Agency Information Collection Activities: Proposed Collection; Comment Request, 946-949 [2012-31592]
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Federal Register / Vol. 78, No. 4 / Monday, January 7, 2013 / Notices
DEPARTMENT OF HEALTH AND
HUMAN SERVICES
Agency for Healthcare Research and
Quality
Agency Information Collection
Activities: Proposed Collection;
Comment Request
Agency for Healthcare Research
and Quality, HHS.
ACTION: Notice.
AGENCY:
This notice announces the
intention of the Agency for Healthcare
Research and Quality (AHRQ) to request
that the Office of Management and
Budget (OMB) approve the proposed
information collection project: ‘‘Pilot
Test of the Proposed Value and
Efficiency Surveys and Communicating
About Value Checklist.’’ In accordance
with the Paperwork Reduction Act, 44
U.S.C. 3501–3521, AHRQ invites the
public to comment on this proposed
information collection.
DATES: Comments on this notice must be
received by March 8, 2013.
ADDRESSES: Written comments should
be submitted to: Doris Lefkowitz,
Reports Clearance Officer, AHRQ, by
email at doris.lefkowitz@AHRQ.hhs.gov.
Copies of the proposed collection
plans, data collection instruments, and
specific details on the estimated burden
can be obtained from the AHRQ Reports
Clearance Officer.
FOR FURTHER INFORMATION CONTACT:
Doris Lefkowitz, AHRQ Reports
Clearance Officer, (301) 427–1477, or by
email at doris.lefkowitz@AHRQ.hhs.gov.
SUPPLEMENTARY INFORMATION:
SUMMARY:
Proposed Project
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Pilot Test of the Proposed Value and
Efficiency Surveys and Communicating
About Value Checklist
Maximizing value within the
American health care system is an
important priority. Value is often
viewed as a combination of high quality,
high efficiency care, and there is general
agreement by consumers, policy makers,
payers, and providers that it is lacking
in the U.S. A recent report by the
Institute of Medicine estimated that 20
to 30 percent ($765 billion a year) of
U.S. healthcare spending was inefficient
and could be reduced without lowering
quality.
Multiple overlapping initiatives are
currently seeking to improve value
using a variety of approaches. Public
reporting efforts led by the Centers for
Medicare and Medicaid Services (CMS),
other payers and consumer groups seek
to enable consumers to make more
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informed choices about the quality, and
in some cases, the costs of their care. A
variety of demonstration projects and
payment reforms initiated by CMS and
private insurers are attempting to more
closely link care quality with payments
to incent higher value care. And
national improvement initiatives led by
AHRQ (comprehensive unit-based safety
programs [CUSP] for central lineassociated blood stream infection
[CLABSI], catheter-associated urinary
tract infections [CUTI], and surgical
units [SUSP]) and CMS (hospital
engagement networks, QI0 scopes of
work) are seeking to raise care quality
and reduce readmissions. Results from
the CUSP–CLABSI project have
demonstrated that central line infections
can be reduced and unnecessary costs
can be removed from the health care
system by concerted, unit-based
improvement efforts.
As a systems level example, Denver
Health, with initial funding from AHRQ,
has taken major steps towards
redesigning clinical and administrative
processes so as to reduce staff time,
patient waiting, and unnecessary costs.
These improvements occurred without
harm to quality and in some instances
actually improved quality.
In many cases, improving quality
improves efficiency naturally. Reducing
the number of hospital errors for
example will reduce costs associated
with longer length of stay or errortriggered readmissions. It is more costeffective to do things right the first time.
But higher value is more likely if
organizations doing quality
improvement link efforts to improve
care quality with efforts to reduce
unnecessary costs. Ignoring the financial
implications of quality improvement
efforts will fail in the real world where
many providers face acute financial
challenges and where costs are leading
to consumer bankruptcies and increased
insurance costs. AHRQ understands that
many of the root causes of inefficiencies
that drive up costs are closely linked to
root causes of inefficiencies that lead to
poor quality, uncoordinated care where
redundancies and system failures place
patients at risk. Adding value within
healthcare requires understanding the
contribution that organizational culture
makes to value and working to foster a
culture where high value is a cultural
norm. AHRQ’s development of the
Hospital Survey on Patient Safety
Culture (HSOPS) has contributed greatly
to efforts to promote the important role
culture plays in providing safe care.
HSOPS is used extensively in national
improvement campaigns and many
hospitals and health systems now
regularly assess their safety cultures and
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use culture scores on organizational
dashboards and as parts of variable
compensation programs.
If organizations lack cultures
committed to value then discrete efforts
to raise dimensions of value are likely
to yield limited and unsustainable
results. And if organizational leaders
have no plausible way to know whether
their organizational culture is
committed to value, then their ability to
make value a higher organizational
priority will be very limited. Thus,
developing value and efficiency survey
instruments for hospitals and medical
offices fills an important need for many
ongoing and planned efforts to foster
greater value within American health
care.
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 YE 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.
