FINAL20220825_Workforce Survey Eval and TA Supporting Statement A_burden statement updatedFINAL

Supporting Statement A

Health Center Workforce Survey Evaluation and Technical Assistance

OMB Control No. 0915-XXXX

Terms of Clearance: None

A. Justification

1. Circumstances Making the Collection of Information Necessary

Workforce well-being, burnout, and satisfaction are critical factors in assuring high-quality patient care delivery within HRSA-supported health centers. Ignoring staff well-being and satisfaction can lead to rapidly escalating difficulties under which staff become detached or frustrated, which decreases quality, safety, and patient connection while ultimately leading to persistent difficulties with workforce recruitment, retention, and productivity.¹ In order to identify causes, impacts, and extent of staff well-being, burnout, and job satisfaction, a workforce survey was developed as one of the deliverables of the Health Center Workforce Well-Being/Satisfaction Survey contract that will be administered across HRSA funded health centers nationally. The activities conducted during the Health Center Workforce Well-Being/Satisfaction Survey development contract were approved under OMB Control No. 0915-XXXX. This survey will provide insight into the factors impacting workforce well-being and satisfaction at the national and health center levels and across all health center occupations. By quantifying and analyzing these factors, efforts to improve conditions can be implemented and evaluated as to their effectiveness, with the long-term goal of improving patient quality of care and promoting HRSA supported health centers as a leaders in workforce recruitment and retention and well-being.

HRSA selected John Snow, Inc. (JSI) as the contractor for the Health Center Workforce Survey Evaluation and Technical Assistance contract, through a competitive bid process to undertake this project. The HRSA contractor’s charge in this contract is to administer the survey instrument (Health Center Workforce Survey) to all of the approximately 280,000 FTE working at the nearly 1,400 HRSA funded health centers. Participation in the survey is voluntary and will provide baseline information on health center workforce well-being, satisfaction, and burnout that will be used for quality improvement initiatives including future targeted technical assistance.

The Health Center Workforce Well-being Survey was created by HRSA to identify and address challenges related to provider and staff well-being, satisfaction and burnout to improve health care quality and outcomes, and is supported by Statute 330 of the Public Health Service (PHS) Act (42 U.S.C. 254b).

2. Purpose and Use of Information Collection

Health care workforce burnout has been a challenge even prior to COVID-19 and other recent public health emergencies. Clinicians and health care staff have reported experiencing alarming rates of burnout characterized as a high degree of emotional exhaustion, depersonalization, and a low sense of personal accomplishment at work.² Understanding the factors impacting workforce well-being and satisfaction, reducing burnout, and applying evidence-based technical assistance and other quality improvement strategies around workforce well-being is essential as the healthcare workforce continues to expand while recovering from and preparing for future health care delivery challenges.

Administration of the Health Center Workforce Survey will provide a baseline understanding of health center workforce well-being and identify opportunities to improve workforce well-being. Data from the Health Center Workforce Well-being Survey will provide insight into technical assistance needs and other strategies HRSA and HRSA funded health centers can implement to promote workforce well-being and quality improvement. These efforts will further HRSA’s goal of providing access to quality health care and supporting a robust primary care workforce.

In the absence of information gathered through the Health Center Workforce Well-being Survey, HRSA will be unable to determine:

• the level of well-being, job satisfaction, and burnout for health center staff nationally

• factors contributing to staff well-being and job satisfaction which improve staff retention

• factors contributing to burnout and increasing staff turnover

• patterns of health center staff well-being, job satisfaction, and burnout by health center characteristics (i.e., urban or rural, large or small, role, demographics, etc.)

Information on health center staff well-being, job satisfaction and burnout is necessary to develop and implement technical assistance and other quality improvement strategies to decrease burnout and turnover and improve job satisfaction and staff retention. The absence of this information will prevent HRSA from developing robustly informed strategies to improve workforce well-being. This will ultimately affect and be a disservice to historically medically underserved and vulnerable patients and communities served by health centers.

