Hospital Induction (new sample)

ATTACHMENT J:
NHAMCS Hospital Induction Form for New Sample

	OMB No. 0920-0278; Exp. Date: ________ Assurance of confidentiality – All information which would permit identification of an individual, a practice, or an establishment will be held confidential, will be used for statistical purposes only by NCHS staff, contractors, and agents only when required and with necessary controls, and will not be disclosed or released to other persons without the consent of the individual or establishment in accordance with section 308(d) of the Public Health Service Act (42 USC 242m) and the Confidential Information Protection and Statistical Efficiency Act (PL-107-347). Notice – Public reporting burden for this collection of information is estimated to average 30 minutes per response, including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a current valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing burden to: CDC/ATSDR Information Collection Review Office, 1600 Clifton Road, MS D-74, Atlanta, GA 30333, ATTN: PRA (0920-0278).
INTRO_APPT
Text:		? [F1] Hello, This is ... from the U.S. Census Bureau.  I'm (calling/visiting) to let you know that this hospital will be included in our study. I would like to arrange to meet with you so that I can better present the details of the study. Is there a convenient time within the next week or so that I could meet with you or your representative?        Enter 999 to start the induction interview
NAMECHEK
Text:		Let me verify that I have the correct name and address for your hospital. Is the correct name (facility name)?
1.		Yes
2.		No
HSP_NAME
Text:		What is your hospital's name?        Enter 1 to update the hospitals name
1.		Enter 1 to update information
2.		Continue
ADDCHEK
Text:		Is your hospital located at (Facility Address)
1.		Yes
2.		No
HSP_ADDRESS
Text:		What is the correct address?         Enter 1 to update the hospitals address
MAILADD
Text:		Is this also the mailing address?       (Facility Address)
1.		Yes
2.		No
MHSP_STRET
Text:		What is the correct mailing address?
INTRO_AB
Text:		(Although you have not received the letter,) I'd like to briefly explain the study to you at this time and answer any questions about it. The National Center for Health Statistics of the Centers for Disease Control and Prevention is (conduct an/continue its) annual study of hospital-based ambulatory care.  (Intro for the survey) Before discussing the details, I would like to verify our basic information about (facility name) to be sure we have correctly included this hospital in the study.  First, concerning licensing:
LICHOSP
Text:		Is this facility a licensed hospital?
1.		Yes
2.		No
OWN101
Text:		Is this hospital nonprofit, government, or proprietary?
1.		Nonprofit (includes church-related, nonprofit corporation, other nonprofit ownership)
2.		State or local government (includes state, county, city, city-county, hospital district or authority)
3.		Proprietary (includes individually or privately owned, partnership or corporation)
OWNHCC
Text:		Is this hospital owned, operated, or managed by a health care corporation that owns multiple health care facilities (e.g., HCA or Health South)?
1.		Yes
2.		No
3.		Unknown
TEACHOSP
Universe:		LICHOSP = 1
Text:		Is this a teaching hospital?
1.		Yes
2.		No
MERGER
Text:		? [F1] Did this hospital either merge or separate from any OTHER hospital in the past 2 years?
1.		Merged or separated
2.		No
3.		Unknown
MERSEP
Text:		Was this a merger or a separation?
MERGMEDR
Text:		Does YOUR hospital have its own medical records department that is separate from that of the OTHER hospital?
1.		Yes
2.		No
3.		Unknown
OTHNAME
Text:		What is the name and address of this OTHER hospital?
ESA24
Text:		Does this hospital provide emergency services that are staffed 24 HOURS each day either here at this hospital or elsewhere?
1.		Yes
2.		No
ESANOT24
Text:		Does this hospital operate any emergency service areas that are not staffed 24 HOURS each day?
1.		Yes
2.		No
TRAUMA
Text:		? [F1]     5 What is the trauma level rating of this hospital?
