Hospital Leadership Quality Assessment Tool (HLQAT)

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form CMS-10272 Hospital Leadership Quality Assessment Tool (HLQAT) - Nurse	Form and Instruction	New	Available
Form CMS-10272 Hospital Leadership Quality Assessment Tool (HLQAT) - Medical Director	Form and Instruction	New	Available
Form CMS-10272 Hospital Leadership Quality Assessment Tool (HLQAT) - Head Nurse	Form and Instruction	New	Available
Form CMS-10272 Hospital Leadership Quality Assessment Tool (HLQAT) - Doctor	Form and Instruction	New	Available
Form CMS-10272 Hospital Leadership Quality Assessment Tool (HLQAT) - CEO	Form and Instruction	New	Available
Form CMS-10272 Hospital Leadership Quality Assessment Tool (HLQAT) - Board Member	Form and Instruction	New	Available
Form CMS-10272 Hospital Leadership Quality Assessment Tool (HLQAT) - Surgeon	Form and Instruction	New	Available
Form CMS-10272 Hospital Leadership Quality Assessment Tool (HLQAT) - Operations Director	Form and Instruction	New	Available
HLQAT OMB Responses4-13-09 090415 OMB.doc	Supplementary Document	Uploaded 2009-05-06	Available
CMS-10272 Revised Supporting Statement-5-6-09(230PM).doc	Supporting Statement A	Uploaded 2009-05-06	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
187928	Hospital Leadership Quality Assessment Tool (HLQAT) - Nurse	Form and Instruction	New
187927	Hospital Leadership Quality Assessment Tool (HLQAT) - Medical Director	Form and Instruction	New
187926	Hospital Leadership Quality Assessment Tool (HLQAT) - Head Nurse	Form and Instruction	New
187925	Hospital Leadership Quality Assessment Tool (HLQAT) - Doctor	Form and Instruction	New
187924	Hospital Leadership Quality Assessment Tool (HLQAT) - CEO	Form and Instruction	New
187923	Hospital Leadership Quality Assessment Tool (HLQAT) - Board Member	Form and Instruction	New
187922	Hospital Leadership Quality Assessment Tool (HLQAT) - Surgeon	Form and Instruction	New
187921	Hospital Leadership Quality Assessment Tool (HLQAT) - Operations Director	Form and Instruction	New

ICR Details

OMB Control No: 0938-1060	ICR Reference No: 200901-0938-010
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/CMS	Agency Tracking No:
Title: Hospital Leadership Quality Assessment Tool (HLQAT)
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: 05/08/2009
	Date Received in OIRA: 01/30/2009
Terms of Clearance: This ICR is approved consistent with revised supporting statement, revised instrument, and CMS memo of 5-6-09. Specifically, CMS acknowledges that this instrument alone is not likely to improve care quality and spur transformational change in the healthcare system. Rather, implementing this survey will be part of a suite of activities that QIOs will undertake with the aim of improving care quality. CMS agrees to inform respondents about how their responses will be used and how their privacy will be protected by printing such information on the cover of the survey instrument and/or on any recruitment materials sent to potential respondents. Finally, per the PRA, CMS agrees to print the expiration date of this ICR's approval on the survey instrument prior to fielding the survey.

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	12/31/2010	36 Months From Approved
Responses	36,000	0	0
Time Burden (Hours)	44,820	0	0
Cost Burden (Dollars)	0	0	0

---

Abstract: Hospitals leaders will take the HLQAT instrument via web-based technology. This function will be carried out in conjunction with CMS and the QIO 9th SOW, to convey the importance of this effort in relation to Medicare and other public priorities. The American Hospital Association (AHA) and Institute for Healthcare Improvement (IHI) have expressed support as part of their global interest in hospital quality improvement.

---

Authorizing Statute(s): US Code: 42 USC 1395y(g) Name of Law: Exclusions from Coverage and Medicare as Secondary Payer
   US Code: 42 USC 1395y(i) Name of Law: Exclusions from Coverage and Medicare as Secondary Payer
   US Code: 42 USC 1320c-3(a)(10) Name of Law: Functions of Peer Review Organizations
  

Citations for New Statutory Requirements: None

---

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

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	73 FR 57630	10/03/2008
30-day Notice:	Federal Register Citation:	Citation Date:
	73 FR 76032	12/15/2008
Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 8

table that charts list of burden

IC Title	Form No.	Form Name
Hospital Leadership Quality Assessment Tool (HLQAT) - Head Nurse	CMS-10272	HLQAT Instrument
Hospital Leadership Quality Assessment Tool (HLQAT) - Medical Director	CMS-10272	HLQAT Instrument
Hospital Leadership Quality Assessment Tool (HLQAT) - Nurse	CMS-10272	HLQAT Instrument
Hospital Leadership Quality Assessment Tool (HLQAT) - Operations Director	CMS-10272	HLQAT Instrument
Hospital Leadership Quality Assessment Tool (HLQAT) - Surgeon	CMS-10272	HLQAT Instrument
Hospital Leadership Quality Assessment Tool (HLQAT) - Board Member	CMS-10272	HLQAT Instrument
Hospital Leadership Quality Assessment Tool (HLQAT) - CEO	CMS-10272	HLQAT Instrument
Hospital Leadership Quality Assessment Tool (HLQAT) - Doctor	CMS-10272	HLQAT Instrument

---

ICR Summary of Burden

table that charts list 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	36,000	0	0	36,000	0	0
Annual Time Burden (Hours)	44,820	0	0	44,820	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 ICR.

---

Annual Cost to Federal Government: $95,745

Does this IC contain surveys, censuses, or employ statistical methods? No

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]? Uncollected

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? Uncollected

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

Is this ICR related to the Pandemic Response? Uncollected

---

Common Form ICR:  No

---

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: 01/30/2009

---