Consumer Assessment of Healthcare Providers and Systems Outpatient and Ambulatory Surgery (OAS CAHPS) Survey (CMS-10500)

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form CMS-10500 OAS CAHPS (Web Survey Screenshots)	Form and Instruction	Modified	Available
Form CMS-10500 OAS CAHPS (Telephone Script)	Form	Modified	Available
Form CMS-10500 OAS CAHPS (Mail Survey)	Form and Instruction	Modified	Available
Form CMS-10500 OAS CAHPS (Web Survey Screenshots)	Form and Instruction	Modified	Available
Form CMS-10500 OAS CAHPS (Telephone Script)	Form and Instruction	Modified	Available
Form CMS-10500 OAS CAHPS (Mail Survey)	Form	Modified	Available
Form CMS-10500 OAS CAHPS (Web Survey Screenshots)	Form and Instruction	Modified	Available
Form CMS-10500 OAS CAHPS (Telephone Script)	Form and Instruction	Modified	Available
Form CMS-10500 OAS CAHPS (Mail Survey)	Form	Modified	Available
OAS CAHPS-Response to OMB Public Comments Submitted 06-15-18.docx	Supplementary Document	Uploaded 2018-07-31	Available
CMS-10500 - Supporting_Statement_A [07-31-2018].docx	Supporting Statement A	Uploaded 2018-07-31	Available
CMS-10500 - Supporting_Statement_B [07-31-2018].docx	Supporting Statement B	Uploaded 2018-07-31	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
216391	Patient Records	Form and Instruction	Modified	OAS CAHPS (Web Survey Screenshots)
216391	Patient Records	Form	Modified	OAS CAHPS (Telephone Script)
216391	Patient Records	Form and Instruction	Modified	OAS CAHPS (Mail Survey)
216390	National Implementation	Form and Instruction	Modified	OAS CAHPS (Web Survey Screenshots)
216390	National Implementation	Form and Instruction	Modified	OAS CAHPS (Telephone Script)
216390	National Implementation	Form	Modified	OAS CAHPS (Mail Survey)
209906	Mode Experiment	Form and Instruction	Modified	OAS CAHPS (Web Survey Screenshots)
209906	Mode Experiment	Form and Instruction	Modified	OAS CAHPS (Telephone Script)
209906	Mode Experiment	Form	Modified	OAS CAHPS (Mail Survey)

ICR Details

OMB Control No: 0938-1240	ICR Reference No: 201807-0938-016
Status: Historical Active	Previous ICR Reference No: 201510-0938-003
Agency/Subagency: HHS/CMS	Agency Tracking No: CM-CPC
Title: Consumer Assessment of Healthcare Providers and Systems Outpatient and Ambulatory Surgery (OAS CAHPS) Survey (CMS-10500)
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 12/20/2018
Retrieve Notice of Action (NOA)	Date Received in OIRA: 07/31/2018
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	12/31/2021	36 Months From Approved	12/31/2018
Responses	641,224	0	2,823,073
Time Burden (Hours)	155,208	0	687,511
Cost Burden (Dollars)	0	0	0

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Abstract: The information collected in the national implementation of OAS CAHPS will be used for the following purposes: -To provide a source of information from which selected measures can be publicly reported to beneficiaries to help them make informed decisions for outpatient surgery facility selection; -To aid facilities with their internal quality improvement efforts and external benchmarking with other facilities; and -To provide CMS with information for monitoring and public reporting purposes. For the mode experiment, CMS plans to use information from this mode experiment to determine whether additional mode of administration (i.e. Web data collection) should be included in the current national implementation of OAS CAHPS protocols.

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Authorizing Statute(s): PL: Pub.L. 111 - 148 931 Name of Law: Quality Measure Development, Patient Protection and Affordable Care Act
  

Citations for New Statutory Requirements: PL: Pub.L. 111 - 148 931 Name of Law: Quality Measure Development, Patient Protection and Affordable Care Act

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	83 FR 16362	04/16/2018
30-day Notice:	Federal Register Citation:	Citation Date:
	83 FR 32667	07/13/2018
Did the Agency receive public comments on this ICR? Yes

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Number of Information Collection (IC) in this ICR: 3

table that charts list of burden

IC Title	Form No.	Form Name
Mode Experiment	CMS-10500, CMS-10500, CMS-10500	OAS CAHPS (Mail Survey) ,   OAS CAHPS (Telephone Script) ,   OAS CAHPS (Web Survey Screenshots)
National Implementation	CMS-10500, CMS-10500, CMS-10500	OAS CAHPS (Mail Survey) ,   OAS CAHPS (Telephone Script) ,   OAS CAHPS (Web Survey Screenshots)
Patient Records	CMS-10500, CMS-10500, CMS-10500	OAS CAHPS (Mail Survey) ,   OAS CAHPS (Telephone Script) ,   OAS CAHPS (Web Survey Screenshots)

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ICR Summary of Burden

table that charts list of burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	641,224	2,823,073	0	-2,181,849	0	0
Annual Time Burden (Hours)	155,208	687,511	0	-532,303	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: Yes

Burden Reduction Due to: Miscellaneous Actions

Short Statement: At this time, there are no changes planned for the response time for the survey itself, however, due to the delay in implementing required participation linked to reimbursement, we estimate that the number of hospitals and ambulatory surgery centers that choose to voluntarily participate in 2018 will be reduced. For the Mode Experiment, we project an increase of 3,140 responses and 409 hours (3,140 responses x 0.13 hr/response). For the National Implementation, we project a decrease of -2,177,700 responses and -283,101 hours (-2,177,700 responses x 0.13 hr/response). For Patient Records, we project a decrease of -7,289 responses and -249,611 hours (see section 12). Overall we project a decrease of -2,181,849 responses (3,140 -2,177,700 -7,289) and -532,303 hours (409 -283,101 -249,611).

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Annual Cost to Federal Government: $1,737,341

Does this IC contain surveys, censuses, or employ statistical methods? Yes Part B of Supporting Statement

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     No

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? Yes

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 07/31/2018

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