### 29192 Federal Register / Vol. 79, No. 98 / Wednesday, May 21, 2014 / Notices

Method of Collection

To achieve the goals of this project, AHRQ will train primary care practice facilitators using the TeamSTEPPS in Primary Care training curriculum. Primary care practice facilitators may voluntarily sign up for this free, AHRQ sponsored training. Training will be delivered through a combination of online and in-person instruction. Online training will cover the core TeamSTEPPS tools and strategies thatcan be implemented in primary care. Inperson instruction will cover coaching, organizational change, and implementation science. Practice facilitators, who complete the training,will be surveyed six months posttraining.

The TeamSTEPPS Primary Care PostTraining Survey is an online instrument that will be administered to all primary care practice facilitators who complete the TeamSTEPPS in Primary Care training. The survey will be administered six months after participants complete training.

This is a new data collection effort for the purpose of conducting an evaluation of TeamSTEPPS in Primary Care Training. The evaluation is formative in nature as AHRQ seeks information to improve the content and delivery of the training. Training will be providedthrough a combination of online and inperson instruction.

To conduct the evaluation, theTeamSTEPPS in Primary Care PostTraining Survey will be administered to all individuals who complete the TeamSTEPPS in Primary Care training six months after training. The survey assesses the degree to which participants felt prepared by the training and what they did to implement TeamSTEPPS in primary care practices. Specifically, participants will be asked about their reasons for participating in the program; the degree to which they feel the training prepared them to train others in and use TeamSTEPPS in the primary care setting; what tools they have implemented in primary care practices; and resulting changes they have observed in the delivery of care.

Estimated Annual Respondent Burden

Exhibit 1 shows the estimated
annualized burden hours for the respondent’s time to participate in the study. The TeamSTEPPS in Primary Care Post-Training Survey will be completed by approximately 150
individuals. We estimate that each respondent will answer 20 items (i.e., number of responses per respondent) and responding to these 20 questions will require 20 minutes. The total
annualized burden is estimated to be 50
hours.

Exhibit 2 shows the estimated
annualized cost burden based on the respondents’ time to participate in the study. The total cost burden is estimated to be $4,348.



### EXHIBIT 

### 1—E STIMATED 

### A NNUALIZED 

### B URDEN 

### H OURS

Form name Number of respondents Number of

responses per

respondent Hours per

response Total burden hours

TeamSTEPPS in Primary Care Post-Training Survey .................................... 150 1 20/60 50

Total .......................................................................................................... 150 NA NA 50



### EXHIBIT 

### 2—E STIMATED 

### A NNUALIZED 

### C OST 

### B URDEN

Form name Number of respondents Total burden hours Average hourly wage rate * Total cost burden

TeamSTEPPS Primary Care Post-training Survey ......................................... 150 50 a $86.95 $4,348

Total .......................................................................................................... 150 50 86.95 4,348

* National Compensation Survey: Occupational wages in the United States May 2012, ‘‘U.S. Department of Labor, Bureau of Labor Statistics.’’

a Based on the mean wages for Family and General Practitioners 29–1062.

Request for Comments

In accordance with the Paperwork Reduction Act, comments on AHRQ’s information collection are requested with regard to any of the following: (a) Whether the proposed collection of information is necessary for the proper performance of AHRQ health care
research and health care information dissemination functions, including
whether the information will have practical utility; (b) the accuracy of AHRQ’s estimate of burden (including hours and costs) of the proposed collection(s) of information; (c) ways to enhance the quality, utility, and clarity of the information to be collected; and (d) ways to minimize the burden of the collection of information upon the respondents, including the use of automated collection techniques or other forms of information technology.

Comments submitted in response to

this notice will be summarized and included in the Agency’s subsequent request for OMB approval of the proposed information collection. All

comments will become a matter of public record.

Dated: May 13, 2014.

Richard Kronick,

AHRQ Director.

