Form 2-2 - HAI/AR Performance Measures (SHARP Project II

Confidential

HAI/AR Performance Measures (SHARP Project III; Stewardship), 2024
Page 1

SHARP PM 3.2 Implementation of Antibiotic Stewardship
Activities
Recipient

__________________________________

Antibiotic Stewardship (SHARP Project III) Performance Measures - Measure 2   
Purpose: The purpose of this measure is to capture details on all Stewardship activities planned and/or implemented
during this reporting period (August 1st, 2024 - December 31st, 2024). 

INSTRUCTIONS: One form should be completed for EACH activity.  To add a NEW activity, click "Save and Add New
Instance", which is located at the bottom of this form.
This form will only ask about the details of a single stewardship activity. Please fill out another form to report on an
additional stewardship activity (e.g., if your jurisdiction is engaged in three stewardship activities, submit Measure 2
three times, once for each activity). 
To see a complete list of all questions and answer choices, download the PDF attachment.
[Attachment: "Performance Measures_2024_UPDATED.pdf"]

Measure 2: Implementation of Antibiotic Stewardship Activities
Title of Activity:

__________________________________

Summary of activity (up to 300 words):
Please provide a brief summary of the activity.
Include any key actions, data sources, partners,
outcomes, timelines, and personnel involved. 
Stage of implementation of activity:
- Planning: activity has not yet been initiated or
implemented
- Ongoing: activity is actively being implemented
- Completed: activity has been completed
- Evaluation: activity has been completed and is
being evaluated for impact
Healthcare setting where activity is implemented:
If activity is across multiple settings, select more
than one setting.
Outpatient Setting:
Type of Outpatient Setting: (Check all that apply)

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Planning
Ongoing
Completed
Evaluation

Outpatient Setting
Acute Care Setting
Long-term Care Setting
Other Setting
Primary care clinic
Outpatient specialty and subspecialty
Emergency department
Retail health clinic
Urgent care clinic
Other

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If Other, please specify:

Acute Care Setting:
Type of Acute Care Setting: (Check all that apply)

If Other, please specify:

Long-Term Care Setting:
Type of Long-Term Care Setting: (Check all that
apply)

If Other, please specify:

Other Setting:
Type of Other Setting: (Check all that apply)

If Other, please specify:

__________________________________
General acute care hospital
Critical access hospital
Children's hospital
Long-term acute care hospital
Other

__________________________________
Nursing home
Skilled-nursing facility
Ventilator skilled-nursing facility
Assisted living facility
Other

__________________________________
Dialysis facility
Dental setting
One Health Collaborative
Telehealth
Ambulatory surgical center
Veterinary setting
Other

__________________________________

Measure 2.1 Outpatient Setting
Select the category that describes the activity:
- Assessment of Antibiotic Stewardship
Implementation: Identify healthcare professionals or
settings where improving antibiotic use and enhancing
Core Elements of Antibiotic Stewardship uptake is
needed
- Antibiotic Use Tracking & Reporting: Monitor
antibiotic prescribing. Measuring antibiotic use is
critical to identify variability in antibiotic use and
to assess, support, and improve stewardship
interventions
- Antibiotic Stewardship Action & Collaboration:
Implement evidence-based, local-level stewardship
activities with partners or in the setting of a
stewardship collaborative
- Antibiotic Stewardship Education & Communication:
Engage with healthcare professionals, patients, and
the public to optimize antibiotic use, and inform
guidelines and policies to strengthen stewardship
practice (Check all that apply)

03/03/2025 10:34am

Assessment of Antibiotic Stewardship Implementation
Antibiotic Use Tracking & Reporting
Antibiotic Stewardship Action & Collaboration
Antibiotic Stewardship Education & Communication

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Outpatient: Assessment of Antibiotic Stewardship
Implementation (Identify healthcare professionals or
settings where improving antibiotic use and enhancing
Core Elements of Antibiotic Stewardship uptake is
needed)
Select the element(s) used to identify healthcare
professionals or settings.

High or inappropriate antibiotic prescribing rates
overall or for priority conditions
MDRO outbreak
Identification on Infection Control Assessment &
Response (ICAR) tool
Limited access to antibiotic stewardship expertise
(e.g., rural facilities)

The list is not inclusive of all elements. If your
stewardship activity is not included, you may include
other elements not listed here in the Summary of
Activity section above.
(Check all that apply)
Outpatient: Antibiotic Use Tracking &
Reporting (Monitor antibiotic prescribing. Measuring
antibiotic use is critical to identify variability in
antibiotic use and to assess, support, and improve
stewardship interventions)
Select the element(s) that are part of the activity.

