Hospital Induction Interview

National Hospital Ambulatory Medical Care Survey

Attachment E - 2016 NHAMCS Induction Questions

Hospital Induction Interview

OMB: 0920-0278

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 0920-0278 can be found here:

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Attachment E: NHAMCS Hospital Induction Questionnaire
START
Universe:
Text:

CENSUS CAPI SYSTEM
NATIONAL HOSPITAL AMBULATORY MEDICAL CARE SURVEY
DATE: (current date)
Earliest Induction Date: (earliest Induction date)
(Reference week)

TIME: (time)
Reporting Period:

CASE STATUS IS: (inteview progress)
Press ALT-F9 to update Facility/facility contact information
Press ALT-F10 to update Department contact information
OMB No. 0920-0278; Expiration date 02/28/2018
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 D74, Atlanta, GA 30333, ATTN: PRA (0920-0278).

1.
2.
3.

Continue
Noninterview (Unable to locate, refusal, etc.)
Quit

Skip Instructions:

1: IF LST_MARK = 3 goto RO_RESOLUTION
ELSEIF LST_MARK = 4, 12 or 20 goto RO_PERMISS
ELSEIF LST_MARK = 5 or 14 goto RO_MOVER
ELSEIF LST_MARK = 16 goto RO_MERGSEP
ELSEIF LST_MARK = 18 AND (Current date before
STARTBYDATE) goto TOEARLY_INDUCTION
ELSEIF LST_MARK = 17, 18, 19 or 21 goto BlkInduct
ELSEIF LST_MARK = 22 goto BlkF9_DEPT
ELSE goto BlkTELSCR
2: IF LST_MARK = 3 goto RO_RESOLUTION
ELSEIF LST_MARK = 4, 12 or 20 goto RO_PERMISS
ELSEIF LST_MARK = 5 or 14 goto RO_MOVER
ELSEIF LST_MARK = 16 goto RO_MERGSEP
ELSE goto NONINT_TYPE
3: Exit instrument

NONINT_TYPE
Universe:

Text:

1.
2.
3.
4.
5.
6.
7.
Skip Instructions:

(START = 2 AND LST_MARK = EMPTY, 2, 6-11, 13, 15, 17-19, 21 or 22)
OR (RO_RESOLUTION = 2) OR (RO_MOVER = 2) OR
(RO_PERMISS = 3) OR (RO_MERGSEP = 3)
♦ Enter the type of noninterview

Unable to locate - await guidance
Name/address changed - await guidance
Closed - temporary
Closed - permanent
Permission needed before continuing interview
Potential Refusal - followup required
Refused (TRANSMIT)
1:

IF LST_MARK >= 11 then goto NONINT_CK
ELSE goto NONINT_NAME

2-7: Goto NONINT_NAME
INTRO_SCR
Universe:
Text:

(HELLO = 1 OR NEW_CONTACT = 2 OR SCREENER_PV = 1) AND
(LST_MARK < 11)
? [F1]
Hello,
This is ... from the U.S. Census Bureau. I'm calling for the Centers for
Disease Control and
Prevention concerning their study of hospital outpatient and emergency
departments and hospital-based ambulatory surgery locations.
You should have received a letter from Charles J. Rothwell, the Director
of the National Center for Health Statistics, describing the study.
You've probably also received a letter from the U.S. Census Bureau,
which is collecting the data for this study.
Did you receive the letter(s)?
♦ If "No" or "DK", offer to send or deliver another copy.

1.
2.
3.
Skip Instructions:
INTRO_SCR_PT
Universe:
Text:

Yes
No
Don't know
Goto INTROB

(HELLO = 1 OR NEW_CONTACT = 2 OR SCREENER_PV = 1) AND
(LST_MARK = 11-17)
? [F1]
Hello, this is ...... from the U.S. Census Bureau.
If necessary, introduce survey
We completed part of the interview for the National Hospital
Ambulatory Medical Care Survey and would like to finish it now.

1.
Skip Instructions:

Enter 1 to Continue
Goto INTROB

INTROB
Universe:
Text:

1.
2.
3.
Skip Instructions:

INTRO_SCR = 1-3, DK OR INTRO_SCR_PT = 1
♦
Is respondent ready to complete the interview?

Continue
Inconvenient time
Other Outcome - Exit Case
1: IF LST_MARK = 11-17 goto INTRO_RESUME
ELSE exit block and goto END_FRONT
2: Exit block and goto BlkBack.callbacknotes
3: Exit instrument

INTRO_RESUME
Universe:
Text:

(INTROB = 1) AND LST_MARK = 11-17
Some of the questions have already been answered
Let me see where we should begin.
♦

Press 1 to continue. Once on the (NAMECHEK / INTRO_AB) screen,
press END to move to the next unanswered item.

Enter 1 to Continue

Skip Instructions:

Exit block and BlkScreener

DIAL
Universe:
Text:

♦ Dial number:

(Try all numbers before selecting options 2 or 3)

Administrator's: (Administrator's Name)
Phone 1: (Administrator's phone number)
Phone 2: (Administrator's 2nd phone number)
Phone 3: (Administrator's 3rd phone number)
Phone 4: (Administrator's 4th phone number)
Facility Phone: (Facility phone number)
Alt Contact: (Contact 1's Name)
(Alternate Contact's Phone number)
(Alternate Contact's 2nd phone number)
2nd Alt Contact: (Contact 2's name)
(2nd Alternate Contact's Phone number)
(2nd Alternate Contact's 2nd phone number)

1.
2.
3.
4.
Skip Instructions:

NOGOOD_PHN
Universe:
Text:

1.
Skip Instructions:

Someone Answers
ALL phone numbers Bad/Need new number
No Answer/problem
Personal visit for Screener
1: Goto HELLO
2,3: Goto NOGOOD_PHN
4: Goto INDAPPT_PV

DIAL = 2 or 3
♦ (No good phones/No one answered)

Enter 1 to Continue
Exit Instrument

HELLO
Universe:
Text:

DIAL = 1
Hello. This is . . . . from the U.S. Census Bureau.
May I speak to Read appropriate name?
Contacts
(Administrator's Name)
(Contact 1's Name)
(Contact 2's name)
If call is transferred, repeat this screen when phone is answered

1.
2.
3.
4.
5.
6.
Skip Instructions:

Correct person, Correct person called to the phone, or call is transferred to
correct person
Unknown/no longer there
Reached on a different number
Not available now, not at desk, etc.
On vacation or otherwise temporarily away from work
Other outcome or problem interviewing respondent
1: Goto INTRO_APPT
2: Goto KNOWL_RESP
3: Goto REACHED_ON
4,5: Goto TRY_BACK
6:
Exit Instrument

TRY_BACK
Universe:
Text:

HELLO = 4 or 5
♦ Do you want to callback later to try and speak to contact person
or do you want to continue with a new/different respondent?
REPORTING PERIOD: (Reporting period begin date) - (Reporting period
end date)

1.
2.
Skip Instructions:

KNOWL_RESP
Universe:
Text:

1.
2.
Skip Instructions:
NEW_CONTACT
Universe:
Text:

Callback later
Continue with new/different respondent
1:
Exit Instrument
2: Goto NEW_CONTACT

HELLO = 2
Perhaps you can help me. I am calling on behalf of the National Center
for Health
Statistics. May I speak to someone who can answer questions about
this hospital?

Person you are speaking with can help
Someone else can help
Goto NEW_CONTACT
(KNOWL_RESP = 1 or 2) OR (TRY_BACK = 2)
♦ Enter 1 to record a new contact information
If necessary, explain survey to new respondent

1.
2.

New contact
Continue interview

Skip Instructions:

1: Bring up manipula dialogue box

2: Goto INTRO_APPT

REACHED_ON
Universe:
Text:

HELLO = 3
What phone number should I use to reach (him/her)?
♦ Press ALT-F9 To update Phone number(s)
(When done updating phone(s), enter 1 to continue)

1.
Skip Instructions:
TRANSFER
Universe:
Text:

1.
2.
Skip Instructions:

Enter 1 to Continue
Goto TRANSFER
REACHED_ON = 1
Can you transfer me?

Yes
No
1: Go back to HELLO
2: Exit block and goto EXIT_THANK

INDAPPT_PV
Universe:
Text:

DIAL = 4
♦ DO NOT READ AS WORDED BELOW
o Identify yourself - show I.D.
o Ask to speak to:
Contacts
(Administrator's Name)
(Contact 1's Name)
(Contact 2's name)
(Press ALT-F9 to update Administrator/Alternate contact information)
o Introduce survey if necessary

1.
Skip Instructions:
INTRO_APPT

Enter 1 to Continue
1: Goto INTRO_APPT

Universe:
Text:

(HELLO = 1 OR NEW_CONTACT = 2 OR SCREENER_PV = 1)
? [F1]
Hello,
This is ... from the U.S. Census Bureau.
I'm (calling/visiting) 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?
♦ Enter 999 to start the induction interview

NAMECHEK
Universe:
Text:

1.
2.
Skip Instructions:

LETTER = 2 or 3
Let me verify that I have the correct name and address for your
hospital.
Is the correct name (facility name)?

Yes
No
1: Goto ADDCHEK
2: Goto HSP_NAME

HSP_NAME
Universe:
Text:

NAMECHEK = 2
What is your hospital's name?
♦ Enter 1 to update the hospitals name

1.
2.
Skip Instructions:

Enter 1 to update information
Continue
1: Bring up Manipula dialogue box
2: Goto ADDCHEK

ADDCHEK
Universe:
Text:

1.
2.

LETTER = 2 or 3
Is your hospital located at
(Facility Address)

Yes
No

Skip Instructions:

HSP_ADDRESS
Universe:
Text:

1: Goto MAILADD
2: Goto HSP_ADDRESS

ADDCHECK = 2
What is the correct address?
♦ Enter 1 to update the hospitals address

1.
2.
Skip Instructions:

Enter 1 to update information
Continue
1: Bring up Manipula dialogue box
2: Goto MAILADD

MAILADD
Universe:
Text:

LETTER = 2 or 3
Is this also the mailing address?
(Facility Address)

1.
2.
Skip Instructions:

Yes
No
1: Goto INTRO_AB
2: MHSP_STRET

MHSP_STRET
Universe:
Text:

MAILADD = 2
What is the correct mailing address?
♦ Enter the number and street or press enter if same

Skip Instructions:
MHSP_STRET2
Universe:
Text:

Goto MHSP_STRET2

MAILADD = 2
What is the correct mailing address?
♦ Enter the second line of address or press enter if same/none

Skip Instructions:
MHSP_CITY
Universe:

Goto MHSP_CITY
MAILADD = 2

Text:

What is the correct mailing address?
♦ Enter city or press enter if same

Skip Instructions:
MHSP_ST
Universe:
Text:

Goto MHSP_ST
MAILADD = 2
What is the correct mailing address?
♦ Enter state or press enter if same

Skip Instructions:

Goto MHSP_ZIP

MHSP_ZIP
Universe:
Text:

MAILADD = 2
What is the correct mailing address?
♦ Enter zipcode or press enter if same

Skip Instructions:
LICHOSP
Universe:
Text:

1.
2.
Skip Instructions:

Goto INTRO_AB

Is this facility a licensed hospital?

Yes
No
1: Goto OWN101
2: Goto ELIGREQ

OWN101
Universe:
Text:

LICHOSP = 1
?[F1]
Is this hospital nonprofit, government, or proprietary?
♦ Read answer categories out loud

1.
2.
3.

Skip Instructions:
OWNHCC

Nonprofit (includes church-related, nonprofit corporation, other nonprofit
ownership)
State or local government (includes state, county, city, city-county, hospital
district or authority)
Proprietary (includes individually or privately owned, partnership or
corporation)
Goto OWNHCC

Universe:
Text:

LICHOSP = 1
?[F1]
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.
2.
3.
Skip Instructions:
TEACHOSP
Universe:
Text:

Yes
No
Unknown
Goto TEACHOSP
LICHOSP = 1
?[F1]
Is this a teaching hospital?

1.
2.
Skip Instructions:
MERGER
Universe:
Text:

Yes
No
Goto MERGER
LICHOSP = 1
? [F1]
Did this hospital either merge or separate from any OTHER hospital in
the past 2 years?

1.
2.
3.
Skip Instructions:

Merged or separated
No
Unknown
1: Goto MERSEP
2,3: Goto ESA24

MERSEP
Universe:
Text:

Skip Instructions:
MERGMEDR
Universe:
Text:

MERGER = 1
Was this a merger or a separation?

Goto MERGMEDR
MERGER = 1
Does YOUR hospital have its own medical records department that is
separate from that of the OTHER hospital?

Yes

2.
3.
Skip Instructions:
OTHNAME
Universe:
Text:

No
Unknown
Goto OTHNAME
MERGER = 1
What is the name and address of this OTHER hospital?
♦ Enter name

Skip Instructions:
OTHSTRET
Universe:
Text:

Goto OTHSTRET
MERGER = 1
What is the name and address of this OTHER hospital?
♦ Enter number and street

Skip Instructions:
OTHSTRET2
Universe:
Text:

Goto OTHSTRET2
MERGER = 1
What is the name and address of this OTHER hospital?
♦ Enter the second line of address or press enter if same/none

Skip Instructions:
OTHCITY
Universe:
Text:

Goto OTHCITY
MERGER = 1
What is the name and address of the OTHER hospital?
♦ Enter city

Skip Instructions:
OTHSTATE
Universe:
Text:

Goto OTHSTATE
MERGER = 1
What is the name and address of this OTHER hospital?
♦ Enter state

Skip Instructions:
OTHZIP
Universe:
Text:

Goto OTHZIP
MERGER = 1
What is the name and address of this OTHER hospital?
♦ Enter zip code

Skip Instructions:

Goto ESA24

ESA24
Universe:
Text:

LICHOSP = 1
?[F1]
Does this hospital provide emergency services that are staffed 24
HOURS each day either here at this hospital or elsewhere?