[FR Doc. 2014–11727 Filed 5–20–14; 8:45 am]

**BILLING CODE 4160–90–P DEPARTMENT OF HEALTH AND** 
**HUMAN SERVICES**

**Agency for Healthcare Research and Quality** 

**Agency Information Collection Activities: Proposed Collection;**  **Comment Request**

**AGENCY :**  Agency for Healthcare Research and Quality, HHS.

**ACTION :**  Notice.

**SUMMARY :**  This notice announces the intention of the Agency for Healthcare Research and Quality (AHRQ) to request that the Office of Management and Budget (OMB) approve the proposed information collection project: ‘‘ Guide to Nursing Home Antimicrobial


### 29193 Federal Register / Vol. 79, No. 98 / Wednesday, May 21, 2014 / Notices

Stewardship. ’’ In accordance with the Paperwork Reduction Act of 1995, Public Law 104–13 (44 U.S.C. 3506(c)(2)(A)), AHRQ invites the public to comment on this proposed
information collection.

**DATES :**  Comments on this notice must be received by July 21, 2014.

**ADDRESSES :**  Written comments should be submitted to: Doris Lefkowitz, Reports Clearance Officer, AHRQ, by
email at doris.lefkowitz@ahrq.hhs.gov.

Copies of the proposed collection plans, data collection instruments, and specific details on the estimated burden can be obtained from the AHRQ Reports
Clearance Officer.

**FOR FURTHER INFORMATION CONTACT :**  Doris Lefkowitz, AHRQ Reports Clearance Officer, (301) 427–1477, or by
email at doris.lefkowitz@ahrq.hhs.gov.

**SUPPLEMENTARY INFORMATION :** 
Proposed Project

Guide to Nursing Home Antimicrobial Stewardship

This project seeks to contribute to AHRQ’s mission by assisting nursing homes to optimize antimicrobial (e.g., antibiotics and antifungals) prescribing practices, also referred to as antimicrobial stewardship. Antimicrobial stewardship programsreduce the development of drugresistant organisms, enhance patient outcomes, and reduce unnecessary

costs.

Nursing homes serve as one of our most fertile breeding grounds for
antibiotic-resistant strains of bacteria. This stems from high rates of infection in nursing home residents due to the effects of normal aging combined with multiple chronic diseases. The most
common infections encountered in nursing home residents are pneumonia, urinary tract infections, and skin and soft tissue infections. In one study by Yoshikawa and Norman, researchers found that these three types of infections accounted for approximately75 percent of all nursing homeassociated infections (NHAIs) . High
rates of these infections lead to antimicrobials being among the most commonly prescribed pharmaceuticals in long-term care settings. In nursing homes, where polypharmacy is the rule rather than the exception, as many as 40 percent of all prescriptions are for antimicrobial agents, and depending on the study, 25 percent to 75 percent have been deemed inappropriately prescribed. Such inappropriate prescribing results in negative outcomes, including adverse drug events, hospital admissions, and higher health care costs. Most significantly, inappropriate antimicrobial prescribinggives rise to the development of multidrug resistant organisms (MDROs), including Methicillin-resistantStaphylococcus aureus, Vancomycinresistant Enterococci, and fluoroquinolone-resistant strains of a variety of bacteria, and leads to the development of Clostridium difficile
infections.

In general, determining ‘‘appropriateness’’ of antimicrobial use in healthcare settings is challenging to
standardize. This becomes even more complicated in the nursing home setting
because most antimicrobial courses are started empirically (without results from labs) due to the limited diagnostics available to many nursing homes. In an effort to address the need for optimizing antibiotic use in the nursing homes, AHRQ is testing a Guide to Nursing Home Antimicrobial Stewardship (the Guide). The Guide is intended to help nursing home staff easily identify
toolkits that have been shown to be effective in optimizing antimicrobial use. There are multiple toolkits that could be used by a nursing home, andnursing homes face a potentially timeconsuming decision process to choose the most appropriate one. The Guide is intended to help nursing homes make this choice efficiently and effectively.

The research has the following goals: Develop a nursing home-specific antimicrobial stewardship guide, containing toolkits to assist nursing homes to optimize antimicrobial prescribing practices, monitor microbes and antimicrobial use, enhance communication between nursing home staff and attending clinicians, and
enhance communication and engagement with residents and family members regarding optimizing antimicrobial practices.

Evaluate the ability of nursing homes to use the Guide and improve antimicrobial use through better stewardship.

