Hand Hygiene Patient Survey Generic Clearance Statement

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

T ITLE OF INFORMATION COLLECTION: Patient Centered Hand Hygiene Survey

PURPOSE: To collect voluntary and anonymous observations from patients of staff and Provider hand hygiene. Currently, we know of no approved patient hand hygiene surveys/questionnaires. This form will not contain any patient identifiers. Its primary purpose is to collect information regarding staff and Provider hand hygiene from the patient’s perspective.

Traditional secret shopper and Infection Control Practitioner monitoring of staff and Providers have a number of challenges: Low number of observations hinder any conclusions as to whether or not staff are compliant with hand hygiene; Staff and Providers are known to react differently when they know they are being observed by the Infection Control team, “the Hawthorne Effect”; It is not possible to get accurate data of what occurs when a Provider or staff member is in a room where secret shoppers cannot see into the room. Most clinics and medical-surgical units are built in such a manner.

This survey form helps to put the patient at the center of their care. This simple survey serves a few purposes: It allows Infection Control Departments the opportunity to get patients’ feedback of how staff and Providers are adhering to the hand hygiene policy; It increases the number of responses from areas that traditionally have been challenging to get accurate data from; It also serves as an opportunity for conversations between staff, Providers, and patients around hand hygiene. Because current methods exclude active patient involvement, patient education has often been a missing component. This helps address those issues.

Patient centered hand hygiene has been a Joint Commission “Best Practice” for monitoring hand hygiene since at least 2009. Please see attached Joint Commission monograph “Measuring Hand Hygiene Adherence: Overcoming the Challenges”. In that monograph, the Army was recognized as having developed and implemented this best practice. See page 27. We have spoken to Mr. Yamada at Tripler Army Medical Center, who has sent us their currently approved Army Hand Hygiene form. Please see attached. Because the Army’s form is very simple to reproduce, easy to understand by patients, quick to fill out, and may already be familiar to veterans, our intention is to use the same form. We are including the Army’s form “Semmelweis0708”, How Tripler Army Medical Center administers their program “Ignaz Philipp Semmelweis v7.”

DESCRIPTION OF RESPONDENTS: Respondents are patients of the medical center. It is our intention to give the survey out to patients who have either appointments in our clinics or are inpatients in our medical-surgical, telemetry, intensive care, community living center units. Our goal is to pick a couple clinics and units each month, hand out the survey to those interested, educate those patients as needed, then collect the forms after the appointment is done. For inpatients, we would return after a period of a few hours has elapsed to give an opportunity for patients to witness staff and Providers to visit. Patients will generally be selected at random from these areas, but in some circumstances, such as inpatient dementia and mental health, we may need to confer with unit managers and staff.

TYPE OF COLLECTION: (Check one)

[X] 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, Position Title and Credentials: Michael Raczynski RN MSN CIC, Infection Preventionist

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
Individual Patients (Clinic and inpatient).	120 monthly= 1440 yearly	2 minutes	48 hours yearly burden
Totals

FEDERAL COST: The estimated annual cost to the Federal government is $400.00 for printing and Infection Control teams administrative time_

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?

We plan on creating a list of all medical center clinics, e.g. Primary care, dental, orthopedic, and also its inpatient units, e.g. medical-surgical ICU, CLC, etc. From that list, we will pick two clinic and two inpatient areas a month to administer the instrument in.

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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