Antibiotic Stewardship Long-Term Care Honor Roll

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Thank you for your interest in the Minnesota Antibiotic Stewardship Honor Roll for Long-Term Care Facilities. Please complete the application below. If you start the application and need to finish it later, select "Save and Return" at the bottom of the page. If you are renewing your commitment, please review the information below and select "Renewal" when prompted. After completing your application, you will be able to download a PDF of the submission for your records.

Thank you!

Thank you for completing the application. Please tell us about yourself.

Your First and Last Name
Email Address
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Job Title

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Are you applying to the Honor Roll for the first time, or are you renewing your commitment to antibiotic stewardship?

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First-time Applicant

Renewing Commitment

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For which Honor Roll level are you applying?

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Facility Name:

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For which facility are you completing this application?

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Is your facility affiliated with a health system?

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Yes

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Health System:

Other health system:

Street Address
Street Address 2 (optional)
City
Zip Code
County

Part One: Facility-wide Commitment to Antibiotic Stewardship

This section is required of all applicants. Facilities applying for Bronze Level (Commitment) recognition are required to meet the criteria outlined in this section. A copy of the facility's antibiotic stewardship policy and a letter of commitment from leadership must be uploaded to meet criteria for recognition.

Facilities applying for Silver or Gold Level recognition are required to meet the criteria outlined in this section and parts 2 and 3, which follow.

Structure of the Antibiotic Stewardship Program (ASP)

Which of the following positions are represented on the facility ASP team and/or ASP advisory committee (by full-time, part-time, or contract staff; onsite or tele-based)? All Honor Roll facilities must engage with, at minimum, a physician, pharmacist, and infection preventionist.

Infection preventionist

Nursing staff

Medical staff

Consultant pharmacist

Consultant infectious disease physician

Information technology staff

Quality improvement staff

Administration

Other (describe)

Please describe the additional positions represented on the facility's ASP team or advisory committee.

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Names of ASP Leaders

Nursing Leader	Physician Leader	Consultant Pharmacist
Name and degrees:	Name and degrees:	Name and degrees:
Email Address:	Email Address:	Email Address:
Is this position fulfilled through tele-stewardship?	Is this position fulfilled through tele-stewardship?	Is this position fulfilled through tele-stewardship?
Does the nursing leader have formal stewardship training? This is not required for Honor Roll recognition.	Does the physician leader have formal stewardship training? This is not required for Honor Roll recognition.	Does the consultant pharmacist have formal stewardship training? This is not required for Honor Roll recognition.
If yes, what type of stewardship training?	If yes, what type of stewardship training?	If yes, what type of stewardship training?
		Other training:

Leadership Commitment Verification

Upload a letter of commitment from the organization CEO/COO or other relevant executive.

A new letter must be submitted with each Honor Roll application or renewal.
The letter must include a description of how the facility has established antibiotic stewardship as an organizational priority through support of its ASP, including provision of staffing, financial, and information technology resources.

Upload a copy of the facility antibiotic stewardship policy.

Education Verification

Honor Roll recognition requires that antibiotic stewardship education or training is provided to health care providers. You must report one or more of the education activity types (i.e., didactic, pharmacy-driven, case-based) below to describe. Selection of more than one activity type is encouraged.

Didactic Education

Provide information describing didactic education sessions targeted to providers and clinical caregivers. You will be able to enter information for up to three didactic education sessions that were held in the last year.

Date of Education Session:

Staff Included:

Description of Education Event or Series:

Do you have another didactic education activity to report?

Education Session 2:

Date of Education Session:

Staff Included:

Description of Education Event or Series:

Do you have another didactic education activity to report?

Education Session 3:

Date of Education Session:

Staff Included:

Description of Education Event or Series:

Pharmacy-driven Education

Select the pharmacy-driven approach(es) you have used to educate prescribers in the last year. Prospective audit and feedback are required for facilities applying for Silver or Gold Level recognition, and more information will be collected in Part Two of the application.

