Form #1 Form #1 Questionnaire -- Mailed Version

Adverse Event
Reporting
Follow-Up Survey

Agency for Healthcare Research and Quality (AHRQ)

Form Approved

OMB No. 0395-XXXX

Exp. Date XX/XX/20XX

Your ID#: Revision 8-20-08

Public reporting burden for this collection of information is estimated to average 25 minutes per response, the estimated time required to complete the survey. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Form Approved: OMB Number 0935-XXXX Exp. Date xx/xx/20xx. Send comments regarding this burden estimate or any other aspect of this collection f information, including suggestions for reducing this burden, to: AHRQ Reports Clearance Officer Attention: PRA, Paperwork Reduction Project (0935-XXXX) AHRQ, 540 Gaither Road, Room $35036, Rockville, MD 20850.

Adverse Event Reporting Questionnaire

RISK MANAGERS

Introduction

Thank you for taking part in this adverse event reporting follow-up survey. We are asking Risk Managers of hospitals to assist us in collecting information about adverse event reporting systems used in inpatient settings. The results of the survey will be used to understand if and how hospitals collect and use information on adverse events and how that has changed over time since our first survey. Your participation in this study is voluntary, and all responses will be kept confidential. The questionnaire takes about 25 minutes to complete. If you have any questions, please contact the Project Coordinator Ms. Chau Pham at RANDby phone at XXX-XXX-XXXX or by email at [email protected].

Marking Instructions

• Do not use felt tip pens.

• Mark response boxes with an X.

CORRECT: X

• Make no stray marks on this survey.

• Erase cleanly any marks you wish to change.

• Please try to answer every question (unless you are asked to skip questions because they do not apply to you). If you prefer not to answer a specific question for any reason, leave it blank.

• If you are not sure of the answer, please try to give us your best estimate.

• Please return the completed survey in the enclosed postage-paid envelope addressed to RAND as soon as possible.

Description of the Reporting System

Q1. Does your hospital collect information where harm has occurred or might have occurred to a patient during the course of his or her care?

(Check One)

1 Yes

2 No

• NOTE: For the remaining questions, we refer to instances where harm occurred or might have occurred to the patient as “occurrences.”

Q2. We are interested in the sources from which you might learn about these occurrences.

(MARK YES OR NO FOR EACH SOURCE LISTED BELOW.)

Have you ever learned about these occurrences…	Yes		No
a. From hospital staff filling out an occurrence form?		1	2
b. From hospital staff calling you directly?		1	2
c. Through a hotline?		1	2
d. By attending a committee meeting?		1	2
e. By conducting rounds or walk arounds?		1	2
f. By a patient notifying the hospital?		1	2
g. By a Federal or state agency contacting the hospital?		1	2

Q3. At this time, is your hospital storing information on occurrences in a central location?

(Check One)

1 Yes

2 No

Q4. At this time, is the occurrence information stored on paper only, computer only, or both?

(Check One)

1 Paper only  GO TO NOTE BEFORE Q5

2 Computer only

3 Both paper and computer

Q4a. Which type of software does your hospital use?

(CHECK YES OR NO FOR EACH SOFTWARE BELOW.)

My hospital uses…	Yes		No
a. A prepackaged patient safety software such as DoctorQuality.com, RiskMaster, or Meditech		1	2
b. A non-commercially available software designed specifically for my hospital		1	2
c. Software designed for external reporting systems, such as the NHSN or for state health departments (PLEASE SPECIFY)		1	2
d. Standard office software, such as Microsoft Word, Excel, or Access		1	2
e. Other (PLEASE SPECIFY)		1	2

• NOTE: For the remainder of the questions, we will be referring to your collection of occurrences as your hospital’s “reporting system.” Please respond for the reporting system currently in place.

Q5. Does your hospital’s current reporting system allow for descriptive accounts of the occurrences?

(Check One)

1 Yes

2 No

Q6. Does your hospital’s current reporting system collect the severity of harm that occurred to the patient?

(Check One)

1 Yes  Q6a. How many levels of severity does the

hospital’s current reporting system have? |___|___|___|

2 No

Q7. In your opinion, how important is it to have common formats that allow standardized reporting for hospitals?

(Check One)

1 Very important

2 Somewhat important

3 Somewhat unimportant

4 Not important at all

Q8. Is the information in the hospital’s current reporting system protected from legal discovery in your state?

(Check One)

1 Yes

2 No

Q9. Below is a list of groups and committees. Please indicate if occurrences, either individually or in aggregate form, are discussed in these committees. If so, are the discussions protected from legal discovery?

(MARK AN Answer for each committee/GROUP.)

Are occurrences discussed at the…				Don’t have
	Yes		No
a. Quality Management Committee?		1	2	3
b. Performance Improvement Committee?		1	2	3
c. Patient Safety Committee?		1	2	3
d. Departmental Peer Review Committee?		1	2	3
e. Hospital Peer Review Committee?		1	2	3
f. Morbidity and Mortality Conference?		1	2	3
g. Medical Executive Committee?		1	2	3
h. Senior Management Administrative Committee?		1	2	3
i. Risk Management Committee?		1	2	3
j. The Board or Committee of the Board?		1	2	3
k. Any other committee? (PLEASE SPECIFY)		1	2

Q10. Below is a list of staff who may report occurrences to your reporting system. Of the total occurrences in your reporting system, please indicate how many come from the different staff groups.