Since the proper goal for any health care
delivery system is to improve the value
delivered to patients, such a tool will
address the important aspects of health
care that are of value to patients. Value
in health care is typically measured in
terms of the patient outcomes achieved
per dollar expended. But a good
outcome must be defined in terms of
what is meaningful and valuable to the
individual patient.
Better identification of patients’
preferences is not only the right ethical
thing to do but it also can reduce the
cost of healthcare. Studies indicate that
engaged and informed patients often
choose to have less intensive care and
become more careful about having lots
of procedures. In addition, participatory
decision making can reduce medication
non-adherence which has been directly
linked to increased morbidity, mortality
and potentially avoidable healthcare
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costs totaling $290 billion annually in
the U.S.
The CV checklist will address three
major topics: who should talk with
patients about value issues (e.g., nurses,
physicians, etc.), when should these
conversations occur (e.g., when patients
may incur costs, when they express
financial concerns, etc.), and how can
clinicians prepare for and effectively
facilitate such discussions.
This research has the following goals:
(1) Develop, cognitively test and
modify as necessary the VE surveys (one
for hospitals and one for medical
offices);
(2) Pretest the VE surveys in hospitals
and medical offices and modify as
necessary based on the results;
(3) Develop, cognitively test and
modify as necessary the CV checklist;
(4) Pretest the CV checklist in
hospitals and medical offices and
modify as necessary based on the
results;
(5) Make the final VE surveys and CV
checklist available for use by the public.
This study is being conducted by
AHRQ through its contractor, Health
Research & Educational Trust (HRET),
and subcontractor, Westat, pursuant to
AHRQ’s statutory authority to conduct
and support research on healthcare and
on systems for the delivery of such care,
including activities with respect to the
quality, effectiveness, efficiency,
appropriateness and value of healthcare
services and with respect to quality
measurement and improvement. 42
U.S.C. 299a(a)(1) and (2).
Method of Collection
To achieve these goals the following
activities and data collections will be
implemented:
(1) Cognitive interviews for the VE
surveys. One round of interviews on the
VE surveys will be conducted by
telephone with 9 respondents from
hospitals and 9 respondents from
medical offices. The purpose of these
interviews is to understand the
cognitive processes the respondent
engages in when answering a question
on the VE survey and to refine the
survey’s items and composites. These
interviews will be conducted with a mix
of senior leaders and clinical staff (i.e.,
unit/department managers,
practitioners, nurses, technicians, and
medical assistants) from hospitals and
medical offices throughout the U.S. with
varying characteristics (e.g., size,
geographic location, type of medical
office practice/hospital, and possibly
extent of experience with wastereduction efforts).
(2) Pretest for the VE surveys. The
surveys will be pretested with senior
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leaders and clinical staff from 42
hospitals and 96 medical offices. The
purpose of the pretest is to collect data
for an assessment of the reliability and
construct validity of the surveys’ items
and composites, allowing for their
further refinement. A site-level point-ofcontact (POC) will be recruited in each
medical office and hospital to manage
the data collection at that organization
(compiles sample information,
distribute surveys, promote survey
response, etc.). Exhibit 1 includes a
burden estimate for the POC’s time to
manage the data collection.
(3) Medical office information form.
This form will be completed by the
medical office manager in each of the 96
medical office pretest sites to provide
background characteristics, such as type
of specialty(s) and majority ownership.
A hospital information form will not be
needed because characteristics on
pretest hospitals will be obtained from
the American Hospital Association’s
(AHA) data set based on a hospital’s
AHA ID number.
(4) Survey to identify items for CV
checklist. In order to identify items to
put on the checklist, a survey will be
developed and sent to 160
representative participants (40
Physicians, 40 Registered Nurses, 20
Social Workers, 20 Health Educators,
and 40 Patients). Once the survey
responses have been collected,
responses will be analyzed to help
inform the development of the CV
checklist. Checklist items will be chosen
based on what is learned. For example,
if clinicians strongly believe that it is
inappropriate to discuss costs and value
with patients, the checklist may require
different items than if clinicians
recognize the importance of such
conversations but believe they lack
required information to facilitate them.
(5) Cognitive Interviews for the CV
checklist. Once checklist items have
been identified, cognitive interviews
will be conducted with 9 respondents in
hospitals and 9 respondents in medical
offices to understand the cognitive
processes the respondent engages in
when using the CV checklist. Cognitive
interviewing will allow checklist
developers to identify and classify
difficulties respondents may have
regarding checklist items. To get
different perspectives, interviews will
be conducted with a mix of physicians,
nurses, social workers, health educators,
and patients in hospitals and medical
offices.
(6) Pretest the CV checklist. The
checklist will then be pretested to solicit
feedback from 50 physicians in
hospitals and 50 physicians in medical
offices. The pilot testing process will
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947
help identify areas where users of the
checklist have trouble understanding,
learning, and using the checklist. It also
provides the opportunity to identify
issues that can prevent successful
deployment of the checklist.
(7) Dissemination activities. The final
VE Surveys and CV checklist will be
made available to the public through the
AHRQ Web site. This activity does not
impose a burden on the public and is
therefore not included in the burden
estimates in Section 12.