1.		Level I
2.		Level II
3.		Level III
4.		Level IV
5.		Level V
6.		Other/unknown
7.		None
ELIGREQ
Text:		** Not displayed **
STUDY_DESC
Text:		Thank you.          Explain the following ONLY if this is a new hospital.  Provide the administrator or other hospital representative with a brief description of the study.  Cover the following points -  Now I would like to provide you with further information on the study.         (1)    NHAMCS is the only source of national data on health care provided in hospital emergency and outpatient departments and ambulatory surgery centers.         (2)    NHAMCS is endorsed by the:                         American College of Emergency Physicians                        Emergency Nurses Association                        Society for Academic Emergency Medicine                        American College of Osteopathic Emergency Physicians                        Federation of American Hospitals                                Ambulatory Surgery Center Association                        American College of Surgeons                        American Health Information Management Association                        American Academy of Ophthalmology                        Society for Ambulatory Anesthesia          (3)  Nationwide sample of about 600 hospitals and 246 freestanding ambulatory surgery centers.          (4)  Four-week data collection period          (5)  Brief form completed for a sample of patient visits. As one of the hospitals that has been selected for the study, your contribution will be of great value in producing reliable, national data on ambulatory care.
INDUCTION_APPT
Text:		I would like to arrange to meet with you so that I can better present the details of the study. Is there a convenient time within the next week or so that I could meet with you or your representative?               Record day, date and time of appointment                          Enter 999 if the respondent wants to continue with the induction now
SCREENER_THK
Text:		Thank you for your cooperation.  I am looking forward to our meeting.
THANK_MERGSEP
Text:		Since your hospital has merged or separated within the last 2 years, I need to get further instructions from the Centers for Disease Control and Prevention (CDC) on how to proceed.  I will call you back within a week and let you know which parts of your hospital will be in the survey.  Thank you for your cooperation.
CALLRO_MERGSEP
Text:		Call your RO and inform them of the situation.      Await resolution from the RO before continuing with this case.
THANK_B1
Text:		Thank you, but it seems that our information is incorrect. Since (facility name) is not a licensed hospital, it should not have been chosen for our study. Thank you very much for your cooperation.
THANK_B2
Text:		Thank you, but it seems that our information is incorrect. Since (facility name) does not have 24-hour emergency services, outpatient clinics, or ambulatory surgery centers, it should not have been chosen for our study.  Thank you very much for your cooperation.
REVIEW
Text:		? [F1] I would like to begin with a brief review of the background for this study.            Provide the administrator or other hospital representative with a brief introduction to             the study and a general overview of procedures.              Press F1 for points to be covered
SURGDAY
Text:		Now I would like to ask you a few more questions about your hospital. How many days in a week are inpatient elective surgeries scheduled?           Enter CTRL-D if unknown
BEDCZAR
Text:		Does your hospital have a bed coordinator, sometimes referred to as a bed czar?
1.		Yes
2.		No
3.		Unknown
BEDDATA
Text:		How often are hospital bed census data available?           Read answer categories.
1.		Instantaneously
2.		Every 4 hours
3.		Every 8 hours
4.		Every 12 hours
5.		Every 24 hours
6.		Other
7.		Unknown
HLIST
Text:		Does your hospital have hospitalists on staff? A hospitalist is a physician whose primary professional focus is the general care of hospitalized patients.  He/she may oversee ED patients being admitted to the hospital.
1.		Yes
2.		No
3.		Unknown
HLISTED
Text:		Do the hospitalists on staff at your hospital admit patients from your ED?
1.		Yes
2.		No
3.		Unknown
PAYHITH
Text:		Medicare and Medicaid offer incentives to practices that demonstrate “meaningful use of health IT”. Does your hospital have plans to apply for these incentive payments?
		1. Yes, we already applied 2. Yes, we intend to apply 3. Uncertain if we will apply 4. No, we will not apply
PAYDR
Text:		In which year did you first apply for meaningful use payments?
1.		2011
2.		2012
PAYYR
Text:		In which year do you expect to apply for the meaningful use payments?
1.		2012
2.		2013 or later
3.		Unknown
PERMPART
Text:		As I mentioned earlier, I would like to discuss the plan for conducting the study.  This hospital has been assigned to a 4-week data collection period beginning on Monday, (Reporting period begin date). First, I would like to discuss the steps needed to obtain approval for the study. Are there any additional steps needed to obtain permission for the hospital to participate in the study?
