Form CMS-10808 iQIES HCD User Research Form

Request for Approval under the “Generic Clearance for the Center for Clinical Standards and Quality IT Product and Support Teams” (OMB Control Number: 0938-1397)

TITLE OF INFORMATION COLLECTION: Internet Quality Improvement and Evaluation System (IQIES) HCD User Research Form (CMS-10808)

PURPOSE OF COLLECTION:

What are you hoping to learn / improve? How do you plan to use what you learn? Are there artifacts (user personas, journey maps, digital roadmaps, summary of customer insights to inform service improvements, performance dashboards) the data from this collection will inform? 

CMS developed the Quality Improvement and Evaluation System (QIES) over a decade ago to directly support provisions within the legislations. As time has progressed, the QIES system architecture has become outdated and expensive to maintain. As a result, CMS initiated a project to modernize QIES by developing the Internet Quality Improvement and Evaluation System (IQIES) as a replacement. IQIES is an Internet-facing system that utilizes industry standard technologies to deliver the capabilities that CMS has mandated. IQIES functional capabilities are divided into three major categories, Patient Assessments (PA), Survey and Certification (S&C) and Reporting. User research with the IQIES user community will help drive decisions about how to improve quality patient assessments and survey and certifications that are conducted.

The IQIES HCD User Research form is designed to collect user’s contact information in real time from site visitors who are willing to volunteer to participate in user research. The form will be available through a link on the IQIES website to provide users the opportunity to input their contact details to improve our system. This information will allow the IQIES HCD Research team to effectively conduct research and analysis, as well as assess the needs of their user experience. Information will be collected through a form using drop-down menus and open text fields. Demographic data will be collected to better understand the type of user, however no Personally Identifiable Information (PII) or Protected/Personal Health Information (PHI) will be included in the IQIES HCD User Research Form. Estimated time to complete form is less than 5 minutes.

TYPE OF COLLECTION: (Check one)

[ ] Card Sorting [ ] Cognitive Testing

[ ] Field Studies [ ] First Click Tests

[ ] Focus Groups [ ] Participatory Design

[ ] Survey [ ] Tree Testing

[ ] User Interviews [ ] Usability Testing

[X] Other: Form

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: Gladys Olomukoro (IQIES HCD Lead)

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

3. If Yes, has an up-to-date System of Records Notice (SORN) been published? [ ] Yes [ ] No

GIFTS OR PAYMENTS

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

If Yes, describe:

BURDEN HOURS

Category of Respondent	No. of Respondents	Participation Time	Burden
IQIES Users	2,000	0.083	167 hours
Totals	2,000	0.083	167 hours

FEDERAL COST

The estimated annual cost to the Federal government is:

There is no additional cost for this form implementation, as it is part of the IQIES contract scope that has already been awarded.

ACTIVITY DETAILS

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

[X] Web-based or other forms of social media

[ ] Telephone

[ ] In-person

[ ] Mail

[ ] Other, Explain.

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

3. Who will you collect the information from?

Data will be collected through an online form from visitors to the IQIES website. This may include, but not limited to federal surveyors, health care surveyors, compliance surveyors, registered nurses, CMS staff, assessment coordinators, and health care providers.

4. How will you ask a respondent to provide this information?

Respondents will provide their contact information using an online form on the IQIES website. The link will be placed at the footer of the IQIES website. The link will present an opportunity for users to input their contact information using an online form. Completion of the form is voluntary.

5. What will the activity look like?

During a user’s visit to the IQIES website, they will be presented an opportunity to voluntarily input their contact information. They form will include a combination of text entry fields and drop-down menus. If they choose to participate, they will respond to the questions and click submit to send their responses to a secure database stored in ServiceNow.

6. Please provide your question list.

1. Full name (type in)

2. Email address (confirm email address)

3. Type of HCD research participant is willing to participate in (drop down): Survey & Certification, Patient Assessment, Reports

4. Location (drop down)

5. Affiliation/Organization (type in)

6. Area of work responsibility/role (type in)

7. Provider/Assessment Type Responsibility (drop down)

• Hospitals

• Nursing Homes

• Home Health Agencies

• Psychiatric Residential Treatment Facilities

• Portable X-Ray Suppliers

• Outpatient Physical Therapy / Speech Pathology Services

• End-Stage Renal Disease Facilities

• Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICFs-IID)

• Rural Health Clinics

• Comprehensive Outpatient Rehabilitation Facilities

• Ambulatory Surgical Centers

• Hospices

• Organ Procurement Organizations

• Community Mental Health Centers (CMHCs)

• Federally Qualified Health Centers

• Clinical Laboratories

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

7. When will the activity happen?

Data will be collected in real-time throughout the year to collect IQIES HCD User Research participants. The team aims to launch the form in the beginning of Spring 2022. We plan to conduct HCD user research studies for Hospice and Nursing Home provider types over the course of 2022.

Instructions for completing Request for Approval under the “Generic Clearance for the Center for Clinical Standards and Quality IT Product and Support Teams”

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.

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. Note: Agencies should only collect PII to the extent necessary, and they should only retain PII for the period that is necessary to achieve a specific objective.

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 per row.

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.

ACTIVITY DETAILS: Complete each section as described.

If you are conducting a focus group, survey, or plan to employ statistical methods, please provide a description of how you plan to identify your potential group of respondents and how you will select them.

Submit all instruments, instructions, and scripts are submitted with the request.

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