Outpatient and Ambulatory Surgery Experience of Care Survey (CMS-10500)

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form CMS-1500 Telephone Interview Script for the Outpatient and Ambulatory Surgery Experience of Care Survey	Form and Instruction	New	Available
Form CMS-10500 Outpatient and Ambulatory Surgery Experience of Care Survey	Form	New	Available
CMS-10500 - Supporting Statement B [5-28-2014].docx	Supporting Statement B	Uploaded 2014-05-28	Available
Crosswalk_Changes_Outpatient and Ambulatory Surgery Experience of Care Survey_post_60-day_notice.docx	Supplementary Document	Uploaded 2013-12-27	Repair queued
60 day notice response to comments new 12-13.docx	Supplementary Document	Uploaded 2013-12-27	Available
CMS-10500 - Supporting Statement A [5-28-2014].docx	Supporting Statement A	Uploaded 2014-05-28	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
209906	Outpatient and Ambulatory Surgery Experience of Care Survey	Form and Instruction	New	Telephone Interview Script for the Outpatient and Ambulatory Surgery Experience of Care Survey
209906	Outpatient and Ambulatory Surgery Experience of Care Survey	Other-Cover Letter	New
209906	Outpatient and Ambulatory Surgery Experience of Care Survey	Form	New	Outpatient and Ambulatory Surgery Experience of Care Survey

ICR Details

OMB Control No: 0938-1240	ICR Reference No: 201312-0938-022
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/CMS	Agency Tracking No: 21242
Title: Outpatient and Ambulatory Surgery Experience of Care Survey (CMS-10500)
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 with change	Conclusion Date: 06/03/2014
Retrieve Notice of Action (NOA)	Date Received in OIRA: 12/31/2013
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	06/30/2017	36 Months From Approved
Responses	2,304	0	0
Time Burden (Hours)	384	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: Outpatient surgeries and procedures performed at Ambulatory Surgery Centers (ASC) have increased significantly in the past two decades with the advances in technology and medical care that allow the procedures to be safely performed outside of the hospital outpatient surgery department (HOSD) setting. There is currently no standardized survey administered by all ASCs and HOSDs to assess patients' experiences of care. Considering the large number of patients who receive outpatient surgery in both ASCs and HOSDs, a standardized survey of outpatient surgery patients that will produce statistically valid survey comparative results is imperative. The Outpatient and Ambulatory Surgery Experience of Care Survey will support the Affordable Care Act and enhance Medicare's capacity to evaluate HOSDs and ASCs by assessing patients' experiences with outpatient and ambulatory surgery. This submission is in support of a field test of the survey. The field test will examine how well questions in the survey perform under real-world survey administration conditions and how appropriate they are for making objective comparisons between ASCs and HOSDs across the U.S. In addition, CMS plans to submit the instrument for certification as a Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey, which requires a field test as part of the certification process. The target population for the Outpatient and Ambulatory Surgery Experience of Care Survey is patients who had an outpatient surgery or procedure at an HOSD or ASC. A rigorous, well-designed outpatient and ambulatory surgery experience of care survey will allow us to understand patients' experiences in HOSDs and ASCs. This information will be used to help improve the quality of outpatient care patients receive from HOSDs and ASCs.

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Authorizing Statute(s): PL: Pub.L. 111 - 148 931 Name of Law: Quality Measure Development, Patient Protection and Affordable Care Act
  

Citations for New Statutory Requirements: PL: Pub.L. 111 - 148 931 Name of Law: Quality Measure Development, Patient Protection and Affordable Care Act

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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 61848	10/04/2013
30-day Notice:	Federal Register Citation:	Citation Date:
	78 FR 78969	12/27/2013
Did the Agency receive public comments on this ICR? Yes

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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
Outpatient and Ambulatory Surgery Experience of Care Survey	CMS-10500, CMS-1500	Outpatient and Ambulatory Surgery Experience of Care Survey ,   Telephone Interview Script for the Outpatient and Ambulatory Surgery Experience of Care 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	2,304	0	2,304	0	0	0
Annual Time Burden (Hours)	384	0	384	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.

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Annual Cost to Federal Government: $873,964

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

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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: 12/31/2013

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