Form 1 Hospital Induction Form

Attachment G. Hospital Induction Form

Ambulatory Care Pretest, National Hospital Care Survey

OMB No. 0920-xxxx; Exp. Date: 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). Notice – Public reporting burden for this collection of information is estimated to average 90 minutes per response, 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 current 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 Information Collection Review Office, 1600 Clifton Road, MS D-74, Atlanta, GA 30333, ATTN: PRA (0920-xxxx).
	INTRO_APPT
	Text:	Hello, This is ... calling on behalf of the National Center for Health Statistics, part of the Centers for Disease Control and Prevention. I'm (calling/visiting) about the National Hospital Care Survey and to let you know that this hospital will be included in our study. 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 for about 15 minutes?
	NAMECHEK
	Text:	Let me verify that I have the correct name and address for your hospital. Is the correct name (facility name)?
	1.	Yes
	2.	No
	HSP_NAME
	Text:	What is your hospital's name?
	1.	Enter 1 to update information
	2.	Continue
	ADDCHEK
	Text:	Is your hospital located at (Facility Address)
	1.	Yes
	2.	No
	HSP_ADDRESS
	Text:	What is the correct address?
	MAILADD
	Text:	Is this also the mailing address? (Facility Address)
	1.	Yes
	2.	No
	MHSP_STRET
	Text:	What is the correct mailing address?
	INTRO_AB
	Text:	(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. The National Center for Health Statistics of the Centers for Disease Control and Prevention is (conducting an/continuing its) annual study of hospital-based ambulatory care.  (Intro for the survey) Before discussing the details, I would like to verify our basic information about (facility name) to be sure we have correctly included this hospital in the study.  First, concerning licensing:
	LICHOSP
	Text:	Is this facility a licensed hospital?
	1.	Yes
	2.	No
	OWN101
	Text:	Is this hospital nonprofit, government, or proprietary?
	1.	Nonprofit (includes church-related, nonprofit corporation, other nonprofit ownership)
	2.	State or local government (includes state, county, city, city-county, hospital district or authority)
	3.	Proprietary (includes individually or privately owned, partnership or corporation)
	OWNHCC
	Text:	Is this hospital owned, operated, or managed by a health care corporation that owns multiple health care facilities (e.g., HCA or Health South)?
	1.	Yes
	2.	No
	3.	Unknown
	TEACHOSP
	Text:	Is this a teaching hospital?
	1.	Yes
	2.	No
	MERGER
	Text:	Did this hospital either merge or separate from any OTHER hospital in the past 2 years?
	1.	Merged or separated
	2.	No
	3.	Unknown
	MERSEP
	Text:	Was this a merger or a separation?
	MERGMEDR
	Text:	Does YOUR hospital have its own medical records department that is separate from that of the OTHER hospital?
	1.	Yes
	2.	No
	3.	Unknown
	OTHNAME
	Text:	What is the name and address of this OTHER hospital?
	ESA24
	Text:	Does this hospital provide emergency services that are staffed 24 HOURS each day either here at this hospital or elsewhere?
	1.	Yes
	2.	No
	ESANOT24
	Text:	Does this hospital operate any emergency service areas that are not staffed 24 HOURS each day?
	1.	Yes
	2.	No
	TRAUMA
	Text:	What is the trauma level rating of this hospital?
	1.	Level I
	2.	Level II
	3.	Level III
	4.	Level IV
	5.	Level V
	6.	Other/unknown
	7.	None
	OOOPD
	Text:	Does this hospital operate an organized outpatient department either at this hospital or elsewhere?
	1.	Yes
	2.	No
	PHYSSERV
	Text:	Does this OPD include physician services?
	1.	Yes
	2.	No
	AMBSURG
	Text:	Does this hospital have locations that perform ambulatory surgery? Ambulatory surgery 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, or a pain block room.
	1.	Yes
	2.	No
	3.	Unknown
	ELIGREQ
	Text:	** Not displayed **
	STUDY_DESC
	Text:	Thank you.          Provide the administrator or other hospital representative with a brief description of the study.
	INDUCTION_APPT
	Text:	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?               Record day, date and time of appointment             Enter 999 if the respondent wants to continue with the induction now
	SCREENER_THK
	Text:	Thank you for your cooperation.  I am looking forward to our meeting.
	THANK_MERGSEP
	Text:	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.
	CALLRO_MERGSEP
	Text:	Call Headquarters and inform them of the situation.      Await resolution from Headquarters before continuing with this case.
	THANK_B1
	Text:	Thank you, but it seems that our information is incorrect. Since (facility name) is not a licensed hospital, it should not have been chosen for our study. Thank you very much for your cooperation.
	THANK_B2
	Text:	Thank you, but it seems that our information is incorrect. Since (facility name) 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.
	REVIEW
	Text:	I would like to begin with a brief review of the background for this study.    Provide the administrator or other hospital representative with a brief introduction to the study and a general overview of procedures.
	SURGDAY
	Text:	Now I would like to ask you a few more questions about your hospital. How many days in a week are inpatient elective surgeries scheduled?
	BEDCZAR
	Text:	Does your hospital have a bed coordinator, sometimes referred to as a bed czar?
	1.	Yes
	2.	No
	3.	Unknown
	BEDDATA
	Text:	How often are hospital bed census data available?
	1.	Instantaneously
	2.	Every 4 hours
	3.	Every 8 hours
	4.	Every 12 hours
	5.	Every 24 hours
	6.	Other
	7.	Unknown
	HLIST
	Text:	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.
	1.	Yes
	2.	No
	3.	Unknown
	HLISTED
	Text:	Do the hospitalists on staff at your hospital admit patients from your ED?
	1.	Yes
	2.	No
	3.	Unknown
	EMEDRES
	Text:	Does this hospital have an emergency medicine residence program?
	1.	Yes
	2.	No
	3.	Unknown
	PAYHITH
	Text:	Medicare and Medicaid offer incentives to practices that demonstrate “meaningful use of health IT”. Does your hospital have plans to apply for these incentive payments?
		1. Yes, we already applied 2. Yes, we intend to apply 3. Uncertain if we will apply 4. No, we will not apply
	PAYDR
	Text:	When did you first apply?
	1.	2011
	2.	2012
	3.	Unknown
	PAYYR
	Text:	When do you intend to first apply?
	1.	2012
	2.	2013 or later
	3.	Unknown

REMACC If PAYHIT=1

Text: Now I’d like to ask you some questions about your hospital’s electronic health records system. Can this system be accessed from the outside by entities not associated with the hospital?

