I

NATIONAL CENTER Series 2

For HEALTH STATISTICS Number 19

VITAL and HEALTH STATISTICS

DATA EVALUATION AND METHODS RESEARCH

Participation of Hospitals

in the Pilot Study of the

Hospital Discharge Survey

Evaluation of the wi Ilingness of short-stay hospitals to participate in a continuing patient-oriented survey.

DHEW Publication No. I(HRA) 74-1285

U.S. DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE

Public Health Service

Health Services and Mental Health Administration

National Center for Health Statistics

Rockville, Maryland

..
Vital and Health Statistics-Series 2-No. 19

First issued in the Public Health k-vice Publication Series No. 1000- october 1966
NATIONAL CENTER FOR HEALTH STATISTICS

EDWARD B. PERRIN, Ph. D., Acting Director

PHILIP S. LAWRENCE, SC.D., Deputy Director

GAIL F. FISHER, Assistant Directorfor Health Statistics Deve~opment

WALT R. SIMMONS, M. A., Assistant Director for Research and Scientific Development

JOHN J. HANLON, M. D., Medical Advisor

JAMES E. KELLY, D. D. S., Dental Advisor

EDWARD E. MINTY, Execu tiue Officer

ALICE HAYWOOD, Information Officer

DHEW Publication No. (HRA) 74-1 285-Series 2-No. 19

Library of Congress Card Number 66-62090
PREFACE

The National Health Survey collects data on the health

of the population in three different ways: (1) by househoId

interview techniques; (2) by direct examination; and (3) by

abstracting information from existing records.

In connection with the latter method, a contract was

made with the Graduate School of Public Health, University

of Pittsburgh, to explore the feasibility of conducting a

national patient-oriented survey in short-stay hospitals. In

fiscal year 1965 the Hospital Discharge Survey was inaugurated with a large-scale pilot study by the National

Center for Health Statistics in cooperation with the Bureau

of the Census and the University of Pittsburgh Graduate

School of Public Health. As part of a contract with the

Center, the University of Pittsburgh has evaluated the

willingness of hospitals to participate in a continuing

survey.

Milton C. Rossoff, Chief, Hospital Discharge Survey

Branch, Division of Health Records Statistics, edited the

report for publication.
CONTENTS

Page

Preface --------------------------------------------------------------

Introduction ----------------------------------------------------------

The FeasibiliW Smdy --------------------------------------------------

Introduction --------------------------------------------------------

Hospitals Visited ---------------------------------------------------

Procedure ---------------------------------------------------------

Findtigs -----------------------------------------------------------

Summary of Recommendations ---------------------------------------

Pilot Study Methodolo~------------------------------------------------

Groundwork --------------------------------------------------------

Initial Contact With the Hospital ---------------------------------------

Personal Interviews ------------------------------------------------

Coopration ----------------------------------------------------------

Acceptabilityof Data-Collection Procedures ---------------------------

Payment ---------- -------- -------- --------------- ------- ------- ----

Interview With the Administrator ------------------- ------------- -----

Interview Wititie,Metical Record Libraian --------------------------

Evaluation Program ---------------------------------------------------

Procedure ---------------------------------------------------------

Cooperation Obtained --------------------------- ----------- ---------

Recommendations --------------------------------------------------

Summary -------------------------------------------------------------

References -----------------------------------------------------------

Appendix I. FeasibilitySmdy -------------------------------------------

Exhibit A. Letter to Hospital Administrator ----------------------------

Exhibit B. Abstract Sheet --------------------------------------------

Appendix H. Pilot Study ---------------------------- --------- -------------

Exhibit C. Conventional AbsmactForm --------------------------------

Exhibit D. IBMAbstractForm ----------------------------------------

Exhibit E.NCHS ''Fact Sheet''-------=--------------------------------

Exhibit F.AHA Lefierto HospitaI Atiinistrator -----------------------

ExhibitG. NCHS Letter to Hospital Administrator ----------------------

Exhibit H. Statement on theSurvey ------------------------------------

Exhibit I. Hospital Interview Form-- -------- -------- --------------- -.

Exhibit J. MemorandumofAgreement ------------------- ---------------

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55
IN THIS REPOR T— which relates to a national continuing suwey of

patients in sho~t-stay hospitals—findings, conclusions, and recommendations aye made concerning two studies.

A study conducted in fiscal yeay 1964 investigated the feasibility of

conducting a Hospital Discha?’ge Su?wey and concluded that such a suYvey was practicable and would be welL ~eceived by the hospitals falling

into the sample.

The Hospital DischaYge SuYvey commenced in fiscal yeav 1965 as a

pilot study with the intent of testing vayiows pvoceduyes in 84 hospitals,

involving pevsonnel, fovms, and suitability of quality checks. Only 2 of

the 84 hospitals which weye asked to pa~ticipate in the pilot stwdy

failed to do so. UnYeseYved coope~ation was obtained fvom 74 of the

hospitals, and qualijted cooperation was Yeceived fyom the vemaining

8 participating hospitals.

The appendixes contain many of the foyms used in the feasibility study

and in the pilot study.

SYMBOLS

I

Data not available ------------------------ ---

I

Category not applicable ------------------ . . .

Quantity zero ---------------------------- -

Quantity more than O but less than 0.05 ----- 0.0

Figure does not meet standards of

reliability or precision ------------------

*
PARTICIPATION OF HOSPITALS IN THE PILOT

STUDY OF THE HOSPITAL DISCHARGE SURVEY

The report was prepored by Ann M. Brown, A. B.; lsidore Altman, Ph. D., Professor of Medical Care Statistics; ond Dono -

van J. Thompson, Ph. D., Professor of Biometry, Department of Biostatistics, Graduate Schaol of Public Health, University

of Pittsburgh. The findings, conclusions, and recommendations are those of the authars.

INTRODUCTION

In the summer of 1964 the National Center for

Health Statistics of the U.S. Public Health Service

inaugurated the Hospital Discharge Survey, a

continuing study designed to provide comprehensive general-purpose statistics on morbidity in

patients discharged from the Nation’s short-term

hospitals. The authority for the survey is derived

from the National Health Survey Act of 1956

(Public Law 652–84th Congress), which authorizes the Public Health Service to conduct continuing surveys on the health of the Nation’s people

and to develop and test new methods for gathering

such information. 132The survey has the endorsement of the American Hospital Association.

The principal source of information for the

survey is the medical record in the hospital,

or more precisely, for the time being, the face

or summary sheet of the medical record. The

data are to be obtained from probability samples

of medical records abstracted in a sample of the

Nation’s general hospitals. They will provide useful information on length of stay, diagnosis, and

operative procedures for the general population

classified according to such demographic characteristics as age, sex, color, and marital status.

The Hospital Discharge Survey is one part

of a comprehensive National Health Survey 3 composed of three basic programs: the Health Interview Survey >4 the Health Examination Survey, 5

and the Health Records Survey. Ike Health Records Survey, which includes the Hospital Dis.

charge Survey, is actually a family of surveys

designed to gather and publish statistics from

facilities which provide medical care; it is

under the direction of the Division of Health

Records Statistics.

One of the early projects of this division

was the compilation of the most complete listing

yex available of the Nation’s hospitals and resident institutions providing medical, nursing, personal, or custodial care. This Master Facility

Inventory, Gas it is called, functions dually by

serving as a sampling frame for the various

health records surveys and

tistics on the numbers and

these establishments, Every

keep this inventory up to date.

THE FEASIBILITY STUDY

by providing stacharacteristics of

effort is made to

INTRODUCTION vey. More than a year before the survey itself

was initiated, and as part of this planning, the

A great deal of exploratory work and care- Graduate School of Public HeaIth of the University

ful planning must necessarily precede a national of Pittsburgh undertook a study, by contract

undertaking such as the Hospital Discharge Sur- with the National Center for Health Statistics

1
of the Public Health Service, to examine the

feasibility of sampling hospital medical records

in order to collect statistics on morbidity in

hospitalized patients. A report on this study,

“Study of Feasibility of Sampling Hospital Discharge Records, ” has been made to the Division

of Health Records Statistics. This section is a

summary of that report.

Forty-five purposively selected hospitals

throughout the United States were visited to

obtain information about the following: the circur’nstances under which hospitals would be willing to cooperate in a national discharge !survey;

the questions they would ask; whose permission

would be needed; the problems that would be encountered in translating records of discharges into

Table 1. Distribution of hospitals visited in the 1963 feasibility study, by geographic

region, type of control, and bed capacity:l United States

Type of control and bed capacityg

All hospitals

All bed capacities ---------------------

Under 100 beds-------------------------------

100-199 beds---------------------------------

200-299 beds---------------------------------

300 beds or more-----------------------------

Government

All bed capacities ---------------------

Under 100 beds -------------------------------

100-199 beds---------------------------------

200-299 beds---------------------------------

300 beds or more-----------------------------

Nonprofit

All bed capacities ---------------------

Under 100 beds-------------’ -----------------

100-199 beds---------------------------------

200-299 beds---------------------------------

300 beds or more -----------------------------

Proprietary

All bed capacities ---------------------

Under 100 beds-------------------------------

100-199 beds---------------------------------

200-299 beds---------------------------------

300 beds or more-----------------------------

All

regions

45

17

12

1:

9

5

2

Geographic region

NortheastNorth

Central

2

7

3

3

i

South

- 12 —

8

:

1

3

“1

1

1

5

3

2

4

4

West

10

1

4

3

2

1

;

2

2

3

1

2

lData relate to the year ending September 30, 1962.

2Exclusive of bassinets for newborn infants.
a sampling frame; the maximum

which wouid be uniformly available

information

in all hos -

pitals; and the methods most appropriate for

extracting the desired information from the

medical records. Emphasis was on the problems

that might arise in connection with securing

cooperation.

The study of these 45 hospitals in 1963-

64 will be referred to as the feasibility study;

the activities to be described for the succeeding

year, 1964-65, will be referred to as the pilot

study.

The feasibility study procedure involved, as

a rule, separate interviews with the hospital

administrators and their medical record librarians, the selection of a small sample of the medical records of discharged patients, and the

abstracting of certain information from these

records. The interview with the administrator

dealt primarily with elements of cooperation,

whereas the medical record librarian was interviewed mainly about the record keeping system

in relation to establishing a procedure within

the hospital for the regular, periodic collection

of information from a sample of the medical

records.

HOSPITALS VISITED

All but 2 of the 45 hospitals visited in the

1963 feasibility study were general hospitals.

The two exceptions were a small eye, ear, nose,

and throat hospital and a short-term psychiatric

hospital. we characteristics of the 45 hospitals

are presented in table 1. As may be seen from

the table, nearly two-thirds of the hospitals

were nonprofit, and the remainder were nearly

evenly divided between government and proprietary hospitals. Of the nine government hospitals,

one was federally operated and the others were

run by State or local governments. Approximately one-third of the nonprofit hospitals were

church operated.

Most of the hospitals ranged in size from 30

to 700 beds, but a few had well over 1,000 beds.

In general, the government hospitals were the

largest and the proprietary hospitals were the

smallest. The feasibility study hospitals were

larger on the average than U.S. short-term hospitals, but the distribution of the study’s hospitals

by type of control was much like that of the Nation’s hospitals. A disproportionately large number of Northeastern hospitals were included in the

study. Because this particular study was not concerned with obtaining actuaI data but was a beginning study to learn about hospital procedures,

the cooperation that might be anticipated, and the

like, a national probability sample was not felt

to be necessary.

PROCEDURE

The administrators of the 45 hospitals to be

visited were first notified of the study by a

letter from the Graduate School of Public Health

explaining its purpose and procedure and requesting cooperation in the study (exhibit A).

About 1 week later the letter was followed by a

telephone call in which the university representative requested an appointment to visit the

hospital. Two administrators among the original

45 who were contacted failed to cooperate even

to this extent, and their hospitals were replaced

by others in the same cities. Both “alternate”

hospitals readily agreed to participate.

At nearly all of the hospitals visited, the

administrators and their medical record librarians were most cooperative and helpful. They

gave considered replies to the questions asked,

and the medical record librarians often went

to considerable effort to locate records which the

interviewer requested. Unpleasant experiences

were surprisingly few, in view of the fact that

many of the medical record departments gave

evidence of being overcrowded, understaffed, and

burdened with work.

At only four hospitals was the university

representative refused access to a sample of

medical records once the interviews had taken

place. At least one of the refusals was based

on a question of legality; the administrator stated

that he had been advised by the local hospital

council not to participate because of the possibility of Iaw suits. Another refusal probably

stemmed more from embarrassment about the

disorganized state of the hospital’s medical rec-
orals than from concern about confidentiality.

At a third hospital the refusal came from a

generally uncooperative medical record librarian who was interviewed before the administrator. Although the issue was not reopened, the

interviewer felt certain that the administrator

would have let him abstract records had the

administrator been talked to first. A small proprietary hospital was unwilling to let its records

be seen but said it would participate in the event

of a national survey.

FINDINGS

This section summarizes the 1963-64 feasibility study findings and presents the recommendations made at the conclusion of the study. No

attempt has been made to modify the recommendations, though modifications might have been

indicated by the 1964-65 pilot study experience,

which is described in subsequent sections.

The feasibility study showed that for the

elements it covered, a hospital discharge survey

of national scope is clearly practicable. Cooperation of hospitals falling into the survey sample

can be anticipated, with very few exceptions,

provided the survey is tailored to the hospital’s

problems of personnel and space and to the

hospital’s reasonable wishes about the mode of

abstracting information from the medical records.

The majority of the administrators interviewed

indicated that there would be no question about

their willingness to participate in a national

hospital discharge survey. Some replied that

participation would depend on such practical

considerations as time, expense, and personnel

limitations.

A few administrators expressed concern

about confidentiality and legality, but their fears

seemed for the most part to be allayed upon

reassurance about the maintenance of confidentiality. The administrators were in general agreement that legal objections would be unlikely

if patients’ names were not abstracted. However,

two administrators suggested that individual patient authorization might be required before rec -

orals could be looked at for statistical purposes,

even though names were not to be copied. The

name, they said, would still be there for the

abstracter to see. On the other hand, the adminis -

trator of one large hospital explained that although the consent of the patient may be technically required by law, it can usually be clmitted

when a responsible agency is conducting the

research. This would appear to be the general

feeling among administrators.

Ready willingness to participate in a discharge survey seemed to be positively associated

with hospital size; that is, the administrators of

the larger hospitals seemed more receptive to

the survey than those of the smaller hospitals.

One likely reason is that larger hospitals receive

more requests of this nature and are accustomed

to research endeavors. The small hospitals,

receiving fewer or no requests, would have little

experience on which to base an immediate decision. By type of control, the government hospitals,

which were the largest visited, seemed to be the

most willing to participate, and the proprietary

hospitals, which were the smallest visited, seemed

to be the least willing.

The initial request for participation’ in the

survey should be directed to the administrator,

who may approve it himself or refer it to, someone else. At half the hospitals visited, the administrator said that his approval would be sufficient, but at the other hospitals the administrator

said he would have to seek the approval of at

least one other person or group of persons such

as the medical staff or the board of trustees.

Some administrators said they would” clear the

request with a legal advisor even though no legal

objections were anticipated. Authority to approve

requests of this nature was more likely to rest

solely with the administrator in the larger hospitals, whereas consultation with a second party

was more likely to be required at the smaller

hospitals.

The time required for obtaining cooperation

will depend partly on who is to make the decision.

If the authority is the administrator’s alone, a

speedier decision should result than if several

people have to be consulted. It seems likely that

when the board of trustees must be contacted,

more time will be required, particularly if the

request must be held until a regularly scheduled

board meeting.

Before any hospital is approached about the

survey, the endorsement of the American HOSpital Association and similar organizations such

4
as the State hospital association should be obtained

and publicized, The local hospital council should

also be informed of the survey, perhaps by the

American Hospital Association, and encouraged

to lend its support. As some administrators

hinted, such support could mean the difference

between cooperation and refusal.

It is also recommended that a strong statement on the value of the survey be sent to each

hospital selected and that a representative of the

National Center for Health Statistics visit each

hospital to explain the survey personally and

secure cooperation. Although there are no indications that legal problems will present serious

difficulty for the survey, it might be advisable to

review the various State laws and regulations

(where such exist) governing the release of

medical records for statistical purposes. Should

a question be raised, the position of the person

who visits the hospital to explain the survey will

be stronger if he is informed about the relevant

laws and thei~ interpretation.

While some hospitals indicated they might

be willing to collaborate in the survey without

reimbursement, it was clear that, most would

expect some compensation for their contribution,

especially where it was felt that overtime or the

employment of additional personnel might be

required. The tentative form shown to the administrator (exhibit B) was quite detailed and

implied a fairly exhaustive review of the medical

record. It contained questions on the characteristics of the patient and his hospitalization, including final diagnoses, operations, complications, Iaborator y tests, therapies, and the like.

There were some differences about whether

payment should be made to the hospital or to the

personnel doing the work, but most administrators

favored payment to the hospital, It is recommended that a uniform policy be adopted for the

compensation of hospitals and that fair payment,

based on further examination of the true cost

to the hospitals, be made. Establishing a working relation between the Federal government

and the individual hospital is not a simple process, especially where transfer of funds is involved. Contracts will have to be made (at which

some hospitals might conceivably balk), the

status of the persons doing the abstracting defined. and so forth,

Administrative opinions as to who should do

the abstracting ranged from a strong preference

for utilizing hospital persomel to an equally

strong preference for having someone sent in

to do the work. Any reasonable procedure for

abstracting records that the National Center for

Health Statistics decided to adopt could probably

be made to work.

