ICR A-11 Section 280 Clearance request VHA CLC Add SCI/D question

Request for Approval under the “Generic Clearance for Improving Customer Experience: OMB Circular A-11, Section 280 Implementation”

(OMB Control Number:2900-0876)

TITLE OF INFORMATION COLLECTION: Community Living Centers (CLC) Survey

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 feed?

This is an update to a previously OMB approved survey instrument to add a question if the respondent is in a Spinal Cord Injury/Disorder unit to distinguish that in the data analysis. This is the first question on the wireframe. The survey is ongoing and continuous.

Improve the ability for Residents to provide feedback on their experience at a Community Living Centers (CLC) by creating space for Residents to share preferences, providing multiple pathways for them to be heard, empowering someone to listen and act, and making opportunities visible across CLCs.

CLCs are like nursing homes where veterans stay for an extended period to receive care.

The survey’s purpose is to cover a Government Accountability Office (GAO) recommendation for the CLCs to gauge high level metrics like quality and trust. As part of GAO-22-104027 report it was identified that VA has not surveyed current residents about their CLC experience. The GAO recommendation was to have a survey for CLC residents that would help VA identify quality of care issues across CLCs. Survey will be administered in person, at bedside. If Veteran agrees to be contacted about their survey response fields would appear so the Veteran can provide their last name and date of birth. In the history of this survey, last name and date of birth have been determined to be the most effective method to organize follow up conversations given that the respondents are residents in a center and have not been shown to consistently access their personal email or phone.

The Department of Veterans Affairs (VA) is committed to implementing the new race and ethnicity data standards outlined in Statistical Policy Directive No. 15 (SPD-15) but faces some challenges in immediate full compliance. VA's current systems require significant upgrades to accommodate the new categories and write-in fields, which could potentially disrupt services if implemented hastily. There are substantial costs associated with updating forms and modifying IT infrastructure that are not currently budgeted. VA anticipates achieving full compliance prior to March 28, 2029, as permitted by the directive. The VA is requesting approval to maintain its current race and ethnicity data collection practices currently, with the understanding that it the enterprise is working to develop an implementation plan, including prioritization of existing collections, to bring all data collections into compliance. The exact timeline for implementation is not yet final, but VA anticipates the first updates to occur in FY2026.

TYPE OF ACTIVITY: (Check one)

[ ] Customer Research (Interview, Focus Groups, Surveys)

[ X] Customer Feedback Survey

[ ] Usability Testing of Products or Services

ACTIVITY DETAILS

1. If this is a survey, will the results of this survey be reported to Touchpoints as part of quarterly reporting obligations specified in OMB Circular A-11 Section 280?

[ ] Yes

[X ] No

[ ] Not a survey

2. 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

3. Who will you collect the information from?

Explain who will be interviewed and why the group is appropriate for the Federal program / service to connect with. Please provide a description of how you plan to identify your potential group of respondents and if only a sample will be solicited for feedback, how you will select them(e.g., anyone who provided an email address to a call center rep, a representative sample of Veterans who received outpatient services in May 2019, do you have a list of customers to reach out to (e.g., a CRM database that has the contact information, intercept interviews at a particular field office?)

• All Veterans who are admitted to the CLC will receive the survey after they have been in residence at the center for at least 14 days.

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

(e.g., after an application is submitted online, the final screen will present the opportunity to provide feedback by presenting a link to a feedback form / an actual feedback form)

• The survey will be administered by an Ombudsman who is a VA employee but is outside of the CLC care.

• The Ombudsman will help make the veteran feel more comfortable in being honest with their responses as opposed to having CLC staff administering the survey.

• The survey will also be available in a QR code format on flyers that a Veteran can take on demand.

5. What will the activity look like?

Describe the information collection activity – e.g. what happens when a person agrees to participate? Will facilitators or interviewers be used? What’s the format of the interview/focus group? If a survey, describe the overall survey layout/length/other details? If User Testing, what actions will you observe / how will you have respondents interact with a product you need feedback on?

• The Ombudsman will be there in person to help the respondent take the survey on a tablet or a printed version.

• There will also be flyers with QR codes available for Veterans to take the survey on demand.

• Additional feedback mechanisms will be in place to reach out to the veterans if they select, they want to be contacted about their responses, and there are also nurse rounding tools to gather comments.

• If Veteran selects that they can be contacted about their survey response fields would appear so the Veteran can provide their last name and date of birth. In the history of this survey, last name and date of birth have been determined to be the most effective method to organize follow up conversations given that the respondents are residents in a center and have not been shown to consistently access their personal email or phone.

6. Please provide your question list.

Please see attached documents for correct formatting. Some formatting may have been lost due to issues with copy/pasting into this writeup. Additionally, “Required” and “Logic” statements are for explaining survey logic and will not appear on the actual survey.

