Anticoagulation (warfarin/Coumadin)Satisfaction Survey Request

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

TITLE OF INFORMATION COLLECTION:

Anticoagulation (warfarin/Coumadin) Patient Satisfaction Survey

PURPOSE:

The purpose of the Anticoagulation (warfarin/Coumadin) Patient Satisfaction Survey is to systematically receive feedback regarding overall patient satisfaction regarding their anticoagulation care within VISN 1. The VISN 1 Improving and Systemizing Outpatient Anticoagulation in VISN 1 team has set a goal to improve patient satisfaction regarding their anticoagulation care. This survey is intended to provide the team with insight into patients' satisfaction with their care as well as what they would desire.

The resulting data will be used to provide feedback to anticoagulation clinics throughout VISN 1 to guide improvement. The data will not be used for research or publishing purposes or for grant submission.

DESCRIPTION OF RESPONDENTS:

The pool of respondents will consist of a random and anonymous sample of patients who are enrolled in an anticoagulation clinic in VISN 1.

TYPE OF COLLECTION: (Check one)

[ ] Customer Comment Card/Complaint Form [] 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: Angela Park, Pharm.D., CACP, VISN 1 Anticoagulation Coordinator

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

Personally Identifiable Information:

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

BURDEN HOURS

Category of Respondent Individuals & Households	No. of Respondents	Participation Time	Burden
VA Form 10-211002	4800	7 minutes	560
Totals	4800	7 minutes	560

FEDERAL COST: The estimated annual cost to the Federal government is $4800

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 [ ] 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?

VISN 1 has an Anticoagulation Dashboard which pulls all patients with an active warfarin prescription. Once monthly, 50 patients from each of 8 sites within VISN 1 will be randomly selected to be mailed the survey. They will be given the option to answer the survey on paper and mail it back to the VISN 1 Anticoagulation Program office through a self-addressed stamped envelope or they may answer the survey on Survey Monkey through a link that will be provided within the mailing. There is no identifying information on the survey that will allow us to identify the veterans who complete the survey.

Administration of the Instrument

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

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

[ ] Telephone

[ ] In-person

[ ] Mail

[ ] Other, Explain

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

Link to Survey: https://www.surveymonkey.com/s/VISN1_Anticoagulation

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