Clinical Video Telehealth (CVT) Patient Satisfaction Survey

R equest for Approval under the “Generic Clearance for the Collection of Routine Customer Feedback” (OMB Control Number: 2900-0770)

TITLE OF INFORMATION COLLECTION:

Clinical Video Telehealth (CVT) Patient Satisfaction Survey

PURPOSE:

The Office of Telehealth Services (OTS) within the Veterans Healthcare Administration (VHA) seeks approval from the Office of Management and Budget (OMB) for the Clinical Video Telehealth (CVT) Patient Satisfaction Survey. The questions developed for this survey tool are the product of field staff development working through the OTS’ CVT Lead Committee. The goal is to collect appropriate data regarding current patient perceptions of their satisfaction specifically with the CVT services program and technology utilized.

CVT technology is utilized now, more frequently than ever before, as a means to improve healthcare access to rural and remote Veterans and has become a mission critical component
of care in the VHA. A CVT satisfaction survey is required to capture patients’ perspectives
on satisfaction with specific aspects of the program services and video conferencing
technology used.

This satisfaction survey is a traditional paper and pencil survey using a Scantron tool. A total of 12 questions utilizing a simple questionnaire with a Lykert scale response format will be utilized and a comments section is at the end of the survey. The VA Form 10-0481a survey tool will be delivered to Veteran patients who are receiving their clinical care via CVT. Responses are based on a 1-5 scale of satisfaction answer options. A comment box is available for any optional comments/remarks the Veteran may want to add. The completed satisfaction questionnaire is then scanned through a Scantron device at a central VA location for data capture and tabulation of the Veteran’s responses.

DESCRIPTION OF RESPONDENTS:

The CVT satisfaction survey is administered to Veteran patients after completion of a clinical encounter with their provider who has utilized video conferencing to conduct the Veteran’s medical or mental health visit.

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: Carla Anderson

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 Hour
Individuals or Households	2,500	3 minutes	125
VA Form 10-0481a (CVT Patient Survey)
Totals			125

FEDERAL COST: The estimated annual cost to the Federal government is $645.

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

2. 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 respondent universe is currently 10,000 (rounded) unique Veterans that are currently utilizing Clinical Video Telehealth (CVT) programs across the nation at the end of FY 10. The number of Veteran encounters using this technology is well over 60,000 nationwide. National targets have been set to increase the number of encounters (50% increase in FY 11) using this modality nationwide. The number of unique Veterans connecting with their providers using CVT continues to grow daily with the target for CVT encounters set to increase by 100% by 2012. The respondent universe will continue to grow as well.

Each VISN CVT Lead will distribute satisfaction surveys to a convenience sample no greater than 30% of the total number of unique veterans using CVT in the network. The total number of unique Veterans using CVT will be determined from the VSSC data cube at the end of the previous FY. The sample amount is equally divided for quarterly distribution in each VISN. The CVT lead distributes the blank survey tools to the actual point of care sites within the network on a quarterly basis.

The Telehealth Clinical Technician (TCT) or designee located at the point of care sites in the VISN administers the satisfaction survey to patients following their CVT encounter. The TCT provides the patient with written instructions as well as verbally reinforces reasons for completion. Each patient places their completed survey in an envelope to preserve their anonymity. The envelope is sealed and sent directly to the centralized scanning location at the Rocky Mountain Telehealth Training Center (RMTTC) in Denver, Colorado whereby the completed surveys are then scanned into a Scantron device.

This Scantron data collected from the patient satisfaction surveys is automatically uploaded into an SPSS database for tabulation and analysis for reporting. Individual patient responses are scored utilizing a five - point satisfaction scale. The results are provided to clinical and administrative staff members in a quarterly report developed by Scantron and the RMTTC. The report provides for rate and frequency of results of survey data to be shown at the national, VISN or facility levels for comparison over time and for benchmarking across sites.

Administration of the Instrument

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

[ ] Web-based or other forms of Social Media

[ ] Telephone

[X] In-person

[ ] Mail

[ ] Other, Explain

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

The Telehealth Clinical Technician (TCT) or designee located at the point of care sites in the VISN administers the satisfaction survey to patients following their CVT encounter.

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 Routine Customer Feedback”

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 this in your explanation.

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.

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.

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: (1) Individuals or Households;(2) Private Sector; (3) State, local, or tribal governments; or (4) Federal Government. Only one type of respondent can be selected per row.

No. of Respondents: Provide an estimate of the Number of respondents.

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)

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

FEDERAL COST: Provide an estimate of the annual cost to the Federal government.

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. 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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