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
For which Honor Roll level are you applying?
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Bronze Silver Gold
Hospital Name:
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Other hospital not listed Abbott Northwestern Hospital Alomere Health Appleton Municipal Hospital (Appleton Area Health Services) Avera Marshall Regional Medical Center Avera Tyler Bigfork Valley Hospital Buffalo Hospital Cambridge Medical Center Carris Health-Redwood Cass Lake Hospital Centracare Health -Long Prairie Centracare Health Sauk Centre Centracare Health Systems-Monticello Centracare Health Systems-Paynesville Centracare Health-Melrose CHI LakeWood Health Center CHI St. Joseph's Health Children's Hospitals and Clinics of MN Chippewa Country-Montevideo Hospital Community Memorial Hospital Cook Hospital and Care Center Cuyuna Regional Medical Center District One Hospital Ely Bloomenson Community Hospital Essentia Health - Graceville/Holy Trinity Hospital Essentia Health-Ada Essentia Health-Deer River Hospital Essentia Health-Duluth Essentia Health-Fosston Essentia Health-Northern Pines Essentia Health-Sandstone Essentia Health-St. Josephs Medical Center Essentia Health-St. Marys Detroit Lakes Essentia Health-St. Marys Medical Center Essentia Health-Virginia M Health Fairview Lakes Medical Center M Health Fairview Northland Regional Hospital M Health Fairview Range Medical Center M Health Fairview Ridges Hospital M Health Fairview Southdale Hospital Gillette Children's Specialty Hospital Glacial Ridge Hospital Glencoe Regional Health Services Grand Itasca Clinic and Hospital Granite Falls Health M Health Fairview Bethesda Hospital M Health Fairview St. Johns Hospital M Health Fairview St. Josephs Hospital M Health Fairview Woodwinds Hospital Hendricks Community Hospital Hennepin County Medical Center Hutchinson Health Johnson Memorial Health Services Kittson Memorial Hospital Lake Region Healthcare Corporation Lake View Hospital Lakeview Hospital-Stillwater Lakewood Health System Lifecare Medical Center Madelia Community Hospital Madison Healthcare Services Mahnomen Health Center Maple Grove Hospital Mayo Clinic Health Systems in Red Wing Mayo Clinic Health Systems- St. James Mayo Clinic Health Systems-Albert Lea Mayo Clinic Health Systems-Austin Mayo Clinic Health Systems-Cannon Falls Mayo Clinic Health Systems-Fairmont Mayo Clinic Health Systems-Lake City Mayo Clinic Health Systems-Mankato Mayo Clinic Health Systems-New Prague Mayo Clinic Health Systems-Springfield Mayo Clinic Health Systems-Waseca Mayo Clinic Hospital-Rochester Meeker Memorial Hospital Mercy Hospital - Unity Campus Mercy Hospital-Coon Rapids Mercy Hospital-Moose Lake Mille Lacs Health System Minneapolis VA Health Care System Murray County Memorial Hospital New Ulm Medical Center North Memorial Health Hospital North Shore Health Northfield Hospital Olmsted Medical Center Ortonville Area Health Service Owatonna Hospital Park Nicollet Methodist Hospital Perham Health Phillips Eye Institute Pipestone Country Medical Center and Family clinic / Avera Prairie Ridge Hospital Health Services Rainy Lake Medical Center Red Lake Hospital Regency Hospital of Minneapolis LLC Regina Hospital Regions Hospital Renville County Hospital and Clinics Rice Memorial Hospital Ridgeview Le Sueur Medical Center Ridgeview Medical Center Ridgeview Sibley Medical Center River's Edge Hospital & Clinic Riverview Health Riverwood Healthcare Center Sanford Canby Medical Center Sanford Luverne Medical Center Sanford Medical Center-Bagley Sanford Medical Center-Bemidji Sanford Medical Center-Jackson Sanford Medical Center-Thief River Falls Sanford Medical Center-Tracy Sanford Medical Center-Westbrook Sanford Medical Center-Wheaton Sanford Worthington Medical Center and Clinic Shriners Hospital for Children Sleepy Eye Medical Center St. Cloud Hospital St. Cloud VA Health Care System St. Elizabeths Medical Center St. Francis Healthcare Campus St. Francis Regional Medical Center St. Gabriels Hospital St. Lukes Hospital Stevens Community Medical Center Swift County Benson Health Services Astera Health United Hospital United Hospital District University of Minnesota Medical Center Welia Health Windom Area Hospital Winona Health Services M Health Fairview Masonic Children's Hospital Mayo Clinic Health Systems - Southwest MN Region Asp Team Mayo Clinic Health Systems - Southeast MN Region Asp Team
For which hospital are you completing this application?