Generally the administrators indicated they

would be willing to have an employee of a survey

organization come to the hospital periodically to

select a sample of discharges and abstract information from records, provided the work was

carried out in an ethical manner by properly

trained personnel. In favor of having the sampling

and abstracting done by representatives of the

National Center for Health Statistics rather than

by the medical record librarians is the fact that

representatives’ training and performance could

be closely controlled by the Center. Also, the

abstracter’s first responsibility would be to the

survey, rather than to the hospital. The survey

would naturally be of secondary importance to

the medical record librarian, who might not

always be able to direct his or her best efforts

toward it. (However, greater training and experience might more than compensate for any

lack of enthusiasm or time.)

Contraindicating the use of abstracters with

no medical record training would be their lack

of familiarity with medical terminology; such

familiarity is a great aid in making out the

handwriting of the physicians. If the work is to

be done by persons without experience in the

medical field, special instruction in medical

terminology might be included in the training

program. Such instructions might also prove

advantageous even if hospital personnel do the

abstracting, because not all hospitals have welltrained persons handling their records. It was

not unusual to find a clerk responsible for the

records at smaller hospitals.

The majority of administrators said that

hospital personnel could be made available for

abstracting records; yet, the majority of the

medical record librarians indicated they could

not handle an added assignment without overtime

or additional help. Certainly many did not appear

to welcome the idea of another assignment.

5
Aside from the obvious advantages of having

the abstracting done by persons familiar with

the records and the doctors’ handwriting, the

utilization of medical record personnel could

result in improved medical records as the survey

progresses, Because of training and experience

with the particular hospital’s records, the medical record librarian is in a far better position

than an outsider would be to handle abstracting

problems when they arise and to encourage

physicians to complete records. If medical record personnel are to do the sampling and abstracting, a representative of the National Center

for Health Statistics could instruct them initially

and then call periodically to review their work,

which would be edited for completeness on a

continuing basis.

A question as to whether records would be

abstracted on a daily basis, before the records

were filed away, or at monthly intervals was

raised by a number of administrators and medical record librarians. Those who mentioned

this point clearly favored the former alternative.

The monthly procedure, they said, meant that

charts would have to be pulled and refiled and

the record room routine disrupted.

The importance of cordial relationships with

the administrator and, especially, with the medical record librarian cannot be overstressed. The

success of the entire venture depends on the

latter’s cooperativeness, willingness to devote

time and effort, and motivation for completeness

and accuracy. Good will is a sine qua non. To the

maximum extent possible, the procedures for

sampling the records and abstracting data from

them should be in line with the customs and practices already being observed in the hospital and

with the wishes of the administrator and the

medical record librarian. Unless the decision is

made to follow a single procedure in all hospitals, it is recommended that the choice as to

whether the abstracting be done by hospital

personnel or by an outsider, presumably welltrained, should be the hospital’s.

Some lag occurs between the patient’s date of

discharge and the date the medical record is completed. The amount of time an outside abstracter

should wait before seeking to abstract records

from a particular month’s discharges was not

determined, but obviously the time which is

optimal for one hospital may not be so for

another. Nevertheless, the experience indicated

that 3 months would probably be an adequate

period in most hospitals. It is recommended

that the sample for month X (JanL12Wy, for

example) be selected in month X + 2 (March)

and abstracted in month X + 3 (April). This ,

procedure should allow the medical record librarian sufficient time to locate and review the sample

charts for completeness. No matter how long an

interval is established or what kind of procedure

is employed there will inevitably be some charts

which cannot be located or made available for

abstracting at the prescribed time. Under these

circumstances the medical record librarian might

be asked to complete and mail abstracts for the

missing records as soon as they become available,

to avoid unnecessary y delay in processing the

monthly data. An alternative would be to have the

charts put aside to be abstracted with the next

month’s records. Whatever policy is deemed

advisable, an instruction covering the situation

should be prepared.

The discharge rosters observed in the hospitals visited consisted usually of simple straightforward lists of the discharges on a day-by-day

basis. The order in which discharged patients were

listed varied from hospital to hospital,, The four

principal ways of listing were by record number,

alphabet,room number, and time of day. If a

simple systematic sample of every kth discharge

is to be drawn, this can be accomplished readily

in most hospitals. On the other hand, if a-ny withinhospital control on age, hospital service, or other

variable is contemplated, many hospitals may

have to be asked to develop a discharge roster

tailored specifically to the needs of the survey.

To insure the maintenance of the desired withinhospital sampling rate and overall control, a discharge roster specifically designed for the purposes of the Hospital Discharge Survey may

have to be developed for at least some of any

sample of hospitals. Small hospitals may not

have a discharge list, but a suitable form can

easily be designed for them.

The several items of information called for

on the abstract form which was tested (exhibit B)

were extracted from the hospitals’ medical records with varying degrees of success. Because

of the importance of establishing mutually satis6
factory relationships with each hospital from the

very start, data collection should at first besimple. It is recommended that data collection be

limited, at least initially, to information generally

available on the medical record face sheets—

admission and discharge dates, date of birth

(or age, if birth date is not available), color,

sex, marital status, final diagnoses, and operations. Expansion to items within the record,

which present greater difficulties, can come

after collection of data from the face sheet has

become systematized. Variations in record forms

and recording practices for newborn infants

suggest that the newborn had best be excluded

from the study, at least at first.

The medical record face sheets were found

to. be eminently suitable for fairly speedy abstracting, especially where the diagnoses and

operations were typed rather tian written in longhand. Thought should be given to possibilities

of “automating” the abstracting procedures to the

extent practicable. Marked-sense or other devices might be tried in hospitals which are

willing to experiment in this fashion.

SUMMARY OF RECOMMENDATIONS

To summarize, the more important recommendations and suggestions coming out of this

feasibility study were as folIows:

1. Endorsement by the American Hospital

Association and State and local hospital

groups would be influential in obtaining

a hospital’s cooperation. Personal visits

by representatives of the National Center

for Health Statistics to describe the Hospital Discharge Survey would be helpful,

as would a statement about the uses of

the survey.

PILOT STUDY

To some extent on the encouragement gained

from the feasibility study findings, which have just

been described, the Division of Health Records

Statistics of the National Center for Health Statistics undertook a pilot study during the 1964-

65 fiscal year to pretest procedures for the

Hospital Discharge Survey. In designing and

2.

3.

4.

5.

6.

7.

8.

Payment to the hospitals should be on a

uniform basis calculated ultimately on

true cost to the hospitals.

Contractual arrangements would seem to

be necessary to formalize procedures; the

matter appeared to be generally acceptable. ”

It was found that a lag in time often

occurred between discharge of the patient and completion of the medical record. This is an impm?ant factor to W

considered in establishing procedures for

the abstracting of medical records.

The procedures for coHection of data

should be simple and, at least in the early

stages of the Hospital Discharge Survey,

limited to the summary or face sheet of

the medical record. Newborn bifants might

at first be excluded.

Because of the fairly high degree of

uniformity noted in the style of the summary sheet employed in hospitals and because of their relative simplicity, techniques of mechanical processing should

be tried out.

The choice as to whether the abstracting

is to be done by hospital or by government personnel should be the hospital’s,

(Note: In the subsequent pilot study, which

is described next, the hospitals were

assigned one procedure or the other.

Therefore, further trial of this recommendation could not be made.) “

FinaIly and most important, the feasibility study showed that a hospital discharge survey of national scope was

practicable and would be well received

by the hospitals falling into the sample.

k

METHODOLOGY

conducting the study, the National Center for

Health Statistics received assistance from both

the U.S. Bureau of the Census and the Department

of Biostatistics, Graduate School of Public Health,

University of Pittsburgh. The details of this study

will be reported elsewhere. The emphasis in the

present report is on the cooperation and the man7
I ‘ea’~!!5-E--------.-----t2!!rY

i

Selection of sample and distribution

of hospitals among participating

agencies

Letters from AHA

and NCHS to sample

hospitals and

hospital councils

+

Interview with Interview with - ~

1

,1 First sample

administrator MRL of records

and agreement reached selected

i

I

Interview materials

sent to NCHS I

+

Sampling —

and

abstracting

Hospital contacted

I for evaluation

program

Y 1 I

Evaluation of Evaluation Reproduction of

sampling frame of sampling face sheet

J

1 1.

Data processing

* and 4

analysis

MFI - Master Facility Inventory NCHS - National Center for Health

AHA - American Hospital Association Statistics

MRL - Medical record librarian

Figure 1. Pilot study of the Hospital Discharge Survey.

8
ner of participation of hospitals in the pilot study

of the Hospital Discharge Survey.

The survey activities which were carried

out prior to and during the pilot study are summarized in figure 1, a flow chart depicting the

initiation of the Hospital Discharge Survey.

GROUNDWORK

Definition Qf Hospital

For the purpose of the study a hospital was

defined in the following way:

1.

2.

3.

4.

5.

maintains six beds or more for inpatient care;

is licensed by the State in which it is

located (if the State has a licensure law);

provides inpatient care under the supervision of a duly licensed doctor of medicine or doctor of osteopathy;

provides nursing service 24 hours a day

under the supervision of a registered

nurse;

maintains medical records for each patient admitted.

The study was limited to “short-term” hospitals meeting all the above requirements, that is,

to hospitals in which the average length of stay

was less than 30 days.

Selection. of Sample

From the Master Facility Inventory a probability sample of 95 hospitals was selected for

the 1964-65 pilot study. Of these hospitals, two

were judged to be out of scope on the basis of

the ahove criteria—one because it provided

services for outpatients only, the other because

it was a long-term hospital—and were consequently dropped frcm the study. ‘l%ese two hospitals, as well as the nine Veterms Administration Hospitals which fell into the sample,

are not included in this report. The Veterans

Administration Hospitals are excluded because

the details of their participation were not settled

during the pilot study year.

The distribution of the remaining 84 hospitals by geographic region, type of control, and

bed capacity may be seen in tables 2 and 3.

Although the sample was drawn from the Master

Facility Inventory, the data shown in the tables

are based on information provided by the hospitals on first contact. Since the Master Facility

Inventory was by this time over 2 years old,

some changes occurred in bed capacity and type

of control, and the figures here may differ

slightly from figures published elsewhere.

Nearly one-half the hospitals visited had

more than 300 beds, and 20 percent had over

1,000 beds. The reason for this high proportion

of large hospitals is that the sample was made

up of two panels: (1) a certainty panel of all hospitals having 1,000 beds or more and (2) a probability panel of hospitals with fewer than 1,000

beds. As might be expected, the governmentowned hospitals—State and local-were the largest, with nearly one-half of these falling into

the category of 1,000 beds or more, and the

proprietary hospitals were the smallest, with none

of the four having more than 400 beds. The government hospitals comprised 33 percent of the pilot

study hospitals. Church-owned hospitals accounted for 23 percent, and other nonprofit hospitals

accounted for 39 percent. The proprietary hospitals amounted to only 5 percent of the total.

By geographic region, nearly one-third of the ●

sample hospitals were located in Northeastern

States; one-seventh were in the West. The remaining 45 hospitals were evenly divided between

the North Central and Southern States. All but 7

of the 84 hospitals were members of the American

Hospital Association. The nonmembers were, for

the most part, small hospitals with fewer than

100 beds.

Distribution Among Agencies

The responsibility for contacting hospitals

and bringing them into the Hospital Discharge

Survey fell largely to the Bureau of the Census,

whose personnel setup was particularly well

suited for such a study. llleir field personnel,

located throughout the Nation, were already

experienced in sampIe surveys in the health

field. It is they who conduct the field work for

the Health Interview Survey.

9
Table 2. Distribution of pilot study hospitals in each geographic region, by selected

characteristics: Hospital Discharge Survey, 1964-65

Characteristic

Total----------------------------------

Bed capacityl

Under 50 beds--------------------------------

50-99 beds-----------------------------------

100-199 beds---------------------------------

200-299 beds---------------------------------

300-499 beds---------------------------------

500-999 beds---------------------------------

1,000 beds or more ---------------------------

Control

State and local government -------------------

Church---------------------------------------

Other nonprofit ------------------------------

Proprietary ----------------------------------

AHA membership

Member ---------------------------------------

Nonmember ------------------------------------

All

regions

84

8

1;

;:

10

17

28

19

33

4

77

7

Geographic region

Northeast

27

North

Central

22

2

3

:

5

2

3

:

8

20

2

South

23

West

12

2

1

3

2

1

5

2

3

2

11

1

lExclusive of bassinets for newborn infants.

NOTE: AHA-American Hospital Association.

Table 3. Distribution of pilot study.hospitals, by type of control and bed caplacity:

Hospital Discharge Survey, 1964-65

Type of control

Bed capacityl State Other

Total Pro- and local Church nongovernment profit prietary

All bed capacities--------------- 84 28 19 33 4

Under 50 beds-------------------------- 8 3

50-99 beds----------------------------- 2 i ; i

100-199 beds--------------------------- 1? 5 1

200-299 beds--------------------------- 11 : 3 ;

300-499 beds--------------------------- 14 6 i

500-999 beds--------------------------- ; :

1,000 beds or more --------------------- :; 13 :

‘Exclusive of bassinets for newborn infants.

10
The 84 hospitals which comprised the pilot

study sample were distributed among the three

participating agencies in the following way:

HospiAgency ta.k

Bureau of the Census --------------- 72

Gradpate School of Public Health ----- 8

National Center for Health Statistics-- 4

Methods of Data Collection

Several different data-collection procedures,

or combinations of procedures, were developed

for the pilot study year and assigned to the hospitals by a quasi-random process. These are defined below. Figure 2 shows for each procedure

(which will be designated A, B, C, D, and E) the

agency responsible for each phase of the data

collection. The distribution of the sample hospitals by type of data-collection procedure offered

and selected characteristics is shown in table 4.

In two instances, the procedure offered to the

hospital was not the one originally set by the

National Center for Health Statistics. For this

reason, the figures in this report for “offered”

procedure may differ slightly from figures published elsewhere on “assigned” procedure.

In procedures A and E, the sampling and

abstracting were done by nonhospital personnel.

In procedure A, representatives of the Bureau

of the Census conducted the initial interview,

sampled and abstracted the medical records,

and edited the abstracts; in procedure E, these

operations were handled by representatives of the

National Center for Health Statistics. As may be

seen from figure 2, 43 hospitals were offered

procedure A and 4 were offered procedure E.

In the protocol for procedure A, the data

collection was set up in such a way that the

abstracter would visit the hospital once every

3 months, select a ,sample of records to be abstracted on the next visit, and then abstract

the records which had fallen into the sample on

the preceding visit. The purpose of the interval

between sampling and abstracting was to allow

time for the records to be completed and made

available for abstracting. Procedure E was the

same as procedure A, except that the hospitals

were visited every other month instead of every

3 months.

In procedure B, which is essentially a combination of procedures A and C (below), a representative of the Bureau of the Census selected

a sample of records each month but prepared

only the demographic portion of the abstract

form. An employee of the hospital—the medical

record librarian or someone under her supervision—completed the medical portion of the form,

that is, the diagnostic and surgical “information.

The Census representative conducted the initial

interviews, and the abstracts were sent to the

Bureau of the Census each month for editing.

In procedures C and D, the sampling and abstracting were done by hospital personnel. Both

C and D called for monthly sample selection and

completion of abstracts. The abstracts were

then sent to the Bureau of the Census for editing

if a Census representative had made the initial

contact with the hospital (procedure C), or

to the National Center for Health Statistics if

the contact had been made by a representative

of the Graduate School of Public Health (procedure D). Twenty-one hospitals were offered

procedure C, and eight were offered procedure D.

Because procedure E, for our purposes

here, is essentially the same as procedure A,

and procedure D the same as procedure C, we

shall refer simply to procedures A, B, and C—

as they affect and are affected by the matter

of cooperation. Table 4 shows the distribution

of the sample hospitals by both offered and finaI

procedure and by selected characteristics of the

hospitals.

Abstract Forms

Two different abstract forms were developed

for the pilot study: (1) a conventional form in

which the entries were written in (exhibit C), and

(2) a form in which appropriate spaces were

blocked in for scanning by an IBM “reader”

(exhibit D). The first form was assigned to 41

hospitals and the second to 43. The two forms

were fairly evenly distributed among the hospitals by size, type of control, geographic region,

and assigned data-collection procedures. The

assignment of the abstract form to a particular

hospital was random within paired groupings of

hospitals.

11
Survey operation

Interviewing ----------------------------

Sampling --------------------------------

Abstracting -----------------------------

Editing ---------------------------------

Number of hospitals ---------------------

Data-collection procedure

A B c D E

Agency

Censusl Census 1 Census 1 GSPH NCHS

Census Census Hospital .Hospital NCHS

Census

Census and Hospital Hospital NCHS

hospital

Census Census Census NCHS NCHS

43 8 21 8 4

lAt a small number of hospitals the Census Bureau supervisor observed while a representative of the National Center for Health Statistics or the Graduate School of Public

Health conducted the interviews.

NOTE:

tistics.

Figure 2.

Sampling

GSPH-Graduate School of Public Health; NCHS—National Center for Health StaAlternative procedures that were offered, defined in terms of survey operations and aqencies

involved.