Commercial/proprietary data (e.g., IQVIA)
CMS data (e.g., Medicaid data, Medicare public use
files)
All Payer Claims data
HEDIS measures
Antibiotic use reporting dashboard

The list is not inclusive of all elements. If your
stewardship activity is not included, you may include
other elements not listed here in the Summary of
Activity section above.
(Check all that apply)
Outpatient: Antibiotic Stewardship Action &
Collaboration (Implement evidence-based, local-level
stewardship activities with partners or in the setting
of a stewardship collaborative)   

Electronic health record-based interventions
Prescriber feedback letters or emails

Select the element(s) that are part of the activity.
The list is not inclusive of all elements. If your
stewardship activity is not included, you may include
other elements not listed here in the Summary of
Activity section above.
(Check all that apply)
Outpatient: Antibiotic Stewardship Education &
Communication (Engage with healthcare professionals,
patients, and the public to optimize antibiotic use,
and inform guidelines and policies to strengthen
stewardship practice)  
Select the element(s) that are part of the activity.
The list is not inclusive of all elements. If your
stewardship activity is not included, you may include
other elements not listed here in the Summary of
Activity section above.

Plan and participate in US Antibiotic Awareness
Week promotional activities
Support a jurisdiction-wide stewardship
educational activity (e.g., workshop, conference,
or summit)
Provide facility-specific antibiotic stewardship
mentorship and support (virtual or in-person) to
outpatient settings with limited access to
antibiotic stewardship expertise (e.g., rural
facilities)

(Check all that apply)

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Number of outpatient facilities engaged:
(Enter 0 if no facilities engaged)
Number of outpatient healthcare professionals engaged:
(Enter 0 if no healthcare professionals engaged)
Type of partner(s) engaged:
(Check all that apply)

If Other, please describe:

__________________________________

__________________________________

Healthcare system
Payer
Academic partner
Other state or local health department (outside of
your state)
Multi-state collaborative
Local health department (within your state)
Regulatory/licensing agency
Local or national professional organization
HIINS or QIN/QIOs
Other
None

__________________________________

Measure 2.2 Acute Care Setting
Select the category that describes the activity:
- Assessment of Antibiotic Stewardship
Implementation: Identify healthcare professionals or
settings where improving antibiotic use and enhancing
Core Elements of Antibiotic Stewardship uptake is
needed
- Antibiotic Use Tracking & Reporting: Monitor
antibiotic prescribing. Measuring antibiotic use is
critical to assess, support, and improve stewardship
interventions, and identify variability in antibiotic
use
- Antibiotic Stewardship Action & Collaboration:
Implement evidence-based, local-level stewardship
activities with partners or in the setting of a
stewardship collaborative
- Antibiotic Stewardship Education & Communication:
Engage with healthcare professionals, patients, and
the public to optimize antibiotic use, and inform
guidelines and policies to strengthen stewardship
practice (Check all that apply)

03/03/2025 10:34am

Assessment of Antibiotic Stewardship Implementation
Antibiotic Use Tracking & Reporting
Antibiotic Stewardship Action & Collaboration
Antibiotic Stewardship Education & Communication

projectredcap.org

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Acute Care: Assessment of Antibiotic Stewardship
Implementation (Identify healthcare professionals or
settings where improving antibiotic use and enhancing
Core Elements of Antibiotic Stewardship uptake is
needed)
Select the element(s) used to identify healthcare
professionals or settings.

Not meeting Core Elements on National Healthcare
Safety Network (NHSN) annual hospital survey
NHSN AU Option outlier
MDRO outbreak
Identification on Infection Control Assessment &
Response (ICAR) tool
Limited access to antibiotic stewardship expertise
(e.g., rural facilities)

The list is not inclusive of all elements. If your
stewardship activity is not included, you may include
other elements not listed here in the Summary of
Activity section above.
(Check all that apply)
Acute Care: Antibiotic Use Tracking &
Reporting (Monitor antibiotic prescribing. Measuring
antibiotic use is critical to assess, support, and
improve stewardship interventions, and identify
variability in antibiotic use)

Support NHSN AU Option enrollment

Select the element(s) that are part of the activity.
The list is not inclusive of all elements. If your
stewardship activity is not included, you may include
other elements not listed here in the Summary of
Activity section above.
(Check all that apply)
Acute Care: Antibiotic Stewardship Action &
Collaboration (Implement evidence-based, local-level
stewardship activities with partners or in the setting
of a stewardship collaborative)   
Select the element(s) that are part of the activity.
The list is not inclusive of all elements. If your
stewardship activity is not included, you may include
other elements not listed here in the Summary of
Activity section above.

