Generic Clearance Request

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

T ITLE OF INFORMATION COLLECTION: Clinic Based Telehealth (CBT) Patient Satisfaction Survey (VA Form 10-0481a OMB 2900-0770)

PURPOSE:

The VHA Telehealth Services (TS) within the Veterans Healthcare Administration (VHA) seeks approval from the Office of Management and Budget (OMB) for the Clinical Based Telehealth (CBT) patient satisfaction survey. The questions developed for this survey tool are the product of field staff development working through the TS’ CBT Telehealth Community. The goal is to collect appropriate data regarding current patient perceptions of their satisfaction specifically with the CBT program and technology utilized.

Although telehealth technology has been used throughout the past within the VA, its utility for delivering effective clinical care in an efficient manner is now becoming far better known. Utilization of this program is expected to grow by 100% in the VHA in the next two years. Efforts are under way to formalize the use of telehealth technologies to ensure that care delivery via this modality is safe, effective and of high quality. Thus, the Clinic Based Telehealth (CBT) program remains a relatively new program in many areas of the VHA and provides a unique innovative service to improve veteran’s access to healthcare.

CBT delivers clinical care with the assistance of video conferencing technology (actual “live” video and audio) along with connecting medical measurement peripherals (such as Stethoscope, BP monitor, EKG, pulse oximeter, and many others) to veterans in their own communities such as at local CBOC, outreach clinics and other non-VA locations. Because this program is so distinct in the key elements of clinical care, business practice, and types of technology used, currently approved questions/surveys are not able to capture the true essence of this program. Hence, there is no duplication of information with any other survey.

DESCRIPTION OF RESPONDENTS:

CBT technology is utilized now, more frequently than ever before, as a means to improve healthcare access to rural and remote veterans and has become a mission critical component of care in the VHA. A CBT satisfaction survey is required to capture patients’ perspectives on satisfaction with specific aspects of the program and video conferencing technology used.

This satisfaction survey is a traditional paper and pencil survey using a Scantron tool. The CBT satisfaction survey is administered to veteran patients after completion of a clinical encounter with their provider who has utilized video conferencing to conduct the veteran’s medical or mental health visit. A total of 15 questions utilizing a simple questionnaire with a Lykert scale response format will be utilized and a comments section is at the end of the survey. Out of the 15 total questions there are 3 ICARE Survey Questions. The VA Form 10-0481a survey tool will be delivered to veteran patients who are receiving their clinical care via CBT.

TYPE OF COLLECTION: (Check one)

[ ] Customer Comment Card/Complaint Form [ X] 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: Rhonda Johnston, Director, National Telehealth Training Resource & Quality

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

Personally Identifiable Information:

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

2. If Yes, will any information that is collected be included in records that are subject to the Privacy Act of 1974? [ ] Yes [ X ] 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 [ X ] No

BURDEN HOURS

Category of Respondent	No. of Respondents	Participation Time	Burden
Veteran Individual Responses	10,000	15 minutes	2500
Totals

FEDERAL COST: The estimated annual cost to the Federal government is $26,290.00.

All costs associated with collection of the response data to the survey, calculation of averages and display of the data on a web site is accomplished electronically. There will be a one-time cost to modify the software program for capture of the responses to the new survey questions ($5,000.00).

Programming Scantron for scanning, data capture, calculations and display: GS12 salary $32.25/hour x 40 hours= $1290.00

Mailing costs to package and ship surveys, return mailing and envelopes: $20,000.00

There are no other anticipated annual costs of the Telehealth Survey to the Federal Government.

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? [ x] 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?

The respondent universe is currently 600,000 (rounded) unique veterans that are currently utilizing Clinical Based Telehealth (CBT) programs across the nation at the end of FY 15. The number of veteran encounters using this technology is well over 1,500,000 nationwide. National targets have been set to increase the number of encounters (50% increase in FY 16) using this modality nationwide. The number of unique veterans connecting with their providers using CBT continues to grow daily with the target for CVT encounters set to increase by 100% by 2020. The respondent universe will continue to grow as well.