1.
2.
Skip Instructions:

Yes
No
1: Go to TRAUMA
2: GO to ESANOT24

ESANOT24
Universe:
Text:

ESA24 = 2
?[F1]
Does this hospital operate any emergency service areas that are not
staffed 24 HOURS each day?

1.
2.
Skip Instructions:

Yes
No
Goto OOOPD

TRAUMA
Universe:
Text:

ESA24 = 1
? [F1]

What is the trauma level rating of this hospital?

1.
2.
3.
4.
5.
6.
7.
Skip Instructions:

Level I
Level II
Level III
Level IV
Level V
Other/unknown
None
Goto OOOPD

OOOPD
Universe:
Text:

(ESANOT24 = 1 or 2) OR (TRAUMA ne empty)
?[F1]
Does this hospital operate an organized outpatient department either at
this hospital or elsewhere?

1.
2.
Skip Instructions:

Yes
No
1: Goto PHYSSERV
2: Goto AMBSURG

PHYSSERV
Universe:
Text:

1.
2.
Skip Instructions:
AMBSURG
Universe:
Text:

OOOPD = 1
Does this OPD include physician services?

Yes
No
Goto AMBSURG
LICHOSP = 1 AND 2540.QTYPE = EMPTY
?[F1]
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.
Does this hospital have locations that perform ambulatory surgery?

1.
2.
Skip Instructions:
ELIGREQ
Universe:
Text:

Skip Instructions:

Yes
No
Goto ELIGREQ

** Not displayed **

1-3,6-9: Goto STUDY_DESC
4: Goto THANK_B1
5: Goto THANK_B2

STUDY_DESC
Universe:

ELIGREQ = 1-3 or 6-9

Text:

Thank you.
♦ Explain the following ONLY if this is a new hospital. Provide the
administrator or other hospital representative with a brief description of the
study.
Cover the following points Now I would like to provide you with further information on the study.
(1) NHAMCS is the only source of national data on health care
provided in hospital emergency and outpatient departments and ambulatory
surgery locations.
(2)

NHAMCS is endorsed by the:
American College of Emergency Physicians
Emergency Nurses Association
Society for Academic Emergency Medicine
American College of Osteopathic Emergency Physicians
Federation of American Hospitals
Ambulatory Surgery Center Association
American College of Surgeons
American Health Information Management Association
American Academy of Ophthalmology
Society for Ambulatory Anesthesia

(3) Nationwide sample of about 600 hospitals.
(4) Four-week data collection period
(5) Brief form completed for a sample of patient visits.
As one of the hospitals that has been selected for the study, your contribution
will be of great value in producing reliable, national data on ambulatory care.

1.
Skip Instructions:
INDUCTION_APPT
Universe:
Text:

Enter 1 to Continue
IF MERGER = 2 or 3 goto INDUCTION_APPT
ELSE goto THANK_MERGSEP
STUDY_DESC = 1 AND (MERGER = 2 or 3)
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.

Skip Instructions:
SCREENER_THK

999: Exit block and goto BlkInduction
All other, goto SCREENER_THK

Universe:
Text:

1.
Skip Instructions:
SURGDAY
Universe:
Text:

INDUCTION_APPT ne 999
Thank you for your cooperation.
I am looking forward to our meeting.

Enter 1 to Continue
Exit block and goto BlkBACK
BlkScreener.ELIGREQ = 1, 6, 7 or 9
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?
♦ Enter CTRL-D if unknown

Skip Instructions:

1-7: Goto BEDCZAR

BEDCZAR
Universe:
Text:

BlkScreener.ELIGREQ = 1, 6, 7 or 9
[?] F1

Does your hospital have a bed coordinator, sometimes referred to as a
bed czar?

1.
2.
3.
Skip Instructions:
BEDDATA
Universe:
Text:

Yes
No
Unknown
Goto BEDDATA
BlkScreener.ELIGREQ = 1, 6, 7 or 9
How often are hospital bed census data available?
♦ Read answer categories.

1.
2.
3.
4.
5.
6.
7.
Skip Instructions:

Instantaneously
Every 4 hours
Every 8 hours
Every 12 hours
Every 24 hours
Other
Unknown
Goto HLIST

HLIST
Universe:
Text:

BlkScreener.ELIGREQ = 1, 6, 7 or 9
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.
2.
3.
Skip Instructions:

Yes
No
Unknown
1: Goto HLISTED
2,3: Goto EMEDRES

HLISTED
Universe:
Text:

1.
2.
3.
Skip Instructions:
EMEDRES
Universe:
Text:

1.
2.
3.
Skip Instructions:
PERMPART
Universe:
Text:

HLIST = 1
Do the hospitalists on staff at your hospital admit patients from your
ED?

Yes
No
Unknown
Goto EMEDRES
BlkScreener.ELIGREQ = 1, 6, 7 or 9
Does this hospital have an emergency medicine residence program?

Yes
No
Unknown
Go to PERMPART
(MUINC = 2,3,4) OR (MUSTAGE2 = 1-4, DK)
As I mentioned earlier, I would like to discuss the plan for conducting
the study. This hospital has been assigned to a 4-week 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.
2.

Yes
No

Skip Instructions:
PERMPARTSPEC
Universe:
Text:

1: Goto PERMPARTSPEC
2: Goto VSREPPER
PERMPART = 1
♦ 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

Skip Instructions:
PERM_THANK
Universe:
Text:

1.
Skip Instructions:
RO_PERMISSION
Universe:
Text:

1.
Skip Instructions:
VSREPPER
Universe:
Text:

1.
2.
Skip Instructions:

Goto PERM_THANK
PERMPART = 1
Thank you for your help.

Enter 1 to Continue
Goto RO_PERMISSION
PERMPART = 1
♦ Call the Regional Office to inform them of the additional steps needed to
obtain permission

Enter 1 to Continue
Exit block and goto BlkBack
PERMPART = 2 OR [(BlkFront.BlkInduct.INTRO_IND = 1 or
BlkFront.BlkInduct.INTROB = 1) and BlkFront.RO_PERMISS = 1]
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 4-week reporting period. Would you prefer I
(get/verify) this information from you or someone else?

Respondent
Someone else
1: Exit block and goto BlkF9_DEPT
2: Goto CINFO

CINFO
Universe:

VSREPPER = 2

Text:

What is the name of the person with whom I should speak?
♦ Enter 1 to enter/update hospital contact information
Enter 2 to enter/update department contact information

1.
2.
3.
Skip Instructions:

Hospital level contact
Department contact
Continue interview
1: Bring up manipula dialogue box
2: Bring up department contacts manipula dialogue box
3: Goto THANK_RESP

THANK_RESP
Universe:
Text:

1.
Skip Instructions:
CONTACT_DEPT
Universe:
Text:

VSREPPER = 2
♦ Thank current respondent for his/her time and cooperation

Enter 1 to Continue
Exit block and goto BlkF9_DEPT

♦
(All eligible departments are complete. Enter 9 to wrap up the case./All
eligible departments are complete or refusals. Press F10 if you plan to fol

Department Status
ED
(Elig /Partial /Elig (refusal) / Partial (refusal) / Cmplt / Inelig/DKFollowup - AUs created/DK-Followup - AUs NOT created/Complete - AUs
NOT create ((Dk Follow-up)/ )
OPD
(Elig /Partial /Elig (refusal) / Partial (refusal) / Cmplt / Inelig) ((Dk
Follow-up)/ )
ASL
(Elig /Partial /Elig (refusal) / Partial (refusal) / Cmplt / Inelig) ((Dk
Follow-up)/ )

1.
2.
3.
4.
5.
9.

ED
OPD
ASL
Department refusal
Department callback
Induction Interview Complete - Wrap up case

Skip Instructions:

IF EDSTATUS = 6 goto CK_STATUS
ELSE goto BlkED_DEPT

IF OPDSTATUS = 6 goto CK_STATUS
ELSE goto BlkOPD_DEPT

IF ASCSTATUS = 6 goto CK_STATUS
ELSE goto BlkASL_DEPT

4,5: Goto WHICH_DEPT
9. IF (ASCSTATUS = 1 or 3) OR (EDSTATUS = 1 or 3) OR
(OPDSTATUS = 1 or 3) goto CK_STATUS3
ELSE exit block and goto BlkBack
WHICH_DEPT
Universe:
Text:

1.
2.
3.
Skip Instructions:

CONTACT_DEPT = 4 or 5
♦ Which department (is refusing/are you setting a callback for)?

ED
OPD
ASL
1: IF EDSTATUS = 6 goto CK_STATUS2
ELSEIF CONTACT_DEPT = 4 goto DEPT_REFUSAL
ELSE goto DEPT_CALLBACK
2: IF OPDSTATUS = 6 goto CK_STATUS2
ELSEIF CONTACT_DEPT = 4 goto DEPT_REFUSAL
ELSE goto DEPT_CALLBACK
3: IF ASCSTATUS = 6 goto CK_STATUS2
ELSEIF CONTACT_DEPT = 4 goto DEPT_REFUSAL
ELSE goto DEPT_CALLBACK

DEPT_CALLBACK
Universe:
Text:

Skip Instructions:
DEPT_REFUSAL
Universe:
Text:

1.
Skip Instructions:
ASCSTATUS
Universe:
Text:
EDSTATUS
Universe:

CONTACT_DEPT = 5
♦ Enter callback information for the (ED/OPD/ASC)

Go back to CONTACT_DEPT
CONTACT_DEPT = 4
♦ The (ED/OPD/ASC) has been changed to a refusal

Enter 1 to Continue
Go back to CONTACT_DEPT

** NOT DISPLAYED **

Text:

** NOT DISPLAYED **

Universe:
Text:

** NOT DISPLAYED **

Universe:
Text:

** Show only **

OPDSTATUS

ESA_NUM

Skip Instructions:
DEL_ESA
Universe:
Text:

(Does (ESA name) still exist and is it still operational?)
♦ (Enter 97 to delete this ESA / If No, Enter 97 to delete If Yes, Press END
to move to number of visits)

Skip Instructions:
ESA_NAME
Universe:
Text:

97: Goto DEL_ESA/ESA_NAME, as appropriate, for the next row
DEL_ESA ne 97
?[F1]
(What is the name of the (first/next) emergency service area? /Are there
any other emergency service areas?)
♦ Enter 999 for no more

Skip Instructions:

999: Exit block
All others, Goto ESA_TYPE

ESA_TYPE
Universe:
Text:

TblESA_NAME.DEL_ESA ne 97 and ESA_NAME ne 999
? [F1]
What type of ESA is (ESA name)?

1.
2.
3.
4.
5.
6.
Skip Instructions:
ESA_EVISITS
Universe:
Text:

General
Adult
Pediatric
Urgent care/Fast track
Psychiatric
Other
Goto ESA_EVISITS
ESA_NAME ne 999 and TblESA_NAME.DEL_ESA ne 97
?[F1]
What is the expected number of visits from (Reporting period begin
date) to (Reporting period end date) for (ESA name)?

Skip Instructions:

Goto ESA_NAME for the next row

I_ESA
Universe:
Text:

ESA was in sample in previous year (** NOT DISPLAYED **)

Skip Instructions:
I_ESA_VISITS
Universe:
Text:

ESA’s estimated visits in previous year (** NOT DISPLAYED **)

Skip Instructions:
ESA_EVISITS_TOTAL
Universe:
Text:

Total number of estimated visits (** NOT DISPLAYED **)

Skip Instructions:
TOTVSED
Universe:
Text:

Skip Instructions:

Is the total number of expected ED visits during the reporting period
between and ? (** NOT DISPLAYED **)

IF TOTVSED = 2 goto TWICELY
ELSEIF TOTVSED = 3 goto HALFLY
ELSE goto EBILLRECE

TWICELY
Universe:
Text:

TOTVSED = 2
?[F1]
♦ Is the number of expected visits to any of the ESAs more than twice the
number on the previous sampling plan?
ESA
(ESA NAME

1.
2.
Skip Instructions:
TWICELY_SPEC
Universe:
Text:

Visits
Visits Previous
Current visits Previous visits)

Yes
No
1: Goto TWICELY_SP
2: Goto EBILLRECE
TWICELY = 1
♦ Specify why visits have increased this year or were too low the last time
the ED participated

Skip Instructions:
HALFLY
Universe:
Text:

Goto EBILLRECE
TOTVSED = 3
?[F1]
♦ Is the number of expected visits to any of the ESAs less than half of the
number of visits on the previous sampling plan?
ESA
(ESA NAME

1.
2.
Skip Instructions:

Visits
Visits Previous
Current visits Previous visits)

Yes
No
1: Goto HALFLYSP
2: Goto EBILLRECE

HALFLYSPEC
Universe:
Text:

Skip Instructions:
ED_EMR
Universe:
Text:

Skip Instructions:

HALFLY = 1
♦ Specify why visits have decreased this year or were too high the last
time the ED participated

Goto EBILLRECE
If ed_emr = 1 then block emr for Ed
♦ Enter 1 to complete the EMR questions
OrEnter 2 to skip EMR questions and complete later

1) if 1 then emr block
2) Go to blkaddress

EBILLRECE
Universe:
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.
2.
3.
Skip Instructions:
EMEDRECE
Universe:

Yes
No
Unknown
Goto EMEDRECE

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

1.
2.
3.
4.
Skip Instructions:

Yes, all electronic
Yes, part paper and part electronic
No
Unknown
1,2:
Goto EHRINSYRE
3,4,DK,RF: Goto EHRINSE

EHRINSYRE
Universe:
Text:

Skip Instructions:
HHSMUE
Universe:
Text:

EMEDRECE = 1 or 2
In which year did your ED install the current EHR/EMR system?