1. Yes

2. Unsure (will have to check and get back to interviewer)

3. No – Skip to PERMPART

4. Unknown

REMREP Text: Would your hospital be willing to allow CDC’s contractor to obtain password access to your hospital’s electronic health records system and load the charting software onto desktop computers at their headquarters? The contractor’s Data Security Plan complies with all relevant laws, regulations, and policies governing the security of data and protection of confidentiality.

1. Yes

2. Unsure (will have to check and get back to interviewer)

3. No

4. Unknown

PERMPART

Text:

As I mentioned earlier, I would like to discuss the plan for conducting the study.  This hospital has been assigned to a (1-month, 2-month, 3-month) data collection period beginning on Monday, (Reporting period begin date). First, I would like to discuss the steps needed to obtain approval for the study. Are there any additional steps needed to obtain permission for the hospital to participate in the study?

1.

Yes

2.

No

PERMPARTSPEC

Text:

  Specify the necessary steps needed to obtain permission for the hospital
to participate in the study.    Include the name, address, phone and title of the person(s) who can grant approval

PERM_THANK

Text:

Thank you for your help.

RO_PERMISSION

Text:

  Call the Regional Office to inform them of the additional steps needed to
    obtain permission

VSREPPER

Text:

Now I would like to make arrangements to obtain the information needed for sampling. I will need to (know/verify) how your (emergency department and/or outpatient department and/or ambulatory surgery location) (is/are) organized and obtain an estimate of the number of patient visits expected during the (1-month, 2-month, 3-month) reporting period.  Would you prefer I (get/verify) this information from you or someone else?

1.

Respondent

2.

Someone else

CWHO

Text:

What is the name of the person I should talk to?

1.

Existing Contact

2.

New Contact

3.

Continue interview

CINFO

Text:

What is the name of the person I should talk to?

1.

New contact

2.

Continue interview

THANK_RESP

Text:

       Thank current respondent for his/her time and cooperation

CONTACT_DEPT

Text:

• All eligible departments are complete.

Department    Status
ED      (Elig /Partial /Elig (refusal) / Partial (refusal) / Cmplt / Inelig)
OPD   (Elig /Partial /Elig (refusal) / Partial (refusal) / Cmplt / Inelig)
ASL    (Elig /Partial /Elig (refusal) / Partial (refusal) / Cmplt / Inelig)

1.

ED

2.

OPD

3.

ASL

4.

Department refusal

5.

Department callback

9.

Wrap up case

INTRO_ED

Text:

       If necessary, introduce yourself and explain the survey using the hospital administrator script
       Explain that in order to develop a sampling plan, you would like to collect more specific information about this hospital's emergency department and need about 25 minutes of their time

ESA_NAME

Text:

(What is the name of the (first/next) emergency service area? /Are there any other emergency service areas?)

ESA_TYPE

Text:

What type of ESA is (ESA name)

1.

General

2.

Adult

3.

Pediatric

4.

Urgent care/Fast track

5.

Psychiatric

6.

Other

ESA_EVISITS

Text:

What is the expected number of visits from (Reporting period begin date) to (Reporting period end date) for (ESA name)?

EBILLRECE

Text:

Now I would like to ask you some questions about your ED.

 If ESAs within the ED vary with respect to their use of the EHR/EMR systems, then ask these questions of the ESA with the largest number of expected visits during the reporting period.
Does your ED submit any CLAIMS electronically (electronic billing)?

1.

Yes

2.

No

3.

Unknown

EINSE

Text:

Does your ED verify an individual patient's insurance eligibility electronically?

1.

Yes

2.

No

3.

Unknown

EINSHOWE

Text:

How does your ED electronically verify an individual patient's insurance eligibility? Is it through an EHR/EMR system, a stand-alone practice management system, or some other electronic system?
       Read answer categories out loud

1.

Yes, with a stand-alone practice management system

2.

Yes, with an EMR/EHR system

3.

Yes, using another electronic system

4.

No

5.

Unknown

EINSFASTE

Text:

When your staff electronically verifies a patient's insurance eligibility, do you usually get results back before the patient leaves the ED?

1.

Yes

2.

No

3.

Unknown

EMEDRECE

Text:

Does your ED use an electronic MEDICAL record (EMR) or electronic HEALTH record (EHR) system?  Do not include billing record systems.
  Read answer categories out loud

1.

Yes, all electronic

2.

Yes, part paper and part electronic

3.

No

4.

Unknown

EHRINSYRE

Text:

In which year did your ED install the EMR/EHR system?

EHRNAME

Text:

What is the name of your current EMR/EHR system?

1.

Allscripts

2.

Cerner

3.

eClinicalWorks

4.

Epic

5.

GE/Centricity

6.

Greenway Medical

7.

McKesson/Practice Partner

8.

NextGen

9.

Sage

10.

Other - Specify

11.

Unknown

EHRNAME_SP

Description:

Other-Specify name of EHR/EMR system

Other-Specify name of EHR/EMR system

Text:

  Enter name of EMR/EHR system

EHRINSE

Text:

Does your ED have plans for installing a new EMR/EHR system within the next 18 months?

1.

Yes

2.

No

3.

Maybe

4.

Unknown

EDEMOGE

Text:

Indicate whether your ED has each of the following computerized capabilities.  Does your ED have a computerized system for:
   Recording patient history and demographic information?

1.

Yes, used routinely

2.

Yes, but not used routinely

3.

Yes, but turned off or not used

4.

No

5.

Unknown

EPROLSTE

Text:

Does this include a patient problem list?

1.

Yes, used routinely

2.

Yes, but not used routinely

3.

Yes, but turned off or not used

4.

No

5.

Unknown

EVITALE

Text:

Recording and charting vital signs?

1.

Yes, used routinely

2.

Yes, but not used routinely

3.

Yes, but turned off or not used

4.

No

5.

Unknown

ESMOKEE

Text:

Recording patient smoking status?

1.

Yes, used routinely

2.

Yes, but not used routinely

3.

Yes, but turned off or not used

4.

No

5.

Unknown

EPNOTESE

Text:

   Recording clinical notes?

1.

Yes, used routinely

2.

Yes, but not used routinely

3.

Yes, but turned off or not used

4.

No

5.

Unknown

EMEDALGE

Text:

Do they include a comprehensive list of the patient's medications and allergies?

1.

Yes, used routinely

2.

Yes, but not used routinely

3.

Yes, but turned off or not used

4.

No

5.

Unknown

ECPOEE

Text:

Ordering prescriptions?

1.

Yes, used routinely

2.

Yes, but not used routinely

3.

Yes, but turned off or not used

4.

No

5.

Unknown

ESCRIPE

Text:

Are prescriptions sent electronically to the pharmacy?

1.

Yes, used routinely

2.

Yes, but not used routinely

3.

