| *Name of Facility |
|
| City: |
|
| State: |
|
| Zip: |
|
| Phone: |
|
| *Email: |
|
| *Type of facility: |
Freestanding
Hospital Based
Multispecialty
|
| Specialty (check all that apply) |
GASTROENTEROLOGY
OPTHAMOLOGY
ORTHOPEDICS
COSMETIC
UROLOGY
ENT
GYN
ORAL/MAXILLO/FACIAL
PLASTICS
OTHER
|
| Number of operating rooms |
|
| Number of physicians |
|
| Number of cases |
|
| Number of returned satisfaction surveys |
|
| Number of positive satisfaction surveys |
|
| Number of satisfaction survey's with needs improvement |
|
| Types of anesthesia used in surgeries: |
Regional
MAC
IV
Nurse Monitor
Local
General
|
| Number of infections |
|
| Number of hospital transfer |
|
| Number of return to OR |
|
| Number of complications |
|
| Number of wrong site near misses |
|
| Number of medication error near misses |
|
| Number of hospitalizations after discharge |
|
| Amount of time from discharge to hospitalization |
Within 24 hours
Within 2-3 days
Within 4-7 days
Greater
than 7 days
|
| Type of anesthesia used on hospitalized patient |
|
| |
|
