Appendix B. Medical Office Background Characteristics Survey

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To Be Completed by Office Point-of-Contact for Each Medical Office Submitting Data to the Medical Office Survey on Patient Safety Comparative Database

Instructions: Please provide the following information, which will be used to analyze data collected with the Medical Office Survey on Patient Safety. If you need assistance in answering any of the questions, please email DatabasesOnSafetyCulture@ahrq.hhs.gov

Name of Office Point-of-Contact:	(First)		(Last)
Job Title:
Name of Office:
Office Mailing Address:	(Street)
	(City)	(State)	(Zip code)
POC	(Phone)	(Fax)	(Email)

1a. Does your medical practice have:

1 One location?        (SKIP TO QUESTION 2)
2 Multiple locations?        Total number of locations:

1b. Is this office location the:
1 Primary/headquarters location?
2 Satellite location (not the primary/headquarters location)?

2.  Which best describes the majority ownership of this medical office/practice?

1 Provider(s) and/or Physician(s)
2 Managed Care or Health Maintenance Organization (MCO/HMO)
3 University or Medical School or Academic Medical Institution
4 Hospital or health system
5 Federal, state, or local government, community board, etc.
6 Other, please specify:

Please record the total number of providers and staff from your medical office asked to complete the survey in each of the following staff categories.

Staff Position	Number of Individuals
a. Physician (MD/DO)
b. Physician Assistant
c. Nurse Practitioner/Clinical Nurse Specialist/Nurse Midwife/ Advanced Practice Nurse, etc.
d. Practice Manager/Office Manager/Office Administrator/ Business Manager/Nurse Manager, Lab Manager, Other Manager
e. Administrative or Clerical Insurance Processor Medical Records Billing Staff Receptionist Referral Staff Scheduler (appt., surgery, etc.) Front Desk Other administrative or clerical staff
f. Registered Nurse/LVN/LPN
g. Medical Assistant/Nursing Aide
h. Other Clinical Staff Technician (all types), Therapist (all types), Other clinical staff
i. Other Positions
TOTAL NUMBER OF INDIVIDUALS ASKED TO COMPLETE THE SURVEY (This is your response rate denominator)

4a.  Which of the following best describes the type of practice at this office location?

1 Single specialty
2 Multispecialty with primary care only (family medicine, internal medicine, pediatrics, OB/GYN, general practice)
3 Multispecialty with primary and specialty care
4 Multispecialty with specialty care only

4b.  In the table below, record the number of providers who work in your office in each specialty listed below. By providers, we mean physicians (MDs and DOs), physician assistants (PAs), and nurse practitioners (NPs) who diagnose, treat patients, and prescribe medications. If a provider is certified in more than one specialty, record only the specialty for which the provider spends most of his/her time. See example:

Example: An office with 3 Family Practice providers and 1 doctor certified in both Gastroenterology (works in this area 70% of time) and General Practice (works in this area 30% of time):

Number of Providers	Specialty
3	Family Practice / Family Medicine
	Forensic Pathology
1	Gastroenterology
	General Practice

Record the number of providers in each specialty in your medical office. Any specialties not represented in your medical office can be left blank.

Number of Providers	Specialty
	1. Allergy/Immunology
	2. Anesthesiology
	3. Cardiology
	4. Child & Adolescent Psychiatry
	5. Dermatology
	6. Diagnostic Radiology
	7. Emergency Medicine
	8. Endocrinology/Metabolism
	9. Family Practice/Family Medicine
	10. Forensic Pathology
	11. Gastroenterology
	12. General Practice
	13. General Preventive Medicine
	14. General Surgery
	15. Geriatrics
	16. Hematology/Oncology
	17. Internal Medicine
	18. Medical Genetics
	19. Nephrology
	20. Neurology
	21. Nuclear Medicine
	22. OB/GYN or GYN
	23. Ophthalmology
	24. Orthopedics
	25. Otolaryngology
	26. Pathology – Anatomic/Clinical
	27. Pediatrics
	28. Physical Medicine & Rehabilitation
	29. Psychiatry
	30. Public Health & Rehabilitation
	31. Pulmonary Medicine
	32. Radiology
	33. Rheumatology
	34. Surgery (All)
	35. Urology
	36. Vascular Medicine
	37. Other specialties

5.  To what extent has this medical office implemented the following electronic (computer-based) tools? (By implemented, we mean the office has the tool capability and is using it.)

Tool	Not implemented & no plans to implement in the next 12 months	Not implemented but implementation planned in the next 12 months	Implementation in process (only partial implementation)	Fully implemented
a) Electronic appointment scheduling	1	2	3	4
b) Electronic ordering of medications (with pharmacies capable of processing electronic orders)	1	2	3	4
c) Electronic ordering of tests, imaging, or procedures (with test/imaging centers capable of processing electronic orders)	1	2	3	4
d) Electronic access to your patients' test or imaging results	1	2	3	4
e) Electronic medical/health records (EMR/EHR)	1	2	3	4

6.   What is the total number of patient visits in a typical week in this medical office location? _________total patient visits in a typical week

7.   What is the total number of providers (MDs, DOs, PAs, NPs, etc.) working in this medical office location during a typical week?   
_________total number of providers working during a typical week

8.   When did your medical office finish its administration of the Medical Office Survey on Patient Safety?
_________month  _________year

9.  What was the mode used to administer the survey?
1  Paper only
2  Web only
3  Mixed mode (paper and web)

Return to Contents

AHRQ Publication No. 08(09)-0059
Current as of December 2008

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Internet Citation:

Sorra J, Franklin M, Streagle S. Survey User's Guide: Medical Office Survey on Patient Safety Culture. AHRQ Publication No. 08(09)-0059, December 2008. Agency for Healthcare Research and Quality: Rockville, MD. http://www.ahrq.gov/qual/mosurvey08/

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