Post Induction - Facility Questionnaire (Part D)

Attachment F Post-Induction Annual Facility Questionnaire OMB No. 0920-0212: Approval expires 10/31/2011

Notice - Public reporting burden for this collection of information is estimated to average 2 hours, including 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 burden to: CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road, MS D-24, Atlanta, GA 30333, ATTN: PRA (0920-0212).

Assurances of Confidentiality –All information which would permit identification of any individual, a practice, or an establishment will be held confidential, will be used 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 the 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).

Hospital Number: ___________________________ (Office use only)

NATIONAL HOSPITAL DISCHARGE SURVEY

Part D: Facility Questionnaire

Thank you for participating in the National Hospital Discharge Survey. The information collected will be invaluable to hospitals, policymakers, researchers, and all who provide patient care in America’s hospitals and health care systems.

If you have questions as you complete this form, please contact TBD. Once this questionnaire is completed, please put it in the FedEx envelope provided and send it back to Social and Scientific Systems (SSS), 8757 Georgia Avenue, Silver Spring, MD 20910.

1. Hospital Information (pre-printed label)

Legal Name:
Address:
City:				State:		__ __	ZIP Code:	__ __ __ __ __
Telephone:		(__ __ __) __ __ __ - __ __ __ __			Fax:	(__ __ __) __ __ __ - __ __ __ __

2. Person Completing This Form

Name:
Title:
E-mail:
Dept. Address:
Telephone:	(____)____-_____	Fax:	(____)____-_____

3. Is the information provided on this questionnaire only for the hospital named on the above label?

 Yes

 No  Please provide names of hospitals also included: ___________________________________________

Hospital Demographics

4. Please provide the hospital utilization statistics below for calendar year 2010. If not for calendar year 2010, please indicate the 12 month period provided: ________________________

a. Was this facility open as of 01/01/2010?  Yes  No  When did your hospital open _____________________?
b. Total number of acute inpatient admissions: _______________
c. Average length of stay (all acute inpatients): _____________days
d. Total number of live births:_____________________________

5. What is the ownership type of this hospital?

Please mark (X) only one.

 Non-profit, not religious order affiliated

 Non-profit, religious order affiliated

 Government

 Proprietary

 Other  Please specify: ________________________________________________

6. Is this a primary teaching hospital for a medical school?

 Yes

 No

7. Is this a critical access hospital?

 Yes

 No

Health Information Technology

8. Does your hospital use electronic medical records (EMR) or electronic health records (EHR) system? Do not include billing record systems.

 Yes, all electronic

 Yes, part paper and part electronic

 No  Skip to Q.11

 Don’t know  Skip to Q.11

9. In which year did you install your EMR/EHR system? Year: _____________

10. What is the name of you current EMR/EHR system? CHECK ONLY ONE BOX. IF OTHER IS CHECKED, PLEASE SPECIFY THE NAME.

□ Allscripts □ Cerner □ CHARTCARE

□ eClinicalWorks □ Epic □ eMDs

□ GE/Centricity □Greenway Medical □MED3000

□ NextGen □ Sage □ SOAPware

□13 Practice Fusion □14 Other_________ □15 Unknown

11. Are there plans for installing a new EMR/EHR system within the next 18 months?

 Yes

 No

 Maybe

 Unknown

12. If orders for prescriptions or lab tests are submitted electronically, who submits them? CHECK ALL THAT APPLY.

 Prescribing practitioner

 Other

 Prescriptions and lab test orders not submitted electronically

 Unknown

13. Please indicate whether your hospital inpatient departments have each of the computerized capabilities listed below. CHECK NO MORE THAN ONE BOX PER ROW. Does the reporting location have a computerized system for:

	Hospital Inpatient Wards
	Yes	Yes, but turned off or not used	No	Unknown
13a. Recording patient history and demographic information?				
13a1. If yes, does this include patient problem list?				
13b. Recording clinical notes?				
13b1. If yes, do they include a comprehensive list of the patient’s medications and allergies?				
13c. Ordering prescriptions?				
13c1. If yes, are prescriptions sent electronically to the pharmacy?				
13c2. If yes, are warnings of drug interactions or contraindications provided?				
13d. Providing reminders for guideline-based intervention or screening tests?				
13e. Ordering for lab tests?				
13e1. If yes, are orders sent electronically?				
13f. Providing standard order sets related to a particular condition or procedure?				
13g. Viewing lab results?				
13g1. If yes, are results incorporated into EMR/EHR?				
13h. Viewing imaging results?				
13i. Viewing data on quality of care measures?				
13j. Electronic reporting to immunization registries?				
13k. Public health reporting?				
13k1. If yes, are notifiable diseases sent electronically?				
13l. Providing patients with clinical summaries for each visit?				
13m. Exchanging secure messages with patients?				

14. Can inpatient electronic medical records be accessed from the following hospital units?

	Yes	No	Unknown
a. Intensive Care Unit			
b. Emergency Department			
c. Observation Unit			
d. Outpatient			

15a. Beginning in 2011, Medicare and Medicaid will offer incentives to hospitals that have demonstrated “meaningful use of health IT”. Are there plans to apply for Medicare or Medicaid incentive payments for meaningful use of health IT?

Outpatient

 Yes, we intend to apply  go to Q.15b

 Uncertain whether we will apply  Skip to Q.16

 No, we will not apply  Skip to Q. 16

15b. In which year do you expect to apply for the meaningful use payments?

 2011

 2012

 After 2012

 Unknown

Financial information

16. What percent of your patient care revenue for calendar year 2010 came from the following?

1. Medicare	%
Medicaid/CHIP	%
Private insurance	%
Patient payments	%
Other (including charity, research, CHAMPUS, VA, etc.)	%
TOTAL	100%

17. What percentage of your hospital’s revenue came from Medicaid and Medicare Disproportionate Share Program in 2010?

a. ________% Medicaid Disproportionate Share Program in 2010

b. ________% Medicare Disproportionate Share Program in 2010

Outpatient and Emergency Departments and Special Hospital Units

18. Does this hospital operate an organized outpatient department either at this hospital or elsewhere?

 Yes  Number of beds ______________

 No – Skip to Q. 20.

 Don’t know – Skip to Q. 20.

19. Does this OPD include physician services?

 Yes

 No

 Don’t know

20. Does this hospital have an Ambulatory Surgery Center (ASC)?

ACS 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.

 Yes  Number of beds ______________

 No

 Don’t know

21a. Does your hospital have an Emergency Department?

 Yes  Number of beds _________________

 No – Skip to Q.22.

 Don’t know – Skip to Q. 22.

21b. Is the Emergency Department staffed 24 hours per day?

 Yes

 No

 Don’t know

22. Does this hospital have a dedicated Pediatric Emergency Services Area?

 Yes

 No

 Don’t know

23. Does this hospital have a dedicated Psychiatric Emergency Services Area?

 Yes

 No

 Don’t know

24. What is the trauma level rating of the Emergency Department and hospital?

For each row, please mark (X) only one box.

	None	Level I	Level II	Level III	Level IV	Level V	Other/Unknown
Adult trauma							
Pediatric trauma							

25. Does your hospital have a Neonatal Intensive Care Unit (NICU)?

 Yes

 No -- Skip to Q. 27.

 Don’t know -- Skip to Q. 27.

26. What is the level of care provided by your NICU?

Please mark (X) only one.

 I

 II

 III

 IV

 V

 Don’t know

27. Does your hospital have an Intensive Care Unit (ICU) other than the NICU?

 Yes

 No

 Don’t know

28. Does your hospital have a dedicated observation unit?

 Yes  Number of beds __________

 No

 Don’t know

Staffing

We are also interested in finding out about hospitalists (physicians whose primary professional focus is the general medical care of hospitalized inpatients), excluding physicians who work in Intensive Care Unit(s).

29. Does your hospital employ hospitalists (exclude physicians who work only in Intensive Care Units)?

 Yes

 No

 Don’t know

Thank you for your participation!

Please return your completed facility questionnaire in the provided FedEx envelope!

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