Yes, but turned off or not used

4.

No

5.

Unknown

ERXWHOE/ EHRWHOE

Text:

At your ED, when orders for prescriptions are submitted electronically, are they submitted by the prescribing practitioner, or by someone else?          Enter all that apply, separate with commas

1.

Prescribing practitioner

2.

Someone else

3.

Unknown

EWARNE

Text:

Are warnings of drug interactions or contraindications provided?

1.

Yes, used routinely

2.

Yes, but not used routinely

3.

Yes, but turned off or not used

4.

No

5.

Unknown

EREMINDE

Text:

Indicate whether your ED has each of the following computerized capabilities.  Does your ED have a computerized system for:

Providing reminders for guideline-based interventions or screening tests?

1.

Yes, used routinely

2.

Yes, but not used routinely

3.

Yes, but turned off or not used

4.

No

5.

Unknown

ESETSE

Text:

Providing standard order sets related to a particular condition or procedure?

1.

Yes, used routinely

2.

Yes, but not used routinely

3.

Yes, but turned off or not used

4.

No

5.

Unknown

ECTOEE

Text:

Ordering lab tests?

1.

Yes, used routinely

2.

Yes, but not used routinely

3.

Yes, but turned off or not used

4.

No

5.

Unknown

EORDERE

Text:

Are orders sent electronically?

1.

Yes, used routinely

2.

Yes, but not used routinely

3.

Yes, but turned off or not used

4.

No

5.

Unknown

ELABWHOE

Text:

At your ED, when orders for lab tests are submitted electronically, are they submitted by the prescribing practitioner, or by someone else?

Enter all that apply, separate with commas

1.

Prescribing practitioner

2.

Someone else

3.

Unknown

ERESULTE

Text:

Indicate whether your ED has each of the following computerized capabilities.  Does your ED have a computerized system for: Viewing lab results?

1.

Yes, used routinely

2.

Yes, but not used routinely

3.

Yes, but turned off or not used

4.

No

5.

Unknown

EGRAPHE

Text:

Can the EHR/EMR automatically graph a specific patient's lab results over time?

1.

Yes, used routinely

2.

Yes, but not used routinely

3.

Yes, but turned off or not used

4.

No

5.

Unknown

EIMGRESE

Text:

Indicate whether your ED has each of the following computerized capabilities Does your ED have a computerized system for: Viewing imaging results? 

1.

Yes, used routinely

2.

Yes, but not used routinely

3.

Yes, but turned off or not used

4.

No

5.

Unknown

EQOCE

Text:

Viewing data on quality of care measures?

1.

Yes, used routinely

2.

Yes, but not used routinely

3.

Yes, but turned off or not used

4.

No

5.

Unknown

ECQME

Text:

Reporting clinical quality measures to federal or state agencies (such as CMS or Medicaid)?

1.

Yes, used routinely

2.

Yes, but not used routinely

3.

Yes, but turned off or not used

4.

No

5.

Unknown

EGENLISTE

Text:

Generating lists of patients with particular health conditions?

1.

Yes, used routinely

2.

Yes, but not used routinely

3.

Yes, but turned off or not used

4.

No

5.

Unknown

EIMMREGE

Text:

Electronic reporting to immunization registries? 

1.

Yes, used routinely

2.

Yes, but not used routinely

3.

Yes, but turned off or not used

4.

No

5.

Unknown

EMUREPE

Text:

Is the electronic reporting to immunization registries reported in standards specified by Meaningful Use criteria?

1.

Yes, used routinely

2.

Yes, but not used routinely

3.

Yes, but turned off or not used

4.

No

5.

Unknown

ESUME

Text:

Indicate whether your ED has each of the following computerized capabilities.  Does your ED have a computerized system for:
   Providing patients with clinical summaries for each visit?

1.

Yes, used routinely

2.

Yes, but not used routinely

3.

Yes, but turned off or not used

4.

No

5.

Unknown

EMSGE

Text:

Exchanging secure messages with patients?

1.

Yes, used routinely

2.

Yes, but not used routinely

3.

Yes, but turned off or not used

4.

No

5.

Unknown

EHLTHINFOE

Text:

Providing patients with an electronic copy of their health information?

1.

Yes, used routinely

2.

Yes, but not used routinely

3.

Yes, but turned off or not used

4.

No

5.

Unknown

EXCHSUME/ESHAREE

Text:

Does your ED share any patient health information electronically (not fax) with other providers, including hospitals, ambulatory providers, or labs?

1.

Yes

2.

No

EXCHSUM1E/ESHAREHOWE

Text:

How does your ED electronically share patient health information?
    Enter all that apply, separate with commas

1.

EHR/EMR

2.

Web portal (separate from EHR/EMR)

3.

Other electronic method: ___________________

LABRESE

Text:

Please indicate whether your ED electronically (not fax) shares each of the following types of health data and with which types of health care providers.
Lab results?
  Enter all that apply, separate with commas

1.

Hospitals with which your ED is affiliated

2.

Other departments inside your hospital

3.

Hospitals with which your ED is not affiliated

4.

Ambulatory providers outside your hospital

IMAGREPE

Text:

Imaging reports?
  Enter all that apply, separate with commas

1.

Hospitals with which your ED is affiliated

2.

Other departments inside your hospital

3.

Hospitals with which your ED is not affiliated

4.

Ambulatory providers outside your hospital

PTPROBE

Text:

Patient problem lists?
  Enter all that apply, separate with commas

1.

Hospitals with which your ED is affiliated

2.

Other departments inside your hospital

3.

Hospitals with which your ED is not affiliated

4.

Ambulatory providers outside your hospital

MEDLISTE

Text:

Medication lists?
  Enter all that apply, separate with commas

1.

Hospitals with which your ED is affiliated

2.

Other departments inside your hospital

3.

Hospitals with which your ED is not affiliated

4.

Ambulatory providers outside your hospital

ALGLISTE

Text:

Medication allergy lists?
  Enter all that apply, separate with commas

1.

Hospitals with which your ED is affiliated

2.

Other departments inside your hospital

3.

Hospitals with which your ED is not affiliated

4.

Ambulatory providers outside your hospital

OBSUNITS

Text:

Does your ED have a physically separate observation or clinical decision unit?

1.

Yes

2.

No

3.

Unknown

OBSDECMD

Text:

What type of physicians make decisions for patients in this observation or clinical decision unit?
    Enter all that apply, separate with commas

1.

ED physicians

2.

Hospitalists

3.

Other physicians

4.

Unknown

BOARD

Text:

Are admitted ED patients ever "boarded" for more than 2 hours in the ED or the observation unit while waiting for an inpatient bed?

1.

Yes

2.

