Generic Request - VCP

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

TITLE OF INFORMATION COLLECTION:

Veterans Choice Program Provider Satisfaction Survey

PURPOSE:

The Veterans Health Administration Office of Community Care (VHA OCC) will use the information gathered as a result of this survey to focus specifically on the satisfaction of community providers who deliver health care services to Veterans through the Department of Veterans Affairs (VA) Veterans Choice Program (VCP) in order to identify problems or complaints that require attention and to improve the satisfaction and quality of services delivered to community providers through this program.

The resulting data will be used to demonstrate that VA Medical Center staff and contracted health care networks, Health Net and TriWest staff are providing timely, high-quality services to community providers through VCP and to measure improvement in the efficiencies of VCP processes and communications toward the goal of meeting or exceeding internal benchmark performance.

DESCRIPTION OF RESPONDENTS:

The pool of respondents will consist of an annual sampling of 10,000 community providers who have provided care to Veterans through VCP within the 3 months 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: Roxanne Hoffner, Stakeholder Relations

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 (Veterans Choice Program Provider Satisfaction Survey)	2,000	10 minutes	333
Total			333

FEDERAL COST: The estimated annual cost to the Federal government is $20,619.00.

Cost includes burden hours ($8,016.00) plus supplies, printing, mailing and processing of the survey ($12,603.00).

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 community providers who provided care to Veterans through VCP during the 3 months leading up to the annual data extraction.

Sample size:

The sample size will be a maximum of 10,000 community providers who provided health care services to Veterans through VCP. It is anticipated that there will be an estimated response rate of 20 percent. The provider names, addresses and services offered will be provided by Health Net and TriWest health care networks 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 community providers who provide health care services to Veterans through VCP. The invitation letter will contain a Web link to the VA Community Care Web-site in order to access the survey instrument which resides in the Web-based survey tool, Survey Monkey. A phone number will also be provided in the letter for the provider to request a paper copy of the survey instrument, in lieu of using the Web-based option.

A survey reminder letter will also be sent to the same sampling of providers approximately two weeks after the invitation was sent to either remind the provider 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.

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