Pilot Survey Template

Form Approved

OMB Control No.: 0920-XXXX

Expiration date: XX/XX/XXXX

LHD HAI/AR Strategy Pilot Survey Template

LHDs with Review and Implement Capacity

Survey

TITLE OF INFORMATION COLLECTION: Survey for soliciting feedback from local health departments (LHDs) on CDC’s Interim Local Health Department (LHD) Strategy for Response, Control, and Prevention of Healthcare Associated Infections (HAI) and Antibiotic Resistance (AR).

PURPOSE: CDC will collect feedback from LHDs on the interim strategy and supplemental materials to inform updates to the strategy based on the needs and experiences of LHDs.

Dear Participant,

Thank you for piloting CDC’s Interim Local Health Department (LHD) Strategy for Response, Control, and Prevention of Healthcare Associated Infections (HAI) and Antibiotic Resistance (AR). This survey is designed to collect your LHD’s feedback on how you used/implemented the strategy and identify successes and challenges as well as any suggestions to improve the strategy to make it more useful to LHDs. CDC intends to use your feedback to accomplish the following:

• Understand how your LHD used the strategy

• Identify successes and challenges your LHD had with implementing the strategy

• Capture any best practices or lessons learned from your experience as a pilot participant

• Identify ways that the CDC and its partners can support your organization in HAI and AR efforts in the short-term and long-term

We value your privacy and would like to assure you that all responses will be aggregated with those from other participants and deidentified before they are shared. Insights from this survey will be used to inform updates to the strategy and considerations for supplemental resources. We would appreciate your candid experiences and perspectives. This survey should take no more than 60 minutes of your time.

Survey Guidance

To fill out and submit the survey, please complete the following steps:

• Access the survey at this link

• Complete the survey by the specified deadline

• Reach out to [email protected] if you have any questions

Early on in the pilot, your LHD completed a feedback form to provide your thoughts on the LHD HAI/AR Strategy and accompanying materials. A copy of your feedback form has been shared with you; you may use your feedback form responses to inform responses to this survey. For additional assistance or questions about the survey, including questions about the deadline, please contact the pilot team at [email protected].

Thank you for your participation and continued support,

State Strategy and Evaluation Team

Division of Healthcare Quality Promotion

LHD INFORMATION
LHD Name:
Name(s) and Title(s) of Person(s) Completing the Survey:
Email Address(es):

SURVEY QUESTIONS & RESPONSES: LHDS WITH IMPLEMENT CAPACITY

SURVEY QUESTIONS	RESPONSES
LHD CONTEXTUAL INFORMATION
How would you describe your LHD’s experience with HAI/AR work? Little to no experience leading HAI/AR activities Some previous experience leading HAI/AR activities 3) Extensive experience leading HAI/AR activities
How often does your LHD work with your state on HAI/AR work? Rarely (a few times per year) Sometimes (every few months) Regularly (about once a month) Follow up: If you answered rarely, can you please describe why working with the state program is limited?
What percentage of staff at your LHD work on HAI/AR efforts? 0—25% of team 26—50% of team 51—75% of team 76—100% of team
HOW YOUR LHD USED THE STRATEGY
How did your LHD prioritize the goals, objectives, and activities you chose to pursue from the strategy during implementation?
Which goals, objectives, and activities did you choose?
Was the LHD HAI/AR Strategy One Pager helpful for understanding the strategy better? How can the One Pager be improved to make it more useful to LHDs?
Was the Framework for Implementation helpful for providing instructions on how to use the strategy? How can the Framework be improved to make it more useful to LHDs?
Was the Facilitation Guide helpful for facilitating conversations with your state HAI/AR program? How can the Facilitation Guide be improved to make it more useful to LHDs?
Was the Action Planning Tool helpful for setting strategic goals and objectives? How can the Action Planning Tool be improved to make it more useful to LHDs?
Was the Glossary and Resources helpful for providing additional resources and insight on strategy development and implementation? How can the Glossary and Resources be improved to make it more useful to LHDs?
SUCCESSES AND CHALLENGES YOUR LHD HAD WITH IMPLEMENTING THE STRATEGY
What challenges did you have with implementing the strategy?
What challenges did you have in achieving the goal(s) and objective(s) you outlined in your strategic plan? How did you (attempt to) resolve these challenges?
What challenges did you have related to your chosen activities and how did you resolve those?
What was the impact of implementing the strategy at your LHD? For example, did implementing the strategy change your HAI/AR priorities and / or activities?
Did your organization face any capacity or resource constraints in the area of HAI/AR during strategy implementation? If yes, what would have helped alleviate those constraints? Select all that apply. More funding Additional hands-on training More staff Stronger partnerships Other Please explain how the above solution(s) would alleviate challenges faced by your LHD.
Were there any success factors or enablers at your LHD that helped you implement the strategy? Particular HAI/AR expertise Strong partner networks Technical assistance and support from CDC, your state, or NACCHO Other Follow up: If you answered other, can you please explain what success factors or enablers at your LHD helped you implement the strategy?
BEST PRACTICES OR LESSONS LEARNED FROM YOUR EXPERIENCE AS A PILOT PARTICIPANT
In your experience, which components of the strategy do you think are the best places for LHDs to start and why?
If you could pick one goal and objective that LHDs should prioritize, which would you pick? For example, is there a particular activity that is a “must-do” for LHD HAI/AR programs?
How did the state HAI/AR program support your LHD with implementing the strategy? Do you have any suggestions for how states can best collaborate with LHDs on the strategy?
What key partners in HAI/AR does your LHD work with (facilities, State HAI/AR program, other LHDs)? Can you please describe what those relationships look like and how they changed via strategy implementation?
What external partners do you recommend LHDs collaborate with to support strategy implementation? How would these partners help LHDs implement the strategy?
What collaboration processes (between states, partners, and CDC) work best for your LHD? Do you have a preferred method of contact?
HOW CDC CAN SUPPORT YOUR ORGANIZATION IN HAI AND AR EFFORTS
What is something you would like to see from CDC (guide, resource, tool)? How would this help LHDs better understand and / or implement the strategy?
What additional materials would have been useful to include with the strategy?
WRAP-UP
Is there anything else you would like to share that we have not asked about?

Public reporting burden of this collection of information is estimated to average 120 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 Reports Clearance Officer, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA 0920-XXXX