Attachment A -- Introductory Pages of Website

CONSUMER REPORTING SYSTEM FOR PATIENT SAFETY: INTRODUCTORY PAGES FOR WEBSITE

Introductory pages for Website

[First screenCover Page of Website]

Welcome to the Consumer Reporting System for Patient Safety

The purpose of this system is to make health care safer. It is a new system. Researchers are testing it now in your town.

Here is how the system works. “Consumers” are the people who use health care services. They are people like you and your family and friends. You and other consumers will tell us about your health care safety concerns. Researchers will use a computer to put together all of the information they get from consumers. Then they will write a report about what they learn. The researchers will give the report to doctors’ offices, hospitals, and pharmacies so they can make health care safer. (No personal information is in the research report. Your information will be private.)

What You Can Report

Health care safety concerns. We want to hear about anything that happens with your doctor or hospital or pharmacy that worries you because you think it isn’t safe. Maybe there was a mistake and you were harmed. Or maybe you were almost harmed. For example, you might be concerned if you or a family member:

• Receive the wrong medicine or the wrong dose of medicine

• Get an infection after having an operation or other procedure

• Get the wrong diagnosis

• Have the wrong surgery performed

What NOT to Report

Complaints about bills and insurance. (Link to” “Frequently Asked Questions – What is a grievance?”)

Complaints about parking, hospital food, or long wait times in a doctor’s office.

(Link to” “Frequently Asked Questions – What is a service complaint?”)

Click here to find out about resources in your area for reporting complaints.

How to Report

Online. Click here to report a patient safety concern online [Takes respondent to Second page of website]

By Phone. Please call 1-800-XXX-XXXX

Para reporter en español, llame al 1-800-XXX-XXXX

Frequently Asked Questions (FAQs) about the Consumer Reporting System for Patient Safety

PROGRAMMER NOTE: TEXT FOR THESE BULLET POINT ITEMS FOUND IN FILE “FAQ’s 6-3-2012” PROGRAM FAQ IMMEDIATELY BELOW SO THAT WHEN ITEM IS “CLICKED” OR CHOSEN, REPORTER JUMPS TO THAT SECTION OF FAQ.

• What is this system for?

• What is a health care safety concern?

• What is a grievance?

• What is a service complaint?

• What will you ask me to do?

• Who is developing this system?

• How are people recruited or how can someone find out about this reporting system?

• Why should I participate?

• What will I get if I report a concern through the system?

• What are the risks of reporting a concern through this system?

• Do I have to participate?

• How will you protect my privacy?

• Will my report be secure when submitted over the Internet?

• What browser and technical requirements are needed to use this online form?

• Where are the instructions for completing this form?

• Who can I call if I have technical difficulties submitting the form?

• Will I be able to print my form or save it on my own computer?

• Can I submit other documents using this online reporting form?

• How will I know that my report has been received?

• What if I want more information?

• What if I want to tell a different organization about my health care safety concerns?

The OMB Paperwork Reduction Act Statement

(The United States government Office of Management and Budget (OMB) requires this statement is on the web site. It explains how long the data collection procedures will maximally take and how we minimize paperwork.)

Public reporting burden for this collection of information is estimated to average 25 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. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to:

AHRQ Reports Clearance Officer, Attention: PRA
Paperwork Reduction Project (0935-XXXX)

AHRQ

540 Gaither Road, Room # 5036

Rockville, MD 20850

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.

[Second Page of Website=SCREENER]

Before you share your health care safety concern, please answer the questions below.

Eligibility

To be eligible to report, you must be 18 years old or older.

Are you 18 years old or older?

□_A Yes

□_B No  GO TO THANK1

Setting A Password So You Can Save Your Report and Finish it Later

Setting up a password requires you to provide an email address, but then allows you to save your work and come back later to finish and submit the report.

Would you like to set up the form so you can finish it later if you want to?

□_A Yes  [GO TO Third Page of website, LOG-EMAIL]

□_B No  [GO TO Fourth Page of website, POLICY]

[Third Page of Website]

>LOG-EMAIL<

To set up your form so you can come back to it and finish it later

Please type your email address here:

[FREE TEXT BOX WITH FORMAT _______________ @_______________. __________

]

Please type your email address again just to be safe:

[FREE TEXT BOX WITH FORMAT _______________ @_______________. __________

PROGRAMMER: IF THE TWO EMAILS DO NOT MATCH, DISPLAY ERROR BOX.

Please type a password here: [Password: FREE TEXT BOX. ALLOW 10]

Please confirm your password here: [Password: FREE TEXT BOX. ALLOW 10]

PROGRAMMER: IF THE TWO PASSWORDS DO NOT MATCH, DISPLAY ERROR BOX.

We will send you an email message shortly. Click on the link in the email message. This will tell us that we sent the message to the right email address. It sets up a link to your form so that you can come back to it later. Then please return to this website to continue working on your report.

[Fourth Page of Website]

>POLICY<

The Consumer Reporting System for Patient Safety (CRSPS) allows patients and their families and friends to voluntarily report on the safety of their health care. CRSPS staff will use the information that you and others give us to understand patients’ concerns. CRSPS staff are researchers from the RAND Corporation, Brigham and Women’s Hospital and Dana-Farber Cancer Institute, and the ECRI Institute.

If you agree to give us information about a safety concern, we will ask you if you or a family member have had safety concerns about your health care. If the answer is “Yes,” we will want to hear more. There are no right answers or wrong answers. We want to hear your opinions, and completing the questions should take about 15 minutes. You will be given the option to give us the contact information of any doctor, nurse, or other health care provider (or facility) that was involved in your concern. We will also give you the option to share your report with any doctor, nurse, or other health care provider (or facility) that was involved. You are able to choose to share a report without your name or one that includes your name. You can also choose to not provide any names or share your identity in any way. This would keep everything you say private.

With all of the reports collected, we will write a report about what we learn and give this report to doctors’ offices, hospitals, and pharmacies so they can make health care safer. (No personal information is in the research report. Your information will be private.) We hope that reports from consumers like you will make health care safer.

The Consumer Reporting System for Patient Safety was paid for by an agency that is part of the United States government. The agency is called the Agency for Healthcare Research and Quality. It has strict laws about protecting patients’ privacy.

Please read, then accept or decline:

I have read and understood the information that describes this data system. I promise that I am 18 years old and that I will give information that is true and complete. I give my permission to the CRSPS team to use my information as long as they do not share my name and other identifying information. I will not share my access to my report (e.g., passwords) with anyone. I understand that I will not be paid for my participation.

I understand my individual answers to the survey questions are strictly confidential and will not be seen by anyone outside the CRSPS team, unless during the reporting process I agree to allow the CRSPS team to share this information. This confidentiality is established by provisions in the AHRQ authorization legislation.

Accept  GO TO First page of the CRSPS Intake Form, SECTION 1]

Decline  GO TO THANKS2

TEXT FOR CASES THAT SHOULD EXIT:

THANKS1: Unfortunately, you must be at least 18 years old to report a safety concern.

>CASE SHOULD THEN EXIT<

THANKS2: Thank you for your time.

>CASE SHOULD THEN EXIT<