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Outpatient and Ambulatory Surgery CAHPS® Survey

Protocols and Guidelines Manual

Version 1.1

October 2015

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COMMUNICATIONS AND TECHNICAL SUPPORT FOR THE OUTPATIENT AND AMBULATORY SURGERY CAHPS SURVEY

Hospital outpatient departments, ambulatory surgery centers and survey vendors may use the following resources to obtain information or technical support with any aspect of the Outpatient and Ambulatory Surgery CAHPS Survey.

For general information, important news, updates, and all materials to support implementation of the Outpatient and Ambulatory Surgery CAHPS Survey:

https://oascahps.org/

For technical assistance, contact the Outpatient and Ambulatory Surgery CAHPS Survey Coordination Team as noted below.

By e-mail: [email protected] telephone: (866) 590-7468

Hospital outpatient departments, ambulatory surgery centers and Outpatient and Ambulatory Surgery CAHPS (OAS CAHPS) Survey vendors must provide the facility’s name and CMS Certification Number (CCN) when contacting the OAS CAHPS Survey Coordination Team by e-mail or telephone for technical assistance.

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mailto:[email protected]



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LIST OF ABBREVIATIONS AND ACRONYMSOUTPATIENT AND AMBULATORY SURGERY CAHPS SURVEY PROTOCOLS AND

GUIDELINES MANUAL

Abbreviation/Acronym Term/Phrase

AAPOR American Association for Public Opinion ResearchAHRQ Agency for Healthcare Research and QualityASC Ambulatory surgery centerCAH Critical access hospitalCAHPS Consumer Assessment of Healthcare Providers and SystemsCATI Computer-assisted telephone interviewCCN CMS Certification Number (formerly known as the Medicare Provider

Number)CMS Centers for Medicare & Medicaid Services

CPT Current Procedural TerminologyDHHS Department of Health and Human ServicesDSRS Disproportionate stratified random samplingFAQ Frequently Asked Questions (a list of frequently asked questions and

suggested responses) HIPAA Health Insurance Portability and Accountability ActHOPD Hospital outpatient departmentICD-9-CM International Classification of Diseases, 9th Revision, Clinical ModificationICD-10 International Classification of Diseases, 10th RevisionIRB Institutional Review BoardMRN Medical Record Number NCOA National Change of Address NQF National Quality ForumOAS CAHPS Outpatient and Ambulatory Surgery CAHPS SurveyOMB Office of Management and BudgetOPPS Outpatient Prospective Payment SystemPHI Private health informationPII Personally identifiable informationPSRS Proportionate stratified random samplingQAP Quality Assurance PlanRAT-STATS Regional Advanced Techniques Staff Statistics Program

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Abbreviation/Acronym Term/Phrase

SAS Statistical Analysis SystemSID Sample identification (number)SRS Simple random samplingSSS Stratified systematic samplingXML Extensible Markup Language

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OUTPATIENT AND AMBULATORY SURGERY CAHPS SURVEYPROTOCOLS AND GUIDELINES MANUAL

TABLE OF CONTENTS

Communications and Technical Support for the Outpatient and Ambulatory Surgery CAHPS SurveyList of Abbreviations and Acronyms Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines ManualI. Overview of the Contents of the Protocol and Guidelines Manual

OverviewSection-by-Section Contents of the Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual

II. Introduction and BackgroundOverview of CAHPS SurveyDevelopment of the OAS CAHPS SurveyOffice of Management and Budget and Public Comment ProcessOAS CAHPS Survey InstrumentOAS CAHPS Survey Data Collection and Public ReportingSources of Information About the OAS CAHPS Survey

III. Survey Participation RequirementsOverviewRoles and ResponsibilitiesResponsibilities of Both HOPDs/ASCs and Survey VendorsVendor Business Requirements

IV. Sampling ProceduresOverviewStep 1: Obtain a Monthly Patient Information File from Each Client HOPD or ASC Under the Same CCNStep 2: Examine the Monthly Patient Information File for Completeness and Possible DuplicationStep 3: Identify Eligible Patients and Construct a Sampling FrameStep 4: Determine the Sampling Method Most Appropriate for the OAS CAHPS Survey for This CCNStep 5: Determine the Sample Size and Sampling Rate, and Select the SampleStep 6: Verify or Update Contact Information For Sampled PatientsStep 7: Assign Unique Sample Identification NumbersStep 8: Finalize the Monthly Sample File and Initiate Data Collection ActivitiesSampling Issues and Errors

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TABLE OF CONTENTS

V. Mail-Only Administration ProceduresOverviewData Collection ScheduleQuestionnaires, Letters, and EnvelopesMailing Requirements and RecommendationsData Receipt, Data Entry, and Optical Scanning RequirementsStaff TrainingQuality Control Guidelines for Mail-only Survey

VI. Telephone-Only Administration ProceduresOverviewData Collection ScheduleTelephone Interview Development ProcessTelephone Interviewing RequirementsTelephone Interviewer TrainingTelephone Data Processing ProceduresTelephone-Only Quality Control Guidelines

VII. Mail with Telephone Follow-Up (Mixed-Mode) Survey Administration Procedures

OverviewData Collection ScheduleQuestionnaires, Letters, and EnvelopesData Receipt, Data Entry, and Optical Scanning RequirementsStaff TrainingTelephone Interview Development ProcessTelephone Interviewing Requirements and RecommendationsInterviewer TrainingTelephone Data Processing ProceduresMixed-Mode Quality Control Guidelines

VIII. Confidentiality and Data SecurityOverviewSafeguarding Patient DataConfidentiality AgreementsPhysical and Electronic Data SecurityCommunicating With Sample Members About Confidentiality and Security