Go to HHSMUE
EMEDRECE = 1 or 2
?[F1]
Does your current system meet meaningful use criteria as defined by
the Department of Health and Human Services?

Skip Instructions:
EHRNAME16
Universe:
Text:

Go to EHRNAME16
EMEDRECE = 1 or 2
B
What is the name of your current EHR/EMR system?

1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.

Allscripts
Amazing Charts
athenahealth
Cerner
eClinicalWorks
e-MDs
Epic
GE/Centricity
Greenway Medical
McKesson / Practice Partner
NextGen
Practice Fusion
Sage/Vitera
Other - Specify

15.
Skip Instructions:
EHRNAMOTHE
Universe:
Text:

Skip Instructions:
EHRINSE
Universe:
Text:

1.
2.
3.
4.
Skip Instructions:
TEDEMOGE
Universe:
Text:

Unknown
14: Goto EHRNAMOTHE
All others: Goto SECURCHCKE
EHRNAME16 = 14
♦ Enter name of EHR/EMR system

Go to EHRINSE

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

Yes
No
Maybe
Unknown
Go to EDEMOGE

C
Indicate whether your ED has each of the following computerized
capabilities and how often these capabilities are used.
Recording patient history and demographic information?

1.
2.
3.
Skip Instructions:

Yes
No
Unknown
Go to EPROLSTE

EPROLSTE
Universe:
Text:

EDEMOGE = 1-3, DK, RF
C
Indicate whether your ED has each of the following computerized capabilities
and how often these capabilities are used.

Recording patient problem list?

1.
2.
3.
Skip Instructions:
EPNOTESE
Universe:
Text:

Yes
No
Unknown
Go to EPNOTESE

C
Indicate whether your ED has each of the following computerized capabilities
and how often these capabilities are used.
Recording clinical notes?

1.
2.
3.
Skip Instructions:

Yes
No
Unknown
Goto EMEDALGE

EMEDALGE
Universe:
Text:

EPNOTESE = 1-3, DK, RF
C
Recording patient's medications and allergies?

1.
2.
3.
Skip Instructions:
EMEDIDE
Universe:
Text:

Yes
No
Unknown
Go to EMEDIDE
EMEDALGE = 1-3, DK, RF
C
Indicate whether your ED has each of the following computerized capabilities
and how often these capabilities are used.
Reconciling lists of patient medications to identify the most
accurate list?

1.
2.
3.

Yes
No
Unknown

Skip Instructions:
EREMINDE
Universe:
Text:

Go to EREMINDE

C
Indicate whether your ED has each of the following computerized capabilities
and how often these capabilities are used.
Providing reminders for guideline-based interventions or screening
tests?

1.
2.
3.
Skip Instructions:
ECPOEE
Universe:
Text:

Yes
No
Unknown
Go to ECPOEE

C
Indicate whether your ED has each of the following computerized capabilities
and how often these capabilities are used.
Ordering prescriptions?

1.
2.
3.
Skip Instructions:

Yes
No
Unknown
1: go to ESCRIPE
2, DK, RF: go to ECONTRSUBE

ESCRIPE
Universe:
Text:

ECPOEE = 1
C
Indicate whether your ED has each of the following computerized capabilities
and how often these capabilities are used.
Are prescriptions sent electronically to the pharmacy?

1.
2.
3.
Skip Instructions:
EWARNE

Yes
No
Unknown
1-2,DK,RF: Goto EWARNE

Universe:
Text:

ECPOEE = 1
ESCRIPE = 1-2, DK, RF
C
Indicate whether your ED has each of the following computerized capabilities
and how often these capabilities are used.

Are warnings of drug interactions or contraindications provided?

1.
2.
3.
Skip Instructions:
ECONTRSUBE
Universe:
Text:
1.
2.
3.
Skip Instructions:

ECONTRSUBSE
Universe:
Text:
1.
2.
3.
Skip Instructions:

Yes
No
Unknown
Goto ECONTRSUBE

Do you prescribe controlled substances?
Yes
No
Unknown
1 go to ECONTRSUBSE
2-3 go to ECTOEE

Are prescriptions for controlled substances sent electronically to the
pharmacy?
Yes
No
Unknown
Go to ECTOEE

ECTOEE
Universe:
Text:

EFORMULAE = 1-2, DK, RF
C
Indicate whether your ED has each of the following computerized capabilities
and how often these capabilities are used.
Ordering lab tests?

1.
2.
3.
Skip Instructions:

Yes
No
Unknown
1-2,DK,RF: Goto ERESULTE

ERESULTE
Universe:
Text:

ECTOEE = 1-3,DK,RF
C
Indicate whether your ED has each of the following computerized capabilities
and how often these capabilities are used.
Viewing lab results?

1.
2.
3.
Skip Instructions:
ERADIE
Universe:
Text:

Yes
No
Unknown
1-2,DK,RF: Goto ERADIE
ERESULTE = 1-2,DK,RF
C
Indicate whether your ED has each of the following computerized capabilities
and how often these capabilities are used.
Ordering radiology tests?

1.
2.
3.
Skip Instructions:
EIMGRESE
Universe:
Text:

Yes
No
Unknown
Go to EIMGRESE
ERADIE = 1-2,DK,RF
C
Indicate whether your ED has each of the following computerized capabilities
and how often these capabilities are used.
Viewing imaging results?

1.
2.
3.
Skip Instructions:
EIDPTE
Universe:

Yes
No
Unknown
Go to EIDPTE
EIMGRESE = 1-2,DK,RF

Text:

C
Indicate whether your ED has each of the following computerized capabilities
and how often these capabilities are used.
Identifying patients due for preventive or follow-up care in order to
send patients reminders?

1.
2.
3.
Skip Instructions:
EGENLISTE
Universe:
Text:

Yes
No
Unknown
Go to EGENLISTE

C
Indicate whether your ED has each of the following computerized capabilities
and how often these capabilities are used.
Generating lists of patients with particular health conditions?

1.
2.
3.
Skip Instructions:
EDATAREPE
Universe:
Text:

Yes
No
Unknown
Go to EIMMREGE

C
Indicate whether your ED has each of the following computerized capabilities
and how often these capabilities are used.
Providing data to create reports on clinical care measures for
patients with specific chronic conditions (e.g., HbA1C for diabetes)

1.
2.
3.
Skip Instructions:
ESUME
Universe:

Yes
No
Unknown
Go to ESUME

Text:

C
Indicate whether your ED has each of the following computerized capabilities
and how often these capabilities are used.
Providing patients with clinical summaries for each visit?

1.
2.
3.
Skip Instructions:
EMSGE
Universe:
Text:

Yes
No
Unknown
Goto EMSGE

C
Indicate whether your ED has each of the following computerized capabilities
and how often these capabilities are used.
Exchanging secure messages with patients?

1.
2.
3.
Skip Instructions:
ESHAREE
Universe:
Text:

Yes
No
Unknown
Go to ESHAREE

The next questions are about sharing (either sending or receiving)
patient health information.
Do you send or receive patient health information electronically?
Electronically does not include scanned or pdf documents from fax,
eFax, or mail.

1.
2.
3.
Skip Instructions:

Yes
No
Unknown
1: Goto ESHARESE
2,DK,RF: Goto EDISCHSRE

ESHARESE
Universe:

ESHAREE = 1

Text:
Do you electronically send patient health information to another
provider whose EHR system is different from your own?
♦ Read answer categories
Enter all that apply, separate with commas

1.
2.
3.
Skip Instructions:
ESHARERE
Universe:
Text:

Yes
No
Unknown
1-2,DK,RF: Go to ESHARERE
ESHAREE = 1
ESHARESE = 1-2,DK,RF
Do you electronically send patient health information to another
provider whose EHR system is different from your own?
♦ Read answer categories
Enter all that apply, separate with commas

1.
2.
3.
Skip Instructions:
EDISCHSRE
Universe:
Text:

Yes
No
Unknown
Go to EDISCHSRE
ESHARERE = 1, 2, DK, RF
Do you electronically send or receive hospital discharge summaries to
or from providers outside of your medical organization?
Check all that apply.

Send electronically

Receive electronically

Do not send or receive

Skip Instructions:
EEDSRE
Universe:
Text:

Go to EEDSRE
EDISCHSRE = 1, 2, DK, RF
D
Do you electronically send or receive ED notifications to or from
providers outside of your medical organization?
Check all that apply.

Send electronically

Receive electronically

Do not send or receive

Skip Instructions:
ESUMCSRE
Universe:
Text:

Go to ESUMCSRE
EEDSRE = 1, 2, DK, RF
Do you electronically send or receive summary of care records for
transitions of car or referrals to or from providers outside of your
medical organization?
Check all that apply.

Send electronically

Receive electronically

Do not send or receive

Skip Instructions:
PTONLINEE
Universe:
Text:

1-2, DK, RF go to PTONLINEE

Can patients seen at the reporting location do the following online
activities?
Check all that apply.

View their medical record online

Download and transmit health information in the electronic medical record to
their personal files

Request corrections to their electronic medical record

Skip Instructions:
EDPRIM
Universe:
Text:

1.
2.
3.
4.

go to EDPRIM
PTONLINEE: 1-3, DK, RF
When patients with identified primary care physicians arrive at the
Emergency Department, how often do you electronically send
notifications to the patients' primary care physicians?

Always
Sometimes
Rarely
Never

5.
Skip Instructions:
EDINFO
Universe:
Text:

1.
2.
3.
Skip Instructions:
OBSUNITS
Universe:
Text:

1.
2.
3.
Skip Instructions:

Do not know

When patients arrive at the Emergency Department, are you able to
query for patients' healthcare information (e.g. medications, allergies)
electronically from outside sources?

Yes
No
Don't know

Does your ED have an observation or clinical decision unit?

Yes
No
Unknown
1:
Goto OBSSEP
2,3,DK,RF: Goto BOARD

OBSSEP
Universe:
Text:

1.
2.
3.
Skip Instructions:
OBSDECMD
Universe:
Text:

OBSUNITS = 1
Is this observation or clinical decision unit physically separate from the
ED?

Yes
No
Unknown

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

1.
2.
3.

ED physicians
Hospitalists
Other physicians

4.
Skip Instructions:

Unknown
IF (OBSDECMD[2] = 4) OR
[(OBSDECMD[1] = 4) and (OBSDECMD[2] = 1-3)]
goto CK_OBSDECMD
ELSE goto BOARD

BOARD
Universe:
Text:

OBSDECMD or
OBSUNITS = 2,3,dk,rf
? [F1]
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.
2.
3.
Skip Instructions:
BOARDHOS
Universe:
Text:

Yes
No
Unknown

? [F1]
Does your ED allow some admitted patients to move from the ED to
inpatient corridors while awaiting a bed ("boarding") - sometimes called
a "full capacity protocol?"

1.
2.
3.
Skip Instructions:
AMBDIV
Universe:
Text:

1.
2.
3.
Skip Instructions:

Yes
No
Unknown

Did your ED go on ambulance diversion in TOTHRDIV_FILL?

Yes
No
Unknown
1:
Goto TOTHRDIV
2,3,DK,RF: Goto NUMSTATX

TOTHRDIV
Universe:
Text:

AMBDIV = 1
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

Skip Instructions:
REGDIV
Universe:
Text:

1.
2.
3.
Skip Instructions:
ADMDIV
Universe:
Text:

1.
2.
3.
Skip Instructions:
NUMSTATX
Universe:
Text:

AMBDIV = 1
Is ambulance diversion actively managed on a regional level versus
each hospital adopting diversion if and when it chooses?

Yes
No
Unknown

AMBDIV = 1
Does your hospital continue to admit elective or scheduled surgery
cases when the ED is on ambulance diversion?

Yes
No
Unknown

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

Skip Instructions:
NUMOTHTX
Universe:
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

Skip Instructions:
EDSPACES
Universe:

Text:

1.
2.
3.
Skip Instructions:
PHYSSPACE
Universe:
Text:

1.
2.
3.
Skip Instructions:
EXPAND
Universe:
Text:

1.
2.
3.
Skip Instructions:
BEDREG
Universe:
Text:

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

Yes
No
Unknown

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

Yes
No
Unknown

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

Yes
No
Unknown

E
Does your ED use Bedside registration?

1.
2.
3.
Skip Instructions:
KIOSELCHK
Universe:

Yes
No
Unknown

Text:
E
Does your ED use Kiosk self check-in?

1.
2.
3.
Skip Instructions:
CATRIAGE
Universe:
Text:

Yes
No
Unknown

E
Does your ED use Computer-assisted triage?

