1 Appendix A: Organizational Characteristics Survey

Generic Clearance for the Collection of Qualitative Feedback on Agency Service Delivery

Appendix A_Organizational Characteristics Survey

OMB: 0935-0179

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Appendix A – Organization Characteristics Survey



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Form Approved
OMB No.
xxxx-xxxx
Exp. Date xx/xx/
20


Diagnostic Safety Capacity Building – Diagnostic Safety Measurement Resource

Please complete the following information about your organization:

General Information About Your Organization

Organization name


Mailing address (city, state, ZIP code)


Contact person and title


Organization type

Academic medical center

Other not-for-profit

For-profit

Types of facilities within organization (check all that apply and indicate number of facilities)

Hospital(s): ___ (total number of beds: ___)

Annual # of admissions: ___

Emergency department(s): ___

Annual # of ED visits: ____

Ambulatory clinic site(s): ___

Annual # of ambulatory clinic visits: ____

Approximate number of active staff clinicians

Physicians

__________


Advance Practice Practitioners (NP, PA)

___________




Total number of patients served by organization

Number of hospital admissions per year: __________


Number of ambulatory clinic visits per year: __________

Race (indicate % of patients)


White

Black or African American

American Indian or Alaska Native

Asian

Native Hawaiian or Other Pacific Islander

Multiple racial categories

_________%

_________%

_________%

_________%

_________%


_________%



Ethnicity (indicate % of patients)

Hispanic or Latino

Not Hispanic or Latino

_________%

_________%






Information about Patient Safety and Quality Improvement Activities of the Organization

What role(s) and/or department in your organization is responsible for patient safety?


Does your organization routinely conduct a patient safety culture survey?



No

Yes

Please specify which survey you use:

__________________________________

Date of the last survey: _______________


Which of the following activities are held regularly in your organization?

  • Peer reviews

  • Morbidity and mortality conferences

  • Death reviews

  • Root cause analysis

  • Healthcare failure mode and effects analysis

  • Other methods:

Does your organization have a patient safety hotline or incident reporting system for providers?

  • Yes

  • No

Does your organization have a patient safety hotline or incident reporting system for patients?

  • Yes

  • No

Which electronic health record platform does your organization use?


Do you use electronic health record data for patient safety analysis or improvement?

  • Yes

  • No


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This survey is authorized under 42 U.S.C. 299a. The confidentiality of your responses to this survey is protected by Sections 944(c) and 308(d) of the Public Health Service Act [42 U.S.C. 299c-3(c) and 42 U.S.C. 242m(d)].  Information that could identify you will not be disclosed unless you have consented to that disclosure. Public reporting burden for this collection of information is estimated to average 60 minutes per response, the estimated time required to complete the survey. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number.  Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: AHRQ Reports Clearance Officer Attention: PRA, Paperwork Reduction Project (0935-XXXX) AHRQ, 5600 Fishers Lane, Room #07W42, Rockville, MD 20857.





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File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
AuthorHill, Mary A
File Modified0000-00-00
File Created2023-11-13

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