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IX. Data Processing and CodingOverviewSample Identification NumbersData Processing Decision Rules and Coding GuidelinesSurvey Disposition CodesDefinition of a Completed Survey or Survey Completion CriteriaHandling Blank QuestionnairesQuality Control MeasuresComputing the Response Rate

X. The OAS CAHPS Survey Web PortalOverviewThe OAS CAHPS Web PortalSystem and Security Requirements for the OAS CAHPS Web Portal

XI. File Preparation and Data SubmissionOverviewData File PreparationStep 1: Format and Clean Survey Data Following the XML File SpecificationsXML Data File SpecificationsStep 2: Data File SubmissionStep 3: Review and Follow -Up on Data Upload ReportsQuarterly Data Submission DeadlinesPotential Situations When Vendors Will Not Submit DataData Submission Quality Control

XII. Web Portal ReportsOverviewReports for Survey VendorsReports for Ambulatory Surgery Centers and Hospital Outpatient Departments

XIII. Oversight ActivitiesOverviewQuality Assurance PlanData ReviewCommunication Between Survey Vendors and the Coordination TeamRequirement for ClientsSite Visits to Survey VendorsCorrective Action Plans

XIV. Public ReportingOverviewMeasures That Are Reported

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Adjustment and Reporting of ResultsFacility Preview ReportsPublic Reporting Periods

XV. Exceptions Request Process and Discrepancy Notification ReportOverviewExceptions Request ProcessReview ProcessDiscrepancy Notification ReportDiscrepancy Report Review Process

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TABLE OF CONTENTS

Appendix A: Vendor Application FormAppendix B: English: Mail Survey Cover Letters, Mail Questionnaires,

Instructions for Scannable Mail Questionnaire, Telephone Interview Script

Appendix C: Spanish: Mail Survey Cover Letters, Mail Questionnaires, Instructions for Scannable Mail Questionnaire, Telephone Interview Script

Appendix D: Chinese Cover Letters and Questionnaire (forthcoming)Appendix E: Additional Language Cover Letters and Questionnaire

(forthcoming)Appendix F: Consent to Share Identifying Information Question Appendix G: OMB Paperwork Reduction Act LanguageAppendix H: Frequently Asked Questions for Telephone Interviewers

(English)Appendix I: General Guidelines for Telephone InterviewersAppendix J: Frequently Asked Questions for Telephone Interviews

(Spanish)Appendix K: XML Data File Layout for Standard Header Record

(forthcoming)Appendix L: XML Data File Layout for DSRS Header Record

(forthcoming)Appendix M: XML Data File Layout Zero Sampled Patient File

(forthcoming)Appendix N: Instructions for Preparing a Survey Vendor Quality

Assurance PlanAppendix O: Exceptions Request FormAppendix P: Discrepancy Notification Report

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Exhibits

9.1 Steps for Determining Whether a Questionnaire Meets Completeness Criteria

9.2 How Response Rates Are Calculated

10.1 OAS CAHPS Web Portal

10.2 OAS CAHPS Home Page (Public Web portal)

10.3 Announcements Page on the OAS CAHPS Web Portal

10.4 Recent Announcements on the OAS CAHPS Web Portal home page

10.5 Facility User Registration Form

10.6 CCN Registration Form

10.7 Manage User Console

10.8 Vendor Registration Form Link

10.9 Facility Dashboard

10.10 Vendor Dashboard

11.1 Link to Data Submission Tool

11.2 Uploading Multiple Files

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Tables

4.1 Information Needed From ASCs/HOPDs or Patient Served During Sample Month

4.2 Response Rates Obtained by Mode Anticipated for OAS CAHPS

5.1 Mail-Only Administration Schedule and Protocol

6.1 Prescribed Order of Activities and Timing for an All-Telephone OAS CAHPS Survey

7.1 Tasks and Schedule of Activities for Mail with Telephone Follow-Up

9.1 OAS CAHPS Survey Disposition Codes

14.1 Crosswalk of Composite Measures and Global Ratings

14.2 Data Submission Deadlines linked to the (Anticipated) Public Reporting Period

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I. OVERVIEW OF THE CONTENTS OF THE PROTOCOL AND GUIDELINES MANUAL

OverviewThe Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual has been developed by the Centers for Medicare & Medicaid Services (CMS) to provide guidance and standard protocols for conducting the Outpatient and Ambulatory Surgery Consumer Assessment of Healthcare Providers and Systems (CAHPS®) Survey, hereafter referred to as the “OAS CAHPS Survey. The OAS CAHPS Survey measures the experiences of patients who receive outpatient or ambulatory services from hospital outpatient departments (HOPDs) and ambulatory surgery centers (ASCs). This section provides survey vendors, HOPDs, and ASCs with a top-level view of the contents of this manual. Each section is briefly described below, along with an explanation of the contents of the appendices.

Section-by-Section Contents of the Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines ManualII. Introduction and BackgroundThe Introduction and Background chapter provides information about the purpose of the OAS CAHPS Survey and history of the OAS CAHPS Survey initiative, including a discussion of the instrument development and pilot test activities. It also includes information about the public reporting timeline and sources for more information about the OAS CAHPS Survey.

III. OAS CAHPS Survey Participation RequirementsThis chapter describes the roles and responsibilities of CMS, the OAS CAHPS Survey Coordination Team, HOPDs and ASCs, and approved survey vendors during the OAS CAHPS Survey mode experiment. It also includes information on the vendor rules of participation and business requirements for becoming an approved survey vendor. Information about how to communicate with and obtain technical assistance from the OAS CAHPS Survey Coordination Team is also provided in the OAS CAHPS Survey Participation Requirements chapter.

