Hospital Sepsis Program Assessment Tool
The hospital sepsis program assessment tool is a companion to the CDC Hospital Sepsis Program Core Elements. This tool provides examples of ways to implement the Core Elements. The Core Elements are intended to be an adaptable framework that hospitals can use to guide efforts to optimize sepsis care. Thus, not all examples listed in the Core Elements (and below) may be necessary and/or feasible in all hospitals.
The assessment tool can be used on a periodic basis (e.g., annually) to document current program infrastructure and activities and to help identify items that could improve the effectiveness of the sepsis program. Consider listing specific details, such as points of contacts or facility-specific guidelines with the date, in the “comments” column as reference for the hospital sepsis program.
Core Element
Core Element
Established at Facility
Established at Facility
Comments
Comments
[priority example] Our sepsis program leader(s) are given sufficient specified time to manage the hospital sepsis program.
[priority example] Our sepsis program leader(s) are given sufficient specified time to manage the hospital sepsis program.
Yes / No
Yes / No
[priority example] Our sepsis program is provided sufficient resources, including data analytics and information technology support, to operate the program effectively.
[priority example] Our sepsis program is provided sufficient resources, including data analytics and information technology support, to operate the program effectively.
Yes / No
Yes / No
[priority example] Relevant staff from key clinical groups and support departments in our hospital have sufficient time to contribute to sepsis activities.
[priority example] Relevant staff from key clinical groups and support departments in our hospital have sufficient time to contribute to sepsis activities.
Yes / No
Yes / No
[priority example] Our hospital has a senior leader (e.g., Chief Clinical Officer, Chief Medical Officer, of Chief Nursing Officer) who serves as an executive sponsor for the sepsis program.
[priority example] Our hospital has a senior leader (e.g., Chief Clinical Officer, Chief Medical Officer, of Chief Nursing Officer) who serves as an executive sponsor for the sepsis program.
Yes / No
Yes / No
[priority example] Sepsis has been identified as a hospital priority by hospital leadership and this priority has been communicated to hospital staff.
[priority example] Sepsis has been identified as a hospital priority by hospital leadership and this priority has been communicated to hospital staff.
Yes / No
Yes / No
Our hospital leadership communicates to our hospital staff and patients how our hospital is addressing sepsis.
Our hospital leadership communicates to our hospital staff and patients how our hospital is addressing sepsis.
Yes / No
Yes / No
Our hospital leadership has regular meetings with leaders of the sepsis program to assess the resources needed to accomplish the hospital’s goals for sepsis activities and outcomes.
Our hospital leadership has regular meetings with leaders of the sepsis program to assess the resources needed to accomplish the hospital’s goals for sepsis activities and outcomes.
Yes / No
Yes / No
Our hospital sepsis program activities are integrated into other quality improvement and patient safety efforts, such as emergency department triage, antimicrobial stewardship, transitions of care, and Centers for Medicare & Medicaid Services (CMS) Severe Sepsis and Septic Shock: Management Bundle reporting.
Our hospital sepsis program activities are integrated into other quality improvement and patient safety efforts, such as emergency department triage, antimicrobial stewardship, transitions of care, and Centers for Medicare & Medicaid Services (CMS) Severe Sepsis and Septic Shock: Management Bundle reporting.
Yes / No
Yes / No
Our hospital staff performance incentives are tied to the achievement of targets for sepsis care and/or outcomes.
Our hospital staff performance incentives are tied to the achievement of targets for sepsis care and/or outcomes.
Yes / No
Yes / No
Sepsis program-related duties are included in job descriptions or performance reviews for our hospital sepsis program leaders and key support staff.
Sepsis program-related duties are included in job descriptions or performance reviews for our hospital sepsis program leaders and key support staff.
Yes / No
Yes / No
Our hospital leadership supports external training and education for sepsis program leaders and key support staff (e.g., attendance at sepsis meetings and quality improvement trainings).
Our hospital leadership supports external training and education for sepsis program leaders and key support staff (e.g., attendance at sepsis meetings and quality improvement trainings).
Yes / No
Yes / No
Our hospital leadership supports internal training and education on sepsis for hospital staff and trainees.
