Quality Assurance Guidelines CAHPS® Hospital Survey - HCAHPS

March 2011
Program Requirements
N) provides guidelines for developing the QAP. The QAP should be updated, as
necessary, to reflect changes in key personnel, resources and processes. The QAP must
include the following:
• Organizational background and structure for the project
• Work plan for survey administration
• Survey and data management system
• Quality controls
• Confidentiality, privacy and security procedures in accordance with the Health
Insurance Portability and Accountability Act (HIPAA)
• Annual reporting of results from quality control activities
• HCAHPS survey materials
Note: The HCAHPS Project Team’s acceptance of a submitted QAP and corresponding
survey materials does not constitute or imply approval or endorsement of the
hospital’s/survey vendor’s HCAHPS survey processes. Additionally, the QAP and any
submitted materials (e.g., questionnaires, cover letters, tracking forms, etc) must be
sample templates and must not contain any patient protected health information (PHI).
Each hospital/survey vendor must annually submit their QAP and materials relevant to
HCAHPS survey administration (as determined by CMS), including mailing materials
(e.g. cover letters and questionnaires) and/or telephone/IVR scripts (including screen
shots and skip pattern logic, if applicable) to hcahps@azqio.sdps.org for review by the
HCAHPS Project Team. Please monitor the What’s New page on the HCAHPS Web site
(www.hcahpsonline.org) for QAP submission dates.
‣ Become a My QualityNet Registered User
Hospitals/Survey vendors must submit HCAHPS survey data electronically via My
QualityNet using prescribed file specifications. All hospitals/survey vendors participating
in HCAHPS must be registered users of My QualityNet. In addition, hospitals contracting
with a survey vendor must be registered users of My QualityNet and must authorize the
survey vendor to submit data on their behalf via My QualityNet.
‣ Participate in Oversight Activities Conducted by the HCAHPS Project Team
Hospitals/Survey vendors, including subcontractors, must be prepared to participate in all
on-site or off-site oversight activities, such as on-site visits and/or teleconference calls, as
requested by the HCAHPS Project Team, to ensure that correct survey protocols are
followed. All materials relevant to survey administration are subject to review. Noncompliance
with HCAHPS program requirements (including, but not limited to,
participation and cooperation in oversight activities), may result in the hospital’s
HCAHPS scores not being publicly reported, which could affect the hospital’s Annual
Payment Update, and/or other sanctions (see Oversight Activities section for more
information on non-compliance and sanctions).
‣ Review and Acknowledge Agreement with the Rules of Participation
Hospitals/Survey vendors must review and agree to the Rules of Participation in order for
their HCAHPS results to be publicly reported on the Hospital Compare Web site.
Centers for Medicare & Medicaid Services 25
HCAHPS Quality Assurance Guidelines V6.0