Fast track Pediatric Patient Perception Survey (CC)

Request for Approval under the “Generic Clearance for the Collection of Routine Customer Feedback” (OMB#: 0925-0648 Exp Date: 03/2018)

T ITLE OF INFORMATION COLLECTION: Pediatric Patient Perception Survey (CC)

PURPOSE: The purpose of this survey is to solicit feedback on the pediatric patient experience at the National Institutes of Health Clinical Center (NIHCC). We have ensured that these survey activities, which are designed to gather and measure customers’ perceptions of the quality of the Clinical Center’s services and operations, satisfy the requirements and the spirit of Executive Order (EO) 12862. Furthermore, periodic surveys of patient perceptions of their care is a requirement for hospital accreditation by the Joint Commission. Our planned activities for the next several years reflect our emphasis on performance improvement activities, and our reliance on the valuable data generated from these surveys.

DESCRIPTION OF RESPONDENTS: The sample will consist of approximately 5,000 patients admitted to the NIH Clinical Center for participation in clinical research.

TYPE OF COLLECTION: (Check one)

[ ] Customer Comment Card/Complaint Form [x] Customer Satisfaction Survey

[ ] Usability Testing (e.g., Website or Software [ ] Small Discussion Group

[ ] Focus Group [ ] Other: ______________________

CERTIFICATION:

I certify the following to be true:

1. The collection is voluntary.

2. The collection is low-burden for respondents and low-cost for the Federal Government.

3. The collection is non-controversial and does not raise issues of concern to other federal agencies.

4. The results are not intended to be disseminated to the public.

5. Information gathered will not be used for the purpose of substantially informing influential policy decisions.

6. The collection is targeted to the solicitation of opinions from respondents who have experience with the program or may have experience with the program in the future.

Name: Laura Lee

To assist review, please provide answers to the following question:

Personally Identifiable Information:

1. Is personally identifiable information (PII) collected? [X] Yes [x] No

2. If Yes, is the information that will be collected included in records that are subject to the Privacy Act of 1974? [X] Yes [ ] No

3. If Applicable, has a System or Records Notice been published? [X] Yes [ ] No

Gifts or Payments:

Is an incentive (e.g., money or reimbursement of expenses, token of appreciation) provided to participants? [ ] Yes [x] No

ESTIMATED BURDEN HOURS and COSTS

Category of Respondent	No. of Respondents	No. of Responses per Respondent	Time per Response (in hours)	Total Burden Hours
Inpatients (Gen Public)	5,000	1	30/60	2,500
Totals	5,000	5,000		2,500

Category of Respondent	Total Burden Hours	Hourly Wage Rate*	Total Burden Cost
Patients (Gen Public)	2,500	$9.25	$23,125
Totals	2,500		$23,125

*Hourly Wage Rate is minimum wage for Maryland: http://www.ncsl.org/research/labor-and-employment/state-minimum-wage-chart.aspx

FEDERAL COST: The estimated annual cost to the Federal government is $9,904

Staff	Grade/Step	Salary	% of Effort	Fringe (if applicable)	Total Cost to Gov’t
Federal Oversight
Program Specialist	12/4	$90,350	1%		$904
Contractor Cost
					$9,000
Travel
Other Cost
Total					$9,904

If you are conducting a focus group, survey, or plan to employ statistical methods, please provide answers to the following questions:

The selection of your targeted respondents

1. Do you have a customer list or something similar that defines the universe of potential respondents and do you have a sampling plan for selecting from this universe? [x] Yes [ ] No

If the answer is yes, please provide a description of both below (or attach the sampling plan)? If the answer is no, please provide a description of how you plan to identify your potential group of respondents and how you will select them?

The primary care givers of all pediatric patients admitted to the NIH Clinical Center (NIHCC) are sent a patient perception survey not more often than annually while child is an active patient at the NIHCC.

Administration of the Instrument

1. How will you collect the information? (Check all that apply)

[ ] Web-based or other forms of Social Media

[ ] Telephone

[ ] In-person

[x] Mail

[ ] Other, Explain

In keeping with the survey methodology developed by the Centers for Medicare and Medicaid Services for the CHCAHPS survey, the primary care givers of NIH Clinical Center (NIHCC) pediatric inpatients receive a mailed survey approximately two weeks after discharge. Non-respondents are sent a follow up request. Their responses are returned to a third-party contractor, and results are made available to the NIHCC staff through a secure, web-based portal.

2. Will interviewers or facilitators be used? [ ] Yes [x] No

Please make sure that all instruments, instructions, and scripts are submitted with the request.

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