Hospital Information. Facility Name: Primary HEN Contact: Quality Lead: Infection Preventionist: HEN 2.0 Survey Questions

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1 Hospital Information Facility : Quality Lead: Infection Preventionist: HEN 2.0 Survey Questions Patient and Family Engagement 1) Prior to scheduled admission, hospital staff provides and discusses a planning checklist that is similar to CMS Discharge Planning Checklist with every patient, allowing time for questions and comments from patient and family. 2) Hospital conducts shift change huddles and does bedside reporting with patients and family members in all feasible cases. 3) Hospital has a dedicated person or functional area that is proactively responsible for patient and family engagement and systematically evaluates patient and family engagement activities. Yes OR No 4) Hospital has an active Patient and Family Engagement Committee or at least one former patient that serves on a patient safety or quality improvement committee or team. 5) Hospital has at least one or more patient(s) who serve on a governing or leadership board and serves as a patient representative. Criteria 1) Hospital has regular quality review aligned with Partnership for Patients. 2) Hospital has a public commitment to safety improvement with transparency in sharing more than CORE hospital measurement data with the public. 3) Hospital staff, all or nearly all, have a role or perceived goal in patient safety (e.g., can be explicit in HR goals or a group bonus based on patient safety target). 4) Hospital board of trustees has a quality committee established; with regular review of patient safety data, including review and analysis of risk events.

2 Readmissions Use of STARR Model Provide effective teaching and facilitate enhanced learning () Ensure post-hospital follow up care Provide real-time handover communications Create a community care transitions team Does your facility have a policy for Readmissions?

3 Catheter-associated Urinary Tract Infections (CAUTI) Nurse-driven protocols CAUTI bundle ED implementation of CAUTI bundle Insertion and maintenance policies Use of closed systems Surveillance and monitoring according to NHSN definitions Does your facility have a policy for CAUTI? Does your facility have a procedure for CAUTI?

4 Central Line-associated Bloodstream Infections (CLABSI) Insertion bundle Maintenance bundle Surveillance and monitoring according to NHSN definitions Scrub the Hub On the Cusp Wore Does your facility have a policy for CLABSI? Does your facility have a procedure for CLABSI?

5 Surgical Site Infections (SSI) This section does not apply to my facility. Surveillance and monitoring according to NHSN definitions Project Joints Surgical safety checklist CHG shower and prep Does your facility have a policy for SSI? Does your facility have a procedure for SSI?

6 Ventilator-asscoiated Event (VAE) This section does not apply to my facility. Ventilator bundle Surveillance and monitoring according to NHSN definitions CUSP 4 MVP CHG shower and prep Does your facility have a policy for VAE? Does your facility have a procedure for VAE?

7 Adverse Drug Events (ADE) Match/Med reconciliation Post-discharge med rec program Pharmacist part of quality team Basal bolus insulin protocol Completed ISMP self-assessment Implemented ADE trigger system or surveillance system Does your facility have a distinct unit for pediatrics? Does your facility have a policy for ADE? Does your facility have a procedure for ADE?

8 Falls & Immobility Risk assessment on admission and whenever clinical status changes Patient and family education about patient s fall and injury risks Standardized interventions for patients at risk for falling Customized interventions for highest risk patients Does your facility have a policy for Falls and Immobility? Does your facility have a procedure for Falls and Immobility?

9 Pressure Ulcers Risk assessment on admission for all patients Reassessment risk for all patients daily and with change of status Daily skin inspections Management of moisture Optimize nutrition and hydration Minimize pressure Does your facility have a policy for Pressure Ulcers? Does your facility have a procedure for Pressure Ulcers?

10 Obstetrical Adverse Events This section does not apply to my facility. Hard-stop policy for non-medically indicated deliveries (induction and C-section) Induction/C-section scheduling processes Physician leadership of hard-stop policy and scheduling process Does your facility have a policy for Obstetrical Adverse Events? Does your facility have a procedure for Obstetrical Adverse Events?

11 Venous Thromboembolism (VTE) Risk assessment on admission for all patients Provide appropriate VTE prophylaxis based on national guidelines Provide discharge instructions for VTE patients Does your facility have a policy for VTE? Does your facility have a procedure for VTE?

12 Clostridium Difficile (C. Diff) Hand hygiene compliance program and monitoring in place Implementation of C. diff reduction bundle Education and implementation of appropriate environmental cleaning techniques Implementation of ED and OR cleaning procedures Implementation of an antimicrobial stewardship program Does your facility have a policy for C. diff? Does your facility have a procedure for C. diff?

13 Sepsis Use of early detection sepsis screening tool Implementation of Surviving Sepsis campaign bundle Utilize modified early warning score (MEWS) system with existing sepsis bundle to facilitate identification of sepsis Does your facility have a policy for Sepsis? Does your facility have a procedure for Sepsis?

14 Worker Safety This section does not apply to my facility. Implementation of exposure control plan designed to eliminate or minimize worker exposure to blood-borne pathogens Use of devices with safety features engineered to prevent sharps injuries Implementation of Sharps Injury Prevention Plan Implementation of timely post exposure management lan WSHA Safe Patient Handling Safe Patient Handling Checklist Joint Commission Patient and Worker Safety

15 Does your facility have a policy for Worker Safety? Does your facility have a procedure for Worker Safety?

16 Undue Exposure to Radiation This section does not apply to my facility. Promote safe use of medical imaging devices Choosing Wisely Does your facility have a policy for Undue Exposure to Radiation? Does your facility have a procedure for Undue Exposure to Radiation?

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