Pilot Test of the Proposed Value and Efficiency Surveys and Communicating About Value Checklist

Forms and Documents

Document Name	Status
Form Form #10 Pretest for the CV checklist Form and Instruction	New
Form Form #9 Cognitive interviews for the CV checklist Form and Instruction	New
Form Form #8 Survey to identify items for CV checklist Form and Instruction	New
Form Form #7 Medical office information form Form and Instruction	New
Form Form #6 POC Administration of the Medical Office VE survey Form and Instruction	New
Form Form #5 POC Administration of the Hospital VE survey Form and Instruction	New
Form Form #4 Pretest for the Medical Office VE survey Form and Instruction	New
Form Form #3 Pretest for the Hospital VE survey Form and Instruction	New
Form Form #2 Cognitive interviews for the Medical Office VE survey Form and Instruction	New
Form Form #1 Cognitive interviews for the Hospital VE survey Form and Instruction	New
Supporting Statement Part B -- Pilot Test of the High Value and Efficiency Culture Surveys 1-10-2013.docx Supporting Statement B	2013-04-19
Attachment N -- Federal Register Notice.pdf Supplementary Document	2013-04-19
Attachment O - List of Expert Reviewers and Consultants.docx Supplementary Document	2013-04-19
Attachment L - Draft CV Checklist.docx Supplementary Document	2013-04-19
Attachment H - Pretest Cover Letter and Reminder Notice for Medical Office VE Survey.docx Supplementary Document	2013-04-18
Attachment G - Pretest Cover Letter and Reminder Notice for Hospital VE Survey.docx Supplementary Document	2013-04-18
Supporting Statement Part A -- Pilot Test of the Proposed Value and Efficiency Surveys and Checklist 1-10-2013.docx Supporting Statement A	2013-04-19

IC Document Collections

IC ID	Document Title	Status
206682	Pretest for the CV checklist Form and Instruction	New
206681	Cognitive interviews for the CV checklist Form and Instruction	New
206680	Survey to identify items for CV checklist Form and Instruction	New
206679	Medical office information form Form and Instruction	New
206678	POC Administration of the Medical Office VE survey Form and Instruction	New
206677	POC Administration of the Hospital VE survey Form and Instruction	New
206676	Pretest for the Medical Office VE survey Form and Instruction	New
206675	Pretest for the Hospital VE survey Form and Instruction	New
206674	Cognitive interviews for the Medical Office VE survey Form and Instruction	New
206673	Cognitive interviews for the Hospital VE survey Form and Instruction	New

ICR Details

OMB Control No: 0935-0211	ICR Reference No: 201304-0935-003
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/AHRQ	Agency Tracking No: 19290
Title: Pilot Test of the Proposed Value and Efficiency Surveys and Communicating About Value Checklist
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: 07/24/2013
	Date Received in OIRA: 04/25/2013
Terms of Clearance: Necessary materials were included in submission.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	07/31/2014	12 Months From Approved
Responses	5,066	0	0
Time Burden (Hours)	2,534	0	0
Cost Burden (Dollars)	0	0	0

---

Abstract: Given the widespread impact of cost and waste in health care, AHRQ will develop the Value and Efficiency (VE) Surveys for hospitals and medical offices. These surveys will measure staff perceptions about what is important in their organization and what attitudes and behaviors related to value and efficiency are supported, rewarded, and expected. The surveys will help hospitals and medical offices to identify and discuss strengths and weaknesses within their individual organizations. They can then use that knowledge to develop appropriate action plans to improve their value and efficiency. To develop these tools AHRQ will recruit medical staff from 42 hospitals and 96 medical offices to participate in cognitive testing and pretesting. In addition to the VE surveys, AHRQ also intends to develop a Communicating About Value Checklist (CV checklist). The objective of the CV checklist is to aid clinicians in having conversations with patients about value.

---

Authorizing Statute(s): US Code: 42 USC 299 Name of Law: Healthcare Research and 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:
	78 FR 946	01/07/2013
30-day Notice:	Federal Register Citation:	Citation Date:
	78 FR 23256	04/18/2013
Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 10

IC Title	Form No.	Form Name
Cognitive interviews for the Hospital VE survey	Form #1	Cognitive Interview Guide for Hospital VE Survey
Cognitive interviews for the Medical Office VE survey	Form #2	Cognitive Interview Guide for Medical Office VE Survey
Pretest for the Hospital VE survey	Form #3	Pretest Survey for Hospital VE Survey
Pretest for the Medical Office VE survey	Form #4	Pretest Survey for Medical Office VE Survey
POC Administration of the Hospital VE survey	Form #5	Site-level POC Instructions for Hospital VE Survey
POC Administration of the Medical Office VE survey	Form #6	Site-level POC Instructions for Medical Office VE Survey
Medical office information form	Form #7	Medical Office Information Form
Survey to identify items for CV checklist	Form #8	CV Checklist Survey
Cognitive interviews for the CV checklist	Form #9	Cognitive Interview Guide for CV Checklist
Pretest for the CV checklist	Form #10	Draft CV Checklist Evaluation

---

ICR Summary 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	5,066	0	0	5,066	0	0
Annual Time Burden (Hours)	2,534	0	0	2,534	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: $1,001,202

Does this IC contain surveys, censuses, or employ statistical methods? Yes Part B of Supporting Statement

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

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? Uncollected

---

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: 04/25/2013

---