1.		Yes
2.		No
PERMPARTSPEC
Text:		Specify the necessary steps needed to obtain permission for the hospital      to participate in the study      Include the name, address, phone and title of the person(s) who can grant       approval
PERM_THANK
Text:		Thank you for your help.
RO_PERMISSION
Text:		Call the Regional Office to inform them of the additional steps needed to     obtain permission
VSREPPER
Text:		Now I would like to make arrangements to obtain the information needed for sampling.  I will need to (know/verify) how your (emergency department and/or outpatient department and/or ambulatory surgery location) (is/are) organized and obtain an estimate of the number of patient visits expected during the 4-week reporting period.  Would you prefer I (get/verify) this information from you or someone else?
1.		Respondent
2.		Someone else
CWHO
Text:		What is the name of the person I should talk to?                                   Alternate Contacts                                (Alternate contact person(s))
1.		Existing Contact
2.		New Contact
3.		Continue interview
CINFO
Text:		What is the name of the person I should talk to?            Enter 1 to enter/update contact person information
1.		New contact
2.		Continue interview
THANK_RESP
Text:		Thank current respondent for his/her time and cooperation
CONTACT_DEPT
Text:		(All eligible departments are compete. Enter 9 to wrap up the case./All eligible departments are compete or refusals. Press F10 if you plan to follo                     Department    Status                      ED         (Elig /Partial /Elig (refusal) / Partial (refusal) / Cmplt / Inelig)                              OPD        (Elig /Partial /Elig (refusal) / Partial (refusal) / Cmplt / Inelig)                      ASL        (Elig /Partial /Elig (refusal) / Partial (refusal) / Cmplt / Inelig)
1.		ED
2.		OPD
3.		ASL
4.		Department refusal
5.		Department callback
9.		Wrap up case
WHICH_DEPT
Text:		Which department (is refusing/are you setting a callback for)?
1.		ED
2.		OPD
3.		ASC
INTRO_ED
Text:		If necessary, introduce yourself and explain the survey        Explain that in order to develop a sampling plan, you would like to collect more specific information about this hospital's emergency department
ESA_NUM
Text:		**  Show only  **
DEL_ESA
Text:		(Does (ESA name) still exist and is it still operational?)   (Enter 97 to delete this ESA / If No, Enter 97 to delete If Yes, Press ENTER to move to the next row)
ESA_NAME
Text:		(What is the name of the (first/next) emergency service area? /Are there any other emergency service areas?)          Enter 999 for no more
ESA_TYPE
Text:		? [F1]   What type of ESA is (ESA name)
1.		General
2.		Adult
3.		Pediatric
4.		Urgent care/Fast track
5.		Psychiatric
6.		Other
ESA_EVISITS
Text:		What is the expected number of visits from (Reporting period begin date) to (Reporting period end date) for (ESA name)?
TWICELY
Text:		Is the number of expected visits to any of the ESAs more than twice the     number shown on the previous sampling plan?                    ESA            Visits      Visits Previous         ESA_NAME       ESA_VISITS  I_ESA_VISITS
1.		Yes
2.		No
TWICELY_SPEC
Text:		Specify why visits have increased this year or were too low the last time     the ED participated
HALFLY
Text:		Is the number of expected visits to any of the ESAs less than half of the     number of visits shown on the previous sampling plan?                ESA          Visits        Visits Previous         ESA_NAME     ESA_VISITS    I_ESA_VISITS
1.		Yes
2.		No
HALFLYSPEC
Text:		Specify why visits have decreased this year or were too high the last        time the ED participated
EBILLRECE
Text:		Now I would like to ask you some questions about your ED. Does your ED submit any CLAIMS  electronically (electronic billing)?
1.		Yes
2.		No
3.		Unknown
EINSELIGE
Text:		Does your ED verify an individual patient's insurance eligibility electronically, with results returned immediately?        Read answer categories out loud
1.		Yes, with a stand-alone practice management system
2.		Yes, with an EMR/EHR system
3.		Yes, using another electronic system
4.		No
5.		Unknown
EMEDRECE
Text:		Does your ED use an electronic MEDICAL record (EMR) or electronic HEALTH record (EHR) system?  Do not include billing record systems.   Read answer categories out loud
1.		Yes, all electronic
2.		Yes, part paper and part electronic
3.		No
4.		Unknown
EHRINSYRE
Text:		In which year did your ED install the EMR/EHR system?
