7 Attachment F: Surgical Services Team Checkup Tool

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

Attachment F: Team Checkup Tool

Public reporting burden for this collection of information is estimated to average 10 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 (0935-0143), AHRQ, 5600 Fishers Lane, MS 0741A, Rockville, MD 20857

The confidentiality of your responses is protected by Sections 944(c) and 308(d) of the Public Health Service Act [42 U.S.C. 299c-3(c) and 42 U.S.C. 242m(d)]. Information that could identify you will not be disclosed unless you have consented to that disclosure.

TEAM CHECK-UP TOOL – Surgical Services

Please answer the following questions with respect to the past month only:
1. Please estimate what percentage of all patients undergoing the procedure of interest* were tested preoperatively for MRSA in the past month. *Procedure of interest is the specific surgery(s) your group is focusing on.	 <25%  25-50%  51-75%  >75%  N/A
2. Please estimate what percentage of all patients undergoing the procedure of interest received chlorhexidine bathing the night before and morning of their procedure in the past month.	 <25%  25-50%  51-75%  >75%  N/A
3. Please estimate what percentage of patients undergoing the procedure of interest who tested positive for MRSA received nasal decolonization with mupirocin or iodophor prior to the procedure in the past month.	 <25%  25-50%  51-75%  >75%  N/A
4. Please estimate what percentage of patients undergoing the procedure of interest who tested positive for MRSA received preoperative chlorhexidine bathing for 5 days prior to the procedure in the past month. (Urgent/emergent surgeries may not have time to receive the full 5 days.)	 <25%  25-50%  51-75%  >75%  N/A
5. Please estimate what percentage of patients undergoing the procedure of interest who tested positive for MRSA received vancomycin or another anti-MRSA antibiotic in addition to normal prophylactic antibiotics in the past month.	 <25%  25-50%  51-75%  >75%  N/A
6. Please estimate what percentage of patients undergoing the procedure of interest had their glucose monitored and controlled at under 200 mg/dL during their procedure in the past month.	 <25%  25-50%  51-75%  >75%  N/A
7. Please estimate what percentage of patients undergoing the procedure of interest had normothermia maintained during their procedure in the past month.	 <25%  25-50%  51-75%  >75%  N/A
8. Please estimate what percentage of patients undergoing the procedure of interest had appropriate hair removal prior to their procedure in the past month.	 <25%  25-50%  51-75%  >75%  N/A
9. Please estimate what percentage of patients undergoing the procedure of interest had appropriate timing and antibiotic choice according to your protocols in the past month.	 <25%  25-50%  51-75%  >75%  N/A
10. Please indicate the CUSP activities in which your team participated in the past month by checking all that apply:	 CUSP meeting: Frequency  Once  Twice  Identify how patients may be harmed in your service (SSA)  Senior Executive Walk Rounds  A morning briefing or huddle to discuss the patients  Learning from defects or adverse events
11. In the past month, which of the following methods did your team implement to educate the staff on your service on MRSA prevention evidence-based practice? (Check all that apply.)	Members of the staff attended:  Internal seminar  IP visit/ talk/ report  MRSA Project webinar  In-services/demos  Other: _____________________ CUSP Team members:  Developed a new written policy  Posted evidence-based guidelines  Other: _____________________
12. How many times did the AHRQ Safety Program for MRSA Prevention team meet with your senior executive, or review your MRSA data with the senior executive or senior leadership in the past month?	 None  Once  Twice  More than twice  No Senior Executive
13. Was the MRSA performance data (Infection Control Report) reviewed with the CUSP team during the past month?	 Yes  No
14. How many times did your team share your MRSA prevention performance results broadly with your service’s staff in the past month?	 None  Once  Twice  More than twice  Continuous sharing of data (bulletin boards, online portals, etc.) If none, please go to question 14.
15. If AHRQ Safety Program for MRSA Prevention data were shared with your service’s staff in the past month, please indicate how the data were provided by checking all that apply:	 Verbal Report  Poster  N/A  Written Report  Continuous sharing of data (bulletin boards, online portals, etc.)  Other:___________
16. How many members of your quality improvement team permanently left your organization or service in the past month?	_____ (# of people who left)
17. Indicate how many people joined the quality improvement team in the past month.	_____ (# of people who joined the team)
18. Has there been any disruptive event in your service that has distracted staff from this work (e.g., emergency response; re-organization; death of staff; sentinel event; accreditation, etc.) in the past month?	 Yes  No
19. If Yes to Q18, please identify the event that distracted staff from this work. (e.g., emergency response; re-organization; death of staff; sentinel event; accreditation, etc.).
20. In the past month, did any of the following significantly slow your team’s progress? Please check all that apply.
 Insufficient knowledge of evidence supporting interventions  Lack of team member consensus regarding goals  Not enough time to complete all the tasks for this project.  Lack of quality improvement skills  Not enough buy-in from other physician staff in your area  Not enough buy-in from other nursing staff in your area  Not enough buy-in from other staff members in your area  Burden of data collection  Not enough leadership support from executives  Other, if applicable (identify): ____________________________________