Form #2 Form #2 Office Characteristics Survey

B

Form Approved
OMB No. 0935-XXXX
Exp. Date XX/XX/20XX

ackground Questions on Practice Characteristics

(To Be Completed by Office Point of Contact)

Instructions: Please answer the following questions, which will be used to analyze data collected with the Medical Office Survey on Patient Safety Culture. If you need assistance in answering any of the questions, please contact [project staff member] by telephone (xxx-xxx-xxxx) or by email ([email protected]).

Name of Office Point-of-Contact: (First)       (Last)      

Job Title:      

Name of Office:      

Office Mailing Address: (Street)      

(City)       (State)       (Zip code)      

Phone:      

Fax:      

Email:      

1a. Does your medical practice have:

₁ One geographic location? (SKIP TO QUESTION 2)

₂ Multiple geographic locations? Total number of locations:      

1b. Is this office location the:

a. Primary/headquarters location?

b. Satellite location (not the primary/ headquarters location)?

2. Which best describes the majority ownership of this medical office/practice?

₁ Provider(s) and/or Physician(s)

₂ Managed Care or Health Maintenance Organization (MCO/HMO)

₃ University or Medical School or Academic Medical Institution

₄ Hospital or health system

₅ Federal, state, or local government, community board, etc.

₆ Other, please specify:      

3a. Which of the following best describes the type of practice at this office location?

₁ Single specialty

₂ Multispecialty with primary care only (family medicine, internal medicine, pediatrics, OB/GYN, general practice)

Do Not Write in This Space

Site ID:      

₃ Multispecialty with primary and specialty care

₄ Multispecialty with specialty care only

Public reporting burden for this collection of information is estimated to average 15 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 of information, including suggestions for reducing this burden, to: AHRQ Reports Clearance Officer Attention: PRA, Paperwork Reduction Project (0935-XXXX) AHRQ, 540 Gaither Road, Room # 5036, Rockville, MD 20850.

3b. In Table 3b, check all specialties that apply in your medical office and record the number of providers in each specialty. By provider, we mean physicians (MDs and DOs), physician assistants (PAs), and nurse practitioners (NPs) who diagnose, treat patients, and prescribe medications.

If a provider is certified in more than one specialty, record only the specialty for which the provider spends most of his/her time. See example.

Example: An office with 3 Family Practice providers and 1 doctor certified in both Gastroenterology (works in this area 70% of time) and General Practice (works in this area 30% of time):

	Number of Providers	Specialty
9	3	Family Practice / Family Medicine
10		Forensic Pathology
11	1	Gastroenterology
12		General Practice

TABLE 3b (Check specialties and record number of providers in each specialty)

	Number of Providers	Specialty		Number of Providers	Specialty
1	     	Allergy/Immunology	19	     	Nephrology
2	     	Anesthesiology	20	     	Neurology
3	     	Cardiology	21	     	Nuclear Medicine
4	     	Child & Adolescent Psychiatry	22	     	OB/GYN or GYN
5	     	Dermatology	23	     	Ophthalmology
6	     	Diagnostic Radiology	24	     	Orthopedics
7	     	Emergency Medicine	25	     	Otolaryngology
8	     	Endocrinology/Metabolism	26	     	Pathology – Anatomic/Clinical
9	     	Family Practice/Family Medicine	27	     	Pediatrics
10	     	Forensic Pathology	28	     	Physical Medicine & Rehabilitation
11	     	Gastroenterology	29	     	Psychiatry
12	     	General Practice	30	     	Public Health & Rehabilitation
13	     	General Preventive Medicine	31	     	Pulmonary Medicine
14	     	General Surgery	32	     	Radiology
15	     	Geriatrics	33	     	Rheumatology
16	     	Hematology/Oncology	34	     	Surgery (All)
17	     	Internal Medicine	35	     	Urology
18	     	Medical Genetics	36	     	Vascular Medicine
					Other specialty (Please specify):
			37 38 39	                 	                 

4. To what extent has this medical office implemented each of the following electronic (computer-based) tools? (By implemented, we mean the office has the tool capability and is using it.)

	Not implemented & no plans to implement in the next 12 months ▼	Not implemented but implementation planned in the next 12 months ▼	Implementation in process (only partial implementation) ▼	Fully implemented ▼
a) Electronic appointment scheduling	1	2	3	4
b) Electronic billing of services	1	2	3	4
c) Electronic ordering of medications (with pharmacies capable of processing electronic orders)	1	2	3	4
d) Electronic ordering of tests, imaging, or procedures (with test/‌imaging centers capable of processing electronic orders)	1	2	3	4
e) Electronic access to your patients’ test or imaging results	1	2	3	4
f) Electronic medical/health records (EMR/EHR)	1	2	3	4
g) Other (Please specify): ___________________________	1	2	3	4

5. What is the total number of patient visits in a typical week in this medical office location?       total patient visits in a typical week

6. What is the total number of providers (MDs, DOs, PAs, NPs, etc.) working in this medical office location during a typical week?

      total number of providers working during a typical week

NOTE:

• If your medical office is using ID numbers on surveys to track individual response, YOU ARE DONE and you can SKIP question 7 on next page.

• If your medical office is administering the survey anonymously (not using ID numbers to track individual response), please answer question 7 on next page.

7. Please record the total number of staff who will be asked to complete the survey in each of the following categories:

Staff Position	Number of Individuals
a. Physician (MD/DO)	________
b. Physician Assistant	________
c. Nurse Practitioner/Clinical Nurse Specialist/Nurse Midwife/Advanced Practice Nurse, etc.	________
d. Practice Manager/Office Manager/Office Administrator/ Business Manager/Nurse Manager, Lab Manager, Other Manager	________
e. Administrative or Clerical	________
Insurance Processor Medical Records Billing Staff Receptionist Referral Staff Scheduler (appt., surgery, etc.) Front Desk Other administrative or clerical staff
f. Registered Nurse/LVN/LPN	________
g. Medical Assistant/Nursing Aide	________
h. Other Clinical Staff	________
Technician (all types) Therapist (all types) Other clinical staff
i. Other Positions (Please specify): __________________________________________________	________
TOTAL NUMBER OF INDIVIDUALS WHO WILL BE ASKED TO COMPLETE THE SURVEY IN YOUR MEDICAL OFFICE	Individuals

YOU ARE DONE!

THANK YOU FOR COMPLETING THESE QUESTIONS ABOUT YOUR MEDICAL OFFICE.

Please email or fax your responses back to XXXXX

Email:

Fax number:

MEDICAL OFFICE BACKGROUND QUESTIONS 8-19-08 4