Download:
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pdfForm Approved: OMB No. 0920-0278
NOTES
NOTICE – Public reporting burden of this collection of information is estimated to average 60 minutes per response, including the time for reviewing
instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. 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. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden
to CDC/ATSDR Information Collection Review Office; 1600 Clifton Road, MS D-74, Atlanta, GA 30333, ATTN: PRA (0920-0278).
Assurance of confidentiality – All information which would permit identification of an individual, a practice, or an establishment will be held
confidential, will be used for statistical purposes only by NCHS staff, contractors, and agents only when required and with necessary controls, and will
not be disclosed or released to other persons without the consent of the individual or establishment in accordance with section 308(d) of the Public
Health Service Act (42 USC 242m) and the Confidential Information Protection and Statistical Efficiency Act (PL-107-347).
1. Label
NHAMCS-101
(3-26-2009)
U.S. DEPARTMENT OF COMMERCE
Economics and Statistics Administration
U.S. CENSUS BUREAU
ACTING AS DATA COLLECTION AGENT FOR THE
NATIONAL CENTER FOR HEALTH STATISTICS
CENTERS FOR DISEASE CONTROL AND PREVENTION
NATIONAL HOSPITAL AMBULATORY MEDICAL CARE SURVEY
2010 PANEL
2a. Hospital contact information
b. ED contact information
Name
Name
Title
RECORD ON
CONTROL CARD
Telephone number
(Area code and number)
FAX number
Title
Telephone number
(Area code and number)
RECORD ON
CONTROL CARD
FAX number
c. OPD contact information
d. ASC contact information
Name
Name
Title
RECORD ON
CONTROL CARD
RECORD ON
CONTROL CARD
Telephone number
(Area code and number)
FAX number
Title
Telephone number
(Area code and number)
RECORD ON
CONTROL CARD
FAX number
Section I – TELEPHONE SCREENER
3. Field representative
4. Record of telephone calls
information
Call
Date
Time
Results
FR Code
Telephone screener
1
FR Code
Hospital induction
ED induction
OPD induction
ASC induction
2
FR Code
3
FR Code
4
FR Code
5
6
5. Final outcome of hospital screening
1
Appointment
Day
2
Page 24
FORM NHAMCS-101 (3-26-2009)
Date
Time
a.m.
p.m.
Noninterview – Complete sections VI and VII, beginning on page 21.
USCENSUSBUREAU
During your initial call to the hospital, attempt to speak to
the contact person. If the contact person is not available
at this time, determine when he/she can be reached and
call again at the designated time. If, after several
attempts, you are still unable to talk to the contact or
have determined the contact is no longer an appropriate
respondent, begin the interview with a representative of
the contact person or new contact, as appropriate.
Section I – TELEPHONE SCREENER – Continued
Section VII – NONINTERVIEW
18. Where did the nonresponse occur?
Part A. INTRODUCTION
Good (morning/afternoon) . . ., my name is (Your name). I am calling for the Centers for Disease
Control and Prevention concerning their study of hospital outpatient and emergency
departments and hospital-based ambulatory surgery centers. You should have received a
letter from Dr. Edward J. Sondik, the director of the National Center for Health Statistics,
describing the study. (Pause) You’ve probably also received a letter from the U.S. Census
Bureau, which is collecting the data for the study.
6. Did you receive the letter(s)?
(If "No" or "DK," offer to send or deliver another copy.)
and address for your hospital. Is the correct
name (Read name from Control Card)?
Control Card)?
2
1
2
1
2
4
19. What is the reason the hospital did not
}
Hospital closed
END INTERVIEW
Hospital not eligible
Hospital refused – SKIP to Item 20a
Other – Specify
1
participate in this study?
2
Yes
No – Enter correct name
END INTERVIEW
Yes
No – Enter hospital location
RECORD ON CONTROL CARD
City State ZIP Code
1
2
Yes
No – Enter correct mailing address
Number and street
RECORD ON CONTROL CARD
City State ZIP Code
STATEMENT
A
3
4
Number and street
c. Is this also the mailing address?
Mark (X) boxes 2, 3, and 4 if applicable.
Yes – SKIP to STATEMENT A
No
Don’t know
RECORD ON CONTROL CARD
b. Is your hospital located at (Read address from
}
2
3
1
3
7a. Let me verify that I have the correct name
Hospital – Continue with item 19
Emergency service area(s)
SKIP to Item 20a
Clinic(s)
ASC(s)
1
20a. At what point in the interview
(2) During the hospital induction
(3) During the ED/OPD/ASC
induction
(4) After the ED/OPD/ASC
induction, but prior to
assigned reporting period
(5) During the assigned
reporting period
ASC
2
3
3
3
3
4
4
4
4
5
5
5
5
1
1
1
1
2
2
2
3
3
3
b. By whom?
(2) ED/OPD/ASC director
(3) Approval board or official
NOTES
OPD
1
(1) Hospital administrator
(Although you have not received the letter,) I’d like to briefly explain
the study to you at this time and answer any questions about it.
ED
Hospital
did the refusal/breakoff occur?
Mark (X) appropriate box(es)
(1) During the telephone
screening
3
(4) Other hospital official
(5) Was the refusal by
telephone or in person?
5
6
4
4
4
4
Specify
Specify
Specify
Specify
Telephone
In person
Telephone
In person
5
6
Telephone
In person
5
6
Telephone
In person
5
6
c. What reason was given? Please specify hospital, ED, OPD, or ASC (from item 20a) before recording responses.
d. Was conversion attempted?