IV. Sampling ProceduresThis chapter describes the sampling process for the OAS CAHPS Survey. It includes requirements for developing the sample frame of eligible patients from HOPDs and ASCs, and the method to be followed in selecting the sample of patients.

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I. Overview of the Contents of the Protocol and Guidelines Manual October 2015

V. Mail-Only Administration ProceduresThe Mail-Only Administration Procedures chapter contains the protocols and guidelines for administering the OAS CAHPS Survey as a mail-only survey. The data collection schedule, production and mailing requirements, data receipt and processing requirements, and quality control guidelines associated with conducting a mail-only mode survey are covered in detail.

VI. Telephone-Only Administration ProceduresProcedures and guidelines for administering the OAS CAHPS Survey as a telephone-only survey are provided in the Telephone-Only Administration Procedures chapter. The data collection schedule, the electronic data collection and tracking system, telephone interviewing requirements, and quality control guidelines associated with conducting a telephone-only mode survey are covered in detail.

VII. Mixed-Mode Administration ProceduresThe Mixed-Mode Administration Procedures chapter contains the protocols and guidelines for administering the OAS CAHPS Survey as a mixed-mode survey—that is, mail survey with telephone follow-up of nonrespondents. The data collection schedule, production and mailing requirements, electronic data collection and tracking system, telephone interviewing requirements, data receipt and processing requirements, and quality control for conducting a mixed-mode survey are covered in detail.

VIII. Confidentiality and Data SecurityThe requirements and guidelines for protecting the identity of sample members, confidentiality of respondent data, ensuring data security, instructions for handling confidential data, and the importance of confidentiality agreements are covered in this chapter. The importance of establishing and maintaining physical and electronic data security, and explaining these measures to sample members, is also covered.

IX. Data Processing and CodingData processing procedures, including the assignment of a unique sample identification number to each sampled case, decision rules for assigning survey disposition codes, quality control measures, and the definition of a completed survey are described in the Data Processing and Coding chapter.

X. OAS CAHPS Survey WebsiteThe OAS CAHPS Survey website chapter provides detailed information about the OAS CAHPS Survey website and the data submission process, including screen shots of the data submission tool and instructions for data submission.

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October 2015 I. Overview of the Contents of the Protocol and Guidelines Manual

XI. File Preparation and SubmissionThe File Preparation and Submission chapter provides an overview of the purpose and functions of the OAS CAHPS Survey website and a summary description of how to prepare and submit data files following OAS CAHPS Survey data file preparation and submission guidelines.

XII. OAS CAHPS Survey Website ReportsThe OAS CAHPS Survey Website Reports chapter provides an overview of the reports available to vendors and HOPDs and ASCs through the OAS CAHPS Survey website. The reports are described briefly, with an emphasis on the intended audience for each report and how the reports should be used.

XIII. Oversight ActivitiesThe Oversight Activities chapter provides information about the quality assurance activities that the OAS CAHPS Survey Coordination Team and CMS will undertake to ensure the successful administration of the OAS CAHPS Survey by survey vendors. The chapter begins with a discussion of the vendor Quality Assurance Plan and reviews the various activities that the Coordination Team will conduct to ensure compliance with OAS CAHPS Survey protocols and guidelines.

XIV. Public ReportingThe Public Reporting chapter presents an overview of the public reporting of OAS CAHPS Survey results, including the composite measures and global items that are publicly reported, adjustments by mode (if applicable), preview reports, and public reporting periods.

XV. Exceptions Request Process and Discrepancy Notification ReportThe Exceptions Request Process and Discrepancy Notification Report chapter describes the process to be used to request an exception to the OAS CAHPS Survey protocols, including guidelines for submitting an Exceptions Request Form. This section also covers the process for alerting the OAS CAHPS Survey Coordination Team of an unplanned discrepancy in data collection procedures.

AppendicesThe appendices contain copies of the Vendor Application Form, questionnaires, cover letters and telephone interview script (in English and other languages), the optional Consent to Share Identifying Information Question, Office of Management and Budget approval statement, frequently asked questions for telephone interviewers, general guidelines for telephone interviewers, XML data file layout for standard header record, XML data file layout for disproportionate stratified random sampling, XML data file layout for zero sampled patient file,


I. Overview of the Contents of the Protocol and Guidelines Manual October 2015

Quality Assurance Plan instructions, Exception Request Form, and Discrepancy Notification Report.

The Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines ManualAn electronic file of the Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual and its appendices are available on the project website at https://oascahps.org/ in both MS Word and .pdf formats. To conserve paper, the OAS CAHPS Survey Coordination Team is printing a limited number of hardcopy versions of this manual. Organizations can request a hardcopy manual by sending an e-mail to the OAS CAHPS Survey Coordination Team at [email protected].




II. INTRODUCTION AND BACKGROUND

Overview of CAHPS SurveyThe Centers for Medicare & Medicaid Services (CMS) has partnered with the Agency for Healthcare Research and Quality (AHRQ), an agency within the United States Department of Health and Human Services, to develop surveys measuring patient perspectives of care. Beginning in 1995 as part of the Consumer Assessment of Healthcare Providers and Systems (CAHPS) initiative, AHRQ and its CAHPS grantees began to develop surveys focusing on patient experiences with their healthcare. Since 1995, the initiative has expanded to cover a range of surveys of health care services at multiple levels of the delivery system, including patients receiving care from both ambulatory and institutional settings. The intent of the CAHPS initiative is to provide a standardized survey instrument and data collection methodology for measuring patients’ perspectives on patient care. CAHPS is meant to complement the data that providers collect to support improvements in internal customer services and quality-related activities.

