Quality Assurance Guidelines - CMS

1 Quality Assurance GuidelinesCAHPS Hospital Survey (HCAHPS)Version 2020 Centers for medicare & medicaid services i HCAHPS Quality Assurance Guidelines CAHPS Hospital Survey (HCAHPS) Quality Assurance Guidelines ACKNOWLEDGMENTS These Quality Assurance Guidelines were prepared under contract to the Centers for medicare & medicaid services (CMS). The primary author is the Health services Advisory Group, ably assisted by the National Committee for Quality Assurance , expert consultants and CMS. CMS is pleased to acknowledge the role of the Agency for Healthcare Research and Quality , its CAHPS grantees, and Westat in developing and testing the HCAHPS Survey, and that of the Hospital Quality Alliance and the National Quality Forum in supporting the HCAHPS initiative. CMS would like to acknowledge that the Point of Origin for Admission and Visit and Patient Discharge Status codes are reprinted from the National Uniform Billing Committee Official UB-04, Data Specifications Manual by permission, Copyright 2019, by the American Hospital Association.

2 Ii Centers for medicare & medicaid services HCAHPS Quality Assurance Guidelines HCAHPS Quality Assurance Guidelines Table of Contents Centers for medicare & medicaid services iii HCAHPS Quality Assurance Guidelines I. Reader s Guide Purpose of Quality Assurance Guidelines Quality Assurance Guidelines Contents 1 II. Introduction and Overview New for 2020 Overview of the CAHPS Hospital Survey (HCAHPS) HCAHPS Survey Instrument HCAHPS Development, Data Collection and Public Reporting Timeline 5 III. Program Requirements Overview Purpose of the HCAHPS Survey Communicating with Patients about the HCAHPS Survey Roles and Responsibilities Hospital/Survey Vendor HCAHPS Rules of Participation Hospital/Survey Vendor HCAHPS Minimum Survey Requirements to Administer the HCAHPS Survey (Minimum Business Requirements) 23 IV. Communications and Technical Support Overview HCAHPS Information and Technical Assistance QualityNet Help Desk Hospital Value-Based Purchasing (Hospital VBP) General Information, Announcements and Updates 47 V.

3 Survey Management Overview System Resources Personnel Training Monitoring and Quality Oversight Safeguarding Patient Confidentiality Data Security Data Retention and Storage 49 Table of Contents March 2020 iv Centers for medicare & medicaid services HCAHPS Quality Assurance Guidelines VI. Sampling Protocol New for 2020 Overview Eligibility for the HCAHPS Survey Survey Timing Sampling Procedure Methods of Sampling MS-DRG Codes and Service Line Categories 57 VII. Mail Only Survey Administration New for 2020 Overview Production of Questionnaire and Related Materials Mailing of Materials Data Receipt and Retention Quality Control Guidelines 83 VIII. Telephone Only Survey Administration New for 2020 Overview Telephone Interviewing Systems Telephone Attempts Obtaining and Updating Telephone Numbers Data Receipt and Retention Electronic Telephone Interviewing System Quality Control Guidelines 99 IX.

4 Mixed Mode Survey Administration New for 2020 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 111 March 2020 Table of Contents Centers for medicare & medicaid services v HCAHPS Quality Assurance Guidelines X. Active Interactive Voice Response (IVR) Survey Administration New for 2020 Overview IVR Interviewing Systems IVR Attempts Obtaining and Updating Telephone Numbers Data Receipt and Retention Quality Control Guidelines 137 XI. Data Specifications and Coding New for 2020 Overview Random, Unique, De-identified Patient Identification Number File Specifications Decision Rules and Coding Guidelines Survey Disposition Codes Definition of a Completed Survey Survey Response Rate 151 XII.

5 Data Preparation and Submission Overview Preparation for Data Submission Registration for Data Submission via the QualityNet Secure Portal HCAHPS Survey Vendor Authorization Process Data Submission via the QualityNet Secure Portal HCAHPS Data Submission Reports HCAHPS Warehouse Feedback Reports XML Data File Submission Online Data Entry Tool Submission 173 XIII. Oversight Activities Overview Oversight Activities HCAHPS Quality Assurance Plan (QAP) Analysis of Submitted Data On-site Visits/Conference Calls Non-compliance and Sanctions 187 XIV. Data Reporting Overview Public Reporting of HCAHPS Results Hospital Preview Reports 193 XV. Exception Request/Discrepancy Report Processes Overview Exception Request Process Discrepancy Report Process 197 Table of Contents March 2020 vi Centers for medicare & medicaid services HCAHPS Quality Assurance Guidelines XVI.