Hospital
1
2
Page 2
FORM NHAMCS-101 (3-26-2009)
FORM NHAMCS-101 (3-26-2009)
Yes
No
ED
1
2
Yes
No
OPD
1
2
Yes
No
ASC
1
2
Yes
No
Page 23
Section I – TELEPHONE SCREENER – Continued
Section VI – DISPOSITION AND SUMMARY
AMBULATORY UNIT CHECKLIST
• COMPLETE 16a FOR EMERGENCY
DEPARTMENT ONLY
16a. How many emergency service areas
were selected for sample?
Part B. VERIFICATION OF ELIGIBILITY
CHECK
ITEM A
1
2
2
This hospital was in a previous panel – Read INTRODUCTION STATEMENT B1
This hospital is being asked to participate in the study for the FIRST time – Read INTRODUCTION
STATEMENT B2
INTRODUCTION
STATEMENT B1
Number of ESAs
Enter 0 if no ESAs were selected for sample.
Did you include a NHAMCS-101(U)
for each?
1
Yes
No – Explain
Before discussing the details, I would like to verify our basic information
about (Name of hospital) to be sure we have correctly included your
hospital in the study. First, concerning licensing:
• COMPLETE 16b FOR OUTPATIENT
DEPARTMENT ONLY
b. How many clinics were selected for sample?
INTRODUCTION
STATEMENT B2
Number of Clinics
Enter 0 if no clinics were selected for sample.
Did you include a NHAMCS-101(U)
for each?
1
2
Yes
No – Explain
The National Center for Health Statistics of the Centers for Disease
Control and Prevention is conducting an annual study of hospital-based
ambulatory care. The study began data collection in 1992. They have
contracted with the U.S. Census Bureau to collect the data. (Name of
hospital) has been selected to participate in the study. I am calling to
arrange an appointment to discuss this hospital’s participation. The
study is authorized under the Public Health Service Act and the
information will be held strictly confidential. Participation is voluntary.
Before discussing the details, I would like to verify our basic information
about (Name of hospital) to be sure we have correctly included this hospital
in the study. First, concerning licensing:
• COMPLETE 16c FOR AMBULATORY
SURGERY CENTER ONLY
c. How many ASCs were selected for sample?
Enter 0 if no ASCs were selected for sample.
Did you include a NHAMCS-101(U)
for each?
The National Center for Health Statistics of the Centers for Disease
Control and Prevention is continuing its annual study of hospital-based
ambulatory care. We contacted your hospital previously regarding
participation. Collecting data on an annual basis in hospitals, such as
your own, is necessary to keep updated information on the status of
ambulatory care provided in the hospital environment.
Number of ASCs
1
2
8a. Is this facility a licensed hospital?
1
2
Yes
No – Explain
b. Is this hospital voluntary nonprofit,
1
government, or proprietary?
2
FORMS COMPLETED
d. Number of ED Patient Record Forms completed
e. Number of OPD Patient Record Forms completed
Number of OPD PRFs
f. Number of ASC Patient Record Forms completed
Number of ASC PRFs
managed by a health care corporation that
owns multiple health care facilities (e.g.,
HCA or Health South)?
d. Is this a teaching hospital?
Proprietary (includes individually or privately
owned, partnership or corporation)
1
Yes
No
Unknown
2
3
1
2
17a. FINAL DISPOSITION
1
2
3
4
5
b. NATURE OF REFUSAL
Mark (X) all that apply.
1
2
3
4
5
6
All eligible units completed
END interview
Patient Record Forms
Some eligible units completed
GO to Item 17b
Patient Record Forms
Hospital refused
Complete Section VII,
Hospital closed
NONINTERVIEW on page 23
Hospital ineligible
}
}
}
Entire ED refused
Entire OPD refused
Entire ASC refused
Some ESAs refused
Some clinics refused
Some ASCs refused
e. Has this hospital either merged with or
separated from any OTHER hospital in the
past 2 years?
1
2
3
4
f. Does YOUR hospital have its own medical
records department that is separate from
that of the OTHER hospital?
g. What is the name and address of this
OTHER hospital?
Nonprofit (includes church-related, nonprofit
corporation, other nonprofit ownership)
State or local government (includes state, county, city,
city-county, hospital district or authority)
3
Number of ED PRFs
c. Is this hospital owned, operated, or
Yes
No – SKIP to CHECK ITEM B on page 4
1
2
3
Yes
No
Yes, merged
Yes, separated
No
SKIP to item 9a on page 4
Unknown
}
Yes
No
Unknown
Hospital name
Number and street
City State
RECORD ON
CONTROL CARD
ZIP Code
FR NOTE – If one or more responses are marked in 17b, complete Section VII,
NONINTERVIEW on page 23. If no responses marked, END INTERVIEW.
Page 22
FORM NHAMCS-101 (3-26-2009)
FORM NHAMCS-101 (3-26-2009)
Page 3
Section VI –SURGERY
DISPOSITION
ANDDESCRIPTION
SUMMARY
Section V – AMBULATORY
CENTER
– Continued
Section I – TELEPHONE SCREENER – Continued
Part B. VERIFICATION OF ELIGIBILITY
9a. Does this hospital provide emergency
services that are staffed 24 HOURS each day
either here at this hospital or elsewhere?
b. Does this hospital operate any emergency
service areas that are not staffed 24
HOURS each day?
c. What is the trauma level rating of this
hospital?
1
2
1
2
1
2
10a. Does this hospital operate an organized
outpatient department either at this
hospital or elsewhere?
b. Does this OPD include physician services?
