Generic Clearance Submission Template_ESRD Grievance Survey

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

T ITLE OF INFORMATION COLLECTION: End Stage Renal Disease (ESRD) Grievant Satisfaction Survey

PURPOSE:

The ESRD Grievant Satisfaction Survey endeavors to provide data to perform a nationwide evaluation of grievances received from ESRD patients or other individuals who file a grievance with a Medicare-certified ESRD provider or ESRD Network. The evaluation will rely on data collection instruments to identify the following:

1. Grievant satisfaction with the Network in resolving the grievance.

2. Grievant experience with the Networks’ grievance process as it relates to:

1. Customer service.

2. Collecting feedback on the grievant’s personal experience when filing a grievance.

3. Grievant overall satisfaction with the Network Program for filing, investigating, and resolving the grievance.

4. Grievant knowledge and understanding of the Network grievance resolution process.

The information gathered from this data collection will be used to:

1. Track and trend results of beneficiary level satisfaction with Network Grievance Protocol throughout key stages in the process:

   • Intake of grievance

   • Feedback and communication activities

   • Investigation

   • Referral arrangements

2. Identify opportunities for process improvement in Network Grievances.

3. Provide Grievance satisfaction data that the Networks can use in the development of a Quality Improvement Activity (QIA).

4. Gather aggregate information to share with patient SME groups¹ which will enable these groups to offer feedback and suggestions for patient driven with the Network grievance protocol.

5. Develop a validated data driven system to provide feedback to the Networks which could be incorporated into their performance evaluation process.

DESCRIPTION OF RESPONDENTS:

Respondents include ESRD beneficiaries, their representatives, other family members/caregivers, facility employees, physicians and other practitioners, federal or state agencies, Quality Improvement Organizations (QIOs), and State Survey Agencies (SAs), who filed a grievance with an ESRD Network.

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: Kathleen M. Egan RN MSN CPHQ - GTL/COR ESRD/NCC – (Grievant Survey a task within this contract)

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
Individuals or Households	3842	12 minutes per respondent	76.8 hours
Totals	384	12 minutes per respondent	76.8 hours

FEDERAL COST: The estimated annual cost to the Federal government is $15,000³.

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? [x] 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?

Universe

As measured in 2011⁴, over 5,900 dialysis facilities provided life-sustaining treatment to more than 415,000 ESRD patients. Of that patient pool, 1,651 complaints were tracked, whereas only 31 formal grievances were noted across the 18 ESRD Networks (CMS changed the terminology for grievances in 2013, no longer distinguishing between a complaint and a grievance).

Sampling Plan

Based on the pilot study and previous experience with the Medicare population, CMS expects a response rate of approximately 50%. Assuming an overall response rate of 50% for the study, CMS would need a sample of 768 (i.e., 384 x 2) to achieve a final sample size of 384; the number of complete surveys needed to yield sufficient statistical power to generalize findings.

To achieve a sample size of 384, 768 survey participants will be sampled from data extracted from the Patient Contact Utility (PCU), a national Access database that allows Networks to enter grievance data. Stratified random sampling will be used to select an equal number of participants from each Network. This will produce a total of 43 participants from each Network, yielding a total sample size of 774.

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

1 Small focus groups consisting of volunteer patients from ESRD Networks.

2 Using the most conservative assumption of a 50% proportion (based on the pilot study and previous experience with the Medicare population), a sample size of 384 will yield sufficient statistical power to produce a 95% confidence interval, with a 5% margin of error.

3 Includes estimated cost of survey vendor and pre-notification letter mailings.

4 Centers for Medicare and Medicaid Services. End Stage Renal Disease Network Organization Program 2011 Summary Annual Report. Baltimore, MD: CMS; 2012.

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