EHRNAME
Text:		What is the name of your current EMR/EHR system?
1.		Allscripts
2.		Cerner
3.		eClinicalWorks
4.		Epic
5.		GE/Centricity
6.		Greenway Medical
7.		McKesson/Practice Partner
8.		NextGen
9.		Sage
10.		Other - Specify
11.		Unknown
EHRNAME_SP
Text:		Enter name of EMR/EHR system
EHRINSE
Text:		Does your ED have plans for installing a new EMR/EHR system within the next 18 months?
1.		Yes
2.		No
3.		Maybe
4.		Unknown
EDEMOGE
Text:		6 Indicate whether your ED has each of the following computerized capabilities.  Does your ED have a computerized system for:    Recording patient history and demographic information?
1.		Yes, used routinely
2.		Yes, but not used routinely
3.		No
4.		Unknown
EPROLSTE
Text:		Does this include a patient problem list?
1.		Yes, used routinely
2.		Yes, but not used routinely
3.		No
4.		Unknown
EPNOTESE
Text:		Indicate whether your ED has each of the following computerized capabilities.  Does your ED have a computerized system for:    Recording clinical notes?
1.		Yes, used routinely
2.		Yes, but not used routinely
3.		No
4.		Unknown
EMEDALGE
Text:		Do they include a comprehensive list of the patient's medications and allergies?
1.		Yes, used routinely
2.		Yes, but not used routinely
3.		No
4.		Unknown
ECPOEE
Text:		Indicate whether your ED has each of the following computerized capabilities.  Does your ED have a computerized system for:    Ordering prescriptions?
1.		Yes, used routinely
2.		Yes, but not used routinely
3.		No
4.		Unknown
ESCRIPE
Text:		Are prescriptions sent electronically to the pharmacy?
1.		Yes, used routinely
2.		Yes, but not used routinely
3.		No
4.		Unknown
EWARNE
Text:		Are warnings of drug interactions or contraindications provided?
1.		Yes, used routinely
2.		Yes, but not used routinely
3.		No
4.		Unknown
EREMINDE
Text:		Indicate whether your ED has each of the following computerized capabilities.  Does your ED have a computerized system for:  Providing reminders for guideline-based interventions or screening tests?
1.		Yes, used routinely
2.		Yes, but not used routinely
3.		No
4.		Unknown
ECTOEE
Text:		Indicate whether your ED has each of the following computerized capabilities.  Does your ED have a computerized system for:       Ordering lab tests?
1.		Yes, used routinely
2.		Yes, but not used routinely
3.		No
4.		Unknown
EORDERE
Text:		Are orders sent electronically?
1.		Yes, used routinely
2.		Yes, but not used routinely
3.		No
4.		Unknown
ESETSE
Text:		Indicate whether your ED has each of the following computerized capabilities.  Does your ED have a computerized system for:    Providing standard order sets related to a particular condition    or procedure?
1.		Yes, used routinely
2.		Yes, but not used routinely
3.		No
4.		Unknown
ERESULTE
Text:		Indicate whether your ED has each of the following computerized capabilities.  Does your ED have a computerized system for:     Viewing lab results?
1.		Yes, used routinely
2.		Yes, but not used routinely
3.		No
4.		Unknown
EIMGRESE
Text:		Indicate whether your ED has each of the following computerized capabilities.  Does your ED have a computerized system for:    Viewing imaging results?
1.		Yes, used routinely
2.		Yes, but not used routinely
3.		No
4.		Unknown
EQOCE
Text:		Indicate whether your ED has each of the following computerized capabilities.  Does your ED have a computerized system for:    Viewing data on quality of care measures?
1.		Yes, used routinely
2.		Yes, but not used routinely
3.		No
4.		Unknown
EIMMREGE
Text:		Indicate whether your ED has each of the following computerized capabilities.  Does your ED have a computerized system for:    Electronic reporting to immunization registries?