3. Use of Improved Information Technology and Burden Reduction

The Health Center Workforce Survey will be conducted entirely online using SurveyAnalytics, an approved Federal software program for online surveys that is certified as 508 compliant. Use of an online survey tool will enable the surveys to be completed in less time, with reduced burden, and with more accuracy than a paper and pencil questionnaire. If in a few rare instances a respondent asks to complete the survey by paper copy or other means, JSI will attempt to accommodate those requests.

4. Efforts to Identify Duplication and Use of Similar Information

Existing national survey instruments were evaluated for use as possible measures of provider and staff well-being including engagement, satisfaction, and burnout and none were found that measured the number of important concepts related to burnout and job satisfaction in the health center context. In addition, a thorough literature review identified validated measures and instruments for assessing job satisfaction and staff burnout as well as measures of other concepts that have been identified as precursors to job dissatisfaction and burnout. This information was used to create a unique Health Center Workforce Well-being Survey.

HRSA has not conducted any previous national surveys to assess workforce well-being across its nearly 1,400 health centers. Information on workforce well-being by health center size, region, occupation groups and other factors will allow national comparisons of well-being across health center staff and will inform future technical assistance, which would not be possible without the administration of this survey.

5. Impact on Small Businesses or Other Small Entities

No small businesses will be impacted. The Health Center Workforce Well-being Survey will be administered to HRSA-funded health centers.

6. Consequences of Collecting the Information Less Frequently

Within the project period, data collection from the national rollout of the Health Center Workforce Well-being Survey is a one-time effort that is necessary to assess workforce well-being in HRSA-funded health centers. There are no legal obstacles to reduce the burden.

7. Special Circumstances Relating to the Guidelines of 5 CFR 1320.5

The request fully complies with the regulation.

8. Comments in Response to the Federal Register Notice/Outside Consultation

A 60-day Federal Register Notice was published in the Federal Register on March 10, 2022, vol. 87, No. 48; pp. 14019.

There were/were no public comments.

9. Explanation of any Payment/Gift to Respondents

Respondents will not receive any payments or gifts from HRSA.

10. Assurance of Confidentiality Provided to Respondents

Data will be kept private to the extent allowed by law. The data collection process will emphasize privacy and confidentiality throughout. The ability to assure health center staff that their data will be kept confidential at the individual level, as it will not be possible to link individual answers with a person's identity, will be of the utmost importance. Responses will be confidential in the analytic data set. Methods of assuring protection include disassociating responses from the respondents email address; dropping specific job title from the public dataset; providing aggregate data back to health centers, with minimum record count suppression, to remove the possibility of respondents being identified through job titles or demographic characteristics, and using an unidentifiable code in place of health center grant numbers in the final data set. Internally the HRSA contractor will retain the ability to track responses at the individual and organizational level while data collection is underway to allow for effective follow up. Upon the completion of data collection, the linkage to individual email addresses will be severed permanently, and other potentially identifying information, such as job title, will be separated from the final data file. This process will remove personal identifiers from the survey results to avoid triggering the Privacy Act.

In addition, HRSA has granted the project a Certificate of Confidentiality which adds an additional layer of protection from legal action to force disclosure of any individual answers.

11. Justification for Sensitive Questions

Questions regarding well-being, job satisfaction, and burnout can be sensitive in nature. Federal regulations governing the administration of these questions, which might be viewed as sensitive due to personal or private information require (a) clear documentation of the need for such information as it relates to the primary purpose of the study, (b) provisions to respondents that clearly inform them of the voluntary nature of participation in the study, and (c) assurances of private treatment of responses. The following areas have been identified as potentially sensitive:

Topics may include ratings of leadership and job stress. While sensitive, these questions are necessary and important for understanding the causes and impacts of burnout, well-being, and job satisfaction as supported by the extensive literature review conducted during the Health Center Workforce Well-Being Survey.

Respondents will also be asked to provide their race/ethnicity. This information will help HRSA and health centers to identify levels of burnout, job satisfaction, well-being and drivers of these concepts for various groups. Without this information HRSA and health centers will not be able to appropriately develop technical assistance or other strategies to improve workforce well-being for all staff.