The Outpatient and Ambulatory Surgery CAHPS (OAS CAHPS) Quality InitiativeIn November 2002, the Quality Initiative was launched to ensure quality health care for all Americans through accountability and public disclosure. The initiative aims to (a) empower consumers with quality of care information to help them make more informed decisions about their health care, and (b) stimulate and support providers and clinicians to improve the quality of health care.1 The Quality Initiative was launched nationally in November 2002 for nursing homes (the Nursing Home Quality Initiative), and expanded in 2003 to the nation’s home health care facilities (the Home Health Quality Initiative) and hospitals (the Hospital Quality Initiative). This Quality Initiative is continuing for ambulatory surgery centers (ASCs) and hospital outpatient departments (HOPDs), through the national implementation of OAS CAHPS.2

Definition of HOPD and ASCAn HOPD is a unit of a hospital whose primary focus is to perform outpatient surgeries and outpatient procedures. CMS specifically defines eligible HOPDs as units within the hospital which bill under the OPPS (Outpatient Prospective Payment System). Additionally, outpatient-focused units that are within critical access hospitals (CAHs) are also eligible as HOPDs even 1 Centers for Medicare & Medicaid Services. http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/QualityInitiativesGenInfo/index.html. Also http://www.cms.gov/Research-Statistics-Data-and-Systems/Research/CAHPS/index.html2 http://cms.hhs.gov/Research-Statistics-Data-and-Systems/Research/CAHPS/OAS-CAHPS.html


http://cms.hhs.gov/Research-Statistics-Data-and-Systems/Research/CAHPS/OAS-CAHPS.html

http://www.cms.gov/Research-Statistics-Data-and-Systems/Research/CAHPS/index.html

http://www.cms.gov/Research-Statistics-Data-and-Systems/Research/CAHPS/index.html

http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/QualityInitiativesGenInfo/index.html

http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/QualityInitiativesGenInfo/index.html

II. Introduction and Background October 2015

though CAHs do not bill under OPPS. There can be more than one HOPD in a hospital. Not every hospital has an HOPD.

An ASC is a freestanding medical facility that performs outpatient surgeries and procedures. CMS specifically defines eligible ASCs as distinct entities that operate exclusively for the purposes of furnishing outpatient surgical services to patients. The ASC must have an agreement with CMS and meet the general conditions and requirements in accordance with 42 CFR 416 subpart B. The ASC may also have physician offices on site, but it does not have any overnight patients. Some ASCs have more than one location, typically in a geographic region.

Development of the OAS CAHPS SurveyThe OAS CAHPS Survey seeks to provide information about patients’ perception of the care they receive from Medicare-certified HOPDs and ASCs. The OAS CAHPS development began in 2012. The survey development process followed the principles and guidelines outlined by AHRQ and its CAHPS® Consortium in developing a patient experience of care survey. Development included reviewing surveys submitted as a result of a public call for measures, reviewing existing literature, conducting focus groups with patients who had recent outpatient surgery, conducting cognitive interviews with patients to test their understanding and ability to answer the questions, obtaining stakeholder input on the draft survey and other issues that may affect implementation, and conducting a field test. The goal of the survey development contract was to identify and include dimensions of care that patients and other consumers want or need to inform their choice of an outpatient surgery department/center.

A field test was conducted in the summer of 2014 with 36 facilities (18 HOPDs and 18 ASCs) to test the reliability and validity of the survey items and implementation procedures. Based on the field test findings, the survey instrument was revised and finalized.

After the survey instrument was finalized, a mode experiment was conducted in 2015. The objective of the mode experiment was to test the effect on survey responses of using three data collection modes: mail-only, telephone-only, and mixed mode (mail with telephone follow-up of nonrespondents). CMS also used data from the mode experiment to determine whether and to what extent characteristics of patients participating statistically influence OAS CAHPS survey results. Statistical models were developed to adjust or control for these patient characteristics before the survey results were publicly reported. Data from the mode experiment were also analyzed to detect potential nonresponse bias; the results of these analyses determined whether applicable nonresponse statistical adjustments must be made on the OAS CAHPS Survey data.

Office of Management and Budget and Public Comment ProcessCMS received approval of the OAS CAHPS Survey from the United States Office of Management and Budget with control number 0938-1240.


October 2015 II. Introduction and Background

OAS CAHPS Survey InstrumentThe OAS CAHPS Survey instrument contains 37 items that cover topics such as access to care, communications, and experience of the facility and interactions with facility staff. There are two global items: one asks the patient to rate the care provided by the HOPD or ASC, and the second asks the patient about his or her willingness to recommend the HOPD or ASC to family and friends. The survey also contains items that ask for self-reported health status and basic demographic information (race/ethnicity, education attainment level, language spoken in the home, etc.).

The OAS CAHPS Survey is currently available in English, Spanish, and Chinese. A version is provided for both mail and telephone survey administration modes. HOPDs and ASCs and their survey vendors will not be permitted to translate the OAS CAHPS Survey into any other languages. CMS will provide additional translations over time based on the language needs of patients. Please check the OAS CAHPS Survey website, https://oascahps.org/, for announcements about additional translations.

OAS CAHPS Survey Data Collection and Public ReportingStarting in 2016, Medicare-certified HOPDs and ASCs will be invited to submit data on a voluntary basis for national implementation of the OAS CAHPS Survey. Interested facilities contract with survey vendors to conduct the Survey on their behalf. Survey vendors interested in administering the OAS CAHPS Survey must complete and submit an application, attend OAS CAHPS Survey training sessions, complete a Training Certification Form, and participate in periodic update trainings sponsored by CMS. Survey vendors cannot collect and submit data to CMS until they receive approval to conduct the survey.