No

3.

Unknown

BOARDHOS

Text:

If the ED is critically overloaded, are admitted ED patients ever "boarded" in inpatient hallways or in another space outside the ED?

1.

Yes

2.

No

3.

Unknown

AMBDIV

Text:

Did your ED go on ambulance diversion in TOTHRDIV_FILL?

1.

Yes

2.

No

3.

Unknown

TOTHRDIV

Text:

What is the total number of hours that your hospital's ED was on ambulance diversion in TOTHRDIV_FILL?
     Enter CTRL-D if data not available

REGDIV

Text:

Is ambulance diversion actively managed on a regional level versus each hospital adopting diversion if and when it chooses?

1.

Yes

2.

No

3.

Unknown

ADMDIV

Text:

Does your hospital continue to admit elective or scheduled surgery cases when the ED is on ambulance diversion?

1.

Yes

2.

No

3.

Unknown

NUMSTATX

Text:

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.
              Enter CTRL-D if data not available

NUMOTHTX

Text:

As of last week, how many other 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.
            Enter CTRL-D if data not available

EDSPACES

Text:

In the last two years, did your ED increase the number of standard treatment spaces?

1.

Yes

2.

No

3.

Unknown

PHYSSPACE

Text:

In the last two years, did your ED's physical space expand?

1.

Yes

2.

No

3.

Unknown

EXPAND

Text:

Do you have plans to expand your ED's physical space within the next two years?

1.

Yes

2.

No

3.

Unknown

BEDREG

Text:

Does your ED use -   Bedside registration?

1.

Yes

2.

No

3.

Unknown

KIOSELCHK

Text:

Does your ED use -   Kiosk self check-in?

1.

Yes

2.

No

3.

Unknown

IMBED

Text:

Does your ED use -   Immediate bedding (no triage when ED is not at capacity)?

1.

Yes

2.

No

3.

Unknown

ADVTRIAG

Text:

Does your ED use -   Advanced triage (triage-based care) protocols?

1.

Yes

2.

No

3.

Unknown

PHYSPRACTRIA

Text:

Does your ED use -   Physician/Practitioner at triage?

1.

Yes

2.

No

3.

Unknown

CATRIAGE

Text:

Does your ED use -   Computer-assisted triage?

1.

Yes

2.

No

3.

Unknown

FASTTRAK

Text:

Does your ED use -   Separate fast track unit for nonurgent care?

1.

Yes

2.

No

3.

Unknown

EDPTOR

Text:

Does your ED use -   Separate operating room dedicated to ED patients?

1.

Yes

2.

No

3.

Unknown

DASHBORD

Text:

Does your ED use -   Electronic dashboard (i.e., displays updated patient information
   and integrates multiple data sources)?

1.

Yes

2.

No

3.

Unknown

RFID

Text:

Does your ED use -   Radio frequency identification (RFID) tracking (i.e., shows exact location of patients, caregivers, and equipment)?

1.

Yes

2.

No

3.

Unknown

WIRELESS

Text:

Does your ED use -   Wireless communication devices by providers?

1.

Yes

2.

No

3.

Unknown

ZONENURS

Text:

Does your ED use -   Zone nursing (i.e., all of a nurse's patients are located in one area)?

1.

Yes

2.

No

3.

Unknown

POOLNURS

Text:

Does your ED use -   Pool nurses (i.e., nurses that can be pulled to the ED to respond to surges in demand)?

1.

Yes

2.

No

3.

Unknown

ESA_NAME

Text:

*** SHOW ONLY **

ESA_TYPE

Text:

** SHOW ONLY **

1.

General

2.

Adult

3.

Pediatric

4.

Urgent care/Fast track

5.

Psychiatric

6.

Other

ESA_EVISITS

Text:

** SHOW ONLY **

ESA_ONSITE

Text:

  Is (ESA name) on-site?

1.

Yes

2.

No

ESA_STRET

Text:

What is (ESA name)'s address?

ESA_PHONE

Text:

What is (ESA name)'s telephone number?

ESA_CONTACT

Text:

  Enter ESA contact person's name       

INTRO_OPD

Text:

  If necessary, introduce yourself and explain the survey using the hospital administrator script
  Explain that in order to develop a sampling plan, you would like to collect
    more specific information about this hospital's outpatient department and need about 30 minutes of their time.

CLIN_NAME

Text:

(What is the name of the (first/next) clinic? /Are there any other clinics?)
             Enter 999 for no more. Enter XXX if clinic is not listed

CLIN_GROUP

Text:

What is (Clinic Name)'s specialty group?

1.

General Medicine

2.

Surgery

3.

Pediatrics

4.

Obstetrics/Gynecology

5.

Substance Abuse

6.

Other

7.

Out of scope

CLIN_EVISITS

Text:

What is the expected number of visits from (Reporting period begin date) to (Reporting period end date) for (Clinic Name)?

EBILLRECO

Text:

Now I would like to ask you some questions about your OPD.

 If clinics within the OPD vary with respect to their use of the EHR/EMR systems, then ask these questions of the clinic with the largest number of expected visits during the reporting period.

Does your OPD submit any CLAIMS electronically (electronic billing)?

1.

Yes

2.

No

3.

Don't know

EINSELIGO/EINSO

Text:

Does your OPD verify an individual patient's insurance eligibility electronically? 
       Read answer categories out loud

1.

Yes, with a stand-alone practice management system

2.

Yes, with an EMR/EHR system

3.

Yes, using another electronic system

4.

No

5.

Unknown

EBILLRECO

Text:

Now I would like to ask you some questions about your OPD.

 If clinics within the OPD vary with respect to their use of the EHR/EMR systems, then ask these questions of the clinic with the largest number of expected visits during the reporting period.
Does your OPD submit any CLAIMS electronically (electronic billing)?

1.

Yes

2.

No

3.

Unknown

EINSO

Text:

Does your OPD verify an individual patient's insurance eligibility electronically?

1.

Yes

2.

No

3.

Unknown

EINSHOWO

Text:

How does your OPD electronically verify an individual patient's insurance eligibility? Is it through an EHR/EMR system, a stand-alone practice management system, or some other electronic system?
       Read answer categories out loud

1.

Yes, with a stand-alone practice management system

2.

Yes, with an EMR/EHR system

3.

Yes, using another electronic system

4.

No

5.

Unknown

EINSFASTO

Text:

When your staff electronically verifies a patient's insurance eligibility, do you usually get results back before the patient leaves the OPD?

1.

Yes

2.

No

3.

Unknown

EMEDRECO

Text:

Does your OPD use an electronic MEDICAL record (EMR) or electronic HEALTH record (EHR) system?  Do not include billing record systems.
  Read answer categories out loud

1.