1
2
1
2
c. Does this hospital have an Ambulatory
Surgery Center?
Read the following statement.
ASC locations include a general or main
operating room, dedicated ambulatory
surgery room, satellite operating room,
cystoscopy room, endoscopy room, cardiac
catheterization lab, laser procedures room,
and a pain block room.
2
3
Yes – SKIP to item 9c
No
1
2
The ASC uses ELECTRONIC MEDICAL/HEALTH RECORDS (Yes (all) or Yes (part) in item 15fe –
Continue with item 15h.
The ASC either does not use ELECTRONIC MEDICAL/HEALTH RECORDS or it is unknown (No or
Unknown in item 15e) – SKIP to item 15j.
h. What year did your ASC buy or last upgrade
Yes
No
your EMR/EHR system?
Level I
3
Level III
5
Other/unknown
4
Level II
Level IV or V 6 None
See page 28 of the NHAMCS-124 for definitions
i. Is your ASC’s EMR/EHR system certified by
the "Certification Commission for
Healthcare Information Technology"
(CCHIT)?
j. Are there plans for installing a new
Yes
No – SKIP to CHECK ITEM B
EMR/EHR system or replacing the current
system within the next 3 years?
Year
1
2
3
1
2
Yes
No
Unknown
Yes
No
3
4
Maybe
Unknown
NOTES
Yes
No
Yes
No
Unknown
Mark (X) all that apply.
CHECK
ITEM B
1
2
3
4
5
CHECK
ITEM
B-1
1
CHECK
ITEM G
ED meets eligibility requirements (item 9a is YES) . . . . . . . . . . . .
OPD meets eligibility requirements (item 9a is NO
and item 9b is YES, or items 10a and b are YES) . . . . . . . . . . . . .
}
SKIP to CHECK ITEM B-1
ASC meets eligibility requirements (item 10c is YES) . . . . . . . . . .
Hospital is ineligible because it is not licensed (item 8a is NO) – Go to CLOSING
STATEMENT B1 on page 5.
Hospital is ineligible because it has NEITHER an ED nor OPD nor ASC (items 9a, 9b,
10a, 10b, and/or 10c are NO) – Go to CLOSING STATEMENT B2 on page 5.
Hospital refused
Yes – SKIP to item a
No – SKIP to Part C. STUDY DESCRIPTION on page 5
a. Determine whether hospital has an eligible ED and if so,
inquire as to how many visits are expected during the
reporting period.
1
2
Eligible ED?
1
2
b. Determine whether hospital has an eligible OPD and if
so, inquire as to how many visits are expected during
the reporting period.
expected visits
Eligible OPD?
1
2
c. Determine whether hospital has an eligible ASC and if
so, inquire as to how many visits are expected during
the reporting period.
Yes –
No
Yes –
No
expected visits
Eligible ASC?
1
2
Yes –
No
expected visits
d. If unable to determine expected visits for the assigned reporting period, obtain the number of
visits to the department last year.
ED visits
last year
OPD visits
last year
ASC visits
last year
Go to Section VII, NONINTERVIEW on page 22.
Page 4
FORM NHAMCS-101 (3-26-2009)
FORM NHAMCS-101 (3-26-2009)
Page 21
Section I – TELEPHONE SCREENER – Continued
Section V – AMBULATORY SURGERY CENTER DESCRIPTION – Continued
Now I would like to ask you some questions about your ASC.
15c. Now I have some questions about generating a report for all outpatient surgery patients
for sampling.
Would you or your IT staff be able to
generate a single list of outpatient surgery
cases for the following locations?
(Read each ASC name listed above.)
1
2
3
d. Would you or your IT staff be able to
1
generate one list of outpatient surgery
cases for some of these locations?
Give a copy of the "Single Sampling List
Instructions" to the IT contact.
2
}
Yes
SKIP to item 15e
No – ONLY 2 LOGS
No – More than 2 logs – Continue with item 15d.
Yes – Make sure that the "Single log/list" box is marked
on the NHAMCS-101(U) in item 11 for each AU.
No – Continue with item 15e.
1
2
RECORD ON
CONTROL CARD
Yes, all electronic
Yes, part paper and
part electronic
f. Does your ASC have a computerized system for –
(1) Patient demographic information?
If "Yes," ask – Does this include patient
problem lists?
(2) Orders for prescriptions?
If "Yes," ask – (a) Are warnings of drug
interactions or contraindications
provided?
(b) Are prescriptions sent
electronically to the pharmacy?
(3) Orders for tests?
If "Yes," ask – Are orders sent electronically?
(4) Viewing of lab results?
If "Yes," ask – Are out of range levels highlighted?
4
Cover following points –
(1) The NHAMCS is the only source of national data on health care provided in hospital emergency and
outpatient departments and ambulatory surgery centers
No
Unknown
Unknown
Turned off
Yes
No
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
(6) Clinical notes?
1
2
3
4
1
2
3
4
(7) Reminders for guideline-based
interventions and/or screening tests?
1
2
3
4
(8) Public health reporting?
1
2
3
4
1
2
3
4
If "Yes," ask – Do they include medical
history and follow-up notes?
If "Yes," ask – Are notifiable diseases sent
electronically?
system that your ASC does NOT use or has
turned off?
1
Show flashcard on page 29 of the NHAMCS-124.
2
3
Page 20
3
INSTRUCTIONS
Provide the administrator or other hospital representative with a brief description of the study.
