Form 3 ASC Site Information Form

Site-Level Data File Specifications

AHRQ Ambulatory Surgery Center

Survey on Patient Safety Culture

Use these instructions if you are submitting data from one or more ambulatory surgery centers.

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 Site IDs in your 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 (row) 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:

1. An ambulatory surgery center (ASC) is defined as CMS-certified and approved ASCs with a valid CMS Certification Number (CCN) (see CMS web site for more information https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/CertificationandComplianc/ASCs.html)

NOTE: Visit the Quality Reporting Center website at:
http://www.qualityreportingcenter.com/en/ascqr-program/data-dashboard/asc-compare-tool-2017/ to find your facility and its CCN number. You can also look up your CCN number by entering in your facility's 10-digit NPI number at: http://www.qualityreportingcenter.com/en/ascqr-program/data-dashboard/ccn/

2. ASCs operate exclusively to provide surgical/procedural services to patients that do not require hospitalization (except in unusual circumstances)

3. ASCs do not share space with a hospital or hospital outpatient surgery department

4. Each ASC that is part of an ASC management company or health care system is considered a separate ambulatory surgery center.

	Column	Variable Name	Variable Label	Type			Details/Comments
	Column A*	SiteID	Site ID		Numeric	Unique Site ID matching Site IDs in 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)
	You must enter the name, phone number, and email of the contact person at each ambulatory surgery center.
	Column H*	Contact_First	Contact First Name		Character
	Column I*	Contact_Last	Contact Last Name		Character
	Column J*	Contact_Phone	Contact Phone #		Numeric	10-digit phone number with no spaces or dashes
	Column K	Contact_Ext	Contact Extension		Numeric	Phone number extension
	Column L*	Contact_Email	Contact Email Address		Character
	Column M*	CCN	Facility CMS Certification Number (CCN)	Character			10 digit CMS Certified Number
	Column N*	Ownership	Which best describes the majority ownership of this ambulatory surgery center?	Numeric (1-4)			1 = Management company owned 2 = Physician owned 3 =Hospital or Health System 4 = Other/A mix of ownership
	Column O*	Status	Which type of organization controls and operates the ambulatory surgery center?	Numeric (1-3)			1 = Not for profit 2 = For profit 3 = Government
	Column P*	Denominator	Total number of employees asked to complete the survey	Numeric			Must be 5 or more.
	Column Q*	SurveyMode	What was the mode used to administer the survey?	Numeric (1-4)			1 = Paper 2 = Web 3 = Mixed mode (paper & web) 4 = Other
	Column R*	StartMonth	Start Month of Data Collection Completion	Numeric (1-12)			Month of data collection start
	Column S*	StartYear	Start Year of Data Collection Completion	Numeric			Year of data collection start (YYYY)
	Column T*	EndMonth	End Month of Data Collection Completion	Numeric (1-12)			Month of data collection completion
	Column U*	EndYear	End Year of Data Collection Completion	Numeric			Year of data collection completion (YYYY)
	Column V*	Num_procedure_rms	What is the total number of operating/procedure rooms at this location?	Numeric (1-6)			1 = 1-2 rooms 2 = 3 rooms 3 = 4 rooms 4 = 5 rooms 5 = 6 rooms 6 = 7 or more rooms
	Column W*	Type_procedure	Which of the following best describes the types of procedures performed at this location?	Numeric (1-2)			1 = Single specialty 2 = Multispecialty
	If single specialty ONLY, select one specialty from the list of specialties in Column X.
Column X**		Specialty	What is the specialty of the procedure(s) performed at this location?	Numeric (1-13)			1 = Cardiology 2 = Gastroenterology 3 = General Surgery 4 = Ophthalmology 5 = Oral Surgery 6 = Orthopedics 7 = Otolaryngology 8 = Pain Management 9 = Plastic Surgery 10 = Podiatry 11 = Spine Surgery 12 = Urology 13 = Other specialty (please specify)
	Column Y*	Specialty_OS	For other specialty, please specify	Character (1000 max.)			If specialty (Column X) = 13, please specify the other specialty

*Indicates required information for each ambulatory surgery center.

** Required only for single specialty ambulatory surgery centers.

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