Appendix D – Economic Assessment Questionnaire

PRELIMINARY ECONOMIC ASSESSMENT QUESTIONNAIRE

Institution:                              Location:                              

This questionnaire is designed to help determine the potential savings which the

Point of Use System could have on a healthcare institution.

1)   Information on Hospital:

A. Annual census:                                                                  

B. Licensed beds:                                                                  

C. Payor mix:  Medicare  (%)                                                       

                     Medicaid  (%)                                                      

                     HMO / PPO  (%)                                                     

                     Commercial  (%)  (%) of Private Collected                          

                     Other  (%)                                                         

D. Chargeable supply upcharge (average margin):                                    

E. Inventory carrying cost rate (hospital cost of capital):                        

F. Group purchasing affiliation:                                                   

G. Systems vendors: Inventory: ____    Billing:               ADT:                

H. Managed care affiliation:                                                       

2)   Information on Med/Surg Materials Costs:

A. Annual Med/Surg supply cost ($):       % Chargeable        % Non-Chargeable     %

B. Lost charge percentage (at cost):                                               

C. Percentage of overall Med/Surg supply costs going through carts:                

D. Time spent on data entry charge processing (hours/day):                         

E. Time spent on data entry inventory update processing (hours/day):               

F. Prime vendor:                                                                   

G. Vendor program (standard, JIT, stockless, other):                               

3)   General Supply Cart Information:

A. Supply system employed:   Par (#):         Exchange (#):            Other (#):        

B. Total number of carts:                        C. Inventory value per cart ($):        

D. Number of FTEs dealing with inventory:        E. FTE salary (incl. benefits) ($/hr): 

F. Minutes spent to count a cart:                G. Inventory counts per week/cart:      

H. Minutes spent to restock a cart:              I. Number times carts are

(excluding picking supplies)                         restocked per week:           

J. Minutes spent to exchange a cart:             K. Number of times carts are

                                                  exchanged per week:              

4)   Patient Charge Sticker Information (if applicable):

A.     Time spent applying stickers (hours/day):                                       

B.     Number of stickers used/year:                    

C.     Total sticker cost per year:                                                    

D.     D. Total charge card cost per year:               

E. Who places stickers:    Volunteers               RN                    CS      

   Vendor                  MM                       Technicians                   

5)   Nursing Background:

A. Number of nursing units:                  

B.     Avg. number of nurses per unit:              

C.     Avg. number of nurse’s aides per unit:           

D. Minutes per day spent dealing with:

   i) Patient charge stickers:            Done by:RN        Nurse’s Aide          

   ii) Billing data entry:                Done by:RN        Nurse’s Aide          

   iii) Charge reconciliation:            Done by:RN        Nurse’s Aide          

   iv) Other supply admin. tasks:         Done by:RN        Nurse’s Aide          

E. Nurse salary including benefits ($/hr):      

F. Nurse’s aide salary including benefits ($/hr):          

6)   What are Your Objectives in Evaluating Point of Use Technology

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