Rate

The proportion of records sampled within

each hospital was designed to vary inversely

with the size interval of the hospital as given

in the Master Facility Inventory. Table 5 presents the sampling rates established for each

hospital-size group. The rates ranged from 1

percent at the largest hospitals with 1,000 beds

or more to 20-40 percent in hospitals with fewer

than 50 beds. Bed capacity as reported by the

administrator would in a few instances have

placed the hospital in another size interval in

terms of the sampling rate. However, no adjustment in the original rate was made because each

hospital had fallen into the sample on the basis

of its size as reported in the Master Facility

Inventory.

Sampling Procedure

The methodof sampling the medical records

was determined in each hospital by the format

of its discharge listing. If the listing contained

the patients’ medical record numbers, terminaldigit sampling could be used; otherwise, imerval

sampling was required.

In terminal-digit sampling, the sample fora

particular month would consist of all patients

discharged that month whose medical record

12
Table 4. Distribution of

collection procedures, by

pilot study hospitals with various offered and final dataselected characteristics: Hospital Discharge Survey, 1964-65

Characteristic

Total ------------------------------------

Bed capacity2

Under 50 beds ----------------------------------

50-99 beds -------------------------------------

100-199 beds -----------------------------------

200-299 beds -----------------------------------

300-499 beds -------- -------- --.----- -.------ ---

500-999 beds..----------------------------------

1,000 beds or more-----------------------------

Control

State and local government---------------------

Church-----------------------------------------

Other nonprofit--------------------------------

Proprietary------------------------------------

Region

Northeast--------------------------------------

North Central----------------------------------

South----w-------------------------------------

West--------------------------------------------

Offered procedure

Total

84

—

A

or

E

47

2

7

7

7

1:

17

2;

2

16

10

1:

—

c

or

D

29

Final procedural

Total

81

—

A

or

E

48

c

or

D

30

lFigures for “final procedure” exclude 2 hospitals which failed to participate in

the pilot study and 1 hospital where the final procedure could not be classified as A,

B, C, D, or E.

ProceduresA and E—Bureau of the Census or National Center for Health Statistics

selects the sample and abstracts all the required data.

Procedure B—Bureau of the Census selects the sample and abstracts the demographic

data; hospital abstracts the diagnostic and surgical information.

Procedures C and D—Hospital selects the sample and

data.

abstracts all the required

2Exclusive of bassinets for newborn infants.

numbers ended in a specified digit or pair of

digits. For example, at one hospital where the

sampling rate was four percent, an abstract

would be prepared for each discharged patient

whose medical record number ended, say, in

24, 44, 74, or 94, thusyielding(inthelongrun)

a sample of 4 in every 100 discharges.A separatesetof’’samplekeynumbers”was assigned

to each hospital-size group in each of the four

geographic regions.

Interval sampling ,which was employed when

the patients’ medical record numbers were not

shown in the discharge list, can perhaps best

be explainedby an illustration. In a hospital

where the sampIing rate was 4 percent, the first

month’s sample might consist of the 24th entry

13
Table 5. Rates of sampling records within pilot study hospitals:l Hospital

Discharge Survey, 1964-65

Bed capacity2 Sam- Number

(Master Facility pling of

Inventory) rate hospitals

Percent

Under 50 beds:

Northeast -----------

North Central------- :: ;

South--------------- 40 3

West ---------------- 30 2

50-99 beds ------------ 14

100-199 beds ---------- !;

200-299 beds ---------- : 13

300-499 beds ---------- 3 12

500-999 beds ---------- 2

1,000 beds or more---- 1 1:

lRates were assigned on the basis of

bed capacity reported inthe Master Facility Inventory and do not necessarily relate to current bed capacity.

2Exclusive of bassinets for newborn

infants.

in the discharge listing for that month (a random

start) plus every 25th entrythereafter. Theapplication of the sampling interval 25 was continuous, so that the starting point (24) would be

used only once, at the beginning of the survey.

Thus, in interval sampling, a starting point was

assigned to each hospital-size group in eachof

the four geographic regions. That, incombination

with the assigned interval, yielded the desired

rate of sampling for the hospital. Interval sampling is generally more tedious than terminaldigit sampling and has an additional disadvantage

that the medical record numbers have to be

obtained from the alphabetical patient index before the sample records can be located in the

numerical file. (Interval sampling had to he

employed at only two hospitals.)

Other things being equal, a discharge list

is preferable to an admission list in sampling

because the sample selected has to relate to

those patients discharged during a specified

period. The use of an admission list for sampling

(to be employed only when no discharge list is

available) introduces some complications. TO

obtain from an admission list a sample of

patients discharged during a certain period it

is necessary to begin the sample selection

some time prior to the month under consideration, in order to be reasonably certain of

screening all those eligible for discharge during the survey month. A sample selected in this

way, by either the terminal-digit or interval

method, will obviously contain patients discharged before and after the month under consideration. When admission lists are used, it

is therefore necessary to obtain the dates of

discharge for all the “sample” patients andexclude or hold those not discharged during the

survey month.

Not every patient who fell into the sample

was necessarily included .in the survey. Certain

special classes of patients were considered to

be out of scope even though the hospitals might

have regularly recorded one or more of these

classes on the discharge or admission lists.

Such out-of-scope cases included thefollowing:

well-newborn infants, persons dead on arrival

at the hospital, stillbirths, and a few other kinds

of cases less frequently encountered. Abstracts

were not completed for such out-of-scope cases.

Reimbursement Offer

Each hospital participating inthe surveywas

offered some payment, the amount or rate depending on who was to do the sampling andabstracting of the medical records, Where hospital

personnel wereto handle all the work (procedure

C), 30 cents per completed abstract was offered:

Half that amount per abstract was offered to the

B-procedure hospitals, where the hospital staff

were to complete the medical portion of theabstract’but were not to select the sample. Where

both the sampling and abstracting were tobedone

by a representative of the National Center for

Health Statistics or the Bureau of the Census

(procedure A), the hospital was offered a flat

annual amount related to the expected annual

number of abstracts. These amounts varied from

$10 per year for fewer than 100 abstracts

to $50 per year for 750 abstracts or more

(table 6). Forallparticipating hospitals, payment

was to be made at the end of each fiscal year.

14
Table 6. Schedule of payment for datacollection Procedures in Pilot study

~; i:;ls:

L

Hospital Discha;ge Strrveyj

Procedure and

estimated annual number Payment

of abstracts

I

Per year

A and E

1-99 abstracts ----------

100-299 abstracts -------

300-499 abstracts ------- 30

500-749 abstracts ------- 40

750 abstracts or more--- 50

I

Per abstract

------- -.----- ------- ---- lsf$

~ and D------------------- 30C

lProcedures A and E—Bureau of the

Census or National Center for Health Statistics selects the sample and abstracts

all the required data.

Procedure B—Bureau of the Census

selects the sample and abstracts the demographic data;hospital abstracts the diagnostic and surgical-information.

Procedures C and D—Hospital selects

the sample and abstracta all the required

data.

NCHS ‘Fact Sheetw

The National Center for Health Statistics

prepared an information sheet on each sa,mple

hospital’, giving background information about

the hospita~—name, address, telephone number,

bed capacity, type of control, and annual number

of discharges—as well as details pertaining to

that hospital’s participation in the survey, such

as the sampling rate and sample key digits,

expected number of abstracts per year, and

method of collecting the data (exhibit E). These

were valuable aids in preparing for the personal

contacts with administrators and medical record

librarians.

Special Pretest

Once the methodology for the pilot study

had been developed, a special pretest was conducted in 10 of the 84 sample hospitals to test

the procedures for inducting hospitals into the

survey. A l-day conference for those involved

in the special pretest was held at the Graduate

School of Public Health on September 22, 1964.

Then letters were sent from the American Hospital Association andadministrators were called

on the telephone for appointments. The administrators and their medical record librarians

were subsequently interviewedandinitialsamples

of medical records were selected. This methodology will be described more fully in the section

which follows. Here it is sufficient to saythat the

problems which were encountered in the special

pretest were remedied and the survey materials

were revised accordingly.

At the conclusion of the special pretest a

training program was held in Chicago on November 5 and 6, 1964, for the Bureau ofthe Census

field supervisory personnel who would be working on the survey. The pilot study then continued in the remaining 74 hospitals. Because

the 10 hospitals which were visited during the

special pretest were an integral part of the pilot

study, no distinction will be made between them

and the

report.

Letters

other 74 hospitals in the balance of this

INITIAL CONTACT

WITH THE HOSPITAL

The administrators of the 84 hospitals which

had fallen into this first Hospital Discharge Survey

sample were notified of the survey during September, October, and November of 1964 by a

letter from the Director of the American Hospital Association (exhibit F). This letter stressed

the importance of the study andrequested thehospital’s participation. It was followed, in about 1

week, by a letter from the Director or the Deputy

Director of the National Center for Health Statistics (exhibit G), in which the survey was

described in more detail and cooperation was

again requested. The letter from the National

Center for Health Statistics contained a twopage statement on the survey entitled “The

Hospital Discharge Survey” (exhibit H). This

may be seen in Appendix II, following the letters

which were sent to the administrators.

15
Most of the hospitals which fell into the

survey sample were sent both of the letters described above. However, in the special pretest,

the letter from the National Center for Health

Statistics” was omitted because of time considerations. The statement on the survey which would

have been enclosed was given to the administrator

at the start of the interview. The approach was

also modified somewhat for the two sample hospitals which were not listed in the directory of

hospitals published by the American Hospital

Association. These hospitals received only a letter

from the National Center for Health Statistics.

The local hospital associations were informed

of the survey and asked to lend their support. They

were told the names of the hospitals in their

area which had fallen into the survey sample,

Telephone Call

The letter from the National Center for

Health Statistics informed the administrators

that a survey representative would telephone

within a few days to make an appointment to

discuss the hospital’s participation in the survey.

Approximately half of the administrators were

called within 2 weeks of the letter, and all except

one were called within 4 weeks. With one exception, the telephone contacts were completed

by the middle of December.

PERSONAL INTERVIEWS

Interview With the Administrator

AH of the administrators but two were interviewed by the end of December, generally within

8 weeks of the letter from the American Hospital Association. Seventy-five percent of the

administrators were interviewed within 6 weeks

of this letter.

The primary objective of this interview was

to establish a good relationship with the hospital

and to secure participation in the Hospitai Discharge Survey under mutually satisfactory conditions. Another important purpose was to obtain

a certain amount of information about the hos -

pital, for example,

discharges. These

16

the current annual number of

objectives were served by

Section B of the interview form (exhibit I).

When an agreement had been reached on

the manner of abstracting and the amount of

payment, the details of the agreement were

recorded on a form designed for this purpose

(exhibit J). This document was needed in order

to prepare a type of purchase order. (Although

the form carried the heading’ ‘Contract Proposal, ”

the interviewers were informed that this could

be modified to read “Memorandum of Agreement” or altered by merely striking out the

word “Contract,” to read “Proposal.”)

Interview With the Medical Record

Librarian

By and large, the medical record librarians

were interviewed on the same day as the administrator. At approximately half the hospitals, the

medical record librarian was present for the

interview with the administrator, and she and the

administrator were interviewed together. At most

of the other hospitala the interview with the

medical record librarian took place immediately following the interview with the administrator. At only two hospitals was the survey

representative not able to see the medical record

librarian, or her delegate, that day because of

some question about the hospital’s participation

in the survey.

The purpose of the interview with the medical

record librarian was to develop a procedure within the hospital for sampling and abstracting the

medical records of discharged patients and to

actually inaugurate that procedure. To this end

the medical record librarian was asked the series

of questions in Sections C, D, E, and F of the

interview form (exhibit I), covering the composition of the discharge list to be used in selecting

the sample and the procedures for sampling and

abstracting.

Once a sample scheme had been devised the

interviewer selected the initial sample of discharges and set a date for another meeting with

the medical record librarian. The agenda for this

second meeting depended largely upon ‘the abstracting procedure which had been established

during the first interview. Where the Bu[reau of

the Census was to handle the mechanics- of the
survey (procedure A), the interviewer returned

to introduce an assistant who would at regular

intervals visit the hospital to sample and abstract records. Where the work was to bedone by

hospital personnel (procedure C), the interviewer

returned to assist the medical record librarian

with any problems she might have in connection

with the survey. Most of the hospitals in the

study had been visited a second time by the.end

of January. By the end of the second visit, the

pattern for sampling and abstracting the medical

records was set.

In the spring of 1965 theparticipating hospitals were contacted in connection with the survey’s evaluation program, which was essentially

a review of the sampling and abstracting which

had been done. This program is described later

in this report.

COOPERATION

Some of the main purposes of the pilot

study were to obtain a further check on the

degree of cooperation that might be anticipated

by the Hospital Discharge Survey (HDS), to discover the questions that might be raised, and to

develop techniques for dealing with them. This

section describes these important aspects of

the pilot study. It is based largely upon the reactions of the interviewers recorded on the interview form (exhibit I) and submitted in response

to a subsequent request for more detail.

In a general way, it can safely be said that

the results of the pilot study in terms of cooperation received from the sample hospitals were

highly satisfactory. As an indication, only 2 of the

84 hospitals which were asked to participate in the

pilot study failed to do so, and one of these later

came into the regular survey. In the opinion of

the HDS representatives who conducted the initial

interviews, unreserved cooperation was obtained

from 74 of the hospitals which were asked to

participate in the survey and qualified cooperation

was received from the remaining 8 participating

hospitals.

Obtaining Interviews

The interview with the administrator as an

early step in the pilot study procedure was described in the preceding chapter. With one exception, the interviews with the administrators of

the 84 hospitals were quite easily arranged by

telephone, Even the two administrators who withheld participation during the pilot study readily

agreed to an appointment to discuss the survey.

Occasionally an administrator asked questions

about the survey over the telephone, but generally

the telephone contacts were brief and limited to

the detail of establishing a mutually satisfactory

appointment time. Some of the administrators indicated on the telephone that their hospitals would

participate in the survey, and at least two administrators notified the National Center for

Health Statistics of their willingness to cooperate

even before the telephone call had been made.

Approval of Request

At 73 of the 84 hospitals visited, the request

for participation in the Hospital Discharge Survey

was approved by the administrator during the

initial interview. At 7 of the remaining 11 hospitals there was no question about cooperation.

A signed memorandum of agreement was ultimately obtained from these hospitals as well as

from two of the four hospitals where participation

had been questionable.

The reason usually given for the delay in

signing the proposaI form was that the approval

or advice of someone other than the hospital

administrator had to be sought. Where this was

the case, the question was generally referred

to a legal advisor, the medical director, the

executive committee of the medical staff, the

board of trustees, or to the record room committee. Usually this was a mere formality.

Occasionally more than one such agent was consulted.

Nonparticipation

The two hospitals which failed to participate

during the pilot study year gave different reasons

for holding back. One of the hospitals had recently had a time study conducted throughout the

hospital, aimed at improving efficiency and re-
ducing expenses. As a result of the study, the

medical record staff had been reduced for a trial

period of 1 year. Because this action created

an additional workload for the remaining staff,

the administrator was unwilling to add to their

responsibilities. In his opinion, 4 hours each

month would have been required to pull and

refile the medical records needed by the HDS

abstractor,s, and he said he doubted that the

ultimate results would justify this time.

At the other hospital the reason given for

nonparticipation was primarily a legal one. The

question of legality, raised by the medical director, was referred to the county attorney for an

opinion in connection with the State statute on

privileged communication. The opinion, which

was received too late to allow for participation

in the pilot study, did not preclude participation,

and the hospital is now taking part in the regular

survey. Although a few other administrators may

have raised this question with legal advisors,

none was apparently advised against participation.

It seems to be the general policy to approve a

survey of this nature when carried out by responsible government agencies, particularly when

care is taken to insure the confidentiality of the

information.

Two hospitals almost refused to cooperate

in the study because of the attitude of some members of the medical staff. A few of the staff

were inclined to be somewhat suspicious of any

project sponsored by the Federal government.

In addition, one hospital was currently participating in a local study which some physicians

felt to be a nuisance since it required them to

complete their medical records sooner than they

might otherwise have been expected to. However,

the hospital did agree to participate after discussions with its medical leaders.

ACCEPTABILITY OF

DATA-COLLECTION PROCEDURES

The data-collection procedure offered by

the Hospital Discharge Survey was accepted

by 75 of the 82 hospitals which agreed to participate in the study. The changes in procedure

made at the other 7 hospitals are reflected in

table 7, which shows the distribution of all 84

hospitals by both the offered procedure and the

final procedure agreed upon.

Table 7. Distri_buti.on of pilot study hospitals, by offered and final datacollection procedures:1 Hospi,tal. Discharge Survey, 1964-65

I

Offered procedure

Fins 1 procedure

agreed upon

mF

All procedures--

Hw

A or E-------------- 48 44 3 1

B--------.-- -------

C or D------------- 3; i ? 2;

Other procedures--- 1 1 .- -

Nonparticipation--- 2 1 IL -

lprocedures A and E--Bureau of the Census or National Center for Health Sl:ati_a -

tics selects the sample and absmacl:s all

the required data.

Procedure B—Bureau ‘of the Census

selects the sample and abstracts the demographic data; hospital abstracts the diagnostic and surgical information.

Procedures C and D—Hospital selects

the sample and abstracts all the required

data.

