Form #2 Form #2 Medical Office SOPS Database Data Use Agreement

Medical Office Survey on Patient Safety Culture Database
Data Use Agreement
Instructions
1. Westat has pre-signed this Data Use Agreement (DUA) in its current form. Any changes or
modifications to the DUA other than those required to complete the DUA, such as contact
information, will require review and execution, by both parties, of a new DUA or addendum.
2. Data collection vendors may not sign and submit this DUA on behalf of a health system, practice,
or Medical Office (even if they have been given permission by the health system or Medical
Office to handle the actual submission of data). Only a duly appointed representative from a health
system, practice, or Medical Office may sign this DUA.
3. Please return this signed Data Use Agreement by mail, or fax a signed copy to:
Willow Burns
Westat
1600 Research Boulevard
Rockville, MD 20850
Fax: 1-888-852-8277 (toll free)
Phone: 1-888-324-9790 (toll free)
Email: DatabasesOnSafetyCulture@westat.com

Form Approved
OMB No. 0935-XXXX
Exp. Date XX/XX/20XX

Medical Office Survey on Patient Safety Culture
Database Data Use Agreement
1.

This Data Use Agreement (DUA) is made by and between Westat and the organization named below (hereinafter termed
“Participating Organization”) which includes any medical offices listed under item 11 on page 2 of this Data Use
Agreement.
_________________________________________________________________________________
Name of Medical Office (or Health System/Practice Name if more than one medical office is included in this DUA)
_________________________________________________________________________________
Street Address of Medical Office (or Health System/Practice main location)
_________________________________________________________________________________
City
State
Zip Code
VERY IMPORTANT: Type or write in the name of the Participating Organization above. If more than one
medical office location is represented, list the name of the overall health system or practice above, and under item
11 on page 2 of this Data Use Agreement, IDENTIFY EACH INDIVIDUAL MEDICAL OFFICE LOCATION for
which data will be submitted.

2.

This DUA specifies the terms and conditions of Participating Organization’s submission of its Medical Office Survey on
Patient Safety Culture (MO SOPS) data to Westat for participation in the Medical Office SOPS Comparative Database
(hereinafter termed the “Database”).

3.

The purpose of the Database is to establish a central repository of MO SOPS survey data to facilitate comparisons across
medical offices. The Database will be populated with MO SOPS survey data through the voluntary participation of
medical offices that have implemented the MO SOPS survey and are willing to submit their MO SOPS survey data to
Westat for inclusion in the Database.
The Database is funded by the Agency for Healthcare Research and Quality (AHRQ) under a contract and the Database is
managed and administered by Westat, a private research organization under contract with AHRQ. Westat will operate the
Database to comply with the provisions in this DUA. Within this framework, Westat will manage and administer the
Database using its discretion as necessary, and it will seek and be guided by the advice and counsel of the SOPS Database
Technical Expert Panel (TEP) established by Westat, in accordance with its contractual obligations, to obtain Panel input
throughout the design, development and administration of the Database. The TEP consists of 12 representatives
knowledgeable about hospital, medical office, and nursing home patient safety and quality from various health care
organizations, professional societies, and research institutions, as well as government agencies concerned with patient
safety and health care.

4.

Participating Organizations will provide their MO SOPS survey data to the Database for analysis and reporting according
to the terms specified in this DUA. By agreeing to participate in the Database, each Participating Organization agrees to
make a good faith effort to provide data, as specified by the data specifications outlined below, for inclusion in the MO
SOPS Database (this data being collectively referred to as the “Data”), including:
a)

A copy of the final MO SOPS survey instrument(s) administered, including copies of paper and/or web-based versions
as applicable, showing all survey instructions and items administered. If more than one version of the MO SOPS
survey was administered, a copy of each MO SOPS survey instrument administered must be provided with the
corresponding results for each version of the survey instrument for which data is submitted;

b) Participating Organization’s final, respondent-level MO SOPS survey data, as collected by Participating Organization
itself or by a survey data collection vendor, according to the data specifications outlined for the Database; and
Public reporting burden for this collection of information is estimated to average 3 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, 540 Gaither Road, Room #
5036, Rockville, MD 20850.

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c)

Selected organizational characteristics data (e.g., ownership, medical specialties represented etc.) and background
information related to survey administration (e.g., mode of survey administration, dates of administration, sample size,
response rate, etc.).

5.

