Quality Assurance Guidelines CAHPS® Hospital Survey - HCAHPS

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HCAHPS Quality Assurance Guidelines Table of Contents VII. Mail Only Survey Administration ‣ Overview ‣ Production of Questionnaire and Related Materials ‣ Mailing of Materials ‣ Data Receipt and Retention ‣ Quality Control Guidelines VIII. Telephone Only Survey Administration ‣ Overview ‣ Telephone Interviewing Systems ‣ Telephone Attempts ‣ Obtaining and Updating Telephone Numbers ‣ Data Receipt and Retention ‣ Electronic Telephone Interviewing System ‣ Quality Control Guidelines IX. Mixed Mode Survey Administration ‣ Overview ‣ Mail Protocol ‣ Data Receipt and Retention of Mailed Questionnaires ‣ Quality Control Guidelines for Mail Data ‣ Telephone Protocol ‣ Telephone Interviewing Systems ‣ Receipt and Retention of Telephone Data ‣ Electronic Telephone Interviewing System ‣ Quality Control Guidelines for Telephone Data Collection X. Active Interactive Voice Response (IVR) Survey Administration ‣ Overview ‣ IVR Interviewing Systems ‣ IVR Attempts ‣ Obtaining and Updating Telephone Numbers ‣ Data Receipt and Retention ‣ Quality Control Guidelines XI. Data Specifications and Coding ‣ Overview ‣ Random, Unique, De-identified Patient Identification Number ‣ File Specifications ‣ Decision Rules and Coding Guidelines ‣ Disposition of Survey Codes ‣ Definition of a Completed Survey ‣ Survey Response Rate 59 71 81 101 111 iv Centers for Medicare & Medicaid Services HCAHPS Quality Assurance Guidelines V6.0
HCAHPS Quality Assurance Guidelines Table of Contents XII. Data Preparation and Submission ‣ Overview ‣ Preparation for Data Submission ‣ Registration for Data Submission via My QualityNet ‣ HCAHPS Survey Vendor Authorization Process ‣ Data Submission via My QualityNet ‣ HCAHPS Data Submission Reports ‣ HCAHPS Warehouse Feedback Reports XIII. Oversight Activities ‣ Overview ‣ Oversight Activities ‣ HCAHPS Quality Assurance Plan (QAP) ‣ Analysis of Submitted Data ‣ On-site Visits/Conference Calls ‣ Non-compliance and Sanctions XIV. Data Reporting ‣ Overview ‣ Public Reporting of HCAHPS Results ‣ Hospital Preview Reports XV. Exceptions Request/Discrepancy Report Processes ‣ Overview ‣ Exceptions Request Process ‣ Discrepancy Report Process XVI. Appendices A. HCAHPS Mail Survey (English) • Survey Instrument • Survey Instrument (Scannable Instrument) • Sample Initial Cover Letter • Sample Follow-up Cover Letter • OMB Paperwork Reduction Act Language B. HCAHPS Mail Survey (Spanish) • Survey Instrument • Survey Instrument (Scannable Instrument) • Sample Initial Cover Letter • Sample Follow-up Cover Letter • OMB Paperwork Reduction Act Language 131 143 149 153 157 Centers for Medicare & Medicaid Services HCAHPS Quality Assurance Guidelines V6.0 v
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Page 14 and 15: Introduction and Overview March 201
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Active Interactive Voice Response (
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Data Specifications and Coding Marc
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Oversight Activities March 2011 HCA
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Data Reporting March 2011 Bar graph
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Exceptions Request/Discrepancy Repo
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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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OMB Paperwork Reduction Act Languag
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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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Sample Follow-Up Cover Letter for t
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OMB 減低公文法案 Overvie
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APPENDIX D HCAHPS MAIL SURVEY (Russ
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4. Во время данного
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ОБЩИЙ РЕЙТИНГ БОЛЬ
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4. Во время данного
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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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OMB Paperwork Reduction Act Languag
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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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Q19 During this hospital stay, did
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[FOR TELEPHONE INTERVIEWING, QUESTI
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Overview HCAHPS Telephone Script (S
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S1 La información que tenemos indi
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Q6 Durante esta vez que estuvo en e
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Q14 Durante esta vez que estuvo en
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Q21 Queremos saber la calificación
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Q26A ¿Es usted Blanco/a? Sí/Blan
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APPENDIX H IVR Script (English)
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NOTE: SEE INTERVIEWING GUIDELINES I
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Q16 Before giving you any new medic
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Q23_INTRO This last set of question
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Q27 What language do you mainly spe
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HCAHPS Interviewing Guidelines for
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• Skip patterns should be program
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APPENDIX J Frequently Asked Questio
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‣ How can I verify this survey is
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I understand your concern. This is
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HCAHPS SAMPLE FRAME FILE LAYOUT Bel
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Data Element Length Value Labels an
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Data Element Length Value Labels an
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APPENDIX L Data File Structure Vers
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Determination of Service Line Elig
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Discharge Status Patient’s disch
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Survey Language Identify whether s
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Q9 “During this hospital stay, h
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Q22 “Would you recommend this ho
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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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APPENDIX P Participation Form for H
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3. TYPE(S) OF MODE OF SURVEY ADMINI
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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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II. Exception Request Please comple
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HCAHPS DISCREPANCY REPORT FORM Sect
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