2900-0712 justification A 28AUG2017

NATION-WIDE CUSTOMER SATISFACTION

SURVEY OF HEALTHCARE EXPERIENCES OF PATIENTS (SHEP)

OMB 2900-0712

SHEP Inpatient Long Form: 10-1465-1

SHEP Inpatient Short Form: 10-1465-2
Ambulatory Care Long Form: 10-1465-3

Ambulatory Care Short Form: 10-1465-4
Clinician and Group CAHPS 3.0 Patient Centered Medical Home Short Form: 10-1465-5

Clinician and Group CAHPS 3.0 Patient Centered Medical Home Long Form: 10-1465-6
Home Healthcare CAHPS Long Form: 10-1465-7

In-Center Hemodialysis CAHPS Long Form: 10-1465-8

Clinician & Group CAHPS 3.0: 10-1465-9

SHEP Community Care survey: 10-1465-10

A. JUSTIFICATION

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

The Survey of Health Experience of Patients (SHEP) has been developed to measure patient satisfaction in the Veterans Health Administration, and has been in use in its present form since 2008. The mission of the Veterans Health Administration (VHA) is to provide high quality medical care to eligible veterans. Executive Order 12862, dated September 11, 1993, calls for the establishment and implementation of customer service standards, and for agencies to “survey customers to determine the kind and quality of services they want and their level of satisfaction with current services”. Further emphasized by the Executive Order 13571, on "Streamlining Service Delivery and Improving Customer Service," issued on April 27, 2011, VA must work continuously to ensure that their programs are effective and meet their customers' needs. To this end, VA is always seeking new and innovative ways to ensure the highest levels of customer satisfaction.

In 2014, Congress passed the Veterans Access, Choice, and Accountability Act (Public Law 113-146) (“Choice Act”), as amended by the Department of Veterans Affairs Expiring Authorities Act of 2014 (Public Law 113-175), was a bipartisan response to the health care access issues facing The Department of Veterans Affairs. The Choice Act states that VA shall provide “Survey data of patient experiences, including the HCAHPS” (section 206(c)(2)(C) “Improved Transparency Concerning Health Care Provided By Department Of Veterans Affairs”). VA is now required to report and make publicly available patient experience results through the Centers for Medicare and Medicaid Services (CMS) Hospital Compare website and other publically facing web portals.

Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) is approved by the Office of Management and Budget (OMB) for use by the Center for Medicare and Medicaid Services (CMS), a U.S. government agency, for use in measuring patient satisfaction among patients of hospitals that accept Medicare reimbursement. The OMB Control number for this use is 0938-0981. The HCAHPS and a combination of the Consumer Assessment of Healthcare Providers and Systems (CAHPS) Health Plan and CAHPS Clinician and Group surveys were approved for use in SHEP.

The CAHPS Health Plan survey (OMB Control No.: 0935-0165), and the CAHPS Clinician and Group (OMB Control No.: 0935-0197) surveys have been approved by OMB for use by government agencies. Both of these ambulatory care surveys have undergone extensive testing and validation in a variety of populations. Their psychometric properties are well documented.

SHEP Inpatient Long Form: 10-1465-1

This form is not currently in the field, but may be required by VHA leadership in the future. It will consist of 80 questions with a burden of 20 minutes. This form is no longer being fielded, but may be required to be re-implemented by VHA leadership at some point in the future. This form will be comprised of:

1. Satisfaction - HCAHPS

2. Patient perceptions of safety and satisfaction with Environment of Care in hospital settings

3. Patient Complaints

4. Functional outcomes (SF-12 (Veteran modification))

5. Healthy behaviors (Healthcare Effectiveness Data and Information Set (HEDIS) Smoking measures and Audit C)

6. Satisfaction with influenza vaccination (October through March)

7. Trust in VA

SHEP Inpatient Short Form: 10-1465-2

This form will be administered via mail only as per the HCAHPS survey administration and data collection protocol. This form is comprised of 53 questions. The short form inpatient SHEP will be comprised of three groups of questions with a total burden of 15 minutes:

1. Satisfaction - HCAHPS

2. Patient perceptions of safety and satisfaction with Environment of Care in hospital settings

3. Patient Complaints

4. Trust in VA

Ambulatory Care Long Form: 10-1465-3

This form is not currently in the field, but may be required by VHA leadership in the future. It will be mailed to 5% of the outpatient sample, and will consist of 70 questions with a burden of 25 minutes. The long form will contain:

