SUPPORTING STATEMENT - PART A
Centralized Credentials and Quality Assurance System – 0720-AAGX
Centralized Credentials and Quality Assurance System (CCQAS) is a Department of Defense (DoD) Defense Health Agency (DHA) system governed within the overall corporate sponsorship and policies of the Office of the Assistant Secretary of Defense for Health Affairs (OASD/HA). The information collection requirement is necessary to operate, manage, evaluate, and improve DoD clinical quality management and risk management programs. This information is essential for the DHA and DoD Services to support credentialing, privileging, and healthcare risk management of Active Duty, Reserve, Guard, Civil Service, contractors, and volunteer direct health care providers within the Military Health System (MHS).
This collection of information is authorized by the following:
10 U.S. Code § 55 - Medical and Dental Care. This authority mandates the creation and maintenance of high morale in the uniformed services by providing an improved and uniform program of medical and dental care for members and certain former members of the services, and for their dependents.
10 U.S. Code § 1094 - Licensure requirement for health care professionals. This authority provides the statutory basis for licensure requirements for health care professionals.
10 U.S. Code § 1102 - Confidentiality of medical quality assurance records: qualified immunity for participants. This authority provides the statutory basis for the privileges and confidentiality of records created or maintained through the DoD Clinical Quality Program and DoDD 6040.37 [Confidentiality of Medical Quality Assurance (QA) Records].
42 U.S. Code § 117 - Encouraging Good Faith Professional Review Activities. This authority establishes the standards for professional review actions and outlines the criteria for review actions as they relate to a health care facility and the provider.
DHA-PM 6025.13. This procedural manual provides implementation guidance for DHA Procedures Manual, “Clinical Quality Management (CQM) in the MHS.” Procedures for data collection are identified for credentialing, privileging, risk management, and adverse actions business processes.
Memorandum of Understanding between Department of Veterans Affairs (VA) and Department of Defense (DoD) for sharing of Provider Credentialing Data. This Memorandum of Understanding (MOU) authorizes and facilitates the sharing of certain healthcare provider credentialing data between the Department of Veterans Affairs (VA) and the Department of Defense (DoD).
Executive Order 9397 (SSN). This authority requires Federal agencies to conduct agency activities that involve personal identifiers in a manner consistent with protection of such identifiers against unlawful use.
The information entered in the CCQAS E-application is necessary to validate that an MHS health care provider is educated and trained to be credentialed and privileged to provide health care within a Military Treatment Facility (MTF) or military installation. Respondents are MHS health care providers and CQM managers that update records in CCQAS. The credentialing and privileging information collection begins with the online registration process at https://ccqas.csd.disa.mil. Before completing a registration request, all respondents must acknowledge the CCQAS Privacy Act Statement by selecting the “Yes” button that appears at the bottom of the webpage. All prospective users require a valid Common Access Card (CAC) or Personal Identify Verification (PIV) card to access CCQAS to begin the registration process. Exceptions can be made for users awaiting receipt of a CAC/PIV where a limited time username and password is issued.
Once the respondent has completed registration and gained access to CCQAS, a new Credentials record is generated. A single Credentials record is maintained in CCQAS for each health care provider over the entirety of his or her service to the MHS and is updated over time to reflect the provider’s qualifications for providing care. This information collection occurs by manual entry directly into CCQAS. The professional staff managers at each MTF review and process the provider e-application for approval by the MTF Credentialing and Privileging Authority.
100% of responses are collected electronically via the CCQAS website.
The information obtained through this collection is unique and is not already available for use or adaptation from another cleared source.
This information collection does not impose a significant economic impact on a substantial number of small businesses or entities.
Collections are driven in accordance with DHA’s credentialing, privileging, and health care risk management policies, on an as needed basis, to ensure health care provider’s credentials are current to maintain their privileges to practice. The frequency of collection generally occurs biennially and may also occur on occasion, weekly, monthly, quarterly, semi-annually, and annually. When or if the data is not available, it will negatively impact the MHS’s ability to credential and privilege providers in a timely manner and thus delay patient care.
This collection of information does not require collection to be conducted in a manner inconsistent with the guidelines delineated in 5 CFR 1320.5(d) (2).
Part A: PUBLIC NOTICE
A 60-Day Federal Register Notice (FRN) for the collection published on Monday, June 13, 2022. The 60-Day FRN citation is 87 FRN 35742-35743.
No comments were received during the 60-Day Comment Period.
A 30-Day Federal Register Notice for the collection published on Thursday, September 8, 2022. The 30-Day FRN citation is 87 FRN 54984-54985.
Part B: CONSULTATION
Consultations occur situationally with others to determine continued viability of collection elements, procedures, polices, etc. Consultations may occur with Military Inspector General Inspectors (Inspector General Staff, Medical Inspector General Staff, etc.), National and
International Accreditation Organizations (The Joint Commission, etc.), MHS CQM governance (Health Affairs, DHA leadership (DAD-Medical Affairs), Service leadership, etc.), and DHA Program Management of the Collection System, (DHA Office of the Chief Information Officer DAD-IO/J6, Program Management Leadership and Program Managers).
