Form 1 Structural Assessment-Improving Antibiotic Use Cohort-Br

STRUCTURAL ASSESSMENT

Improving Antibiotic Use Cohort

Brick and Mortar Practices

Survey Instructions

The structural assessment asks about your practice’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 practice’s infrastructure and capacity to implement the Safety Program over time.

• If a question does not apply to you or you don’t know the answer, please select “Not Sure.”

• If you work in more than one office or location for your practice, when answering this survey answer only about the practice specified on your Baseline Structural Assessment.

• If your medical office is in a building with other medical offices, answer only about the specific medical office where you work—do not answer about any other medical offices in the building.

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

MDs/DOs

NPs/PAs

Registered Nurses

Medical Assistants

Pharmacists

__Care Coordinator/Patient Navigator

Other (please describe)

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

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

Yes No Not sure

4. Has your practice used a team-based safety program (e.g., comprehensive unit-based safety program) to drive improvement activities in the practice 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 practice 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 practice developed local guidelines covering conditions for which antibiotics are commonly prescribed? Yes No Not sure

6a. If yes, please describe.

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

Yes No Not sure

7a. If yes, please describe.

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

Yes No Not sure

8a. If yes, please describe.

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

Yes No Not sure

10. Approximately what proportion of visits in your practice 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 practice 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

• community-based health clinic (including Federally Qualified Health Centers)

• outpatient specialty clinic that provides primary care

• student health

• retail clinic (Walgreens, CVS, etc.)

• employee health

• other (please specify) _______________

13. Do patient satisfaction scores impact provider compensation in your practice? 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.