Our hospital leadership supports internal training and education on sepsis for hospital staff and trainees.
Yes / No
Yes / No
Our hospital leadership supports participation in regional, national, and international sepsis quality improvement collaboratives and initiatives.
Our hospital leadership supports participation in regional, national, and international sepsis quality improvement collaboratives and initiatives.
Yes / No
Yes / No
Core Element
[priority example] Our sepsis program leader(s) are given sufficient specified time to manage the hospital sepsis program.
[priority example] Our sepsis program is provided sufficient resources, including data analytics and information technology support, to operate the program effectively.
[priority example] Relevant staff from key clinical groups and support departments in our hospital have sufficient time to contribute to sepsis activities.
[priority example] Our hospital has a senior leader (e.g., Chief Clinical Officer, Chief Medical Officer, of Chief Nursing Officer) who serves as an executive sponsor for the sepsis program.
[priority example] Sepsis has been identified as a hospital priority by hospital leadership and this priority has been communicated to hospital staff.
Our hospital leadership communicates to our hospital staff and patients how our hospital is addressing sepsis.
Our hospital leadership has regular meetings with leaders of the sepsis program to assess the resources needed to accomplish the hospital’s goals for sepsis activities and outcomes.
Our hospital sepsis program activities are integrated into other quality improvement and patient safety efforts, such as emergency department triage, antimicrobial stewardship, transitions of care, and Centers for Medicare & Medicaid Services (CMS) Severe Sepsis and Septic Shock: Management Bundle reporting.
Our hospital staff performance incentives are tied to the achievement of targets for sepsis care and/or outcomes.
Sepsis program-related duties are included in job descriptions or performance reviews for our hospital sepsis program leaders and key support staff.
Our hospital leadership supports external training and education for sepsis program leaders and key support staff (e.g., attendance at sepsis meetings and quality improvement trainings).
Our hospital leadership supports internal training and education on sepsis for hospital staff and trainees.
Our hospital leadership supports participation in regional, national, and international sepsis quality improvement collaboratives and initiatives.
Established at Facility
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Comments
Core Element
Core Element
Established at Facility
Established at Facility
Comments
Comments
[priority example] Our hospital has a program or committee charged with monitoring and improving sepsis care and/or outcomes.
[priority example] Our hospital has a program or committee charged with monitoring and improving sepsis care and/or outcomes.
Yes / No
Yes / No
[priority example] Our hospital has one leader or two co-leaders (physician and nurse) responsible for sepsis program or committee management and outcomes.
[priority example] Our hospital has one leader or two co-leaders (physician and nurse) responsible for sepsis program or committee management and outcomes.
Yes / No
Yes / No
[priority example] Our hospital sets ambitious but achievable goals for improving sepsis care and patient outcomes that are informed by review of hospital practices, hospital sepsis outcomes, and clinical practice guidelines.
[priority example] Our hospital sets ambitious but achievable goals for improving sepsis care and patient outcomes that are informed by review of hospital practices, hospital sepsis outcomes, and clinical practice guidelines.
Yes / No
Yes / No
[priority example] Our hospital assesses progress towards hospital sepsis goals at regular intervals and updates goals periodically (e.g., annually) to promote continual improvement.
[priority example] Our hospital assesses progress towards hospital sepsis goals at regular intervals and updates goals periodically (e.g., annually) to promote continual improvement.
Yes / No
Yes / No
[priority example] Our hospital has one physician and one nurse lead or champion to ensure physician and nursing engagement in the sepsis program.
[priority example] Our hospital has one physician and one nurse lead or champion to ensure physician and nursing engagement in the sepsis program.
Yes / No
Yes / No
Sepsis program-related activities and outcomes are included in annual performance reviews for our sepsis program leaders.
Sepsis program-related activities and outcomes are included in annual performance reviews for our sepsis program leaders.
Yes / No
Yes / No
Our hospital has unit-level physician and nurse champions for sepsis activities.
Our hospital has unit-level physician and nurse champions for sepsis activities.
