Michael E. DeBakey Home Care Program Patient Satisfaction Survey

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

TITLE OF INFORMATION COLLECTION:

Michael E. DeBakey Home Care Program Patient Satisfaction Survey

PURPOSE:

The mission of the Veterans Health Administration (VHA) is to provide high quality medical and patient care services to eligible Veterans. Executive Order 12862, Setting Customer Service Standards, dated September 11, 1993, calls for the establishment and implementation of customer service standards, and for agencies to “survey customers to determine the kind and quality of services they want and their level of satisfaction with current services”. The Michael E. DeBakey Home Care Program Patient Satisfaction tool will allow for patient objective and anonymous feedback.

DESCRIPTION OF RESPONDENTS:

The feedback will be garnered from patients and used to identify opportunities for improvements in the Home Care Program services. The Patient Satisfaction survey data is collected by telephone because the patients who are on the home care program are the elderly/frail and Spinal Cord Injury.

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: Rosa M. Scott, LMSW-AP ____

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 Individuals & Households	No. of Respondents	No. of Responses	Participation Time	Burden
VA Form 10-0476	50	2	10 min.	17
Totals				17

FEDERAL COST: The estimated annual cost to the Federal government is $450.00

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?

The Home Care Program will randomly select 50 patients biannually to be surveyed; patients will have been enrolled into the home care program for at least three months. The survey will be conducted and collected via telephone. The survey will be conducted by a non employee of the home care program or by an approved volunteer of the Michael E. DeBakey VAMC. All individuals participating in the survey will be provided instructions on the intent and contents of the survey instrument.

Patients will be informed during enrollment about the patient satisfaction survey and how data obtained will be used to improve services. Verbal permission will be requested to survey the caregiver if the veteran is unable to respond.

Administration of the Instrument

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

[ ] Web-based or other forms of Social Media

[X] Telephone

[ ] In-person

[ ] Mail

[ ] Other, Explain

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

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