1.		Yes, used routinely
2.		Yes, but not used routinely
3.		No
4.		Unknown
ESUME
Text:		Indicate whether your ED has each of the following computerized capabilities.  Does your ED have a computerized system for:    Providing patients with clinical summaries for each visit?
1.		Yes, used routinely
2.		Yes, but not used routinely
3.		No
4.		Unknown
EMSGE
Text:		Indicate whether your ED has each of the following computerized capabilities.  Does your ED have a computerized system for:    Exchanging secure messages with patients?
1.		Yes, used routinely
2.		Yes, but not used routinely
3.		No
4.		Unknown
EHRWHOE
Text:		At your ED, if orders for prescriptions or lab tests are submitted electronically, who submits them?      Read answer categories out loud           Enter all that apply, separate with commas
1.		Prescribing practitioner
2.		Other
3.		Prescriptions and lab test orders not submitted electronically
4.		Unknown
EXCHSUME
Text:		Do you share any patient health information electronically (not fax) with other providers, including hospitals, ambulatory providers, or labs?        Read answer categories out loud
1.		Yes
2.		No
EXCHSUM1E
Text:		How do you electronically share patient health information?       Read answer categories out loud     Enter all that apply, separate with commas
1.		EHR/EMR
2.		Web portal (separate from EHR/EMR)
3.		Other electronic method: ___________________
OBSUNITS
Text:		Does your ED have a physically separate observation or clinical decision unit?
1.		Yes
2.		No
3.		Unknown
OBSDECMD
Text:		What type of physicians make decisions for patients in this observation or clinical decision unit?      Read answer categories out loud     Enter all that apply, separate with commas
1.		ED physicians
2.		Hospitalists
3.		Other physicians
4.		Unknown
BOARD
Text:		? [F1] Are admitted ED patients ever "boarded" for more than 2 hours in the ED or the observation unit while waiting for an inpatient bed?
1.		Yes
2.		No
3.		Unknown
BOARDHOS
Text:		? [F1] If the ED is critically overloaded, are admitted ED patients ever "boarded" in inpatient hallways or in another space outside the ED?
1.		Yes
2.		No
3.		Unknown
AMBDIV
Text:		Did your ED go on ambulance diversion in TOTHRDIV_FILL?
1.		Yes
2.		No
3.		Unknown
TOTHRDIV
Text:		What is the total number of hours that your hospital's ED was on ambulance diversion in TOTHRDIV_FILL?      Enter CTRL-D if data not available
REGDIV
Text:		Is ambulance diversion actively managed on a regional level versus each hospital adopting diversion if and when it chooses?
1.		Yes
2.		No
3.		Unknown
ADMDIV
Text:		Does your hospital continue to admit elective or scheduled surgery cases when the ED is on ambulance diversion?
1.		Yes
2.		No
3.		Unknown
NUMSTATX
Text:		As of last week, how many standard treatment spaces did your ED have? Standard treatment spaces are beds or treatment spaces specifically designed for ED patients to receive care, including asthma chairs.                Enter CTRL-D if data not available
NUMOTHTX
Text:		As of last week, how many other treatment spaces did your ED have? Other treatment spaces are other locations where patients might receive care in the ED, including chairs, stretchers in hallways that may be used during busy times.             Enter CTRL-D if data not available
EDSPACES
Text:		In the last two years, did your ED increase the number of standard treatment spaces?
1.		Yes
2.		No
3.		Unknown
PHYSSPACE
Text:		In the last two years, did your ED's physical space expand?
1.		Yes
2.		No
3.		Unknown
EXPAND
Text:		Do you have plans to expand your ED's physical space within the next two years?
1.		Yes
2.		No
3.		Unknown
BEDREG
Text:		7 Does your ED use -    Bedside registration?
1.		Yes
2.		No
3.		Unknown
CATRIAGE
Text:		7 Does your ED use -    Computer-assisted triage?
1.		Yes
2.		No
3.		Unknown
FASTTRAK
Text:		7 Does your ED use -    Separate fast track unit for nonurgent care?
1.		Yes
2.		No
3.		Unknown
EDPTOR
Text:		7 Does your ED use -    Separate operating room dedicated to ED patients?
