The AHRQ Safety Program for Telemedicine: Improving the Diagnostic Process and Improving Antibiotic Use

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form 11 Attachment K: Antibiotic Prescription Data Template_Antibiotic Stewardship Cohort	Form and Instruction	New	Available
Form 11 Antibiotic Prescription Data Template_Antibiotic Stewardship Cohort	Form and Instruction	New	Repair queued
Form 10 Attachment J: Clinical Data Collection Instrument_Cancer Diagnostic Process Cohort	Form and Instruction	New	Available
Form 10 Clinical Data Collection Instrument_Cancer Diagnostic Process Cohort	Form and Instruction	New	Repair queued
Form 9 Attachment I: Draft Interview Guide for Semi-Structured Interviews_Antibiotic Stewardship Cohort	Form and Instruction	New	Available
Form 8 Attachment H: Draft Interview Guide for Semi-Structured Interviews_ Cancer Diagnostic Process Cohort	Form and Instruction	New	Available
Form 8 Interview Guide for Semi-Structured Interviews	Form and Instruction	New	Repair queued
Form 7 Attachment G: Participant Experience Survey_Antibiotic Stewardship Cohort	Form and Instruction	New	Available
Form 7 Participant Experience Survey_Antibiotic Stewardship Cohort	Form and Instruction	New	Repair queued
Form 6 Attachment F: Participant Experience Survey_Cancer Diagnostic Process Cohort	Form and Instruction	New	Available
Form 6 Participant Experience Survey_Cancer Diagnostic Process Cohort	Form and Instruction	New	Repair queued
Form 5 Attachment E: Diagnostic Safety Supplement	Form and Instruction	New	Available
Form 5 Diagnostic Safety Supplement	Form and Instruction	New	Repair queued
Form 4 Attachment D: The Medical Office Survey on Patient Safety Culture (MOSOPS)	Form and Instruction	New	Available
Form 4 The Medical Office Survey on Patient Safety Culture (MOSOPS)	Form and Instruction	New	Repair queued
Form 3 Attachment C: The Office Readiness Survey_Cancer Diagnostic Process Cohort	Form and Instruction	New	Available
Form 3 The Office Readiness Survey_Cancer Diagnostic Process Cohort	Form and Instruction	New	Repair queued
Form 2 Attachment B: Structural Assessment_Antibiotic Stewardship Cohort	Form and Instruction	New	Available
Form 1 Attachment A: Structural Assessment_Cancer Diagnostic Process Cohort	Form and Instruction	New	Available
Form 1 Structural Assessments	Form and Instruction	New	Repair queued
Supporting Statement A.docx	Supporting Statement A	Uploaded 2023-03-16	Repair queued
Att N_Schedule of Assessment Activities, 2022-2026.docx	Supplementary Document	Uploaded 2023-03-09	Repair queued
Supporting Statement B .docx	Supporting Statement B	Uploaded 2023-03-06	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
258926	Antibiotic Prescription Data Template_Antibiotic Stewardship Cohort	Form and Instruction	New	Attachment K: Antibiotic Prescription Data Template_Antibiotic Stewardship Cohort
258926	Antibiotic Prescription Data Template_Antibiotic Stewardship Cohort	Form and Instruction	New
258925	Clinical Data Collection Instrument_Cancer Diagnostic Process Cohort	Form and Instruction	New	Attachment J: Clinical Data Collection Instrument_Cancer Diagnostic Process Cohort
258925	Clinical Data Collection Instrument_Cancer Diagnostic Process Cohort	Form and Instruction	New
258922	Interview Guide for Semi-Structured Interviews	Form and Instruction	New	Attachment I: Draft Interview Guide for Semi-Structured Interviews_Antibiotic Stewardship Cohort
258922	Interview Guide for Semi-Structured Interviews	Form and Instruction	New	Attachment H: Draft Interview Guide for Semi-Structured Interviews_ Cancer Diagnostic Process Cohort
258922	Interview Guide for Semi-Structured Interviews	Form and Instruction	New
258921	Participant Experience Survey_Antibiotic Stewardship Cohort	Form and Instruction	New	Attachment G: Participant Experience Survey_Antibiotic Stewardship Cohort
258921	Participant Experience Survey_Antibiotic Stewardship Cohort	Form and Instruction	New
258920	Participant Experience Survey_Cancer Diagnostic Process Cohort	Form and Instruction	New	Attachment F: Participant Experience Survey_Cancer Diagnostic Process Cohort
258920	Participant Experience Survey_Cancer Diagnostic Process Cohort	Form and Instruction	New
258919	Diagnostic Safety Supplement	Form and Instruction	New	Attachment E: Diagnostic Safety Supplement
258919	Diagnostic Safety Supplement	Form and Instruction	New
258916	The Medical Office Survey on Patient Safety Culture (MOSOPS)	Form and Instruction	New	Attachment D: The Medical Office Survey on Patient Safety Culture (MOSOPS)
258916	The Medical Office Survey on Patient Safety Culture (MOSOPS)	Form and Instruction	New
258915	The Office Readiness Survey_Cancer Diagnostic Process Cohort	Form and Instruction	New	Attachment C: The Office Readiness Survey_Cancer Diagnostic Process Cohort
258915	The Office Readiness Survey_Cancer Diagnostic Process Cohort	Form and Instruction	New
258913	Structural Assessments	Form and Instruction	New	Attachment B: Structural Assessment_Antibiotic Stewardship Cohort
258913	Structural Assessments	Form and Instruction	New	Attachment A: Structural Assessment_Cancer Diagnostic Process Cohort
258913	Structural Assessments	Form and Instruction	New

