Form #2 Form #2 Data Use Agreement

Nursing Home Survey on Patient Safety Culture Database
Data Use Agreement
Instructions
1. Westat has signed this agreement in its current form as presented to you. Any changes or
modifications to the agreement other than those required to complete the agreement such as
contact information will require review and execution, by both parties, of a new agreement.
2. Data collection vendors may not sign and submit this Data Use Agreement on behalf of a health
system or Nursing Home (even if they have been given permission by the health system or
Nursing Home to handle the actual submission of data). Only a duly appointed representative
from a health system or Nursing Home may sign this Data Use Agreement.
3. Please return this signed Data Use Agreement by mail, or fax a signed copy to:
Willow Burns
Westat
1600 Research Boulevard
Rockville, MD 20850
Fax: 1-888-852-8277 (toll free)
Phone: 1-888-324-9790 (toll free)
Email: [email protected]

Form Approved
OMB No. 0935-XXXX
Exp. Date XX/XX/20XX

Nursing Home Survey on Patient Safety Culture Database
Data Use Agreement
1.

This Data Use Agreement (DUA) is made by and between Westat and the organization named below (hereinafter termed
“Participating Organization”), which includes any nursing homes listed under item 11 on page 2 of this Data Use
Agreement.
Name of Nursing Home (or System/Chain Name if more than one nursing home is included in this DUA)

Street Address of Nursing Home (or System/Chain headquarters location)

City

State

Zip Code

VERY IMPORTANT: Type or write in the name of the Participating Organization above. If more than one nursing
home is represented, list the name of the overall system or chain above, and under item 11 on page 2 of this Data Use
Agreement, IDENTIFY EACH INDIVIDUAL NURSING HOME LOCATION for which data will be submitted.
2.

This DUA specifies the terms and conditions of Participating Organization’s submission of its Nursing Home Survey on
Patient Safety Culture data to Westat for participation in the Nursing Home Survey on Patient Safety Culture Comparative
Database (hereinafter termed the “Database”).

3.

The purpose of the Database is to establish a central repository of the Nursing Home Survey on Patient Safety Culture
survey data to facilitate comparisons across health care organizations. The Database will be populated with Nursing Home
Survey on Patient Safety Culture survey data through the voluntary participation of organizations that have implemented
the Nursing Home Survey on Patient Safety Culture survey and are willing to submit their Nursing Home Survey on
Patient Safety Culture survey data to Westat for inclusion in the Database.
The Database is funded by the Agency for Healthcare Research and Quality (AHRQ) under a contract and the Database is
managed and administered by Westat, a private research organization under contract with AHRQ. Westat will operate the
Database to comply with the provisions in this DUA. Within this framework, Westat will manage and administer the
Database using its discretion as necessary, and it will seek and be guided by the advice and counsel of the Surveys on
Patient Safety Culture Database Technical Expert Panel (TEP) established by Westat, in accordance with its contractual
obligations, to obtain Panel input throughout the design, development and administration of the Database. The TEP
consists of 12 representatives knowledgeable about hospital, medical office, nursing home, and pharmacy patient safety
and quality from various stakeholder organizations, research institutions, and selected health care systems as well as
government agencies concerned with patient safety and health care.

4.

Participating Organizations will provide their Nursing Home Survey on Patient Safety Culture survey data to the Database
for analysis and reporting according to the terms specified in this DUA. By agreeing to participate in the Database, each
Participating Organization agrees to make a good faith effort to provide data, as specified by the data specifications
outlined below, for inclusion in the Nursing Home Survey on Patient Safety Culture Comparative Database (this data being
collectively referred to as the “Data”), including:
a) A copy of the final Nursing Home Survey on Patient Safety Culture instrument(s) administered, including copies of
paper and/or web-based versions as applicable, showing all survey instructions and items administered. If more than
one version of the Nursing Home survey was administered, a copy of each Nursing Home survey instrument
administered must be provided with the corresponding results for each version of the survey instrument for which data
is submitted;
b) Participating Organization’s final, respondent-level Nursing Home Survey on Patient Safety Culture survey data, as
collected by Participating Organization itself or by a survey data collection vendor, according to the data specifications
outlined for the Database; and

Public reporting burden for this collection of information is estimated to average 3 minutes per response, the estimated time
required to complete the survey. 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: AHRQ
Reports Clearance Officer Attention: PRA, Paperwork Reduction Project (0935-XXXX) AHRQ, 540 Gaither Road, Room #
5036, Rockville, MD 20850.