6 Data Quality Checks Overview Traceable Data File Trail Review of Data Files Accuracy of Data Processing Activities Summary 201 XVII. Index XVIII. Appendices A. HCAHPS Mail Survey (English) Survey Instrument Survey Instrument (Scannable Instrument) Sample Standard Initial Cover Letter Sample Standard Follow-up Cover Letter OMB Paperwork Reduction Act Language A-1. HCAHPS Optional Modified Cover Letters (English) Initial Cover Letter Follow-up Cover Letter 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 C. HCAHPS Mail Survey (Chinese) Survey Instrument Survey Instrument (Scannable Instrument) Sample Initial Cover Letter Sample Follow-up Cover Letter OMB Paperwork Reduction Act Language D.

7 HCAHPS Mail Survey (Russian) Survey Instrument Survey Instrument (Scannable Instrument) Sample Initial Cover Letter Sample Follow-up Cover Letter OMB Paperwork Reduction Act Language March 2020 Table of Contents Centers for medicare & medicaid services vii HCAHPS Quality Assurance Guidelines E. HCAHPS Mail Survey (Vietnamese) Survey Instrument Survey Instrument (Scannable Instrument) Sample Initial Cover Letter Sample Follow-up Cover Letter OMB Paperwork Reduction Act Language F. HCAHPS Mail Survey (Portuguese) Survey Instrument Survey Instrument (Scannable Instrument) Sample Initial Cover Letter Sample Follow-up Cover Letter OMB Paperwork Reduction Act Language G. HCAHPS Mail Survey (German) Survey Instrument Survey Instrument (Scannable Instrument) Sample Initial Cover Letter Sample Follow-up Cover Letter OMB Paperwork Reduction Act Language H.

8 HCAHPS Standard Telephone Script (English) H-1. HCAHPS Telephone Script with Optional Modified Introduction (English) I. HCAHPS Telephone Script (Spanish) J. HCAHPS Telephone Script (Chinese) K. HCAHPS Telephone Script (Russian) L. HCAHPS Standard Active IVR Script (English) L-1. HCAHPS Active IVR Script with Optional Modified Introduction (English) M. HCAHPS Active IVR Script (Spanish) N. Interviewing Guidelines for Telephone and IVR Surveys O. Frequently Asked Questions for Customer Support P. Sample Frame Layout Q. Data File Structure Version Table of Contents March 2020 viii Centers for medicare & medicaid services HCAHPS Quality Assurance Guidelines R. XML File Layout Version Sample XML File Layout without DSRS Sample XML File Layout with DSRS S. HCAHPS Quality Assurance Plan Outline T. Participation Form for Hospitals Self-administering Survey U.

9 Participation Form for Hospitals Administering Survey for Multiple Sites V. Participation Form for Survey Vendors W. Exception Request Form X. Discrepancy Report Form Y. Attestation Statement Form Z. Use of HCAHPS with Other Hospital Inpatient Surveys Centers for medicare & medicaid services 1 HCAHPS Quality Assurance Guidelines Reader s Guide Purpose of Quality Assurance Guidelines The Quality Assurance Guidelines manual has been developed by the Centers for medicare & medicaid services (CMS) to standardize the survey data collection process and to ensure comparability of data reported through the CAHPS 1 Hospital Survey (also known as Hospital CAHPS or HCAHPS). The Hospital Consumer Assessment of Healthcare Providers and Systems, or HCAHPS (pronounced H-caps ) Survey is part of a larger Consumer Assessment of Healthcare Providers and Systems (CAHPS) initiative sponsored by the Agency for Healthcare Research and Quality (AHRQ).

10 This Reader s Guide provides hospitals and survey vendors with a high-level overview and reference for essential information presented in the Quality Assurance Guidelines Readers are directed to the related chapters of the Quality Assurance Guidelines for more detail. Quality Assurance Guidelines Contents The Quality Assurance Guidelines contains chapters that address HCAHPS Survey administration requirements. These include: Introduction and Overview This chapter includes a New for 2020 section which highlights key changes in the HCAHPS Survey administration, a description of the HCAHPS initiative and the history of its development. It also includes an overview of the HCAHPS data collection and public reporting timeline. Program Requirements This chapter presents the Program Requirements, including the purpose of the HCAHPS Survey, use of HCAHPS with other hospital inpatient surveys, communicating with patients about the HCAHPS Survey, the roles and responsibilities for participating organizations ( , CMS, hospitals and survey vendors), Rules of Participation, and Minimum Survey Requirements to administer the HCAHPS Survey.