Annual Inpatient Hospital Interview

Attachment K: Annual Inpatient Hospital Interview

OMB No. 0920-0212; Expiration date XX/XX/XXXX

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 60 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 (0920-0212).

Part 1. Hospital Utilization Statistics

1. What is the number of currently staffed inpatient beds in this hospital, not including “newborn” bassinets?

Total staffed inpatient beds: _______

1a. If you submit data combined with other hospital(s), what is the number of currently staffed inpatient beds, not including “newborn” bassinets, for all the hospitals that report together?

Combined total staffed inpatient beds: _______

2. What was the average length of stay (in days) for inpatients in this hospital in calendar year 2012? _______

3. Please provide the hospital utilization statistics below for every month for calendar year 2012. If you submit data combined with another hospital, please provide the hospital utilization statistics for all the hospitals that report together. Also, please check the appropriate box to indicate to whom these statistics apply.

 This hospital only  Combined reporting hospital

NOTE: If you do not have information about discharges, please provide numbers for total admissions and births. Indicate that these are the numbers you are providing by checking this box:

 Information provided below is for admissions and births.

	Total inpatient discharges		Inpatient discharges (not including live births)		Total discharges of live births
January
February
March
April
May
June
July
August
September
October
November
December

Part 2. General Questions

4. What is the primary service type of this hospital?

• General acute care

• Specialty acute care hospital (e.g. surgical, maternity, cancer, heart, ENT, orthopedic, etc…)

• Children’s hospital (including general, orthopedic, ENT, cancer, heart, and other acute care)

• Psychiatric hospital (including children’s psychiatric and alcohol/chemical dependency)

• Long term acute care (including adult and children’s rehabilitation, chronic disease, TB)

5. Are there 6 or more hospital beds staffed for inpatient use at this hospital, not including “newborn” bassinets?

• Yes

• No

6. Was this hospital open for the full calendar year 2012?

• Yes

• No Please provide the dates the hospital was open for inpatient service in 2012: ______________________________________________

• Never open in 2012

7. In the past year, has this hospital merged with or separated from another hospital?

• Merger  Please continue with item 7a below.

• Separation Please continue with item 7a below.

• Neither Please proceed to item 8.

7a. Please provide the name(s) and address(es) of the other hospital(s) involved:

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________

7b. What is the primary service type(s) of the other hospital(s) involved? Check all that apply.

• General acute care

• Specialty hospital (e.g. surgical, maternity, cancer, heart, ENT, orthopedic, etc…)

• Children’s hospital (including general, orthopedic, ENT, cancer, heart, and other acute care)

• Psychiatric hospital (including children’s psychiatric and alcohol/chemical dependency)

• Long term acute care (including adult and children’s rehabilitation, chronic disease, TB)

8. Do you anticipate any significant changes in your discharge volume in the coming year (for example, opening a cardiac wing or closing a birthing center)?

• Yes  Please explain_____________________________________________

• No

Part 3. Data Reporting

9. When this hospital reports data to the State or to the hospital association, is the information solely for this hospital or are other hospital(s) included in the data submission?

• Solely for this hospital

• Combined with other hospital(s)  Please provide the name(s) of the other hospital(s):

__________________________________________________________________

__________________________________________________________________

10. Do the data you provide to us include records from your hospital only?

• Yes  Please proceed to item 11 below.

• No  Please continue with item 10a below.

• Don’t know

10a. Is it possible to identify the records from your hospital only as opposed to those from the other hospital(s) that report with you?

 Yes  No  Don’t know

11. Do the data you send include records for:

Discharges of patients paying their bills themselves (i.e. self-pay) Yes  No

If No, how many discharges were self-pay in 2012? _______

Discharges for charity patients Yes  No

If No, how many discharges were charity patients in 2012? _______

Discharges to court or law enforcement (e.g. inmates or prisoners) Yes  No

If No, how many of these discharges were not billed in 2012? _______

Discharges for any other groups of patients not billing to public or

private insurance (e.g. patients participating in research studies, etc)  Yes  No

If No, how many of these discharges were not billed in 2012? _______