Yes / No
Yes / No
Sepsis program activities and outcomes are reported to our senior hospital leadership and/or hospital board of directors on a regular basis.
Sepsis program activities and outcomes are reported to our senior hospital leadership and/or hospital board of directors on a regular basis.
Yes / No
Yes / No
Core Element
[priority example] Our hospital has a program or committee charged with monitoring and improving sepsis care and/or outcomes.
[priority example] Our hospital has one leader or two co-leaders (physician and nurse) responsible for sepsis program or committee management and outcomes.
[priority example] Our hospital sets ambitious but achievable goals for improving sepsis care and patient outcomes that are informed by review of hospital practices, hospital sepsis outcomes, and clinical practice guidelines.
[priority example] Our hospital assesses progress towards hospital sepsis goals at regular intervals and updates goals periodically (e.g., annually) to promote continual improvement.
[priority example] Our hospital has one physician and one nurse lead or champion to ensure physician and nursing engagement in the sepsis program.
Sepsis program-related activities and outcomes are included in annual performance reviews for our sepsis program leaders.
Our hospital has unit-level physician and nurse champions for sepsis activities.
Sepsis program activities and outcomes are reported to our senior hospital leadership and/or hospital board of directors on a regular basis.
Established at Facility
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Comments
Core Element
Core Element
Established at Facility
Established at Facility
Comments
Comments
[priority example] Our hospital has a sepsis coordinator, who oversees day-to-day implementation of sepsis program activities.
Note: The hospital sepsis coordinator may be the same or different individual as the lead or co-lead of the hospital sepsis program.
[priority example] Our hospital has a sepsis coordinator, who oversees day-to-day implementation of sepsis program activities.
Note: The hospital sepsis coordinator may be the same or different individual as the lead or co-lead of the hospital sepsis program.
Yes / No
Yes / No
[priority example] Clinicians and leaders from the emergency department, inpatient wards, and intensive care units are fully engaged in our hospital sepsis program activities.
[priority example] Clinicians and leaders from the emergency department, inpatient wards, and intensive care units are fully engaged in our hospital sepsis program activities.
Yes / No
Yes / No
[priority example] Our hospital sepsis program includes diverse multi-disciplinary representation (e.g., antimicrobial stewardship, critical care, emergency medicine, hospital medicine, infectious diseases, nursing, other primary services [e.g., surgery, oncology, obstetrics, pediatrics], pharmacy, and social work).
[priority example] Our hospital sepsis program includes diverse multi-disciplinary representation (e.g., antimicrobial stewardship, critical care, emergency medicine, hospital medicine, infectious diseases, nursing, other primary services [e.g., surgery, oncology, obstetrics, pediatrics], pharmacy, and social work).
Yes / No
Yes / No
[priority example] Our hospital sepsis program has ongoing support from individuals with expertise and formal training in data management and analytics; information technology; and quality improvement and patient safety.
[priority example] Our hospital sepsis program has ongoing support from individuals with expertise and formal training in data management and analytics; information technology; and quality improvement and patient safety.
Yes / No
Yes / No
Our hospital sepsis program has at least ad hoc involvement of case management, microbiology, laboratory medicine, phlebotomy, outpatient clinicians, hospital epidemiologists, infection preventionist, patients, families, caregivers, and community members.
Our hospital sepsis program has at least ad hoc involvement of case management, microbiology, laboratory medicine, phlebotomy, outpatient clinicians, hospital epidemiologists, infection preventionist, patients, families, caregivers, and community members.
Yes / No
Yes / No
Core Element
[priority example] Our hospital has a sepsis coordinator, who oversees day-to-day implementation of sepsis program activities.
Note: The hospital sepsis coordinator may be the same or different individual as the lead or co-lead of the hospital sepsis program.
[priority example] Clinicians and leaders from the emergency department, inpatient wards, and intensive care units are fully engaged in our hospital sepsis program activities.
[priority example] Our hospital sepsis program includes diverse multi-disciplinary representation (e.g., antimicrobial stewardship, critical care, emergency medicine, hospital medicine, infectious diseases, nursing, other primary services [e.g., surgery, oncology, obstetrics, pediatrics], pharmacy, and social work).
