Nationwide Dialysis Program Fast Track Request

Request for Approval under the “Generic Clearance for the Collection of Routine Customer Feedback” (OMB Control Number: 2900-0770)

TITLE OF INFORMATION COLLECTION:

Nationwide Dialysis Contracts Program Veterans Survey

PURPOSE:

The Nationwide Dialysis Contracts (NDC) Program of the Department of Veterans Affairs’ (VA) Chief Business Office Purchased Care (CBOPC) will use the information gathered as a result of this survey to focus specifically on the care, provisions and processes of the NDC Program in order to identify problems or complaints that require attention and to improve the satisfaction and quality of purchased care dialysis services received by Veterans through this program.

The resulting data will be used to demonstrate that the NDC Program is providing timely, high-quality dialysis services to Veteran patients and to measure improvement toward the goal of meeting or exceeding internal benchmark performance.

DESCRIPTION OF RESPONDENTS:

The pool of respondents will consist of an annual sampling of approximately 75 percent of Veterans who have received dialysis services through the NDC program within the year leading up to the annual data extraction.

TYPE OF COLLECTION: (Check one)

[ ] Customer Comment Card/Complaint Form [] 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: Douglas Katason, Stakeholder Relations Manager

To assist review, please provide answers to the following question:

Personally Identifiable Information:

1. Is personally identifiable information (PII) collected? [ ] Yes [] 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 [] No

BURDEN HOURS

Category of Respondent: Individuals & Households	No. of Respondents	Participation Time	Burden
VA Form 10-XXXXXX (NDC Survey)	2,000	5 minutes	167
Totals			167

FEDERAL COST: The estimated annual cost to the Federal government is $14,725.00. (Cost includes burden hours plus supplies/printing/mailing/processing of survey)

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? [ ] 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?

Inclusion criteria:

Sampling will be from all Veterans who received dialysis services through the NDC Program during the year leading up to the annual data extraction.

Sample size:

The sample size will be a minimum of 75 percent of those Veterans who received dialysis services through the NDC Program. It is anticipated that approximately 10,000 surveys will be sent out each year with an estimated response rate of 20 percent. The patient names, addresses, services received, dates of service, and scrambled social security numbers will be extracted from internal VA databases in accordance with existing approved standards ensuring privacy and security of the data.

Administration of the Instrument

1. How will you collect the information? (Check all that apply)

[ ] Web-based or other forms of Social Media

[ ] Telephone

[ ] In-person

[ ] Mail

[ ] Other, Explain

2. Will interviewers or facilitators be used? [ ] Yes [] No

A survey invitation letter will be sent to the sampling of Veterans who receive dialysis services through the NDC Program. The invitation letter will contain a web link to the survey instrument which resides in the internet-based survey tool, Survey Monkey. A phone number will also be provided in the letter for the Veteran to request a paper copy of the survey instrument, in lieu of using the internet-based survey tool.

A survey reminder letter will also be sent to the same sampling of Veterans approximately two weeks after the invitation was sent to either remind the Veteran to take the survey or thank them for taking the survey.

Please make sure that all instruments, instructions, and scripts are submitted with the request.

Survey Invitation/Instructions:

NAME

ADDRESS 1

ADDRESS 2

CITY, STATE, ZIP

UID 1234567

Dear Veteran,

The Department of Veterans Affairs (VA) is committed to providing the highest level of patient care services for Veterans. As a patient receiving dialysis services through the Nationwide Dialysis Contracts Program, we request that you complete an online patient satisfaction Survey regarding the dialysis services you currently receive from your non-VA community provider. Your participation will help improve the quality of dialysis services received by you and many other Veterans through the Nationwide Dialysis Contracts Program.

The Survey should take about 5 minutes to complete and we ask that you complete it within a week of receipt, so that we may begin to take action on the results. We value your honest and forthright feedback. Please note the Survey is voluntary and completely anonymous.

To access the Survey, please enter the following address into your web browser exactly as it appears:

https://www.research.net/s/VANDC15

Important – Once you access the online Survey, you will be asked to enter the Unique Identifier code (UID) listed above under your name, which is used to let us know you completed the Survey.

If you do not have access to the internet, please call 1-877-466-7124 toll-free to request that a paper copy of this Survey be mailed to you.

If you have a specific question or need help with your VA care, you may contact VA:

1. By telephone:

   1. VA Benefits: 1 (800) 827-1000

   2. VA Health Care Benefits: 1 (877) 222-8387

   3. Telecommunications Device for the Deaf (TDD): 1 (800) 829-4833

2. At your local VA Medical Center or through the Patient Advocate

3. Online: http://www.nonvacare.va.gov

Thank you for your service and for your time and interest in helping us to serve you better.