(5) Viewing of electronic imaging results
in the ASC?
g. Are there any of the above features of your
Part C. STUDY DESCRIPTION
Thank you. Now I would like to provide you with further information on the study.
Telephone number
(Area code and number)
OR HEALTH RECORDS (EMR/EHR) (not
including billing records)?
Mark (X) only one box.
Thank you . . ., but it seems that our information was incorrect. Since (Name of
hospital) does not have 24-hour emergency services, outpatient clinics, or
ambulatory surgery centers, it should not have been chosen for our study.
Thank you very much for your cooperation. Terminate telephone call and complete
sections VI and VII beginning on page 21.
CLOSING
STATEMENT
B2
IT Contact name
e. Does your ASC use ELECTRONIC MEDICAL
Thank you . . ., but it seems that our information was incorrect. Since (Name of
hospital) is not a licensed hospital it should not have been chosen for our study.
Thank you very much for your cooperation. Terminate telephone call and complete
sections VI and VII beginning on page 21.
CLOSING
STATEMENT
B1
(2) NHAMCS is endorsed by the:
• American College of Emergency Physicians
• Emergency Nurses Association
• Society for Academic Emergency Medicine
• American College of Osteopathic Emergency Physicians
• Federation of American Hospitals
• American College of Surgeons
• American Health Information Management Association
• American Academy of Ophthalmology
• Society for Ambulatory Anesthesia
• Surgeon General’s office
(3) Nationwide sample of about 600 hospitals and 200 free-standing ambulatory surgery centers
(4) Four-week data collection period
(5) Brief form completed for a sample of patient visits
As one of the hospitals that has been selected for the study, your contribution will be of
great value in producing reliable, national data on ambulatory care.
CHECK
ITEM
B-2
Hospital HAS MERGED with or SEPARATED from another in the past two years? (Item 8e is YES.)
1
2
Yes – Go to CLOSING STATEMENT C1 below.
No – Go to CLOSING STATEMENT C2 below.
CLOSING
STATEMENT
C1
Since your hospital has merged or separated within the last 2 years, I need to
get further instructions from the Centers for Disease Control and Prevention
(CDC) on how to proceed. I will call you back within a week and let you know
which parts of your hospital will be in the survey. Thank you for your
cooperation! Telephone your Regional Office to report the Hospital Name and ID Number.
CLOSING
STATEMENT
C2
I would like to arrange to meet with you so that I can better present the details
of the study. Is there a convenient time within the next week or so that I could
meet with you or your representative?
Thank you . . . for your cooperation. I am looking forward to our meeting. Record
day, date and time of appointment in item 5, page 1; and terminate telephone call.
NOTES
Yes – Please specify
FR NOTE – Indicate in item 15f, last column, any
component(s) turned off.
No
Unknown
1
Unknown
FORM NHAMCS-101 (3-26-2009)
FORM NHAMCS-101 (3-26-2009)
Page 5
Section II – INDUCTION INTERVIEW
Section V – AMBULATORY SURGERY CENTER DESCRIPTION
Part A. INTRODUCTION
CHECK
ITEM E
1
2
Hospital has at least one ASC (Yes in item 10c).
Hospital does not have any ASCs – SKIP to Section VI, DISPOSITION AND SUMMARY on page 22.
I would like to begin with a brief review of the background for this study.
15a. Does this facility have any satellite
INSTRUCTIONS
1
facilities which perform ambulatory
(outpatient) surgery?
Provide the administrator or other hospital representative with a brief introduction to the study
and a general overview of procedures.
2
Name
b. What are the names, addresses, and
telephone numbers of the satellite
facilities?
Cover the following points –
Address
(3) NAMCS and NHAMCS data are used extensively by health care organizations, health services
planners, researchers and educators
To develop the sampling plan, I would like to (collect/verify) more specific information about
this hospital’s ambulatory surgery center(s).
(1) Obtain an estimate of ambulatory (outpatient) surgery cases for each ASC, covering the
4-week reporting period. Enter the estimate in column (d) of the listing below.
(2) After asking 15c and 15d to determine if the ASC log/list is included in a single or multiple
log/list, assign each ASC an AU number and enter it in column (c).
(4) Annually, there are almost 200 million visits to hospital emergency and outpatient departments
and 20 million visits to hospital-based ambulatory surgery centers
(5) The U.S. Census Bureau is acting as the data collection agent for the study
FR
NOTE
(6) The study is authorized by Title 42, U.S. Code, Section 242k
(9) NO patients’ names or identifiers are collected
In-scope ASC locations:
• Laser procedures
• General or main operating room
• Cystoscopy room
room
• Dedicated ambulatory surgery room • Endoscopy room
• Cardiac catheterization • Pain block room
• Satellite operating room
lab
ASC specialty groups include:
• GEN – General
• GI – Gastroenterology
• MULTI – Multi-specialty
• OPH – Ophthalmology
(7) Participation is voluntary
(8) Any identifiable information will be held confidential and will be used only by NCHS staff, contractors
or agents, only when necessary and with strict controls, and will not be disclosed to anyone else
without the consent of your facility. By law, every employee as well as every agent has taken an
oath and is subject to a jail term of up to five years, a fine of up to $250,000, or both if he or she
willfully discloses ANY identifiable information about you, your hospital and its patients
• ORTHO – Orthopedics
• PAIN – Pain Block
Line
No.