Yes, all electronic

2.

Yes, part paper and part electronic

3.

No

4.

Unknown

EHRINSYRO

Text:

In which year did your OPD install the EMR/EHR system?

EHRNAMO

Text:

What is the name of your current EMR/EHR system?

1.

Allscripts

2.

Cerner

3.

eClinicalWorks

4.

Epic

5.

GE/Centricity

6.

Greenway Medical

7.

McKesson/Practice Partner

8.

NextGen

9.

Sage

10.

Other - Specify

11.

Unknown

EHRNAMO_SP

Description:

Other-Specify name of EHR/EMR system

Other-Specify name of EHR/EMR system

Text:

  Enter name of EMR/EHR system

EHRINSO

Text:

Does your OPD have plans for installing a new EMR/EHR system within the next 18 months?

1.

Yes

2.

No

3.

Maybe

4.

Unknown

EDEMOGO

Text:

Indicate whether your OPD has each of the following computerized capabilities.  Does your OPD have a computerized system for:
   Recording patient history and demographic information?

1.

Yes, used routinely

2.

Yes, but not used routinely

3.

Yes, but turned off or not used

4.

No

5.

Unknown

EPROLSTO

Text:

Does this include a patient problem list?

1.

Yes, used routinely

2.

Yes, but not used routinely

3.

Yes, but turned off or not used

4.

No

5.

Unknown

EVITALO

Text:

Recording and charting vital signs?

1.

Yes, used routinely

2.

Yes, but not used routinely

3.

Yes, but turned off or not used

4.

No

5.

Unknown

ESMOKEO

Text:

Recording patient smoking status?

1.

Yes, used routinely

2.

Yes, but not used routinely

3.

Yes, but turned off or not used

4.

No

5.

Unknown

EPNOTESO

Text:

   Recording clinical notes?

1.

Yes, used routinely

2.

Yes, but not used routinely

3.

Yes, but turned off or not used

4.

No

5.

Unknown

EMEDALGO

Text:

Do they include a comprehensive list of the patient's medications and allergies?

1.

Yes, used routinely

2.

Yes, but not used routinely

3.

Yes, but turned off or not used

4.

No

5.

Unknown

ECPOEO

Text:

Ordering prescriptions?

1.

Yes, used routinely

2.

Yes, but not used routinely

3.

Yes, but turned off or not used

4.

No

5.

Unknown

ESCRIPO

Text:

Are prescriptions sent electronically to the pharmacy?

1.

Yes, used routinely

2.

Yes, but not used routinely

3.

Yes, but turned off or not used

4.

No

5.

Unknown

ERXWHOO/ EHRWHOO

Text:

At your OPD, when orders for prescriptions are submitted electronically, are they submitted by the prescribing practitioner, or by someone else?

Enter all that apply, separate with commas

1.

Prescribing practitioner

2.

Someone else

3.

Unknown

EWARNO

Text:

Are warnings of drug interactions or contraindications provided?

1.

Yes, used routinely

2.

Yes, but not used routinely

3.

Yes, but turned off or not used

4.

No

5.

Unknown

EREMINDO

Text:

Indicate whether your OPD has each of the following computerized capabilities.  Does your OPD have a computerized system for:

Providing reminders for guideline-based interventions or screening tests?

1.

Yes, used routinely

2.

Yes, but not used routinely

3.

Yes, but turned off or not used

4.

No

5.

Unknown

ESETSO

Text:

Providing standard order sets related to a particular condition or procedure?

1.

Yes, used routinely

2.

Yes, but not used routinely

3.

Yes, but turned off or not used

4.

No

5.

Unknown

ECTOEO

Text:

Ordering lab tests?

1.

Yes, used routinely

2.

Yes, but not used routinely

3.

Yes, but turned off or not used

4.

No

5.

Unknown

EORDERO

Text:

Are orders sent electronically?

1.

Yes, used routinely

2.

Yes, but not used routinely

3.

Yes, but turned off or not used

4.

No

5.

Unknown

ELABWHOO

Text:

At your OPD, when orders for lab tests are submitted electronically, are they submitted by the prescribing practitioner, or by someone else?

Enter all that apply, separate with commas

1.

Prescribing practitioner

2.

Someone else

3.

Unknown

ERESULTO

Text:

Indicate whether your OPD has each of the following computerized capabilities.  Does your OPD have a computerized system for:

Viewing lab results?

1.

Yes, used routinely

2.

Yes, but not used routinely

3.

Yes, but turned off or not used

4.

No

5.

Unknown

EGRAPHO

Text:

Can the EHR/EMR automatically graph a specific patient's lab results over time?

1.

Yes, used routinely

2.

Yes, but not used routinely

3.

Yes, but turned off or not used

4.

No

5.

Unknown

EIMGRESO

Text:

Indicate whether your OPD has each of the following computerized capabilities.  Does your OPD have a computerized system for:

Viewing imaging results? 

1.

Yes, used routinely

2.

Yes, but not used routinely

3.

Yes, but turned off or not used

4.

No

5.

Unknown

EQOCO

Text:

Viewing data on quality of care measures?

1.

Yes, used routinely

2.

Yes, but not used routinely

3.

Yes, but turned off or not used

4.

No

5.

Unknown

ECQMO

Text:

Reporting clinical quality measures to federal or state agencies (such as CMS or Medicaid)?

1.

Yes, used routinely

2.

Yes, but not used routinely

3.

Yes, but turned off or not used

4.

No

5.

Unknown

EGENLISTO

Text:

Generating lists of patients with particular health conditions?

1.

Yes, used routinely

2.

Yes, but not used routinely

3.

Yes, but turned off or not used

4.

No

5.

Unknown

EIMMREGO

Text:

Electronic reporting to immunization registries? 

1.

Yes, used routinely

2.

Yes, but not used routinely

3.

Yes, but turned off or not used

4.

No

5.

Unknown

EMUREPO

Text:

Is the electronic reporting to immunization registries reported in standards specified by Meaningful Use criteria?

1.

Yes, used routinely

2.

Yes, but not used routinely

3.

Yes, but turned off or not used

4.

No

5.

Unknown

ESUMO

Text:

Indicate whether your OPD has each of the following computerized capabilities.  Does your OPD have a computerized system for:
   Providing patients with clinical summaries for each visit?

1.

Yes, used routinely

2.

Yes, but not used routinely

3.

Yes, but turned off or not used

4.

No

5.

Unknown

EMSGO

Text:

Exchanging secure messages with patients?

1.

Yes, used routinely

2.

Yes, but not used routinely

3.

Yes, but turned off or not used

4.

No

5.