Sincerely,

Douglas Katason

Stakeholder Relations Manager

Survey Reminder Letter:

NAME

ADDRESS 1

ADDRESS 2

CITY, STATE, ZIP

UID 1234567

Dear Veteran,

You should have received an invitation to participate in an online satisfaction survey regarding the dialysis services you currently receive from your non-VA community provider. Thank you so much for taking the time to complete the survey. Your feedback is critical and your participation will help improve the quality of dialysis services received by you and many other Veterans through the Nationwide Dialysis Contracts Program.

If you haven’t yet completed the survey, please do! The survey will take about 5 minutes to complete and is available until [DATE].  Please note the survey is voluntary and completely anonymous.

To access the survey, please enter the following address into your web browser exactly as it appears:

https://www.research.net/s/VANDC15

Important – Once you access the online survey, please enter the Unique Identifier (UID) listed above under your name. This number will help us track our response rate.

If you do not have access to the internet, please call 1-877-466-7124 toll-free to request that a paper copy of the survey be mailed to you.

Thank you for your service and for your time and interest in helping us to serve you better.

Sincerely,

Doug Katason

Stakeholder Relations Manager

Survey Instrument:

Thank you for your willingness to help us improve our dialysis services.

The survey uses the following phrases as defined:

• “VA” refers to the Department of Veterans Affairs and care provided in a VA facility.

• “Non-VA Provider” refers to a non-VA community dialysis provider and care provided in the home or at a non-VA facility.

#	Question
1	Please enter the Unique Identification Code that was provided on your survey invitation letter. (This number is 7-9 characters long) (Text box)
2	What is your level of satisfaction with how clearly VA staff explained the transfer of your dialysis treatments from VA to a non-VA provider? 􀂆 Highly Satisfied 􀂆 Satisfied 􀂆 Neither Satisfied nor Dissatisfied 􀂆 Dissatisfied 􀂆 Highly Dissatisfied
3	How satisfied are you with the transition experience from VA to your non-VA provider? 􀂆 Highly Satisfied 􀂆 Satisfied 􀂆 Neither Satisfied nor Dissatisfied 􀂆 Dissatisfied 􀂆 Highly Dissatisfied
4	After your initial appointment scheduled by VA, how satisfied are you with the scheduling process followed by your non-VA provider? 􀂆 Highly Satisfied 􀂆 Satisfied 􀂆 Neither Satisfied nor Dissatisfied 􀂆 Dissatisfied 􀂆 Highly Dissatisfied
5	Where do you receive your dialysis treatments? 􀂆 Home 􀂆 Non-VA provider facility Q11
6	How satisfied are you with the training that was provided to receive your dialysis treatments at home? 􀂆 Highly Satisfied 􀂆 Satisfied 􀂆 Neither Satisfied nor Dissatisfied 􀂆 Dissatisfied 􀂆 Highly Dissatisfied
7	Did your in-home provider give you the tools, knowledge and equipment to effectively manage your dialysis treatments? 􀂆 Yes 􀂆 No
8	Did your in-home provider answer any questions you may have had in a satisfactory manner? 􀂆 Yes 􀂆 No
9	Did your in-home provider give you appropriate points of contact in case you had follow-up questions or concerns? 􀂆 Yes 􀂆 No
10	Is there anything you would like to share regarding your in-home dialysis treatments? 􀂆 No Q17 􀂆 Yes Q17 (Text Box)
11	How far do you have to travel from home to your non-VA provider facility? 􀂆 less than 10 miles 􀂆 10 to 20 miles 􀂆 21 to 30 miles 􀂆 more than 30 miles
12	How satisfied are you with the convenience of your non-VA provider facility location? 􀂆 Highly Satisfied 􀂆 Satisfied 􀂆 Neither Satisfied nor Dissatisfied 􀂆 Dissatisfied 􀂆 Highly Dissatisfied
13	How satisfied are you with the quality of care provided by the clinical staff at your non-VA provider facility? 􀂆 Highly Satisfied 􀂆 Satisfied 􀂆 Neither Satisfied nor Dissatisfied 􀂆 Dissatisfied 􀂆 Highly Dissatisfied
14	On average, how long do you have to wait for your dialysis treatments after your appointment time at the non-VA provider facility? 􀂆 less than 15 minutes 􀂆 15 to 30 minutes 􀂆 31 minutes to 1 hour 􀂆 more than 1 hour
15	Do the clinical staff at the non-VA provider facility show concern for your well-being during your dialysis treatment? 􀂆 Yes 􀂆 No ( Text Box)
16	Is the physical environment at the non-VA provider facility comfortable during your dialysis treatment? 􀂆 Yes 􀂆 No ( Text Box)
17	Have you ever received a bill from your non-VA provider? 􀂆 Yes 􀂆 No
18	Did you receive a copy of the Patients’ Rights and Responsibilities from your non-VA provider? 􀂆 Yes 􀂆 No
19	Do you know how to inform VA should you have a concern regarding your non-VA provider? 􀂆 Yes 􀂆 No
20	Overall, how satisfied are you with your dialysis treatment experience? 􀂆 Highly Satisfied 􀂆 Satisfied 􀂆 Neither Satisfied nor Dissatisfied 􀂆 Dissatisfied 􀂆 Highly Dissatisfied
21	Is there anything that you would like to share about your dialysis care? 􀂆 No 􀂆 Yes (Text Box)