(12) NHAMCS covers hospital facilities on and off hospital grounds
ASC name
(Generic)
Specialty
group
(a)
(b)
(13) NHAMCS covers care provided by or under the direct supervision of a physician
• PLASTIC – Plastic Surgery
• OTHER – Other specialty
AU
number
(c)
Expected No. of ambulatory
(outpatient) surgery cases
from __________ to __________
(d)
Take
every
number
Random
start
number
(e)
(f)
1
(14) NHAMCS excludes office-based physicians (these are covered under the NAMCS)
(15) NHAMCS excludes visits to clinics where only ancillary services are provided, e.g., X-ray,
laboratories, and pharmacies, and where physician services are not provided, e.g., physical,
speech, and occupational therapy, and dental and podiatry clinics
(16) For the first time, we are including ambulatory surgery visits in the survey
2
3
4
5
(17) Only a 4-week data collection period
6
(18) On average, sample of approximately 100 ED, 150 to 200 OPD, and 100 ASC visits per hospital
SHOW PATIENT RECORD FORMS
7
8
TOTAL
(19) Form takes only 6 or 7 minutes to complete
(20) Forms are to be completed by hospital staff at their convenience
(21) Portion containing patient’s name or other identifying information is removed before collecting
Page 6
Out-of-scope locations:
• Dentistry
• Podiatry
• Family planning • Abortion
• Lump and bump • Birth center
procedure rooms
INSTRUCTIONS
Only
record generic ASC names in column (a) (e.g., ambulatory surgery center, cardiac cath). If the ASC has a
•
formal/proper name, enter a generic ASC name in (a) and record the Line No. and the formal/proper name on
page 2 of the control card.
• Complete columns (e) and (f) after developing the sampling plan. See page 18 of the NHAMCS-124
for instructions.
(10) The study was approved by the NCHS Research Ethics Review Board or IRB
(11) Data from the study will be used only in statistical summaries
RECORD UP TO 3 ON
CONTROL CARD
Telephone number
(Area code and number)
(1) NHAMCS is a sister survey of the National Ambulatory Medical Care Survey (NAMCS). NAMCS
collects data on visits to physicians in office-based practices
(2) NAMCS and NHAMCS are sponsored by the National Center for Health Statistics of the
Centers for Disease Control and Prevention
Yes – Continue with item 15b.
No – SKIP to developing sampling plan
FORM NHAMCS-101 (3-26-2009)
CHECK
ITEM F
1
2
Hospital has only 1 ASC location – SKIP to Item 15e.
Hospital has more than 1 ASC location – Continue with item 15c. Make sure that the
"Single log/list" or "Multiple log/list" box is marked on the NHAMCS-101(U) in item 11.
FORM NHAMCS-101 (3-26-2009)
Page 19
Section II – INDUCTION INTERVIEW – Continued
Section IV – OUTPATIENT DEPARTMENT DESCRIPTION – Continued
Now I would like to ask you some questions about your OPD.
14t. Does your OPD use ELECTRONIC MEDICAL
OR HEALTH RECORDS (EMR/EHR) (not
including billing records)?
Mark (X) only one box.
1
2
CHECK
ITEM B-3
Yes, all electronic
Yes, part paper and
part electronic
u. Does your OPD have a computerized system for –
(1) Patient demographic information?
If "Yes," ask – Does this include patient
problem lists?
3
4
No
Unknown
1
2
CHECK ITEM B = 1 (ED meets eligibility requirements)
CHECK ITEM B = 2, 3, 4, or 5 (ED does NOT meet eligibility requirements) – SKIP to Part B. Survey
Implementation on page 8.
Now I would like to ask you a few more
questions about your hospital.
Yes
No
1
2
Unknown
Turned off
3
4
1
2
3
4
1
2
3
4
11a. How many days in a week are inpatient
elective surgeries scheduled?
Number of days
b. Does your hospital have a bed coordinator,
(2) Orders for prescriptions?
If "Yes," ask – (a) Are warnings of drug
interactions or contraindications
provided?
(b) Are prescriptions sent
electronically to the pharmacy?
(3) Orders for tests?
sometimes referred to as a bed czar?
1
Unknown
1
Yes
No
Unknown
2
3
1
2
3
4
c. How often are hospital bed census data
available?
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
Read answer categories.
1
2
3
4
5
If "Yes," ask – Are orders sent electronically?
7
(4) Viewing of lab results?
If "Yes," ask – Are out of range levels highlighted?
(5) Viewing of electronic imaging results
in the OPD?
1
2
3
4
(6) Clinical notes?
1
2
3
4
1
2
3
4
If "Yes," ask – Do they include medical
history and follow-up notes?
(7) Reminders for guideline-based
interventions and/or screening tests?
1
2
3
4
(8) Public health reporting?
1
2
3
4
1
2
3
4
system that your OPD does NOT use or has
turned off?
1
Show flashcard on page 29 of the NHAMCS-124.
2
3
CHECK
ITEM D-2
1
2
d. Does your hospital have hospitalists on
staff?
A hospitalist is a physician whose primary
professional focus is the general care of hospitalized
patients. He/she may oversee ED patients being
admitted to the hospital.
e. Do the hospitalists on staff at your hospital
admit patients from your ED?
1
2
3
1
2
If "Yes," ask – Are notifiable diseases sent
electronically?
v. Are there any of the above features of your
6
3
Instantaneously
Every 4 hours
Every 8 hours
Every 12 hours
Every 24 hours
Other
Unknown
Yes
No
Unknown
to Part B. Survey Implementation
} SKIP
on page 8
Yes
No
Unknown
NOTES
Yes – Please specify
FR NOTE – Indicate in item 14u, last column,
any component(s) turned off.