1.		Yes
2.		No
3.		Unknown
DASHBORD
Text:		7 Does your ED use -    Electronic dashboard  (i.e., displays updated patient information    and integrates multiple data sources)?
1.		Yes
2.		No
3.		Unknown
RFID
Text:		7 Does your ED use -    Radio frequency identification (RFID) tracking (i.e., shows exact    location of patients, caregivers, and equipment)?
1.		Yes
2.		No
3.		Unknown
ZONENURS
Text:		7 Does your ED use -    Zone nursing (i.e., all of a nurse's patients are located in one area)?
1.		Yes
2.		No
3.		Unknown
POOLNURS
Text:		7 Does your ED use -    Pool nurses (i.e., nurses that can be pulled to the ED to respond to    surges in demand)?
1.		Yes
2.		No
3.		Unknown
FULLCAP
Text:		7 Does your ED use -    Full capacity protocol   (i.e., allows some admitted patients to move    from the ED to inpatient corridors while awaiting a bed)?
1.		Yes
2.		No
3.		Unknown
FREDIND
Text:		** Not Displayed **
ESA_NUM
Text:		** SHOW ONLY **
ESA_NAME
Text:		*** SHOW ONLY **
ESA_TYPE
Text:		** SHOW ONLY **
1.		General
2.		Adult
3.		Pediatric
4.		Urgent care/Fast track
5.		Psychiatric
6.		Other
ESA_EVISITS
Text:		** SHOW ONLY **
ESA_ONSITE
Text:		Is (ESA name) on-site?
1.		Yes
2.		No
ESA_STRET
Text:		What is (ESA name)'s address?
ESA_PHONE
Text:		What is (ESA name)'s telephone number?
ESA_CONTACT
Text:		Enter ESA contact person's name
TE
Text:		** NOT DISPLAYED **
RS
Text:		** NOT DISPLAYED **
AU_TYPE
Text:		** NON_DISPLAYED **
EXIT_REFUSAL
Text:		Are you exiting this case because of a refusal?
1.		Yes
2.		No
CALLBACKNOTES
Text:		I'd like to schedule a DATE to (conduct/complete) the interview. What DATE AND TIME would be best to visit again?            Today is:  ^IntDate
THANKCB
Text:		Thank you. I will call/come back at the time suggested       Revisit   (Callback information)
FOLLOW_UP
Text:		The following departments have refused.      Do you plan to follow-up on these department(s)?
1.		Yes, will follow-up on department(s)
2.		No , wrap case up
CALLBACKNOTES
Text:		I'd like to schedule a DATE to (conduct/complete) the interview. What DATE AND TIME would be best to visit again?            Today is:  ^IntDate
THANKCB
Text:		Thank you. I will call/come back at the time suggested       Revisit   (Callback information)
THANKYOU
Text:		This concludes the interview.  Thank you for your patience, and for taking the time to answer our questions.
SET_REINT
Text:		** Non Displayed **
HOSPREF
Text:		**  Not displayed **
ELIGED
Text:		Does this hospital have an eligible ED?
1.		Yes
2.		No
VSED101
Text:		Enter number of expected visits for the ED
VSEDLY
Text:		Enter the number of visits to the department last year
WHOMHOSP
Text:		By whom?
1.		Hospital administrator
2.		Approval board or official
3.		Other hospital official
WHOMED
Text:		By whom?
1.		Hospital administrator
2.		ED/OPD/Ambulatory Surgery Director
3.		Approval board or official
4.		Other hospital official-Specify
WHOMHOSPSPEC
Text:		Specify the name of the other hospital official who refused for the hospital
WHOMEDSPEC
Text:		Specify the name of the other hospital official who refused for the ED
TELPERHO
Text:		Was the refusal by telephone or in person for the hospital?
1.		Telephone
2.		In person
TELPERED
Text:		Was the refusal by telephone or in person for the ED?
1.		Telephone
2.		In person
REASON
Text:		Specify what reason was given for the refusal/breakoff   Specify if hospital or ED
CONVHOSP
Text:		Was conversion attempted?
1.		Yes
2.		No
CONVED
Text:		Was conversion attempted?
1.		Yes
2.		No