Develop a plan to ensure wide dissemination of the findings and
recommendations for antimicrobial stewardship uptake in nursing homes.

This study is being conducted by AHRQ through its contractor, American Institutes for Research, pursuant to AHRQ’s statutory authority to conduct and support research on healthcare and on systems for the delivery of such care, including activities with respect to the quality, effectiveness, efficiency, appropriateness and value of healthcare services and with respect to quality measurement and improvement. 42 U.S.C. 299a(a)(1) and (2). Method of Collection
To achieve the goals of this project the following data collections will be implemented:

(1) Medical Record Review (MRR).
The MRR will be used to obtain data about antimicrobial prescribing practices, infection prevalence, and
residents’ health and functional
statuses. These data will be used in the evaluation of the Guide’s impact.
Members of the research team will review the nursing home’s medical charts, the Nursing Home Minimum Data Set (MDS), and the nursing home’s infection control log for an evaluation period of at least 12 months (6 months
before and 6 months after the introduction of the Guide). The MDS is part of the federally mandated process
for clinical assessment of all residents in
Medicare and Medicaid certified nursing homes. This process provides a comprehensive assessment of each resident’s functional capabilities and helps nursing home staff identify health problems. Care Area Assessments are part of this process, and provide the foundation upon which a resident’s individual care plan is formulated. MDS assessments are completed for all residents in certified nursing homes, regardless of source of payment for the individual resident. AHRQ will support data abstraction at all nursing homes.

(2) Cost Data Analysis. AHRQ will use the number and type of antimicrobial prescriptions and secondary estimates of the unit cost of these prescriptions, obtained from external sources, to compute the marginal impact of the
Guide on the cost of antimicrobials for nursing homes.

(3) Pre-intervention Interviews with nursing home leaders. The purpose of these interviews is to gain an understanding of perceptions and current activities regarding antimicrobial stewardship and to assess
the likelihood that the Guide will be used with a reasonable degree of fidelity to the implementation plan. This will involve both closed and open-ended interviews with nursing home leaders (administrator, director of nursing, assistant director of nursing, and/or medical director). The open ended interviews will examine (1) how the staff perceive antimicrobial stewardship; (2) the amount of experience the staff has in antimicrobial stewardship and its processes for handling the diagnosis and treatment of infections; and (3) which toolkit or toolkits are likely to be adopted and why. This information will help us identify interests by nursing homes and potential barriers to adopting a toolkit


### 29194 Federal Register / Vol. 79, No. 98 / Wednesday, May 21, 2014 / Notices

from the Guide. This information also will be used to develop dissemination guidance. The closed ended interview questions, will be comprised of the Absorptive Capacity for Change survey, which asks about (1) leadership culture; (2) clinician culture; (3) presence of certified medical directors; and (4) level
of antimicrobial surveillance. For the Evaluation, two leadership staff at each nursing home will be interviewed for a total of 20 interviews prior to implementing the intervention.

(4) Passive Technical Assistance (TA). The purpose of collecting these data is to obtain information on the types of TA needed as they emerge during the 6- month intervention period. This information will be used to improve the Guide. AHRQ projects 60 contacts from nursing home staff involved in implementing the Guide (10 sites, one per month at each site during the 6- month intervention period).

(5) Proactive TA discussions. The purpose of collecting these data is to obtain information on the facilitators, challenges, and unintended consequences of implementing a particular tool or toolkit. These informal discussions will be held at each nursing home once a month during the 6-month intervention phase. Staff will be asked about what activities they are conducting, changes to implementation, any facilitators, any challenges, and how they have addressed any challenges. This information will be used to improve the Guide. For the Evaluation, two individuals from each nursing home are projected to attend
each of the six conference calls for a
total of 20 individuals and a total of 120

contacts.

(6) Post-intervention interviews. The purpose of these interviews is to identify (1) facilitators and barriers to implementation; (2) perceived impacts
of the Guide on the use of antimicrobials within the nursing home; (3) the nursing home’s views on the business case for the Guide; and (4) ways to improve the tools. At a minimum two nursing home leaders and two champions (if different from leaders) will be interviewed. In addition, depending on the tool or toolkit selected, up to two prescribing clinicians, two nurses, or two residents or family members might be interviewed after the 6-month intervention period is completed. No more than six individuals per nursing home will be
interviewed for a total of 60 interviewees. Interviews may take place together.