JUSTIFICATION TEMPLATE

TITLE
OMB FORM 2900-0770

A. JUSTIFICATION

1. Explain the circumstances that make the collection of information necessary. Identify legal or administrative requirements that necessitate the collection of information.

Legal authority for this data collection is found under 38 USC, Part I, Chapter 5, Section 527 which authorizes the collection of data that will allow measurement and evaluation of the Department of Veterans Affairs (VA) Programs, the goal of which is improved health care for veterans.

2. Indicate how, by whom, and for what purposes the information is to be used; indicate actual use the agency has made of the information received from current collection.

The Nationwide Dialysis Contracts (NDC) Program of VA’s Chief Business Office Purchased Care (CBOPC) will use the information gathered as a result of this survey to systematically obtain information from Veteran dialysis patients that can be used to identify problems or complaints that need attention and to improve the quality and efficiencies of VA processes and communications related to purchased care dialysis services delivered to Veterans. This is a new survey, and as such, no current collection exists.

3. Describe whether, and to what extent, the collection of information involves the use of automated, electronic, mechanical, or other technological collection techniques or other forms of information technology, e.g. permitting electronic submission of responses, and the basis for the decision for adopting this means of collection. Also describe any consideration of using information technology to reduce burden.

Collection of the information will involve the use of an internet-based website to automate collection of the survey information, which will improve ease of use, efficiency and data accuracy, while effectively reducing the burden on both VA and the Veteran.

The Veteran will receive a NDC Program survey invitation letter in the mail, requesting the Veteran to access the survey simply by navigating to the secure internet-based website to answer the survey questions. Once the Veteran accesses the website and completes the survey, no recordkeeping, document management activities or additional action by the Veteran is necessary.

All respondent actions will be voluntary and no adverse action will be taken should the Veteran choose not to participate.

4. Describe efforts to identify duplication. Show specifically why any similar information already available cannot be used or modified for use for the purposes described in Item 2 above.

All efforts have been made to avoid duplication of effort and/or data. As this is a new survey, no existing information is available.

Duplication of effort by the Veteran will be mitigated by restricting the pool to only those who have received care under the NDC Program. Additionally, questions will be limited to subject matter specific to the Veteran’s dialysis care experience.

5. If the collection of information impacts small businesses or other small entities, describe any methods used to minimize burden.

The survey is targeted specifically for the assessment of Veterans’ care; no small businesses or other small entities will be impacted by the information collection.

6. Describe the consequences to Federal program or policy activities if the collection is not conducted or is conducted less frequently as well as any technical or legal obstacles to reducing burden.

If this survey is not conducted, it would inhibit VA’s ability to be responsive to the needs of Veterans receiving dialysis services through the NDC Program.

7. Explain any special circumstances that would cause an information collection to be conducted more often than quarterly or require respondents to prepare written responses to a collection of information in fewer than 30 days after receipt of it; submit more than an original and two copies of any document; retain records, other than health, medical, government contract, grant-in-aid, or tax records for more than three years; in connection with a statistical survey that is not designed to produce valid and reliable results that can be generalized to the universe of study and require the use of a statistical data classification that has not been reviewed and approved by OMB.

There are no special circumstances.

8. (a.) If applicable, provide a copy and identify the date and page number of publication in the Federal Register of the sponsor’s notice, required by 5 CFR 1320.8(d), soliciting comments on the information collection prior to submission to OMB. Summarize public comments received in response to that notice and describe actions taken by the sponsor in responses to these comments. Specifically address comments received on cost and hour burden.