Unknown

EHLTHINFOO

Text:

Providing patients with an electronic copy of their health information?

1.

Yes, used routinely

2.

Yes, but not used routinely

3.

Yes, but turned off or not used

4.

No

5.

Unknown

EXCHSUMO/ESHAREO

Text:

Does your OPD share any patient health information electronically (not fax) with other providers, including hospitals, ambulatory providers, or labs?

1.

Yes

2.

No

EXCHSUM1O/ESHAREHOWO

Text:

How does your OPD electronically share patient health information?
    Enter all that apply, separate with commas

1.

EHR/EMR

2.

Web portal (separate from EHR/EMR)

3.

Other electronic method: ___________________

LABRESO

Text:

Please indicate whether your OPD electronically (not fax) shares each of the following types of health data and with which types of health care providers.
Lab results?
  Enter all that apply, separate with commas

1.

Hospitals with which your OPD is affiliated

2.

Other departments inside your hospital

3.

Hospitals with which your OPD is not affiliated

4.

Ambulatory providers outside your hospital

IMAGREPO

Text:

Imaging reports?
  Enter all that apply, separate with commas

1.

Hospitals with which your OPD is affiliated

2.

Other departments inside your hospital

3.

Hospitals with which your OPD is not affiliated

4.

Ambulatory providers outside your hospital

PTPROBO

Text:

Patient problem lists?
  Enter all that apply, separate with commas

1.

Hospitals with which your OPD is affiliated

2.

Other departments inside your hospital

3.

Hospitals with which your OPD is not affiliated

4.

Ambulatory providers outside your hospital

MEDLISTO

Text:

Medication lists?
  Enter all that apply, separate with commas

1.

Hospitals with which your OPD is affiliated

2.

Other departments inside your hospital

3.

Hospitals with which your OPD is not affiliated

4.

Ambulatory providers outside your hospital

ALGLISTO

Text:

Medication allergy lists?
  Enter all that apply, separate with commas

1.

Hospitals with which your OPD is affiliated

2.

Other departments inside your hospital

3.

Hospitals with which your OPD is not affiliated

4.

Ambulatory providers outside your hospital

CLIN_NAME

Text:

*** SHOW ONLY **

CLIN_GROUP

Text:

** SHOW ONLY **

1.

General Medicine

2.

Surgery

3.

Pediatrics

4.

Obstetrics/Gynecology

5.

Substance Abuse

6.

Other

7.

Out of scope

CLIN_EVISITS

Text:

** SHOW ONLY **

CLIN_STRET

Text:

What is (Clinic Name)'s address?
    Enter number and street.

CLIN_CONTACT

Text:

  Enter clinic director/contact person's name       

TE

Text:

** NOT DISPLAYED **

RS

Text:

** NOT DISPLAYED **

AU_TYPE

Text:

** NON_DISPLAYED **

TOT_GOODCLIN

Text:

** NOT Displayed **

ASL_INTRO

• Text: If necessary, introduce yourself and explain the survey using the hospital administrator script

• Text: Explain that in order to develop a sampling plan, you would like to collect more specific information about this hospital’s ambulatory surgery locations and need about 20 minutes of their time

Text:

To develop the sampling plan, I would like to (collect/verify) more specific information about this facility's ambulatory surgery (centers/locations).
We are interested in the following types of (centers/locations):
General or main operating rooms                 Endoscopy rooms
Dedicated ambulatory surgery rooms          Cardiac catheterization labs
Satellite operating rooms                               Laser procedures rooms
Cystoscopy rooms                                           Pain block rooms

1.

Continue

2.

No in-scope locations

ASL_NUM

Text:

** SHOW ONLY **

ASL_NAME

Text:

( What is the name of the (first/next) ambulatory surgery location? /Are there any other ambulatory surgery locations?)
       Enter only IN_SCOPE ASLs   (Press F1 for in-scope (centers/locations)).  Include any ASLs that are located in satellite facilities

ASL_SPEC_GRP

Text:

What is ASL Name's specialty group?

1.

General

2.

Multi-specialty

3.

Gastroenterology

4.

Ophthalmology

5.

Orthopedics

6.

Pain Block

7.

Plastic Surgery

8.

Urology

9.

Other specialty

ASL_EVISITS

Text:

What is the expected number of ambulatory (outpatient) surgery cases for ASL Name from (Reporting period begin date) to (Reporting period end date)?

I_ASL

Text:

** Not Displayed **

TOT_GOODASL

Text:

** NOT Displayed **

ANYMORE_ASLS

Text:

  The max of 15 ASLs were entered. Are there any more ASLs?

1.

Yes

2.

No

EXTRA_ASLS

Text:

  How many other ASLs are there?

TOT_GOODASL2

Text:

** NOT Displayed **

CHECK_EVISITS

Text:

You have indicated that none of your ambulatory surgery (centers/locations) will be seeing patients from (Reporting period begin date) to (Reporting period end date).
Is that correct?

1.

Yes

2.

No

THANK_INELIG

Text:

Since there are no in-scope ambulatory surgery (centers/locations) for (facility name), it should not have been chosen for our survey. Thank you very much for your cooperation.

ASCLISTA

Text:

Now I have some questions about generating a report for all ambulatory surgery patients for sampling. Would you or your IT staff be able to generate a single list of ambulatory surgery cases for any of the following (centers/locations)? 
(Name of all ASLs)

1.

Yes

2.

No - ONLY 2 LOGS

3.

No - More than 2 logs

ASCLISTB

Text:

For which of these (centers/locations) can lists be combined? 
        Enter all that apply, separate with commas

1.

ASL_NAME [1]

2.

ASL_NAME [2]

3.

ASL_NAME [3]

4.

ASL_NAME [4]

5.

ASL_NAME [5]

6.

ASL_NAME [6]

7.

ASL_NAME [7]

8.

ASL_NAME [8]

9.

ASL_NAME [9]

10.

ASL_NAME [10]

11.

ASL_NAME [11]

12.

ASL_NAME [12]

13.

ASL_NAME [13]

14.

ASL_NAME [14]

15.

ASL_NAME [15]

IT_CNAME

Text:

What is the name of the IT contact?

IT_CTITLE

Text:

What is (IT contact name)'s title?

IT_CSTRET

Text:

What is (IT contact name)'s address?
         Enter number and street or press enter if same

AU_NUMBER

Text:

  Assign AU number
    Assign the same AU number to each (center/location) where the ambulatory surgery cases can be combined into the one listing.

EBILLRECA

Text:

Now I would like to ask you some questions about your ASL.

Does your ASL submit any CLAIMS electronically (electronic billing)?

1.

Yes

2.

No

3.