Procedure A

In procedure A the responsibility for data

collection rests largely with nonhospital personnel. Where the medical record department

is already overburdened with work this cannot

help but be a consideration. Several administrators and medical record librarians were

plainly relieved to learn that the mechanics of

sampling and abstracting were to be ‘handled

by persons connected with the survey. Of the

47 hospitals which were offered procedure A,

44 cooperated on that basis. Of the remaining

three hospitals, one failed to participate in the

pilot study altogether, another was permittedto

do its own sampling and abstracting (procedure

C), and the third hospital, after accepting procedure A, suggested an alternate method of data

collection which was eventually employed. That

method is described later in this chapter.

18
The hospital which switched to procedure C

had two objections to procedure A. The first concerned the confidential nature of the medical records. Although the administrator was willing to

participate in the study to the extent of providing

abstracts of the face sheet which did not contain

the patient’s name, he was unwilling to have the

medical records seen by nonhospital personnel.

Even though the administrator agreed that divulgence of information by an HDS abstracter was

extremely unlikely, he preferred to have the

abstracts prepared by hospital employees. This

administrator believed further that the work

could be handled more efficiently by hospital

personnel, for the medical record department

would be able to absorb the abstracting in the

daily routine. He felt that the abstracts of the

sample records should be prepared as soon as

the records were completed by the physicians

and before they were filed away. In this way

the need to retrieve records for survey representatives or to keep the records out of file for

appreciable periods of time would be eliminated.

It should be noted here that these objections

to procedure Awere also voiced by administrators

who nevertheless accepted the procedure. Some

of those who agreed to procedure A would have

preferred to handle the survey themselves. l%e

actual number who felt this way could not be

ascertained because administrators were not

asked to state a preference and, in fact, were

encouraged to accept the procedure the interviewer offered.

An interesting modification in procedure A

was made at one of the hospitals to which it

was assigned. The administrator there preferred

to have hospital personnel prepare the abstracts

for certain patients who were well-known to the

general public and for patients with illnesses which

carry a stigma in the public mind. The administrator himself wanted to review the listing of

sample cases in order to select those few

which should be abstracted by the hospital. With

this modification he was quite willing to participate in accordance with procedure A.

Procedure C

Only 1 of the 29 hospitals which were offered

procedure C, whereby hospital personnel would be

responsible for the sampling and abstracting, was

not willing to cooperate on this basis. When procedure A was offered as an alternative, the hospital agreed to participate. Even though the other

28 hospitals were willing to cooperate in accordance with this procedure, some administrators

and medical record librarians did voice objection

to the procedure because it placed the responsibility for sampling and abstracting on medical

record persomel who were already quite busy.

On the other hand, to the extent that the administrators had confidence in the integrity of the

employees who handled the medical records, they

could be assured that confidentiality would be

maintained.

In addition, under procedure C the sampling

and abstracting could be incorporated in the daily

routine, if the hospital so desired, and sample records would not have to be pulled for. survey representatives. During the interviews, at least five

of the hospitals which agreed to do the work themselves indicated that they would like to abstract

the sample records daily as such records were

completed and before they were filed away. Probably many of the remaining C-procedure hospitals

are also handling the abstracting in this way.

Procedure B

From table 7 it may be seen that procedure

B, in which the abstracting was to be shared by

hospital employees and survey personnel, was the

least favorably received by the sample hospitals.

Only three of the eight hospitals which were offered

procedure B were willing to cceperate under

these circumstances. The procedure was generally regarded as inefficient by administrators who

could see no reason to have two persons abstracting from the same records, particularly

at different times. lhree of the four hospitals

which rejected procedure B preferred to have

all the work done by Hospital Discharge Survey

personnel, while the fourth hospital preferred

to have its own employees handle the survey, so

that completed records would not have to remain

unfiled or be pulled for outside abstracters. One

of the hospitals which were offered procedure B

did not participate in the pilot study—for other

reasons which have been noted.

19
Since procedure B was so poorly received by

the pilot study hospitals, it is recommended that

it not be among the procedures settled upon in

later stages of the survey. While procedure B

should not be proposed ‘to any hospital, this

suggestion is not meant to preclude all arrangements whereby hospital employees and survey

personnel would share the abstracting. For example, if the demographic data for the sample

discharges can be obtained directly from a computer tape and only the medical information

needs to be taken from the medical record, a

division of labor might prove to be efficient.

Other Data-Collection Procedures

At one of the hospitals which had been

offered procedure A, the medical record librarian was able to suggest an alternate method of

data collection which was accepted and followed

at her hospital. When a record which fell into

the sample was completed, a Xerox copy of the

face sheet was made and sent to the National

Center for Health Statistics for abstracting. This

method relieved the hospital of the need to make

sample records available to abstracters on prescribed dates and also avoided tying up the records within the hospital. Since this was a large

teaching hospital where the medical records

were quite active, these were important considerations. For its participation on this basis

the hospital was paid 20 cents for each Xerox

copy submitted. At the end of the pilot study

year this procedure should be carefully evaluated

and a determination made as to its general

application. It is possible that ‘its use might be

indicated at other hospitals as well.

At another A-procedure hospital where the

medical records were very active and not always

available at prescribed times, the medical record

librarian suggested that she make copies of the

sample medical record face sheets and have them

available for the HDS abstracter at the time of

his visit, Without further study it is not possible

to say whether the additional expense of reproducing the face sheets would be warranted

in this situation, but the suggestion deserves

consideration.

Conclusion

The experience in the pilot study indicates

that either one of the basic data-collection

procedures, A or C, would work at most hospitals. To summarize briefly, only 4 of the 76

hospitals which were offered procedure A or C

did not participate in accordance with the proposed procedure. (One such hospital did not participate at all. ) On the other hand, four of the

eight hospitals which were offered procedure B

rejected it and an additional one failed to participate.

It seems clear from this experience that

hospitals will almost always accept the procedure

outlined to them by the Hospital Discharge Survey.

Offering the hospital a choice of procedures may

create good will, but if such a policy is deemed

impracticable, the large majority of hospitals

can be persuaded to accept a preassigned method.

Any variations in the basic method suggested by

the hospital should be given consideration.

PAYMENT

As was previously stated, hospitals in which

nonhospital personnel did the sampling and abstracting (procedure A) were to be paid amounts

ranging from $10 to $50, depending on the number

of discharges; where hospital personnel performed this job (procedure C) the payment was

to be 30 cents per abstract. (In the few hospitals

where the procedure was mixed, 15 cents was to

be paid.)

The amount of payment proposed by the Hospital Discharge Survey, in accordance with the

data-collection procedure, was acceptecl by 86

percent of the participating hospitals. Ten percent of the hospitals declined any payment, while

4 percent sought an additional amount (table

8). While the administrators who refused payment

were not asked to give their reasons, some

voluntarily stated they felt they were performing

a public service by participating in the /survey;

others’ indicated that the amount involved did not ‘

warrant the cost of setting up and maintaining a

special account.

The 30 hospitals which were to do their own

sampling and abstracting seemed, for the most

20
Table 8. Distribution of pilot study hospitals, by acceptance of proposed payment and

selected characteristics:l Hospital Discharge Survey, 1964-65

Characteristic

Total-----------------------------------------

Final procedure

Census or NCHS samples and

abstracts all the data-----------------------------

Census samples and abstracts

demographic data; hospital

completes abstract ---------------------------------

Hospital samples and abstracts

all the data---------------------------------------

Bed capacitys

Under 50 beds---------------------------------------

50-99 beds------------------------------------------

100-199 beds---------------- ----------4----- --------

200-299 beds----------------------------------------

300-499 beds----------------------------------------

500-999 beds----------------------------------------

1,000 beds or more ---------------- ------------------

Control

State and local government --------------------------

Church-------------------------------- --------------

Other nonprofit -------------------------------------

Proprietary -----------------------------------------

Region

Northeast ..----------------------.------------------

.Nyu[: C;tral --------------..-----------.--------- ---

-----------------------------------------------

West---J --------------------------------------------

Total

81

48

3

30

8

9

H

H

15

27

;;

4

26

21

22

12

Payment

Accepted

70

39

3

28

;

15

10

10

1;

22

;;

4

22

H

9

f%ed

8

In- ~

creased

3

lFigures exclude 2 hospitals which failed to participate in the pilot study and 1

hospital where the final procedure could not be classified as A, B, C, D, or E.

21ncludes only those hospitals which requested an increase in payment. (Does not include hospitals where payment was increased on the basis of a revised estimated number

of annual discharges.)

3Exclusive of bassinets for newborn infants.

part, satisfied with a payment of30 cents per to maintain cost records during the pilot study

abstract. One administrator in this grouprefused year. Where survey representatives were to

payment; however another was reported asobvi- handle the sampling and abstracting (procedure

ously pleased that the hospital would be paid. A), the monetary offer, never more than $50

One hospitaI felt that the amount given would per year, was received humorously by some

not cover thesurvey-related expensesandplanned administrators, especially where the annual pay21
ment was to be $10 or $20. The A-procedure

hospitals accounted for seven of the eight hospitals which refused payment and for two of the

three hospitals where an increase was requested.

To evaluate the payment scale is beyond the

scope of this report. The National Center for

Health Statistics will undoubtedly want to appraise

it carefully.

INTERVIEW WITH THE

ADMINISTRATOR

Although a structured interview was developed for the pilot study (exhibit I), interviewers found it necessary or expedient to deviate from a formal approach. The consensus

among the interviewers seemed to be that the

interview should begin with an informal discussion

of the Hospital Discharge Survey—its purpose,

general program, and details of participation—

and then proceed to the matter of collecting

statistics about the hospital, which now is placed

first. The start of the interview is generally not

a good time td solicit data. Once the administrator has obtained a clear understanding of the

survey and its requirements and it appears that

an agreement will be reached, the statistical data

may be obtained. The memorandum of agreement

can then be prepared at the conclusion of the

interview in accordance with the kind of agreement ultimately reached.

It would be helpful to the interviewer, when

obtaining information about the hospital itself,

to have the pertinent information from the “fact

sheet” also available in the interview form. This

would facilitate comparing the respondent’s information with the corresponding information supplied by the National Center for Health Statistics.

If a serious difference occurred, the interviewer

could investigate further to ascertain which

source of information was correct. Comparisons

of the two sets of data might also be facilitated

by presenting the “fact sheet” data in outline

form with the numbers of the outline corresponding to the item numbers in the questionnaire.

Administrators’ Questions and comments

The questions asked by the administrators

during the interviews were of two general typesstraightforward questions seeking information

about the survey, which usually required only

brief replies, and questions which implied some

objection to the survey. The same question

might be asked in different ways by different

administrators, depending on their attitudes toward the survey. For example, numerous aciministrators inquired about the purpose of the survey.

Some were satisfied by a brief explanation stated

in terms of the printed statement on the survey

which had been sent to all the hospitals. Others

questioned the v,alue of the survey and wanted to

know more about its specific objectives.

The administrator of a large teaching institution asked how he, as a hospital administrator,

would be able to use the published data from the

survey. In his opinion, combined utilization figures

for a number of hospitals were meaningless,

even if the hospitals were located in the same

geographical area, and were of no value to an

administrator in making policy decisions for one

hospital. Another administrator wanted to” know

why the objectives of the survey could not be

accomplished by using the statistics published

by the American Hospital Association. Others

inquired about duplication of effort; quite a few

hospitals were already participating in some

local project for which medical record abstracts

had to be prepared.

Quite a few administrators asked how (or why)

their hospitals had been selected for the survey.

Other administrators showed concern that the

needs of the survey would not be met by their

hospital’s participation; because their hospitals

were not “typical” short-term institutions, a

point a number of them made, they feared the

overall statistics might not be sound. A brief

explanation of the sampling theory underlying

the selection of the hospitals, including the

reasons why one hospital cannot readily be

substituted for another, should be prepared for

the interviewers, who may need to react to such

statements.

Because questions of this kind were encountered frequently and were often difficult to

answer, it is suggested that the survey materials,

particularly the letters and the enclosed statement, be made more specific concerning objectives of the survey and practical uses of the

data. The interviewers should be better pre22
pared to answer such questions than they were

in the pilot study.

Occasionally an administrator asked what

other hospitals in the area were participating

in the survey. Since it has been the general

policy of the Bureau of the Census not to release

the names of participants in sample surveys, the

Census interviewers generally tried to evade

this question. However, the local hospital councils had been notified of the survey by the National

Center for Health Statistics and given the names

of the area hospitals selected for the survey.

Some of the councils had in turn passed this

information on to the hospitals themselves. The

position of the interviewer under these circumstances was uncomfortable. The policy of the

survey with respect to releasing participants’

names should be well defined, and the interviewers should be informed of that policy.

“When is the survey to begin?” and “How

long will it last?” were other questions frequently encountered. The answers were not provided in the written statement on the survey.

The answer to the latter question had, in fact,

not yet been determined for individual hospitals at the time the interviews were held.

Since the administrators deserve an answer to

this question, it is hoped that such details will

be available for the next set of interviews.

At Ieast one administrator gained the impression from the correspondence that his hospital’s participation was being requested for

1 year only. He may have been led to believe

this by a statement in the letter from the American Hospital Association to the effect that the

hospital was being asked to participate in the pretesting phase of the study. The printed statement

which was enclosed in the followup letter from

the National Center for Health Statistics could

have been interpreted to imply that the pilot

study would end by July of 1965. It is unfortunate

that such misunderstandings occurred. Providing

pertinent details in the letters and any other

advance materials may help to prevent such

difficulties in the future.

Quite a few administrators inquired about the

amount of work the survey entailed. Some merely

wanted to have the knowledge. But to others the

question was a matter of real concern since their

medical record personnel were already working

to near capacity.

Some administrators had not realized that

only a sample of the medical records was to be

abstracted. The letter from the American Hospital Association did not mention this point, and

in the letter from the National Center for Health

Statistics the reference to the record sample was

rather general. (“The survey will collect information for a sample of discharges in a national

sample of short-term hospitals.”) In the statement on the survey, “sample discharges” was

used twice, but this term was not defined.

It was not until the second page of the statement

that one learned that there would be ‘‘. . . a

sample of a relatively small number of discharges

within each sample hospital. ” This is one of the

big “selling” points of the survey, and it cannot

be overemphasized. The administrator shouId be

aware of this before the interview is even held.

Consideration should be given to the possibility

of informing the administrator in one of the

advance letters of the actual sampling ratio for

his hospital.

The reference in the survey statement to

possible future expansion of the survey disturbed some administrators. (“Several years

hence it is likely that additional information

about the sample discharges available from the

hospital records would be collected.”) One administrator inquired about the kinds of data

which might later be collected the interviewer

was unable to provide the answer. Another

administrator stated that he was willing to

cooperate with the study as it then stocd but

might not want to participate if it became more

involved. Still, a few administrators were a

little critical about the seeming paucity of information being collected initially.

Some administrators wanted to know if the

signed agreement was legally binding on the

hospital, or if the hospital could drop out of the

survey at a later date if it became too much of

a burden. The interviewers were told that they

might reply in the negative to the first part

and hence affirmatively to the second part of

the question. An instruction about the extent

of obligation should be prepared for the manual;

it should explain at the same time why the

memorandum of agreement is necessary.

“How are the records to be sampled?” was

frequently asked by both administrators and medical record librarians. A simple explanation in23
volving the sample key digits usually sufficed.

It is both desirable and necessary to quote the

sample key digits when explaining the sampling

procedure. Since the digits are not now recorded

in the interview form, space should be provided

for them at the beginning of the interviews with

the administrator and the medical record librarian and perhaps on the first page of the form, as

well, in the box where the hospital’s name and

address are recorded (exhibit I). It is inconvenient and awkward for the interviewer to have

to refer to some other sheet when he is ready

to explain the sampling process. If the sampling

ratio is stated in one of the letters to the administrator, the sample key digits might be quoted

as well.

A few administrators inquired how the amount

of payment for participation had been determined.

It seems to be quite important that the interviewers have some knowledge in this respect.

Of course, the questions of confidentiality and

legality were also raised. These topics have

been discussed previously.

Presence of Medical Record Librarian

The Hospital Discharge Survey had recommended that if possible the medical record librarian be present at the interview with the administrator, but that suggestion had to be made

tactfully inasmuch as it was entirely the administrator’s prerogative as to which members

of his staff should be present at the interview.

About one-half the administrators chose to have

their medical record librarians present from the

first (table 9). It is likely that many felt that she

should be there for the entire interview since

the survey directly concerned her department.

Indeed, at one hospital the administrator asked

the medical record librarian to handle the interview and left to return only to sign the memorandum of agreement.

In 70 percent of those instances where the

medical record librarian had been present during

the interview with the administrator, the interviewer said that her presence had been helpful,

and a number of interviewers recommended that

this become standard procedure. When the administrator and the medical record librarian

are interviewed together, a second explanation

of the survey becomes unnecessary. Also, having

both present facilitates reaching an agreement

which is acceptable to all concerned. If the administrator and the medical record librarian are

not in accord about some of the details, their

differences can be reconciled before an agreement is signed. Because of her special Icnc)wledge

and insight about the medical record system in the

particular hospital, the medical record librarian

may be able to recommend an alternate datacollection procedure which is acceptable. The

ultimate procedure is more likely to fit the hospital when the administrator and the medical record librarian are interviewed at the same time.