No
Unknown
The OPD uses ELECTRONIC MEDICAL/HEALTH RECORDS (Yes (all) or Yes
(part) in item 14t) – Continue with item 14w.
The OPD either does not use ELECTRONIC MEDICAL/HEALTH RECORDS or it is unknown (No or
Unknown in item 14t) – SKIP to item 14y.
w. What year did your OPD buy or last upgrade
your EMR/EHR system?
x. Is your OPD’s EMR/EHR system certified by
the "Commission for Healthcare
Information Technology" (CCHIT)?
y. Are there plans for installing a new
EMR/EHR system or replacing the current
system within the next 3 years?
Page 18
Year
1
2
3
1
2
1
Unknown
Yes
No
Unknown
Yes
No
3
4
Maybe
Unknown
FORM NHAMCS-101 (3-26-2009)
FORM NHAMCS-101 (3-26-2009)
Page 7
Section IV – OUTPATIENT DEPARTMENT DESCRIPTION – Continued
Section II – INDUCTION INTERVIEW – Continued
Part B. SURVEY IMPLEMENTATION
As I mentioned earlier, I would like to discuss the plan for conducting the study. This hospital has
CHECK
ITEM D
1
2
been assigned to a 4-week data collection period beginning on Monday, ( _____ / _____ ).
Month
Day
CHECK
ITEM D-1
First, I would like to discuss the steps needed to obtain approval for the study.
At least one OPD Clinic in-scope.
All OPD Clinics out-of-scope – SKIP to Section V, AMBULATORY SURGERY CENTER
DESCRIPTION on page 19.
Is the total number of expected OPD visits during the reporting period between
and
12. Are there any additional steps needed to obtain permission for the hospital to
1
participate in the study?
1
2
2
Yes – Specify the necessary steps below
No
3
?
Yes – SKIP to 14t on page 18.
No, it is MORE THAN the range – GO to item a.
No, it is LESS THAN the range – SKIP to item c.
a. Compare to previous sampling plan. Are there more clinics this year compared to last year? (If "Yes"
then verify scope and ownership of the new clinics this year, make changes if needed, and then check
one of the following responses.)
Yes, this is correct, some clinics have opened or should have been included last year. – List
1
No, the number of clinics has not increased.
2
b. Is the number of expected visits to any of the clinics more than twice the number shown on last year’s
sampling plan?
1
Yes, this is correct, visits have increased this year or were too low last year. – Explain
2
No, the number of visits has not increased dramatically.
✰ SKIP to item 14t on page 18
c. Compare to previous sampling plan. Are there fewer clinics this year compared to last year?
1
Yes, this is correct, some clinics have closed or shouldn’t have been included last year. – List
2
No, the number of clinics has not decreased.
d. Is the number of expected visits to any of the clinics less than half of the number shown on last year’s
sampling plan?
Page 8
FORM NHAMCS-101 (3-26-2009)
1
Yes, this is correct, visits have decreased this year or were too high last year. – Explain
2
No, the number of visits has not decreased dramatically.
FORM NHAMCS-101 (3-26-2009)
Page 17
Section II – INDUCTION INTERVIEW – Continued
Section IV – OUTPATIENT DEPARTMENT DESCRIPTION – Continued
FR
NOTE
OPD Specialty Groups include:
• GM – General Medicine
• PED – Pediatrics
• SURG – Surgery
• OBG – Obstetrics/Gynecology
13. Now I would like to make arrangements to
• SA – Substance Abuse
• OTHER – Other
INSTRUCTIONS
• Only record generic clinic names in column (a) (e.g., pediatric clinic). If the clinic has a formal/proper name, enter a
generic clinic name in (a) and record the Line No. and the formal/proper name on page 2 of the control card.
• Complete columns (b) and (c) using pages 10 to 20 of the NHAMCS-124, Sampling and Information Booklet.
Complete columns (e) and (f) after developing the sampling plan. See page 4 of the NHAMCS-124 for instructions.
Line
No.
Outpatient department clinic name
(Generic)
(a)
Specialty
group
(b)
NHAMCS-124
Specialty
Group Scope
(c)
1
In-Scope
Out-of-Scope
2
In-Scope
Out-of-Scope
3
In-Scope
Out-of-Scope
4
In-Scope
Out-of-Scope
5
In-Scope
Out-of-Scope
6
In-Scope
Out-of-Scope
7
In-Scope
Out-of-Scope
8
In-Scope
Out-of-Scope
9
In-Scope
Out-of-Scope
10
In-Scope
Out-of-Scope
11
In-Scope
Out-of-Scope
Expected No. of visits
from __________ to __________
Take
every
number
Random
start
number
(d)
(e)
(f)
obtain the information needed for sampling.
I will need to (know/verify) how your
(emergency department/(and), outpatient
department/(and), ambulatory surgery
center) (is/are) organized and obtain an
estimate of the number of patient visits
expected during the 4-week reporting
period. Would you prefer I (get/verify) this
information from you or someone else?
1
2
Respondent – Go to CHECK ITEM C below
Someone else – Specify below
If different respondent(s), arrange to obtain data
today if possible. Otherwise arrange an appointment
with designated person(s). Briefly explain the study to
the new respondent(s). Then proceed with Section III,
Emergency Department Description, Section IV,
Outpatient Department Description, or Section V,
Ambulatory Surgery Center Description as
appropriate. Thank current respondent for his/her
time and cooperation.