Unknown

EINSA

Text:

Does your ASL verify an individual patient's insurance eligibility electronically?

1.

Yes

2.

No

3.

Unknown

EINSHOWA

Text:

How does your ASL electronically verify an individual patient's insurance eligibility? Is it through an EHR/EMR system, a stand-alone practice management system, or some other electronic system?
       Read answer categories out loud

1.

Yes, with a stand-alone practice management system

2.

Yes, with an EMR/EHR system

3.

Yes, using another electronic system

4.

No

5.

Unknown

EINSFASTA

Text:

When your staff electronically verifies a patient's insurance eligibility, do you usually get results back before the patient leaves the ASL?

1.

Yes

2.

No

3.

Unknown

EMEDRECA

Text:

Does your ASL use an electronic MEDICAL record (EMR) or electronic HEALTH record (EHR) system?  Do not include billing record systems.
  Read answer categories out loud

1.

Yes, all electronic

2.

Yes, part paper and part electronic

3.

No

4.

Unknown

EHRINSYRA

Text:

In which year did your ASL install the EMR/EHR system?

EHRNAMA

Text:

What is the name of your current EMR/EHR system?

1.

Allscripts

2.

Cerner

3.

eClinicalWorks

4.

Epic

5.

GE/Centricity

6.

Greenway Medical

7.

McKesson/Practice Partner

8.

NextGen

9.

Sage

10.

Other - Specify

11.

Unknown

EHRNAMA_SP

Description:

Other-Specify name of EHR/EMR system

Other-Specify name of EHR/EMR system

Text:

  Enter name of EMR/EHR system

EHRINSA

Text:

Does your ASL have plans for installing a new EMR/EHR system within the next 18 months?

1.

Yes

2.

No

3.

Maybe

4.

Unknown

EDEMOGA

Text:

Indicate whether your ASL has each of the following computerized capabilities.  Does your ASL have a computerized system for:
   Recording patient history and demographic information?

1.

Yes, used routinely

2.

Yes, but not used routinely

3.

Yes, but turned off or not used

4.

No

5.

Unknown

EPROLSTA

Text:

Does this include a patient problem list?

1.

Yes, used routinely

2.

Yes, but not used routinely

3.

Yes, but turned off or not used

4.

No

5.

Unknown

EVITALA

Text:

Recording and charting vital signs?

1.

Yes, used routinely

2.

Yes, but not used routinely

3.

Yes, but turned off or not used

4.

No

5.

Unknown

ESMOKEA

Text:

Recording patient smoking status?

1.

Yes, used routinely

2.

Yes, but not used routinely

3.

Yes, but turned off or not used

4.

No

5.

Unknown

EPNOTESA

Text:

   Recording clinical notes?

1.

Yes, used routinely

2.

Yes, but not used routinely

3.

Yes, but turned off or not used

4.

No

5.

Unknown

EMEDALGA

Text:

Do they include a comprehensive list of the patient's medications and allergies?

1.

Yes, used routinely

2.

Yes, but not used routinely

3.

Yes, but turned off or not used

4.

No

5.

Unknown

ECPOEA

Text:

Ordering prescriptions?

1.

Yes, used routinely

2.

Yes, but not used routinely

3.

Yes, but turned off or not used

4.

No

5.

Unknown

ESCRIPA

Text:

Are prescriptions sent electronically to the pharmacy?

1.

Yes, used routinely

2.

Yes, but not used routinely

3.

Yes, but turned off or not used

4.

No

5.

Unknown

ERXWHOA/ EHRWHOA

Text:

At your ASL, when orders for prescriptions are submitted electronically, are they submitted by the prescribing practitioner, or by someone else?          Enter all that apply, separate with commas

1.

Prescribing practitioner

2.

Someone else

3.

Unknown

EWARNA

Text:

Are warnings of drug interactions or contraindications provided?

1.

Yes, used routinely

2.

Yes, but not used routinely

3.

Yes, but turned off or not used

4.

No

5.

Unknown

EREMINDA

Text:

Indicate whether your ASL has each of the following computerized capabilities.  Does your ASL have a computerized system for:

Providing reminders for guideline-based interventions or screening tests?

1.

Yes, used routinely

2.

Yes, but not used routinely

3.

Yes, but turned off or not used

4.

No

5.

Unknown

ESETSA

Text:

Providing standard order sets related to a particular condition or procedure?

1.

Yes, used routinely

2.

Yes, but not used routinely

3.

Yes, but turned off or not used

4.

No

5.

Unknown

ECTOEA

Text:

Ordering lab tests?

1.

Yes, used routinely

2.

Yes, but not used routinely

3.

Yes, but turned off or not used

4.

No

5.

Unknown

EORDERA

Text:

Are orders sent electronically?

1.

Yes, used routinely

2.

Yes, but not used routinely

3.

Yes, but turned off or not used

4.

No

5.

Unknown

ELABWHOA

Text:

At your ASL, when orders for lab tests are submitted electronically, are they submitted by the prescribing practitioner, or by someone else?

Enter all that apply, separate with commas

1.

Prescribing practitioner

2.

Someone else

3.

Unknown

ERESULTA

Text:

Indicate whether your ASL has each of the following computerized capabilities.  Does your ASL have a computerized system for:

Viewing lab results?

1.

Yes, used routinely

2.

Yes, but not used routinely

3.

Yes, but turned off or not used

4.

No

5.

Unknown

EGRAPHA

Text:

Can the EHR/EMR automatically graph a specific patient's lab results over time?

1.

Yes, used routinely

2.

Yes, but not used routinely

3.

Yes, but turned off or not used

4.

No

5.

Unknown

EIMGRESA

Text:

Indicate whether your ASL has each of the following computerized capabilities.  Does your ASL have a computerized system for:

Viewing imaging results? 

1.

Yes, used routinely

2.

Yes, but not used routinely

3.

Yes, but turned off or not used

4.

No

5.

Unknown

EQOCA

Text:

Viewing data on quality of care measures?

1.

Yes, used routinely

2.

Yes, but not used routinely

3.

Yes, but turned off or not used

4.

No

5.

Unknown

ECQMA

Text:

Reporting clinical quality measures to federal or state agencies (such as CMS or Medicaid)?

1.

Yes, used routinely

2.

Yes, but not used routinely

3.

Yes, but turned off or not used

4.

No

5.

Unknown

EGENLISTA

Text:

Generating lists of patients with particular health conditions?

1.

Yes, used routinely

2.

Yes, but not used routinely

3.

Yes, but turned off or not used

4.

No

5.

Unknown

EIMMREGA

Text:

Electronic reporting to immunization registries? 

1.

Yes, used routinely

2.

Yes, but not used routinely

3.