1.
2.
3.

Yes
No
Unknown

Skip Instructions:
IMBED
Universe:
Text:

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

1.
2.
3.

Yes
No
Unknown

Skip Instructions:
ADVTRIAG
Universe:
Text:

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

1.
2.

Yes
No

3.
Skip Instructions:
PHYSPRACTRIA
Universe:
Text:

Unknown

E
Does your ED use Physician/Practitioner at triage?

1.
2.
3.
Skip Instructions:
FASTTRAK
Universe:
Text:

Yes
No
Unknown

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

1.
2.
3.
Skip Instructions:
EDPTOR
Universe:
Text:

Yes
No
Unknown

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

1.
2.
3.
Skip Instructions:
DASHBORD
Universe:

Yes
No
Unknown

Text:

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

1.
2.
3.

Yes
No
Unknown

Skip Instructions:
RFID
Universe:
Text:

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

1.
2.
3.
Skip Instructions:
WIRELESS
Universe:
Text:

Yes
No
Unknown

E
Does your ED use Wireless communication devices by providers?

1.
2.
3.
Skip Instructions:
ZONENURS
Universe:
Text:

Yes
No
Unknown

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

Yes

2.
3.
Skip Instructions:
POOLNURS
Universe:
Text:

No
Unknown

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

1.
2.
3.
Skip Instructions:
FREDIND
Universe:
Text:

Skip Instructions:
AU_ONSITE
Universe:
Text:

1.
2.
Skip Instructions:

Yes
No
Unknown
Go to AU_ONSITE
POOLNURS = 1-3, DK or RF
** Not Displayed **

DEL_ESA ne 97 AND ESA_NAME ne 999 AND ESA_EVISITS = 1-99999
♦ Is (ESA name) on-site?

Yes
No
1: Goto ESA_PHONE
2: Goto ESA_STRET

ESA_STRET
Universe:
Text:

DEL_ESA ne 97 AND ESA_NAME ne 999 AND ESA_EVISITS = 1-99999
What is (ESA name)'s address?
♦ Enter number and street.

Skip Instructions:

Goto ESA_STRET2

ESA_STRET2
Universe:
Text:

DEL_ESA ne 97 AND ESA_NAME ne 999 AND ESA_EVISITS = 1-99999
What is (ESA name)'s address?
♦ Enter the second line of address or press enter if same/none

Skip Instructions:

Goto ESA_CITY

ESA_CITY
Universe:
Text:

DEL_ESA ne 97 AND ESA_NAME ne 999 AND ESA_EVISITS = 1-99999
What is (ESA name)'s address?
♦ Enter city

Skip Instructions:

Goto ESA_STATE

ESA_STATE
Universe:
Text:

DEL_ESA ne 97 AND ESA_NAME ne 999 AND ESA_EVISITS = 1-99999
What is (ESA name)'s address?
♦ Enter state

Skip Instructions:

Goto ESA_ZIP

ESA_ZIP
Universe:
Text:

DEL_ESA ne 97 AND ESA_NAME ne 999 AND ESA_EVISITS = 1-99999
What is (ESA name)'s address?
♦ Enter zipcode

Skip Instructions:

Goto ESA_PHONE

ESA_PHONE
Universe:
Text:

Skip Instructions:
ESA_PHTYP
Universe:
Text:

0.
1.
2.
3.
4.
5.
6.
7.
8.
9.

DEL_ESA ne 97 AND ESA_NAME ne 999 AND ESA_EVISITS = 1-99999
What is (ESA name)'s telephone number?

Goto ESA_PHTYP
DEL_ESA ne 97 AND ESA_NAME ne 999 AND ESA_EVISITS = 1-99999
♦ Enter phone type

Main
Home
Work
Mobile
Pager, Beeper, Answering Service
Public Pay Phone
Toll Free
Other
Fax
Unknown

Skip Instructions:
ESA_CONTACT
Universe:
Text:

DEL_ESA ne 97 AND ESA_NAME ne 999 AND ESA_EVISITS = 1-99999
♦ Enter ESA contact person's name

Skip Instructions:
TE
Universe:
Text:

DEL_ESA ne 97 AND ESA_NAME ne 999 AND ESA_EVISITS = 1-99999
Take Every

Skip Instructions:
RS
Universe:
Text:

Skip Instructions:
EDDK_CHECK
Universe:
Text:

DEL_ESA ne 97 AND ESA_NAME ne 999 AND ESA_EVISITS = 1-99999
Random Start

ed_emr = 1 then EDDK_CHECK
♦ Are there any Don't Know items that you need to callback for?
Press Ctrl-M to review DKs and RFs
Press Shift-F7 to review all DK Follow-up remarks
If you MUST close this case now, due to pending close-out, and you will not
be collecting your remaining DKs and RFs, please select 2 "No", and make
any required explanation in the case notes.

1.
2.
Skip Instructions:
DONE_ED
Universe:
Text:

Yes
No
Goto DONE_ED

♦ Enter 1 to continue to the next department
WARNING: once you pass this screen, the ED portion of the induction
interview will be closed, and you will not be allowed to re-enter to change
any answers or add additional AUs. If you need to go back, use your up
arrow to go back now, or press F10 to come back in later. DO NOT press 1 if
you need to come back to this department section later.

Enter 1 to Continue

Skip Instructions:

Exit block and goto BlkF9_DEPT.CONTACT_DEPT

I_EDMIN
Universe:
Text:

Minimum estimated visits in ED from previous year

Skip Instructions:
I_EDMAX
Universe:
Text:

Maximum estimated visits in ED from previous year

Skip Instructions:
TOT_GOODESA
Universe:
Text:

Total number of ‘good’ ESA sampled

Skip Instructions:
INTRO_OPD
Universe:
Text:

OPDSampled ne 1
♦ If necessary, introduce yourself and explain the survey
♦ Explain that in order to develop a sampling plan, you would like to collect
more specific information about this hospital's outpatient department

1.
Skip Instructions:
CLIN_NUM
Universe:
Text:

Skip Instructions:
DEL_CLIN
Universe:
Text:

Enter 1 to Continue
Goto TblClinics

** NOT DISPLAYED **

(Does (clinic name) still exist and is it still operational?)
♦ (Enter 97 to delete this clinic / If Yes, Press END to move to number
of visits If No, Enter 97 to delete )

Skip Instructions:

97: Goto CLIN_NAME or DEL_CLIN for the next row
Else goto CLIN_NAME or DEL_CLIN for this row

CLIN_NAME
Universe:

sample_question = 2

Text:

H
(What is the name of the (first/next) clinic? /Are there any other clinics?)
♦ Enter 999 for no more

Skip Instructions:

999: Exit block and goto TblCLIN_TYPVIS
All others, goto GENERIC_NAME

GENERIC_NAME
Universe:
Text:

CLIN_NAME ne 999 and DEL_CLIN ne 97
H
What is the generic name of the clinic?
♦ Enter XXX if clinic is not listed

Skip Instructions:

CLIN_SELECTGROUP
Universe:
Text:

1.
2.
3.
4.
5.
6.
Skip Instructions:
CLIN_EVISITS
Universe:
Text:

XXX: Goto CK1_CLINIC
If alpha code = OS, goto CK2_CLINIC
All others, goto CLIN_EVISITS
GENERIC_NAME = XXX
What is (Clinic Name)'s specialty group?

General Medicine
Surgery
Pediatrics
Obstetrics/Gynecology
Substance Abuse
Other

CLIN_GROUP = 1-6
What is the expected number of visits from (Reporting period begin
date) to (Reporting period end date) for (Clinic Name)?

Skip Instructions:
I_CLIN
Universe:
Text:

Skip Instructions:
SAMPLE_QUESTION

Clinic was in sample from previous year

Universe:
Text:

♦ You have completed data entry for the OPD.
Enter 1 to have the system perform sampling.
-orEnter 2 to return to the previous screen to enter additional clinics.

1.
2.
Skip Instructions:

verifies clinic list is complete, ready to sample
returns to clinic list to add additional clinics before sampling
1: Goto BlkCLINICS_Sampling_table
2: Go back to CLIN_NAME

SAMPLED
Universe:
Text:

Skip Instructions:
Probability
Universe:
Text:

** Not Displayed **

** NOT DISPLAYED **

Skip Instructions:
SU
Universe:
Text:

Sampling Unit

Skip Instructions:
CLIN_EVISITS_TOTAL
Universe:
Text:

Total number of estimated visits in OPD

Skip Instructions:
TOTAL_CLIN
Universe:
Text:

** Not Displayed **

Skip Instructions:
TOTVSOP
Universe:
Text:

** Not Displayed **

Skip Instructions:

MORECLIN

ELSEIF TOTVSOP = 2 AND TOTAL_CLIN gt I_TOTCLIN
goto MORECLINSPEC
ELSEIF TOTVSOP = 2 goto TWICECLINSPEC
ELSEIF TOTVSOP = 3 AND TOTAL_CLIN lt I_TOTCLIN
goto LESSCLINSPEC
ELSEIF TOTVSOP = 3 goto HALFCLINSPEC
ELSE goto EBILLRECO
?[F1]
♦ Are there more clinics this year compared to last year? (If Yes, then verify
the scope and ownership of the new clinics this year)
Clinic
This Year
Previous Year
(CLINIC NAME No. of clinics
No. of clinics)

MORECLINSPEC
Universe:
Text:

Skip Instructions:

TWICECLIN

(TOTAL_CLIN > (2 X I_TOTCLIN)) AND TOTVSOP = 2
♦ List clinics that have opened or should have been included previously

Goto TWICECLINSPEC (TOTVSOP is more than twice the previous
TOTVSOP)
?[F1]
♦ Is the number of expected visits to any of the clinics more than twice the
number on the previous sampling plan?
Clinic
(CLIN NAME

TWICECLINSPEC
Universe:
Text:

Skip Instructions:
LESSCLIN

Visits
Visits Previous
Current visits Previous visits)

TOTVSOP = 2
♦ Explain why visits have increased this year or were too low previously

Go to EBILLRECO
?[F1]
♦ Are there fewer clinics this year compared to last year?
Clinic
This Year
Previous Year
(CLINIC NAME No. of clinics
No. of clinics)

LESSCLINSPEC
Universe:
Text:

(TOTAL_CLIN < (I_TOTCLIN/2)) AND TOTVSOP = 3
♦ There are fewer clinics this year than in previous panel
Specify which clinics have closed or should not have been included
previously

Skip Instructions:

HALFCLIN

Go to HALFCLINSPEC (TOTVSOP is less than half of the previous
TOTVSOP)
?[F1]
♦ Is the number of expected visits to any of the clinics less than half of the
number of visits on the previous sampling plan?
Clinic
Visits
Visits Previous
(CLINIC NAME
Current visits Previous visits)

HALFCLINSPEC
Universe:
Text:

Skip Instructions:
OPD_EMR
Universe:
Text:

Skip Instructions:

TOTVSOP = 3
♦ Specify why visits have decreased this year or were too high last year

If opd_emr = 1 then block emr for OPD
♦ Enter 1 to complete the EMR questions
OrEnter 2 to skip EMR questions and complete later

1) if 1 then emr block
2) Go to blkaddress

EBILLRECO
Universe:
Text:

Now I would like to ask you some questions about your OPD.
♦ If clinic 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.
2.
3.
Skip Instructions:
EMEDRECO
Universe:
Text:

Yes
No
Unknown
Goto EMEDRECO

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

1.
2.
3.
4.
Skip Instructions:

Yes, all electronic
Yes, part paper and part electronic
No
Unknown
1,2:
Goto EHRINSYRO
3,4,DK,RF: Goto EHRINSO

EHRINSYRO
Universe:
Text:

EMEDRECO = 1 or 2
In which year did your OPD install the current EHR/EMR system?

Skip Instructions:
HHSMUO
Universe:
Text:

Go to HHSMUO
EMEDRECO = 1 or 2
?[F1]
Does your current system meet meaningful use criteria as defined by
the Department of Health and Human Services?

Skip Instructions:
EHRNAMO16
Universe:
Text:

Go to EHRNAMO16
EMEDRECE = 1 or 2
B
What is the name of your current EHR/EMR system?

1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
Skip Instructions:
EHRNAMOTHO
Universe:
Text:

Skip Instructions:
EHRINSO
Universe:
Text:

Allscripts
Amazing Charts
athenahealth
Cerner
eClinicalWorks
e-MDs
Epic
GE/Centricity
Greenway Medical
McKesson / Practice Partner
NextGen
Practice Fusion
Sage/Vitera
Other - Specify
Unknown
14: Goto EHRNAMOTHO
All others: Goto EHRINSO
EHRNAMO16 = 14
♦ Enter name of EHR/EMR system

Go to EHRINSO

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

Yes

2.
3.
4.
Skip Instructions:
TEDEMOGO
Universe:
Text:

No
Maybe
Unknown
Go to TEDEMOGO

C
Indicate whether your OPD has each of the following computerized
capabilities and how often these capabilities are used.
Recording patient history and demographic information?

1.
2.
3.
Skip Instructions:

Yes
No
Unknown
Go to EPROLSTO

EPROLSTO
Universe:
Text:

TEDEMOGO = 1-3, DK, RF
C
Indicate whether your OPD has each of the following computerized
capabilities and how often these capabilities are used.

Recording patient problem list?