The Federal Register Notice with a 60-day comment period soliciting comments on this collection of information was published on March 27, 2014, at pages 7285-7286. No comments were received in response to this notice.

b. Describe efforts to consult with persons outside the agency to obtain their views on the availability of data, frequency of collection, clarity of instructions and recordkeeping, disclosure or reporting format, and on the data elements to be recorded, disclosed or reported. Explain any circumstances which preclude consultation every three years with representatives of those from whom information is to be obtained.

Outside consultation is conducted with the public through the 60-day and 30-day Federal Register notices.

9. Explain any decision to provide any payment or gift to respondents, other than remuneration of contractors or grantees.

No payment or gift will be provided to respondents.

10. Describe any assurance of privacy, to the extent permitted by law, provided to respondents and the basis for the assurance in statute, regulation, or agency policy.

A record indicating delivery of the NDC Program survey invitation and/or participation may occur in the following area. All participants are assured of privacy, to the extent permitted by law, by the following provision:

Information on these forms may become part of a system of records which complies with the Privacy Act of 1974. This system is identified as "Veteran, Patient, Employee and Volunteer Research and Development Project Records-VA (34VA11)" as set forth in the Compilation of Privacy Act Issuances via online GPO access at http://www.gpoaccess.gov/privacyact/index.html

11. Provide additional justification for any questions of a sensitive nature (Information that, with a reasonable degree of medical certainty, is likely to have a serious adverse effect on an individual's mental or physical health if revealed to him or her), such as sexual behavior and attitudes, religious beliefs, and other matters that are commonly considered private; include specific uses to be made of the information, the explanation to be given to persons from whom the information is requested, and any steps to be taken to obtain their consent.

There are no questions of a sensitive nature.

12. Estimate of the hour burden of the collection of information:

1. The number of respondents, frequency of responses, annual hour burden, and explanation for each form is reported as follows:

VA Form: 10-XXXX	No. of respondents	x No. of responses	x No. of minutes	÷ by 60 =	Number of Hours
NDC Program Veterans Survey	2,000	1	5 minutes		167

b. If this request for approval covers more than one form, provide separate hour burden estimates for each form and aggregate the hour burdens in Item 13 of OMB 83-I.

This request covers only one form.

c. Provide estimates of annual cost to respondents for the hour burdens for collections of information. The cost of contracting out or paying outside parties for information collection activities should not be included here. Instead, this cost should be included in Item 14.

VA does not require any additional recordkeeping. The estimated cost to the respondents for completing this form is $4,008 ($24 per hour x 167 burden hours (Bureau of Labor and Statistics)).

13. Provide an estimate of the total annual cost burden to respondents or record keepers resulting from the collection of information. (Do not include the cost of any hour burden shown in Items 12 and 14).

a. There is no capital, start-up, operation or maintenance costs.

b. Cost estimates are not expected to vary widely. The only cost will be for the time of the respondent.

c. There is no anticipated recordkeeping burden.

14. Provide estimates of annual cost to the Federal Government. Also, provide a description of the method used to estimate cost, which should include quantification of hours, operation expenses (such as equipment, overhead, printing, and support staff), and any other expense that would not have been incurred without this collection of information. Agencies also may aggregate cost estimates from Items 12, 13, and 14 in a single table.

It is anticipated that the total cost to the federal government will be $10,717.00 for the supplies and activities related to the mailing and processing of the survey invitation letters, reminders and envelopes. This cost is based upon the fact that all required software to administer the survey has been created and paid for. Furthermore automated collection and analysis of the data is being utilized.

$3200.00 Estimated printing/imprinting/mailing cost (10,000 x 16 cents per invitation) plus (10,000 x 16 cents per reminder)

$5167.00 Estimated cost for processing (2,000 responses x 5 minutes per

Response x $31.00 per hour (average salary for reviewers))

$2350.00 Estimated costs for letters and envelopes (20,500 x 6.5 cents per letter) plus

(20,500 x 4.8 cents per envelope) (Includes over-run and invitation/reminder)

$10,717.00 Total cost to the Government

15. Explain the reason for any burden hour changes or adjustments reported in items 13 or 14 of the OMB form 83-1.

This is a new collection and all burden hours are considered a program increase.

16. For collections of information whose results will be published, outline plans for tabulation and publication. Address any complex analytical techniques that will be used. Provide the time schedule for the entire project, including beginning and ending dates of the collection of information, completion of report, publication dates, and other actions.

VA does not intend to publish this data.

17. If seeking approval to omit the expiration date for OMB approval of the information collection, explain the reasons that display would be inappropriate.

N/A

18. Explain each exception to the certification statement identified in Item 19, “Certification for Paperwork Reduction Act Submissions,” of OMB 83-I.

There are no exceptions.

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