Each VISN CBT Lead will distribute satisfaction surveys to a convenience sample no greater than 10% of the total number of unique veterans using CBT in the network. The total number of unique veterans using CBT will be determined from the VSSC data cube at the end of the previous FY. The sample amount is equally divided for twice a year distribution in each VISN. The CBT lead will distribute the blank survey tools to the actual point of care sites within the network on a quarterly basis.

The Telehealth Clinical Technician (TCT) or designee located at the point of care sites in the VISN will administer the satisfaction survey to patients following their CBT encounter. The TCT provides the patient with written instructions (with survey instrument) as well as verbally reinforcing reasons for completion. Each patient places their completed survey in an envelope to preserve their anonymity. The envelope is sealed and sent directly to the centralized scanning location at the National Telehealth Training & Resource Center (NTTRC) in Denver, Colorado whereby the completed surveys will then be scanned using Scantron device into a secure database.

This Scantron data collected from the patient satisfaction surveys will be automatically uploaded into an SPSS database for tabulation and analysis for reporting. Individual patient responses are scored utilizing a five - point satisfaction scale. The results are provided to clinical and administrative staff members in a quarterly report developed by Scantron and the NTTRC. The report provides for rate and frequency of results of survey data to be shown at the national, VISN or facility levels for comparison over time and for benchmarking across sites.

The data will be collected by the VHA TS NTTRC. The VISN CBT leads will send the completed satisfaction survey data to the NTTRC for collection and analysis. A Scantron consultant will assist in the design and methodology used for the survey. The analysis will include Descriptive Statistics to match the discrete and continuous data used in the survey. The survey is primarily quantitative data with an expected normal distribution. The hypothesis will be tested to determine if the CVT service is attributed to the satisfaction of the veteran.

Administration of the Instrument

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

[ ] Web-based or other forms of Social Media

[ ] Telephone

[x ] In-person

[ ] Mail

[ ] Other, Explain

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

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

Instructions for completing Request for Approval under the “Generic Clearance for the Collection of Routine Customer Feedback”

TITLE OF INFORMATION COLLECTION: Provide the name of the collection that is the subject of the request. (e.g. Comment card for soliciting feedback on xxxx)

PURPOSE: Provide a brief description of the purpose of this collection and how it will be used. If this is part of a larger study or effort, please include this in your explanation.

DESCRIPTION OF RESPONDENTS: Provide a brief description of the targeted group or groups for this collection of information. These groups must have experience with the program.

TYPE OF COLLECTION: Check one box. If you are requesting approval of other instruments under the generic, you must complete a form for each instrument.

CERTIFICATION: Please read the certification carefully. If you incorrectly certify, the collection will be returned as improperly submitted or it will be disapproved.

Personally Identifiable Information: Provide answers to the questions. Note: Agencies should only collect PII to the extent necessary, and they should only retain PII for the period of time that is necessary to achieve a specific objective.

Gifts or Payments: If you answer yes to the question, please describe the incentive and provide a justification for the amount.

BURDEN HOURS:

Category of Respondents: Identify who you expect the respondents to be in terms of the following categories: (1) Individuals or Households;(2) Private Sector; (3) State, local, or tribal governments; or (4) Federal Government. Only one type of respondent can be selected per row.

No. of Respondents: Provide an estimate of the Number of respondents.

Participation Time: Provide an estimate of the amount of time required for a respondent to participate (e.g. fill out a survey or participate in a focus group)

Burden: Provide the Annual burden hours: Multiply the Number of responses and the participation time and divide by 60.

FEDERAL COST: Provide an estimate of the annual cost to the Federal government.

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. Please provide a description of how you plan to identify your potential group of respondents and how you will select them. If the answer is yes, to the first question, you may provide the sampling plan in an attachment.

Administration of the Instrument: Identify how the information will be collected. More than one box may be checked. Indicate whether there will be interviewers (e.g. for surveys) or facilitators (e.g., for focus groups) used.

Submit all instruments, instructions, and scripts are submitted with the request.

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