[priority example] Our hospital sepsis program has ongoing support from individuals with expertise and formal training in data management and analytics; information technology; and quality improvement and patient safety.
Our hospital sepsis program has at least ad hoc involvement of case management, microbiology, laboratory medicine, phlebotomy, outpatient clinicians, hospital epidemiologists, infection preventionist, patients, families, caregivers, and community members.
Established at Facility
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Comments
Core Element
Core Element
Established at Facility
Established at Facility
Comments
Comments
[priority example] Our hospital has implemented a standard process to screen for sepsis on presentation and throughout hospitalization.
[priority example] Our hospital has implemented a standard process to screen for sepsis on presentation and throughout hospitalization.
Yes / No
Yes / No
[priority example] Our hospital has a hospital guideline or a standardized care pathway for management of sepsis, that addresses:
- screening
- clinical evaluation
- diagnosis
- antimicrobial selection
- source control
- fluid resuscitation
- indications for treatment escalation
- antimicrobial narrowing and stopping
- patient and family/caregiver education
- peri-discharge management.
[priority example] Our hospital has a hospital guideline or a standardized care pathway for management of sepsis, that addresses:
- screening
- clinical evaluation
- diagnosis
- antimicrobial selection
- source control
- fluid resuscitation
- indications for treatment escalation
- antimicrobial narrowing and stopping
- patient and family/caregiver education
- peri-discharge management.
Yes / No
Yes / No
[priority example] Our hospital has order sets for the management of sepsis tailored to patient populations served.
[priority example] Our hospital has order sets for the management of sepsis tailored to patient populations served.
Yes / No
Yes / No
[priority example] Our hospital has structures and processes in place to facilitate prompt delivery of antimicrobials, including:
- stocking of common antimicrobials in locations outside the pharmacy
- immediate processing of new antimicrobial orders
- clinician order entry systems that default to immediate administration of new antimicrobials
- pharmacists on-site in key locations outside the pharmacy.
[priority example] Our hospital has structures and processes in place to facilitate prompt delivery of antimicrobials, including:
- stocking of common antimicrobials in locations outside the pharmacy
- immediate processing of new antimicrobial orders
- clinician order entry systems that default to immediate administration of new antimicrobials
- pharmacists on-site in key locations outside the pharmacy.
Yes / No
Yes / No
[priority example] Our hospital has structures and processes in place to support effective hand-offs of patients with sepsis, such as templated notes to document sepsis diagnosis and treatment information.
[priority example] Our hospital has structures and processes in place to support effective hand-offs of patients with sepsis, such as templated notes to document sepsis diagnosis and treatment information.
Yes / No
Yes / No
Our hospital rapid response teams trained in sepsis recognition and care.
Our hospital rapid response teams trained in sepsis recognition and care.
Yes / No
Yes / No
Our hospital has a “code sepsis” protocol for facilitating prompt recognition and team-based care of sepsis.
Our hospital has a “code sepsis” protocol for facilitating prompt recognition and team-based care of sepsis.
Yes / No
Yes / No
Our hospital completes peri-discharge evaluations of patients after sepsis to screen for new or worsening functional limitations, cognitive impairment, post-traumatic stress disorder/anxiety symptoms, and chronic health conditions.
Our hospital completes peri-discharge evaluations of patients after sepsis to screen for new or worsening functional limitations, cognitive impairment, post-traumatic stress disorder/anxiety symptoms, and chronic health conditions.
Yes / No
Yes / No
Our hospital provides post-discharge care coordination and anticipatory guidance designed to optimized recovery from sepsis.
Our hospital provides post-discharge care coordination and anticipatory guidance designed to optimized recovery from sepsis.
Yes / No
Yes / No
Out hospital has prevention of healthcare-associated infections and hospital-onset sepsis that follow facility-based infection prevention recommendations.
Out hospital has prevention of healthcare-associated infections and hospital-onset sepsis that follow facility-based infection prevention recommendations.
Yes / No
Yes / No
Core Element
[priority example] Our hospital has implemented a standard process to screen for sepsis on presentation and throughout hospitalization.
