Culture of Patient Safety Medical Office Campaign Request …



To support a culture of safety and quality improvement, the Indiana Hospital Association (IHA) offers the Agency for Healthcare Research and Quality (AHRQ) Surveys on Patient Safety Culture free to all IHA members. Please fill out the information below to start the survey set-up process. For the questions with multiple choices, please highlight your answer. Hospital InformationName:Address:Medicare Provider ID:American Hospital Association (AHA) ID:Bed size:6-24 beds25-49 beds50-99 beds100-199 beds200-299 beds300-399 beds400-499 beds500 or more bedsOwnership:Government, non-federalNongovernment (not-for-profit)Investor-owned (for profit)Government, federalTeaching Status:TeachingNon-teachingName of Campaign AdministratorFirst Name: Last Name:Phone Number:Email:Campaign InformationOpen Campaign Date:Close Campaign Date:Number of staff asked to complete the survey:Type of staff surveyed:All staff/sample of all staffSelected departments/units only (please specify)Selected staff positions only (please specify)Selected departments/units and selected staff positions (please specify)Survey Mode (choose one):WebPaperMixedHow long has your hospital had its primary EMR/HER system?Less than 1 year1 year to less than 2 years2 years to less than 3 years3 years to less than 5 years5 years to less than 10 years10 years or moreDon’t know Do you want to submit your survey data to AHRQ as part of the National Comparative Database? (AHRQ will not receive any written comments) YES NODo you wish to add any additional questions at the end of your survey ? YES NOQuestions to be added to end of survey (if applicable): ................
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