1. Satisfaction - Health Plan 4.0 and Clinician and Group Surveys

2. Patient perceptions of safety and satisfaction with Environment of Care in clinic settings

3. Patient Complaints

4. Functional outcomes (SF-12 (Veteran modification))

5. Healthy behaviors (Healthcare Effectiveness Data and Information Set (HEDIS) Smoking measures and Audit C)

6. Satisfaction with influenza vaccination (October through March)

7. Trust in VA

Ambulatory Care Short Form: 10-1465-4

This form is not currently in the field, but may be required by VHA leadership in the future. It will consist of 45 questions with a burden of 15 minutes. This form is no longer being fielded, but may be required to be re-implemented by VHA leadership at some point in the future. This form will be comprised of:

1. Satisfaction – Questions from CAHPS Health Plan 4.0 and Clinician and Group Surveys

2. Patient perceptions of safety and satisfaction with Environment of Care in clinic settings

3. Patient Complaints

4. Trust in VA

Clinician and Group CAHPS 3.0 Patient Centered Medical Home Short Form: 10-1465-5

This form will be administered in both mail and on-line formats, and will consist of 54 questions with a burden of 10 minutes. The short form will contain:

1. Patient Experiences - Clinician & Group Survey Patient Centered Medical Home survey

• How well providers communicate with patients (6 items)

• Helpful, courteous, and respectful office staff (2 items)

• Patients’ rating of the provider (1 item)

• Providers pay attention to your mental or emotional health (3 items)

• Providers support you in taking care of your own health (2 items)

• Providers discuss medication decisions (3 items)

2. Trust in VA

Clinician and Group CAHPS 3.0 Patient Centered Medical Home Long Form: 10-1465-6

This form will be administered by mail only, and consists of 85 questions with a burden of 20 minutes. The long form will contain:

1. Patient Experiences - Clinician & Group Survey Patient Centered Medical Home survey

• How well providers communicate with patients (6 items)

• Helpful, courteous, and respectful office staff (2 items)

• Patients’ rating of the provider (1 item)

• Providers pay attention to your mental or emotional health (3 items)

• Providers support you in taking care of your own health (2 items)

• Providers discuss medication decisions (3 items)

1. Functional outcomes (SF-12 (Veteran modification))

2. Healthy behaviors (Healthcare Effectiveness Data and Information Set (HEDIS) Smoking measures and Audit C)

3. Satisfaction with influenza vaccination (October through March)

4. Trust in VA

Home Healthcare CAHPS Long Form: 10-1465-7

This form is not currently in the field, but may be required by VHA leadership in the future. It will consist of 43 questions with a burden of 10 minutes. The long form will contain:

1. Patient Experiences - Home Healthcare CAHPS survey

• Care of Patients (4 items)

• Communications Between Providers and Patients (2 items)

• Providing Information to Patients (9 items)

• Supplemental questions (9 items)

2. Trust in VA
   
   

Home Healthcare CAHPS website

In-Center Hemodialysis CAHPS Long Form: 10-1465-8

This form is not currently in the field, but may be required by VHA leadership in the future. It will consist of 75 questions with a burden of 15 minutes. The long form will contain:

1. Patient Experiences - the In-Center Hemodialysis survey CAHPS survey

• Nephrologists’ Communication and Caring (6 items)

• Quality of Dialysis Center Care and Operations (17 items)

• Specific Care Issues (7 items)

• Global Ratings (3 items)

• Supplemental questions (15 items)

2. Trust in VA

In-Center Hemodialysis CAHPS website

Each of these key elements of care will be collected concurrently on a monthly basis in separate surveys of the various key patient populations, i.e., inpatients (recently discharged), outpatients who have had a recent clinic visit (ambulatory care), patients who recently received home healthcare, and patients recently receiving in-center hemodialysis. Each sample size will be sufficient to allow for valid statistical results at the national, network and facility levels. Sample sizes for the non-satisfaction questions on the long forms have been calculated to provide valid estimates at the network or national level only. Data for each survey will be analyzed and posted on the Office of Analytics and Business Intelligence (OABI) Web Site for field use (monthly for outpatients and inpatients), or posted as special reports. The intent is to develop relational data that will allow us to conduct powerful, selected, cohort analyses. De-identified, unadjusted survey results will be posted in the contractor’s web page for rapid access by local VA facilities.

