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 that 

can 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 provided 

through a combination of online and inperson instruction. 

To conduct the evaluation, the 

TeamSTEPPS 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—ESTIMATED ANNUALIZED BURDEN HOURS

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—ESTIMATED ANNUALIZED COST BURDEN

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.’’ aBased 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 

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

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 programs 

reduce 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 approximately 

75 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 prescribing 

gives rise to the development of multidrug resistant organisms (MDROs), 

including Methicillin-resistant 

Staphylococcus 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, and 

nursing 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 

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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, if 

found 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—ESTIMATED ANNUALIZED BURDEN HOURS

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—ESTIMATED ANNUALIZED COST BURDEN

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. 

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

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 Phase 

2 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. 

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