Form b1. Structural Ass b1. Structural Ass Attachment B Structural Assessment for Ambulatory Care S

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

Attachment B: Structural Assessment Form for Ambulatory Care Settings

STRUCTURAL ASSESSMENT

1. How many of the following clinicians work in your practice?

MDs/DOs

NPs/PAs

Nurses

Medical Assistants

Other (please describe)

2. Approximately how many patients does your practice see in an average week?

3. Does your practice use an electronic health record system? Yes No

3a. If yes, has your practice implemented any prompts in your EHR to assist with antibiotic-decision making? Yes No

4. Has your practice used a team-based safety program (e.g., comprehensive unit-based safety program) to drive improvement activities in the practice in the past? Yes No

4a. If yes, please describe previous initiatives that have used a team-based safety approach.

5. Do any clinicians in your practice receive any protected time or salary designated specifically for antibiotic stewardship related activities? Yes No

5a. If yes, please describe.

6. Have clinicians in your practice developed local guidelines covering conditions for which antibiotics are commonly prescribed? Yes No

6a. If yes, please describe.

7. Does your practice use any other tools to assist with antibiotic decision-making? Yes No 7a. If yes, please describe.

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.

8. Have clinicians in your practice developed a list of conditions for which antibiotic prescriptions are discouraged? Yes No

8a. If yes, please describe.

9. Does your practice formally review data on rates of antibiotic prescriptions periodically? Yes No