Name
Title
Department
Record on
Control Card
Telephone number
12
In-Scope
Out-of-Scope
13
In-Scope
Out-of-Scope
14
In-Scope
Out-of-Scope
15
In-Scope
Out-of-Scope
Name
Title
Department
Record on
Control Card
Telephone number
Name
Title
Department
Record on
Control Card
Telephone number
CHECK
ITEM C
1
The hospital provides emergency services that are staffed 24 hours each day. (Yes in item 9a) –
GO to Section III, EMERGENCY DEPARTMENT DESCRIPTION on page 10.
2
The hospital DOES NOT provide emergency services that are staffed 24 hours each day. (No in
item 9a) – SKIP to Section IV, OUTPATIENT DEPARTMENT DESCRIPTION on page 15.
NOTES
TOTAL
Page 16
FORM NHAMCS-101 (3-26-2009)
FORM NHAMCS-101 (3-26-2009)
Page 9
Section III – EMERGENCY DEPARTMENT DESCRIPTION
Section IV – OUTPATIENT DEPARTMENT DESCRIPTION
To develop the sampling plan, I would like to (collect/verify) more specific information about this
hospital’s emergency department.
(1) If the hospital has previously participated, simply verify that the emergency service area(s) (ESA)
listed below is/are still operating in the hospital by –
(1) If the hospital has previously participated, simply verify that the clinic(s) listed on page 16 is (are) still operating in
the hospital by –
(a) crossing through any ESAs on the list that no longer exist or are no longer operational in that hospital.
(b) adding the name(s) of any new ESA(s) that has/have been created or has/have become operational in that
hospital. For each new ESA added to the list, be sure to obtain the proper type to be entered in column (b).
(c) obtaining an estimate of visits for each ESA, covering the 4-week reporting period. Enter the estimate in
column (c).
(2) If the hospital has not previously participated, obtain a complete listing of all eligible ESAs along
with their corresponding type and expected number of visits for each ESA during the 4-week
reporting period. Record this information in columns (a), (b), and (c) below.
Line
No.
(2) If the hospital has not previously participated or a clinic list is not attached to this 101, obtain a complete listing of
all eligible outpatient clinics along with their corresponding specialty group code, and expected number of visits
for each clinic during the 4-week reporting period. Record this information in columns (a), (b), and (d) on the
next page.
• Psychiatric
• Other
Emergency service area name
(Generic)
ESA
type
(a)
(b)
(b) adding the name(s) of any new clinic(s) which has/have been created or become operational in that hospital.
For each new clinic added to the list, be sure to obtain the proper specialty code. Remember, include only
ELIGIBLE clinics.
(d) If this Outpatient Department has more than 5 clinics – FAX the updated list to your regional office.
The regional office will choose the clinics for sample and provide you with the sampling instructions. Upon
receiving the instructions, attach a copy of the completed clinic listing showing sampled clinics, the Take Every
and Random Start numbers, etc., to page 16 of the NHAMCS-101, Questionnaire.
• Only record generic ESA names in column (a) (e.g., pediatric emergency department). If the ESA has a
formal/proper name, enter a generic name in (a) and record the Line No. and the formal/proper name on
page 2 of the control card.
FR
NOTE
(a) crossing through any clinics on the list which no longer exist or are no longer operational in that hospital.
(c) obtaining an estimate of visits for each clinic, covering the 4-week reporting period. Enter the estimate in
column (d).
INSTRUCTION:
ESA types include:
• General
• Pediatric
• Adult
• Urgent care/Fast track
To develop the sampling plan, I would like to (collect/verify) more specific
information about this hospital’s outpatient department.
Expected No. of visits
from __________ to __________
Take
every
number
Random
start
number
(c)
(d)
(e)
NOTES
1
2
3
4
5
6
7
8
9
10
TOTAL
INSTRUCTIONS – Complete columns (d) and (e) after developing the sampling plan. See page 2 of
the NHAMCS-124, Sampling and Information Booklet.
Page 10
FORM NHAMCS-101 (3-26-2009)
FORM NHAMCS-101 (3-26-2009)
Page 15
Section III – EMERGENCY DEPARTMENT DESCRIPTION – Continued
Section III – EMERGENCY DEPARTMENT DESCRIPTION – Continued
14s. Which of the following procedures does
your ED use?
Show flashcard on page 30 of the NHAMCS-124.
Mark (X) all that apply.
1
2
3
4
5
6
7
8
9
10
CHECK
ITEM C-3
1
2
Bedside registration
Computer-assisted triage
Separate fast track unit for nonurgent care
Separate operating room dedicated to ED patients
Electronic dashboard (i.e., displays updated patient
information and integrates multiple data sources)
Radio frequency identification (RFID) tracking (i.e.,
shows exact location of patients, caregivers, and
equipment)
Zone nursing (i.e., all of a nurse’s patients are
located in one area)
"Pool" nurses (i.e., nurses that can be pulled to the
ED to respond to surges in demand)
Full capacity protocol (i.e., allows some admitted
patients to move from the ED to inpatient corridors
while awaiting a bed)
None of the above
CHECK
ITEM C-1
Is the total number of expected ED visits during the reporting period between
and
1
2
3
?
Yes – SKIP to item 14a on page 12
No, it is MORE THAN the range – GO to item a.
No, it is LESS THAN the range – SKIP to item b.
a. Is the number of expected visits to any of the ESAs more than twice the number shown on last year’s
sampling plan?
1
The hospital has an organized outpatient department that provides physician services. (Yes in items 10a
and b) – SKIP to Section IV, OUTPATIENT DEPARTMENT DESCRIPTION on page 15.
