Quality Assurance Guidelines CAHPS® Hospital Survey - HCAHPS

March 2011
Sampling Protocol
Note: Patients should be included in the HCAHPS survey sample frame unless the
hospital/survey vendor has positive evidence that a patient is ineligible or fits within an excluded
category. If information is missing on any variable that affects survey eligibility when the sample
frame is constructed (for instance, MS-DRG), the patient must be included in the sample frame.
De-Duplication
To reduce respondent burden, the hospital/survey vendor is required on a monthly basis to deduplicate
eligible patients based on household and multiple discharges within the same calendar
month. The de-duplication process covers the following two areas:
‣ De-duplication by Household: Only one adult member per household is included in the
HCAHPS survey sample frame for a given month. De-duplication must be performed
within each calendar month, utilizing address information (or telephone number for
Telephone Only mode) and the patient’s medical record number (or other unique
identifier).
• For de-duplication purposes, healthcare facilities are not considered to be a
household, and thus must not be de-duplicated. Examples of healthcare facilities
include: long-term care facilities, assisted living facilities and, group homes.
‣ De-duplication for Multiple Discharges: While patients are eligible to be included in the
HCAHPS survey sample in consecutive months, if a patient is discharged more than once
within a given calendar month, only one discharge date is included in the sample frame.
The method used for de-duplicating depends on whether sampling is conducted
continuously throughout the month, or is conducted only at the end of the month.
• If continuous daily sampling is used, then include only the first discharge date
identified in the sample frame. As the sampling frame is created daily, subsequent
discharges would not be known at the time the daily sample is drawn. Each daily
discharge list must be compared to the previous discharge lists received in the month
in order to exclude additional discharges for a particular patient.
• If weekly sampling is used, each weekly discharge list must be compared to the
previous weekly discharge lists for the month. The first discharge encountered would
be included in the sample frame and discharges encountered in subsequent weeks
would be excluded from the sample frame. In the event a patient is listed with two
discharges in the same week (provided the patient had not been included in the
sample frame in an earlier week with the same month), then include only the last
discharge date during the week in the sample frame. Each weekly discharge list must
be compared to the previous discharge lists received in the month in order to exclude
additional discharges for a particular patient.
• If end-of-the-month sampling is used, then include only the last discharge date of the
month in the sample frame
Sample Frame Creation
Hospitals/Survey vendors participating in HCAHPS are responsible for generating complete,
accurate, and valid sample frame data files each month that contain information on all patients
who meet the eligible population criteria.
‣ It is recommended that hospitals contracting with an HCAHPS approved survey vendor
submit their entire patient discharge list to their survey vendor, excluding no-publicity
patients and patients excluded because of state regulations
Centers for Medicare & Medicaid Services 43
HCAHPS Quality Assurance Guidelines V6.0