Quality Assurance Guidelines CAHPS® Hospital Survey - HCAHPS

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Program Requirements March 2011 ‣ The zero cases and five or fewer eligible HCAHPS patient discharges submission protocols should not be used when hospitals or survey vendors missed surveying eligible patients, such as when hospitals do not submit any discharge lists for the month to their survey vendor in a timely manner. In instances such as this, a Discrepancy Report must be completed and submitted. Hospitals should monitor the HCAHPS Web site, as well as the QualityNet Web site (www.qualitynet.org), for future information and announcements with regard to completion/submission of required notice of participation and/or pledge forms Hospitals participating in HCAHPS have the following options for conducting the survey: (1) contract with an approved HCAHPS survey vendor; (2) self-administer their own HCAHPS survey; or (3) administer the survey for multiple sites, provided they meet the Program Requirements (Rules of Participation and Minimum Survey Requirements). Hospitals Contracting with a Survey Vendor to Conduct HCAHPS ‣ Contract with an HCAHPS approved Survey Vendor or Hospital Administering Surveys for Multiple Sites (hospitals acting as a survey vendor) to conduct HCAHPS surveys ‣ Ascertain from the survey vendor the date on which it must receive the patient discharge list. If a hospital excludes any patients from the discharge list they provide to their survey vendor, then they must also submit a count of patients by exclusions category to the survey vendor. Survey vendors set these dates independently based on many factors, including length of the survey protocol, due date for data file submission, and time they need to draw the random sample and generate the data file. ‣ Hospitals must deliver the patient discharge list to their survey vendor by their specified date and according to specified file layout, which allows the survey vendor to administer the survey and submit data files to My QualityNet by the data submission deadline. Note: If the hospital is unable to provide the patient discharge list by the survey vendor’s specified date, the survey vendor may not be able to proceed with survey administration for that hospital according to the HCAHPS timeline. As a result, the hospital’s HCAHPS scores may not be publicly reported, which could affect the hospital’s Annual Payment Update for the fiscal year. ‣ Authorize survey vendor or hospital acting as a survey vendor to submit data via My QualityNet on the hospital’s behalf ‣ Review the three HCAHPS Feedback Reports: 1) Provider Survey Status Summary Report; 2) Data Submission Detail Report and 3) RHQDAPU Provider Participation Report to ensure that the survey vendor has submitted the data on time and accurately ‣ Preview HCAHPS results prior to public reporting Hospitals Self-Administering HCAHPS ‣ Complete the Participation Form for Hospitals Self-Administering Survey and become approved to administer the HCAHPS survey ‣ Follow the Rules of Participation to administer the HCAHPS survey 20 Centers for Medicare & Medicaid Services HCAHPS Quality Assurance Guidelines V6.0
March 2011 Program Requirements ‣ Sample patients according to the sampling protocols contained in the Quality Assurance Guidelines V6.0 ‣ Administer the HCAHPS survey and oversee the quality of work of staff and subcontractors, if applicable, according to protocols contained in the Quality Assurance Guidelines V6.0 ‣ Submit data files to My QualityNet in accordance with the required survey file layouts by the data submission deadline ‣ Review HCAHPS Data Submission Reports and HCAHPS Warehouse Feedback Reports and confirm successful upload of hospital’s data files to My QualityNet ‣ Preview HCAHPS results prior to public reporting Hospitals Administering HCAHPS for Multiple Sites ‣ Complete the Participation Form for Hospitals Administering HCAHPS for Multiple Sites and become approved to administer the HCAHPS survey ‣ Follow the Rules of Participation to administer the HCAHPS Survey Note: A hospital that administers the HCAHPS survey for more than one site is considered a survey vendor and must adhere to the Program Requirements stated for survey vendors. ‣ Receive and perform checks of the patient discharge list and create the sample frame to ensure that it includes the entire eligible population and all required data elements Note: If a hospital client excludes any patients from the discharge list they provide to the Hospitals Administering HCAHPS for Multiple Sites, then the Hospitals Administering HCAHPS for Multiple Sites must have their hospital client provide them with counts of patients by exclusion category. ‣ Sample patients according to the sampling protocols contained in the Quality Assurance Guidelines V6.0 ‣ Administer the HCAHPS survey and oversee the quality of work of staff and subcontractors, if applicable, according to the protocols contained in the Quality Assurance Guidelines V6.0 ‣ Verify that each hospital client has authorized the Hospital Administering HCAHPS for Multiple Sites as a survey vendor to submit data on the hospital’s behalf ‣ Submit data files to My QualityNet in accordance with the required survey file layouts by the data submission deadline ‣ Review HCAHPS Data Submission Reports, for client hospital(s), and ensure successful upload of client hospitals’ data files to My QualityNet ‣ Request client hospitals to grant survey vendor access to the HCAHPS Warehouse Feedback Reports Note: If a Hospital Administering HCAHPS for Multiple Sites is non-compliant with program requirements for any of their contracted hospitals, the hospital’s HCAHPS results may not be publicly reported, which could affect the hospital’s Annual Payment Update for that fiscal year. In addition, approved Hospitals Administering HCAHPS for Centers for Medicare & Medicaid Services 21 HCAHPS Quality Assurance Guidelines V6.0
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Data Reporting March 2011 Bar graph
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Appendices March 2011 O. Participat
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HCAHPS Survey SURVEY INSTRUCTIONS
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15. During this hospital stay, were
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HCAHPS Survey SURVEY INSTRUCTIONS
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14. During this hospital stay, how
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Sample Initial Cover Letter for the
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Sample Follow-up Cover Letter for t
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APPENDIX B HCAHPS MAIL SURVEY (Span
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4. Durante esta vez que estuvo en e
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CALIFICACIÓN GENERAL DEL HOSPITAL
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4. Durante esta vez que estuvo en e
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CALIFICACIÓN GENERAL DEL HOSPITAL
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HCAHPS 意見調查問卷指
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14. 此次住院期間 , 醫
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26. 您屬於哪一種族 ?
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問卷指示 ♦ 您是信函
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12. 此次住院期間 , 您
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26. 您屬於哪一種族 ?
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ОБЩИЙ РЕЙТИНГ БОЛЬ
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THĂM DÒ Ý KIẾN HCAHPS CHỈ D
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14. Trong lần nằm bệnh viện
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THĂM DÒ Ý KIẾN HCAHPS CHỈ D
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15. Trong lần nằm bệnh viện
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[SAMPLED PATIENT NAME] [ADDRESS] [C
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APPENDIX F Telephone Script (Englis
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NOTE: SEE INTERVIEWING GUIDELINES I
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Q2 During this hospital stay, how o
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Q11 How often did you get help in g
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Overview HCAHPS Telephone Script (S
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S1 La información que tenemos indi
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Q21 Queremos saber la calificación
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‣ How can I verify this survey is
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Determination of Service Line Elig
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Survey Language Identify whether s
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Sample XML File Layout Without DSRS
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APPENDIX N Quality Assurance Plan O
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4. Provide and attach an HCAHPS org
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C. Describe the process for convert
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D. Describe any opportunities for i
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HCAHPS Participation Form For Hospi
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2. Organizational Survey Capacity I
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Hospital Name and Address (required
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HCAHPS Participation Form For Surve
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IVR Mode of Survey Administration (
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If not submitting this form online
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APPENDIX R Exceptions Request Form
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HCAHPS DISCREPANCY REPORT FORM Sect
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Quality Assurance Guidelines CAHPS® Hospital Survey - HCAHPS

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