[priority example] Our hospital has a hospital guideline or a standardized care pathway for management of sepsis, that addresses:
- screening
- clinical evaluation
- diagnosis
- antimicrobial selection
- source control
- fluid resuscitation
- indications for treatment escalation
- antimicrobial narrowing and stopping
- patient and family/caregiver education
- peri-discharge management.
[priority example] Our hospital has order sets for the management of sepsis tailored to patient populations served.
[priority example] Our hospital has structures and processes in place to facilitate prompt delivery of antimicrobials, including:
- stocking of common antimicrobials in locations outside the pharmacy
- immediate processing of new antimicrobial orders
- clinician order entry systems that default to immediate administration of new antimicrobials
- pharmacists on-site in key locations outside the pharmacy.
[priority example] Our hospital has structures and processes in place to support effective hand-offs of patients with sepsis, such as templated notes to document sepsis diagnosis and treatment information.
Our hospital rapid response teams trained in sepsis recognition and care.
Our hospital has a “code sepsis” protocol for facilitating prompt recognition and team-based care of sepsis.
Our hospital completes peri-discharge evaluations of patients after sepsis to screen for new or worsening functional limitations, cognitive impairment, post-traumatic stress disorder/anxiety symptoms, and chronic health conditions.
Our hospital provides post-discharge care coordination and anticipatory guidance designed to optimized recovery from sepsis.
Out hospital has prevention of healthcare-associated infections and hospital-onset sepsis that follow facility-based infection prevention recommendations.
Established at Facility
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Comments
Core Element
Core Element
Established at Facility
Established at Facility
Comments
Comments
[priority example] Our hospital monitors hospital sepsis epidemiology, such as number of hospitalizations with community-onset sepsis, hospital-onset sepsis, and septic shock.
[priority example] Our hospital monitors hospital sepsis epidemiology, such as number of hospitalizations with community-onset sepsis, hospital-onset sepsis, and septic shock.
Yes / No
Yes / No
[priority example] Our hospital monitors of hospital sepsis management, such as time to antibiotic delivery and time from antibiotic order to antibiotic delivery.
[priority example] Our hospital monitors of hospital sepsis management, such as time to antibiotic delivery and time from antibiotic order to antibiotic delivery.
Yes / No
Yes / No
[priority example] Our hospital monitor sepsis outcomes, such as in-hospital mortality, length of hospitalization, and new discharge to a healthcare facility.
[priority example] Our hospital monitor sepsis outcomes, such as in-hospital mortality, length of hospitalization, and new discharge to a healthcare facility.
Yes / No
Yes / No
[priority example] Our hospital assesses use, usability, and impact of hospital sepsis tools to inform their ongoing improvement, such as use of sepsis order sets.
[priority example] Our hospital assesses use, usability, and impact of hospital sepsis tools to inform their ongoing improvement, such as use of sepsis order sets.
Yes / No
Yes / No
[priority example] Our hospital monitors progress towards achieving hospital goals for sepsis management and/or outcomes.
[priority example] Our hospital monitors progress towards achieving hospital goals for sepsis management and/or outcomes.
Yes / No
Yes / No
Our hospital completes near real-time chart reviews for the purpose of clinician feedback and education.
Our hospital completes near real-time chart reviews for the purpose of clinician feedback and education.
Yes / No
Yes / No
Our hospital completes chart reviews regularly for the purpose of root cause analysis and process improvement.
Our hospital completes chart reviews regularly for the purpose of root cause analysis and process improvement.
Yes / No
Yes / No
Core Element
[priority example] Our hospital monitors hospital sepsis epidemiology, such as number of hospitalizations with community-onset sepsis, hospital-onset sepsis, and septic shock.
[priority example] Our hospital monitors of hospital sepsis management, such as time to antibiotic delivery and time from antibiotic order to antibiotic delivery.
[priority example] Our hospital monitor sepsis outcomes, such as in-hospital mortality, length of hospitalization, and new discharge to a healthcare facility.
[priority example] Our hospital assesses use, usability, and impact of hospital sepsis tools to inform their ongoing improvement, such as use of sepsis order sets.