(MARK AN ANSWER FOR EACH STAFF GROUP.)

How many of the reports come from…	All		Most	Some	A few	None	Don’t have this type of staff
a. Nursing staff?		1	2	3	4	5	6
b. Physicians in training, including medical students, interns, residents, & fellows?		1	2	3	4	5	6
c. Other physicians? (i.e., not employed by your hospital)		1	2	3	4	5	6
d. Other medical staff? (e.g., Nurse Practitioners, Physician Assistants)		1	2	3	4	5	6
e. Technicians, technologists, or therapists?		1	2	3	4	5	6
f. Pharmacy staff?		1	2	3	4	5	6
g. Administrative staff?		1	2	3	4	5	6
h. Other staff? (PLEASE SPECIFY)		1	2	3	4	5

Q11. Do physicians who are not employed by your hospital but working in your hospital report occurrences to your reporting system?

(Check One)

1 Yes

2 No

3 All physicians are employed by the hospital

4 Don’t know

Q12. Do other individuals who are not employed by your hospital but working in your hospital (e.g., agency nurses) report occurrences to your reporting system?

(Check One)

1 Yes

2 No

3 Do not have such employees

4 Don’t know

Q13. Can individuals report occurrences without identifying themselves?

(Check One)

1 Yes, in all cases

2 Yes, in some cases

3 Never, in no case

Q14. If the reporter identifies him/herself, is that person’s identity protected?

(Check One)

1 Yes, in all cases

2 Yes, in some cases

3 Never, in no case

Q15. Are nosocomial infections generally reported to your reporting system?

(Check One)

1 Yes

2 No

Q16. Of the total occurrences in your reporting system, please estimate the percentage that resulted in patient harm. Do not include near misses, variances, and the like, in your percentage estimate. Your best estimate is fine.

|___|___|___| %

Q17. Does risk management receive reports of occurrences from all areas or departments?

(Check One)

1 Yes  GO TO Uses of Data ON NEXT PAGE

2 No Q18a. From which areas or departments does risk management not receive reports of occurrences?

Uses of Data

• NOTE: The next questions are about how your hospital may use collected occurrence data.

Q18. Please indicate how often your hospital uses the occurrence information for each reason listed below.

(MARK AN ANSWER FOR EACH REASON.)

How often does your hospital use the occurrence information…	Always		Often	Sometimes	Rarely	Never
a. To develop performance or quality indicators?		1	2	3	4	5
b. To produce trends of occurrences?		1	2	3	4	5
c. For Failure Mode Effects (FME) analysis?		1	2	3	4	5
d. To conduct root cause analysis?		1	2	3	4	5
e. To educate or train?		1	2	3	4	5
f. To compare against other hospitals?		1	2	3	4	5
g. To fill a state or federal agency’s (e.g., FDA’s or CDC’s) requirement?		1	2	3	4	5
h. To report sentinel events to the Joint Commission on Accreditation of Healthcare Organizations (JCAHO)?		1	2	3	4	5
i. To counsel or correct physicians?		1	2	3	4	5
j. To counsel or correct other employees?		1	2	3	4	5
k. To perform actions to improve performance?		1	2	3	4	5

Q19. Are reports of occurrences routinely kept in an employee’s personnel file?

(Check One)

1 Yes, in all cases

2 Yes, in some cases

3 Never, in no case

Q20. In the last year, how often has learning about occurrences led to immediate action at your hospital?

(Check One)

1 Always

2 Often

3 Sometimes

4 Rarely

5 Never

Q21. In the last year, how often has learning about occurrences led to launching a quality or performance improvement at your hospital?

(Check One)

1 Always

2 Often

3 Sometimes

4 Rarely

5 Never

Q22. Does your hospital produce reports of its occurrence data? (These reports could be either written summaries or presentations at meetings.)

(Check One)

1 Yes

2 No  GO TO Q23 ON NEXT PAGE

Q22a. On average, how often does your hospital produce reports of occurrence data?

(Check One)

1 Weekly

2 Monthly

3 Quarterly

4 Yearly

5 Something else (PLEASE SPECIFY)

Q22b. Does your hospital distribute any occurrence reports within the hospital?

(Check One)

1 Yes

2 No  GO TO Q23 ON NEXT PAGE

Q22c. Below is a list of possible areas or departments in your hospital. Please indicate how frequently your hospital distributes a report of occurrences, either directly or through a committee meeting, to the following hospital departments.

(MARK AN ANSWER FOR EACH DEPARMENT.)

