OMB Number: 0915-0366; Expiration date: XX/XX/202X
Entities Survey: Module 4
Number of questions: 21
This module is relevant for the following entities identified in Module 2:
Health Plan and Other Health Care Entities (e.g., Group Practice, Clinic, Community Health Center, Urgent Care Facility or Ambulatory Health Care), and the Other category.
Demographics Related Questions
Q 4.1. Which of the following best characterizes your organization?
Health Plan
Group Practice
Clinic
Community Health Center
Urgent Care Facility
Ambulatory Health Care
Other (Please Specify) _________________
Q 4.2. Is your organization affiliated with a larger enterprise or network that provides employment or credentialing services for practitioners on your behalf?
Yes
No
Other (Please Explain) _________
Survey Page Break
Q 4.3. How would you classify the larger enterprise or network that provides your organization with employment or credentialing services (if applicable)?
Hospital
Hospital System
Health Plan
Credentialing Verification Organization
Locum Tenens Group
Other Business Entity (Please Explain) ______
Not applicable
Q 4.4. Does your organization serve inpatients, outpatients, or both?
Inpatients
Outpatients
Both Inpatients and Outpatients
Not Applicable (Please Explain) __________
Q 4.5. For the typical year, approximately how many patients does your organization 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) ________
Not applicable
Q 4.6. For each of the categories listed below, how many health care practitioners serve in your organization? 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 4.7. How many employees in your organization are responsible for hiring and granting privileges to practitioners?
Type a number: __________
Do not know (Please Explain) ________
Q 4.8. How often does your organization review the records of practitioners employed on staff or that have been 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) __________
Q 4.9. Which of the following sources does your organization 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 4.10. Has your organization ever taken any NPDB reportable action(s)?
Yes
No Skip to Q 4.12
Q 4.11. How many NPDB reportable actions has your organization taken in the last 5 years?
Dropdown menu: 1 to 10, more than 10
Do not know (Please Explain)
Q 4.12. In the last 5 years, how many times has your organization 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 4.13. In the last 5 years, how many times does your organization suspend or restrict the clinical privileges / panel membership of practitioners for the following length of time? (Only one answer per row.)
Dropdown menu for each item: 1 to 10, more than 10, Do not know
Fewer than 31 days
More than 30 days
Q 4.14. Does your organization use a risk management program for reducing medical errors?
Yes
No
Do not know
Other (Please Explain) _____________
Q 4.15. How confident are you in your organization’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 4.16. How is your organization insured for medical malpractice?
Self-Insured
Captive Insured Skip to Q 4.18
Third Party Insured Skip to Q 4.18
Uninsured Skip to Q 4.18
Other (Please Explain) ___________ Skip to Q 4.18
Q 4.17. In your organization, who is named in medical malpractice cases?
Health Care Practitioner
Health Care Organization
Both
Other (Please Explain) __________
Q 4.18. For the typical year, to how many health care practitioners does your organization provide medical malpractice insurance?
Type a number: __________
Do not know (Please Explain) ________
Not applicable (Please Explain) _______
Other comments (if you have any) _________
Survey Page Break
Q 4.19. Is your organization accredited by a national accreditation organization?
Yes
No
Not Applicable (Please Explain) _______
If “yes”, show the next two questions. Otherwise, end this module.
Q 4.20. Which organization has accredited your organization?
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 4.21. Does this accreditation organization require your organization to query the NPDB?
Yes
No
Piping Logic:
Survey will be directed to Module 8 next.
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| Author | Microsoft User |
| File Modified | 0000-00-00 |
| File Created | 2021-04-12 |