2 Structural Assessment - Improving Antibiotic Use Cohort

STRUCTURAL ASSESSMENT

Improving Antibiotic Use Cohort

Telemedicine-Only Organizations

Survey Instructions

The structural assessment asks about your organization’s characteristics, experience related to antibiotic stewardship activities, and any existing supports you may have in place that are intended to improve antibiotic prescribing. You will be asked to complete this survey twice: once at the start of the Safety Program and again at the end of the Safety Program. The results will be used to assess changes in your organization’s infrastructure and capacity to implement the Safety Program over time. If a question does not apply to you or your organization or if you don’t know the answer, please select “Not Sure.”

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

MDs/DOs

NPs/PAs

Registered Nurses

Medical Assistants

Pharmacists

__Care Coordinator/Patient Navigator

Other (please describe)

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

3. Has your organization implemented any prompts in the EHR to assist with antibiotic decision-making?

Yes No Not sure

4. Has your organization used a team-based safety program (e.g., comprehensive unit-based safety program) to drive improvement activities in the organization in the past? Yes No Not sure

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

5. Do any clinicians in your organization receive any protected time or salary designated specifically for antibiotic stewardship related activities? Yes No Not sure

5a. If yes, please describe.

6. Have clinicians in your organization developed local guidelines covering conditions for which antibiotics are commonly prescribed? Yes No Not sure

6a. If yes, please describe.

7. Does your organization use any other tools to assist with antibiotic decision-making?

Yes No Not sure

7a. If yes, please describe.

8. Have clinicians in your organization developed a list of conditions for which antibiotic prescriptions are discouraged?

Yes No Not sure

8a. If yes, please describe.

9. Does your organization formally review data on rates of antibiotic prescriptions periodically?

Yes No Not sure

10. Approximately what proportion of visits in your organization are via telemedicine, as defined by use of synchronous video visits?

• 1% to 24%

• 25% to 49%

• 50% to 74%

• 75% to 99%

• All (100%)

11. Approximately what proportion of telemedicine visits in your organization are via telephone?

• 0%

• 1%-24%

• 25%-49%

• 50%-74%

• 75%-100%

12. Is your practice considered any of the following? (Select all that apply)

• primary care (adult, family, or pediatric)

• urgent care

• direct to consumer

• virtual first

• retail clinic (Walgreens, CVS, etc.)

• other (please specify) ______________

12. Do patient satisfaction scores impact provider compensation in your organization?

Yes No Not sure

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.