TITLE: Community Living Centers (CLC) Survey

We want to hear about your experience with your Community Living Center. By responding

to this survey, you will directly help us improve the services we provide to CLC residents like

you. VA wants to provide you with the best possible living experiences!

This voluntary survey should take approximately 2 minutes to complete.

1. Are you a Spinal Cord Injury and Disorders (SCI/D) resident? Required [Logic: Display only for CLCs with an SCI/D section: Louis Stokes Cleveland Department of Veterans Affairs Medical Center, OH (541), Brockton VA Medical Center, MA (523A5), Hampton VA Medical Center, VA (590), Tibor Rubin VA Medical Center, CA (600), & James A. Haley Veterans' Hospital, FL (673)]

   1. Yes

   2. No

2. I feel like the staff really listen to me here.

Strongly Disagree Disagree Neither Agree nor Disagree Agree Strongly Agree

3. If I have a problem, I feel comfortable speaking up.

Strongly Disagree Disagree Neither Agree nor Disagree Agree Strongly Agree

4. This CLC feels home-like to me.

Strongly Disagree Disagree Neither Agree nor Disagree Agree Strongly Agree

5. I’m getting good quality care here.

Strongly Disagree Disagree Neither Agree nor Disagree Agree Strongly Agree

6. I trust VA Strongly Disagree CLC to take care of me. Required

Strongly Disagree Disagree Neither Agree nor Disagree Agree Strongly Agree

7. CLC can contact me about my experience to learn more about the feedback you provided to improve your experience.

1. Yes [Logic proceed to question #8]

2. No [Logic proceed to question #9]

8. Please provide your last name and date of birth so our staff can identify you to contact you about your experience:

   1. Last Name: Required [Logic: Display and make required if question #7 is yes]

   2. Date of Birth: Required [Logic: Display and make required if question #7 is yes]

9. Would you like to volunteer your demographic information to help VA better serve you?

   1. Yes [Logic proceed to Demographics page]

   2. No [Logic skip Demographics page]

10. What is your age?

    1. <30

    2. 30-39

    3. 40-49

    4. 50-59

    5. 60-69

    6. 70-79

    7. 80-89

    8. 90+

11. How would you describe your race? Please select all that apply.

    1. American Indian or Alaska Native

    2. Asian

    3. Black or African American

    4. Native Hawaiian or Pacific Islander

    5. White

    6. Middle Eastern or North African

12. Are you Hispanic or Latino?

    1. Yes

    2. No

13. How would you describe your gender? Please select all that apply.

    1. Male

    2. Female

    3. Transgender

    4. Non-Binary/Third Gender

    5. Prefer not to say [Logic: when Prefer not to say is selected, no other option can be selected in the question]

    6. Other

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

• Done

7. When will the activity happen?

Describe the time frame or number of events that will occur (e.g., We will conduct focus groups on May 13,14,15, We plan to conduct customer intercept interviews over the course of the Summer at the field offices identified in response to #2 based on scheduling logistics concluding by Sept. 10^th, or “This survey will remain on our website in alignment with the timing of the overall clearance.”)

• The survey will be a continuous, ongoing survey to collect feedback from residents of CLCs. The survey will be available to all Veterans in the CLC after they have been admitted for at least 14 days.

8. Is an incentive (e.g., money or reimbursement of expenses, token of appreciation) provided to participants?

[ ] Yes [X ] No

If Yes, describe:

Not Applicable

BURDEN HOURS

Category of Respondent	No. of Respondents	Participation Time	Burden Hours
Individuals	10,000	2 minutes	333
Totals	10,000	2 minutes	333

CERTIFICATION:

I certify the following to be true:

1. The collections are voluntary;

2. The collections are low-burden for respondents (based on considerations of total burden hours or burden-hours per respondent) and are low-cost for both the respondents and the Federal Government;

3. The collections are non-controversial;

4. Any 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 near future;

5. Personally identifiable information (PII) is collected only to the extent necessary and is not retained;

6. Information gathered is intended to be used for general service improvement and program management purposes;

7. Upon agreement between OMB and the agency aggregated data may be released as part of A-11, Section 280 requirements only on performance.gov. Summaries of customer research and user testing activities may be included in public-facing customer journey maps;

8. Additional release of data will be coordinated with OMB.

Name and email address of person who developed this survey/focus group/interview:

Name: __Todd Stawicki Enterprise Measurement Project Manager, Veterans Experience Office, VA (908) 768-5372__________________

Email address: __[email protected]_________

All instruments used to collect information must include:

OMB Control No. 2900-0876

Expiration Date: 2/28/2026

HELP SHEET

(OMB Control Number: 2900-0876)

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

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.

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