Leverage NHSN AU Option Standardized Antimicrobial
Administration Ratio (SAAR) metrics to inform
where to focus improvement activities
Create facility certificates (e.g., honor roll) to
acknowledge success based on the implementation of
advanced stewardship criteria
Prescriber feedback letters or emails

(Check all that apply)
Acute Care: Antibiotic Stewardship Education &
Communication (Engage with healthcare professionals,
patients, and the public to optimize antibiotic use,
and inform guidelines and policies to strengthen
stewardship practice) 
Select the element(s) that are part of the activity.
The list is not inclusive of all elements. If your
stewardship activity is not included, you may include
other elements not listed here in the Summary of
Activity section above.

Plan and participate in US Antibiotic Awareness
Week promotional activities
Support a jurisdiction-wide stewardship
educational activity (e.g., workshop, conference,
or summit)
Provide facility-specific antibiotic stewardship
mentorship and support (virtual or in-person) to
acute care settings with limited access to
antibiotic stewardship expertise (e.g., rural
facilities)

(Check all that apply):

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Number of acute care facilities engaged:
(Enter 0 if no facilities engaged)

__________________________________

Number of acute care healthcare professionals engaged:
(Enter 0 if no healthcare professionals engaged)

__________________________________

Type of partner(s) engaged:
(Check all that apply)

If Other, please describe:

Healthcare system
Payer
Academic partner
Other state or local health department (outside of
your state)
Multi-state collaborative
Local health department (within your state)
Regulatory/licensing agency
Local or national professional organization
HIINS or QIN/QIOs
Other
None

__________________________________

Measure 2.3 Long-Term Care Setting
Select the category that describes the activity:
- Assessment of Antibiotic Stewardship
Implementation: Identify healthcare professionals or
settings where improving antibiotic use and enhancing
Core Elements of Antibiotic Stewardship uptake is
needed
- Antibiotic Use Tracking & Reporting: Monitor
antibiotic prescribing. Measuring antibiotic use is
critical to assess, support, and improve stewardship
interventions, and identify variability in antibiotic
use
- Antibiotic Stewardship Action & Collaboration:
Implement evidence-based, local-level stewardship
activities with partners or in the setting of a
stewardship collaborative
- Antibiotic Stewardship Education & Communication:
Engage with healthcare professionals, patients, and
the public to optimize antibiotic use, and inform
guidelines and policies to strengthen stewardship
practice (Check all that apply)

03/03/2025 10:34am

Assessment of Antibiotic Stewardship Implementation
Antibiotic Use Tracking & Reporting
Antibiotic Stewardship Action & Collaboration
Antibiotic Stewardship Education & Communication

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Long-term Care: Assessment of Antibiotic Stewardship
Implementation (Identify healthcare professionals or
settings where improving antibiotic use and enhancing
Core Elements of Antibiotic Stewardship uptake is
needed)
Select the element(s) used to identify healthcare
professionals or settings.
The list is not inclusive of all elements. If your
stewardship activity is not included, you may include
other elements not listed here in the Summary of
Activity section above.

Not meeting the Core Elements on NHSN annual
facility survey or health department-specific LTC
survey
Stewardship-related citation on regulatory
assessment
High or inappropriate antibiotic prescribing rates
or for priority conditions
MDRO outbreak
Identification on Infection Control Assessment &
Response (ICAR) tool
Limited access to antibiotic stewardship expertise
(e.g., rural facilities)

(Check all that apply)
Long-term Care: Antibiotic Use Tracking &
Reporting (Monitor antibiotic prescribing. Measuring
antibiotic use is critical to assess, support, and
improve stewardship interventions, and identify
variability in antibiotic use)

Support collaboratives and partnerships to use
long-term care pharmacy or electronic health
record data to track and report facility-level AU

Select the element(s) that are part of the activity.
The list is not inclusive of all elements; you may
include other elements not listed here in the Summary
of Activity section above.
(Check all that apply)
Long-term Care: Antibiotic Stewardship Action &
Collaboration (Implement evidence-based, local-level
stewardship activities with partners or in the setting
of a stewardship collaborative)   
Select the element(s) that are part of the activity.
The list is not inclusive of all elements. If your
stewardship activity is not included, you may include
other elements not listed here in the Summary of
Activity section above.

Support collaboratives that implement activities
to improve AU such as electronic health
record-based stewardship interventions
Create facility certificates (e.g., honor roll) to
acknowledge success based on the implementation of
activities outlined in the Core Elements checklist
Prescriber feedback letters or emails

(Check all that apply)
Long-term Care: Antibiotic Stewardship Education &
Communication (Engage with healthcare professionals,
patients, and the public to optimize antibiotic use,
and inform guidelines and policies to strengthen
stewardship practice) 
Select the element(s) that are part of the activity.
The list is not inclusive of all elements. If your
stewardship activity is not included, you may include
other elements not listed here in the Summary of
Activity section above.

