Survey of Hospital Quality Leaders

Forms and Documents

Document Name	Status
Form 1 USE OF PATIENT EXPERIENCE INFORMATION IN HOSPITALS: A SURVEY OF HOSPITAL QUALITY LEADERS Form and Instruction	New
Attachment 5 SHQL_survey invitation third mail reminder.docx Supplementary Document	2016-06-06
Attachment 4 SHQL_survey invitation second mail reminder.docx Supplementary Document	2016-06-06
Attachment 3 SHQL_survey invitation first mail reminder.docx Supplementary Document	2016-06-06
Attachment 2 SHQL_survey invitation email.docx Supplementary Document	2016-06-06
Survey of Hospital Quality Leaders OMB Statement A revised 12062016.doc Supporting Statement A	2016-12-06
Survey of Hospital Quality Leaders OMB Statement B revised 12062016.doc Supporting Statement B	2016-12-06

IC Document Collections

IC ID	Document Title	Status
221802	USE OF PATIENT EXPERIENCE INFORMATION IN HOSPITALS: A SURVEY OF HOSPITAL QUALITY LEADERS Form and Instruction	New

ICR Details

OMB Control No: 0935-0234	ICR Reference No: 201606-0935-001
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/AHRQ	Agency Tracking No:
Title: Survey of Hospital Quality Leaders
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 12/09/2016
	Date Received in OIRA: 06/10/2016
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	12/31/2019	36 Months From Approved
Responses	500	0	0
Time Burden (Hours)	295	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: The Consumer Assessment of Healthcare Providers and Systems (CAHPS®) Hospital Survey (HCAHPS) was first implemented on a voluntary basis in 2006 to assess patients’ experiences with care. Today, hospitals subject to the Inpatient Prospective Payment System (IPPS) annual payment update provisions are required to collect and submit HCAHPS data in order to receive their full annual payment update (CMS, HCAHPS: Patients’ Perspectives of Care Survey; Goldstein et al., 2005). In October 2012, HCAHPS performance was added to the calculation of the value-based incentive payment in the Hospital Value-Based Purchasing (Hospital VBP) program by the Patient Protection and Affordable Care Act of 2010 (CMS, HCAHPS Fact Sheet). The FY 2015 Hospital VBP program links 30% of the Inpatient Prospective Payment System hospitals' payment from CMS to HCAHPS performance (Medicare.gov). Despite the high stakes associated with HCAHPS scores, little is known about the ways in which hospitals are using HCAHPS data and supplemental information about patient experience to understand and improve their patients’ experiences. This research has the following goals: 1) to characterize the role of HCAHPS in hospitals’ efforts to improve patient experiences 2) to identify the types of quality improvement activities hospitals implement to improve their HCAHPS scores 3) to describe hospitals’ perspectives on HCAHPS 4) to determine the types of information collected by hospitals beyond those required for VBP To achieve the goals of this project, the following data collections will be implemented: 1) Survey of Hospital Quality Leaders: this survey will elicit information from approximately 500 hospital quality leaders in a variety of hospital settings, including high- and low-performing hospitals, facilities of varying sizes, and hospitals representing all nine geographic Census divisions. Hospital quality leaders will be asked to provide information about the use of HCAHPS in their hospital, with questions addressing all of the substantive areas identified in the goals section above. This study is being conducted by AHRQ through a cooperative agreement with the RAND Corporation, pursuant to AHRQ’s statutory authority to conduct and support research on healthcare and on systems for the delivery of such care, including activities with respect to the quality, effectiveness, efficiency, appropriateness and value of healthcare services and with respect to quality measurement and improvement. 42 U.S.C. 299a(a)(1) and (2).

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Authorizing Statute(s): US Code: 42 USC Sec. 299 Name of Law: Healthcare Research and Quality Act of 1999
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	81 FR 17714	03/30/2016
30-day Notice:	Federal Register Citation:	Citation Date:
	81 FR 37596	06/10/2016
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
USE OF PATIENT EXPERIENCE INFORMATION IN HOSPITALS: A SURVEY OF HOSPITAL QUALITY LEADERS	1	USE OF PATIENT EXPERIENCE INFORMATION IN HOSPITALS: A SURVEY OF HOSPITAL QUALITY LEADERS

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ICR Summary of Burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	500	0	0	500	0	0
Annual Time Burden (Hours)	295	0	0	295	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: This is a new information collection request.

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Annual Cost to Federal Government: $262,427

Does this IC contain surveys, censuses, or employ statistical methods? Yes Part B of Supporting Statement

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 06/10/2016

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