Form 1 Appendix A – Organizational Characteristics Survey

Appendix A – Organizational Characteristics Survey

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

Diagnostic Safety Capacity Building – Measure Dx 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

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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