The information described above will be used to evaluate the Guide and, iffound to be effective, develop a widespread dissemination plan for the
Guide.

Estimated Annual Respondent Burden

Exhibit 1 shows the estimated
annualized burden hours for the respondents’ time to participate in this
information collection.



### EXHIBIT 

### 1—E STIMATED 

### A NNUALIZED 

### B URDEN 

### H OURS

Form name Number of respondents Number of

responses per

respondent Hours per

response Total burden hours

Passive TA Collection Protocol ....................................................................... 20 3 20/60 20
General Review of the Guide .......................................................................... 20 1 2 40 Pre-intervention interview protocol .................................................................. 20 1 1 20 Proactive TA discussion protocol .................................................................... 20 6 30/60 60 Post-intervention interview protocols ............................................................... 60 1 1 60

Total .......................................................................................................... 140 na na 200



### EXHIBIT 

### 2—E STIMATED 

### A NNUALIZED 

### C OST 

### B URDEN

Form name Number of respondents Total burden hours Average hourly wage rate * Total cost burden

Passive TA Collection Protocol ....................................................................... 20 20 $30.34 $607

General review of the Guide ........................................................................... 20 40 30.34 1,214 Pre-intervention interview protocol .................................................................. 20 20 30.34 607 Proactive TA discussion protocol .................................................................... 20 60 30.34 1,820 Post-intervention interview protocols ............................................................... 60 60 30.34 1,820

Total .......................................................................................................... 140 200 na 6,068

* National Compensation Survey: Occupational wages in the United States May 2013, ‘‘U.S. Department of Labor, Bureau of Labor Statistics.’’ We used an average across the following types of staff: Nursing home registered nurses ($29.81) 29–1141, nursing home licensed practical/vocational nurses ($21.14) 29–2061, and nursing home administrator ($40.07) 11–9111. Our average was created by adding each of these three
and dividing by three for the average. Sources: http://www.bls.gov/oes/current/oes291141.htm and http://www.bls.gov/oes/current/oes292061.htm; http://www.bls.gov/oes/current/oes119111.htm.

Request for Comments

In accordance with the Paperwork Reduction Act, comments on AHRQ’s information collection are requested with regard to any of the following: (a) Whether the proposed collection of information is necessary for the proper performance of AHRQ health care
research and health care information dissemination functions, including whether the information will have practical utility; (b) the accuracy of AHRQ’s estimate of burden (including hours and costs) of the proposed collection(s) of information; (c) ways to enhance the quality, utility, and clarity of the information to be collected; and (d) ways to minimize the burden of the collection of information upon the respondents, including the use of automated collection techniques or other forms of information technology.

Comments submitted in response to

this notice will be summarized and included in the Agency’s subsequent request for OMB approval of the proposed information collection. All

comments will become a matter of public record.


### 29195 Federal Register / Vol. 79, No. 98 / Wednesday, May 21, 2014 / Notices

Dated: May 13, 2014.

Richard Kronick,

AHRQ Director.

[FR Doc. 2014–11726 Filed 5–20–14; 8:45 am]

**BILLING CODE 4160–90–P**

**DEPARTMENT OF HEALTH AND**
**HUMAN SERVICES**

**Centers for Disease Control and**
**Prevention**

**[30Day–14–14GW]**

**Agency Forms Undergoing Paperwork**
**Reduction Act Review**

The Centers for Disease Control and Prevention (CDC) has submitted the following information collection request to the Office of Management and Budget (OMB) for review and approval in accordance with the Paperwork
Reduction Act of 1995. The notice for the proposed information collection is published to obtain comments from the public and affected agencies.

Written comments and suggestions from the public and affected agencies concerning the proposed collection of information are encouraged. Your comments should address any of the following: (a) Evaluate whether the proposed collection of information is necessary for the proper performance of the functions of the agency, including
whether the information will have practical utility; (b) Evaluate the accuracy of the agencies estimate of the burden of the proposed collection of information, including the validity of the methodology and assumptions used; (c) Enhance the quality, utility, and clarity of the information to be collected; (d) Minimize the burden of
the collection of information on those who are to respond, including through the use of appropriate automated, electronic, mechanical, or other technological collection techniques or other forms of information technology, e.g., permitting electronic submission of responses; and (e) Assess information
collection costs.

