Generic Request_NCL

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

TITLE OF INFORMATION COLLECTION:

Patient Satisfaction Questionnaire
Network Consolidated Laboratory (NCL) Phlebotomy Service

PURPOSE:

As a College of American Pathologists (CAP) accredited clinical laboratory VISN 1 Network Consolidated Laboratories (NCL) are required to monitor key indicators of quality and measure patient or client satisfaction every two years. In our experience, CAP inspectors expect to see evidence of both patient satisfaction and client/physician satisfaction assessments over time. In order to satisfy this expectation VHA would perform a patient satisfaction questionnaire every other year and a client/physician satisfaction questionnaire in the off year.

Other patient satisfaction assessment tools and surveys conducted by the facility do not specifically address the laboratory aspect of a patient’s visit to the facility hence do not fulfill our accreditation requirement. VISN 1 Network Consolidated Laboratories will be administering this questionnaire. All yearly statistics will be aggregated and tracked and trended as a VISN and per location, looking for areas where improvement in services may be needed. The questionnaire will be anonymous and voluntary.

Improvements implemented from questionnaire responses would address the layout of phlebotomy areas in the event where patient mobility is identified as an issue; overall reduction in customer wait time for phlebotomy services; staff awareness and knowledge of patient safety and compliance procedures related to the service they are providing our patients.

DESCRIPTION OF RESPONDENTS:

Potential respondents will be VHA phlebotomy patients in facility areas for which laboratory service has oversight (including Community Based Outpatient Clinics (CBOCs)).

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: Janet Lane, Lab QA Manager
VA Boston Healthcare System (Brockton Campus)
[email protected]

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 [ ] 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 ( × minutes =)	Burden (÷ 60 =)
Individuals	8612	3 minutes	430.6 hours
Totals	8612	25,836 minutes	431 hours

FEDERAL COST: The estimated annual cost to the Federal government is $9453.61__

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 [ x] 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?

Potential respondents will be VA customers in phlebotomy patient facility areas. Data will be collected by having paper forms and pencils available for distribution by the Phlebotomists. Patients will place completed questionnaires in a drop box located within the phlebotomy room. All responses will remain private. Questionnaire responses are compiled into a results report by the NCL Quality Manager and presented to facility PLMS chiefs, managers and supervisors for identification of areas requiring improvement, and may be shared with facility management if requested.

NCL’s decision to use a paper format is based on the following points. Currently NCL facilities do not have additional computer terminals available for use by patients in the laboratory or phlebotomy areas and given the age of our patient population, many are not comfortable using electronic devices. For these reasons it is believed that while improved information technology would decrease VA time and effort it would not decrease the burden on the public.

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? [x ] Yes [ ] 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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