No payments or gifts are being offered to respondents as an incentive to participate in the collection.
A Privacy Act Statement is required for this collection. The statement appears in the CCQAS application immediately following the DoD Warning banner.
CCQAS is currently under the EDHA 09 System of Records Notice (SORN), which can be viewed here: https://dpcld.defense.gov/Privacy/SORNsIndex/DOD-wide-SORN-ArticleView/Article/570674/edha-09/
A Privacy Impact Assessment is required for CCQAS and can be accessed here: https://www.health.mil/Reference-Center/Forms/2022/04/18/PIA-Summary-Centralized-Credentials-Quality-Assurance-System
Records Retention and Disposition Schedule: A Records Retention and Disposition Schedule for CCQAS was approved by the National Archives and Records Administration (NARA) to delete/destroy data after 10 years old; cutoff is annually (Administrative Instruction (AI)-15 “Office of the Secretary of Defense (OSD) Records and Information Management Program”: OSD Records Disposition Schedule 900 Series Assistant Secretary of Defense (ASD) Health Affairs: N1-330-11-003, item 1 [page 233]).
A moratorium was placed on CCQAS records retention and disposition schedule in 2020. The DHA CQM functional community and Service-level leaders justified a record retention requirement of 50-years with support for the DHA Office of the General Counsel. The retention requirement will be documented in the reissuance of the DoDI 6025.13. An updated Records Retention and Disposition Schedule will then be submitted to NARA for approval.
CCQAS stores individually identifiable health information of health care providers to include individual’s Full Name, Social Security Number (SSN), DoD Identification Number (DoD ID Number), National Provider Identifier, driver's license number, citizenship, gender, date of birth, health status, and marital status. This system may include his or her personal and work contact information i.e. telephone number, e-mail address, and mailing address. This system also includes information about his or her past work history, personnel records, court records, military service, credentials, clinical privileges, clinical practices, clinical performances, occupational competencies, specialties, certifications, registrations, medical records, and medical readiness. This sensitive data is collected to provide a snapshot of the provider’s qualifications, as well as, identify personnel who may pose risk to patient care, patient safety and/or the organization.
A SSN Justification Memo is submitted with this package.
PART A. Estimation of Respondent Burden
CCQAS E-Application
Number of Respondents: 62,500
Number of Responses per Respondent: 3
Number of Total Annual Responses: 187,500
Response Time: 4 hours
Respondent Burden Hours: 750,000
Total Submission Burden
Total Number of Respondents: 62,500
Total Number of Annual Responses: 187,500
Total Respondent Burden Hours: 750,000
PART B. Labor Cost of Respondent Burden
CCQAS E-Application
Number of Total Annual Responses: 187,500
Response Time: 4 hours
Respondent Hourly Wage: $52.88
Labor Burden per Response: $211.52
Total Labor Burden: $39,660,000
Overall Labor Burden
Total Number of Annual Responses: 187,500
Total Labor Burden: $39,660,000
The CCQAS respondent is a health care provider (Office of Personnel Management (OPM)
Occupation series 0600) that may hold a General Schedule (GS) position ranging from GS5 to GS15. The average salary is an estimated $110,000 nationwide across all health care provider types. The following OPM websites were referenced to calculate the Respondent’s average salary and hourly wage: https://apps.opm.gov/SpecialRates/search.aspx and
https://www.opm.gov/policy-data-oversight/classification-qualifications/classifying-generalschedule-positions/#url=Standards.
There are no annualized costs to respondents other than the labor burden costs addressed in Section 12 of this document to complete this collection.
PART A. Labor Cost to the Federal Government
CCQAS E-Application
Number of Total Annual Responses: 187,500
Processing Time per Response: 4 hours
Hourly Wage of Worker(s) Processing Responses: $52.88
Cost to Process Each Response: $211.52
Total Cost to Process Responses: $39,660,000
Overall Labor Burden to Federal Government
Total Number of Annual Responses: 187,500
Total Labor Burden: $39,660,000
PART B. Operational and Maintenance Costs
Cost Categories
Equipment: $0
Printing: $0
Postage: $0
Software Purchases: $0
Licensing Costs: $0
Other: $3,869,000
Total Operational and Maintenance Cost: $3,869,000
PART C. Total Cost to the Federal Government
Total Labor Cost to the Federal Government: $39,660,000
Total Operational and Maintenance Costs: $3,869,000
Total Cost to the Federal Government: $43,529,000
Reasons for Change in Burden
This is an existing collection currently in use without an OMB Control Number.
Publication of Results
The results of this information collection will not be published.
We are not seeking approval to omit the display of the expiration date of the OMB approval on the collection instrument.
We are not requesting any exemptions to the provisions stated in 5 CFR 1320.9.
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| File Title | Supporting Statement A revised |
| Author | Kaitlin Chiarelli |
| File Modified | 0000-00-00 |
| File Created | 2022-09-09 |