GenIC Request Template

Request for Approval under the “Generic Clearance for the Collection of Routine Customer Feedback” (OMB Control Number: 0920-1071)

TITLE OF INFORMATION COLLECTION: Survey of Nursing Homes to Support a Pilot Test of a National Healthcare Safety Network (NHSN) Electronic Health Record (EHR) Implementation Guide (IG)

PURPOSE:

We intend to field a brief 15-to-20-minute survey about the processes used to collect information on and monitor Clostridium difficile (C. diff.) infections in US nursing homes and about the availability of data related to C. diff. infection monitoring that may or may not be commonly accessible through the nursing home’s Electronic Health Records (EHR) system. This survey will be used to obtain feedback from nursing homes regarding specific experiences, such as the availability of data, ease of entry of data within your Electronic Health Record system, level of encouragement from administrators to track and report data, barriers and challenges to reporting into established systems, and overall work burden related to the identification and monitoring of Clostridioides difficile infections among residents. This will provide valuable contextual information to support other analyses for our pilot test of an implementation guide for EHR capture of C. diff. infections at nursing homes, which we are carrying out as part of a contract for the Centers for Disease Control and Prevention (CDC).

DESCRIPTION OF RESPONDENTS:

The intended respondents for this nursing home survey are Medicare and/or Medicaid-certified nursing homes in the United States. Specifically, the ideal respondents will be staff members within these nursing homes who are knowledgeable about infection management activities related to healthcare associated infections (HAI) within the nursing homes.

TYPE OF COLLECTION: (Check one)

[ ] Customer Comment Card/Complaint Form [ ] Customer Satisfaction Survey

[ ] Usability Testing (e.g., Website or Software [ ] Small Discussion Group

[ ] Focus Group [X] Other: Survey about provider experience

CERTIFICATION:

I certify the following to be true:

1. The collection is voluntary.

2. The collection is low-burden for respondents and low-cost for the Federal Government.

3. The collection is non-controversial and does not raise issues of concern to other federal agencies.

4. The results are not intended to be disseminated to the public.

5. Information gathered will not be used for the purpose of substantially informing influential policy decisions.

6. The collection is targeted to the solicitation of opinions from respondents who have experience with the program or may have experience with the program in the future.

Name:__________Jeneita Bell______________________________________

To assist review, please provide answers to the following question:

Personally Identifiable Information:

1. Is personally identifiable information (PII) collected? [ ] Yes [X ] No

2. If Yes, is the information that will be collected included in records that are subject to the Privacy Act of 1974? [ ] Yes [X ] No

3. If Applicable, has a System or Records Notice been published? [ ] Yes [ ] No [X] Not Applicable

Gifts or Payments:

Is an incentive (e.g., money or reimbursement of expenses, token of appreciation) provided to participants? [ ] Yes [X] No

BURDEN HOURS

Category of Respondent	No. of Respondents	Participation Time	Burden
Infection Preventionist	250	20 minutes	83hours
Totals

FEDERAL COST: The estimated annual cost to the Federal government is approximately $25,553.36 for one planned administration.

If you are conducting a focus group, survey, or plan to employ statistical methods, please provide answers to the following questions:

The selection of your targeted respondents

1. Do you have a customer list or something similar that defines the universe of potential respondents and do you have a sampling plan for selecting from this universe? [X] Yes [ ] No

If the answer is yes, please provide a description of both below (or attach the sampling plan)? If the answer is no, please provide a description of how you plan to identify your potential group of respondents and how you will select them?

The sampling frame for the nursing home survey will come from the Provider Information file of the publicly available database CMS Care Compare – Nursing homes including rehab services, and Provider Data Catalog (https://data.cms.gov/provider-data/topics/nursing-homes/data-sources). This data source contains a census of all Medicare-certified nursing homes in operation in a given month and includes data on nursing home characteristics, including location, mailing/street address, and size of each nursing home. We will send surveys to selected recipients by mail. Potential respondents will be invited to submit responses either by paper copy mailed using a postage-paid return envelope or by electronically responding through visiting a confidential and secure website URL provided in the survey cover letter. We plan to implement random selection of a stratified sample of up to approximately 4,000 nursing homes (aiming for 250 respondents) using strata such as (1) member of a multi-facility organization vs. independent facility, (2) size (e.g. small, medium, large in terms of number of resident days), star rating (high vs. low), % use of RNs (high vs. low), rural/non-rural, and the 10 HHS regions to ensure representativeness. A staggered survey administration approach will be applied in achieving the target number of 250 respondents. The purpose of the stratified sampling is to help achieve representation of nursing homes with key characteristics as opposed to gaining statistical power for analyses within or across particular strata.

Administration of the Instrument

1. How will you collect the information? (Check all that apply)

[X] Web-based or other forms of Social Media

[ ] Telephone

[ ] In-person

[X] Mail

[ ] Other, Explain

2. Will interviewers or facilitators be used? [ ] Yes [X] No

Please make sure that all instruments, instructions, and scripts are submitted with the request.

Instructions for completing Request for Approval under the “Generic Clearance for the Collection of Routine Customer Feedback”

TITLE OF INFORMATION COLLECTION: Provide the name of the collection that is the subject of the request. (e.g., Comment card for soliciting feedback on xxxx)

PURPOSE: Provide a brief description of the purpose of this collection and how it will be used. If this is part of a larger study or effort, please include this in your explanation.

DESCRIPTION OF RESPONDENTS: Provide a brief description of the targeted group or groups for this collection of information. These groups must have experience with the program.

TYPE OF COLLECTION: Check one box. If you are requesting approval of other instruments under the generic, you must complete a form for each instrument.

CERTIFICATION: Please read the certification carefully. If you incorrectly certify, the collection will be returned as improperly submitted or it will be disapproved.

Personally Identifiable Information: Provide answers to the questions.

Gifts or Payments: If you answer yes to the question, please describe the incentive and provide a justification for the amount.

BURDEN HOURS:

Category of Respondents: Identify who you expect the respondents to be in terms of the following categories: (1) Individuals or Households;(2) Private Sector; (3) State, local, or tribal governments; or (4) Federal Government. Only one type of respondent can be selected.

No. of Respondents: Provide an estimate of the Number of respondents.

Participation Time: Provide an estimate of the amount of time required for a respondent to participate (e.g. fill out a survey or participate in a focus group)

Burden: Provide the Annual burden hours: Multiply the Number of responses and the participation time and divide by 60.

FEDERAL COST: Provide an estimate of the annual cost to the Federal government.

If you are conducting a focus group, survey, or plan to employ statistical methods, please provide answers to the following questions:

The selection of your targeted respondents. Please provide a description of how you plan to identify your potential group of respondents and how you will select them. If the answer is yes, to the first question, you may provide the sampling plan in an attachment.

Administration of the Instrument: Identify how the information will be collected. More than one box may be checked. Indicate whether there will be interviewers (e.g. for surveys) or facilitators (e.g., for focus groups) used.

Please make sure that all instruments, instructions, and scripts are submitted with the request.

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