OMB Number: 0915-0366; Expiration date: XX/XX/202X
Entities Survey: Module 3
Number of questions: 28
This module is relevant for the Hospital and Hospital System categories, as identified in Module 2.
Demographics Related Questions
Q 3.1. Which of the following two categories best describes your organization?
An independent hospital with its own credentialing Skip to Q 3.3
A hospital system consisting of two or more hospitals with centralized credentialing
A hospital system consisting of two or more hospitals with decentralized credentialing
Other (please specify) __________
Survey Page Break
Q 3.2. For how many hospitals do your work responsibilities include reviewing health care practitioner records?
Dropdown menu: 2 to 10, 10+
Survey Page Break
Please note that the term, “hospital” in subsequent questions refers to a single hospital or a hospital system for which you have credentialing responsibilities.
Survey Page Break
Q 3.3. For the typical year, how many staffed beds are in your hospital?
Fewer than 100 beds
100 to 399 beds
400 to 999 beds
1000 or more beds
Do not know (Please Explain) _______
Survey Page Break
Q 3.4. For the typical year, approximately how many patients (including inpatients and outpatients) does your hospital serve?
Less than 2,500 patients
At least 2,500 patients but less than 5,000 patients
At least 5,000 patients but less than 7,500 patients
At least 7,500 patients but less than 10,000 patients
At least 10,000 patients or more
Do not know (Please Explain)
Q 3.5. How would you characterize your hospital? Select one of the categories below:
Federal government hospital (e.g., Veterans Affairs, Department of Defense)
State government hospital
Local government hospital
Tribal hospital
Non-profit hospital
For-profit hospital
Other (Please Explain) __________
Q 3.6. How is your hospital insured for medical malpractice?
Self-Insured
Captive or Third Party Insured Skip to Q 3.9
Uninsured Skip to Q 3.9
Other (Please Explain) ______ Skip to Q 3.9
Q 3.7. In your hospital, who is named in medical malpractice cases?
Health Care Practitioner
Health Care Organization
Both
Other (Please Explain) __________
Q 3.8. For the typical year, to how many health care practitioners does your hospital provide medical malpractice insurance?
Type a number: __________
Do not know (Please Explain) ________
Other comments (if you have any) _________
Q 3.9. For each of the categories listed below, how many health care practitioners serve in your hospital? Type a number for each category. If you do not know, select “do not know” and explain your response. If the category is not applicable to your organization, select “Not applicable.” If your organization does not employ anyone for a particular category, type “0” (zero) for that category. If you are not sure of the exact number for any given category, provide your best estimate. If you have any comments, please enter them in the text box provided below.
MDs and DOs
Full-Time _____
Part-Time _____
Contractors ____
Locum tenens_____
Do not know (please explain) ______
Not applicable
Dentists
Full-Time _____
Part-Time _____
Contractors ____
Locum tenens_____
Do not know (please explain) ______
Not applicable
Advanced Practice Registered Nurses
Full-Time _____
Part-Time _____
Contractors ____
Do not know (please explain) ______
Not applicable
Registered Nurses
Full-Time _____
Part-Time _____
Contractors ____
Do not know (please explain) ______
Not applicable
Physician Assistants
Full-Time _____
Part-Time _____
Contractors ____
Do not know (please explain) ______
Not applicable
Other Health Care Practitioners
Full-Time _____
Part-Time _____
Contractors ____
Do not know (please explain) ______
Not applicable
Comments (if you have any) _________________
Q 3.10. How many employees in your hospital are responsible for hiring and granting privileges to practitioners?
Type a number: __________
Comments (if you have any): ____________
Q 3.11. How often does your hospital review the records of practitioners employed on staff or granted privileges at your facility?
Once every 6 months
Once per year
Once every 2 years
Once every 3 years
Once every 4 or more years
Ongoing
Other (Please Explain) __________
Survey Page Break
Q 3.12. Which of the following sources does your hospital utilize for hiring or granting privileges to a practitioner? (Please select all that apply.)
National Practitioner Data Bank (NPDB)
Practitioner’s Self-Queries of the NPDB
Board Action Data Bank of the Federation of State Medical Boards (FSMB) or other national organization(s) of state licensing boards for non-physician practitioners
Licensing board(s) in your state
Licensing board(s) in another state
Practitioner’s current medical malpractice/liability insurance carrier(s)
Practitioner’s previous medical malpractice/liability insurance carrier(s)
Practitioner’s current affiliated health plan(s)
Practitioner’s previous affiliated health plan(s)
Other health care entities (other hospitals, HMOs, group practice, etc.)
Professional society(ies) (e.g., AMA, AOA, ANA, etc.).
