Emergency Room Patient Experiences with Care Survey

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form CMS-10461 Emergency Department Patient Experience of Care Survey	Form	New	Available
OMB Supporting Statement B rev 4-25-13 CLEAN.docx	Supporting Statement B	Uploaded 2013-04-28	Available
Response to Comments to OMB_ED survey.doc	Supplementary Document	Uploaded 2013-04-28	Available
508 ATTACHMENT F ER Patient Experience Initial Letter Admitted HCAHPS Add-on.pdf	Supplementary Document	Uploaded 2013-04-28	Available
508 ATTACHMENT E ER Patient Experience Initial Letter Admitted Stand Alone.pdf	Supplementary Document	Uploaded 2013-04-28	Available
508 ATTACHMENT D ER Patient Experience Initial Letter Discharged To Community.pdf	Supplementary Document	Uploaded 2013-04-28	Available
CMS-10461 - Supporting Statement part A rev 4-19-2013 with responses CLEAN.docx	Supporting Statement A	Uploaded 2013-04-28	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
206749	Emergency Department Patient Experience of Care Survey	Form	New

ICR Details

OMB Control No: 0938-1209	ICR Reference No: 201305-0938-001
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/CMS	Agency Tracking No: 19377
Title: Emergency Room Patient Experiences with Care Survey
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: 08/23/2013
	Date Received in OIRA: 05/01/2013
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	08/31/2015	13 Months From Approved
Responses	3,600	0	0
Time Burden (Hours)	799	0	0
Cost Burden (Dollars)	0	0	0

---

Abstract: The Emergency Department patient experience of care survey supports the six national priorities for improving care from the National Quality Strategy developed by the U.S. Department of Health and Human Services (HHS) that was called for under the Affordable Care Act to create national aims and priorities to guide local, state, and national efforts to improve the quality of health care. This strategy has established six priorities that support a three-part aim focusing on better care, better health, and lower costs through improvement. The six priorities include: making care safer by reducing harm caused by the delivery of care; ensuring that each person and family are engaged as partners in their care; promoting effective communication and coordination of care; promoting the most effective prevention and treatment practices for the leading causes of mortality, starting with cardiovascular disease; working with communities to promote wide use of best practices to enable healthy living; and making quality care more affordable for individuals, families, employers, and governments by developing and spreading new health care delivery models. This survey will provide patient experience of care data that enables making comparisons of emergency departments across the nation and promoting effective communication and coordination. The Centers for Medicare & Medicaid Services (CMS) has already implemented patient experience surveys in a number of settings including traditional Medicare, Medicare Advantage, and Part D Prescription Drug Plans, hospitals, and home health agencies. While CMS and/or the Agency for Healthcare Research and Quality (AHRQ) have developed additional Consumer Assessment of Healthcare Providers and Systems (CAHPS?) surveys for in-center hemodialysis facilities, nursing homes and clinician and group practices, none of these surveys address patients' experiences with emergency department services.

---

Authorizing Statute(s): PL: Pub.L. 111 - 148 3013 Name of Law: ACA - Quality Measure Development
  

Citations for New Statutory Requirements: PL: Pub.L. 111 - 148 3013 Name of Law: ACA - Quality Measure Development

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	78 FR 7433	02/01/2013
30-day Notice:	Federal Register Citation:	Citation Date:
	78 FR 21955	04/12/2013
Did the Agency receive public comments on this ICR? Yes

---

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

table that charts list of burden

IC Title	Form No.	Form Name
Emergency Department Patient Experience of Care Survey	CMS-10461, CMS-10461, CMS-10461	ER Patient Experience Survey - Admitted to Hospital Stand Alone Version ,   ER Patient Experience Survey - Discharge Version ,   ER Patient Experience Survey - Admitted to Hospital (HCAHPS Add On) Version

---

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	3,600	0	3,600	0	0	0
Annual Time Burden (Hours)	799	0	799	0	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: This is a new collection.

---

Annual Cost to Federal Government: $1,265,149

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]? Yes

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

---

Common Form ICR:  No

---

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: 05/01/2013

---