1.
2.
3.
Skip Instructions:
EPNOTESO
Universe:
Text:

Yes
No
Unknown
Go to EPNOTESO

C
Indicate whether your OPD has each of the following computerized
capabilities and how often these capabilities are used.
Recording clinical notes?

1.
2.
3.
Skip Instructions:

Yes
No
Unknown
Goto EMEDALGO

EMEDALGO
Universe:
Text:

EPNOTESO = 1-2, DK, RF
C
Recording patient's medications and allergies?

1.
2.
3.
Skip Instructions:
EMEDIDO
Universe:
Text:

Yes
No
Unknown
Go to EMEDIDO
EMEDALGO = 1-2, DK, RF
C
Indicate whether your OPD has each of the following computerized
capabilities and how often these capabilities are used.
Reconciling lists of patient medications to identify the most
accurate list?

1.
2.
3.
Skip Instructions:
EREMINDO
Universe:
Text:

Yes
No
Unknown
Go to EREMINDO

C
Indicate whether your OPD has each of the following computerized
capabilities and how often these capabilities are used.
Providing reminders for guideline-based interventions or screening
tests?

1.
2.
3.
Skip Instructions:

Yes
No
Unknown
Go to ECPOEO

ECPOEO
Universe:
Text:

C
Indicate whether your OPD has each of the following computerized
capabilities and how often these capabilities are used.
Ordering prescriptions?

1.
2.
3.
Skip Instructions:

Yes
No
Unknown
1: ESCRIPO
2, DK, RF: ECONSTRSUBO

ESCRIPO
Universe:
Text:

ECPOEO = 1
C
Indicate whether your OPD has each of the following computerized
capabilities and how often these capabilities are used.
Are prescriptions sent electronically to the pharmacy?

1.
2.
3.
Skip Instructions:

Yes
No
Unknown
1-2,DK,RF: Goto EWARNO

EWARNO
Universe:
Text:

ECPOEO = 1
ESCRIPO = 1-2,DK,RF
C
Indicate whether your OPD has each of the following computerized
capabilities and how often these capabilities are used.

Are warnings of drug interactions or contraindications provided?

1.
2.
3.

Yes
No
Unknown

Skip Instructions:
ECONTRSUBO
Universe:
Text:
1.
2.
3.
Skip Instructions:

ECONTRSUBSO
Universe:
Text:
1.
2.
3.
Skip Instructions:

Goto ECONTRSUBO

Do you prescribe controlled substances?
Yes
No
Unknown
1 go to ECONTRSUBSO
2-3 go to ECTOEO

Are prescriptions for controlled substances sent electronically to the
pharmacy?
Yes
No
Unknown
Go to ECTOEO

ECTOEO
Universe:
Text:

ECONTRSUBO = 2, DK, RF
ECONTRSUBSO = 1-2, DK, RF
C
Indicate whether your OPD has each of the following computerized
capabilities and how often these capabilities are used.
Ordering lab tests?

1.
2.
3.
Skip Instructions:
ERESULTO
Universe:
Text:

Yes
No
Unknown
1-2,DK,RF: Goto ERESULTO
ECTOEO = 1-2,DK,RF
C
Indicate whether your OPD has each of the following computerized
capabilities and how often these capabilities are used.
Viewing lab results?

1.
2.
3.
Skip Instructions:

Yes
No
Unknown
1-2,DK,RF: Goto ERADIO

ERADIO
Universe:
Text:

ERESULTO = 1-2,DK,RF
C
Indicate whether your OPD has each of the following computerized
capabilities and how often these capabilities are used.
Ordering radiology tests?

1.
2.
3.
Skip Instructions:
EIMGRESO
Universe:
Text:

Yes
No
Unknown
Go to EIMGRESO
ERADIO = 1-2,DK,RF
C
Indicate whether your OPD has each of the following computerized
capabilities and how often these capabilities are used.
Viewing imaging results?

1.
2.
3.
Skip Instructions:
EIDPTO
Universe:
Text:

Yes
No
Unknown
Go to EIDPTO
EIMGRESO = 1-2,DK,RF
C
Indicate whether your OPD has each of the following computerized
capabilities and how often these capabilities are used.
Identifying patients due for preventive or follow-up care in order to
send patients reminders?

1.
2.
3.
Skip Instructions:
EGENLISTO
Universe:

Yes
No
Unknown
Go to EGENLISTO

Text:

C
Indicate whether your OPD has each of the following computerized
capabilities and how often these capabilities are used.
Generating lists of patients with particular health conditions?

1.
2.
3.
Skip Instructions:
EDATAREPO
Universe:
Text:

Yes
No
Unknown
Go to EIMMREGO

C
Indicate whether your OPD has each of the following computerized
capabilities and how often these capabilities are used.
Providing data to create reports on clinical care measures for
patients with specific chronic conditions (e.g., HbA1C for diabetes)

1.
2.
3.
Skip Instructions:
ESUMO
Universe:
Text:

Yes
No
Unknown
Go to ESUMO

C
Indicate whether your OPD has each of the following computerized
capabilities and how often these capabilities are used.
Providing patients with clinical summaries for each visit?

1.
2.
3.
Skip Instructions:
EMSGO
Universe:

Yes
No
Unknown
Goto EMSGO

Text:

C
Indicate whether your OPD has each of the following computerized
capabilities and how often these capabilities are used.
Exchanging secure messages with patients?

1.
2.
3.
Skip Instructions:
REFOUTO
Universe:
Text:

Yes
No
Unknown
Go to REFOUTO
EMSGO = 1-2, DK, RF
Do you refer patients to providers outside of your hospital?
Electronic does not include fan, eFax, or mail.

1.
2.
Skip Instructions:
REFOUTHOWO
Universe:
Text:

Yes
No
1 goto REFOUTHOWO
2, DK, RF goto REFINO
REFOUTO = 1
How do you send patient health information to them?

Electronically (EHR, web portal, or online registries)

Via paper-based methods (Fax, eFax, or mail)

We do not send patient health information to the provider

Skip Instructions:

1 or 2 goto REFOUTSEO
3,DK,RF goto REFINO

REFINO
Universe:

REFOUTO = 2,DK,RF
REFOUTHOWO = 1,2,3,DK,RF

Text:
Do you see patients to providers outside of your hospital? Electronic
does not include fan, eFax, or mail.

1.
2.
Skip Instructions:

Yes
No
1 goto REFINSO
2, DK, RF goto REFINHOWO

REFINHOWO
Universe:
Text:

REFINO = 1
How do you receive patient health information from them? Check all
that apply.

Electronically (EHR, web portal, or online registries)

Via paper-based methods (Fax, eFax, or mail)

We do not send patient health information to the provider

Skip Instructions:
ESHAREO
Universe:
Text:

1-3, DK, RF goto ESHAREO

1.
2.
3.
Skip Instructions:

Yes
No
Unknown
1: Goto ESHARESO
2,DK,RF: Goto EDISCHSRO

ESHARESO
Universe:
Text:

ESHAREO = 1
Do you electronically send patient health information to another
provider whose EHR system is different from your own?
♦ Read answer categories
Enter all that apply, separate with commas

1.
2.
3.
Skip Instructions:
ESHARERO
Universe:
Text:

Yes
No
Unknown
1-2,DK,RF: Go to ESHARERO
ESHAREO = 1
ESHARESO: 1-2,DK,RF
Do you electronically send patient health information to another
provider whose EHR system is different from your own?
♦ Read answer categories
Enter all that apply, separate with commas

1.
2.
3.
Skip Instructions:
EDISCHSRO
Universe:
Text:

Yes
No
Unknown
Go to EDISCHSRO
ESHARERE = 1, 2, DK, RF
Do you electronically send or receive hospital discharge summaries to
or from providers outside of your medical organization?
Check all that apply.

Send electronically

Receive electronically

Do not send or receive

Skip Instructions:
EEDSRO
Universe:
Text:

Go to EEDSRO
EDISCHSRO = 1, 2, DK, RF
D
Do you electronically send or receive OPD notifications to or from
providers outside of your medical organization?
Check all that apply.

Send electronically

Receive electronically

Do not send or receive

Skip Instructions:
ESUMCSRO
Universe:
Text:

Go to ESUMCSRO
EEDSRE = 1, 2, DK, RF
Do you electronically send or receive summary of care records for
transitions of car or referrals to or from providers outside of your
medical organization?
Check all that apply.

Send electronically

Receive electronically

Do not send or receive

Skip Instructions:
PTONLINEO
Universe:
Text:

1-2, DK, RF go to PTONLINEO

Can patients seen at the reporting location do the following online
activities?
Check all that apply.

View their medical record online

Download and transmit health information in the electronic medical record to
their personal files

Request corrections to their electronic medical record

Skip Instructions:
AU_ONSITE
Universe:
Text:

1.
2.
Skip Instructions:

go to AU_ONSITE
DEL_CLIN ne 97 AND CLIN_NAME ne 999 AND CLIN_EVISITS = 1-99999
♦ Is (Clinic Name) on-site?

Yes
No
1: Goto CLIN_PHONE
2: Goto CLIN_STRET

CLIN_STRET
Universe:
Text:

DEL_CLIN ne 97 AND CLIN_NAME ne 999 AND CLIN_SCOPE = 1
What is (Clinic Name)'s address?
♦ Enter number and street.

Skip Instructions:

Goto CLIN_STRET2

CLIN_STRET2
Universe:
Text:

DEL_CLIN ne 97 AND CLIN_NAME ne 999 AND CLIN_SCOPE = 1
What is (Clinic Name)'s address?
♦ Enter the second line of address or press enter if same/none

Skip Instructions:

Goto CLIN_CITY

CLIN_CITY
Universe:
Text:

DEL_CLIN ne 97 AND CLIN_NAME ne 999 AND CLIN_SCOPE = 1
What is (Clinic Name)'s address?
♦ Enter city

Skip Instructions:

Goto CLIN_STATE

CLIN_STATE
Universe:
Text:

DEL_CLIN ne 97 AND CLIN_NAME ne 999 AND CLIN_SCOPE = 1
What is (Clinic Name)'s address?
♦ Enter state

Skip Instructions:

Goto CLIN_ZIP

CLIN_ZIP
Universe:
Text:

DEL_CLIN ne 97 AND CLIN_NAME ne 999 AND CLIN_SCOPE = 1
What is (Clinic Name)'s address?
♦ Enter zipcode

Skip Instructions:

Goto CLIN_PHONE

CLIN_PHONE
Universe:
Text:

Skip Instructions:
CLIN_PHTYP
Universe:
Text:

0.
1.

DEL_CLIN ne 97 AND CLIN_NAME ne 999 AND CLIN_SCOPE = 1
What is (Clinic Name)'s telephone number?

Goto CLIN_PHTYP
DEL_CLIN ne 97 AND CLIN_NAME ne 999 AND CLIN_SCOPE = 1
♦ Enter phone type

Main
Home

2.
3.
4.
5.
6.
7.
8.
9.
Skip Instructions:
CLIN_CONTACT
Universe:
Text:

Work
Mobile
Pager, Beeper, Answering Service
Public Pay Phone
Toll Free
Other
Fax
Unknown

DEL_CLIN ne 97 AND CLIN_NAME ne 999 AND CLIN_SCOPE = 1
♦ Enter clinic director/contact person's name

Skip Instructions:
TE
Universe:
Text:

** NOT DISPLAYED **

Skip Instructions:
RS
Universe:
Text:

Skip Instructions:
OPDDK_CHECK
Universe:
Text:

** NOT DISPLAYED **

opd_emr = 1 then OPDK_CHECK
♦ Are there any Don't Know items that you need to call back for?
Press Ctrl-M to review DKs and RFs
Press Shift-F7 to review all DK Follow-up remarks
If you MUST close this case now, due to pending close-out, and you will not
be collecting your remaining DKs and RFs, please select 2 "No", and make
any required explanation in the case notes.

1.
2.
Skip Instructions:
DONE_OPD
Universe:

Yes
No
Goto DONE_OPD

Text:

♦ Enter 1 to continue to the next department
WARNING: once you pass this screen, the OPD portion of the induction
interview will be closed, and you will not be allowed to re-enter to change
any answers or add additional AUs. If you need to go back, use your up
arrow to go back now, or press F10 to come back in later. DO NOT press 1 if
you need to come back to this department section later.

1.
Skip Instructions:

Enter 1 to Continue
Exit block and goto BlkF9_DEPT.CONTACT_DEPT

I_OPDMIN
Universe:
Text:

** Not displayed **

Skip Instructions:
I_OPDMAX
Universe:
Text:

** Not displayed **

Skip Instructions:
I_TOTCLIN
Universe:
Text:

** Not displayed **

Skip Instructions:
TOT_GOODCLIN
Universe:
Text:

** NOT Displayed **

Skip Instructions:
ASL_INTRO
Universe:
Text:

To develop the sampling plan, I would like to (collect/verify) more
specific information about this facility or hospital 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.
2.
Skip Instructions:

Continue
No in-scope ^centerslocations
1: Goto BlkASL1
2: Goto CK_NOASL

ASL_NUM
Universe:
Text:

Skip Instructions:
DEL_ASL
Universe:
Text:

** SHOW ONLY **

I_ASL = 1 OR (backing-up after entering something in ASL_NAME)
(Does (ASL name) still exist and is it still operational?)
♦ (Enter 97 to delete this ASL entered by mistake/ If Yes, Press END to
move to expected visits If No, Enter 97 to delete )

Skip Instructions:
ASL_NAME
Universe:
Text:

Goto the next row (DEL_ASL or ASL_NAME)
DEL_ASL = EMPTY
[?] F1
( What is the name of the (first/next) ambulatory surgery location? /Are
there any other ambulatory surgery locations?)
♦ Enter only IN_SCOPE (ASCs/ASLs) (Press F1 for in-scope
(centers/locations))
Include any (ASCs/ASLs) that are located in satellite facilities
Enter 999 for no more

Skip Instructions:

999: IF ASL_NAME[1] = 999 goto CK1_ASLNAME
IF ASL_NAME = 999 and PREVASL_NAME ne EMPTY goto
CK2_ASLNAME
ELSE goto ASL_SPEC_GRP

ASL_SPEC_GRP
Universe:
Text:

(ASL_DEL is not 97) AND (ASL_NAME is not 999)
[?] F1

What is ASL Name's specialty group?