Clinician & Group CAHPS 3.0: 10-1465-9

This form will be administered in both mail and on-line formats. It consists of 33 questions with a burden of 10 minutes. The form contains:

1. Patient Experiences - Clinician & Group Survey

• Getting Timely Appointments, Care, and Information (3 items)

• How well providers communicate with patients (4 items)

• Helpful, courteous, and respectful office staff (2 items)

• Patients’ rating of the provider (1 item)

• Care Coordination (3 items)

• Providers discuss medication decisions (3 items)

2. Trust in VA

SHEP Community Care survey: 10-1465-10

This form will be administered in both mail and on-line formats. A maximum sample of 40,000 Veterans per month will be selected from a 3-month rolling sampling frame.  It consist of 47 questions with a burden of 11 minutes.  The survey will cover the following topics related to Veterans’ satisfaction with their CC experience:

1. Your VA Community Care utilization (2 items)

• Questions regarding confirmation of receipt of type of CC care specified, and report of how long ago care began

2. Your Eligibility for VA Community Care (2 items)

• Questions regarding clarity of requirements and helpfulness of information available

3. Your referral and getting your first appointment (7 items)

• Questions regarding clarity of appointment scheduling process, responsibility for process steps, input into selecting a CC provider and selecting time/day of first appointment, timeliness of first appointment, ease of getting first appointment

4. Recent (last 3 months) appointments for CC (4 items)

• Questions regarding the number of CC service encounters, timeliness of appointments, convenience of appointment time and location

5. Your Experience with VA Community Care (17 items)

• Questions regarding wait time, information and patient education provided, interpersonal warmth and patient-centeredness of provider, coordination of patient care by the CC provider and between VA and the CC provider, provision of test results to patients, access to CC provider’s office during and after regular business hours, overall evaluation of CC provider

6. Billing for Community Care (4 items)

• Questions regarding expectations regarding out-of-pocket expenses, clarity of the billing process, smoothness of billing process operation

7. Overall experience with VA CC (1 item)

8. Overall experience with the Department of Veterans Affairs (4 items)

• Questions about whether respondent obtained the service needed, ease of obtaining that service, feeling like a valued customer, and trust in VA

9. About Your (6 items)

• Questions about general physical and mental health, health insurance coverage, education, ethnicity and race.

10. Trust in VA

The Choice Act was not the first mechanism whereby Veterans could be authorized to receive community care paid for by VA, but its passage brought renewed attention to the issue of the satisfaction of Veterans with their community care experience. To address this gap in knowledge and assess the satisfaction of the growing cohort of Veterans receiving VA-authorized care outside of the VA system, thus satisfying The Choice Act, the VHA has developed a new survey focused on community care. As with other surveys in the SHEP family of surveys that assess patient experiences and satisfaction with inpatient and outpatient care received within the VA system, the VA Community Care survey was based largely on the Consumer Assessment of Healthcare Providers and Systems (CAHPS) surveys developed by the Agency for Healthcare Research and Quality (AHRQ).

The CC survey will be administered monthly using both paper (mail) and on-line (web) modes of administration. A rolling three-month sampling strategy will be employed using a community care payment claims database. All Veterans with a claim for community care registered in that claims database during the three month period will be included in the initial sampling frame.

Both the paper and the on-line CC surveys will be customized to include the name of the type of care associated with the claim on the basis of which the Veteran was chosen (e.g., audiology, cardiology, ophthalmology, physical therapy, and so on). For those with multiple claims during the three month sample period, the nature of the care associated with the most recent claim on file will be the type of care named in the survey.

Each monthly sample will be sufficient to allow for valid statistical results at the national and network levels, and within networks at the level of the CC program (e.g., Choice) that represents the mechanism or pathway whereby CC was authorized. Valid statistical results at the latter level (network x CC program) will likely require the quarterly accumulation of data. Data will be analyzed and posted on the Reporting, Analytics, Performance, Improvement & Deployment (RAPID) web site for field use on a monthly basis.

