Pilot Test of the Proposed Value and Efficiency Surveys and Communicating About Value Checklist

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form Form #10 Draft CV Checklist Evaluation	Form and Instruction	New	Available
Form Form #9 Cognitive Interview Guide for CV Checklist	Form and Instruction	New	Available
Form Form #8 CV Checklist Survey	Form and Instruction	New	Available
Form Form #7 Medical Office Information Form	Form and Instruction	New	Available
Form Form #6 Site-level POC Instructions for Medical Office VE Survey	Form and Instruction	New	Available
Form Form #5 Site-level POC Instructions for Hospital VE Survey	Form and Instruction	New	Available
Form Form #4 Pretest Survey for Medical Office VE Survey	Form and Instruction	New	Available
Form Form #3 Pretest Survey for Hospital VE Survey	Form and Instruction	New	Available
Form Form #2 Cognitive Interview Guide for Medical Office VE Survey	Form and Instruction	New	Available
Form Form #1 Cognitive Interview Guide for Hospital VE Survey	Form and Instruction	New	Available
Supporting Statement Part B -- Pilot Test of the High Value and Efficiency Culture Surveys 1-10-2013.docx	Supporting Statement B	Uploaded 2013-04-19	Available
Attachment N -- Federal Register Notice.pdf	Supplementary Document	Uploaded 2013-04-19	Available
Attachment O - List of Expert Reviewers and Consultants.docx	Supplementary Document	Uploaded 2013-04-19	Available
Attachment L - Draft CV Checklist.docx	Supplementary Document	Uploaded 2013-04-19	Available
Attachment H - Pretest Cover Letter and Reminder Notice for Medical Office VE Survey.docx	Supplementary Document	Uploaded 2013-04-18	Available
Attachment G - Pretest Cover Letter and Reminder Notice for Hospital VE Survey.docx	Supplementary Document	Uploaded 2013-04-18	Available
Supporting Statement Part A -- Pilot Test of the Proposed Value and Efficiency Surveys and Checklist 1-10-2013.docx	Supporting Statement A	Uploaded 2013-04-19	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
206682	Pretest for the CV checklist	Form and Instruction	New	Draft CV Checklist Evaluation
206681	Cognitive interviews for the CV checklist	Form and Instruction	New	Cognitive Interview Guide for CV Checklist
206680	Survey to identify items for CV checklist	Form and Instruction	New	CV Checklist Survey
206679	Medical office information form	Form and Instruction	New	Medical Office Information Form
206678	POC Administration of the Medical Office VE survey	Form and Instruction	New	Site-level POC Instructions for Medical Office VE Survey
206677	POC Administration of the Hospital VE survey	Form and Instruction	New	Site-level POC Instructions for Hospital VE Survey
206676	Pretest for the Medical Office VE survey	Form and Instruction	New	Pretest Survey for Medical Office VE Survey
206675	Pretest for the Hospital VE survey	Form and Instruction	New	Pretest Survey for Hospital VE Survey
206674	Cognitive interviews for the Medical Office VE survey	Form and Instruction	New	Cognitive Interview Guide for Medical Office VE Survey
206673	Cognitive interviews for the Hospital VE survey	Form and Instruction	New	Cognitive Interview Guide for Hospital VE Survey

ICR Details

OMB Control No: 0935-0211	ICR Reference No: 201304-0935-003
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/AHRQ	Agency Tracking No: 19290
Title: Pilot Test of the Proposed Value and Efficiency Surveys and Communicating About Value Checklist
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 07/24/2013
Retrieve Notice of Action (NOA)	Date Received in OIRA: 04/25/2013
Terms of Clearance: Necessary materials were included in submission.

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	07/31/2014	12 Months From Approved
Responses	5,066	0	0
Time Burden (Hours)	2,534	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: Given the widespread impact of cost and waste in health care, AHRQ will develop the Value and Efficiency (VE) Surveys for hospitals and medical offices. These surveys will measure staff perceptions about what is important in their organization and what attitudes and behaviors related to value and efficiency are supported, rewarded, and expected. The surveys will help hospitals and medical offices to identify and discuss strengths and weaknesses within their individual organizations. They can then use that knowledge to develop appropriate action plans to improve their value and efficiency. To develop these tools AHRQ will recruit medical staff from 42 hospitals and 96 medical offices to participate in cognitive testing and pretesting. In addition to the VE surveys, AHRQ also intends to develop a Communicating About Value Checklist (CV checklist). The objective of the CV checklist is to aid clinicians in having conversations with patients about value.

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Authorizing Statute(s): US Code: 42 USC 299 Name of Law: Healthcare Research and Quality Act of 1999
  

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:
	78 FR 946	01/07/2013
30-day Notice:	Federal Register Citation:	Citation Date:
	78 FR 23256	04/18/2013
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 10

table that charts list of burden

IC Title	Form No.	Form Name
Cognitive interviews for the CV checklist	Form #9	Cognitive Interview Guide for CV Checklist
Cognitive interviews for the Hospital VE survey	Form #1	Cognitive Interview Guide for Hospital VE Survey
Cognitive interviews for the Medical Office VE survey	Form #2	Cognitive Interview Guide for Medical Office VE Survey
Medical office information form	Form #7	Medical Office Information Form
POC Administration of the Hospital VE survey	Form #5	Site-level POC Instructions for Hospital VE Survey
POC Administration of the Medical Office VE survey	Form #6	Site-level POC Instructions for Medical Office VE Survey
Pretest for the CV checklist	Form #10	Draft CV Checklist Evaluation
Pretest for the Hospital VE survey	Form #3	Pretest Survey for Hospital VE Survey
Pretest for the Medical Office VE survey	Form #4	Pretest Survey for Medical Office VE Survey
Survey to identify items for CV checklist	Form #8	CV Checklist Survey

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ICR Summary of Burden

table that charts list of burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	5,066	0	0	5,066	0	0
Annual Time Burden (Hours)	2,534	0	0	2,534	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

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: This is a new information collection request.

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Annual Cost to Federal Government: $1,001,202

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: 04/25/2013

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