1.
2.
3.
4.

General Surgery
Multi-specialty
Gastroenterology
Ophthalmology

5.
6.
7.
8.
9.
10.
11.
Skip Instructions:
ASL_EVISITS
Universe:
Text:

Skip Instructions:

Orthopedics
Pain Block
Plastic Surgery
Urology

Other specialty
Goto ASL_EVISITS
ASL_DEL is not 97 and ASL_NAME is not 999
What is the expected number of ambulatory (outpatient) surgery cases
for ASL Name from (Reporting period begin date) to (Reporting period
end date)?

Goto ASL_NAME for the next row

I_ASL
Universe:
Text:

** Not Displayed **

Skip Instructions:
I_ASL_VISITS
Universe:
Text:

** Not Displayed **

Skip Instructions:
TOT_GOODASL
Universe:
Text:

** NOT Displayed **

Skip Instructions:

ANYMORE_ASLS
Universe:
Text:

1.
2.
Skip Instructions:

IF (TOT_GOODASL = 15 AND 25.ASSGNTYP = FS)
OR (TOT_GOODASL = 13) goto ANYMORE_ASLS
ELSE goto TOT_GOODASL2
(TOT_GOODASL = 15 AND 25.ASSGNTYP = FS)
OR (TOT_GOODASL = 13)
♦ The max of (15/13) (ASCs/ASLs) were entered.
Are there any more (ASCs/ASLs)?

Yes
No
1: Goto EXTRA_ASLS
2: Goto TOT_GOODASL2

EXTRA_ASLS
Universe:

ANYMORE_ASLS = 1

Text:

Skip Instructions:
TOT_GOODASL2
Universe:
Text:

Skip Instructions:
CHECK_EVISITS
Universe:
Text:

♦ How many other (ASCs/ASLs) are there?

Goto TOT_GOODASL2

** NOT Displayed **

ASL_EVISITS = 0 for all "good" ASL's (DEL_ASL ne 97 and ASL_NAME ne
999) AND ASL_INTRO = 1
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.
2.
Skip Instructions:
THANK_INELIG
Universe:
Text:

1.
Skip Instructions:
ASL_EVISITS_TOTAL
Universe:
Text:

Skip Instructions:
TOTVSAS
Universe:
Text:

Skip Instructions:

TWICELYAS

Yes
No
1: Goto EBILLRECA
2: Go back to TblASL1.ASL_NAME
(CK_NOASL = SUPPRESS AND INTRO_ASL = 2) OR (ALL ASL's have
DEL_ASL = 97 or ASC_NAME = 999)
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.

Enter 1 to Continue
Exit block and goto DONE_ASC

** Not displayed **

ASSGNTYP = HP
** Not displayed **

IF TOTVSAS = 2 goto TWICELYAS
ELSEIF TOTVSAS = 3 goto HALFLYAS
ELSE goto EBILLRECA

Universe:
Text:

TOTVSAS = 2
?[F1]
♦ Is the number of expected visits to any of the ASLs more than twice the
number shown on the previous sampling plan?
ASL
(ASL NAME

1.
2.
Skip Instructions:
TWICELYAS_SPEC
Universe:
Text:

Skip Instructions:
HALFLYAS
Universe:
Text:

Visits
Visits Previous
Current visits Previous visits)

Yes
No
1: Goto TWICELYAS_SPEC
2: Goto EBILLRECA
TWICELYAS = 1
♦ Specify why visits have increased this year or were too low the last time
the ASL participated

Goto EBILLRECA
TOTVSAS = 3
?[F1]
♦ Is the number of expected visits to any of the ASLs less than half of the
number of visits shown on the previous sampling plan?
ASL
Visits
Visits Previous
(ASL NAME
Current visits Previous visits)

1.
2.
Skip Instructions:
HALFLYAS_SPEC
Universe:
Text:

Skip Instructions:
ASCLISTA
Universe:

Yes
No
1: Goto HALFLYAS_SPEC
2: Goto EBILLRECA
HALFLYAS = 1
♦ Specify why visits have decreased this year or were too high the last
time the ASL participated

Goto EBILLRECA
TOT_GOODASL > 1 AND ASL_INTRO = 1

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.
2.
3.

Yes
No - ONLY 2 LOGS
No - More than 2 logs

Skip Instructions:

1, 2: Goto IT_CNAME
3: Goto AU_NUMBER

IT_CNAME
Universe:
Text:

ASCLISTA = 1 or 2
What is the name of the IT contact?

Skip Instructions:
IT_CTITLE
Universe:
Text:

Goto IT_CTITLE

Skip Instructions:
IT_CSTRET
Universe:
Text:

Goto IT_CSTRET

ASCLISTA = 1 or 2
What is (IT contact name)'s title?

ASCLISTA = 1 or 2
What is (IT contact name)'s address?
♦ Enter number and street or press enter if same

Skip Instructions:
IT_CSTRET2
Universe:
Text:

Goto IT_CSTRET2
ASCLISTA = 1 or 2
What is (IT contact name)'s address?
♦ Enter second line of address or press enter for none/same

Skip Instructions:
IT_CCITY
Universe:
Text:

Goto IT_CCITY
ASCLISTA = 1 or 2
What is (IT contact name)'s address?
♦

Skip Instructions:
IT_CSTATE

Enter city or press enter if same

Goto IT_CSTATE

Universe:
Text:

ASCLISTA = 1 or 2
What is (IT contact name)'s address?
♦ Enter state or press enter if same

Skip Instructions:
IT_CZIP
Universe:
Text:

Goto IT_CZIP
ASCLISTA = 1 or 2
What is (IT contact name)'s address?
♦ Enter zipcode or press enter if same

Skip Instructions:

IF entry is less than 5 digits, goto CK_IT_CZIP
ELSE goto IT_CPHONE

IT_CPHONE
Universe:
Text:

Skip Instructions:

ASCLISTA = 1 or 2
What is (IT contact name)'s phone number?

IF entry = EMPTY, goto UPDATE_BCONTACTS
ELSEIF less than 10 digits, goto CK_IT_CPHONE
ELSE Goto IT_CPHTYP

IT_CPHTYP
Universe:
Text:

0.
1.
2.
3.
4.
5.
6.
7.
8.
9.

IT_CPHONE = RESPONSE other than EMPTY
♦ Enter phone type

Main
Home
Work
Mobile
Pager, Beeper, Answering Service
Public Pay Phone
Toll Free
Other
Fax
Unknown

Skip Instructions:
UPDATE_BCONTACTS
Universe:
Text:

Goto UPDATE_BCONTACTS

Skip Instructions:
AU_NUMBER

Goto TblASL4

** Not Displayed **

Universe:

Text:

DEL_ASL ne 97 and ASL_NAME ne 999 AND ASL_NAME <> EMPTY AND
ASL_EVISITS > 0 AND(ASCLISTA.ORD = 1 or ASCLISTA.ORD = 2 or
ASCLISTA.ORD = 3)
♦ Assign AU number
Assign the same AU number to each (center/location) where the
ambulatory surgery cases can be
combined into the one listing.

Skip Instructions:
ASL_EMR
Universe:
Text:

Skip Instructions:

Goto AU_NUMBER for the next row
If asc_emr = 1 then block emr for asc
♦ Enter 1 to complete the EMR questions
OrEnter 2 to skip EMR questions and complete later

1) if 1 then emr block
2) Go to blkaddress

EBILLRECA
Universe:
Text:

Now I would like to ask you some questions about your ASL.
♦ If the ASL 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 ASL submit any CLAIMS electronically (electronic billing)?

1.
2.
3.
Skip Instructions:
EMEDRECA
Universe:
Text:

Yes
No
Unknown
Goto EMEDRECA

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

1.
2.
3.
4.
Skip Instructions:

Yes, all electronic
Yes, part paper and part electronic
No
Unknown
1,2:
Goto EHRINSYRA
3,4,DK,RF: Goto EHRINSA

EHRINSYRA
Universe:
Text:

Skip Instructions:
HHSMUA
Universe:
Text:

EMEDRECA = 1 or 2
In which year did your ASL install the current EHR/EMR system?

Go to HHSMUA
EMEDRECA = 1 or 2
?[F1]
Does your current system meet meaningful use criteria as defined by
the Department of Health and Human Services?

Skip Instructions:
EHRNAMA16
Universe:
Text:

Go to EHRNAMA16
EMEDRECA = 1 or 2
B
What is the name of your current EHR/EMR system?

1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
Skip Instructions:
EHRNAMOTHA
Universe:
Text:

Skip Instructions:
EHRINSA
Universe:

Allscripts
Amazing Charts
athenahealth
Cerner
eClinicalWorks
e-MDs
Epic
GE/Centricity
Greenway Medical
McKesson / Practice Partner
NextGen
Practice Fusion
Sage/Vitera
Other - Specify
Unknown
14: Goto EHRNAMOTHA
All others: Goto EHRINSA
EHRNAMA16 = 14
♦ Enter name of EHR/EMR system

Go to EHRINSA

Text:

1.
2.
3.
4.
Skip Instructions:
TEDEMOGA
Universe:
Text:

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

Yes
No
Maybe
Unknown
Go to TEDEMOGA

C
Indicate whether your ASL has each of the following computerized
capabilities and how often these capabilities are used.
Recording patient history and demographic information?

1.
2.
3.
Skip Instructions:

Yes
No
Unknown
Go to EPROLSTA

EPROLSTA
Universe:
Text:

TEDEMOGA = 1-3, DK, RF
C
Indicate whether your ASL has each of the following computerized
capabilities and how often these capabilities are used.

Recording patient problem list?

1.
2.
3.
Skip Instructions:
EPNOTESA
Universe:

Yes
No
Unknown
Go to EPNOTESA

Text:

C
Indicate whether your ASL has each of the following computerized
capabilities and how often these capabilities are used.
Recording clinical notes?

1.
2.
3.
Skip Instructions:

Yes
No
Unknown
Goto EMEDALGA

EMEDALGA
Universe:
Text:

EPNOTESA = 1-3, DK, RF
C
Recording patient's medications and allergies?

1.
2.
3.
Skip Instructions:
EMEDIDA
Universe:
Text:

Yes
No
Unknown
Go to EMEDIDA
EMEDALGA = 1-3, DK, RF
C
Indicate whether your ASL has each of the following computerized
capabilities and how often these capabilities are used.
Reconciling lists of patient medications to identify the most
accurate list?

1.
2.
3.
Skip Instructions:
EREMINDA
Universe:

Yes
No
Unknown
Go to EREMINDA

Text:

C
Indicate whether your ASL has each of the following computerized
capabilities and how often these capabilities are used.
Providing reminders for guideline-based interventions or screening
tests?

1.
2.
3.
Skip Instructions:
ECPOEA
Universe:
Text:

Yes
No
Unknown
Go to ECPOEA

C
Indicate whether your ASL has each of the following computerized
capabilities and how often these capabilities are used.
Ordering prescriptions?

1.
2.
3.
Skip Instructions:

Yes
No
Unknown
1: go to ESCRIPA
2, DK, RF: go to ECONTRSUBA

ESCRIPA
Universe:
Text:

ECPOEA = 1
C
Indicate whether your ASL has each of the following computerized
capabilities and how often these capabilities are used.
Are prescriptions sent electronically to the pharmacy?

1.
2.
3.
Skip Instructions:

Yes
No
Unknown
1-2,DK,RF: Goto EWARNA

EWARNA
Universe:

ECPOEA = 1
ESCRIPA: 1-2,DK,RF

Text:

C
Indicate whether your ASL has each of the following computerized
capabilities and how often these capabilities are used.

Are warnings of drug interactions or contraindications provided?

1.
2.
3.
Skip Instructions:
ECONTRSUBA
Universe:
Text:
1.
2.
3.
Skip Instructions:

ECONTRSUBSA
Universe:
Text:
1.
2.
3.
Skip Instructions:

Yes
No
Unknown
Goto ECONTRSUBA

Do you prescribe controlled substances?
Yes
No
Unknown
1 go to ECONTRSUBSA
2, DK go to ECTOEA

Are prescriptions for controlled substances sent electronically to the
pharmacy?
Yes
No
Unknown
Go to ECTOEA

ECTOEA
Universe:
Text:

ECONTRSUBA = 2, DK, RF
ECONTRSUBSA = 1-2, DK, RF
C
Indicate whether your ASL has each of the following computerized
capabilities and how often these capabilities are used.
Ordering lab tests?