To request additional information on the proposed project or to obtain a copy of the information collection plan and instruments, call (404) 639–7570 or
send an email to omb@cdc.gov. Written comments and/or suggestions regarding
the items contained in this notice
should be directed to the Attention: CDC Desk Officer, Office of Management and Budget, Washington, DC 20503 or by fax to (202) 395–5806. Written
comments should be received within 30 days of this notice. Proposed Project

Total Worker Health for Small
Business—New—National Institute for Occupational Safety and Health (NIOSH), Centers for Disease Control and Prevention (CDC).

Background and Brief Description

The mission of the National Institute for Occupational Safety and Health (NIOSH) is to promote safety and health at work for all people through research and prevention. In this capacity, NIOSH will administer in-depth interviews designed to assess perceptions and opinions among small business owners in the Cincinnati/Northern Kentucky area regarding the Total Worker Health concept. This information will guide the development of a model for diffusion of the Total Worker Health approach among small businesses by community organizations. Total Worker Health for Small Business is a four-year field study whose overall goal is to identify the perceived costs and benefits of offering integrated occupational safety and health (OSH) and workplace wellness services to employees among small businesses (SBs), and to inform methods that will successfully diffuse the use of a Total Worker Health approach among small businesses and the community organizations that serve them. The data gathered in this study regarding small businesses’ specific training needs, motivational factors, and preferred
information sources will be of significant practical value when designing and implementing future

interventions.

The proposed in-depth interviews
described here for which Office of Management and Budget review and approval is being requested are a critical step toward the development of this
TWH diffusion model. Phase 1 of this project included interview development and revision. The primary goal of Phase2 of this project is to gather keyinformant perceptions and opinions among the target audience, small
business owners in the Cincinnati/ Northern Kentucky area. Data gathered from in-depth interviews will guide the development of efforts to diffuse the Total Worker Health approach among small businesses and the community organizations which serve them.

About 90% of U.S. employer organizations have fewer than 20 employees, and 62% have less than five. Eighteen percent of all U.S. employees
work for businesses that have less than 20 employees. In addition, more than 21
million U.S. businesses have zero employees, meaning that, although they are not counted as employees, the owner is also the worker. Workers in smaller organizations endure a disproportionate share of the burden of occupational injuries, illnesses, and
fatalities.

There is no data available on the prevalence of TWH programs in smaller organizations. What is known about smaller organizations is divided into information about health protection and health promotion activities. Smaller organizations engage in fewer safety activities than larger organizations. The need for reaching this population with effective, affordable, and culturally appropriate training has been documented in publications and is increasingly becoming an institutional priority at NIOSH. Given the numerous
obstacles which small business owners face in effectively managing occupational safety and health (e.g., financial and time constraints), there is a need for identifying the most crucial components of occupational safety and health and health promotion training.

This interview will be administered to a sample of approximately 60 owners of small businesses with 5–49 employees from the Cincinnati/Northern Kentucky area. Each participant will be administered the survey two times, approximately one year apart to assess for changes in perceptions regarding health protection and health promotion activities. The sample size is based on recommendations related to qualitative
interview methods and the research team’s prior experience.

Participants for this data collection
will be recruited with the assistance of contractors who have successfully performed similar tasks for NIOSH in the past. Participants will be receive $50 as a token of appreciation for their time. The interview questionnaire will be administered verbally to participants in English.

Once this study is complete, results
will be made available via various means including print publications and the agency internet site. The information gathered by this project could be used by OSHA, state health department, occupational health providers to determine guidelines for the development of appropriate training
materials for small businesses. The results of this project will benefit small business workers by developing recommendations for increasing the effectiveness of occupational safety and health outreach methods specifically targeted to small businesses. Although beyond the scope of this study, it is expected that improved use of TWH programs will lower rates of injuries and
fatalities for workers. The total burden
hours are 180.