Request for Approval - Patient Experience of Care Survey Pilot Project

Request for Approval under the “Generic Clearance for the Collection of Qualitative Feedback on Agency Service Delivery”

(OMB Control Number: 0917-0036)

T ITLE OF INFORMATION COLLECTION: Patient Experience of Care Survey Pilot Project

PURPOSE: Indian Health Service (IHS) will administer and collect primary care-focused patient experience of care information at four Indian Health Service facilities during a three-month pilot period. The purpose of the pilot patient survey is to gather information on the ability and effectiveness of collecting information in real time, using a brief survey. The pilot work will allow sites to test the most efficient and patient centered approaches to surveying patients. The information collected will be used to identify specific areas of patient concern. IHS seeks to better understand patients’ perception of the care received at IHS facilities and will act on patient feedback using a rapid-cycle performance improvement process. This data collection effort is in response to OIG recommendations published in October 2016, related to improving quality of care and patient satisfaction.

DESCRIPTION OF RESPONDENTS: The targeted groups of respondents are patients who receive care at one of the four pilot facilities during the three-month pilot test period. These sites were selected to provide a cross section of IHS Direct Service facilities and service units. A variety of criteria were used in the site selection:

• Geography. – The sites are located in various geographies – Northwest, Southwest, Great Plains and Northeast.

• Type of facility - Two facilities are hospitals, which have strong ambulatory care services and two sites are health centers.

• Size and location of the facility – Phoenix is in an urban setting. Rosebud is in a rural setting. Micmac and Warm Springs are health centers.

All facilities agreed to participate and each pilot facility has members assigned to our pilot project workgroup.

(1) Phoenix Indian Medical Center, Phoenix Area, Phoenix, AZ

(2) Rosebud Hospital, Great Plains Area, Rosebud, SD

(3) Warm Springs Health and Wellness Center, Portland Area, Warm Springs, OR

(4) Micmac Family Health Center, Nashville Area, Presque Isle, ME

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: web-surveys

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:

Kathleen C. Kimmel and Jeff Salvon-Harman MD, Indian Health Service

202.969.3655

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

Personally Identifiable Information:

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

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

3. If Yes, has an up-to-date System of Records Notice (SORN) been published? [ ] Yes [ ] No

Gifts or Payments:

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

BURDEN HOURS

Category of Respondent	No. of Respondents	Participation Time	Burden Hours
Individuals per facility during a 3-month pilot period	1,000 patients per facility	7 minutes	116.7
Totals for all 4 facilities in a 3-month pilot period	4,000		467

FEDERAL COST: The estimated annual cost to the Federal government is $2,760.00

Data Collection Device Costs:

• 12 tablet devices at approximately $200.00 each = $2,400.00

• Tablet device security case and lock $30.00 each = $ 360.00

Survey Instrument Costs: An existing IHS Survey Monkey account was used to create the survey. Survey Monkey will be used for survey collection and analysis. Therefore, there are no additional costs for the survey preparation, administration, reports or analytics.

Software Costs: Will use the existing IHS Survey Monkey account.

Server Costs: The existing IHS Survey Monkey account will be used. The server and data storage fees are included in the Survey Monkey account license.

Labor Costs: Assume it takes approximately two-three minutes of staff time (record keeping) to explain, administer and collect the devices containing the completed surveys, the cost for staff time at the service unit is not additional.

Marketing Costs: IHS Headquarters Office will provide each facility participating in the pilot a Word document to print, which they will use as a brochure to explain the purpose of the data collection and provide instructions for completing the survey. No additional costs are expected.

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? [ ] Yes [x] 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?

Selection: Convenience sample. Each of the four pilot facilities will determine random dates and time periods for sample collection. During designated sampling periods, the sampling plan involves asking patients who are leaving the facility after having received care if they are willing to respond to a voluntary patient experience of care survey. If the patient answers yes, a staff member provides instructions for use of an electronic tablet device to complete the patient survey.

Administration of the Instrument

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

[x] Web-based or other forms of Social Media

[ ] Telephone

[x] In-person

[ ] Mail

[] Other, Explain

The data collection will be created using the Survey Monkey tool. The survey will be administered in person at the clinic site using an electronic tablet device at the end of the clinic visit.

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

Each of the four pilot clinics will determine the time and duration of survey distribution. During the collection period, at the time of check in, clinic staff members will hand the patient an informational brochure, which provides details on the patient experience of care pilot program. One of the clinic staff will use the script explaining the program and will ask the patient if he or she is willing to participate in a short patient experience of care survey before leaving the clinic. If yes, a member of the clinic staff will request that the patient complete the survey before leaving.

Upon check out, the patient will be asked to use an electronic tablet device that contains the patient survey. The script will be used by the clinic staff member. The clinic staff member administering the survey and providing the device will answer questions and assist patients who request help or have a disability.

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

Instructions for completing Request for Approval under the “Generic Clearance for the Collection of Qualitative Feedback on Agency Service Delivery”

TITLE OF INFORMATION COLLECTION: Provide the name of the collection that is the subject of the request (e.g., Comment card for soliciting feedback on xxxx).

PURPOSE: Provide a brief description of the purpose of this collection and how it will be used. If this is part of a larger study or effort, please include a statement to that effect in your explanation. Please include how the information will be used to improve services or the program.

DESCRIPTION OF RESPONDENTS: Provide a brief description of the targeted group or groups for this collection of information. These groups must have experience with the program.

TYPE OF COLLECTION: Check one box. If you are requesting approval of other instruments under the generic, you must complete a form for each instrument.

CERTIFICATION: Please read the certification carefully. If you incorrectly certify, the collection will be returned as improperly submitted or it will be disapproved. Provide the name of the individual who is the lead contact and responsible for the collection.

Personally Identifiable Information: Provide answers to the questions. Note: Agencies should only collect PII to the extent necessary, and they should only retain PII for the period of time that is necessary to achieve a specific objective. If you request PII, then ensure that you state the reason why it is being collected (i.e., in order to respond to inquiries from the participants).

Gifts or Payments: If you answer yes to the question, please describe the incentive and provide a justification for the amount.

BURDEN HOURS:

Category of Respondents: Identify who you expect the respondents to be in terms of the following categories: Respondents to the survey are adult patients (18 or older) receiving care at the four pilot outpatient clinics. Each of the four pilots will determine the dates and times of survey collection and will approach all patients who arrive for care during the designated sampling period.

No. of Respondents: 1,000 respondents per pilot site in the three-month pilot.

Participation Time: Provide an estimate of the amount of time required for a respondent to participate (e.g. fill out a survey or participate in a focus group) we anticipate 5-7 minutes for a respondent to complete the survey

Burden: Provide the Annual burden hours: Multiply the Number of responses and the participation time and divide by 60 = 467.

FEDERAL COST: Provide an estimate of the annual cost (and description) to the Federal government. Please provide a brief break down of the costs, including wages for staff utilizing OPM pay scale table. See http://www.opm.gov/policy-data-oversight/pay-leave/salaries-wages/2014/general-schedule/

If you are conducting a focus group, survey, or plan to employ statistical methods, please provide answers to the following questions: This data collection effort will not include focus groups. Data analysis will consist of descriptive statistics of the responses and review of text responses in comment boxes.

The selection of your targeted respondents. Please provide a description of how you plan to identify your potential group of respondents and how you will select them. If the answer is yes, to the first question, you may provide the sampling plan in an attachment.

Administration of the Instrument: Identify how the information will be collected. More than one box may be checked. Indicate whether there will be interviewers (e.g. for surveys) or facilitators (e.g., for focus groups) used.

Submit all instruments, instructions, and scripts are submitted with the request.

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