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c) Selected organizational characteristics data (e.g., bed size, ownership, etc.) and background information related to
survey administration (e.g., mode of survey administration, dates of administration, sample size, response rate, etc.).
5. Westat agrees to establish appropriate and necessary administrative, technical, and physical procedures and safeguards to
protect the data. Only Westat and duly authorized representatives appointed by AHRQ will have access to the identifiable
source data provided by a Participating Organization. In addition, Westat will ensure appropriate staff training to protect
the confidentiality of the identifiable data and to prevent unauthorized access to it and any unauthorized use of it.
6.

Participating Organization’s Data will be accepted into the Database provided that the version of the Nursing Home Survey
on Patient Safety Culture administered by Participating Organization is deemed acceptable by Westat (i.e., not modified
substantially from the original Nursing Home survey instructions and items). Westat will promptly notify Participating
Organization of any problem, if any, with the survey version(s) administered or with the data submitted. If the survey
version administered is acceptable but the data submitted are problematic, Westat will make a good faith effort to work
with the Participating Organization to complete or correct the Data submission, but reserves the right to not include
incompatible or flawed data in the Database.

7. Participating Organization’s data files will be aggregated for comparative purposes along with other Participating
Organizations’ Data in the Database. Westat will produce a Nursing Home Survey on Patient Safety Culture Comparative
Database Report providing aggregate statistics on survey composite scores and items across all Participating Organizations
and across various subsets of Participating Organizations (e.g., bed size, ownership, etc.). The Report will not identify
individual Participating Organizations by name. Only aggregate data will be reported, and only when there are sufficient
data so that such aggregation will not permit the identification of Participating Organizations by other Participating
Organizations or the public. The Database Report will be made available to Participating Organizations and the public
through electronic media and at no charge. The Database Report will be in the public domain and may be reproduced
without permission.
8.

Westat may conduct psychometric analyses of the aggregate data to examine its distributional properties (variability,
missing data, skewness), and to assess the factor structure and reliability of the safety culture dimensions. In any data
analysis reports that may be produced, such reports will not identify individual Participating Organizations by name and
results will only be reported in a manner that will not permit the identification of Participating Organizations.

9.

Westat may grant access to Participating Organization’s data files for health care research purposes approved by AHRQ and
in accordance with the AHRQ confidentiality statute [at 42 USC 299c-3(c)] according to the following provisions:
a) Access to aggregate data files that do not identify individual Participating Organizations or permit reidentification
may be granted by Westat without the specific authorization of Participating Organizations whose data are included
as part of the aggregate data files. These data files may include variables describing the Participating Organization
according to types (e.g., bed size, ownership, etc.), provided the variables do not permit reidentification.
b) Access to data files specific to an identifiable Participating Organization may be approved only with the express
written authorization of the Participating Organization whose data files are requested. Researcher analyses of the data
files provided to researchers under these provisions and containing any identifying information, may not be released,
disclosed or made public by the researchers without the express written authorization of any Participating
Organizations that may be identified in the published research analysis.

10. Westat agrees to use the Data submitted by Participating Organization only for the purposes stated in this agreement.
11. If Participating Organization represents more than one nursing home, use the space below to TYPE OR WRITE
THE NAME OF EACH INDIVIDUAL NURSING HOME AND ITS ADDRESS, CITY AND STATE which is
represented by Participating Organization and therefore covered under this Data Use Agreement. Attach
additional sheet if necessary.
NAME(S) OF NURSING HOME(S) REPRESENTED

ADDRESS, CITY & STATE

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PLEASE SIGN, COMPLETE THE INFORMATION BELOW, AND FAX OR MAIL ALL PAGES OF THIS DATA
USE AGREEMENT BACK TO WESTAT.
The undersigned individual hereby attests that he/she is duly authorized to represent the Participating Organization and all
nursing homes listed under item 11, and in so doing, enters into this Data Use Agreement on behalf of the Participating
Organization and the nursing homes listed under item 11 and agrees to all the terms specified herein.
Name:
Title:

(Signature)

(Date)

Name and address of person from Participating Organization who should be sent the completed Data Use Agreement once it is
signed by Westat:
Name of contact (if different from above): Name of contact
Title (if different from above):
Address:

Phone number:
Fax number:
Email address:

THIS SECTION TO BE COMPLETED BY WESTAT AFTER IT RECEIVES PARTICIPATING ORGANIZATION’S
COMPLETE AND SIGNED DATA USE AGREEMENT.
The undersigned individual hereby attests that he/she is duly authorized to represent Westat in entering into this Data Use
Agreement and in agreeing to all the terms specified herein on their behalf.
W. Sherman Edwards
Vice-President, Associate Director at Westat
Surveys on Patient Safety Culture Project

(Signature)

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