Survey

Form Approved

OMB No. 0920-1308

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	Interventions
Clinician Education	Infectious Diseases Updates During In-Person Meetings
	Opportunities to Consult Infectious Diseases Experts
	Antibiotic Stewardship Website Resources
Access to Internal Guidelines	CPMs
	Flash Cards
iCentra Tools	Quick Visits
	Azithromycin Justification Alerts
Patient-Focused Marketing	Waiting Room Posters
	Reception Area Desk & Door Wraps
Transparent Data & Feedback	Antibiotic Prescribing Dashboards (Provider and Clinic Level Views)
	Professional conversations with Associate Medical Directors
Shared Decision Making	Watchful Waiting Handouts
	Electronic/Written Delayed Prescriptions
Leadership Commitment	Leadership Commitment Posters

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.”

	Completely disagree	Disagree	Neither agree nor disagree	Agree	Completely agree
1. (INSERT INTERVENTION) were fitting.					
2. (INSERT INTERVENTION) were suitable.					
3. (INSERT INTERVENTION) were applicable.					
4. (INSERT INTERVENTION) were a good match.					

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	Infectious Diseases Updates During In-Person Meetings
	Opportunities to Consult Infectious Diseases Experts
	Antibiotic Stewardship Website Resources
ACCESS TO INTERNAL GUIDELINES	CPMs
	Flash Cards
iCENTRA TOOLS	Azithromycin Justification Alerts
	Quick Visits
SHARED DECISION MAKING	Electronic / Written Delayed Prescriptions
	Watchful Waiting Handouts
PATIENT-FOCUSED MARKETING	Waiting Room Posters
	Reception Area Desk & Door Wraps
LEADERSHIP COMMITMENT	Leadership Commitment Posters
TRANSPARENT DATA & FEEDBACK	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

Public reporting burden of this collection of information is estimated to average 20 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 Information Collection Review Office, 1600 Clifton Road NE, MS H21-8, Atlanta, Georgia 30333; ATTN:  PRA (0920-1308).