Another advantage to interviewing the administrator and the medical record librarian together is that the medical record librarian is

often in a better position than the administrator

to furnish the needed statistical information on

discharges, births, and the like. It is frequently

the medical record department which compiles

these data. If the medical record librarian is

present, the questions can be directed to both, and

whoever has the information can supply iL

Although the interviewers at 10 hospitals

replied that the presence of the medical record

librarian was not particularly helpful, for only 2

of the 10 was it reported that her presence had

had a detrimental effect. At one of these hospitals the medical record librarian objected to

the survey, and cooperation was obtained only by

agreeing to furnish Census personnel to do the

work. At the other hospital the medical record

librarian reportedly complicated the interview

with the administrator by asking questions

irrelevant to her role in the survey.

The. potential advantages of interviewing the

administrator and the medical record librarian

simultaneously probably far outweigh the potential disadvantages, and it is recommended that

this become standard practice. It is also suggested

that, as was done in the pilot study, after the survey has been explained and an agreement reached,

the interview with the medical record librarian

be continued in the medical record department.

In that way the administrator’s time need not be

taken up with the mechanics of sampling and abstracting which do not directly concern him. The

propitious time for adjourning to the medical record department might be the point at which, in

24
Table 9. Distribution of pilot study hospitals, by presence and helpfulness of medical

record librarian (MRL) during interview with administrator and by selected characteristics:] Hospital Discharge Survey, 1964-65

Characteristic

Total ---------------------------------

Final procedure2

A or %-------------------------------------

B--------------------.----,------------------

C or D--------------------------------------

Other procedure -----------------------------

Nonparticipation ----------------------------

Bed capacitys

Under 50 beds-------------------------------

50-99 beds----------------------------------

100-199 beds--------------------------------

200-299 beds-----------,---------------------

300-499 beds--------------------------------

500-999 beds------------------------>-------

1,000 beds or more --------------------------

Control

State and local goverment ------------------

church--------------------------------------

Other nonprofit -----------------------------

Proprietary ---------------------------------

Total

80

MRL present

Helpful

Not

helpful

10

Undetermined

2

1

1

1

i

2

Mu

not

present

39

lFigures exclude 3 hospitals where the administrator was also

librarian and 1 hospital where the administrator

the medical record

asked the medical record librarian

to handle the induction interview.

‘Procedures A and E—Bureau of the Census or National Center for Health Statistics

selects the sample and abstracts all the required data.

Procedure B—Bureau of the Census selects the sample and abstracts the demographic

data; hospital abstracts the diagnostic and surgical information.

Procedures C and D—Hospital selects the sample and abstracts all the required

data.

3Exclusive of bassinets for newborn infants.

the pilot-studyprocedure,theinterviewwiththe do soimpIies thatthehospitalwillparticipatein

medical record librarianis supposed to start. the survey,apresumption thattieadministrator

The medical record librarianshould not be may resent.

interviewedin advance of the administrator. To

25
INTERVIEW WITH THE MEDICAL

RECORD LIBRARIAN

Most of the medical record librarians were

quite receptive to the survey, although some,

naturally, had reservations about the amount of

work involved. One medical record librarian who

was asked to prepare abstracts from the face

sheets of approximately 550 medical records a

year felt this amount would place too much of a

burden on her limited staff. Other medical record

librarians were concerned about the amount of

time that would be required to locate and pull

the sample medical records. At large teaching

hospitals where the records are very active, the

time taken in tracking records down can be considerable. If the hospital requires an “out-card”

to be prepared for each record removed from

file, even more time is consumed in pulling each

chart.

The survey’s policy of requesting abstracts

from participating hospitals as of July 1, 1964,

regardless of the date an agreement was reached,

drew complaints from some. of the medical record librarians who were to do their own abstracting. This request meant that if the medical record

librarian wished to incorporate the sampling and

abstracting in her daily routine, the work would

be some months behind before it even began.

Such circumstances do not create good will with

the hospitals. To avoid this situati?n in the future

it is suggested that sampling, particularly for the

hospitals that are to do the work themselves, begin with the discharges of the month following the

one in which an agreement is ;eached. At most

hospitals this would be the month following the

month of initial interview. In that way the medical record librarians could do the abstracting

monthly or daily, whichever they preferred.

The cooperation and interest of the medical

record librarians are reflected in their discerning

questions, their helpful suggestions, and their

willingness to modify office procedures. For example, several medical record librarians who

normally did not prepare lists of discharges

agreed to maintain daily records for the Hospital

Discharge Survey. Others who had lists of discharges without the medical record numbers

offered to begin adding the numbers as of the day

of interview. Where more difficult sampling problems were presented, the medical record librarians went to even greater lengths to assist the

survey representatives. It is true that in some

instances the medical record librarian tended to

be resistant and was difficult to interview, but

this is to be expected in any study which involves

personal contact with a sizable number of individuals.

The vast majority of interviewers seemed to

be satisfied with the questionnaire used in the

interview with the medical record librarian,, Their

objections tended to be minor in nature and to

concern specific items rather than the general

approach. Perhaps the most frequent difficulties

arose in connection with the definitions of the

special classes of patients, referred to in questions 3a and 4a (page 7 of exhibit I), whiclh were

designed to establish the composition of the discharge lists to be used in sampling. The definition

of “well-newborn infants” was especiall y troublesome. This term was not precisely defined for the

pilot study. Consequently, when medical :record

librarians inquired about its meaning—ancl many

did inquire— the interviewer was often unable to

give a satisfactory reply. Medical record librarians also asked if abstracts should be prepared

for the following classes of newborn infants: (a)

premature births which were otherwise nqrmal,

(b) well-newborn infants who were discharged before the mother, and (c) well-newborn infants who

were to be adopted and therefore remained after

the mother was discharged. Although answers to

each’ of these specific questions were circulated

earl y in the pilot study, it would seem well to add

this information to the Hospital Discharge Survey

reference manual. Even with specific written

instructions, situations will occasionally arise in

which the medical record librarian is in doubt

about whether to prepare an abstract. .Perhaps

there should be a general rule for abstracting if

in doubt.

The wording of questions 3a anti 4a could

stand improvement. It was the impression of the

writers that these questions did not fully serve

their intended purpose of defining the composition

of the daily discharge sheets.

Another question which should be rewritten

is number lb, which asks if the newborn infant

receives the same medical-record number as the

26
mother. Since the infant is far more likely to be

assigned a number of its own, the question should

be worded in this way. Also, it should provide for

the reply that the infant receives the mother’s

number but with a letter attached. The latter

practice seems to be as common as that of

assigning the mother’s number to the infant.

The person interviewed about the medical

records should be the person who will be responsiEVAN.JATION

in the spring of 1965 an evaluation program

was carried out inmost of the pilot study hospitals

in order to check the quality of the sampling and

abstracting. me purpose of this program was not

to assess blame for errors but rather to gauge

the magnitude of these errors and the effect they

might have on the data which are collected and

tabulated.

PROCEDURE

The check on the quality of the medical record

samples consisted of two parts—first, an evaluation of the completeness of the frame from which

the sample was selected, and second, a check on

the accuracy of the sample selection. The completeness of the sampling frame was verified by

compiling the following figures for a 3-month

period: (1) the number of patients in the hospital

at the beginning of the period, (2) the number of

admissions during the period, obtained by counting

the patients on the appropriate admission lists,

(3) the number of discharges during the period,

obtained by counting the number of patients on the

appropriate discharge lists (i.e., the sampling

frame), and (4) the number of patients in the

hospitzd at the end of the period. The sampling

frame was considered to be complete if the sum

of the first two figures minus the third figure

was equal to the fourth figure. Small discrepancies

were acceptable, but differences larger than the

sampling interval for that hospital (for example,

25, where the sampling rate was 4 percent) had

to be reconciled.

Once the sampling frame had been evaluated

in terms of total numbers, the sampling itself was

checked for a l-month period. The procedure

which was followed depended on the types of

ble for future work on the survey. This is

especially important at hospitals which will be

doing their own sampling and abstracting. If the

interviewer learns that. someone other than the

medical record librarian will handle the survey,

he should request that person’s presence for the

interview.

PROGRAM

records which the individual hospitals had available. The usual procedure was to check the sample

drawn from the discharge lists against what the

sample would have been had it been taken from

the admission lists.

The evaluation of the data obtained from the

medical records also consisted of two parts.

First, the medical-record face sheet form used

by each hospital was scrutinized by Hospital Discharge Survey staff to determine its adequacy in

terms of information needed for the survey. Then

a sample of the medical records which had already been abstracted was reabstracted by the

National Center for Health Statistics, and the two

sets of data were compared to see if the instructions for abstracting were being uniformly followed by all abstracters.

In order for the duplicate abstracts to be completed at the National Center for Health Statistics,

facsimiles of the sample medical-record face

sheets had to be prepared at the participating

hospitals. The methtis by which these face sheets

were reproduced will be discussed in the following

section.

COOPERATION OBTAINED

Seventy-two of the 82 hospitals which participated in the piIot gtudy ccqerated in reproducing

the, sample face sheets. Of the remaining 10 hospitals, 1 was already submitting facsimiles as

part of the regular data-collection program; it

is not included in table 10. Five hospitals which

had hesitated about participating in the survey

initially were not asked to submit facsimiles because of the risk that an additional request might

result in their withdrawing from the study entirely,

and four hospitals which were asked refused the

request.

27
Table 10. Distribution of pilot study hospitals, by procedure for sampling and abstracting records and degree of cooperation in supplying face sheet facsimilea:l Hospital Discharge Survey, 1964-65

Final procedure2

Degree of cooperation All A c

pro- or B or

cedures E D

Total -- -------------------------------------- - -- -- --- -- --- 81 48 3 30

Cooperation obtained -------------------------------------------- 72 44 3 25

Cooperation refused--------------------------------------------- 4 3

Not asked to cooperate ------------------------------------------ 5 ; : 2

lFigures exclude 2 hospitals which failed to participate

hospital which supplied facsimiles

in the pilot study and 1

as part of the regular data-collection procedure.

2Procedures A and E— Bureau of the Census or National Center for Health Statistics

selects the sample and abstracts all the required data.

Procedure B—Bureau of the Census selects the sample and abstracts the demographic

data; hospital abstracts the diagnostic and surgical information.

Procedures C and D—Hospital selects

data.

Ninety-two percent of the hospitals which

were following procedureA and83percentofthose

which were following procedure C were willing

to submit facsimiles (table 10). Although thehospitals were instructed by the Hospital Discharge

Survey to block out the patient’s name when preparing the facsimile, a number of hospitals did

not feel it necessary to do so. About halfof the

hospitals which agreed to cooperate stipulated

that the facsimiles should be made at the same

time the initial abstracts were prepared, inorder

to avoid pulling the sample records solely forthe

evaluation program.

Most of the hospitals which agreedtoprovide

face sheet facsimiles weregiventheir choiceasto

how the reproductions would be made. (Afewof

the hospitals which didtheabstracting themselves

were asked to make copies of the face sheets at

the same time the abstracts were preparedandto

send them to the National Center for Health Statistics alongwiththe regular monthlytransmittal. )

The facsimiles were preparedbyhospital personnel at slightly more than one-halfofthecooperating hospitals and by nonhospital personnel at the

remaining hospitals (table 11).

the sample and abstracts all the required

Eighty-eight percent of the hospitals which

did their own abstracting prepared their own

facsimiles, whereas 61 percent of the hospitals

at which the abstracting was done by nonhospital

personnel preferred to have the facsimiles made

by nonhospital personnel. Where thehospitalshad

no equipment suitableforreproducingface sheets,

the Bureau of the Census provided a special

camera which could be used for this purpose. In

29 hospitals the facsimiles were made by survey

representatives using the Census camera.

RECOMMENDATIONS

Considerable tact may be required of the

individual who introduces the evaluation program

in a hospital where the sampling and abstracting

are done by hospital personnel, to make sure the

medical record librarian does not feel that the

quality of her work is being questioned. Animpression of this kind can create resentment. The

Hospital Discharge Survey should continue the

practice of informing themedicalrecord librarian

of the evaluation program at the time of initial

interview, explaining at the same time the reason

28
Table 11. Distribution of pilot study hospitals cooperating in the evaluation program,

by procedure for sampling and abstracting records and method of obtaining. face sheet

facsimiles: Hospital Discharge Survey, 1964-65

I

Final procedural

Method of obtaining facsimiles

All methods ------------------------ -------- ---------------

NCHS or Census representative with Census camera----------------

NCHS or Census representative with hospital equipment -----------

Hospital. personnel with hospital equipment ----------------------

~ All A c

pro- or B or

cedures E D

72 44 3 25

29 25 2

2 1 ;

3: 17 - 22

1

Procedures A and E—Bureau of the Census or National Center for Health Statistics

selects the sample and abstracts all the required data.

Procedure B—Bureau of the Census selects the sample and abstracts the demographic

data; hospital abstracts the diagnostic and surgical information.

Procedures C and D—Hospital selects the sample and abstracts all the required

data.

.

for the evaluation .An official statement prepared

by the National Center for Health Statistics onthe

need for evaluation might prove to be helpful.

The arrangements fortheevaluation program

were made with the medical record librarian,

occasionally by telephone. When the appointment

was made bytelephone, theinterviewertentatively

determined which of several evaluation methods

hewouldfol,low at the hospitalby asking aseries

of prescribed questions. Because it is difficult

for the medical record librarian to understand

from the questions precisely what materials the

interviewer will require, itis suggested that the

interviewer write to the medical recordlibrarian

to confirm the appointment and to requestthat the

necessary materials be made ava:lable. The materials should be listed preciselytoavoid possible

misunderstanding. The list should include materials needed for the verification ofthesampling

frame as wellas those neededto verify thesampling itself. Such advance notice might help to

avoid confusion on the day of the visit.

29
In the summer of 1963 the Graduate School

of Public Health, University of Pittsburgh, undertook a study for the National Center for Health

Statistics of the U.S. Public Health Service to

develop the mechanics of securing cooperation

of hospitals in the continuing collection of morbidity statistics on hospitalized patients and to

explore methods of obtaining such data. The Public

Health Service had already inaugurated a Household Interview Survey and a Health Examination

Survey and planned to complement its program

with a Hospital Discharge Survey of “national

Scope .

In order to determine the circumstances

under which hospitals would be willing to cooperate in a national survey, the problems that

would be encountered in translating records of

discharges into a sampling frame, and the amount

of information that would be uniformly available

in all hospitals, the Graduate School of Public

Health interviewed hospital administrators and

medical record librarians and scrutinized medical

records in 45 purposively selected hospitals

throughout the United States. A detailed report on

the study was presented to the National Center for

Health Statistics in 1964. An earlier section of the

present report has summarized the feasibility

study findings, with emphasis on those which relate to securing cooperation in a hospital discharge

survey.

While the feasibility study was still in progress, methodology was developed by the Nationa 1

Center for Health Statistics, with the assistance

of the U.S. Bureau of the Census and the Graduate

School of Public Health, for a national hospital

discharge survey. The new procedures and forms

were then tested by these three agencies in a

probability sample of 84 of the Nation’s shortterm hospitals during the fiscal year 1965. This

report has, in earlier sections, described the

methodology and presented some of the results

of this pilot study. Again, aspects of the study

which relate to the matter of cooperation have

been emphasized. The more important findings

and recommendations are restated in this summary.

‘l’he procedure for getting in touch with the

administrators of the 84 hospitals which fell into

the pilot study sample consisted of the following

steps: (1) a letter from the Director of the

American Hospital Association, in which the survey was briefly described and the hospital’s

participation was requested; (2) a letter from an

official of the National Center for Health Statistics, in which the survey was described in more

detail and participation was again requested and

(3) a telephone call from a representative of the

National Center for Health Statistics, the Bureau

of the Census, or the Graduate School of Public

Health, depending on who was to conduct the

particular interview, requesting a personal interview with the administrator and his medical

record librarian. All of the administrators but

one readily granted interviews, and an interview

was eventually arranged with the remaining

administrator.

The primary objective of the interview with

the administrator was to establish rapport with

the hospital and to secure cooperation under

mutually satisfactory circumstances; another

important objective was to obtain certain statistical information about the hospital itself. Nearly

one-half of the administrators chose to have their

medical record librarians present from the

beginning of the meeting, and where this was the

case, the interviewers generally believed that

her presence had been helpful. When the administrator and the medical record librarian are interviewed together, a second explanation of the survey

is not required. Also, having both present facilitates reaching an agreement which is acceptable

to all concerned. If the administrator and the

medical record librarian are not in accord about

the most acceptable way of proceeding, their differences can probably be reconciled without delay:

Another advantage to interviewing the two together is that the medical record librarian is often the one who can furnish the needed statistical

information on discharges, births, and the like.

After the survey has been explained and an agreement reached, that part of the interview which

relates specifically to sampling and abstracting

30
medical records can be continued with the medical

record librarian in her own office.

Only 2 of the 84 hospitals which were asked

to participate in the pilot study failed to do so,

and 1 of these is now participating in the regular

survey. The memorandum of agreement, which

served as a record of understanding with the

hospital, was signed during the interview with the

administrator at 73 hospitals. At the remaining

9 participating hospitals, the approval or advice

of someone other than the administrator @d to

be sought, which resulted in a delay in obtaining

a signed agreement.