ICR Details

OMB Control No: 0935-0265	ICR Reference No: 202303-0935-001
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/AHRQ	Agency Tracking No:
Title: The AHRQ Safety Program for Telemedicine: Improving the Diagnostic Process and Improving Antibiotic Use
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 04/21/2023
Retrieve Notice of Action (NOA)	Date Received in OIRA: 03/20/2023
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	04/30/2026	36 Months From Approved
Responses	11,100	0	0
Time Burden (Hours)	5,581	0	0
Cost Burden (Dollars)	0	0	0

---

Abstract: This program aims to improve two at-risk areas among telemedicine practices by implementing the AHRQ- and Johns Hopkins Armstrong Institute for Patient Safety and Quality (JHAI)-developed Comprehensive Unit-based Safety Program (CUSP) approach: 1) the diagnostic process for breast, colorectal, and lung cancer; and 2) antibiotic stewardship (AS). The CUSP approach improves safety culture at the practice level, enables harm prevention, and engages providers who are on the front lines while integrating technical and adaptive/cultural approaches to making sustainable change. This program constitutes the first large-scale implementation of a quality improvement effort for the cancer diagnostic process and AS in telemedicine. Given the need for clearer guidance and evidence-based telemedicine practices for clinicians and potential for positive impact on outcomes, as described below, these two areas were chosen.

---

Authorizing Statute(s): US Code: 42 USC 299b-2 Name of Law: Health Care Quality Act of 1999
  

Citations for New Statutory Requirements: None

---

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

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	87 FR 76621	12/15/2022
30-day Notice:	Federal Register Citation:	Citation Date:
	88 FR 13119	03/02/2023
Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 9

table that charts list of burden

IC Title	Form No.	Form Name
Antibiotic Prescription Data Template_Antibiotic Stewardship Cohort	11	Attachment K: Antibiotic Prescription Data Template_Antibiotic Stewardship Cohort
Clinical Data Collection Instrument_Cancer Diagnostic Process Cohort	10	Attachment J: Clinical Data Collection Instrument_Cancer Diagnostic Process Cohort
Diagnostic Safety Supplement	5	Attachment E: Diagnostic Safety Supplement
Interview Guide for Semi-Structured Interviews	9, 8	Attachment H: Draft Interview Guide for Semi-Structured Interviews_ Cancer Diagnostic Process Cohort ,   Attachment I: Draft Interview Guide for Semi-Structured Interviews_Antibiotic Stewardship Cohort
Participant Experience Survey_Antibiotic Stewardship Cohort	7	Attachment G: Participant Experience Survey_Antibiotic Stewardship Cohort
Participant Experience Survey_Cancer Diagnostic Process Cohort	6	Attachment F: Participant Experience Survey_Cancer Diagnostic Process Cohort
Structural Assessments	1, 2	Attachment A: Structural Assessment_Cancer Diagnostic Process Cohort ,   Attachment B: Structural Assessment_Antibiotic Stewardship Cohort
The Medical Office Survey on Patient Safety Culture (MOSOPS)	4	Attachment D: The Medical Office Survey on Patient Safety Culture (MOSOPS)
The Office Readiness Survey_Cancer Diagnostic Process Cohort	3	Attachment C: The Office Readiness Survey_Cancer Diagnostic Process Cohort

---

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	11,100	0	0	11,100	0	0
Annual Time Burden (Hours)	5,581	0	0	5,581	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: No

Burden Reduction Due to:

Short Statement: This is a new Information Collection Request

---

Annual Cost to Federal Government: $907,956

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.     Yes

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

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? No

---

Common Form ICR:  No

---

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: 03/20/2023

---