Pilot Test of the Proposed Pharmacy Survey on Patient Safety Culture

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form Form #3 Draft Pharmacy Background Questionnaire	Form and Instruction	New	Available
Form Form #2 Draft Pretest Questionnaire	Form and Instruction	New	Available
Form Form #1 Cognitive Interview Guide	Form and Instruction	New	Available
Supporting Statement Part B -- Pilot Test of the Proposed Pharmacy SOPS 8-9-11.docx	Supporting Statement B	Uploaded 2011-08-12	Available
Attachment F -- Federal Register Notice.pdf	Supplementary Document	Uploaded 2011-05-31	Available
Attachment A -- Healthcare Research and Quality Act of 1999.pdf	Supplementary Document	Uploaded 2011-05-31	Available
Attachment G -- List of expert reviewers and consultants.docx	Supplementary Document	Uploaded 2011-05-31	Available
Attachment D -- Pretest Cover Letter and Reminder Notice 2-8-11.docx	Supplementary Document	Uploaded 2011-05-31	Available
Supporting Statement Part A -- Pilot Test of the Proposed Pharmacy SOPS 8-9-11.docx	Supporting Statement A	Uploaded 2011-08-12	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
197991	Pharmacy background questionnaire	Form and Instruction	New	Draft Pharmacy Background Questionnaire
197990	Pretest	Form and Instruction	New	Draft Pretest Questionnaire
197989	Cognitive interviews	Form and Instruction	New	Cognitive Interview Guide

ICR Details

OMB Control No: 0935-0183	ICR Reference No: 201106-0935-002
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/AHRQ	Agency Tracking No:
Title: Pilot Test of the Proposed Pharmacy Survey on Patient Safety Culture
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: 08/12/2011
Retrieve Notice of Action (NOA)	Date Received in OIRA: 06/07/2011
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	08/31/2014	14 Months From Approved
Responses	707	0	0
Time Burden (Hours)	197	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: Given the widespread impact of pharmacies on patient safety, the new Pharmacy Survey on Patient Safety Culture (Pharmacy SOPS) will measure pharmacy staff perceptions about what is important in their organization and what attitudes and behaviors related to patient safety are supported, rewarded, and expected. The survey will help community/retail pharmacies to identify and discuss strengths and weaknesses of patient safety culture within their individual pharmacies. They can then use that knowledge to develop appropriate action plans to improve their practices and their culture of patient safety. This survey is designed for use in community/retail pharmacies, which includes chain drugstores (e.g., Walgreens and CVS), supermarket pharmacies, independently owned pharmacies, and mass merchant pharmacies (e.g., Wal-Mart, Costco, Target), not for use in hospital pharmacies.

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Authorizing Statute(s): US Code: 42 USC 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:
	76 FR 13410	03/11/2011
30-day Notice:	Federal Register Citation:	Citation Date:
	76 FR 30172	05/24/2011
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 3

table that charts list of burden

IC Title	Form No.	Form Name
Cognitive interviews	Form #1	Cognitive Interview Guide
Pharmacy background questionnaire	Form #3	Draft Pharmacy Background Questionnaire
Pretest	Form #2	Draft Pretest Questionnaire

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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	707	0	0	707	0	0
Annual Time Burden (Hours)	197	0	0	197	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: $106,939

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: 06/07/2011

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