Following each quarter of survey data collection, vendors submit the survey data they collected using the data submission tool function on the OAS CAHPS Survey website (https://oascahps.org/). The data submitted are reviewed, cleaned, scored, and adjusted by the OAS CAHPS Survey Coordination Team. Survey results are compiled for each HOPD and ASC. Public reporting includes four rolling quarters of data; the publicly available results are published on CMS' website. Before the data are publicly reported a “preview” report containing the individual results is made available to each facility for review through the OAS CAHPS Survey website.

Sources of Information About the OAS CAHPS SurveyMore information about the OAS CAHPS Survey and ambulatory and outpatient surgical care is available at the two websites described below.





The OAS CAHPS Survey Website (https://oascahps.org/)The OAS CAHPS Survey Coordination Team maintains a website, which is available at https://oascahps.org/ and hereafter in this chapter referred to as the OAS CAHPS website or simply as the “website.” This website provides general information about the OAS CAHPS Survey, contains the protocols and materials needed for survey implementation, and is one of the main vehicles for communicating information about the survey to HOPDs, ASCs, and survey vendors. The website has both public and secure pages.

The public access pages contain the following:

• general information about the OAS CAHPS Survey;

• announcements about updates or changes in the survey protocols or materials and participation requirements;

• requirements for becoming an OAS CAHPS Survey vendor;

• data collection materials, protocols, and guidelines for administration of the OAS CAHPS Survey;

• a list of approved OAS CAHPS Survey vendors;

• quality assurance plan requirements;

• oversight activities;

• data submission requirements; and

• information about how to obtain technical assistance.

The Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual is updated annually to reflect changes to participation requirements and changes in survey protocols, materials, and procedures. However, CMS and the Coordination Team use the OAS CAHPS website to disseminate important interim updates and news about the OAS CAHPS Survey, including information related to participation requirements, updates and changes to survey protocols or survey materials, information about upcoming events (e.g., data submission deadlines, vendor training sessions), and public reporting. Announcements posted on the OAS CAHPS Survey website may clarify or supersede existing protocols.

Therefore, it is critically important that survey vendors, HOPDs, and ASCs check the OAS CAHPS Survey website frequently for updates. To view announcements, go to the website at https://oascahps.org/ and click on the “Announcement” link. The announcements are listed in chronological order with the most recent announcement listed first.





October 2015 II. Introduction and Background

The secure or restricted-access sections of the OAS CAHPS Survey website are accessible only to OAS CAHPS Survey vendors and HOPDs and ASCs that have registered for and been provided credentials to access the links on the private sections of the website. The links provided within this section of the website will enable HOPDs and ASCs to:

• authorize a survey vendor to submit OAS CAHPS Survey data on their behalf, switch vendors, or view the facility’s authorization history;

• view data submission reports for data submitted by their respective survey vendors; and

• “preview” their OAS CAHPS Survey results before the results are publicly reported.

Additional secured links on the OAS CAHPS Survey website are accessible to survey vendors who have been given access credentials. These private secured links allow survey vendors to:

• view the current list of HOPDs and ASCs that have authorized the vendor to submit data on their behalf; and

• access the OAS CAHPS Survey data submission tool and reports containing information about submitted data.

More detailed information about the OAS CAHPS Survey website is included in Chapter X of this manual.

The Medicare Website (http://www.medicare.gov)This website is maintained by CMS and contains information on the services Medicare provides. The Medicare website provides information to the public on various quality measures. Viewers can obtain comparative information about HOPDs and ASCs by state, ZIP code, and county.

OAS CAHPS Survey results are based on survey response data from the four quarters for which OAS CAHPS Survey data are available, and are “refreshed” each calendar year quarter.


http://www.medicare.gov/

III. SURVEY PARTICIPATION REQUIREMENTS

OverviewThis chapter describes participation requirements for the Outpatient and Ambulatory Surgery Patient Experience of Care Survey (OAS CAHPS), including the roles and responsibilities of the Centers for Medicare & Medicaid Services (CMS) and its OAS CAHPS Survey Coordination Team, hospital outpatient departments (HOPDs) and ambulatory surgery centers (ASCs), and survey vendors that administer the OAS CAHPS Survey for HOPDs and ASCs. This chapter also discusses the rules of participation and outlines the business requirements that survey vendors must meet to be approved to administer the OAS CAHPS Survey. Information about obtaining technical assistance from the Coordination Team is also provided in this chapter.

Roles and ResponsibilitiesCMS is responsible for ensuring that the OAS CAHPS Survey is administered using standardized survey protocols and data collection and processing methods. CMS works very closely with its OAS CAHPS Survey Coordination Team to provide training, technical assistance, and oversight to approved survey vendors. Technical assistance is also provided to HOPDs and ASCs because they are responsible for contracting with an approved survey vendor to conduct the OAS CAHPS Survey on their behalf and for providing a patient information file containing data about patients served during the sample month to their survey vendor each month. Survey vendors are responsible for conducting the OAS CAHPS Survey on behalf of their client HOPDs and ASCs following the standard protocols and guidelines described in this manual.

The roles and responsibilities of each of these participating organizations are described below.