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 overall purpose of the SHEP Program is to systematically obtain information from patients that can be used to identify problems or complaints that need attention and to improve the quality of health care services delivered to Veterans. Information obtained from the SHEP Program is one component of a larger Network Directors Performance Agreement system in VHA that culminates in the annual Network Performance Report. Results of each of the customer satisfaction surveys are made readily available to VA Central Office (VACO), Veterans Integrated Service Network (VISN), VHA field staff, and stakeholders as part of the Network Performance Report and via the VA Intranet. Data is used to demonstrate that VA is providing timely, high quality health care services to patients and to measure improvement toward the goal of matching or exceeding the non-VA external benchmark performance. Each VISN has designated a Quality Management Officer (QMO) that is responsible for acting as a resource for field staff for explanation of the data and for determining where opportunities for improvement of services exist.

a. Customer Feedback information is provided to VA medical center staff, VACO management, and others interested in the quality of medical services provided to VA patients. The survey results for each center are used as a local management tool for assessing and improving the quality of services being provided to their patients.

b. VACO management receives system-wide and VISN specific aggregated data, permitting longitudinal trend analysis of changes over time. Information obtained through this survey is useful at all levels of the organization to plan and redirect resources and efforts to improve or maintain a high quality of care to VA beneficiaries. If this information is not collected, vital feedback regarding patients' treatment by providers, related services, and patient-staff communication will not be available.

These voluntary customer service surveys fulfill the requirements of Executive Orders 12862 and 13571. Key requirements of these Executive Orders are for agencies to compare results of satisfaction surveys to comparable external referents. These voluntary surveys also satisfies section 206(c)(2)(C) of The Choice Act “Improved Transparency Concerning Health Care Provided By Department Of Veterans Affairs Survey data of patient experiences, including (HCAHPS) or any similar successor survey developed by the Department of Health and Human Services”.

In order for VHA to be able to achieve the goal of public reporting of inpatient Veteran experience data, VA must comply with the methods described in CMS’s “CAHPS Hospital Survey (HCAHPS) Quality Assurance Guidelines”, currently V12.0, but the methods are updated annually.

The CAHPS guidelines require identifying patients by eligible Diagnostic Related Groups, or DRG codes. Further, CMS requires that the survey components consist of a first mailing of a survey questionnaire and cover letter, followed in approximately 21 days later with a repeat questionnaire to non-respondents.

None of the other surveys fielded by the SHEP program requires adherence to such strict protocols. However, we have and will continue to work closely with responsible parties (CMS, AHRQ, NCQA, etc.) in the survey industry to develop the optimum data collection strategy.

The SHEP program has been used to assess patient experiences and satisfaction in VA since the mid 1990’. The program has continued to evolve its survey methods and design to help VA better understand and the needs of our nation’s Veterans.

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.

Since moving to the HCAHPS surveys, VA is bound by their rigid data collection protocols. The only official mode of administration that is allowed is by mail, with an optional follow-up by telephone. However, VHA will administer web-based surveys where CAHPS data collection protocols allow.

4. Describe effort 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.

There is no information currently being systematically collected that can be used for this purpose. Although there are many small local patient satisfaction surveys largely focused on a specific part of the Medical Center, these do not permit system-wide and VISN specific aggregated data, or longitudinal trend analysis of changes over time. Furthermore, local surveys would not be a reliable basis from which to develop national policies, establish performance targets, or make reliable, valid non-VA comparisons, as required by the Executive Order.

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

No small businesses or other small entities are impacted by this 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 VA is unable to obtain a renewed clearance of the CAHPS-based instruments the collection of customer satisfaction information will cease. VA would be unable to measure satisfaction with VHA healthcare, and would therefore become noncompliant with The Choice Act, and Executive orders 12862 and 13571.

Less frequent collection would reduce the VHA’s ability to both effectively track progress toward national and local performance goals, and identify potential negative trends in a timely fashion, at all levels of the system.

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.

VHA facilities need up-to-date results to manage the customer service programs for facilities, therefore SHEP is collected monthly on a rolling basis. There are no such special circumstances requiring responses in fewer than 30 days. RAPID ensures that no individual is eligible for random selection in any SHEP project more often than once in any calendar month. This is consistent with CAHPS protocol. Eligibility for selection is determined by several factors, and as such, eligibility does not guarantee selection into any given sample. Participation in the survey is completely voluntary.

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 notice of Proposed Information Collection Activity was published in the Federal Register on October 31, 2017, page 82, Volume 50488, page 50488. We received no comments 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 record keeping, disclosure or reporting format, and on the data elements to be recorded, disclosed or reported. Explain any circumstances that preclude consultation every three years with representatives of those from whom information is to be obtained.