Plan and participate in US Antibiotic Awareness
Week promotional activities
Support a jurisdiction-wide stewardship
educational activity (e.g., workshop, conference,
or summit)
Provide facility-specific antibiotic stewardship
mentorship and support (virtual or in-person) to
long-term care settings with limited access to
antibiotic stewardship expertise (e.g., rural
facilities)

(Check all that apply)
Number of long-term care facilities engaged:
(Enter 0 if no facilities engaged)

03/03/2025 10:34am

__________________________________

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Number of long-term care healthcare professionals
engaged:
(Enter 0 if no healthcare professionals engaged)
Type of partner(s) engaged:
(Check all that apply)

If Other, please describe:

__________________________________

Healthcare system
Payer
Academic partner
Other state or local health department (outside of
your state)
Multi-state collaborative
Local health department (within your state)
Regulatory/licensing agency
Local or national professional organization
HIINS or QIN/QIOs
Other
None

__________________________________

Measure 2.4 Other Setting
Select the category that describes the activity:
- Assessment of Antibiotic Stewardship
Implementation: Identify healthcare professionals or
settings where improving antibiotic use and enhancing
Core Elements of Antibiotic Stewardship uptake is
needed
- Antibiotic Use Tracking & Reporting: Monitor
antibiotic prescribing. Measuring antibiotic use is
critical to to assess, support, and improve
stewardship interventions, and identify variability in
antibiotic use
- Antibiotic Stewardship Action & Collaboration:
Implement evidence-based, local-level stewardship
activities with partners or in the setting of a
stewardship collaborative
- Antibiotic Stewardship Education & Communication:
Engage with healthcare professionals, patients, and
the public to optimize antibiotic use, and inform
guidelines and policies to strengthen stewardship
practice (Check all that apply)
Other: Assessment of Antibiotic Stewardship
Implementation (Identify healthcare professionals or
settings where improving antibiotic use and enhancing
Core Elements of Antibiotic Stewardship uptake is
needed)
Select the element(s) used to identify healthcare
professionals or settings.

Assessment of Antibiotic Stewardship Implementation
Antibiotic Use Tracking & Reporting
Antibiotic Stewardship Action & Collaboration
Antibiotic Stewardship Education & Communication

High or inappropriate antibiotic prescribing rates
overall or for priority conditions
MDRO outbreak
Identification on Infection Control Assessment &
Response (ICAR) tool
Limited access to antibiotic stewardship expertise
(e.g., rural facilities)

The list is not inclusive of all elements. If your
stewardship activity is not included, you may include
other elements not listed here in the Summary of
Activity section above.
(Check all that apply)

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Other: Antibiotic Use Tracking & Reporting (Monitor
antibiotic prescribing. Measuring antibiotic use is
critical to to assess, support, and improve
stewardship interventions, and identify variability in
antibiotic use)

Support collaboratives and partnerships to track
and report facility-level AU

Select the element(s) that are part of the activity.
The list is not inclusive of all elements. If your
stewardship activity is not included, you may include
other elements not listed here in the Summary of
Activity section above.
(Check all that apply)
Other: Antibiotic Stewardship Action &
Collaboration (Implement evidence-based, local-level
stewardship activities with partners or in the setting
of a stewardship collaborative)   
Select the element(s) that are part of the
activity. 

Support collaboratives that implement activities
to improve AU such as electronic health
record-based stewardship interventions
Create facility certificates (e.g., honor roll) to
acknowledge success based on the implementation of
stewardship activities
Prescriber feedback letters or emails

The list is not inclusive of all elements. If your
stewardship activity is not included, you may include
other elements not listed here in the Summary of
Activity section above.
(Check all that apply)
Other: Antibiotic Stewardship Education &
Communication (Engage with healthcare professionals,
patients, and the public to optimize antibiotic use,
and inform guidelines and policies to strengthen
stewardship practice) 
Select the element(s) that are part of the activity.
The list is not inclusive of all elements. If your
stewardship activity is not included, you may include
other elements not listed here in the Summary of
Activity section above.

Plan and participate in US Antibiotic Awareness
Week promotional activities
Support a jurisdiction-wide stewardship
educational activity (e.g., workshop, conference,
or summit)
Provide antibiotic stewardship mentorship and
support (virtual or in-person) to settings with
limited access to antibiotic stewardship expertise
(e.g., rural facilities)

(Check all that apply)
Number of other facilities engaged:
(Enter 0 if no facilities engaged)
Number of other healthcare professionals engaged:
(Enter 0 if no healthcare professionals engaged)

03/03/2025 10:34am

__________________________________

__________________________________

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Type of partner(s) engaged:
(Check all that apply)

If Other, please describe:

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Healthcare system
Payer
Academic partner
Other state or local health department (outside of
your state)
Multi-state collaborative
Local health department (within your state)
Regulatory/licensing agency
Local or national professional organization
HIINS or QIN/QIOs
Other
None

__________________________________

projectredcap.org