0920-1308 Validated Survey Instrument

Form Approved
OMB No. 0920-xxxx
Expires xx/xx/xxxx

Appendix 2: Validated survey instrument to assess if the interventions within the stewardship
initiative were acceptable, appropriate, and feasible.

Interventions to be studied will be based on the Core Elements of Outpatient Antibiotic
Stewardship (see Table below). We determine acceptability, appropriateness, and feasibility of
each intervention selected by the respondent as a representative of the corresponding core
element. The respondent is given the following guidance at the beginning of the survey:
When responding to this survey:
•
•
•

Each group of prompts is part of one measure. Please take great care to
answer each prompt independently.
Prompts using similar terms may capture different aspects of each measure.
Use your best judgment when interpreting the meaning of each prompt
based on the terms used.

The respondent is also given the option to skip any core element for which they indicate they
have no experience. There are two questions about the most important element that influenced
the respondent’s prescribing practices, and change to the system’s prescribing practices,
respectively.
Core Element of the Urgent Care
Antibiotic Stewardship Program
Clinician Education

Access to Internal Guidelines
iCentra Tools
Patient-Focused Marketing
Transparent Data & Feedback

Interventions
Infectious Diseases Updates During In-Person
Meetings
Opportunities to Consult Infectious Diseases
Experts
Antibiotic Stewardship Website Resources
CPMs
Flash Cards
Quick Visits
Azithromycin Justification Alerts
Waiting Room Posters
Reception Area Desk & Door Wraps
Antibiotic Prescribing Dashboards (Provider
and Clinic Level Views)
Professional conversations with Associate
Medical Directors

Public reporting burden of this collection of information is estimated to average 5 minutes per response,
including the time for reviewing instructions, searching existing data sources, gathering and maintaining
the data needed, and completing and reviewing the collection of information. 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 CDC/ATSDR
Inf ormation Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333;
ATTN: PRA (0920-xxxx).

Watchful Waiting Handouts
Electronic/Written Delayed Prescriptions
Leadership Commitment Posters

Shared Decision Making
Leadership Commitment

For Acceptability of Intervention Measure (AIM), the respondent is guided to “ Consider
how agreeable or satisfactory these were to you personally.”

Completely
Disagree
disagree

Neither
agree
nor
disagree

Agree

Completely
agree

1. (INSERT INTERVENTION) met my
approval.
2. (INSERT INTERVENTION) were
appealing to me.





















3. I liked (INSERT INTERVENTION).











4. I welcomed (INSERT
INTERVENTION).











For Intervention Appropriateness Measure (IAM), the respondent is guided to “ Consider
how these fit into or were compatible with the setting in which you see patients.”
Neither
agree
Completely
Disagree
nor
disagree
disagree
1. (INSERT INTERVENTION) were
fitting.
2. (INSERT INTERVENTION) were
suitable.
3. (INSERT INTERVENTION) were
applicable.
4. (INSERT INTERVENTION) were a
good match.

Agree

Completely
agree









































For Feasibility of Intervention Measure (FIM), the respondent is guided to “ Consider how
easy or convenient these were to implement in the setting where you see
patients.”

Completely
Disagree
disagree

Neither
agree
nor
disagree

Agree

Completely
agree

1. (INSERT INTERVENTION) were
implementable.











2. (INSERT INTERVENTION) were
possible.
3. (INSERT INTERVENTION) were
doable.































4. (INSERT INTERVENTION) were
easy to use.

The respondent is provided with the following table for reference in answering the last two
questions of the survey:
CLINICIAN EDUCATION
ACCESS TO INTERNAL
GUIDELINES
iCENTRA TOOLS
SHARED DECISION
MAKING
PATIENT-FOCUSED
MARKETING
LEADERSHIP
COMMITMENT
TRANSPARENT DATA &
FEEDBACK

Infectious Diseases Updates During In-Person Meetings
Opportunities to Consult Infectious Diseases Experts
Antibiotic Stewardship Website Resources
CPMs
Flash Cards
Azithromycin Justification Alerts
Quick Visits
Electronic / Written Delayed Prescriptions
Watchful Waiting Handouts
Waiting Room Posters
Reception Area Desk & Door Wraps
Leadership Commitment Posters
Antibiotic Prescribing Dashboards
Professional Conversations with Associate Medical Dirs

What was the single most important element that
influenced YOUR prescribing practices?

OClinician Education
O Internal Guidelines
O iCentra Tools
O Shared Decision Making
O Patient-focused marketing

O Leadership Commitment
O Transparent Data & Feedback
What was the single most important element that
influenced the SYSTEM to change prescribing
practices?

OClinician Education
O Internal Guidelines
O iCentra Tools
O Shared Decision Making
O Patient-focused marketing
O Leadership Commitment
O Transparent Data & Feedback