The information collected will be
used to test and improve the draft
survey items in the VE Surveys and CV
checklist.
The final VE instruments will be
made available to the public for use in
hospitals and medical offices to assess
value and efficiency from the
perspectives of their staff. The survey
can be used by hospitals and medical
offices to identify areas for
improvement. Researchers are also
likely to use the surveys to assess the
impact of hospitals’ and medical offices’
value and efficiency improvement
initiatives.
The final CV checklist will be made
available to hospital and medical office
clinicians to aid in having conversations
with patients about value.
Estimated Annual Respondent Burden
Exhibit 1 shows the estimated
annualized burden hours for the
respondents’ time to participate in this
research. Cognitive interviews for the
Hospital VE survey will be conducted
with 9 hospital staff (approximately 3
managers, 3 nurses, and 3 technicians)
and will take about one hour and 30
minutes to complete. Cognitive
interviews for the Medical Office VE
survey will be conducted with 9
medical office staff (approximately 4
physicians and 5 medical assistants)
and will take about one hour and 30
minutes to complete. The Hospital VE
survey will be administered to about
4,032 individuals from 42 hospitals
(about 96 surveys per hospital) and
requires 15 minutes to complete. A sitelevel POC will spend approximately 16
hours administering the Hospital VE
survey. The Medical Office VE survey
will be administered to about 504
individuals from 96 medical offices
(about 5 surveys per medical office) and
requires 15 minutes to complete. A sitelevel POC will spend approximately 6
hours administering the Medical Office
YE survey. The medical office
information form survey will be
completed by a medical office manager
at each of the 96 medical offices
participating in the pretest and takes 10
minutes to complete.
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One-hundred and sixty individuals
(40 physicians, 40 nurses, 20 social
workers, 20 health educators, and 40
patients) will participate in the survey
to identify items for the CV checklist
and will take 15 minutes to complete.
Cognitive interviews for the CV
checklist will be conducted with 18
individuals (9 in hospitals and 9 in
medical offices, consisting of
approximately 4 physicians, 4 nurses, 2
social workers, 2 health educators, and
6 patients) and will take about one hour
to complete. One hundred physicians
will participate in the pretest of the CV
checklist (50 in hospitals and 50 in
medical offices). The total burden is
estimated to be 2,534 hours annually.
Exhibit 2 shows the estimated
annualized cost burden associated with
the respondents’ time to participate in
this research. The total cost burden is
estimated to be $115,559 annually.
EXHIBIT 1—ESTIMATED ANNUALIZED BURDEN HOURS
Number of
respondents
Form name
Number of
responses per
respondent
Total
burden
hours
Hours per
response
Cognitive interviews for the Hospital VE survey .............................................
Cognitive interviews for the Medical Office VE survey ...................................
Pretest for the Hospital VE survey ..................................................................
Pretest for the Medical Office VE survey ........................................................
POC Administration of the Hospital VE survey ...............................................
POC Administration of the Medical Office VE survey .....................................
Medical office information form .......................................................................
Survey to identify items for CV checklist .........................................................
Cognitive interviews for the CV checklist ........................................................
Pretest for the CV checklist .............................................................................
9
9
4,032
504
42
96
96
160
18
100
1
1
1
1
1
1
1
1
1
1
1.5
1.5
15/60
15/60
16
6
10/60
15/60
1
30/60
14
14
1,008
126
672
576
16
40
18
50
Total ..........................................................................................................
5,066
na
na
2,534
EXHIBIT 2—ESTIMATED ANNUALIZED COST BURDEN
Number of
respondents
Form name
Total
burden
hours
Average
hourly wage
rate *
Total
cost
burden
Cognitive interviews for the Hospital VE survey .............................................
Cognitive interviews for the Medical Office VE survey ...................................
Pretest for the Hospital VE survey ..................................................................
Pretest for the Medical Office VE survey ........................................................
Administration of the Hospital VE survey ........................................................
Administration of the Medical Office VE survey ..............................................
Medical office information form .......................................................................
Survey to identify items for CV checklist .........................................................
Cognitive interviews for the CV checklist ........................................................
Pretest for the CV checklist .............................................................................
9
9
4,032
504
42
96
96
160
18
100
14
14
1,008
126
672
576
16
40
18
50
a $36.16
i 87.98
$506
656
36,308
3,494
37,498
29,364
816
1,801
717
4,399
Total ..........................................................................................................
