Site Assessment Profile
TeamSTEPPS Long-Term Care Instructor Guide
The following items provide an operational profile of your nursing home or department.
Please provide information on as many items as are applicable.
1.1 Name of nursing home: _______________________________________________________________
1.2 Date this survey completed: _____________________________________________________________
1.3 Number of licensed beds: ______________________________________________________
1.4 Annual census: __________________________________________________________
1.5 Staff Profile: Check if for facilitywide __________ or department __________
Complete for the following:
Number of Positions | Filled | Vacant |
---|---|---|
Medical Staff | ||
Nurses (RNs/LPNs) | ||
Nursing Assistants |
1.6 Support Services (check all that apply)
Clinical Laboratories | Information Systems | Pharmacy | Therapeutic Recreation (Activities) |
Dietary/Nutrition | Laundry | PT/OT/ST | Transportation Service |
Finance | Physical Plant/Environmental Services | Radiology | Other |
Housekeeping | Pastoral Service | Respiratory Therapy | Human Resources |
Patient Advocate | Social Services |
1.7 Are there impending changes or initiatives that your facility is expecting in the next 12 months? (Check all that apply)
Change in or absence of administration | Plant renovations |
Change in or absence of medical director | Union contract renewal |
Change in or absence of director of nursing | Facilitywide mandatory training |
Change in or absence of staff development coordinator | Other |
New resident care services |
1.8 Overall Vision for the nursing home (may provide Mission, Vision, and Values):
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
1.9 What are the nursing home's strategic goals?
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
- 1.10 Has a Resident Care Team Training initiative ever been conducted in your nursing home?
- Yes or No. If yes, what was the impact and are teams still functional (list departments)?
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
1.11 What clinical and safety measures are you currently tracking?
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
1.12 Resident Satisfaction Surveys:
1.12a What resident satisfaction tool does your site currently use?
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
1.12b What do residents report being most satisfied with?
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
1.12c What do residents report being least satisfied with?
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
1.12d Please provide most recent reported measures:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
1.13 Family Satisfaction Surveys:
1.13a What tool do you currently use to assess family satisfaction?
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
1.13b What do families report being most satisfied with?
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
1.13c What do families report being least satisfied with?
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
1.13d Please provide most recent reported measures:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
1.14 Staff Satisfaction Surveys:
1.14a What tool do you currently use to assess staff satisfaction?
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
1.14b What do staff report as the most satisfying part of their job?
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
1.14c What do staff report being least satisfied with?
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
1.14d Please provide most recent reported measures:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________