[priority example] Our hospital monitors progress towards achieving hospital goals for sepsis management and/or outcomes.
Our hospital completes near real-time chart reviews for the purpose of clinician feedback and education.
Our hospital completes chart reviews regularly for the purpose of root cause analysis and process improvement.
Established at Facility
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Comments
Core Element
Core Element
Established at Facility
Established at Facility
Comments
Comments
[priority example] Our hospital reports sepsis treatment and outcome data to nursing, physician, unit-based, and hospital leadership at routine intervals (e.g., monthly or quarterly), which include:
- Unit-level data
- Trends over time
Comparative or benchmarking data (e.g., comparison to other similar units or hospitals).
[priority example] Our hospital reports sepsis treatment and outcome data to nursing, physician, unit-based, and hospital leadership at routine intervals (e.g., monthly or quarterly), which include:
- Unit-level data
- Trends over time
Comparative or benchmarking data (e.g., comparison to other similar units or hospitals).
Yes / No
Yes / No
Our hospital provides feedback to individual clinicians regarding the care of recent patients with sepsis.
Our hospital provides feedback to individual clinicians regarding the care of recent patients with sepsis.
Yes / No
Yes / No
Our hospital has and maintains a live dashboard to report sepsis treatment and outcomes in real-time.
Our hospital has and maintains a live dashboard to report sepsis treatment and outcomes in real-time.
Yes / No
Yes / No
Core Element
[priority example] Our hospital reports sepsis treatment and outcome data to nursing, physician, unit-based, and hospital leadership at routine intervals (e.g., monthly or quarterly), which include:
- Unit-level data
- Trends over time
Comparative or benchmarking data (e.g., comparison to other similar units or hospitals).
Our hospital provides feedback to individual clinicians regarding the care of recent patients with sepsis.
Our hospital has and maintains a live dashboard to report sepsis treatment and outcomes in real-time.
Established at Facility
Yes / No
Yes / No
Yes / No
Comments
Core Element
Core Element
Established at Facility
Established at Facility
Comments
Comments
[priority example] Our hospital provides sepsis-specific training and education in the hiring or on-boarding process for healthcare staff and trainees.
[priority example] Our hospital provides sepsis-specific training and education in the hiring or on-boarding process for healthcare staff and trainees.
Yes / No
Yes / No
[priority example] Our hospital provides annual sepsis education to clinical staff.
[priority example] Our hospital provides annual sepsis education to clinical staff.
Yes / No
Yes / No
[priority example] Our hospital provides written and verbal sepsis education to patients, families, and/or caregivers prior to discharge.
[priority example] Our hospital provides written and verbal sepsis education to patients, families, and/or caregivers prior to discharge.
Yes / No
Yes / No
Our hospital posts information on recognition of sepsis in prominent areas for patient-facing staff (e.g., attached to vital sign machines, in staff break rooms).
Our hospital posts information on recognition of sepsis in prominent areas for patient-facing staff (e.g., attached to vital sign machines, in staff break rooms).
Yes / No
Yes / No
Our hospital holds lectures (e.g., grand rounds) or an annual meeting focused on sepsis.
Our hospital holds lectures (e.g., grand rounds) or an annual meeting focused on sepsis.
Yes / No
Yes / No
Our hospital includes sepsis recognition and treatment in annual nursing competencies.
Our hospital includes sepsis recognition and treatment in annual nursing competencies.
Yes / No
Yes / No
Core Element
[priority example] Our hospital provides sepsis-specific training and education in the hiring or on-boarding process for healthcare staff and trainees.
[priority example] Our hospital provides annual sepsis education to clinical staff.
[priority example] Our hospital provides written and verbal sepsis education to patients, families, and/or caregivers prior to discharge.
Our hospital posts information on recognition of sepsis in prominent areas for patient-facing staff (e.g., attached to vital sign machines, in staff break rooms).
Our hospital holds lectures (e.g., grand rounds) or an annual meeting focused on sepsis.
Our hospital includes sepsis recognition and treatment in annual nursing competencies.
Established at Facility
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Comments