In accordance with the AHRQ confidentiality statute [at 42 USC 299c-3(c)], Westat agrees to establish appropriate and
necessary administrative, technical, and physical procedures and safeguards to protect the data. Only Westat and duly
authorized representatives appointed by AHRQ will have access to the identifiable source data provided by Participating
Organization. In addition, Westat will ensure appropriate staff training to protect the confidentiality of the identifiable data
and to prevent unauthorized access to it and any unauthorized use of it.

6.

Participating Organization’s Data will be accepted into the Database provided that the version of the MO SOPS survey
administered by Participating Organization is deemed acceptable by Westat (i.e., not modified substantially from the
original MO SOPS instructions and items). Westat will promptly notify the Participating Organization of any problem, if
any, with the survey version(s) administered or with the data submitted. If the survey version administered is acceptable
but the data submitted are problematic, Westat will make a good faith effort to work with the Participating Organization to
complete or correct the Data submission, but reserves the right to not include incompatible or flawed data in the Database.

7. Participating Organization’s data files will be aggregated for comparative purposes along with other Participating
Organizations’ Data in the Database. Westat will produce an MO SOPS Comparative Database Report providing aggregate
statistics on MO SOPS survey composite scores and items across all Participating Organizations and across various subsets
of Participating Organizations (e.g., ownership, medical specialties represented, etc.). The Report will not identify
individual Participating Organizations by name. Only aggregate data will be reported, and only when there are sufficient
data so that such aggregation will not permit the identification of Participating Organizations by other Participating
Organizations or the public. The Database Report will be made available to Participating Organizations and the public
through electronic media and at no charge. The Database Report will be in the public domain and may be reproduced
without permission.
8.

Westat may conduct psychometric analyses of the aggregate data to examine its distributional properties (variability,
missing data, skewness), and to assess the factor structure and reliability of the safety culture dimensions. In any data
analysis reports that may be produced, such reports will not identify individual Participating Organizations by name and
results will only be reported in a manner that will not permit the identification of Participating Organizations.

9.

Westat may grant access to Participating Organization’s data files for health care research purposes approved by AHRQ
according to the following provisions:
a)

Access to aggregate data files that do not identify individual Participating Organizations or permit reidentification
may be granted by Westat without the specific authorization of Participating Organizations whose data are included
as part of the aggregate data files. These data files may include variables describing the Participating Organization
according to types (e.g., ownership, medical specialties represented, etc.), provided the variables do not permit
reidentification.
b) Access to data files specific to an identifiable Participating Organization may be approved only with the express
written authorization of the Participating Organization whose data files are requested. Researcher analyses of the data
files provided to researchers under these provisions and containing any identifying information, may not be released,
disclosed or made public by the researchers without the express written authorization of any Participating
Organizations that may be identified in the published research analysis.
10. Westat agrees to use the Data submitted by Participating Organization only for the purposes stated in this agreement.
11. If Participating Organization represents more than one medical office, use the space below to TYPE OR WRITE
THE NAME OF EACH INDIVIDUAL MEDICAL OFFICE AND ITS ADDRESS, CITY AND STATE which is
represented by Participating Organization and therefore covered under this Data Use Agreement. Attach
additional sheet if necessary.
NAME OF MEDICAL OFFICE(S) REPRESENTED

ADDRESS, CITY & STATE

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PLEASE SIGN, COMPLETE THE INFORMATION BELOW, MAIL OR FAX ALL PAGES OF THIS DATA USE
AGREEMENT BACK TO WESTAT.
The undersigned individual hereby attests that he/she is duly authorized to represent the named Participating Organization(s)
and all medical offices listed under item 11, and in so doing, enters into this Data Use Agreement on behalf of the Participating
Organization and the medical offices listed under item 11 and agrees to all the terms specified herein.
Name: _______________________________________________________
Title: ________________________________________________________
_______________________________________________
(Signature)

______________________________
(Date)

NAME AND ADDRESS OF PARTICIPATING ORGANIZATION CONTACT
Name and address of person from Participating Organization who is the point of contact for this completed DUA.
Name of contact (if different from above):____________________________________________
Title (if different from above): _____________________________________________________
Address: ______________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Phone number: _________________________________
Fax number: ___________________________________
Email address: ___________________________________________

The undersigned individual hereby attests that he/she is duly authorized to represent Westat in entering into this Data Use
Agreement and in agreeing to all the terms specified herein on their behalf.

W. Sherman Edwards
Vice-President, Associate Director at Westat
Surveys on Patient Safety Culture Project

__________________________________________
(Signature)

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