1.
2.
3.
Skip Instructions:
ERESULTA

Yes
No
Unknown
1-2,DK,RF: Goto ERESULTA

Universe:
Text:

ECTOEA = 1-2,DK,RF
C
Indicate whether your ASL has each of the following computerized
capabilities and how often these capabilities are used.
Viewing lab results?

1.
2.
3.
Skip Instructions:
ERADIA
Universe:
Text:

Yes
No
Unknown
1-2,DK,RF: Goto ERADIA
ERESULTA = 1-2,DK,RF
C
Indicate whether your ASL has each of the following computerized
capabilities and how often these capabilities are used.
Ordering radiology tests?

1.
2.
3.
Skip Instructions:
EIMGRESA
Universe:
Text:

Yes
No
Unknown
Go to EIMGRESA
ERADIA = 1-2,DK,RF
C
Indicate whether your ASL has each of the following computerized
capabilities and how often these capabilities are used.
Viewing imaging results?

1.
2.
3.
Skip Instructions:
EIDPTA
Universe:

Yes
No
Unknown
Go to EIDPTA
EIMGRESA = 1-2,DK,RF

Text:

C
Indicate whether your ASL has each of the following computerized
capabilities and how often these capabilities are used.
Identifying patients due for preventive or follow-up care in order to
send patients reminders?

1.
2.
3.
Skip Instructions:
EGENLISTA
Universe:
Text:

Yes
No
Unknown
Go to EGENLISTA

C
Indicate whether your ASL has each of the following computerized
capabilities and how often these capabilities are used.
Generating lists of patients with particular health conditions?

1.
2.
3.
Skip Instructions:
EDATAREPA
Universe:
Text:

Yes
No
Unknown
Go to EIMMREGA

C
Indicate whether your ASL has each of the following computerized
capabilities and how often these capabilities are used.
Providing data to create reports on clinical care measures for
patients with specific chronic conditions (e.g., HbA1C for diabetes)

1.
2.
3.
Skip Instructions:
ESUMA
Universe:

Yes
No
Unknown
Go to ESUMA

Text:

C
Indicate whether your ASL has each of the following computerized
capabilities and how often these capabilities are used.
Providing patients with clinical summaries for each visit?

1.
2.
3.
Skip Instructions:
EMSGA
Universe:
Text:

Yes
No
Unknown
Goto EMSGA

C
Indicate whether your ASL has each of the following computerized
capabilities and how often these capabilities are used.
Exchanging secure messages with patients?

1.
2.
3.
Skip Instructions:
ESHAREA
Universe:
Text:

Yes
No
Unknown
Go to ESHAREA

1.
2.
Skip Instructions:

Yes
No
1: go to ESHARESA
2,DK,RF: Go to EDISCHSRA

ESHARESA
Universe:

ESHAREA = 1

Text:
Do you electronically send patient health information to another
provider whose EHR system is different from your own?
♦ Read answer categories
Enter all that apply, separate with commas

1.
2.
3.
Skip Instructions:
ESHARERA
Universe:
Text:

Yes
No
Unknown
1-2,DK,RF: Go to ESHARERA
ESHAREA = 1
ESHARESA: 1-2,DK,RF
Do you electronically send patient health information to another
provider whose EHR system is different from your own?
♦ Read answer categories
Enter all that apply, separate with commas

1.
2.
3.
Skip Instructions:
EDISCHSRA
Universe:
Text:

Yes
No
Unknown
Go to EDISCHSRA
ESHARERA = 1, 2, DK, RF
Do you electronically send or receive hospital discharge summaries to
or from providers outside of your medical organization?
Check all that apply.

Send electronically

Receive electronically

Do not send or receive

Skip Instructions:
EEDSRA
Universe:
Text:

Go to EEDSRA
EDISCHSRA = 1, 2, DK, RF
D
Do you electronically send or receive ASL notifications to or from
providers outside of your medical organization?
Check all that apply.

Send electronically

Receive electronically

Do not send or receive

Skip Instructions:
ESUMCSRA
Universe:
Text:

Go to ESUMCSRA
EEDSRA = 1, 2, DK, RF
Do you electronically send or receive summary of care records for
transitions of car or referrals to or from providers outside of your
medical organization?
Check all that apply.

Send electronically

Receive electronically

Do not send or receive

Skip Instructions:
PTONLINEA
Universe:
Text:

1-2, DK, RF go to PTONLINEA

Can patients seen at the reporting location do the following online
activities?
Check all that apply.

View their medical record online

Download and transmit health information in the electronic medical record to
their personal files

Request corrections to their electronic medical record

Skip Instructions:
AU_NUMBER
Universe:
Text:

Skip Instructions:
AU_TYPE
Universe:
Text:

go to AU_ONSITE

** NOT DISPLAYED **

Skip Instructions:
AU_VISITS
Universe:
Text:

** NOT DISPLAYED **

Skip Instructions:
AU_NAME
Universe:
Text:

There is more than 1 ASL associated with this rows AU_NUMBER
♦ Enter facility name where the PRF data will be collected.

Ambulatory Surgery Locations
(Names of ASL's with the same AU Number)

Skip Instructions:
AU_ONSITE
Universe:
Text:

1.
2.
Skip Instructions:

DEL_ASL ne 97 AND ASL_NAME ne 999 AND ASL_EVISITS = 1-99999
♦ Is (AU Name) on-site?

Yes
No
1: Goto ASL_PHONE
2: Goto ASL_STRET

ASL_STRET
Universe:
Text:

ASL_ONSITE = 2
What is (AU Name)'s address or the address where the abstractions will
be done?
♦

Skip Instructions:

Enter number and street.

Goto ASL_STRET2

ASL_STRET2
Universe:
Text:

ASL_ONSITE = 2
What is (AU Name)'s address or the address where the abstractions will be
done?
♦ Enter the second line of address or press enter if same/none

Skip Instructions:

Goto ASL_CITY

ASL_CITY
Universe:

ASL_ONSITE = 2

Text:

What is (AU Name)'s address or the address where the abstractions will be
done?
♦ Enter city.

Skip Instructions:

Goto ASL_STATE

ASL_STATE
Universe:
Text:

ASL_ONSITE = 2
What is (AU Name)'s address or the address where the abstractions will be
done?
♦ Enter state.

Skip Instructions:

Goto ASL_ZIP

ASL_ZIP
Universe:
Text:

ASL_ONSITE = 2
What is (AU Name)'s address or the address where the abstractions will be
done?
♦ Enter zipcode.

Skip Instructions:

IF less than 5 digits, goto CK_ASL_ZIP
ELSE Goto ASL_PHONE

ASL_PHONE
Universe:
Text:

Skip Instructions:

DEL_ASL ne 97 AND ASL_NAME ne 999 AND ASL_EVISIT ne 0
What is (AU Name)'s telephone number or the telephone number where
the abstractions will be done?

IF less than 10 digits, goto CK_ASL_PHONE
ELSE goto ASL_PHTYP

ASL_PHTYP
Universe:
Text:

0.
1.
2.
3.
4.
5.
6.
7.
8.

DEL_ASL ne 97 AND ASL_NAME ne 999 AND ASL_EVISIT ne 0
♦ Enter phone type

Main
Home
Work
Mobile
Pager, Beeper, Answering Service
Public Pay Phone
Toll Free
Other
Fax

9.
Skip Instructions:
ASL_CONTACT
Universe:
Text:

Unknown

DEL_ASL ne 97 AND ASL_NAME ne 999 AND ASL_EVISITS ne 0
♦ Enter contact person's name

Skip Instructions:
TE
Universe:
Text:

DEL_ASL ne 97 AND ASL_NAME ne 999 AND ASL_EVISITS ne 0
** NOT DISPLAYED **

Skip Instructions:
RS
Universe:

Text:

DEL_ASL ne 97 AND ASL_NAME ne 999 AND ASL_EVISITS ne 0 AND (
(AU_NUMBER ne ANY other AU_NUMBER) or (AU_NUMBER eq other
AU_NUMBER and this is the first row with that AU_NUMBER) )
** NOT DISPLAYED **

Skip Instructions:
PRF_WKLD
Universe:
Text:

DEL_ASL ne 97 AND ASL_NAME ne 999 AND ASL_EVISITS ne 0
** NOT DISPLAYED **

Skip Instructions:
MULTIASCFLAG
Universe:
Text:

** Not Displayed **

Skip Instructions:
AU_ASL_NUMS
Universe:
Text:

**Not Displayed **

Skip Instructions:
ASCDK_CHECK
Universe:

TOT_GOODASL >= 1 AND ASL_INTRO = 1 AND ASC_EMR = 1

Text:

♦

Are there any Don't Know items that you need to callback for?
Press Ctrl-M to review DKs and RFs
Press Shift-F7 to review all DK Follow-up remarks

If you MUST close this case now, due to pending close-out, and you will not
be collecting your remaining DKs and RFs, please select 2 "No", and make
any required explanation in the case notes.

1.
2.
Skip Instructions:
DONE_ASC
Universe:
Text:

Yes
No
Goto DONE_ASC

♦ Enter 1 to continue to the next department
WARNING: once you pass this screen, the ASL portion of the induction
interview will be closed, and you will not be allowed to re-enter to change any
answers or add additional AUs. If you need to go back, use your up arrow to
go back now, or press F10 to come back in later. DO NOT press 1 if you
need to come back to this department section later.

1.
Skip Instructions:

Enter 1 to Continue
Exit block and goto BlkF9_DEPT.CONTACT_DEPT

I_ASCMIN
Universe:
Text:

** Not displayed **

Skip Instructions:
I_ASCMAX
Universe:
Text:

** Not displayed **

Skip Instructions:
NUMSAS
Universe:
Text:

** NOT DISPLAYED **

Skip Instructions:
NUMCLINS
Universe:

Text:

** NOT DISPLAYED **

Skip Instructions:
NUMASLS
Universe:
Text:

** NOT DISPLAYED **

Skip Instructions:
EXIT_REFUSAL
Universe:
Text:

F10 was pressed
♦ Are you exiting this case because of a refusal?

1.
2.
Skip Instructions:
CALLBACKNOTES
Universe:
Text:

Yes
No
1: Goto BlkRefused
2: Goto CALLBACKNOTES
(EXIT_REFUSAL = 2)
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

Skip Instructions:
THANKCB
Universe:
Text:

Goto THANKCB
CALLBACKNOTES = RESPONSE
Thank you.
I will call/come back at the time suggested
♦ Revisit (Callback information)

1.
Skip Instructions:
FOLLOW_UP

Enter 1 to Continue
Exit instrument

Universe:

Text:

1.
2.
Skip Instructions:
CALLBACKNOTES
Universe:

Text:

[(EDSTATUS = 2 or 4) AND (OPDSTATUS = 5 or 6) AND
(ASCSTATUS = 5 or 6) ] OR
[(EDSTATUS = 2 or 4) AND (OPDSTATUS = 2 or 4) AND
(ASCSTATUS = 5 or 6) ] OR
[(EDSTATUS = 2 or 4) AND (OPDSTATUS = 2 or 4) AND
(ASCSTATUS = 2 or 4) ] OR
[(EDSTATUS = 2 or 4) AND (OPDSTATUS = 5 or 6) AND
(ASCSTATUS = 2 or 4) ] OR
[(EDSTATUS = 5 or 6) AND (OPDSTATUS = 2 or 4) AND
(ASCSTATUS = 5 or 6) ] OR
[(EDSTATUS = 5 or 6) AND (OPDSTATUS = 2 or 4) AND
(ASCSTATUS = 2 or 4) ] OR
[(EDSTATUS = 5 or 6) AND (OPDSTATUS = 5 or 6) AND
(ASCSTATUS = 2 or 4) ]
♦ The following departments have refused.
Do you plan to follow-up on these department(s)?

Yes, will follow-up on department(s)
No , wrap case up
1: Goto CALLBACKNOTES
2: Goto BlkRefusal_Ques
(BlkFRONT.BlkTELSCR.TRY_BACK = 1) OR
(BlkFRONT.BlkTELSCR.NEW_CONTACT = 2) OR
(BlkFRONT.BlkTELSCR.INTROB = 2) OR
(BlkFRONT.BlkTELSCR.SCREENER_PV = 3) OR
(BlkFront.BlkInduct.INTRO_IND = 2) OR
(BlkFRONT.BlkInduct.TRY_BACK = 1) OR
(BlkFRONT.BlkInduct.NEW_CONTACT = 2) OR
(BlkFRONT.BlkInduct.INTROB = 2) OR
(BlkFRONT.BlkIndAppt.TRY_BACK = 1) OR
(BlkFRONT.BlkIndAppt.NEW_CONTACT = 2) OR
(FOLLOW_UP = 1) OR
(BlkFront.BlkDept_int.INTRO_DEPT = 2)
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

Skip Instructions:
THANKCB
Universe:
Text:

Goto THANKCB
CALLBACKNOTES = RESPONSE
Thank you.
I will call/come back at the time suggested.
♦ Revisit (Callback information)

Enter 1 to Continue

Skip Instructions:
THANKYOU
Universe:

Text:

Exit instrument
[(EDSTATUS = 5 or 6) AND (OPDSTATUS = 5 or 6) AND
(ASCSTATUS = 5 or 6) ]
This concludes the interview. Thank you for your patience, and for
taking the time to answer
our questions.