Prior to participating in the survey, respondents will be informed about the voluntary nature of their participation and the private treatment of their responses. Respondents will understand that they have the right to skip over any question that they do not want to answer. They will also understand that refusing any question will not impact their employment within their respective health center.

Although some items are sensitive in nature, the HRSA contractor anticipates that the procedures that create confidentiality for participants will allow them to answer these questions with acceptable levels of comfort. These responses will generate the data needed to drive research and develop quality improvement initiatives to support HRSA supported health center employees and their patients.

12. Estimates of Annualized Hour and Cost Burden

12A. Estimated Annualized Burden Hours

Type of Respondent	Form Name	No. of Respondents	No. Responses per Respondent	Average Burden per Response (in hours)	Total Burden Hours
Health Center Leadership	HRSA Email Introducing HRSA Health Center Workforce Well-being Survey	1,400	1	20/60	467
Health Center Leadership	1 Day to Launch: HRSA Health Center Workforce Well-being Survey	1,400	1	20/60	467
Health Center Leadership	Complete HRSA’s Health Center Workforce Well-being Survey	1,400	1	20/60	466
Health Center Staff	Health Center Workforce Survey	450,000	1	30/60	225,000
Total					229,200

12B.

Estimated Annualized Burden Costs

Type of Respondent	Full Time Equivalent3	Burden Hours at 0.5 (based on expected survey participation time)	Hourly Wage Rate	Total Respondent Costs
Family Physicians	6441.49	3,220.75	$94.414	$304,067.75
General Practitioners	496.54	248.27	$101.425	$25,179.54
Internists	2099.81	1,049.91	$96.644	$101,467.77
Obstetrician/Gynecologists	1338.83	669.42	$123.714	$82,812.43
Pediatricians	3082.98	1,541.49	$90.104	$138,888.25
Other Specialty Physicians	623.31	311.66	$105.225	$32,792.34
Nurse Practitioners	10512.54	5,256.27	$51.064	$268,375.54
Physician Assistants	3348.28	1,674.14	$52.804	$88,401.03
Certified Nurse Midwives	730.16	365.08	$53.374	$19,484.92
Nurses	19273.33	9,636.67	$31.724	$305,644.44
Laboratory Personnel	2624.02	1,312.01	$26.925	$35,319.31
Dentists	5323.83	2,661.92	$71.144	$189,363.26
Dental Hygienists	2855.58	1,427.79	$37.53	$53,584.96
Psychiatrists	896.64	448.32	$112.564	$50,464.24
Licensed Clinical Psychologists	962.24	481.12	$50.824	$24,452.23
Licensed Clinical Social Workers	4523.91	2,261.96	$28.594	$64,664.73
Ophthalmologists	46.74	23.37	$105.225	$2,458.99
Optometrists	398.06	199.03	$60.315	$12,003.50
Pharmacy Personnel	5982.63	2,991.32	$60.104	$179,766.53
Case Managers	10103.86	5,051.93	$32.924	$166,293.51
Community Health Workers	1483.09	741.55	$18.164	$13,468.31
Fiscal and Billing Staff	14136.74	7,068.37	$37.934	$268,105.31
Chief Executive Officer	1400.00	700.00	$108.124	$75,684.13
Chief Medical Officer	1400.00	700.00	$116.944	$81,860.96
Chief Operating Officer	1400.00	700.00	$70.514	$49,360.43
Chief Financial Officer	1400.00	700.00	$70.234	$49,158.51
Total				$2,683,122.90
Type of Respondent	Full Time Equivalent	Burden Hours at 2 (based on health center engagement efforts)	Hourly Wage Rate	Total Respondent Costs
Chief Executive Officer	1400.00	2,800.00	$108.124	$302,736.54
Total				$302,736.54
Grand Total				$2,985,859.44

13. Estimates of other Total Annual Cost Burden to Respondents or Recordkeepers/Capital Costs

Other than their time, there is no cost to respondents.