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Is your hospital affiliated with a health system?
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Yes
No
Facility Street Address (1):
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Facility Street Address (2):
City:
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Zip Code:
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County:
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Aitkin Anoka Becker Beltrami Benton Big Stone Blue Earth Brown Carlton Carver Cass Chippewa Chisago Clay Clearwater Cook Cottonwood Crow Wing Dakota Dodge Douglas Faribault Fillmore Freeborn Goodhue Grant Hennepin Houston Hubbard Isanti Itasca Jackson Kanabec Kandiyohi Kittson Koochiching Lac qui Parle Lake Lake of the Woods Le Sueur Lincoln Lyon McLeod Mahnomen Marshall Martin Meeker Mille Lacs Morrison Mower Murray Nicollet Nobles Norman Olmsted Otter Tail Pennington Pine Pipestone Polk Pope Ramsey Red Lake Redwood Renville Rice Rock Roseau St Louis Scott Sherburne Sibley Stearns Steele Stevens Swift Todd Traverse Wabasha Wadena Waseca Washington Watonwan Wilkin Winona Wright Yellow Medicine Out of State Unknown
Street Address Street Address 2 (optional) City Zip Code County
Name of Applicant:
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Applicant Job Title:
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Infection Preventionist Pharmacist Physician Administrator Quality Other
Please specify your job title.
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Applicant Email Address:
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Applicant Phone Number:
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Thank you for completing the application. Please tell us about yourself.
Your First and Last Name Job Title Other Job Title Email Address Phone Number
Structure of Your Antibiotic Stewardship Program (ASP) Which of the following positions are represented on the hospital's 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.
Select all that apply
Please describe the additional positions represented on the hospital's ASP team or advisory committee.
Names of ASP Leaders Physician Leader Pharmacist Leader Name and degrees: Name and degrees: Email address:
Email address:
Is this position fulfilled through tele-stewardship?
Is this position fulfilled through tele-stewardship?
Does the physician leader have formal stewardship training? This is not required for Honor Roll recognition.
Does the pharmacist leader 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?
Other training:
Name of Physician Leader:
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Does the physician leader have formal AS training?
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Yes
No
What type of training does the physician have?
Is this physician leadership position fulfilled through tele-stewardship?
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Yes
No
Name of Pharmacist Leader:
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Does the pharmacist leader have formal AS training?
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Yes
No
Select all that apply
What AS training does the pharmacist have?
Is this pharmacist leadership position fulfilled through tele-stewardship?
* must provide value
Yes
No
Leadership Commitment Verification Upload a letter of commitment from the hospital CEO/COO or other relevant executive.
A new letter must be submitted for each year of Honor Roll application. The letter must include a description of how the hospital 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 hospital antibiotic stewardship policy.
Upload a letter of commitment from the hospital CEO/COO or other relevant executive.
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Upload a copy of the hospital antibiotic stewardship policy.
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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?
Date of Education Session:
Today M-D-Y
Description of Education Event or Series:
Do you have another didactic education activity to report?
Yes
No
Education Session 2:
Date of Education Session:
Staff Included:
Description of Education Event or Series:
Do you have another didactic education activity to report?
