Form 3 ASC Site Information Form

Ambulatory Surgery Center Survey on Patient Safety Culture Database

Attachment C - ASC Site-Level Data File Specifications

ASC Site Information Form

OMB: 0935-0242

Document [docx]
Download: docx | pdf



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/

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

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

  3. 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.



ASC-0221 16



File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
File TitleAHRQ Ambulatory Surgery Center Survey on Patient Safety Culture Site-Level Data File Specifications
SubjectAHRQ Ambulatory Surgery Center Survey on Patient Safety Culture Site-Level Data File Specifications
AuthorAHRQ SOPS User Network
File Modified0000-00-00
File Created2021-09-09

© 2024 OMB.report | Privacy Policy