14. Annualized Cost to Federal Government

HRSA has contracted with a vendor selected through a competitive bidding process. The contract is for two years and the total cost of the contract is $4,160,991 and thereby the annualized cost is $2,080,495.50.

15. Explanation for Program Changes or Adjustments

This is a new information collection.

16. Plans for Tabulation, Publication, and Project Time Schedule

The information collected from the Health Center Workforce Survey will be analyzed and published. The components and timeline of this process are reported below:

Data collection

Data collection will launch in September 2022 and be administered in a staggered fashion to four or more cohorts. The data collection will end in November 2022.

Cleaning

The online survey software prevents out of range responses from being entered and allows SKIP instructions to be programmed within the survey, therefore there is a limited number of cleaning steps to be taken. There will be a review of the occupational groups selected by the staff person in relation to the job title they provided. If it seems as though they have misclassified themselves, a re-coding of the occupational group will be done (but the original response will also be preserved). The HRSA contractor will also identify surveys that took an abnormally short time to complete (under 15 minutes on a 25-30 minute survey) and inspect whether, based on the pattern of answers, it seems as if the respondent did not answer the questions seriously (e.g. all the same answer or random answers that are contradictory). For these cases the survey responses will be considered on a case-by-case basis and decision rules created as to how to resolve this situation (e.g. getting back to the respondent to ask for clarification or even in the extreme consideration to drop the responses from the analytic file). Data cleaning will take place November through December 2022 after data collection is completed.

Analysis

Two major types of analyses are contemplated: descriptive analyses and relational analyses. These are described in more detail in the data analysis section which follows. Analysis of the data will take place between December 2022 through March 2023 after data collection and data cleaning is completed.

Concept Construction and Reliability Calculations.

Each of the concepts measured in the survey consists of multiple questions. The HRSA contractor will create a constructed score for each staff person for each concept by first reversing any items that are worded in a different direction than others within that same concept. Coefficient alpha reliability levels will be calculated to confirm that all the presumed questions that make up the concept indeed do demonstrate that they belong together. Means, standard deviations and coefficient alpha of reliability will be calculated for each concept measure. Concept construction and reliability calculations are part of the data analysis and will occur in the same time period: December 2022 through March 2023.

Reporting

1. HRSA Workforce Survey Findings Report. There are two major types of analyses that will be included in this report, a descriptive set of analyses and tests of relationships between drivers and well-being measures.

2. Comparative Studies Report. A second findings report will focus on comparing previous study literature to the major findings described in the survey results report. Literature for each specific well-being measure will identify previous study findings related to both significant mean score differences and significant associations with drivers.

HRSA and/or the HRSA contractor may attempt to publish a portion of the findings in a peer reviewed journal to more widely disseminate results that pass scientific review by industry experts.

17. Reason(s) Display of OMB Expiration Date is Inappropriate

The OMB number and expiration date will be displayed on every page of every form/instrument.

18. Exceptions to Certification for Paperwork Reduction Act Submissions

There are no exceptions to the certification.

1 Friedberg M.W., Reid R.O., Timble J.W., Setodji C., et al. (2017). Federally qualified health center clinicians and staff increasingly dissatisfied with workplace conditions. Health Affairs, 36(8), 1469-1475

2 West, C P, Dyrbye, L. N., Satele, D. V, Sloan, J. A., & Shanafelt, T. D. (2012). Concurrent validity of single-item measures of emotional exhaustion and depersonalization in burnout assessment. J Gen Intern Med, 27(11 PG-1445–52), 1445–1452. https://doi.org/10.1007/s11606-012-2015-7

3 Uniform Data System (UDS) Table 5: Staffing and Utilization https://data.hrsa.gov/tools/data-reporting/program-data/national/table?tableName=5&year=2019

4 NACHC Salary Benefits Report https://chclearning.org/wp-content/uploads/2021/06/2021-2022-NACHC-Salary-Benefits-Report.pdf

5U.S. Bureau of Labor Statistics https://www.bls.gov/oes/current/oes_stru.htm#29-0000

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