Form 3 ASC Site Information Form

AHRQ Ambulatory Surgery Center Survey on Patient Safety Culture Database, Supporting Statement A

Attachment B: Site Information (Data File Specifications)

Site-Level Data File Specifications

AHRQ Ambulatory Surgery Center Survey on

Patient Safety Culture

Use these instructions if you are submitting data from multiple ambulatory surgery centers all at the same time.

INSTRUCTIONS:

Step 1: Site-level data must be in Excel format (.xls, .xlsx).

Step 2: Include a header row with the variable name for each column.

Please include all variable names from the table below and ensure that each one is entered in the correct column. Failure to do so will result in delays in processing your data.

Step 3: Site IDs must match IDs in respondent-level data file.

Please enter a unique Site ID for each ambulatory surgery center. Make sure that each ambulatory surgery center’s Site ID matches its Site ID in your respondent-level data file. This step is crucial for linking site-level and respondent-level data.

Step 4: File must contain one record for each ambulatory surgery center.

Enter each ambulatory surgery center in a separate row, including all required variables from the table below.

Definition of aN Ambulatory Surgery Center:

• An ambulatory surgery center is defined as a facility where patients have surgeries, procedures, and treatments and are NOT expected to need an inpatient stay, and has been certified and approved to participate in the Centers for Medicare & Medicaid Services' ASC program.

Column	Variable Name	Variable Label	Type			Details/Comments
Column A*	SiteID	Site ID		Numeric	Unique Site ID matching respondent-level data file.
Column B*	SiteName	Site Name		Character	Please use a unique name for each ambulatory surgery center.
Column C*	Address1	Street Address 1		Character
Column D	Address2	Street Address 2		Character
Column E*	City	City		Character
Column F*	State	State		Character	2-character State abbreviation
Column G*	ZipCode	Zip Code		Character	5-digit zip code (include leading zeroes)
Column H	ZipPlusFour	Zip Code +4		Numeric	4-digit zip code extension
You must enter the name, phone number, and email of the contact person at each ambulatory surgery center.
Column I*	ContactFirst	Contact First Name		Character
Column J*	ContactLast	Contact Last Name		Character
Column K*	ContactPhone	Contact Phone #		Numeric	10-digit phone number with no spaces or dashes
Column L	ContactExt	Contact Extension		Numeric	Phone number extension
Column M*	ContactEmail	Contact Email Address		Character
*Indicates required information for each ambulatory surgery center.
Column N*	Denominator	Total number of employees asked to complete the survey	Numeric			Must be 5 or more.
Column O*	SurveyMode	What was the mode used to administer the survey?	Numeric (1-4)			Paper Web Mixed mode (paper & web) Other
Column P*	EndMonth	End Month of Data Collection Completion	Numeric (1-12)			Month of data collection completion
Column Q*	EndYear	End Year of Data Collection Completion	Numeric			Year of data collection completion (YYYY)
Column R*	Ownership	Which best describes the majority ownership of this ambulatory surgery?	Numeric (1-2)			Freestanding Hospital Affiliated
Column S*	TypeProcedure	Which of the following best describes the types of procedures performed at this location?	Numeric (1-2)			Single Specialty Mixed Specialty
If single specialty ONLY, select one specialty from the list of specialties in Column T.
Column T**	Specialty	What is the specialty of the procedure(s) performed at this location?				Non-surgical - Ophthalmology & Gastrointestinal Non-surgical - Pain Non-surgical - Ophthalmology Dermatology Orthopedic Pain Gastrointestinal Only Other Specialty
Column U*	NumDoctors	What is the total number of doctors who work at least 4 times in the past month for past 6 months?	Numeric			Enter total number of doctors
Column V*	NumProcedureRms	What is the total number of operating/procedure rooms at this location?	Numeric			Enter total number of rooms

*Indicates required information for each ambulatory surgery center.

** Required only for single specialty ambulatory surgery centers.

ASC-1117 3