’s confidentiality statute, 42 USC 299c-3(c). We expect this survey to take approximately five to ten minutes to complete.

1.	What is your title? (RN/LPN/LNHA)
2.	What is your position at the facility?
3.	How long have you been in practice?
4.	How long have you been working at this facility?
5.	Please describe your facility’s experience with antibiograms. Include both positive and negative aspects.
6.	How would you describe the level of burden imposed on the facility’s staff? On a scale of 1 to 5 where 1 represents minimal burden and 5 represents a high level of burden, what number describes your impression of the burden associated with antibiograms? __________
	a.	Please explain your response (e.g., burden to which staff members, amount of time involved, problems encountered, etc.)
7.	Do you think that the use of antibiograms had any impact on antibiotic prescribing behavior?
	a.	Appropriate choice of antibiotics
	b.	Timely initiation of antibiotic therapy (in other words, did the use of antibiograms cause treatment delays)?  Yes  No
	c.	Use of narrow-spectrum antibiotics
	d.	Other. Please explain
8.	Please describe the costs at your facility associated with the implantation and use of the antibiograms?
9.	Will you continue to use antibiograms, now that the study has been completed?
	 Yes, Definitely
	 Yes, Generally
	 No, Generally
	 No, Definitely
10.	Could you provide us with antibiotic drug pricing information?

Public reporting burden for this collection of information is estimated to average 10 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.

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