Date of Education Session 2:
Today M-D-Y
Description of Education Event or Series:
Do you have another didactic education activity to report?
Yes
No
Education Session 3:
Date of Education Session:
Staff Included:
Description of Education Event or Series:
Date of Education Session 3:
Today M-D-Y
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 hospitals applying for Silver or Gold Level recognition, and more information will be collected in Part 2 of the application.
Select all that apply
Case-based Education
Select the case-based education approach(es) used in your hospital in the last year .
Select all that apply
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?
Method 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?
Yes
No
Are outcomes of these interventions measured?
Yes
No
Required Actions: Antibiotic use tracking Antibiotic use reporting to prescribers, committees, and leadership Prospective audit with feedback Preauthorization Prescribing guidelines Hospital-specific antibiogram 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?
Which antibiotics are tracked?
Where in your hospital are antibiotics tracked?
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.
Which antibiotics are tracked?
All antibiotic drugs
Specific antibiotic classes of interest
Specific antibiotic agents of interest
Where is antibiotic use tracked?
Facility-wide
In a subset of priority units or wards
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)?
Who receives antibiotic-use reports?
How are reports delivered (e.g., directly during in-person meetings, by email)?
Use of Hospital-specific Evidence-based Treatment and Prescribing Guidelines
For which conditions do you have guidelines?
Are outcomes of this intervention measured?
Use of a Hospital-specific Antibiogram
Not required for hospitals without onsite laboratory and susceptibility testing.
Does your hospital have an onsite laboratory with susceptibility testing?
Does your hospital use a hospital-specific antibiogram?
Additional antibiotic stewardship intervention(s)
Information provided here might be included in your hospital's summary on the Honor Roll webpage. This allows others to learn about the great work happening in Minnesota hospitals.
Does your hospital have an onsite laboratory with susceptibility testing?
Yes
No
Do you use a hospital-specific antibiogram?
Yes
No
For which conditions do you have guidelines?
Are outcomes of this intervention measured?
Yes
No
Optional Actions: Which of the following actions or strategies are in place at your hospital?
What other strategies are in place in your hospital?
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?
Method used to provide feedback (e.g., in person, email):
What conditions, drugs, or situations trigger prospective audit with feedback?
Are outcomes of these interventions measured?
Yes
No
Method used for provider communication (e.g., in person, email):
What antibiotic drugs require preauthorization?
Are outcomes of these interventions measured?
Yes
No
Have you submitted your facility's most recent annual antibiogram? This is required of hospitals that have an onsite laboratory that conducts susceptibility testing. We are now collecting annual antibiograms from 2021.
Not yet. Please send me the link to submit my antibiogram.
Yes. I have already submitted our hospital antibiogram to MDH.
No. We do not have a hospital-specific antibiogram.
I don't know.
We will contact you with a link to the electronic form for antibiogram submission.
Thank you for submitting your annual antibiogram!
We will check our records for your hospital's annual antibiogram and let you know if we have it.
Describe how your hospital engages in ongoing, formal collaboration beyond your facility to advance antibiotic stewardship. Some examples of how this requirement can be met are: Formal mentorship of area hospitals, long-term care facilities, or clinics where expertise is shared in a structured, ongoing partnership. Regional coordination of data, protocols, or best practices (e.g., sharing antibiotic use and resistance data with other facilities in a benchmarking process) and using regularly scheduled meetings to facilitate information exchange. Actively optimizing antibiotic stewardship during care transitions through regular meetings among facilities that share patients, and development or improvement of protocols and communication practices.
Describe how your hospital engages in ongoing, formal collaboration beyond your facility to advance antibiotic stewardship.
We are willing to share our Antibiotic Stewardship Program knowledge and experiences with other facilities!
Yes
No
Thank you for your willingness to share knowledge and experience with others!
Thank you for applying to the
(Optional) Approximately how long did it take you to complete this application (minutes)?
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