Please indicate how often EACH department receives a report.	Always		Often	Sometimes	Rarely	Never	Hospital does not have this department
a. Nursing		1	2	3	4	5	6
b. Pharmacy		1	2	3	4	5	6
c. Laboratory Medicine		1	2	3	4	5	6
d. Transfusion Medicine		1	2	3	4	5	6
e. Infection Control		1	2	3	4	5	6
f. Medical Leadership		1	2	3	4	5	6
g. Quality Management or Performance Improvement		1	2	3	4	5	6
h. Central Hospital Administration		1	2	3	4	5	6
i. Any other department (PLEASE SPECIFY)		1	2	3	4	5

Q22d. How long after the reporting period closes does it take to get the reports distributed to relevant departments?

(Check One)

1 Less than one week

2 One week to less than two weeks

3 Two weeks to less than one month

4 One month to less than two months

5 Two months or more

Q23. Does your hospital currently have an organized patient safety program that manages or coordinates all of the hospital’s patient safety activities?

(Check One)

1 Yes

2 No  GO TO Q24 ON THE NEXT PAGE

Q23a. When was the current patient safety program organized relative to the current reporting system?

(Check One)

1 Patient safety program started first

2 Reporting system started first

3 Patient safety program and reporting system started about the same time

4 We currently do not have a reporting system

Q24. Does your hospital have a SINGLE individual – regardless of his or her job title – who functions as a patient safety officer?

(Check One)

 ₁ Yes

 ₂ No

The following question refers to the governing board of the hospital, which may be called the board of directors or board of trustees. If this hospital does not have a governing board with decision-making authority, but has an advisory board, the question applies to the advisory board.

Q25. Which of the following actions does this hospital’s governing board perform regularly in its oversight of the hospital’s patient safety issues and activities?

(MARK YES OR NO FOR EACH SOURCE LISTED BELOW.)

Does the this hospital’s governing board regularly…	Yes		No
a. Review policies or guidelines on patient safety goals, priorities, and strategies		1	2
b. Review reports on risks and hazards identified by hospital management		1	2
c. Review reports from all patient safety culture survey or other culture measures		1	2
d. Review progress in patient safety improvement activities		1	2
e. Review level of participation by patients and families in the hospital’s patient safety activities		1	2

Q26. Does this hospital’s governing board (directors, trustees, or advisory), or one of its standing committees, include the review of patient safety issues and improvements in a standing agenda item for every board meeting, either as a separate agenda item on safety or as part of a larger agenda item?

(Check One)

1 Yes, done by the board

2 Yes, done by a standing committee Specify

3 No

Q27. Has this hospital conducted a standardized survey to assess its patient safety culture?

(Check One)

1 Yes

2 No

Q28. Which of the following products developed by the Agency for Healthcare Research and Quality (AHRQ) to improve safety in health care have you used?

(MARK YES OR NO FOR EACH PRODUCT LISTED BELOW.)

General Patient Safety Products	Yes	No
a. Hospital survey on patient safety culture (SOPS)	1	2
b. TeamSTEPPS system and tools for teamwork improvement	1	2
c. Patient Safety Improvement Corps training DVD	1	2
Publications and Other Written Materials
d. Review Patient Safety Evidence Report, Making Health Care Safer: A Critical Analysis of Patient Safety Practices	1	2
e. AHRQ fact sheets for providers	1	2
f. ARHQ fact sheets for patients and families	1	2
g. Patient brochures or pamphlets	1	2
Specific Patient Safety Web sites (on the AHRQ Web Site)
h. Patient Safety Network (PSNet) Web site	1	2
i. WebM&M web site	1	2
j. Patient Safety Organizations Web site (about the Patient Safety and Quality Improvement Act of 2005)	1	2

Q29. The Partnerships in Implementing Patient Safety (PIPS) projects funded by AHRQ developed a number of toolkits that health care providers can use to implement specific practices to improve safety in health care. The toolkits are posted on the AHRQ web site. Have you used any of these toolkits?

(Check One)

1 Yes

2 No  GO TO You and Your Hospital ON THE NEXT PAGE

Q29a. Which toolkit(s) did you use? (Please Specify): ________________________________

You and Your Hospital

• NOTE. The last few questions are about you and your hospital so that we can better understand your hospital's staffing and structure.

Q30. Do you have a nursing or other clinical degree?

(Check One)

1 Yes

2 No

Q31. Do you have a law degree?

(Check One)

1 Yes

2 No

Q32. Do you have any other credentials related to your job as risk manager?

(Check One)

1 Yes  Q32a. What are they?

2 No

Q33. Did you answer the questions in this survey for your hospital facility only, or did you include other inpatient hospitals or facilities in your answers?

(Check One)

1 Your hospital only

2 Your hospital as well as other inpatient hospitals or inpatient facilities

Q34. How many of the doctors working in your hospital are employed by the hospital?

(Check One)

1 All

2 Most

3 Some

4 A few

5 None

Q35. Is your hospital a teaching hospital?

(Check One)

1 Yes

2 No

Thank you for participating in this study.

Please return the completed questionnaire in the enclosed envelope. If you have misplaced the return envelope, please mail this questionnaire to:

RAND CONTACT, MAIL BOX

RAND Corporation

1776 Main Street, PO Box 2138

Santa Monica, CA 90401-2138