CMS and the OAS CAHPS Survey Coordination Team ResponsibilitiesCMS and the OAS CAHPS Survey Coordination Team are responsible for the following activities on the OAS CAHPS Survey:

• disseminate information about OAS CAHPS Survey administration;

• train survey vendors on OAS CAHPS Survey protocols and requirements;

• monitor data integrity of OAS CAHPS Survey administration to ensure the quality and comparability of the data;


III. Survey Participation Requirements October 2015

• provide technical assistance to HOPDs and ASCs and approved OAS CAHPS Survey vendors via a toll-free telephone number, e-mails, and the OAS CAHPS website at https://oascahps.org/;

• conduct oversight and quality assurance of survey vendors;

• receive and conduct final processing of OAS CAHPS Survey data submitted by all approved survey vendors;

• calculate and adjust OAS CAHPS Survey data for mode and patient-mix effects prior to publicly reporting survey results; and

• generate preview reports containing OAS CAHPS Survey results for participating HOPDs and ASCs to review prior to public reporting.

Hospital Outpatient Departments’ and Ambulatory Surgery Centers’ ResponsibilitiesParticipating HOPDs or ASCs must:

• Contract with an approved OAS CAHPS survey vendor to conduct their survey on a monthly basis.

• Authorize the contracted survey vendor to collect and submit OAS CAHPS Survey data to the OAS CAHPS Survey Data Center on the facility’s behalf.

• Work with their approved vendor to determine a date each month by which the vendor will need the monthly patient information file allowing adequate time for vendor sampling and fielding the survey by the 21st of the month.

• By the agreed-upon date, compile and deliver to the survey vendor a complete and accurate list of patients (i.e., the monthly patient information file) and information that will enable the vendor to administer the survey.

• Use a secure method to transmit monthly patient information files to the survey vendor, ensuring that data are encrypted prior to sending to the vendor.

• Work with their approved vendor to determine a date each month or quarter by which the vendor will submit data to the OAS Data Center.

• Review data submission reports to ensure that their survey vendor has submitted data to the OAS CAHPS Data Center on time and without data problems (allow ample time for this prior to the quarterly data submission deadlines because data cannot be corrected after the deadline has passed).



October 2015 III. Survey Participation Requirements

• Review OAS CAHPS Survey results prior to public reporting.

• Avoid influencing patients in any way about how to answer the OAS CAHPS Survey. For example, HOPDs and ASCs may not hand out any information to patients about how to answer the survey. (Please refer to the section below titled Communications With Patients About the OAS CAHPS Survey.)

Communications With Patients About the OAS CAHPS SurveyIt is important to avoid influencing patient responses to the OAS CAHPS Survey. Any information or communication about the survey from HOPDs and ASCs may introduce bias to the survey. It is acceptable for HOPDs and ASCs to inform patients that they may be asked to respond to a patient experience survey. It is not acceptable, however, for HOPDs or ASCs to do any of the following:

• Send or provide information to patients in advance alerting them about the survey.

• Provide a copy of the OAS CAHPS Survey questionnaire or cover letters to the patients.

• Include words or phrases verbatim from the OAS CAHPS Survey in marketing or promotional materials.

• Attempt to influence their patients’ answers to the OAS CAHPS Survey questions.

• Tell the patients the facility hopes or expects their patients will give them the best or highest rating or to respond in a certain way to the survey questions.

• Offer incentives of any kind to the patients for participating (or not) in the survey.

• Help the patient answer the survey questions, even if the patient asks for the provider’s help.

• Ask patients why they gave a certain response or rating to any of the OAS CAHPS Survey question.

• Include any messages or materials promoting the HOPD or ASC or the services it provides in survey materials, including mail survey cover letters, questionnaires, and telephone interview scripts.

HOPDs and ASCs should never ask their patients if they would like to be included in the survey. All patients selected to participate in the OAS CAHPS Survey must be able to decide on their own whether they wish to participate and will be provided an opportunity to do so as part of the survey process.



Survey Vendor ResponsibilitiesThe list below provides a synopsis of the responsibilities of survey vendors on the OAS CAHPS Survey.

• Complete the Vendor Application, which will be available on the OAS CAHPS Survey website approximately 3 months prior to the next scheduled Introduction to the OAS CAHPS Survey Webinar training session.

• Participate in and successfully complete the Introduction to the OAS CAHPS Survey Webinar training session and in all update training sessions.

• The survey vendor’s designated CAHPS project manager must also complete a Training Certification Form after participating in the Introduction to the OAS CAHPS Survey Webinar training session.

• Ensure that all survey vendor staff who work on the OAS CAHPS Survey are trained and follow the standard OAS CAHPS Survey protocols and guidelines.

• Report any deviations from the protocols and guidelines to the OAS CAHPS Survey Coordination Team within 24 hours after the discrepancy has been discovered, either through a Discrepancy Notification Report (see Chapter XV) or other e-mail or telephone contact with the Coordination Team.

• Follow the participation requirements listed in Section VI of the Vendor Application and also repeated in the following chapters in this manual.

• Work with appropriate HOPD/ASC staff to create monthly patient information files, including data elements needed and file format specifications, and decide on a date each month by which the HOPD or ASC must provide each monthly patient information file.

• Receive and perform checks of the monthly patient information files provided by HOPDs and ASCs to ensure that they include the entire eligible population and all required data elements.

• Sample patients, following the sampling protocols described in this manual (see Chapter IV).

• Administer the OAS CAHPS Survey in accordance with the protocols specified in Chapters V–VII of this manual and oversee the quality of work performed by staff and any subcontractors, if applicable.



• Verify that each client HOPD or ASC has authorized the vendor to submit data on the facility’s behalf.

• Prepare and submit data files to the OAS CAHPS Survey Data Center following the guidelines specified in Chapters IX and X of this manual.

• Review all data submission reports for client facilities to ensure that data have been successfully uploaded and received.