During the interview with the medical record

librarian, the initial sample of medical records

was selected. The proportion of records sampled

within each hospital varied inversely with the size

of the hospitals and ranged from 20 to 40 percent

of the records at the smallest hospitals (fewer

than 50 beds) to 1 percent at the largest hospitals

(1,000 beds or more). The actual method of

selecting the sample was .determined by the

nature of the patient-listing maintained by the

hospital. The preferred type of list was a daily

or monthly listing of discharged patients showing

their medical record numbers.

Several different methods of data collection

were tried out during the pilot study year. These

were of three basic types. The sampling and

abstracting of the medical records were done

either by nonhospital personnel (procedure A),

by hospital personnel (procedure C), or by both

hospit.d and nonhospital personnel (procedure B).

The pilot study experience indicated that either

of the first two data-collection procedures (A or

C) would work at most hospitals. Forty-four of

the 47 hospitals which were offered procedurk

A and 28 of the 29 hospitals which were offered

procedure C agreed to cooperate on that basis.

Only three out of eight hospitals accepted procedure B; it was generally regarded as inefficient

by administrators who could see no reason to have

two persons working on the same abstracts,

particularly at different times.

The hospitals in which survey personnel did

the sampling and abstracting were offered payment ranging from $10 to $50 per year, the amount

depending on the expected annual number of abstracts. Hospitals which did the work themselves

were offered 30 cents per abstract, and those

which shared the work with survey personnel were

offered 15 cents per abstract. Altogether, eight

hospitals declined any payment, and three sought

an additional amount. The A-procedure hospitals

accounted for seven of the hospitals which refused

Pyment and for two of those which requested an

increase. Some administrators who did not accept

PWment let it be ~0~ that they considered their

participation a public servic~ others indicated

that the amount offered did not warrant the cost of

setting up and maintaining a special account.

Two different abstract forms were usedin the

Pflot study (1) a conventional form in which the

entries were written in (exhibit C), and (2) a

form in which appropriate spaces were blocked

in for scanning by an IBM “reader” (exhibit D).

The first form was used in 40 hospitals and the

second in 42. Both forms found ready acceptance,

although a few hospitals had a little difficulty

getting accustomed to the IBM form.

In the spring of 1965 an evaluation program

was carried out in most of the pilot study hospitals. The purpose of this program was not to

assess blame for errors but to measure the errors

and gauge the effect they might have on the data

which are collected and tabulated. The sampling

was evaluated by studying the sampling fkame for

possible deficiencies and by checking the accuracy

of the sample selection. T%equality of the data was

evaluated by studying the medicaI record face

sheet forms to determine their adequacy in terms

of information needed for the survey and by

checking a sample of the abstracts which had

already been prepared.

In order to accomplish this last objective it

was necessary to make reprmluctions of the

medical record face sheets from which the abstracts had. been prepared. Seventy-two of the

82 hospitals complied with this request, but 33

of these stipulated that the facsimiles should be

made at the same time the initial abstracts were

prepared so that the records would not have to be

pulled for the evaluation program.

This report has tried to make plain that the

spirit of cooperation among hospital administrators and medical record librarians is strong.

If any serious problems are encountered in expanding the Hospital Discharge Survey sample

to several hundred hospitals, lack of cooperation

will probably not be one of them.

31
Once again, in order to summarize, among

the main findings and recommendations related

to cooperation in the hospital were the following:

1.

2.

‘3. .

The hospitals by and large accepted the

procedure for abstracting requested of

them by the Hospital Discharge Survey.

The exception was the procedure in which

both hospital and nonhospital personnel

would share in the abstracting (procedure

B). This procedure should be dropped.

Some hospitals requested modifications

in the basic procedure because of personnel, space, and similar problems.

These changes should be accepted where

the y do not affect the data gathering.

At times, the interviewers seeking to obtain the hospital’s cooperation were,

somewhat to their embarrassment, unable to answer questions about the survey

put to them by the administrators. It is

obviously impossible to anticipate every

such question, but some of the need for

more precise informing of the interviewers can be met. Statements about the

purpose and uses of the survey should be

strong and specific.

The interview with the administrator

should not start with the solicitation of

numerical data. Rather, it should begin

with an informal discussion of the survey.

4.

5.

6.

7.

Early in the pilot study, the recommendation was made to the interviewers by the

Hospital Discharge Survey that the administrator and medical record librarian be

interviewed at the same time. This is

preferable to separate interviews. In any

event, the medical record librarian should

not be interviewed in advance of the

administrator.

There are some minor matters which can

further the cause of cooperation but which

may not perhaps have received sufficient

stress during the interviews. Among these

are (1) the relatively small proportion

of records actually to be abstracted,

(2) the maintenance of confidentiality,

and (3) the voluntary. character of the hospital’s participation.

Some definitions involved in the interview

with the medical record librarian seem to

need sharpening. While this matter is a

little removed from the question of cooperation, it is a possible source of

irritation and should be attended to.

The evaluation program, which was described in the foregoing section, was approached with wariness so that hospital

personnel would not feel their abilities

were being questioned. With proper precautions, which have been mentioned, it

appears to have turned out successfully.

REFERENCES

Woolsey, T. D.: Hospital Statistics Fmm the U.S. National Health Survey. Prepared for presentation at the annual

Summer Conference for Executives of Allied Hospital Associations, Mackinac Island, Mich., July 26-27, 1963.

2Sirken, M. G.: National hospital patient statistics. HOSpitazs, Journal of the American Hospital Association, in press.

3N~tiona] center for Health Statistics: Origin, Progr~)

and operation of the U.S. National Health Survey. Vitrd and

Health Statistics. PHS Pub. Nc. 1000-Series l-No. 1. Public.

Health Service. Washington. U.S. Government Printing Office,

Aug. 1963.

%ational Center for Health Statistics: Health Survey procedure, concepts, questionnaire development, and definitions

in the Health Interview Survey. Vital and HeaW Statistic.

PHS Pub. No. 1000-Series l-No. 2. Public Health Service.

Washington. U.S. Government Printing Office, May 1964.

5National cen~r for Health Statistics: plan and initial

program of the Health Examination Survey. Vita2 and f#eah%

Statistics. PHS Pub. No. 1000-Series l-No. 4. Pmblic Health

Service. Washington. U.S. Government Printing (Office, July

1965.

6National Center for Health Statistics: Development and

maintenance of a national inventory of hospitals and institutions. Vita? and ffeatth Statistic. PH~ Pub. No. 1000-

Series 1-No. 3. Public Health Service. Washington. U.S.

Government Printing Office, Feb. 196,5.

—.ooo —

32
APPENDIX I

FEASIBILITY STUDY

Exhibit A. Letter to Hospital Administrator

UNIVERSITY OF PITTSBURGH

GRADUATE SCHOOL OF PUBLIC HEALTH

PITTSBURGH, PENNSYLVANIA, 15213

DEPARTMENT OF B1OSTATIST1CS July Z, 1963

Dear (Hospital Administrator):

The University of Pittsburgh is conducting a study on behalf of

the National Center for Health Statistics of the U.S. Public Health

Service to determine what problems there may be in collecting statis -

tical information from hospital records._ The purpose of this letter is

to request your cooperation in the study.

The main objectives are to determine what information is availa -

ble in hospital records from which comprehensive national statistics can

be generated, the limitations the data might have for statistical purposes ,

and what problems may be encountered in abstracting the information.

To get some answers to these questions we are visiting about 50 shortstay hospitals in various parts of the nation. The study procedure involves a brief interview with the administrator and medical record

librarian. k addition, it calls for selecting a small random sample of

discharges and abstracting information from medical records. The names

of patients would be of no interest to us except as a means of locating

the records.

We will contact you by telephone within the next few days to de -

termine the most convenient time for visiting your hospital.

We will greatly appreciate your cooperation.

Sincerely yours,

Is idore Altman, Ph.D.

Professor of Medical Care Statistics

33
Exhibit B. Abstract Sheet

i“orm HRS 3(d)-3 Budget Bureau No. 68-6341; Approval expires Dec. 31, 1963

University of Pittsburgh - Graduate School of Public Health

Study of Feasibility of Sampling Hospital Discharge Records

DISCHARGE ABSTRACT SHEET

-—

Name of Hospital

I

Address

.—

I

Abstracter Date

1 I

1. HOSPITAL CODE NUMBER

l-Govt. -Nonfed. 3-VO1. -Other

2. CONTROL 2-VO1. -Church 4-Proprietary 5-Govt. -Fed.

NUMBER 1-25-49 3-100-299

3. OF BEDS 2-50-99 4-300+

l-Northeast 3-south

4. GEOGRAPHIC REGION 2-North Central 4- West

I i I I l-l

1. AD IMLSS ON — 99

T

- looiWhite 3‘-Not -a

OY-N

:ed

wborn (Go to —12‘EM 29)

11. COLOR 2- Nonwhite 4-Not answered [ P

1- .Male

12. SEX 2-Female

l-Never married 3- Widowed

13. MARITAL STATUS 2-Married 4-Divorced 5-Separated 1

OCCUPATION 1- Patient 3-Husband

14. ITEM: 2-Father 4-Other 5-Not asked

—-.

OCCUPATION (specify) 000-Not asked

15. OOY-Not a !!1

. .

l-No

16. EMERGENCY? — 2- Yes I

ACCOMMODATION l-On admission 3-Preferred 5-Most of sta~ I

17. ITEM: 2-At discharge 4-C ornbination 6-Not asked

1-Private 3-Ward 5- Other

18. ACCOMMODATION 2-Semi- 4-Nurser y 6-Combination

Alive 1-With approval Died

DISC IMRGE — 2-Against advice ~Autops y

STATUS 3-Transferred 6-No autopsy

19. —,. —.4-Other II

-

CONFIDENTIAL . This information is colkcted un~cf ~u!hority Of ~ubl;c Law ~$2 O( the 84th COnRfess (70 %at. 48%

42 IJ.s.(:. ?I05). All information which would permit identification of an individual Or of an establishment will be held

strictly confidcnci ai, will bc used only by persons cngmgcd in and for che purposes of :h@ survey and will not b.? disclosed or released co ocher persons or used for any othcv purpose (22 FR 1687).

34
Form HR.8 3(d)-3

(Hospital) (City, State) (Medical Record No. )

20. ADMITTING DIAGNOSES OR COMPLAINT (Number 1, 2, 3, etc. )

I

21. FINAL DIAGNOSES OR COMPLAINT (Number 1, 2, 3, etc. )

II 1

II

OPERATIONS (Specify)

COMPLICATIONS (Specify)

1-No

9

23. 2-Yes

Physicians)

22. 00- None

24. CONSULTATIONS (No. of

01 - Not asked II

25. ADMITTING HEIGHT (inches 1 02 - Not answered

888 - Not asked

26. ADMITTING WEIGHT (lbs) 999 - Not answered

1-99.0 or less 5-102 .0-102.9

ADMIT TING 2-99.1 -99.9 6-103 .0-103.9 9-Not asked

TEMPERATURE 3-100 .0-100.9 7-104.0-104, 9 0- Not answered

27. 4-101 .0-101.9 8-105.0+
Form HRS 3(d)-3

(Hospital) (City, State) (Medical Record No. )

28. LABORATORY TESTS AND THERAPIES

URINAL YSIS

HEMATOLOGY

SEROLOGY

BLOOD TYPE

x-RAY

CHEMISTRY

BACTERIOLOGY

GASTRIC STOOL

BODY FLUIDS

HISTOLOGY

FUNCTION (EKG, EEG, BMR)

THERAPIES

OTHER

36
Form HRS 3(d)-3

(Hospital) (City, State) (Medical Record No. )

NEWBORN

29. COLOR 2- Nonwhite 4- Not answered !

1- White 3 - Nbt asked I

1 - Male

30. SEX 2 - Female I

01 - Not asked

31. AGE OF MOTHER 02 - Not answered

1- llLive birth order”

32. BIRTH ORDER ITEM 2- llBirth orderll 3 - Neither asked I

BJFITUfi.lh’13S 2QfQ

34. PR

m .4 n wJs,J.7aJx

32! OY . Not answered 1

l-NQ

:EMATURIT Y? 2 - Yes

2- Yes

3 - Not asked }

2- Yes

3- Not asked

38.

2 - Yes

3 - Not asked }

DISCHARGE 2 - Against advice = Autopsy

STATUS 3 - Transferred 6 - No autopsy }

40. 4- Other

-.

— I

35. BYRTH WEIGHT (Gin.) I

36. BIRTH LENGTH (Cm.

BIRTH INJuRIES (Specify) l-No

37. I

MALFORMATIONS (Specify) l-No

OTHER ABNORMALITIES (Specify) 1-NO

39. I

Aiive 1 - With approval Died (inc. Stillborn)

37
Exhibit

APPENDIX II

PILOT STUDY

c. Conventional Abstract Form

E

[ {)NFIDENTIAf-.Thi.

..—

jnfomatiofi is

.—— collected uncle,—.uthotj~ .f pub]jcLaw(jszof !h~ad!htin~css (70 %*c 4SR 42 IJ.S,C. 242 c). All in

).)

form.tion wI,ich would permit idemi[ictwion of an imdivid.d OCof am est.blishmetu will be held strictly confidential, will be .sed anly by persons

c. a cd ,.- .md for the pumoses of & survey aqd will not be dklosed m reltased to + ptrsons or used for my other PUP sc (22 FR 16s7

-——.——ABSTRACT OF -PATIENT . RECORD-HOSPITAL ._-——— DISCHARGE SURVEY

1. Hospital Number 1

~._ &atient Control Number 1

3. Medical Record Number

lm. dmy w

4a. Date of Birth HIHHI1

Complete 4b and c onJJ if date of birth is not given

I i 1

4r. AVI= is mta+md in: 1 . Year= 2 - Mtmthm !4 . mvs I II

5. Sex 1- Male 2- Female I 1

1- White 4- “Nrmwhite”

6. Color: 2- Negro 5- Not stated rl

3- Other nonwhite I J

1- Married 4- Divorced I

7. Marital Stature 2- Single 5- Separated

3- Wicbwed 6- Not stated

m. day w.

8. Date of Admission 1~111 II 1

.Uay

9. Date of Discharge

r—1

10. Discharge Stature 1,- Alive 2- Dead 1 I

11. Final Diagmoeem

Ma. was an Op eration performed? 1- ,Yee 2-No

12b. Ope-raticmm

1111

Completed by Abstracter Date

PHs-4734-1 DF>ART?4ENT OF HEALTH, EDUCA2’SON, md WELFARE Fom “kppmvek 68 -R62Q. RL2

8-64 Public Hedtb Semite

fkionaf Center dx Sfeakb Sutiwtics

38
Exhibit D. IBM Abstract

CONFIDENTIAL- This information is collected under authority of Public ~e:::f aw the 84* Congrem (70 Stat. 489; 42 U.8.C. 242 c,). All inform- -

ation which would permit ident~lcation of an individual or an eatablin 11be held strictly confidential, wifl be used only by permrrs en- ——

gaged in and for the purposes of the survey and will nut be disclosed or released to other persons or used for any other purpose (22 FR 1087). z

DEPARTMENT OF F.,m App,a”, d

HEALTH, EOUCATION. AND WELFARE 8.6*. I M... M.. 68.R620.R2 ,-

PHS.4734.2 PUEILIC HSALTH SERVICE

8.64

NATIONAL CENTER FOR HEALTH STATISTICS [1. HOSPITAL .NUMBER

..... ..... ,=,:, ~::,, ::::, -... ..... ..... ..... ----- - ----- ----- ..... ..... ---- ..... ..... _

----- ----- ..... ..... ..... ----- ----- ::==: ..... ..... ----- ----- ..... ..... ..... ::=: ::::: _

0. 2?.4 Ss

----- ..!_ . . . . . . . . . . . . . .

7 ●

..-. ---- ::=: -.:.. . . . . . . . . . . — . ..-. . . . . . . . . . . . . . . . . . . . . ---- . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . -

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

----- :=::, ~,=, ----- . . . . . .----- . . . . ---- ---- ---- . . . . . . . . . . -

----- -... ---- ---- -... . . . .

ABSTRACT OF PATlENT RECORO-Hospital Okcharge Suwey

2. PATlENT NUM8ER

..... ,=:, :=,, ----- ----- .-.. :=,, :==, ----- ----....- ..... - .-.. .....

01 2 34 5 s 7 B 9=

----- ----. ---- . . . . . . . . . . ----- :::::

----- . . . . . . . . . . . . . . . . . .

. . ..- . . . . . . . . . .

----- . . . . . . . . . . . . . . . _

3. MEDICAL RECORD NUMBER ----- ..... ..... ..... ..... ----- ....- ..... ..... ---- - ..... ..... ..... ..... ----- ---- ..... ----- ---- .....

..... ..... ----- ..... ~:::: ..... ..... ---- ----- ..... ----- ----- ----- ..... ..... ..... ..... ..... ..... -

-... ----- :::,, ----- ...-. ..... ----- -----..... ..... ----- ---- ..... ....- -... ..... ..... ..... ----

J

,,==

MONTH

M

. . ..-

. . . . .

0. . . . .

-----

O&v 0

.-. .

-----

-l-—..-.

-!.. -.T1

----

-----

I

.—..

-----

. . . . .

. . . . .

1

-...

. . . . .

4a. DATE OF BIRTH

c== ::,::

s= ..... .....

..... - .....

s= ..... ..... —-

M1

----- ---- J. ---- ----- ..---

Aso

. . ..- . . . . . . . . . .

. . . . . . . . . . . . . . .