Yes, but turned off or not used

4.

No

5.

Unknown

EMUREPA

Text:

Is the electronic reporting to immunization registries reported in standards specified by Meaningful Use criteria?

1.

Yes, used routinely

2.

Yes, but not used routinely

3.

Yes, but turned off or not used

4.

No

5.

Unknown

ESUMA

Text:

Indicate whether your ASL has each of the following computerized capabilities.  Does your ASL have a computerized system for:
   Providing patients with clinical summaries for each visit?

1.

Yes, used routinely

2.

Yes, but not used routinely

3.

Yes, but turned off or not used

4.

No

5.

Unknown

EMSGA

Text:

Exchanging secure messages with patients?

1.

Yes, used routinely

2.

Yes, but not used routinely

3.

Yes, but turned off or not used

4.

No

5.

Unknown

EHLTHINFOA

Text:

Providing patients with an electronic copy of their health information?

1.

Yes, used routinely

2.

Yes, but not used routinely

3.

Yes, but turned off or not used

4.

No

5.

Unknown

EXCHSUMA/ESHAREA

Text:

Does your ASL share any patient health information electronically (not fax) with other providers, including hospitals, ambulatory providers, or labs?

1.

Yes

2.

No

EXCHSUM1A/ESHAREHOWA

Text:

How does your ASL electronically share patient health information?
    Enter all that apply, separate with commas

1.

EHR/EMR

2.

Web portal (separate from EHR/EMR)

3.

Other electronic method: ___________________

LABRESA

Text:

Please indicate whether your ASL electronically (not fax) shares each of the following types of health data and with which types of health care providers.
Lab results?
  Enter all that apply, separate with commas

1.

Hospitals with which your ASL is affiliated

2.

Other departments inside your hospital

3.

Hospitals with which your ASL is not affiliated

4.

Ambulatory providers outside your hospital

IMAGREPA

Text:

Imaging reports?
  Enter all that apply, separate with commas

1.

Hospitals with which your ASL is affiliated

2.

Other departments inside your hospital

3.

Hospitals with which your ASL is not affiliated

4.

Ambulatory providers outside your hospital

PTPROBA

Text:

Patient problem lists?
  Enter all that apply, separate with commas

1.

Hospitals with which your ASL is affiliated

2.

Other departments inside your hospital

3.

Hospitals with which your ASL is not affiliated

4.

Ambulatory providers outside your hospital

MEDLISTA

Text:

Medication lists?
  Enter all that apply, separate with commas

1.

Hospitals with which your ASL is affiliated

2.

Other departments inside your hospital

3.

Hospitals with which your ASL is not affiliated

4.

Ambulatory providers outside your hospital

ALGLISTA

Text:

Medication allergy lists?
  Enter all that apply, separate with commas

1.

Hospitals with which your ASL is affiliated

2.

Other departments inside your hospital

3.

Hospitals with which your ASL is not affiliated

4.

Ambulatory providers outside your hospital

ASL_EVISITS

Text:

** SHOW ONLY **

ASL_ONSITE

Text:

  Is [ASL Name] on-site?

1.

Yes

2.

No

ASL_STRET

Text:

What is [ASL Name's] address or the address where the abstractions will be done?
            Enter number and street.

ASL_STRET2

Text:

What is [ASL Name's] address or the address where the abstractions will be done?
           Enter the second line of address or press enter if same/none

ASL_CITY

Text:

What is [ASL Name's] address or the address where the abstractions will be done?
          Enter city.

ASL_STATE

Text:

What is [ASL Name's] address or the address where the abstractions will be done?
          Enter state.

ASL_ZIP

Text:

What is [ASL Name's] address or the address where the abstractions will be done?
         Enter zip code.

ASL_PHONE

Text:

What is [ASL Name's] telephone number or the telephone number where the abstractions will be done?

ASL_CONTACT

Text:

  Enter ambulatory surgery (center/location) contact person's name       

EXIT_REFUSAL

Text:

  Are you exiting this case because of a refusal?

1.

Yes

2.

No

CALLBACKNOTES

Text:

I'd like to schedule a DATE to (conduct/complete) the interview.
What DATE AND TIME would be best to visit again?
           Today is:  ^IntDate                        

THANKCB

Text:

Thank you. I will call/come back at the time suggested
      Revisit   (Callback information)

FOLLOW_UP

Text:

  The following departments have refused. Do you plan to follow-up on these department(s)?

1.

Yes, will follow-up on department(s)

2.

No , wrap case up

CALLBACKNOTES

Text:

I'd like to schedule a DATE to (conduct/complete) the interview. What DATE AND TIME would be best to visit again?    Today is:  ^IntDate                       

THANKCB

Text:

Thank you. I will call/come back at the time suggested   Revisit   (Callback information)

THANKYOU

Text:

This concludes the interview.  Thank you for your patience, and for taking the time to answer our questions.

SET_REINT

Text:

** Non Displayed **

HOSPREF

Text:

**  Not displayed **

ELIGED

Text:

  Does this hospital have an eligible ED?

1.

Yes

2.

No

VSED101

Text:

  Enter number of expected visits for the ED

VSEDLY

Text:

  Enter the number of visits to the department last year

ELIGOPD

Text:

  Does this hospital have an eligible OPD?

1.

Yes

2.

No

VSOPD101

Text:

  Enter number of expected visits for this OPD.

VSOPDLY

Text:

  Enter number of OPD visits last year

ELIGASC

Text:

  Does this hospital have an eligible ambulatory surgery center?

1.

Yes

2.

No

VSASC101

Text:

  Enter number of expected visits

VSASCLY

Text:

  Enter number of ambulatory surgery visits last year

Text:

After completion of the pretest, ask each of the respondents (e.g., hospital administrator, ED director, OPD director, ambulatory surgery director), if he/she would be willing to participate in the survey in 2013)

PARTHOSP Text: Now that your hospital has completed the pretest, would your hospital be willing to participate in the ambulatory component of the National Hospital Care Survey beginning in 2013?

1. Yes

2. Maybe

3. No

PARTED Text: Now that your ED has completed the pretest, would your ED be willing to participate in the emergency department component of the National Hospital Care Survey beginning in 2013?

1. Yes

2. Unsure

3. No

PARTOPD Text: Now that your OPD has completed the pretest, would your OPD be willing to participate in the outpatient department component of the National Hospital Care Survey beginning in 2013?

1. Yes

2. Unsure

3. No

PARTASC Text: Now that your ambulatory surgery locations have completed the pretest, would these locations be willing to participate in the ambulatory surgery component of the full National Hospital Care Survey beginning in 2013?

1. Yes, all

2. Yes, some

3. Unsure

4. No

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