5,066
2,534
na
115,559
b 46.87
c 36.02
d 27.73
e 55.80
f 50.98
f 50.98
g 45.02
h 39.84
a Based
on the weighted average wages for 3 Registered Nurses (29–1111, $33.56), 3 Medical and Clinical Laboratory Technicians (29–2012,
$19.11), and 3 General and Operational Managers (11–1021, $55.80) in the hospital setting;
b Based on the weighted average wages for 4 Family and General Practitioners (29–1062; $87.18) and 5 Medical Assistants (31–9092, $14.63)
in the medical office setting;
c Based on the weighted average wages for 1,937 Registered Nurses, 1,131 Medical and Clinical Laboratory Technicians, 526 General and
Operational Managers and 446 Physicians (29–1069; $66.23) in the hospital setting;
d Based on the weighted average wages for 91 Family and General Practitioners and 413 Medical Assistants in the medical office setting;
e Based on the average wages for General and Operational Managers in the hospital setting;
f Based on the average wages for General and Operational Managers in the medical office setting;
g Based on the weighted average wages for 40 Physician and Surgeons (29–10692; $88.78), 40 Registered Nurses (29–1111; $33.23), 20 Social Workers (21–1022; $24.28), 20 Health Educators (21–1091, $25.07), and 20 Patients (00–0000; $21.74);
h Based on the weighted average wages for 4 Physician and Surgeons, 4 Registered Nurses, 2 Social Workers, 2 Health Educators, and 6 Patients;
i Based on the weighted average wages for 50 Physician and Surgeons in the hospital setting and 50 Family and General Practitioners in the
medical office setting;
* National Occupational Employment and Wage Estimates in the United States, May 2011, ‘‘U.S. Department of Labor, Bureau of Labor Statistics’’ (available at https://www.bls.gov/oes/current/naics4_621100.htm [for medical office setting] and https://www.bls.gov/oes/current/
naics4_622100.htm [for hospital setting]).
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Estimated Annual Costs to the Federal
Government
Exhibit 3 shows the estimated total
and annualized cost to the government
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for this data collection. Although data
collection will last for less than one
year, the entire project will take about
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2 years. The total cost for the three
surveys is approximately is $1,001,202.
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EXHIBIT 3—ESTIMATED TOTAL AND ANNUALIZED COST
Total
cost
Cost component
Annualized
cost
Project Development ...............................................................................................................................................
Data Collection Activities .........................................................................................................................................
Data Processing and Analysis .................................................................................................................................
Publication of Results ..............................................................................................................................................
Project Management ................................................................................................................................................
Overhead .................................................................................................................................................................
$273,838
153,119
171,764
14,753
10,032
377,696
$136,919
76,560
85,882
7,377
5,016
188,848
Total ..................................................................................................................................................................
1,001,202
500,601
Request for Comments
In accordance with the Paperwork
Reduction Act, comments on AHRQ’s
information collection are requested
with regard to any of the following: (a)
Whether the proposed collection of
information is necessary for the proper
performance of AHRQ health care
research and health care information
dissemination functions, including
whether the information will have
practical utility; (b) the accuracy of
AHRQ’s estimate of burden (including
hours and costs) of the proposed
collection(s) of information; (c) ways to
enhance the quality, utility, and clarity
of the information to be collected; and
(d) ways to minimize the burden of the
collection of information upon the
respondents, including the use of
automated collection techniques, or
other forms of information technology.
Comments submitted in response to
this notice will be summarized and
included in the Agency’s subsequent
request for OMB approval of the
proposed information collection. All
comments will become a matter of
public record.
Dated: December 20, 2012.
Carolyn M. Clancy,
Director.
[FR Doc. 2012–31592 Filed 1–4–13; 8:45 am]
BILLING CODE 4160–90–M
DEPARTMENT OF HEALTH AND
HUMAN SERVICES
Centers for Disease Control and
Prevention (CDC)
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Office for State, Tribal, Local and
Territorial Support (OSTLTS)
In accordance with Presidential
Executive Order No. 13175, November
6, 2000, and the Presidential
Memorandum of November 5, 2009 and
September 23, 2004, Consultation and
Coordination with Indian Tribal
Governments, CDC/Agency for Toxic
Substances and Disease Registry
(ATSDR), announces the following
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meeting and Tribal Consultation
Session:
Name: Tribal Advisory Committee
(TAC) Meeting and 10th Biannual Tribal
Consultation Session.
Times and Dates:
8:00 a.m.–9:30 a.m., February 5, 2013
(TAC Meeting).
8:00 a.m.–5:00 p.m., February 6, 2013
(10th Biannual Tribal Consultation
Session).
8:00 a.m.–4:00 p.m., February 7, 2013
(TAC Meeting).
Place: The TAC Meeting and Tribal
Consultation Session will be held at
CDC Headquarters, 1600 Clifton Road,
NE., Global Communications Center,
Auditorium B3, Atlanta, Georgia.
Status: All meetings are being hosted
by CDC/ATSDR. Meetings on February
5, 6, and 7, 2013, are open to the public.
Purpose: In 2011–2012, CDC began
revising its existing Tribal Consultation
Policy (issued in 2005) with the primary
purpose of providing guidance across
the agency to work effectively with
American Indian/Alaska Native (AI/AN)
tribes, communities, and organizations
to enhance AI/AN access to CDC
resources and programs. Within the
CDC Consultation Policy, it is stated
that CDC will conduct government-togovernment consultation with elected
tribal officials or their authorized
representatives before taking actions
and/or making decisions that affect
them. Consultation is an enhanced form
of communication that emphasizes
trust, respect, and shared responsibility.