5 s 7

..-. . . . . . ----

. . . . . . . . . . ----

::::: mm

. . . . . . . . . . . . . . .

. . . . . . . . . . . . . .

M

. . . . .

-----

8

.----

----

. . . . .

. . . . .

8

. . . . .

.-..

2 a

. . . . . . . . .

----- ----- mm

z 3

----- . . . . .

----- . . ..- .--:-- . ..- Ulms

:::=: 1800

----- . . . . . . . . . .

----- . . . . . ---- TV(S

Complete4b and 4C if

date of birth is not given.

w-a . . . . .

. . . . .

0

----

. . . . .

r. 34

---- -... . . . . .

-... . . . . . ----- W7S

5 6 7

. . . . . . . . . . . . .

. . ..- ---- . . . .

4.b. AGE ....- ..... ..... ..... ..... Tch’s .-_. . .. . . . .. . . . . .. . . . .. .

----- . .. . . ---- . . .. . . . . . . -

.. .. . . .. . . . .. . . . .. . . . .. . .

0 s e7 *

..-. . . . . . ..z_. . .. . . ..?-. ~,* ----- ----- :::= -4-- 0=. . . . . . . . . .

---- ----- . . . . ----- . . . . .

----- . . . . .

----- ●

:::= YrARs =::= mums ::== MM

::::: MAlf :Zz: fmblc

4.c. AGE IS STATED IN

5. SEx

:::=: W14111 ::::: ,,”~~~ ,,

::=: lam ::=: aorslmo

::ZZ OTHCR NOliWllTS

6. COLOR

:::,, MAmmco ::::= Wouw

::::: SIIKIE :== acmmlm

::=: Mrwn’m ::=: NOT SIAICO

JF

----- -----

. ---- . ----

MQmn

A 0=

. . . . . -!.. ~:,, $ 0

-L .-!_ ..... .. .. ..... ::::: ----- ----- ....- ..... ----- ..... ----- .....

.....

01 2 s

. . . . . ---- . . . . . . . . .

. . . . . ---- ---- . . . . . lEIN

DAY

01 2 a 4 s s 7 s *=

..-. . . . . . . . . . . . . . . . . . . . . WITS . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . ---- ----- ----- . . . . . . . . . . . . . . . . . . . . . . . ...

01 z 3* 6 e 7 #

WAR

s=

. . . . . ---- ---- ---- . . . . .

---- ---- . ---- . . ..- . . . . .

. . . . . . . . . . . . . . ::::=

-... . . . . . -----

:::::

7. MARITAL STATUS

8. DATE OF AOMISSION

,,

..... . ... -----

mm ‘~-- As

----- ..*L .-”.- ..... .....

0 N 0=

..-. ::::: ~:=: ----- ----- ....- ..... ..... ..... ..... .......... .....

01 2 s

. . . . . ---- ---- . . . . .

..-. . . . . . . . . . ----- Tens

DAY

o I z s s

..:.. WITS

o 7 # s=

----- ----- ----- . . . . . . . . . . . ---- -... . . . . . . . . . . . . . . .

. ---- . ..- . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . — -----

inn 0 1.2 s 4 s 6 7 @s

----- . . . . . ----- . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . ----- . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

9. OATE OF OISCHARGE

10. DISCHARGE STATUS ::::: &uvc ,:::: (mm IBM HS12S4

39
—— I —

IL FINAL DIAGNOSES:

PATlENT NUMBER

. . . . . . . . . . ,,, ,, . ..-. . . . . .

. . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . — . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

I ~,,,,: ,,,,::,::, ,,,::,,:,, .

.....- ... .-----.... .............................. —_

I ——

—_

—_

— —_

—— —

——

—_

12a, WAS AN OPERATION YES NO

—

PERFORMEO ?

. . . . . . . . . .

. . . . . . . . . .

12b, OPERATIONS: —

—

—_

— —_

— —_ —— —— ——

——

COMPLETED BY ABSTRACTOR

—

DATE

F

o

R

N

c

H

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F’H6~4734.2 (BACK)

40

—— —— OPERATION CODES

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IBM H912S5
Exhibit E. NCHS ‘rFact Sheet”

Hospital Number 6703

Procedure A-1

Stratum Number 54

Name of Hospital Sampling Digits 12, 42, 72

Address

Name of administrator

Telephone number

This is a church-owned general hospital. It maintains 371 beds and employs 688

persons. There are operating room and obstetrical delivery room facilities. The

MFI reports a chronic disease ward with 30 beds. This hospital does not maintain

a nursing home unit. The average length of stay is 10 days.

The hospital is accredited and is a member of the American Hospital Association.

It is reported in the 1964 AH4 Directory as having 10,494 admissions for the one

year period ending September 1963. Using a sampling ratio of 3 out of 100, thi~

office would expect about 315 patient record abstracts a year from this facility.

An employee of the Bureau of the Census will abstract the data from this hospital

and record it on conventional forms (PHs-4734-1).

Hospital Discharge Survey Branch

Health Records Statistics Division

NCHS

October 26, 1964

41
Exhibit F. AHA Letter to Hospital Administrator

Dear (Hospital Administrator):

The National Center for Heaith Statistics of the U. S. Public Health

Service is inaugurating a national system of collecting statistical.

information from hospital medical records as part of the National

Health Survey. The importance of such data in contributing to our

knowledge about the Nationfs health and in providing a basis for

sound administrative decision -making cannot be overstated. The

American Hospital Association has been cooperating with the

National Center for Health Statistics in the conduct of the survey

and through its Board of Trustees has endorsed the survey,

Your hospital has fallen into the probability sample developed by

the National Center for Health Statistics. The purpose of this

letter is to request your participation in the pretesting phase of

the survey. The Public Health Service will make every effort to

minimize the burden of reporting on the part of your hospital. An

equitable basis for compensation will be arranged by the National

Center for Health Statistics. All information collected will be given

confidential treatment and will be used for statistical purposes only.

Any published summary will be presented in such a way that no

individual hospital or patient can be identified.

Dr. Forrest Linder, director of the National Center for Health

Statistics, has informed me that within the next few days he will

send you a more detailed statement concerning the survey. He will

greatly appreciate your cooperation.

Without the cooperation of your hospital and others like yours, this

important research effort cannot succeed. 1, therefore, urge you to

make every effort to cooperate in this survey.

Sincerely

Edwin L. Crosby, M. D.

Director

42
Exhibit G. NCHS Letter to Hospital Administrator

Dear (Hospital Administrator)

A few days ago, Dr. Edwin L. Crosby,

Hospital Association, requested your

Executive Director, American

cooperatfl.onin the Hospital

Discharge Survey to be conducted by the National Center for Health

Statistics. He indicated that I would follow up his letter by

sending you a more detailed statement concerning the plsns and

objectives of the Survey. This statement is enclosed.

!!TheHospital Discharge Survey will produce administrative and

morbidity hospital statistics. The Survey will collect information

for a sample of discharges in a national sample of short-term hospitals.

In the remaining months of this fiscal year, a pilot study will be

undertaken in order to try out alternative procedures for conducting

the Survey.

Since your hospital was one of those randomly selected for the Survey

we would like very much to discuss matters relating to participation

of your hospital. Therefore, within the next several days, a representative of the Bureau of the Census, acting as an agent of the

National Center for Health Statistics, will telephone you to arrange

for an appointment. This meeting should not take more than an hour

of your time.

The National Health Survey program, of which the Hospital Discharge

Survey is a part, has been approved by the House of Delegates of the

American Medical Association, and the Hospital Discharge Survey itself

has been endorsed by the Board of Trustees of the American Hospital

Association.

Your cooperation in this Survey will be very much appreciated.

Sincerely yours,

Forrest E. Linder, Ph.D.

Director

Enclosure

43
Exhibit H. statement on the Survey

September

DEPARTMENTOF HEALTH,EDUCATION,AND WELFARE

PublicHealthService

NationalCenterfor HealthStatistics

THE HOSPITALDISCHARGESURVEY

18, 1964

The Hospital.DischargeSurveywill involvethe continuingcollectionand analysis

of nationaldischargestatisticsfor short-stayhospitals. This surveyis a part

of the NationalHealthSurveyprogramof the PublicHealthService. The National

HealthSurveyis authorizedby PublicLaw 652, also known as the NationalHealth

SurveyAct,whichwas passedin 1956by the 84th Congress. Earlier,thisyear,

the Houseof Delegatesof the AmericanMedicalAssociation,impressedwith the

scientificobjectivityof the NationalHealthSurvey,adopteda resolution

approvingthe Surveyprogram.

The short-termhospitalsof the UnitedStatesrepresentan enterpriseof enormous

proportions.Not only do they constitutea largeindustryemployingabouta

millionand a halfpersonsand providingservicesvaluedat over $10 billion

annually,but they are increasinglyoccupyinga centralpositionin the entire

systemof medicalcarein this country. At the sametime,thishospitalenter.

priseis undergoingsignificantchanges. For example,the typicalhospitalis

increasingboth in sizeand complexity.

For thesereasons,the utilizationof hospitals,is being studiedmore and more

intensivelyby hospitalsthemselvesin orderto make betterdecisionsregarding

optimumuse of the facilities.Furthermore,the medicalrecordsof the hospitals

containinvaluableinformationregardingthe relativefrequencyof occurrenceof

many diseasesthat are largelytreatedin hospitals.

To servesuchbroadneedsas these,the NationalCenterfor HealthStatistics

(NCHS),the major statisticalagencyin,the FederalGovernmentresponsiblefor

the collectionof healthstatistics,is undertakingthe HospitalDischarge

Survey. The Surveyhas been endorsedby the Boardof Trusteesof the American

HospitalAssociation.

Initially,the informationobtainedfor the sampledischargesin the Hosp55tal

DischargeSurveywill be limitedto’’’core”datawhichin nearlyallhospitals

wouldbe availablefrom the face sheetof the patients’sfolder. The coredata

will includea few personalcharacteristicsaboutthe patient,such as sex and

age, and it will also includeadmissionand dischargedatesas.wellas final

diagnosesand operationsperformed. Severalyearshenceit is likelythat

additionalinformationaboutthe sampledischargesavailablefrom the hospital

recordswouldbe collected.Informationfromhomital recordswill be ~osted

on abstractformsprovidedby

ment madewith the individual

eitherby the hospitalstaff,

44

the NCHS and,

hospital,the

agentsof the

depen~ingupon the type of &range.

abstractingwouldbe performed

Center,or possiblybyboth.
-2

The HospitalDischargeSurveywill most likelycontaina nationalsampleof

severalhundredshort-stayhospitalswidelydistributedover the major regions

of the country. The NCHSwill make arrangementswith eachof the sample

hospitalsto participatein the survey. Severaltimesduringthe year, the

prescribedinformationwill be abstractedfor a scientificallyselectedsample

of a relativelysmallnumberof dischargeswithineachsamplehospital. The

participatinghospitalswouldremainin the surveyfor severalyearsbefore

beingreplacedby otherhospitals.

The abstractedinformationfor the sampledischargeswill be transmittedto

the NCHSwhere it wouldbe processedprior to the preparationof statistical

tabulations.Statisticalanalysesof the data on a nationaland geographical

basis,but not for individualhospitals,wouldbe preparedfor publicationby

the Centerand made availableto hospitalsand otherinterestedparties. All

informationcollectedin the surveywhichwould permitthe identificationof

individualsor hospitalswill be held strictlyconfidentialand will not be

publishednor be disclosedor releasedto othersfor any purpose.

Exploratorywork on developingthe plansfor the Hospital.DischargeSurveywas

startedlast year. A more formalpilot studyof someof the operational.

problemsis beingundertakenin a nationalsampleof 100hospitalsat this the

in orderto try out alternativeproceduresfor conductingthe full Survey,

which,accordingto presentplans,will be startedwith thesehospitalsabout

July 1965.

45
Exhibit 1. Hospitai Interview Form

>RM NHS-HDS-2x

D.2a-e4]

U.S. DEPARTMENT OF COMMERCE

BuREAu OF THE CENSUS

ACTING AS COLLECTING AGENT FOR THE

U.S. PUBLIC HEALTH SERVICE

HOSPITAL INTERVIEW

HOSPITAL DISCHARGE SURVEY

~- R620. R:

:DN FIDE NTIAL - This information is collected for the U.S. Public Health -

411 information which would permit identification of the individual will be l,eId

;rrictlv—. con~ldenrial. will be used only by persons em?aged in and for k purposes

>f the survey, and w’ill not be disclosed or-r.&ased to &b_crs for any other p&ses.

tome and address (Verify and correct as necessary)

lProcedure I Abstract form —

. Initial

mail

contacts

sctian A - SUMMARY OF TELEPHONE APPOINTMENT AND FIRST PERSONAL VISIT

}

Date sent Received —

I

s. American Hospital Association letter D Yes n NrI

. Tclephene

contoct

. Summary

of persona I

interviow

with

Administrator

i. interviewer

b. National Center for Health Statistics letter I

,

Date

o. Date of telephone contact

b. Appointment made for personal visit

Date Time a.m.

p:m.

Name lTitle

I

Room and building

I

Name

c. Medical Record Librarian~

d. Comments and important items discussed with Administrator on the telephone

a. Hospital cooperating - n I,Jnquslified cooperation m Qualified cooperation n ~&c;d$-

(Deacribe)

b. Contract Proposal - m Signed and attached I-J NOW#&rl

c. Final procedure agteed upon - DA UB UC UD UE m Other

(lhacribe)

If additional space is needed for comments use the last pcge of questionnaire.

Name Regional Office Date foort completed

46
section B - INTERVIEW WITH ADMINISTRATOR

You hove probably tiad a chance to review the statement Name

Dr. Lindar sent you concerning the Hospital Discharge

Survey. If you have any questions obaut the survey, I

Location (if different from that shown on address label)

will try to answer them for you.

Before discussing the details of the survey, I must Type of service (e.g., tuberculosis uait, psycbhttic

verify some infontrotion about - -.

unit, general hospitel, etc.)

1. Is it correct that -- is a Number of discharges in 1963

Patient-days DaiIy censu

awned hospitol? Total patient:days or

a Yes

avetege daily census in 1963

a NO (Indicate correction)

2.0. How many hospital beds are maintained for

Aversge length of stay

inpatient use, ●xcluding bossiaets? Does this unit maintain sepomte discharge records?

m Yes m No - &;:: ~~ij~n;r;:~,s fmm

(Nuder af beds)

b. Haw many bassinets are maintained?

(Number of bassinets)

c. If less than Z5 beds in question 2a, ask:

Does --

Location (if different from that shown on address label)

provide araund-the-clock nursing

service by a registered nurse?

Type of service ( e.6., tuberculosis unit, psycbkttric

unit, general hospital, cCC.)

3a. ~o~imately how many discharges were there

-- in 1963, ●xcluding well-newborn? Number of beds for inpatients

Number of discherrres in 1963

Toml patient-days or Patientd8ys Daily censw

(Number of discharges) average daily census in 1963

b. How many births were there in -- in 1963? Average leagth of stay

(Number of births)

Dees fhis unit maintain sepamte discharge records?

= Yes

4. What is the average length of stay for

n No - How can the discharges from

this unit be identified?

patients in -- ?

(Number of days)

5a. Is - - a hospital complex, port of a hospital ,

complex, or neither?

Location (if different from that shown on eddress label)

I-J complex = l%: ;~xa D Neither

P Type of service ( e+, tuberculosis -unit,psychiatric

b. If “Part of a complex,” ask: umt, genersl bospttala, etc.)

What is the name and address af the

parent organization?

Name

Addmss

I

i

6. If “Complex” or “Part of a complex, ” enter the

in fortnstion requested at right for EACH sepsrmte

unit.

Number of beds for inpatients

Number of discharges in 1963

Torsl petient-days or Pstient-days Daily census

average daily census io 1963

Avekage Ieagth of stay I

Does this unit maintain sepomte discharge records?

D Yes D No - How can the discharges from

this unit be identified?

I

FORM NHS-HDS-Z X (t O-2 S-64J

47
Section B - Continued

.ls -- associated with any other estobl ishment, 8. Does -- maintain a nursing home or nursing

such as a resident institution or a school, hame unit?

excluding medical and nursing schools?

a Yes a No (Skip to question 9)

U. Yes n No (Skip to question 8) If “yes,” ask:

f“yes,” ask: a. How many nursing home beds are maintained?

a. What is the name, address, and nature of the

establishment with which - - is associated? (Number of beds)

Name b. Were these beds excluded from the count

af hospital beds?

Address

m Yes = No

9. Does -- maintain a convalescent unit?

Nature

= Yes D No (Skip to question 10)

b. What type of service does the establishment

named above provide. If “Yes, ” ask:

a. How many convalescent unit beds are maintained?

c. Does - - limit its services primarily to the

population af a residerlt institution?

(Number of beds)

~ yes (Describe population 8erved = No b. Were these beds excluded from the count

and services provided> af hospital beds?

= Yes = No

c. Daes the date of discharge an the hospitol record

refer to the dat6 of discharge from the convalescent

unit or ta the convalescent unit?

m From = To

convalescent unit convalescent unit

Lemarks

.——

— ——

USC OMM-DC

48
Section B.-Continued

10. I will outline briefly the steos in the srrrvew.

Fora sample ofpa~ents, a iimited antount;f

infomration will be abstmcted to this farm

(Show abstmct form.) As you can see, this

irrfamration will genemlly be available on the

medical record face sheet.

