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* 1. Address

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* 2. By electronically signing below, I attest that all content is accurate and true. 

Objective: To create a forum to share success stories in Infection Prevention at the May APIC Atlanta Vendor fair.

Instructions: Please complete this form. You will be asked to use this information in your presentation. We would like you to present this information as a story with a timeline. Please include in the presentation the involvement of all collaborators and the successes and challenges that ensued.

*Note: Presentations may not contain any brand names, commercial influence, or promotional material.

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* 3. Please enter the names of the Infection Preventionists involved in the project:

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* 4. Please enter the name of your facility. 

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* 5. What is the title of your Success Story?

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* 6. Who are your collaborators for the project?

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* 7. Describe the problem (Legionella in water, outbreak in ICU, etc.):

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* 8. Share any data that supports why you think this is a problem (number of Legionella cultured in water or patients with Legionella, CLABSI graph with increased rate, etc.):

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* 9. Share any references or resources that support your contention that this is a problem (OSHA regulations, CDC regulations, NHSN baselines, etc.):

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* 10. Share how you initially presented this information to the involved parties (facilities manager, ICU manager, etc.) and their reaction:

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* 11. Share how you developed a team to work on the problem, and how you got the team to work as a cohesive group (share any team management problems and how you overcame them):

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* 12. Share how you developed a proposed solution to the problem (what was the team process for deciding about water monitoring, scrub the hub, etc.):

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* 13. Share any road blocks you encountered and what you did about them:

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* 14. Share how you worked with a team to solve the problem (team meetings, education programs, involvement of upper management, etc.):

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* 15. Share any involvement of outside entities (OSHA, TJC, State Health Department, etc.):

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* 16. Share the intervention:

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* 17. Share how you followed up after your intervention:

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* 18. What was unique about your success story?

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* 19. What did you learn from working on this situation?

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* 20. How did you improve your collaboration while working on this situation?

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