It is an open and free exchange of
information and opinion among parties
that leads to mutual understanding and
comprehension. CDC believes that
consultation is integral to a deliberative
process that results in effective
collaboration and informed decision
making with the ultimate goal of
reaching consensus on issues. Although
formal responsibility for the agency’s
overall government-to-government
consultation activities rests within the
CDC Office of the Director (OD), other
CDC Center, Institute, and Office (CIO)
leadership shall actively participate in
TAC meetings and HHS-sponsored
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regional and national tribal consultation
sessions as frequently as possible.
Matters To Be Discussed: The TAC
will convene their advisory committee
meeting with discussions and
presentations from various CDC senior
leaders on activities and areas identified
by TAC members and other tribal
leaders as priority public health issues.
The following topics are scheduled for
presentation and discussion during the
TAC Meeting; however, discussion is
not limited to these topics: substance
abuse/mental health, community based
participatory public health, success
stories, and grant information and
opportunities at CDC for Native
participation.
The 10th Biannual Tribal
Consultation Session will engage CDC
senior leadership from the CDC OD and
various CDC CIOs. Sessions that will be
held during the Tribal Consultation
include the following: a listening
session with the director of CDC,
roundtable discussions with CDC senior
leadership and an opportunity for tribal
testimony.
Additional opportunities will be
provided during the Consultation
Session for tribal testimony. Tribal
Leaders are encouraged to submit
written testimony by 12:00 a.m., EST on
January 25, 2013, to Kimberly Cantrell,
Deputy Associate Director for Tribal
Support, OSTLTS, via mail to 4770
Buford Highway NE., MS E–70, Atlanta,
Georgia 30341 or email to
klw6@cdc.gov. Depending on the time
available, it may be necessary to limit
the time of each presenter.
The agenda is subject to change as
priorities dictate.
Information about the TAC, CDC’s
Tribal Consultation Policy, and previous
meetings may be referenced on the
following web link: https://www.cdc.gov/
tribal.
Contact Person For More Information:
Kimberly Cantrell, Deputy Associate
Director for Tribal Support, OSTLTS,
via mail to 4770 Buford Highway NE.,
MS E–70, Atlanta, Georgia 30341 or
email to klw6@cdc.gov.
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]]>Agencies
[Federal Register Volume 78, Number 4 (Monday, January 7, 2013)]
[Notices]
[Pages 946-949]
From the Federal Register Online via the Government Printing Office [www.gpo.gov]
[FR Doc No: 2012-31592]
[[Page 946]]
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DEPARTMENT OF HEALTH AND HUMAN SERVICES
Agency for Healthcare Research and Quality
Agency Information Collection Activities: Proposed Collection;
Comment Request
AGENCY: Agency for Healthcare Research and Quality, HHS.
ACTION: Notice.
-----------------------------------------------------------------------
SUMMARY: This notice announces the intention of the Agency for
Healthcare Research and Quality (AHRQ) to request that the Office of
Management and Budget (OMB) approve the proposed information collection
project: ``Pilot Test of the Proposed Value and Efficiency Surveys and
Communicating About Value Checklist.'' In accordance with the Paperwork
Reduction Act, 44 U.S.C. 3501-3521, AHRQ invites the public to comment
on this proposed information collection.
DATES: Comments on this notice must be received by March 8, 2013.
ADDRESSES: Written comments should be submitted to: Doris Lefkowitz,
Reports Clearance Officer, AHRQ, by email at
doris.lefkowitz@AHRQ.hhs.gov.
Copies of the proposed collection plans, data collection
instruments, and specific details on the estimated burden can be
obtained from the AHRQ Reports Clearance Officer.
FOR FURTHER INFORMATION CONTACT: Doris Lefkowitz, AHRQ Reports
Clearance Officer, (301) 427-1477, or by email at
doris.lefkowitz@AHRQ.hhs.gov.
SUPPLEMENTARY INFORMATION:
Proposed Project
Pilot Test of the Proposed Value and Efficiency Surveys and
Communicating About Value Checklist
Maximizing value within the American health care system is an
important priority. Value is often viewed as a combination of high
quality, high efficiency care, and there is general agreement by
consumers, policy makers, payers, and providers that it is lacking in
the U.S. A recent report by the Institute of Medicine estimated that 20
to 30 percent ($765 billion a year) of U.S. healthcare spending was
inefficient and could be reduced without lowering quality.
Multiple overlapping initiatives are currently seeking to improve
value using a variety of approaches. Public reporting efforts led by
the Centers for Medicare and Medicaid Services (CMS), other payers and
consumer groups seek to enable consumers to make more informed choices
about the quality, and in some cases, the costs of their care. A
variety of demonstration projects and payment reforms initiated by CMS
and private insurers are attempting to more closely link care quality
with payments to incent higher value care. And national improvement
initiatives led by AHRQ (comprehensive unit-based safety programs
[CUSP] for central line-associated blood stream infection [CLABSI],
catheter-associated urinary tract infections [CUTI], and surgical units
[SUSP]) and CMS (hospital engagement networks, QI0 scopes of work) are
seeking to raise care quality and reduce readmissions. Results from the
CUSP-CLABSI project have demonstrated that central line infections can
be reduced and unnecessary costs can be removed from the health care
system by concerted, unit-based improvement efforts.