The hospital does not have an organized outpatient department that provides physician services. (No in
items 10a or 10b) – SKIP to Section V, AMBULATORY SURGERY CENTER DESCRIPTION on page 19.
2
NOTES
Yes, this is correct, visits have increased this year or were too low last year. – Explain
No, the number of visits has not increased dramatically.
✰SKIP to item 14a on page 12
b. Is the number of expected visits to any of the ESAs less than half of the number shown on last year’s
sampling plan?
1
Yes, this is correct, visits have decreased this year or were too high last year. – Explain
2
No, the number of visits has not decreased dramatically.
NOTES
Page 14
FORM NHAMCS-101 (3-26-2009)
FORM NHAMCS-101 (3-26-2009)
Page 11
Section III – EMERGENCY DEPARTMENT DESCRIPTION – Continued
Section III – EMERGENCY DEPARTMENT DESCRIPTION – Continued
14g. Does your ED have a physically separate
Now I would like to ask you some questions about your ED.
14a. Does your ED use ELECTRONIC MEDICAL
OR HEALTH RECORDS (EMR/EHR) (not
including billing records)?
Mark (X) only one box.
1
2
Yes, all electronic
Yes, part paper and
part electronic
b. Does your ED have a computerized system for –
1
observation or clinical decision unit?
3
4
3
No
Unknown
Unknown
2
h. What type of physicians make decisions for
Yes
No
Turned off
1
2
3
4
1
2
3
4
1
2
3
4
1
patients in this observation or clinical
decision unit?
2
3
4
(1) Patient demographic information?
i. Are admitted ED patients ever "boarded" for
If "Yes," ask – Does this include patient
problem lists?
(2) Orders for prescriptions?
If "Yes," ask – (a) Are warnings of drug
interactions or contraindications
provided?
(b) Are prescriptions sent
electronically to the pharmacy?
(3) Orders for tests?
If "Yes," ask – Are orders sent electronically?
(4) Viewing of lab results?
If "Yes," ask – Are out of range levels highlighted?
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
(6) Clinical notes?
1
2
3
4
1
2
3
4
(7) Reminders for guideline-based
interventions and/or screening tests?
1
2
3
4
(8) Public health reporting?
1
2
3
4
1
2
3
4
If "Yes," ask – Are notifiable diseases sent
electronically?
c. Are there any of the above features of your
system that your ED does NOT use or has
turned off?
1
2
3
1
2
FR NOTE – Indicate in item 14b, last column,
any component(s) turned off.
No
Unknown
d. What year did your ED buy or last upgrade
your EMR/EHR system?
the "Commission for Healthcare
Information Technology" (CCHIT)?
f. Are there plans for installing a new
EMR/EHR system or replacing the current
system within the next 3 years?
Page 12
1
admitted ED patients ever "boarded" in
inpatient hallways or in another space
outside the ED?
2
3
k. What is the total number of hours that your
hospital’s ED was on ambulance diversion
in 2009?
1
2
l. Is ambulance diversion actively
managed on a regional level versus
each hospital adopting diversion if and
when it chooses?
m. Does your hospital continue to admit
elective or scheduled surgery cases when
the ED is on ambulance diversion?
1
2
3
1
2
3
ED physicians
Hospitalists
Other physicians
Unknown
Yes
No
Unknown
Yes
No
Unknown
Total number of hours
Data not available
ED did not go on ambulance
diversion in 2009 – SKIP to item 14n
Yes
No
Unknown
Yes
No
Unknown
n. As of last week, how many standard
treatment spaces did your ED have?
Standard treatment spaces are beds or treatment
spaces specifically designed for ED patients to
receive care, including asthma chairs.
Yes – Please specify
The ED uses ELECTRONIC MEDICAL/HEALTH RECORDS (Yes (all) or Yes
(part) in item 14a) – Continue with item 14d.
The ED either does not use ELECTRONIC MEDICAL/HEALTH RECORDS or it is unknown (No or
Unknown in item 14a) – SKIP to item 14f.
e. Is your ED’s EMR/EHR system certified by
3
}
Total number of standard treatment spaces
1
Data not available
1
Data not available
1
Yes
No
Unknown
o. As of last week, how many other
Show flashcard on page 29 of the NHAMCS-124.
CHECK
ITEM C-2
2
j. If the ED is critically overloaded, are
(5) Viewing of electronic imaging results
in the ED?
If "Yes," ask – Do they include medical
history and follow-up notes?
1
more than 2 hours in the ED or the observation
unit while waiting for an inpatient bed?
Yes
No
SKIP to item 14i
Unknown
Year
1
2
3
1
2
p. In the last two years, has your ED increased
the number of standard treatment spaces?
space been expanded?
Unknown
Total number of other treatment spaces
2
3
q. In the last two years, has your ED’s physical
1
1
2
3
Yes
No
Unknown
Yes
No
treatment spaces did your ED have?
Other treatment spaces are other locations where
patients might receive care in the ED, including
chairs, stretchers in hallways that may be used
during busy times.
r. Do you have plans to expand your ED’s
physical space within the next two years?
3
4
1
2
3
Maybe
Unknown
FORM NHAMCS-101 (3-26-2009)
FORM NHAMCS-101 (3-26-2009)
Yes
No
Unknown
Yes
No
Unknown
Page 13
| File Type | application/pdf |
| File Title | nhamcs101p01_24.g |
| File Modified | 2009-03-30 |
| File Created | 2009-03-26 |