Pretest of the Ambulatory Surgery/Procedure Survey on Patient Safety Culture

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form Form # 3 POC Administration of the survey	Form and Instruction	New	Available
Form Form # 2 Pretest for the Ambulatory Surgery SOPS	Form and Instruction	New	Available
Form Form # 1 Cognitive interviews	Form and Instruction	New	Available
Supporting Statement Part B -- Pretest of the Ambulatory Surgery Center SOPS.docx	Supporting Statement B	Uploaded 2013-09-27	Available
Attachment F - List of Expert Reviewers and Consultants.docx	Supplementary Document	Uploaded 2013-09-27	Available
Attachment E - Federal Register Notice.pdf	Supplementary Document	Uploaded 2013-09-27	Available
Attachment D - Pretest Cover Letter and Reminder Notice for Survey.docx	Supplementary Document	Uploaded 2013-09-27	Available
Supporting Statement Part A -- Pretest of the Ambulatory Surgery Center SOPS.docx	Supporting Statement A	Uploaded 2013-09-27	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
208864	POC Administration of the survey	Form and Instruction	New
208863	Pretest for the Ambulatory Surgery SOPS	Form and Instruction	New
208862	Cognitive interviews	Form and Instruction	New

ICR Details

OMB Control No: 0935-0216	ICR Reference No: 201309-0935-001
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/AHRQ	Agency Tracking No: 20638
Title: Pretest of the Ambulatory Surgery/Procedure Survey on Patient Safety Culture
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: 10/31/2013
	Date Received in OIRA: 09/30/2013
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	07/31/2015	18 Months From Approved
Responses	584	0	0
Time Burden (Hours)	395	0	0
Cost Burden (Dollars)	0	0	0

---

Abstract: Given the widespread impact of ASCs on patient safety, the new Ambulatory Surgery/Procedure Survey on Patient Safety Culture (Ambulatory Surgery SOPS) will measure ASC staff perceptions about what is important in their organization and what attitudes and behaviors related to patient safety culture are supported, rewarded, and expected. The survey will help ASCs to identify and discuss strengths and weaknesses of patient safety culture within their individual facilities. They can then use that knowledge to develop appropriate action plans to improve their practices and their culture of patient safety. This survey is designed for use in ASCs that practice all types of surgical procedures including those that require incisions and less invasive or non-surgical procedures such as gastrointestinal procedures or pain management injections.

---

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

Citations for New Statutory Requirements: None

---

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 40740	07/08/2013
30-day Notice:	Federal Register Citation:	Citation Date:
	78 FR 59034	09/25/2013
Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 3

table that charts list of burden

IC Title	Form No.	Form Name
Cognitive interviews	Form # 1	Cognitive Interview Guide
Pretest for the Ambulatory Surgery SOPS	Form # 2	Ambulatory Surgery SOPS
POC Administration of the survey	Form # 3	Site-level POC Instructions for Survey

---

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	584	0	0	584	0	0
Annual Time Burden (Hours)	395	0	0	395	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.

---

Annual Cost to Federal Government: $431,000

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

---

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: 09/30/2013

---