As a systems level example, Denver Health, with initial funding
from AHRQ, has taken major steps towards redesigning clinical and
administrative processes so as to reduce staff time, patient waiting,
and unnecessary costs. These improvements occurred without harm to
quality and in some instances actually improved quality.
In many cases, improving quality improves efficiency naturally.
Reducing the number of hospital errors for example will reduce costs
associated with longer length of stay or error-triggered readmissions.
It is more cost-effective to do things right the first time. But higher
value is more likely if organizations doing quality improvement link
efforts to improve care quality with efforts to reduce unnecessary
costs. Ignoring the financial implications of quality improvement
efforts will fail in the real world where many providers face acute
financial challenges and where costs are leading to consumer
bankruptcies and increased insurance costs. AHRQ understands that many
of the root causes of inefficiencies that drive up costs are closely
linked to root causes of inefficiencies that lead to poor quality,
uncoordinated care where redundancies and system failures place
patients at risk. Adding value within healthcare requires understanding
the contribution that organizational culture makes to value and working
to foster a culture where high value is a cultural norm. AHRQ's
development of the Hospital Survey on Patient Safety Culture (HSOPS)
has contributed greatly to efforts to promote the important role
culture plays in providing safe care. HSOPS is used extensively in
national improvement campaigns and many hospitals and health systems
now regularly assess their safety cultures and use culture scores on
organizational dashboards and as parts of variable compensation
programs.
If organizations lack cultures committed to value then discrete
efforts to raise dimensions of value are likely to yield limited and
unsustainable results. And if organizational leaders have no plausible
way to know whether their organizational culture is committed to value,
then their ability to make value a higher organizational priority will
be very limited. Thus, developing value and efficiency survey
instruments for hospitals and medical offices fills an important need
for many ongoing and planned efforts to foster greater value within
American health care.
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 YE 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. Since the proper goal for any health care
delivery system is to improve the value delivered to patients, such a
tool will address the important aspects of health care that are of
value to patients. Value in health care is typically measured in terms
of the patient outcomes achieved per dollar expended. But a good
outcome must be defined in terms of what is meaningful and valuable to
the individual patient.
Better identification of patients' preferences is not only the
right ethical thing to do but it also can reduce the cost of
healthcare. Studies indicate that engaged and informed patients often
choose to have less intensive care and become more careful about having
lots of procedures. In addition, participatory decision making can
reduce medication non-adherence which has been directly linked to
increased morbidity, mortality and potentially avoidable healthcare
[[Page 947]]
costs totaling $290 billion annually in the U.S.
The CV checklist will address three major topics: who should talk
with patients about value issues (e.g., nurses, physicians, etc.), when
should these conversations occur (e.g., when patients may incur costs,
when they express financial concerns, etc.), and how can clinicians
prepare for and effectively facilitate such discussions.
This research has the following goals:
(1) Develop, cognitively test and modify as necessary the VE
surveys (one for hospitals and one for medical offices);
(2) Pretest the VE surveys in hospitals and medical offices and
modify as necessary based on the results;
(3) Develop, cognitively test and modify as necessary the CV
checklist;
(4) Pretest the CV checklist in hospitals and medical offices and
modify as necessary based on the results;
(5) Make the final VE surveys and CV checklist available for use by
the public.
This study is being conducted by AHRQ through its contractor,
Health Research & Educational Trust (HRET), and subcontractor, Westat,
pursuant to AHRQ's statutory authority to conduct and support research
on healthcare and on systems for the delivery of such care, including
activities with respect to the quality, effectiveness, efficiency,
appropriateness and value of healthcare services and with respect to
quality measurement and improvement. 42 U.S.C. 299a(a)(1) and (2).
Method of Collection
To achieve these goals the following activities and data
collections will be implemented:
(1) Cognitive interviews for the VE surveys. One round of
interviews on the VE surveys will be conducted by telephone with 9
respondents from hospitals and 9 respondents from medical offices. The
purpose of these interviews is to understand the cognitive processes
the respondent engages in when answering a question on the VE survey
and to refine the survey's items and composites. These interviews will
be conducted with a mix of senior leaders and clinical staff (i.e.,
unit/department managers, practitioners, nurses, technicians, and
medical assistants) from hospitals and medical offices throughout the
U.S. with varying characteristics (e.g., size, geographic location,
type of medical office practice/hospital, and possibly extent of
experience with waste-reduction efforts).
(2) Pretest for the VE surveys. The surveys will be pretested with
senior leaders and clinical staff from 42 hospitals and 96 medical
offices. The purpose of the pretest is to collect data for an
assessment of the reliability and construct validity of the surveys'
items and composites, allowing for their further refinement. A site-
level point-of-contact (POC) will be recruited in each medical office
and hospital to manage the data collection at that organization
(compiles sample information, distribute surveys, promote survey
response, etc.). Exhibit 1 includes a burden estimate for the POC's
time to manage the data collection.
