SIDP-ASP Clinical Skills Component Form
SIDP Antimicrobial Stewardship Program
Phase 3 Clinical Skills Component Guidelines
After completion of the self-study and live webinars, the participant is required to implement some aspect of antimicrobial stewardship at their facility.
The Clinical Skills Component is an activity by which the student demonstrates their individual mastery by applying what they learned in the self-study and live webinars to implementor modify some aspect of antimicrobial stewardship at their facility. The Clinical Skills Component may address any facet (structure, policy, or outcome) of Antimicrobial Stewardship at their institution.Because the focus of the Clinical Skills Component is on individual mastery, participants must submit a report on how they applied what they learned from the program, independent from other SIDP certificate program participants, at their facility.
Implementation of the Clinical Skills Component should be completedprior to submission of this form and supporting evidence of implementation MUST be provided when the form is submitted (see question 5).
In order to receive full credit for the Clinical Skills Component you must complete the following form to serve as your final report(Note: All reports must be typed; handwritten reports will not be accepted.)
By completing this form, I am attesting that I have completed or was highly involved in the project presented.
Name Email
Address (provide complete address for mailing of final certificate)
City State Zip
Type of Project(although only one project should be submitted, it might address multiple of the below, choose all that apply):
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SIDP-ASP Clinical Skills Component Form
Prospective audit with intervention and feedback
Identification of targets:
"Bug-drug" mismatch
Positive culture but no antimicrobial
Redundant/duplicate therapy
Retrospective review of identified target & intervention
Start/stop/change therapy
De-escalation/streamlining
Dosing optimization
Formulary restriction with preauthorization
Education (a copy of the educational materials created must be included)
Guideline, clinical pathway, antimicrobial order form
Parenteral to oral conversion
Antibiogram
Other (specify): ______
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SIDP-ASP Clinical Skills Component Form
Briefly describe your facility (type, size, etc):
1. Provide the date (MM/YY) you enrolled in the certificate program:
2. Provide the dates (MM/YY) you completed the self-study and webinars.
Phase 1: / Phase 2:3. Provide the date (MM/YY) your Phase 3 project was implemented:
3a. (Only respond if the date in question 2 is later than the date in question 3. Otherwise skip this question.) Phase 3 projects must be implemented AFTER enrollment in the SIDP AS Program, and preferably after completion of the self-studyand webinarcomponents of the program. If your project was implemented after enrollment and prior to finishing the self-study/webinar portion your project may or may not be approvable. To assist the committee in determining whether your project is suitable for further review and consideration please indicate what SPECIFIC information/skills you learned during the self-study and/or webinars that you APPLIED in your project to improve the care of patients with infectious diseases at your institution.
4.Briefly describe what you implemented at your facility as a result of participation in the program.Please provide protocol or educational materials that were created – if unable to share this material due to institutional policies, then a detailed description must be included in this section.
5. Please specify what supporting documentation is provided as evidence of project implementation (Note: documentation must be submitted with this form):
P&T approved policy (documentation of policy approval must be included)
Meeting minutes
Email from head of P&T or manager confirming project implementation
Other:______
6. Please indicatewhich self-study module(s)/live webinar(s) contributed to the development and implementation of your Phase 3 Clinical Skills Component:
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SIDP-ASP Clinical Skills Component Form
Phase 1 Self-Study Modules
1. Microbiology
2. Pharmacology
3. Pharmacokinetics/Pharmacodynamics (PK/PD)
4. Infection Control
5. Disease States Treatments
6. Interventions
7. Measuring Outcomes
Phase 2 – Live Webinars
Implementation of an ASP: Justification, Cost, and Challenges
Optimizing Infectious Diseases Outcomes in an ASP
Multidrug Resistant Organisms: Detection, Epidemiology, and Management
Understanding the Hospital Antibiogram
Computer Support Systems Technology in an ASP
Antimicrobial Stewardship & Microbiology, Focus on Rapid Diagnostic Tests
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SIDP-ASP Clinical Skills Component Form
7.Please explain how you plan to measure the effectiveness of what you implemented (i.e., outcome measurement).
8. What barriers did you encounter to what you implemented?
9.What strategies did you employ to overcome those barriers?
10.Describe your involvement in implementing and documenting your project (including number of hours).
11.Comments:
B.After the final report is complete, please send it to SIDP c/o ProCE, Inc. at . You will be contacted if there are any questions. The review process will take approximately one month.
C.Once the report is approved, you will receive an email to complete an overall program evaluation online. CE credit for 10.0 hrs CE or 1.0 CEUwill be issued online upon completion of the final evaluation. ACertificate of Completion for the SIDP Antimicrobial Stewardship Program will be mailed to you within two to four weeks of completing the program.
If you have any questions, please email or call us at 630-540-2848.
Are you willing to have your stewardship project used as an example for future SIDP Antimicrobial Stewardship Program participants?
YES, you may use my project as an example
NO, do not use my project as an example
REMINDER: Have you have attached documentation of project implementation? Your project cannot be submitted for review if documentation is not attached.
ProCE, Inc. 848 W. Bartlett Rd., Ste 3E Bartlett, IL 60103
630-540-2848 Fax: 630-540-2849