Prospective audit with feedback (external review of antibiotic therapy by an expert in antibiotic use, accompanied by suggestions to optimize use, after the agent has been prescribed)

Preauthorization

Other pharmacy-driven approach

Description of approach:

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Case-based Education

Select the case-based education approach(es) used in your facility in the last year.

Retrospective review of de-identified cases to identify opportunities to improve antibiotic therapy

Other case-based education

Retrospective Case Review

What method is used to provide education (e.g., in person, email)?

Who is involved in case review (e.g., providers, clinical caregivers)?

Are outcomes of these interventions measured?

Other Case-based Education

Briefly describe this case-based method.

Are outcomes of these interventions measured?

Required Actions:

Antibiotic use tracking
Antibiotic use reporting to prescribers, committees, and leadership
Additional stewardship intervention

Antibiotic Use Tracking

Tracking can be accomplished through multiple methodologies. Tell us about your approach here. You can tell us about optional reporting of antibiotic use to CDC in the section below.

Which measure(s) is used?

Do you also track the following?

Where in your facility are antibiotics tracked?

Which antibiotics are tracked?

How does your facility track antibiotic use data?

How does the ASP use antibiotic-use data to guide action or intervention? Briefly describe your approach to analysis and use of data to inform strategies.

Antibiotic Use Reporting

Who receives antibiotic-use reports or can accesss a dashboard summarizing antibiotic use?

How are reports delivered (e.g., directly during meetings, dashboard, email)?

Use of Facility-specific Evidence-based Treatment and Prescribing Guidelines

For which conditions do you have guidelines?

Are outcomes of this intervention measured?

Prospective Audit with Feedback

What conditions, drugs, or situations trigger prospective audit with feedback?

Which method is used to provide feedback (e.g., in person, email)?

Are outcomes of this intervention measured?

Preauthorization

What drugs require preauthorization?

Which method is used to provide feedback (e.g., in person, email)?

Are outcomes of this intervention measured?

Use of a Facility-specific Antibiogram

Does your facility have an onsite laboratory with susceptibility testing?

Does your facility use a facility-specific antibiogram?

Additional antibiotic stewardship intervention(s)

Information provided here might be included in your facility's summary on the Honor Roll webpage. This allows others to learn about the great work happening in Minnesota nursing homes.

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Optional Actions:

Which of the following actions or strategies are in place at your facility?

Describe how your facility engages in ongoing, formal collaboration beyond your facility to advance antibiotic stewardship. Some examples of how this requirement can be met are:

a) Mentorship of area long-term care facilities, clinics (e.g., dialysis clinics).
b) Regional coordination, e.g., sharing antibiotic use and resistance data with other facilities in benchmarking process.
c) Advancing antibiotic stewardship during care transitions by ongoing, formal communication/collaboration with area nursing homes and other health care facilities

Thank you for your willingness to share knowledge and experience with others!

Thank you for applying to the
Minnesota Antibiotic Stewardship Honor Roll program!

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Antibiotic Stewardship Long-Term Care Honor Roll

Part One: Facility-wide Commitment to Antibiotic Stewardship

Structure of the Antibiotic Stewardship Program (ASP)

Names of ASP Leaders

Leadership Commitment Verification

Education Verification

Part Two: Antibiotic Stewardship Actions

Required Actions:

Optional Actions:

Part Three: Collaborative Antibiotic Stewardship Endeavors

Thank you for applying to the
Minnesota Antibiotic Stewardship Honor Roll program!

You have selected an option that triggers this survey to end right now.

Antibiotic Stewardship Long-Term Care Honor Roll

Part One: Facility-wide Commitment to Antibiotic Stewardship

Structure of the Antibiotic Stewardship Program (ASP)

Names of ASP Leaders

Leadership Commitment Verification

Education Verification

Part Two: Antibiotic Stewardship Actions

Required Actions:

Optional Actions:

Part Three: Collaborative Antibiotic Stewardship Endeavors

Part Four: Optional Collaboration Opportunity

Thank you for applying to the Minnesota Antibiotic Stewardship Honor Roll program!

You have selected an option that triggers this survey to end right now.

Thank you for applying to the
Minnesota Antibiotic Stewardship Honor Roll program!