Forahospital ofthissize, the sampling ratio

will be in , or about

records in the course of a yeor -

approximately records per day.

(Read Procedure at right.)

‘INTERVIEWER:

Wbich procedure was finally agreed upoP?

(Procedure)

Comments

Il. Before lgotathe next item, doyouhave. any

(other) questions on what has been covered?

Dyes (Enter que8tion8 m No

and yorrrmaponaerr)

:ORM NHS.HDS.2X (10.2 s.64)

PROCEDURE A - An agent of the Public Health

Service will visit your hospital about once every 3

months, on a day and at a time convenient to your

Medical Record Librarian. Atihattime we will select

a sample of patients who hove been discharged.

This list will be left with the Merfical Record Libmr.

ian so that the face sheet of the medical records for

these sample patients can be ready for our next visit.

On that second visit, we will abstmct information from

the face sheet of the medical records and select a new

sample of discharges. On all succeeding visits, we

will repeat the process - each visit lasting only a few

hours. Once or twice a year, arepresentative of the

Public Health Service wiIl be into review the work of

the abstracter.

PROCEDURE B - An agent of the Public Health

Service will visit your hospital about once every 3

months, on a day and at a time convenient to your

Medical Record Librariai. At that time we will

select a sample of patients who have been discharged.

This list of cases will be left with the Medical Record Librariar so that the face shed of the medical

records for these satnple patients can be r~ady far

aur next visit. We plan to copy all data except that

relating to the diagnosis ad operations. Before the

time of our next visit, some member of your staff who

is familiar with the handwriting of the physicians

would be assigned by you to enter these medicof

items from the face sheet to the abstract farm. If you

prefer, this operation can be performed at the time of

our visit. We will abstract the remaining data and

select a new sample. On all succeeding visits, we

will repeat the process - each visit lasting only a

few haurs.

In order to be sure that the procedure is working the

same at all hospital ~ we plan to have someone visit

each hospital once or twice a year and review the

sample selection and look at a few of the records that

have fallen in the sample far previous months.

PROCEDURE C - Someone assigned by you or your

Medical Record Librarian will sefect a sample of

discharged patients accordin to instructions which

we will provide. Based oa alf the discharges for one

month, she will select a sample of patients and then

abstract data ftom the face sheet to the abstract

farm. This can be rbne at a time convenient to you.

The completed abstmcts would be mailed to our regional

office each month. We will provide the packet for

mailing.

In order to be sure that the procedure is working the

same at alI hospitals, we plan to have someone visit

each hospital once or twice a year and review the

sample selection and look at a few of the records that

have fallen in the sample far previous months.

INTERVIEWER: ShouId the Administrator object

to the procedure assigned to this hospitsl, an alternative may be suggested, namely the priority 2 procedure as shown in the “Procedure” box on the front

of the questionnaire.

49
Section B - Continued

2. The Notionol Heolth Survey offi ciols hove a uniform

reimbursement fee in accordance with the manner of

abstracting data, taking into consideration the number

of records that could be abstracted per hour. For this

hospital, the amount is set ati

(If item 1-A is proposed) per year.

(If item 1-B or 1-C is proposed)

per completed abstract or about

per year.

This amount will be subiect fo renegotiation if it

proves to be inequitablee.

In order for reimbursement to be made by the Public

Health Service, they require a contract, which will

be mailed to you shortly far your signature. In the

meantime, I must, provide them with information an

which to base the contract. This is in the brn of

a contract preposal.

(Complete contract proposal, Form PHS-47344, based

on the agreement reached in the discussion of the

procedures. Fill all applicable sections of the

proposal, sign, and present it to the administrator for

his signature. Any problems in obtaining the signature or any questions aaked about the proposal should

be noted below. )

= Signed m Not signed

Thank you very much --- Naw I would like, if I may,

to meet with your Medical Record Libmrian.

.emarks

USCOMM-DC

50
Section C - INTERVIEW WITH MEDICAL RECORD LIBRARIAN

Title and/or form number

MTERVIEWER:

Introduce self and explain survey .as fo!fows -- IS the list a completa count of

each cloy’s discharges from - -? . . .’. . . . . n Ye. m No

Iricfly, the survey involvok the collection of a limited If ‘(No,” describe exceptions and how they are handled.

mount of infornurtion kmr the retards of a SAMPLE of

atients discharged from short-term hospitals. All, or

●arly all, of the information will be available from the

me sheet of the patient’s chart. This is the abstra~

ma which will be used. (Show form PHS-4734-7 or 4734-U IS tho data of discharge

showrrmr the list? . . . . . . . . . . . . . . . . . . n Yes n No

NTERVIEWER:

Is disch~rged patient’s medical record

If Medical Record Librarian was not present during

number shown on the list? . . . . . . . . . . . . n Yes a No

~aily listing, can the Ilsting

the explanation of the procedure, explak the pro- far o colendar month be mode availnble? . . . D Yes m No

cedrrre agreed upon by the administmtor.

About how long IS the Iist”mtoined by the hospital?

m 1 year or more OR (No. of months)

M I said, we wi II abstract the records of only a sample

How is the list compiled?

f patients discharged from ifre hospital. For this hospital

t will be about cases a mo~th.

.a. What medical record numbering system is used in --? Title and/or form nunrber

a Serial a Unit n Serial-unit

m Other (Describe)

IS the list a complate count of

each day’s discharges from - -? . . . . .. . . . n Yes m No

If “No,” des tribe exceptions and how they are handled.

Is the date of dischargo

shown on the list? . . . . . . . . . . . . . . . . . a Yes m No

Is discharged patient’s medical racord

number shown on the list? . . . . . . . . . . . . D Yes n No

l~this is a daily listing, can the Iitting

frs o calendar monthbe mmb availoblo? . . . n Yes a No

Aboti how long is the Ilst ratcined by the hospital?

D 1 year or more OR (No. of months)

b. Does a newborn infant rnceive the same number How is the list compiled?

as the mother?

m Yes D No (Skip to question 2)

INTERVIEWER:

1. If - - maintains more than one discharge listing,

c. Is an infant assigned a new number if he remains

in your opinion, which one should be used to

select the sampIe?

in the hospital after the mother is discharged?

n Yca D No

!. [n order to select the sample, we will need to wodr

with a list showing the medical record number of 2. Describe any supplemental listings which should

patients who were discharged from -- during a given be used.

month. We know that these listings vary from hospital

to hospital; for example, some hospitals maintain a

“daily analysis of hospital service,” while others

have a “daily admission and discharge list”. What

kinds of discharge lists am maintained in - -?

May I 90 over them with you? 3. Attach two blank copies of all “discharge lists”

(Review discharge fists and enter information reque=ted

to the r;ght for each list. )

maintained by ---

FORM NHs-HDS-2 X (10-2 S-64)

51
Section C - Continued

1.a.

1.

2.

3.

4.

5.

hr addition to the usual inpatient discharges, we want

to be sure that we INCLUDE certain other classes of

potients in the survey. Are the following included in

tbe list of discharges (i. e., the list to be used for

sampling as described in question 2) --

Inpatients admitted,

assigned a bed, and

discharged later that

day, either with or

withaut approval? . . . . . . . . Dyes i=INo

Newborn infants discharged after having

been admitted to o

Dediatric or special

&are ward af ~he hospital -

those not discharged with

the mother? . . . . . . . . . . . . OY,S ONO DNA

Inpatients whd died in

the hospital?. . . . . . . . . . . nYes ONO

A patient di schorged to

another hospital? (Sometimes spoken of as a

“Transfer” to another

hospital j . . . . . . . . . . . ..nyes DNo

To be asked only if this

is a hospital complex

A patient transferred from

one unit of this complex

to another unit where the

units mointain separate

and distinct records?. . . . . . mYes I_JNo ONA

b. If “No” to any, ask:

Is a separate listing of these cases available?

m Yes = No

(Describe the list, and/or explain the circumstances.)

La.

1.

2.

3.

4.

5.

6.

7.

There are ather classes.of patients we wish to

EXCLUDE from our sample. Are any of the following

included in the list of discharges --

Well-newborn infants

discharged at the same

time as the mother? . . . . . . .

=Yes ONa UNl

Persons dead on arrival? . . . nYes ONO

Fetal deaths? . . . . . . . . . . nYes nNa

Outpatients? . . . . . . . . . . . UYes UNo

Patients who die in the

emergency room, not

having been admitted

as inpatients? . . . . . . . . . . UYes O~[o

Emergency patients who

die in the operating room

not having been admitted

prior to death? . . . . . . . . . . ayes DNo

Patients transferred from

one service or roam to

another but not actual Iy

discharged fram the

hospital?. . . . . . . . . . . . . . Oyes mNo

8. Patients given a pass to

leave the hospital for a

short period of time but

not actually discharged

from the hospital?. . . . . . . . ny~. !_JNo

b. If “Yes” to any, ask;

How can they be identified in the list?

(Describe)

I. Summary description of lists to be used in sampling frame

a. What discharges appear an the primary list?

b. What discharges appear on the supplemental list(s)?

US60MM-DC

52
Section D - A AND B PROCEDURE HOSPITAL SAMPLE SELECTION

NTERVIEWER: 5. About one week before our visit, we wil I telephone you

Draw the sample of discharges for calendar months July, to confirm our appointment. If you ore busy or obsent,

August, and September and prepare am original sad one who should I tolk to obout this?

copy of form PHS-4734-5 as instructed in the Sampling

Instructions. Also note any difficulties you encountered

applying these instructions. Name

Leave a copy of the list of sample cases from which you Title will be abstracting data from the face sheets on your

nest visit.

1. When would be the best time of doy for someone to come

. 6.0. lit the future, would you prefer thot we work with

someone in your deportment other then yourself?

and do the abstrodting?

(Time of oay~ m Yes D No

}.. Do you hove o preference os to doy of the week or time

of month for our visit? I

b. (E “Yes”) With whom would you like uz to work?

(Day)

Name

(Time of month)

~. INTERVIEWER: Telephone No.

Enter date and time for next visit Room No.

(Date) ,

INTERVIEWER:

a.m.

p.m. (Time)

L At thot time, will you be oble to hove the medical

At B Procedure hospitals, leave with the Medical

Record Librarian (or her representative) tbe irrrecords of the sample coses availoble ond the foce . .

srructlons for abstracting medical Items; I.e.,

sheets checked for completeness? final diagnosis, operations, etc.

D Yes a No (Arrange .uitable time for

vieit anti con-ad entry in

quaaticm 3.)

Remarks

—

FORM NHS-HOS-2X ( 10-28-64)

53
Section E - C PROCEDURE HOSPITAL SAMPLE SELECTION

1. When would bethebest time formyvisitnextmon~

VTERVIEWER:

Proceed with the sampling, working with the Medical (Time of month)

Record Librarian. You maywant toaskthe MedicaI 2. Do you hovea preference astodayof week or —

Record Librarian to draw the sampleas you observe

time of month for my visit?

and verify. Answer any questiona she might have

about the sampling procedure. Review the abstract (Day)

form with the Medical Record Librarian and observe

aa sheabsttacta a few records .Explain the procedure (Time of month)

for transmitting completed abstrscts. Leave s copy 3. INTERVIEWER:

of the Manual for Medical Record Librarians. Explain Establish date andtime for next visit.

that you will return next month to assiat in drawing

the nextsample and tohelpin sbstractingthe required (Date)

information; but, after that youwillonlyretum once a.m.

or twice a year to be sure that theprocedare is work- p.m. (Time)

ing the same in all hospitals in the survey and to 4.1fyau are busy orabsent, wlioshouldl talk —

answer any questions that she might have. to about this?

Name

Title

~emarks

iection F - SAMPLE ABSTRACTING OF MEDICAL RECORDS FACE SHEETS (A, B, and E Procedure Hospitals Onl)

Before I leave, I would like ta look at a few of the medical

records - iust the foce sheets - ta see if the information which

wv need is on the face sheet and ta see whether there will be any

problems in copying the information to the obstract form.

INTERVIEWER:

Abstract a minimum of six medical record face sheets and

transmit the abstract forms (form PHS-4734- 1 or 47342)

along with the other material and two blank copies of the

face sheet. If any information requested on the abstract

‘form is missing from the face sheer, inquire where such

information might be obtained.

If the face sheet appears to contain abbreviations or

coded entries in lieu of written-out entries, obtain a list

of definitions for these abbreviations and codes.

Xemarka

54
Exhibit J. Memorandum of Agreement

CONFIDENTIAL.Ihe mdic.1 record in f.rm.cim that i. .btaimd IM6U &i.

“r

UI is coil.cmd under uAority of Pubk Law652c.fth E4dICO~ss

(70 2tmt,48% 42 U.S.C. 242c). AU i.fm-matim which would padt idcan IC.u.m of m kdivid.ml or of M e;t.btkbmmt wiff be held srticdy curdid.nti.1, will be used otiy bypct.mm engaged in ad for the purpo.e. of &e sucrey and will nor bedisclomd or released mother perao .x used h any

ocher rmmose (22 FR 16S7).

U.S. DEPAR’IMEHTOF

HEAL1’H, EDUCATION, AND WELFARS

Public Health Service

National Center for Health Sfxtlstics

Washington, D.C.

CONTMCT PROPOSALFOR SERVICES IN CONNECTIONWITH SELSCTING AND COPTING HOSPITAL RECORDS

I. Service to be provided

❑ A.

❑ B.

•1 c.

❑ D.

The hospital makes available to the National Center for Health Statistics a lfsttng Of patient discharges

from which NCHS will eelect a sample of case records and the NCHS representative will abstract the

required data.

The hospital makes avaifable to the National Center for Health Statistics a fisting of patient discharges

from which NCHS will eeiect a sample of case records. The hospital abstracts the medfcal foformation

and makes the case records available to NCHS for completing the abstract form.

The hospital selects a sample of patient discharges from a iisting of such discharges and abstracts

required data for NCHS.

Other (Specify in detail)

II. Reimbursement of Cost

❑ A. Payment will be made to the hospital in the total sum of $ for fiscal year

❑ B. Payment will be made to the hospital at the rate of cente per abstracted record.

❑ C. No payment will be made to the hospital.

❑ D. Other (Specify)

III, Schedule of Payment

❑ A. Payment is to be made at the end of the fiscal year.

a B. Other (Specify)

IV. Payee will be (exact information

to appear on contract and check):

V. Hospital coordinator of

this project will b=

SIGNATURS OF AUTHORIZEDREPRESENTATIVE SIGNATURE OF AUTHORIZEDREPRESENTATIVE

OF HOSPITAL OF NCHS

Date

Comments

PHS-47W4

10-64

Form &+vo.cd

Rudget Sureau No. 6s.R6z3. R2

55

-J U. S. GOVERNMENT P372NT3NGC3FFfCE :1972 543-879/35
Series 1.

Series 2.

Series 3.

Series 4.

Sen”es 10.

Series 11.

Series 12.

Series 20.

Series 21.

Series 22.

*

OUTLINE OF REPORT SERIES FOR VITAL AND HEALTH STATISTICS

Public Health Sorvico Publication No.1OOO

Programs ad collection procedures. —Reports which describe the general programs of the National

Center for Health Statistics ahd its offices and divisions, data collection methods used, definitions, and

other material necessary for understanding the data.

Reports number 1-4

Data evaluation and methods research .-Studies of new statistical methodology including: experimental

tests of new survey methods, etudies of vital statistics collection methods, new analytical techniques,

objective evaluaticms of reliability of collected data, contributions to statistical theory.

Reports number 1-19

Analytical studies.— Reports presenting analytical or interpretive studies based on vital and health statistics, carrying t,he analysis further than the expository types of reports in the other series.

Reports number 1-4

Documentq and. committee reports.— Final reports of major committees concerned with vital and health

statistics, and documents such as recommended model vital registration laws and revised birth and

death certificates.

Reports number 1-6

Data From the Health Interview Survey. -Statistics on illness, accidental injuries, disability, use of

hospital, medical, dental, and other services, and other health-related topics, based on &ta collected in

a continuing national household intervjew survey.

Reports number 1-33

Data From the Health Examination Survey .—Statistics based on the direct examination, testing, and

measurement of national samples of the population, including the medically defined prevalence of specific diseases, and distributions of the population with respect to various physical, physiological, and

psychological measurements.

Reports number 1-18

Data From the Health Records Survey. —Statistics from records of hospital discharges and statistics

relating to the health characteristics of persons in institutions, and on hospital, medical, nursing, and

personal care received, based on national samples of establishments providing these services and

samples of the residents or patients.

Reports number 1-5

Data on mortality .—Various statistics on mortality other than as included in annual or monthly reportsspecial anal yses by cause of death, age, and other demographic variables, also geographic and tin

series analyses.

Reports number 1-4

Data on natality, marriage, and divorce. —Various statistics on natality, marriage, and divorce other

than as included in annual or monthly reports-special analyses by demographic variable:, also geographic and time series analyses, studies of fertility.

Reports number 1.9

Data From the National Natality and Mortality Surveys. —Statistics on characteristic of births and

deaths not available from the vital records, based on sample surveys stemming from these records,

including such topics as mortality by socioeconomic claas, medical experience in the last year of life,

characteristics of pregnancy, etc.

Reports number 1-3

/

For a list of titles of reports published in these series, write to: National Center for Health Statistics

U.S. Public Health Service

Washington, D.C. 20201