a3 Structural Asse Attachment C: Structural Assessment for Long Term Care S

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

Attachment C: Structural Assessment Form for Long-Term Care Settings

STRUCTURAL ASSESSMENT

1. How many certified beds are in your facility?

2. What is the approximate proportion of residents in skilled beds (compared to residential beds)?

3. Has your facility been actively involved in quality improvement projects or programs in the last 2 years? Yes No

3a. If yes, please briefly describe previous quality improvement programs.

4. How many days does the consultant pharmacist spend at your facility each month?

4a. What percent of their time at your facility is dedicated to antibiotic review?

5. Does your institution have an existing Antibiotic Stewardship Program (ASP)? Yes No

5a. If yes, does the Infection Prevention and Control nurse or practitioner help run the ASP? Yes No

5b. If yes, does the Medical Director help run the ASP? Yes No

• What percent FTE does the Medical Director receive for stewardship activities?

5c. Are there any other members of your ASP? (Please describe)

6. 

   
   

   
   

   
   

   
   

   
   

   
   

   
   

   What are the current antibiotic stewardship activities of your facility? (Check all that apply) Working with the contracted laboratory to develop an antibiogram

Giving in-service training to nurses on topics related to antibiotic use Developing antibiotic prescribing recommendations for your facility Formulary restriction of some antibiotics

Post-prescription review with feedback of select antibiotics

Developing protocols for diagnosis and treatment of common infectious syndromes (i.e. UTI vs. asymptomatic bacteriuria)

Other activities, please describe

Our nursing home does not have active initiatives to improve antibiotic use

Public reporting burden for this collection of information is estimated to average 12 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.

7. Are you measuring antibiotic use at your facility? Yes No

7a. If yes, how are you measuring it?

Antibiotic starts

Antibiotic days of therapy per 1000 resident-days Defined daily doses per 1000 resident-days

Other measures, please describe