Survey Vendor Participation RequirementsSurvey organizations interested in becoming an approved survey vendor for the OAS CAHPS Survey must agree to the following requirements of participation, as specified in Section VI of the Vendor Application Form (Appendix A) and noted below.

• Participate in both the Introduction to the OAS CAHPS Survey Training Session and in any subsequent update trainings. The vendor’s staff member designated as the Project Director for the OAS CAHPS Survey must attend these trainings; we strongly advise that the vendor’s sampling and data managers also attend. All training sessions will be conducted via Webinar and require that the survey vendor register in advance for the session and attend the session. The survey vendor’s designated OAS CAHPS Project Manager must complete a post-training certification exercise, also referred to as a Training Certification Form, after attending the Introduction to the OAS CAHPS Survey training session. The Introduction to the OAS CAHPS Survey training session will be provided in two 4-hour sessions. Each Update training session, when offered, will usually consist of one 2- to 3-hour session.

• Review the Outpatient and Ambulatory Surgery CAHPS Protocols and Guidelines Manual and follow the protocols and procedures described in this manual during survey administration. This manual is the main resource for survey vendors to use in implementing all stages of the OAS CAHPS Survey—from sampling and data collection to file development and submission. It is expected that vendors will refer to this manual frequently and adhere to all protocols contained within it. Protocol and policy updates will be posted on the OAS CAHPS Survey website, so vendors are expected to check the website frequently for such notifications.

• Communicate in a timely manner (within 24 hours when possible) with the OAS CAHPS Survey Coordination Team any instances when the survey is not following the protocols and guidelines in this manual. As explained in Chapter XV, there are two forms which are used in this regard: the Exception Request (regarding a planned deviation) and the Discrepancy Notification (regarding a discrepancy that has already occurred). When these two forms are not appropriate for the instance, contact the OAS CAHPS Survey Coordination team through the Contact Us link on the OAS CAHPS Web Portal (Chapter X).



• Check the OAS CAHPS website frequently to review announcements and protocol updates, and review and respond as appropriate to e-mails from the OAS CAHPS Survey Coordination Team (e-mails will be from [email protected]).

• Develop and submit a Quality Assurance Plan (QAP), following guidelines described in Chapter XIII of this manual and the QAP instructions provided in Appendix N. Survey vendors must complete and submit a QAP within 6 weeks after the vendor’s first quarterly OAS CAHPS Survey data submission. The QAP must be updated annually or as needed whenever changes are made to key personnel, survey modes being administered, or protocols. The QAP must include the following elements:

• organizational background and staff experience;

◦ identifying and recruiting HOPDs and ASCs

◦ work plan;

◦ sampling protocols and quality assurance procedures;

◦ survey administration protocols and quality assurance procedures;

◦ data security, confidentiality, and privacy protocols; and

◦ copies of the survey instrument (questionnaire or computer-assisted telephone interview [CATI] script) and cover letters.

• Participate and cooperate in all oversight activities conducted by the OAS CAHPS Survey Coordination Team, including but not limited to conference calls and site visits, as deemed necessary. Additionally, the Coordination Team may request teleconference calls with vendors to review sampling protocols, file submissions, or any other aspect of the data collection process. Documentation and requirements that vendors are expected to follow in light of these oversight activities are described in the Vendor Application Form (Appendix A) and in Chapter XIII of this manual.

• Acknowledgement that review of, and agreement with, these participation requirements is necessary for participation and public reporting of results through the CMS website. As noted on the Vendor Application, all survey vendors seeking approval to conduct the OAS CAHPS Survey must review and agree to the participation requirements listed in Section VI of the Vendor Application and described in the bullets above. Vendors that fail to adhere to or comply with the participation requirements risk losing their status as an approved OAS CAHPS Survey vendor.




• To maintain their standing as an approved OAS CAHPS vendor, all vendors must update (as needed) and resubmit their QAP annually. All vendors must also correct any issues identified by the OAS CAHPS Survey Coordination Team, whether they are identified at a site visit or during the course of data collection.

Responsibilities of Both HOPDs/ASCs and Survey VendorsAdministering the OAS CAHPS Survey in Conjunction With Other SurveysSome HOPDs and ASCs may wish to conduct other patient surveys to support internal quality improvement activities. A “survey,” for purposes of this project, is defined as a formal, patient experience/satisfaction survey. A formal survey, regardless of the data collection mode employed, is one in which the primary goal is to ask standardized questions of a sample of the patient population. Contacting patients to assess their care at any time or calling a patient to check on services received are both considered to be routine patient contacts, not surveys. HOPDs and ASCs that are administering other outpatient care patient surveys must follow the following guidelines.

With regard to sampling and ensuring that patients are not overburdened by multiple surveys:

• For each sample month, HOPDs and ASCs (working in conjunction with their survey vendor) must select the OAS CAHPS Survey sample prior to selecting the samples for any other HOPD or ASC survey.

• In the event that another CMS-sponsored effort is also conducting a survey of patients in the ASC/HOPD that month, the facility must contact the OAS CAHPS Survey Coordination Team to make arrangements for both surveys.

With regard to questionnaire content:

• In other surveys that an HOPD or ASC conducts, the facility can include questions that ask for more in-depth information about OAS CAHPS issues, but should not repeat the OAS CAHPS questions or include questions that are very similar.

• The following are some examples of the types of questions that should not be included in any other surveys the facility conducts:

◦ “On a scale of 0 to 10, how would you rate the outpatient surgery care you received?” (This question is the same as Q23 in the OAS CAHPS Survey Questionnaire.)

