Nation-wide Customer Satisfaction Surveys

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form VA Form 10-1465-3 Nation-wide Customer Satisfaction Surveys	Form and Instruction	Modified	Repair queued
JUSTIFICATION_B[1].doc	Supporting Statement B	Uploaded 2012-01-03	Available
2900-0712 justification A (v3).docx	Supporting Statement A	Uploaded 2012-10-05	Available
Field Test Report 5-3-2011.pdf	Supplementary Document	Uploaded 2011-12-18	Available
Reminder & Thank You postcard.pdf	Supplementary Document	Uploaded 2010-05-11	Available
Ambulatory Care Pre-notification Letter.pdf	Supplementary Document	Uploaded 2010-05-11	Available
Ambulatory Care Cover Letter.pdf	Supplementary Document	Uploaded 2010-05-11	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
182342	Nation-wide Customer Satisfaction Surveys	Form and Instruction	Modified

ICR Details

OMB Control No: 2900-0712	ICR Reference No: 201112-2900-017
Status: Historical Inactive	Previous ICR Reference No: 201001-2900-008
Agency/Subagency: VA	Agency Tracking No: 2900-0712
Title: Nation-wide Customer Satisfaction Surveys
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Withdrawn and continue	Conclusion Date: 06/04/2013
	Date Received in OIRA: 11/06/2012
Terms of Clearance: Withdrawn to upload revised versions of the instruments and supporting statements.

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	03/31/2014	36 Months From Approved	03/31/2014
Responses	301,244	0	301,244
Time Burden (Hours)	96,125	0	96,125
Cost Burden (Dollars)	0	0	0

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Abstract: The overall purpose of the VHA Office of Quality and Performance Survey of Health Experience of Patients (SHEP) Survey Program is to systematically obtain information from patients that can be used to identify problems or complaints that need attention and to improve the quality of health care services delivered to Veterans. Information obtained from the SHEP Program is one component of a larger Network Directors Performance Agreement system in VHA that culminates in the annual Network Performance Report. Results of each of the customer satisfaction surveys are made readily available to VA Central Office (VACO), Veterans Integrated Service Network (VISN), VHA field staff, and stakeholders as part of the Network Performance Report and via the VA Intranet. Data is used to demonstrate that VA is providing timely, high quality health care services to patients and to measure improvement toward the goal of matching or exceeding the non-VA external benchmark performance.

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Authorizing Statute(s): EO: EO 12862 Name/Subject of EO: Setting Customer Service Standards
   US Code: 38 USC Section 3305 Name of Law: Confidentiality of Medical Quality-Assurance Records
  

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:
	77 FR 10	01/17/2012
30-day Notice:	Federal Register Citation:	Citation Date:
	77 FR 203	10/19/2012
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

table that charts list of burden

IC Title	Form No.	Form Name
Nation-wide Customer Satisfaction Surveys	VA Form 10-1465-4, VA Form 10-1465-3, VA Form 10-1465-2, VA Form 10-1465-5, VA Form 10-1465-6	SHEP Outpatient Long Form 10-1465-3 ,   SHEP Outpatient Short Form 10-1465-4 ,   HCAHPS SHEP Core Short Form 10-1465-2 ,   Clinician and Group Survey , Patient Centered Medical Home ,   Clinician and Group Survey Patient Centered Medical Home

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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: The program change is due to the inclusion of VA Forms 10-1465-5 and 10-1465-6, respectively the C&G PCMH short and long forms. The increase in burden hours is 23,333. However, VHA reduced the amount of SHEP Outpatient Short form surveys (10-1465-4) mailed, such that there will be a net decrease of 25,340 burden hours. VHA is undertaking a new initiative to implement a patient-centered medical home model of care at all VHA Primary Care sites, and is referred to as Patient Aligned Care Teams (PACT). This initiative supports VHA's Universal Health Care Services Plan to redesign VHA healthcare delivery through increasing access, coordination, communication, and continuity of care. PACT provides accessible, coordinated, comprehensive, patient-centered care, and is managed by primary care providers with the active involvement of other clinical and non-clinical staff. PACT allows patients to have a more active role in their health care and is associated with increased quality improvement, patient satisfaction, and a decrease in hospital costs due to fewer hospital visits and readmissions. Currently VHA has no mechanism in place to measure the effectiveness of the PACT model from the patients' perspective. The inclusion of these 2 new forms will fill that void.

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Annual Cost to Federal Government: $12,065,619

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: 11/06/2012

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