Enter 1 to Continue

Skip Instructions:
SET_REINT
Universe:
Text:

Exit instrument

Skip Instructions:
HOSPREF
Universe:
Text:

EXIT INSTRUMENT

Skip Instructions:
REFUSED_FOR
Universe:
Text:

Goto REFUSED_FOR

** Non Displayed **

** Not displayed **

MARK = 22
♦ Is this refusal for the hospital, ED department, OPD department and/or
Ambulatory Surgery?
Enter all that apply, separate with commas

1.
2.
3.
4.

Hospital
ED Department
OPD Department
Ambulatory Surgery

Skip Instructions:

IF (BlkScreener.ELIGREQ = 1, 6, 7 or 9) AND
BlkDepartments.BlkED_DEPT.TOTVSED = EMPTY goto VSED101
IF (BlkScreener.ELIGREQ = 2, 6, 8 or 9) AND
BlkDepartments.BlkOPD_DEPT.TOTVSOP = EMPTY goto VSOPD101
IF (BlkScreener.ELIGREQ = 3, 7, 8 or 9) AND
BlkDepartments.BlkASC_DEPT.BlkASL.TOTVSAS = EMPTY goto
VSASC101
IF 1 selected, goto WHOMHOSP
IF 2 selected, goto WHOMED
IF 3 selected, goto WHOMOP
else goto WHOAS

ELIGED
Universe:
Text:

1.
2.
Skip Instructions:

HOSPREF = 1 AND ELIGREQ = EMPTY AND MARK <= 18
♦ Does this hospital have an eligible ED?

Yes
No
1: Goto VSED101
2: Goto ELIGOPD

VSED101
Universe:
Text:

Skip Instructions:

ELIGED = 1 OR ((BlkScreener.ELIGREQ = 1, 6, 7 or 9) AND
BlkDepartments.BlkED_DEPT.TOTVSED = EMPTY)
♦ Enter number of expected visits for the ED

DK: Goto VSEDLY
All others, goto ELIGOPD

VSEDLY
Universe:
Text:

Skip Instructions:
ELIGOPD
Universe:
Text:

VSED101 = DK
♦ Enter the number of visits to the department last year

Goto ELIGOPD
HOSPREF = 1 AND ELIGREQ = EMPTY AND MARK <= 18
♦ Does this hospital have an eligible OPD?

Yes

2.
Skip Instructions:

No
1: Goto VSOPD101
2: Goto ELIGASC

VSOPD101
Universe:
Text:

Skip Instructions:

ELIGOPD = 1 OR (BlkScreener.ELIGREQ = 2, 6, 8 or 9) AND
BlkDepartments.BlkOPD_DEPT.TOTVSOP = EMPTY)
♦ Enter number of expected visits for this OPD.

DK: Goto VSOPDCLY
All others, goto ELIGASC

VSOPDLY
Universe:
Text:

Skip Instructions:
ELIGASC
Universe:
Text:

1.
2.
Skip Instructions:

VSOPD101 = DK
♦ Enter number of OPD visits last year

Goto ELIGASC
HOSPREF = 1 AND ELIGREQ = EMPTY AND MARK <= 18
♦ Does this hospital have an eligible ambulatory surgery location?

Yes
No
1: Goto VSASL101
2: Exit block and goto DONE

VSASC101
Universe:
Text:

Skip Instructions:

ELIGASC = 1 OR ((BlkScreener.ELIGREQ = 3, 7, 8 or 9) AND
BlkDepartments.BlkASC_DEPT.BlkASL.TOTVSAS = EMPTY)
♦ Enter number of expected visits for the ambulatory surgery location

DK: Goto VSASCLY
All other, exit block and goto DONE

VSASCLY
Universe:
Text:

Skip Instructions:
WHOMHOSP
Universe:
Text:

VSASC101 = DK
♦ Enter number of ambulatory surgery visits last year

Exit block and goto DONE
MARK < 22 OR (1 selected in REFUSED_FOR)
♦ Who refused for the hospital?

1.
2.
3.
Skip Instructions:

Hospital administrator
Approval board or official
Other hospital official
1,2: Goto TELPERHO
3: Goto WHOMHOSPSPEC

WHOMHOSPSPEC
Universe:
Text:

WHOMHOSP = 3
♦ Specify the name of the other hospital official who refused for the hospital

Skip Instructions:
TELPERHO
Universe:
Text:

WHOMHOSP = 1-3
♦ Was the refusal by telephone or in person for the hospital?

1.
2.
Skip Instructions:

Telephone
In person
IF 2 selected in REFUSED_FOR goto WHOMED
IF 3 selected in REFUSED_FOR goto WHOMOP
IF 4 selected in REFUSED_FOR goto WHOMAS

WHOMED
Universe:
Text:

1.
2.
3.
4.
Skip Instructions:

2 selected in REFUSED_FOR
♦ Who refused for the ED Department?

Hospital administrator
ED/OPD/Ambulatory Surgery Director
Approval board or official
Other hospital official-Specify
1-3: Goto TELPERED
4: Goto WHOMEDSPEC

WHOMEDSPEC
Universe:
Text:

♦ Specify the name of the other hospital official who refused for the ED

Skip Instructions:
TELPERED
Universe:
Text:

WHOMED = 1-4
♦ Was the refusal by telephone or in person for the ED?

1.
2.

Telephone
In person

Skip Instructions:

IF 3 selected in REFUSED_FOR goto WHOMOP
IF 4 selected in REFUSED_FOR goto WHOMAS
ELSE goto REASON

WHOMOP
Universe:
Text:

1.
2.
3.
4.
Skip Instructions:

3 selected in REFUSED_FOR
♦ Who refused for the OPD Department?

Hospital administrator
ED/OPD/Ambulatory Surgery Director
Approval board or official
Other hospital official-Specify
1-3: Goto TELPERED
4: Goto WHOMOPSPEC

WHOMOPSPEC
Universe:
Text:

♦ Specify the name of the other hospital official who refused for the OPD

Skip Instructions:
TELPEROP
Universe:
Text:

WHOMOP = 1-4
♦ Was the refusal by telephone or in person for the OPD?

1.
2.
Skip Instructions:

Telephone
In person
IF 4 selected in REFUSED_FOR goto WHOMAS
ELSE goto REASON

WHOMAS
Universe:
Text:

1.
2.
3.
4.
Skip Instructions:
WHOMASSPEC
Universe:
Text:

Skip Instructions:
TELPERAS

4 selected in REFUSED_FOR
♦ Who refused for Ambulatory Surgery?

Hospital administrator
ED/OPD/Ambulatory Surgery Director
Approval board or official
Other hospital official-Specify
1-3: Goto TELPERAS
4: Goto WHOMASSPEC

♦ Specify the name of the other hospital official who refused for the ASL

Universe:
Text:

1.
2.

WHOMAS = 1-4
♦ Was the refusal by telephone or in person for the ASL?

Telephone
In person

Skip Instructions:
REASON
Universe:
Text:

♦ Specify what reason was given for the refusal/breakoff

Skip Instructions:
CONVHOSP
Universe:
Text:

MARK < 22 OR (1 selected in REFUSED_FOR)
♦ Was conversion attempted for the hospital?

1.
2.
Skip Instructions:
CONVED
Universe:
Text:

1.
2.
Skip Instructions:
CONVOP
Universe:
Text:

1.
2.
Skip Instructions:
CONVAS
Universe:
Text:

Yes
No

2 selected in REFUSED_FOR
♦ Was conversion attempted for the ED Department?

Yes
No

3 selected in REFUSED_FOR
♦ Was conversion attempted for the OPD Department?

Yes
No

4 selected in REFUSED_FOR
♦ Was conversion attempted for the Ambulatory Surgery?

Yes

Skip Instructions:
PERSON_TYPE
Universe:
Text:

** NOT DISPLAYED **

Skip Instructions:
PERSON_NUMBER
Universe:
Text:

** NOT DISPLAYED **

Skip Instructions:
MAIN_IND
Universe:
Text:

** NOT DISPLAYED **

Skip Instructions:
FIRST_NAME
Universe:
Text:

** Not Displayed **

Skip Instructions:
MIDDLE_NAME
Universe:
Text:

** Not Displayed **

Skip Instructions:
LAST_NAME
Universe:
Text:

** Not Displayed **

Skip Instructions:
TITLE
Universe:
Text:

Skip Instructions:
ADDR1
Universe:
Text:

** Not Displayed **

** NOT DISPLAYED **

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ADDR2
Universe:
Text:

** NOT DISPLAYED **

Skip Instructions:
CITY
Universe:
Text:

** NOT DISPLAYED **

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STATE
Universe:
Text:

** NOT DISPLAYED **

Skip Instructions:
ZIP
Universe:
Text:

** NOT DISPLAYED **

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PHONE_1
Universe:
Text:

** NOT DISPLAYED **

Skip Instructions:
PHONE_1_EXT
Universe:
Text:

** NOT DISPLAYED **

Skip Instructions:
PHONE_1_TYPE
Universe:
Text:

** NOT DISPLAYED **

Skip Instructions:
PHONE_2
Universe:
Text:

** NOT DISPLAYED **

Skip Instructions:
PHONE_2_EXT
Universe:
Text:

** NOT DISPLAYED **

Skip Instructions:
PHONE_2_TYPE
Universe:
Text:

** NOT DISPLAYED **

Skip Instructions:
PHONE_3
Universe:
Text:

** NOT DISPLAYED **

Skip Instructions:
PHONE_3_EXT
Universe:
Text:

** NOT DISPLAYED **

Skip Instructions:
PHONE_3_TYPE
Universe:
Text:

** NOT DISPLAYED **

Skip Instructions:
PHONE_4
Universe:
Text:

** NOT DISPLAYED **

Skip Instructions:
PHONE_4_EXT
Universe:
Text:

** NOT DISPLAYED **

Skip Instructions:
PHONE_4_TYPE
Universe:
Text:

** NOT DISPLAYED **

Skip Instructions:
SPECIALTY_CODE
Universe:
Text:

** NOT DISPLAYED **

Skip Instructions:
DEGREE_CODE
Universe:
Text:

** NOT DISPLAYED **

Skip Instructions:
RESPONDENT_FLAG
Universe:
Text:

** NOT DISPLAYED **

Skip Instructions:
CALLBACK
Universe:
Text:

** Not Displayed **

Skip Instructions:
MARK
Universe:
Text:

Skip Instructions:
MARK_PROCEDURE
Universe:
Text:

** NOT DISPLAYED **

<1-22>
ALL
** NOT DISPLAYED **

Skip Instructions:
OUTCOME
Universe:
Text:

** Non-Displayed Field **

Skip Instructions:
OUTCOME_Procedure
Universe:
Text:

** Not Displayed **

Skip Instructions:
MANIPULA_OUT_SCRI
PT
Universe:
Text:

** NOT DISPLAYED **

Skip Instructions:
AU_NEW_SCRIPT
Universe:
Text:

** NON Displayed **

Skip Instructions:
DATE_STAMPS
Universe:
Text:

** NOT DISPLAYED **

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LST_MARK
Universe:
Text:

** NOT DISPLAYED **

Skip Instructions:
SITE
Universe:
Text:

** Not Displayed **

Skip Instructions:
OLDSITE
Universe:
Text:

*** NOT DISPLAYED ***

Skip Instructions:
NEWMGTSTRUC
Universe:
Text:

*** NOT DISPLAYED ***

Skip Instructions:
FACILITYNAME
Universe:
Text:

** NOT DISPLAYED **

Skip Instructions:
ADDR1
Universe:
Text:

** NOT DISPLAYED **

Skip Instructions:
ADDR2
Universe:
Text:

** NOT DISPLAYED **

Skip Instructions:
PLACE
Universe:
Text:

** NOT DISPLAYED **

Skip Instructions:
ST
Universe:
Text:

** NOT DISPLAYED **

Skip Instructions:
ZIP5
Universe:
Text:

** NOT DISPLAYED **

Skip Instructions:
ZIP4
Universe:
Text:

** NOT DISPLAYED **

Skip Instructions:
MFACSTRET
Universe:
Text:

** NOT DISPLAYED **

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MFACSTRET2
Universe:
Text:

** NOT DISPLAYED **

Skip Instructions:
MFACCITY
Universe:
Text:

** NOT DISPLAYED **

Skip Instructions:
MFACST
Universe:
Text:

** NOT DISPLAYED **

Skip Instructions:
MFACZIP
Universe:
Text:

** NOT DISPLAYED **

Skip Instructions:
MFACZIP4
Universe:
Text:

** NOT DISPLAYED **

Skip Instructions:
GREETNAME
Universe:
Text:

** Not Displayed **

Skip Instructions:
FACPHONE
Universe:
Text:

** NOT DISPLAYED **

Skip Instructions:
FACEXTN
Universe:
Text:

** NOT DISPLAYED **

Skip Instructions:
FACPHTYP
Universe:
Text:

** NOT DISPLAYED **

Skip Instructions:
FRC_FACIND
Universe:
Text:

** NOT DISPLAYED **

Skip Instructions:
FRN_FACIND
Universe:
Text:

** NOT DISPLAYED **

Skip Instructions:
ROINTID
Universe:
Text:

** NOT DISPLAYED **

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PAPERSUPDROP
Universe:
Text:

** Not Displayed **

Skip Instructions:

File Type	application/pdf
Author	Akinseye, Akintunde (CDC/OPHSS/NCHS)
File Modified	2015-08-28
File Created	2015-08-28