AHRQ Safety Program for Long-Term
Care: Infection Prevention (CAUTI-focus)
FACILITY TEAM ROSTER
Please identify a Team Leader at each facility who will assemble the project team. The Team Leader
should complete the team member contact information below and obtain team member signatures
signifying their commitment to this program.
Facility Name:
Note: depending upon the facility structure and size, several facility staff members may play more than
one role on the team. Thus, these roles may be split among staff in many different ways.
FACILITY TEAM MEMBER EXPECTATIONS
Team Lead is typically an influential team member (e.g., Director of Nursing, Assistant Director of
Nursing, Nurse Practitioner, Clinical Nurse Specialist, Nurse or Infection Preventionist) who will play a
key role in the project’s success at the Long-Term Care Facility (LTCF). S/he is expected to: 1) promote
the goals of the project and encourage other team members to commit to them; 2) attend and ask at
least one additional member of the LTC CAUTI project team to participate in all educational events; 3)
implement with team members the interventions that will be learned over the 12-month project period
and 4) meet regularly with LTCF team members to monitor progress. (Estimated Time Commitment:
110-135 hours/year or 6-7% FTE)
Administrative Champion is the program sponsor who champions the program aims, allocates the
necessary resources to help ensure successful program implementation and closely monitors the team’s
engagement and performance improvement results. S/he ensures that the program remains an
organizational priority. (2-4 hours/month)
Data Coordinator is responsible for data collection, submission, and report retrieval for their facility
according to the schedule that will be provided in the coming weeks. (1 hour/month)
Survey Coordinator is responsible for distributing and encouraging staff to complete the AHRQ Nursing
Home Survey for Patient Safety (NHSOPS) at the beginning and end of the project. The Survey
Coordinator can also be the Facility Team Leader. S/he will encourage and ensure staff completes the
survey, which takes about 15-20 minutes. The goal is to have as many staff members as possible
complete the survey, with a minimum of 60% completion by expected staff members to optimize the
validity of the results.
Nursing Champion will advocate for and support this initiative in her/his facility. Typically, the Director
of Nursing, the Assistant Director of Nursing, Charge Nurse or Unit Supervisor has this role; s/he will
reinforce program aims and support program implementation in the facility. (2-4 hours/month)
Physician Champion will advocate for and support this initiative in his/her facility. Typically the Medical
Director, s/he will reinforce program aims, learn the program basics and support program
implementation in the facility. (2-4 hours/month)
Infection Preventionist will advocate for and support this initiative in her/his facility. S/he will lead and
reinforce program aims, provide important infection prevention expertise and reinforce infection
prevention best practices. (2-4 hours/month)
Other Team Members will advocate for and support this initiative in their facility. They will assist in
program implementation, adding input in areas within their roles. They will also assist with educating
and communicating with peers. Other Team Members may include individuals who are certified nurse
aides, a QA/QI nurse, and occupational and physical therapists. (2-4 hours/month per person)
Acknowledgement of Understanding of Expectations by Team Members
Team Role
Name Printed
Title
Signature
Team Lead
Administrative Champion
Data Coordinator
Survey Coordinator
Nurse Champion
Physician Champion
Other Team Members (list job title)
Other Team Members (list job title)
Other Team Members (list job title)
Please E-mail a copy of the Team Roster to Diana Phelps at
dphelps@mocps.org or fax to 573-636-8608 by September 30, 2014.
Date