(3) Medical office information form. This form will be completed by
the medical office manager in each of the 96 medical office pretest
sites to provide background characteristics, such as type of
specialty(s) and majority ownership. A hospital information form will
not be needed because characteristics on pretest hospitals will be
obtained from the American Hospital Association's (AHA) data set based
on a hospital's AHA ID number.
(4) Survey to identify items for CV checklist. In order to identify
items to put on the checklist, a survey will be developed and sent to
160 representative participants (40 Physicians, 40 Registered Nurses,
20 Social Workers, 20 Health Educators, and 40 Patients). Once the
survey responses have been collected, responses will be analyzed to
help inform the development of the CV checklist. Checklist items will
be chosen based on what is learned. For example, if clinicians strongly
believe that it is inappropriate to discuss costs and value with
patients, the checklist may require different items than if clinicians
recognize the importance of such conversations but believe they lack
required information to facilitate them.
(5) Cognitive Interviews for the CV checklist. Once checklist items
have been identified, cognitive interviews will be conducted with 9
respondents in hospitals and 9 respondents in medical offices to
understand the cognitive processes the respondent engages in when using
the CV checklist. Cognitive interviewing will allow checklist
developers to identify and classify difficulties respondents may have
regarding checklist items. To get different perspectives, interviews
will be conducted with a mix of physicians, nurses, social workers,
health educators, and patients in hospitals and medical offices.
(6) Pretest the CV checklist. The checklist will then be pretested
to solicit feedback from 50 physicians in hospitals and 50 physicians
in medical offices. The pilot testing process will help identify areas
where users of the checklist have trouble understanding, learning, and
using the checklist. It also provides the opportunity to identify
issues that can prevent successful deployment of the checklist.
(7) Dissemination activities. The final VE Surveys and CV checklist
will be made available to the public through the AHRQ Web site. This
activity does not impose a burden on the public and is therefore not
included in the burden estimates in Section 12.
The information collected will be used to test and improve the
draft survey items in the VE Surveys and CV checklist.
The final VE instruments will be made available to the public for
use in hospitals and medical offices to assess value and efficiency
from the perspectives of their staff. The survey can be used by
hospitals and medical offices to identify areas for improvement.
Researchers are also likely to use the surveys to assess the impact of
hospitals' and medical offices' value and efficiency improvement
initiatives.
The final CV checklist will be made available to hospital and
medical office clinicians to aid in having conversations with patients
about value.
Estimated Annual Respondent Burden
Exhibit 1 shows the estimated annualized burden hours for the
respondents' time to participate in this research. Cognitive interviews
for the Hospital VE survey will be conducted with 9 hospital staff
(approximately 3 managers, 3 nurses, and 3 technicians) and will take
about one hour and 30 minutes to complete. Cognitive interviews for the
Medical Office VE survey will be conducted with 9 medical office staff
(approximately 4 physicians and 5 medical assistants) and will take
about one hour and 30 minutes to complete. The Hospital VE survey will
be administered to about 4,032 individuals from 42 hospitals (about 96
surveys per hospital) and requires 15 minutes to complete. A site-level
POC will spend approximately 16 hours administering the Hospital VE
survey. The Medical Office VE survey will be administered to about 504
individuals from 96 medical offices (about 5 surveys per medical
office) and requires 15 minutes to complete. A site-level POC will
spend approximately 6 hours administering the Medical Office YE survey.
The medical office information form survey will be completed by a
medical office manager at each of the 96 medical offices participating
in the pretest and takes 10 minutes to complete.
[[Page 948]]
One-hundred and sixty individuals (40 physicians, 40 nurses, 20
social workers, 20 health educators, and 40 patients) will participate
in the survey to identify items for the CV checklist and will take 15
minutes to complete. Cognitive interviews for the CV checklist will be
conducted with 18 individuals (9 in hospitals and 9 in medical offices,
consisting of approximately 4 physicians, 4 nurses, 2 social workers, 2
health educators, and 6 patients) and will take about one hour to
complete. One hundred physicians will participate in the pretest of the
CV checklist (50 in hospitals and 50 in medical offices). The total
burden is estimated to be 2,534 hours annually.
Exhibit 2 shows the estimated annualized cost burden associated
with the respondents' time to participate in this research. The total
cost burden is estimated to be $115,559 annually.
Exhibit 1--Estimated Annualized Burden Hours
----------------------------------------------------------------------------------------------------------------
Number of
Form name Number of responses per Hours per Total burden
respondents respondent response hours
----------------------------------------------------------------------------------------------------------------
Cognitive interviews for the Hospital VE survey. 9 1 1.5 14
Cognitive interviews for the Medical Office VE 9 1 1.5 14
survey.........................................
Pretest for the Hospital VE survey.............. 4,032 1 15/60 1,008
Pretest for the Medical Office VE survey........ 504 1 15/60 126
POC Administration of the Hospital VE survey.... 42 1 16 672
POC Administration of the Medical Office VE 96 1 6 576
survey.........................................