Medical school(s) or other professional school(s)
Residency program(s)
Speciality certification organizations (e.g., ABMS)
OIG exclusion list
Drug Enforcement Agency exclusion list
Peer or professional references
Other (Please Explain) ____________
Please note that the term, “NPDB reportable action(s)” in subsequent questions refers to adverse actions reportable to the NPDB, and not medical malpractice payment reports.
Q 3.13. Has your hospital ever taken any NPDB reportable action(s)?
Yes
No Skip to Q 3.15
Q 3.14. How many NPDB reportable actions has your hospital taken in the last 5 years?
Dropdown menu: 1 to 10, more than 10
Do not know (Please Explain) _____________
Q 3.15. In the last 5 years, how many times has your hospital taken the following actions regarding practitioners? (Only one answer per row.)
Dropdown menu for each item: 1 to 10, more than 10, Do not know
Terminated employment or contract
Action limiting, restricting, or suspending clinical privileges lasting more than 30 days
Action limiting, restricting, or suspending clinical privileges lasting fewer than 31 days
Fine or loss of compensation
Counseling
Continuing medical education
Professional practice evaluation (e.g., ongoing or focused evaluation)
Reprimand
Assignment of a proctor who must attend or approve the practitioner’s procedures
Assignment of a proctor who is not required to attend or approve the practitioner’s procedures
Acceptance of resignations while under investigation
Other (Please Explain) ___________
Q 3.16. In the last 5 years, how many times does your hospital suspend or restrict clinical privileges of practitioners for the following lengths of time? (Only one answer per row.)
Dropdown menu for each item: 0 to 10, more than 10, Do not know
Fewer than 31 days
More than 30 days
Q 3.17. Does your hospital use a risk management program for reducing medical errors?
Yes
No
Do not know
Other (Please Explain)
Q 3.18. How confident are you in your hospital’s risk management program for reducing medical errors?
Rating Scale
Not at all / To a small extent / To some extent / To a moderate extent / To a great extent / To a very great extent
Survey Page Break
Q 3.19. Is your hospital accredited by a national accreditation organization?
Yes
No Skip to Q 3.22.
Not Applicable (Please Explain) _______ Skip to Q 3.22.
Survey Page Break
Q 3.20. Which organization has accredited your hospital?
Accreditation Association for Ambulatory Health Care (AAAHC)
Accreditation Commission for Health Care, Inc (ACHC)
American Association for Accreditation of Ambulatory Surgery Facilities (AAAASF)
American Osteopathic Association/Healthcare Facilities Accreditation Program (HFAP)
Center for Improvement in Healthcare Quality (CIHQ)
Community Health Accreditation Partner (CHAP)
Commission on Accreditation of Rehabilitation Facilities (CARF)
Council on Accreditation (COA)
DNV GL - Healthcare (DNV GL)
Institute for Medical Quality (IMQ)
National Committee for Quality Assurance (NCQA)
National Dialysis Accreditation Commission (NDAC)
The Compliance Team (TCT)
The Joint Commission (TJC)
Utilization Review Accreditation Commission (URAC)
Other (Please Specify) ________________
Q 3.21. Does this accreditation organization require your organization to query the NPDB?
Yes
No
Survey Page Break
Q 3.22. Is your hospital located in a state where the medical board has a monetary penalty (for the hospital) for not reporting clinical privileges actions to the state medical board?
Yes
No Skip to Q 3.24
Not Applicable (Please Explain) ______________ Skip to Q 3.24
Do not know Skip to Q 3.24
Q 3.23. Has your hospital ever been penalized by the state medical board for not reporting clinical privileges actions to the state medical board?
Yes
No
Do not know
Survey Page Break
Q 3.24. Has your hospital ever received a rating for patient safety and quality of care from the Centers for Medicare & Medicaid Services (CMS)?
Yes
No Skip to Q 3.26
Not Applicable (Please Explain) ______________ Skip to Q 3.26
Do not know Skip to Q 3.26
Q 3.25. Which of the following rating has your hospital received from the CMS?
One star
Two stars
Three stars
Four stars
Five stars
Do not know
Q 3.26. Has your hospital ever received a rating/grade for patient safety and quality of care from any organization other than the CMS?
Yes
No Skip to Module 8
Not Applicable (Please Explain) ______________ Skip to Module 8
Do not know Skip to Module 8
Q 3.27. What is the name of the organization that rated/graded your hospital?
Textbox
Q 3.28. Which rating/grade did the organization give to your hospital?
Textbox
Piping Logic:
Survey will be directed to Module 8 next.
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Microsoft User |
| File Modified | 0000-00-00 |
| File Created | 2021-02-15 |