ICR Template_A11 Section 280 Clearance Telehealth Emergency Medicine Survey Update

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: Telehealth Emergency Medicine Survey Update

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 a request to update the questions on the already OMB approved Emergency Medicine Telehealth Customer Satisfaction Survey. These updates are necessary to ensure clarity and relevance by focusing specifically on tele-emergency care rather than traditional ER visits. The new questions and preamble use concise language that accurately reflects the telehealth services being evaluated, avoiding any potential confusion for respondents. This shift in terminology helps to streamline the survey, making it easier for participants to understand and provide feedback that is directly related to their tele-emergency care experience, ultimately aiding in the improvement of these services.

• This survey will gauge respondents’ perceptions of the patient experience when visiting VHA emergency medical telehealth (emergency medicine or urgent care) services. The Emergency Medicine survey is designed to measure customer satisfaction after using either the Emergency Department or an Urgent Care department at a VHA facility. Any Veterans who recently obtained these services will be invited to participate in a brief online survey. With the rise of Telemedicine in 2020, this survey is been updated to census a cohort of the ED and UC that received care via the VA Telehealth/Virtual Modalities.

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?)

• The target population of the Emergency Medicine surveys is all Veterans who have obtained medical services at a VHA emergency medicine department in the seven days prior to sampling. This is being expended to Veterans who received Virtual Emergency or Urgent Care through various VA Telehealth Modalities. Identification of these Veterans will occur via weekly data extracts from the VHA Corporate Data Warehouse (CDW), which houses the operational records of VHA.

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)

• An email invitation will be sent to all Veterans who were discharged from either the Emergency Room or the Urgent Health Clinic at a VA facility four to eleven days prior to sampling. This lag time ensures that Veterans have adequate time to receive the email invitation. The email will include a link to the online survey and will explain the purpose of the survey, emphasizing the importance of their feedback. Respondents will have 14 days to complete the survey, with a reminder email sent after 7 days if the survey has not been completed. This method ensures timely and convenient participation, improving cognitive recall and reducing measurement error. SORN: Veterans, Dependents of Veterans, and VA Beneficiary Survey Records (43VA008)

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 information collection activity involves sending an email invitation to Veterans who were discharged from either the Emergency Room or the Urgent Health Clinic at a VA facility four to eleven days prior. Upon agreeing to participate, Veterans will complete an online survey designed to measure their experience with various aspects of emergency medical care. The survey is brief, focusing on key experience drivers like Trust, Emotion, Effectiveness, and Ease, and uses a five-point Likert scale for responses. The survey is distributed weekly, and participants have 14 days to complete it, with a reminder email sent after 7 days if not completed. The survey layout includes questions about their interactions with front desk and clinical staff, wait times, the physical environment, and discharge processes.

6. Please provide your question list.

• Please see attached document 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: Telehealth Emergency Medicine Survey Update

Working Draft, Pre-Decisional, Deliberative document – Internal VA Use Only

We want to hear about your recent Atlanta VA Medical Center Emergency Room (ER) visit. By indicating how much you agree or disagree with the statements below, you directly help us improve VA services.

This survey should take approximately 3 minutes to complete.

1. Which of the following influence your decision to utilize tele-emergency care? (Select all that apply. Required)

• I trust VA to take care of me.

• I was worried about receiving bills if I went to an ER in my community.

• It was more convenient.

• The distance to the nearest VAMC is too far.

• None of the above.

2. The process to be seen by a tele-emergency care provider was easy to follow. (Required)

• Strongly Disagree

• Disagree

• Neither Agree nor Disagree

• Agree

• Strongly Agree

3. The tele-emergency care provider listened to my concerns and showed they cared. (Required)

• Strongly Disagree

• Disagree

• Neither Agree nor Disagree

• Agree

• Strongly Agree

4. The tele-emergency care provider made it easy for me to understand my after-care instructions. (Required)

• Strongly Disagree

• Disagree

• Neither Agree nor Disagree

• Agree

• Strongly Agree

5. Overall, I was satisfied with the tele-emergency care service. (Required)

• Strongly Disagree

• Disagree

• Neither Agree nor Disagree

• Agree

• Strongly Agree

6. Based on this tele-emergency care visit, I trust tele-emergency care to serve me in the future. (Required)

• Strongly Disagree

• Disagree

• Neither Agree nor Disagree

• Agree

• Strongly Agree

7. Would you like to provide additional feedback about your tele-emergency care visit? (Select all that apply. Required)

• Compliment

• Concern

• Recommendation

• Will not provide additional feedback

8. Can VA contact you about your feedback? (Required)

• Yes, VA can contact me about my patient experience.

• No, I do not want VA to contact me about my patient experience.

Privacy Notice: By filling out this survey, you are authorizing VA database access to retrieve Veteran contact information to follow up with you accordingly for purposes of service recovery, potential crisis, or to learn more about feedback you have shared regarding your experience with VA. Your contact information and response may be referred to the Veterans Crisis Line if an automated review indicates your response may be concerning. The Veterans Crisis Line may contact you for follow up as a result of that referral. VA may utilize individual Veteran survey data from this survey or other sources to ensure the final scores truly and accurately represent the experiences of Veterans. This collection of information is authorized by 38 U.S.C. Section 301 (https://www.federalregister.gov/d/2021-01526).

Respondent Burden: An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The OMB control number for this project is 2900-0876, and it expires 02/28/2026. Public reporting burden for this collection of information is estimated to average 3 minutes per respondent, per year, including the time for reviewing instructions, searching existing data sources, gathering, and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate and any other aspect of this collection of information, including suggestions for reducing the burden, to VA Reports Clearance Officer at [email protected]. Please refer to OMB Control No. 2900-0876 in any correspondence. Do not send your completed VA Form to this email address.

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 activity will occur on a weekly basis, with email invitations sent to Veterans who were discharged from either the Emergency Room or the Urgent Health Clinic at a VA facility four to eleven days prior. The survey distribution will happen every Tuesday, and participants will have 14 days to complete the survey, with a reminder email sent after 7 days if the survey has not been completed. This ongoing data collection process ensures timely feedback and continuous monitoring of the Veteran experience..

8. 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 Hours
	9,900	3 minutes	495
Totals	9,900	3 minutes	495

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. The agency will follow the procedures specified in OMB Circular A-11 Section 280 for the required quarterly reporting to OMB of trust data and experience driver data from surveys.

8. Outside of the quarterly reporting mentioned in the bullet immediately above, if the agency intends to release journey maps, user personas, reports, or other data-related summaries stemming from this collection, the agency must include appropriate caveats around those summaries, noting that conclusions should not be generalized beyond the sample, considering the sample size and response rates. The agency must submit the data summary itself (e.g., the report) and the caveat language mentioned above to OMB before it releases them outside the agency. OMB will engage in a passback process with the agency.

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

Name: Sergio Gazaryan

Email address: [email protected]

All instruments used to collect information must include:

OMB Control No. 2900-0876

Expiration Date: 02/28/2026

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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