Medical office information form................. 96 1 10/60 16
Survey to identify items for CV checklist....... 160 1 15/60 40
Cognitive interviews for the CV checklist....... 18 1 1 18
Pretest for the CV checklist.................... 100 1 30/60 50
---------------------------------------------------------------
Total....................................... 5,066 na na 2,534
----------------------------------------------------------------------------------------------------------------
Exhibit 2--Estimated Annualized Cost Burden
----------------------------------------------------------------------------------------------------------------
Average
Form name Number of Total burden hourly wage Total cost
respondents hours rate * burden
----------------------------------------------------------------------------------------------------------------
Cognitive interviews for the Hospital VE survey. 9 14 \a\ $36.16 $506
Cognitive interviews for the Medical Office VE 9 14 \b\ 46.87 656
survey.........................................
Pretest for the Hospital VE survey.............. 4,032 1,008 \c\ 36.02 36,308
Pretest for the Medical Office VE survey........ 504 126 \d\ 27.73 3,494
Administration of the Hospital VE survey........ 42 672 \e\ 55.80 37,498
Administration of the Medical Office VE survey.. 96 576 \f\ 50.98 29,364
Medical office information form................. 96 16 \f\ 50.98 816
Survey to identify items for CV checklist....... 160 40 \g\ 45.02 1,801
Cognitive interviews for the CV checklist....... 18 18 \h\ 39.84 717
Pretest for the CV checklist.................... 100 50 \i\ 87.98 4,399
---------------------------------------------------------------
Total....................................... 5,066 2,534 na 115,559
----------------------------------------------------------------------------------------------------------------
\a\ Based on the weighted average wages for 3 Registered Nurses (29-1111, $33.56), 3 Medical and Clinical
Laboratory Technicians (29-2012, $19.11), and 3 General and Operational Managers (11-1021, $55.80) in the
hospital setting;
\b\ Based on the weighted average wages for 4 Family and General Practitioners (29-1062; $87.18) and 5 Medical
Assistants (31-9092, $14.63) in the medical office setting;
\c\ Based on the weighted average wages for 1,937 Registered Nurses, 1,131 Medical and Clinical Laboratory
Technicians, 526 General and Operational Managers and 446 Physicians (29-1069; $66.23) in the hospital
setting;
\d\ Based on the weighted average wages for 91 Family and General Practitioners and 413 Medical Assistants in
the medical office setting;
\e\ Based on the average wages for General and Operational Managers in the hospital setting;
\f\ Based on the average wages for General and Operational Managers in the medical office setting;
\g\ Based on the weighted average wages for 40 Physician and Surgeons (29-10692; $88.78), 40 Registered Nurses
(29-1111; $33.23), 20 Social Workers (21-1022; $24.28), 20 Health Educators (21-1091, $25.07), and 20 Patients
(00-0000; $21.74);
\h\ Based on the weighted average wages for 4 Physician and Surgeons, 4 Registered Nurses, 2 Social Workers, 2
Health Educators, and 6 Patients;
\i\ Based on the weighted average wages for 50 Physician and Surgeons in the hospital setting and 50 Family and
General Practitioners in the medical office setting;
* National Occupational Employment and Wage Estimates in the United States, May 2011, ``U.S. Department of
Labor, Bureau of Labor Statistics'' (available at https://www.bls.gov/oes/current/naics4_621100.htm [for
medical office setting] and https://www.bls.gov/oes/current/naics4_622100.htm [for hospital setting]).
Estimated Annual Costs to the Federal Government
Exhibit 3 shows the estimated total and annualized cost to the
government for this data collection. Although data collection will last
for less than one year, the entire project will take about 2 years. The
total cost for the three surveys is approximately is $1,001,202.
[[Page 949]]
Exhibit 3--Estimated Total and Annualized Cost
------------------------------------------------------------------------
Annualized
Cost component Total cost cost
------------------------------------------------------------------------
Project Development..................... $273,838 $136,919
Data Collection Activities.............. 153,119 76,560
Data Processing and Analysis............ 171,764 85,882
Publication of Results.................. 14,753 7,377
Project Management...................... 10,032 5,016
Overhead................................ 377,696 188,848
-------------------------------
Total............................... 1,001,202 500,601
------------------------------------------------------------------------
Request for Comments
In accordance with the Paperwork Reduction Act, comments on AHRQ's
information collection are requested with regard to any of the
following: (a) Whether the proposed collection of information is
necessary for the proper performance of AHRQ health care research and
health care information dissemination functions, including whether the
information will have practical utility; (b) the accuracy of AHRQ's
estimate of burden (including hours and costs) of the proposed
collection(s) of information; (c) ways to enhance the quality, utility,
and clarity of the information to be collected; and (d) ways to
minimize the burden of the collection of information upon the
respondents, including the use of automated collection techniques, or
other forms of information technology.
Comments submitted in response to this notice will be summarized
and included in the Agency's subsequent request for OMB approval of the
proposed information collection. All comments will become a matter of
public record.
Dated: December 20, 2012.
Carolyn M. Clancy,
Director.
[FR Doc. 2012-31592 Filed 1-4-13; 8:45 am]
BILLING CODE 4160-90-M