Considerable input on the use of HCAHPS has been obtained from the Agency for Healthcare Research and Quality (AHRQ) and from other federal healthcare agencies now using HCAHPS and CAHPS, such as CMS and DOD. In addition, input has been obtained from industry. Collaboration with the CAHPS community has been ongoing since moving the SHEP program to the CAHPS instruments.

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

No payment or gift is 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 statue, regulation, or agency policy.

Each patient who participates is assured privacy to the extent to the law. It is recognized that the survey must be completely voluntary in order to provide reliable results. Survey instructions to patients specify and underscore that responding to the survey is completely voluntary, private to the extent to the law, and will have no effect on entitlement to or eligibility for VHA healthcare benefits, and that the form does not need to be signed. SHEP materials have been reviewed by VA’s Office of Ethics. The patient completes the questionnaire anonymously (giving neither name nor social security number) and returns it to the contractor collecting data for RAPID. All returned survey documents are destroyed once the dataset created from those documents has been validated. In the many years that the VHA has been conducting similar types of surveys, there has never been a single complaint by a veteran concerning a violation of this pledge. Since the responses are not individually identifiable, there is no need to store or process these forms in accordance with the Privacy Act. Nonetheless, the VHA adheres to U.S.C. 38, Section 5705, Confidentiality of Medical Quality-Assurance Records.

11. Provide additional justification for any questions of a sensitive nature, 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 asked of a sensitive nature concerning topics such as sexual behavior, religious beliefs, or similar type subjects.

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

1. Annual respondent burden is computed on this basis as follows:

FORM NUMBER	SAMPLLE SIZE/YR	RESP RATE	# RESP	RESP FREQ	% ELEC	BURDEN	HOURS
10-1465-1	1,200	40%	480	1	0	20	160
10-1465-2	180,000	40%	72,000	1	0	15	18,000
10-1465-3	1,200	40%	480	1	30	20	160
10-1465-4	1,200	40%	480	1	30	15	120
10-1465-5	720,000	40%	288,000	1	30	10	48,000
10-1465-6	60,000	40%	24,000	1	0	20	8,000
10-1465-7	1,200	40%	480	1	30	10	80
10-1465-8	1,200	40%	480	1	30	15	120
10-1465-9	300,000	40%	120,000	1	30	15	30,000
10-1465-10	720,000	40%	288,000	1	30	15	72,000
			794,400				176,640

b. 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.

Legally, respondents may not pay a person or business for assistance in completing the information collection and a person or business may not accept payment for assisting a respondent in completing the information collection. Therefore, there are no expected overhead costs for completing the information collection. VHA estimates the total cost to all respondents to be $4,214,630.40 (176,640 burden hours x $23.86 per hour).

May 2016 National Occupational Employment and Wage Estimates United States:

https://www.bls.gov/oes/current/oes_nat.htm#00-0000

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).

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

2. Cost estimates are not expected to vary widely. The only cost is that for the time of the respondent.

3. There are no anticipated capital start-up cost components or requests to provide information.

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.

The cost to the Government is approximately $12,500,000 for the vendor for printing, mailing, collecting and reporting the data.

15. Explain the reason for any program changes or adjustments reported in Items 13 or 14 of OMB 83-I

VHA has added several forms that may be required by VHA leadership in the near future, and are included here.

The program change is due to the inclusion of VA Forms 10-1465-9 and 10-1465-10.

In an effort to ask better, more pertinent questions of our patients, VA would like to conduct veteran outreach, focus groups, conduct cognitive testing, and other similar qualitative data collection approaches to better understand emerging patient issues and to ensure the relevancy of the questions asked in the SHEP program.

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.

Results of the customer satisfaction surveys are made readily available to VACO, VISN, VHA field staff, and stakeholders via the VA Intranet and in executive summary reports. Inpatient and other CAHPS data will be externally reported in compliance with The Choice Act. Upon request, information will be made available to concerned program officials, OMB, Congress, Veterans' Service Organizations (VSO), the news media, and interested citizens through the Freedom of Information Act Officer.

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

We are not seeking to omit the expiration date from survey forms. Expiration dates will be placed on the forms upon receipt of OMB approval, and its associated expiration date.

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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