◦ “Would you recommend this facility to your family or friends?” and “Would you recommend our services or call us in the future?” (These questions are similar to Q24 in the OAS CAHPS Survey Questionnaire.)



◦ “Was our staff friendly, professional, and courteous?” (This question is similar to Q7 in the OAS CAHPS Survey Questionnaire.)

Adding Supplemental Questions to the OAS CAHPS QuestionnaireSurvey vendors and their client HOPDs and ASCs may elect to add up to 10 questions to the OAS CAHPS survey. These could be questions they develop themselves or use from an existing survey. Guidance for adding the OAS CAHPS Survey supplemental questions and the Consent to Share Identifying Information question is as follows:

• All supplemental questions must be placed after the core OAS CAHPS Survey questions (Q1-Q24). Supplemental questions may be placed either before or after the OAS CAHPS Survey “About You” questions. (Refer to the Questionnaire in Appendix B.)

• We strongly recommend that facilities/vendors avoid sensitive questions or lengthy additions, because these will likely reduce expected response.

• Supplemental questions cannot ask patients why they gave a certain response or rating to any of the OAS CAHPS survey questions.

• Supplemental questions do not need to be approved by or reported to CMS. However, survey vendors should review the appropriateness of supplemental questions added to the OAS CAHPS Survey and share any concerns they have directly with the HOPD or ASC or the OAS CAHPS Survey Coordination Team.

• Survey vendors must not include responses to the supplemental questions on the data files that will be submitted to the OAS CAHPS Survey Data Center.

• HOPDs and ASCs cannot add questions that repeat any of the survey items in the core OAS CAHPS Survey verbatim, even if the response scale is different.

• Supplemental questions cannot be used with the intention of marketing or promoting services provided by the HOPD or ASC or any other organization. An example of question for marketing or promotion is: “Can you provide the names and contact information of any friends or family members who are interested in learning about the services we provide?”

• Supplemental questions cannot ask sample patients to identify other individuals who may need outpatient surgical services because of privacy and confidentiality issues they raise if personally identifiable information (PII) were shared with the HOPD or ASC without that person’s knowledge and permission.

• The Consent to Share Identifying Information question (Appendix F) must be added to all questionnaires where an HOPD or ASC requests that the survey vendor provide the survey



responses linked to a sample member’s name and other identifying information. This question is typically placed at the end of the questionnaire, as the last question. The Consent to Share Identifying Information question is available in English and Spanish at this time. Additional languages may be added in the future.

Vendor Business RequirementsSurvey vendors must have proven experience in conducting mail-only, telephone-only, and mixed-mode surveys. Any organization that owns, operates, or provides staffing for an HOPD or ASC is not permitted to administer its own OAS CAHPS Survey or administer the survey on behalf of any other HOPDs and ASCs. CMS believes an independent third party (survey vendor) will be better able to solicit unbiased responses to the OAS CAHPS Survey; therefore, CMS requires that HOPDs and ASCs contract with an independent, approved OAS CAHPS Survey vendor to administer the OAS CAHPS Survey on their behalf.

The following types of organizations will not be eligible to administer the OAS CAHPS Survey (as an approved OAS CAHPS Survey vendor):

• organizations or divisions within organizations that own or operate an HOPD or ASC or provide outpatient or ambulatory surgical services, even if the division is run as a separate entity to the HOPD or ASC;

• organizations that provide telehealth, monitoring of outpatient or ambulatory surgery patients, or teleprompting services for HOPDs and ASCs; and

• organizations that provide staffing to HOPDs and ASCs for providing care to outpatient or ambulatory surgery patients.

Survey vendors seeking approval as an OAS CAHPS Survey vendor must have the capability and capacity to collect and process all survey-related data for the survey administration mode they intend to use on the OAS CAHPS Survey following standardized procedures and guidelines. The business requirements that survey vendors must meet are described in the following sections.

Relevant Business ExperienceThe following section describes the business experience a vendor must possess. Vendors should submit the Vendor Application Form (Appendix A) only if they meet these requirements. Vendors will also need to document details of this experience in their QAP. The OAS CAHPS Survey Coordination Team will—through its review of Vendor Applications, through its review of QAPs, and through site visits—confirm that vendors meet these requirements. These requirements are the following.



A vendor must have relevant business experience, including a minimum of 3 years in business, a minimum of 2 years conducting surveys with individuals, and a minimum of 2 years conducting surveys in the selected data collection mode. A “survey of individuals” is defined as the collection of data from individuals selected by statistical sampling methods and the data collected are used for statistical purposes. An applicant organization must:

• Have conducted surveys of individuals responding about their own experiences.

• Be able to demonstrate that a statistical sampling process (e.g., simple random sampling, proportionate stratified random sampling, or disproportionate stratified random sampling was used in the conduct of previously conducted survey(s). This means that the organization has to have conducted surveys where a sample of individuals was selected.

• Be able to demonstrate that it has conducted surveys of individuals as an organization for at least 2 years. If someone within the applicant organization has relevant experience obtained while in the employment of a different organization, that experience will not count toward the 2-year minimum of survey experience.

• Currently possess all required facilities and systems to implement the OAS CAHPS Survey. CMS and its OAS CAHPS Survey Coordination Team reserve the right to request photographs of the applicant organization’s telephone call center for organizations applying for the telephone-only and mixed modes, scanning and data processing systems if applying for the mail-only or mixed modes, and other relevant equipment and facilities.

The following are examples of data collection activities that do not satisfy the requirement of experience conducting surveys of individuals, as defined for the OAS CAHPS Survey, and will not be considered as part of the experience that OAS CAHPS requires:

• polling questions administered to trainees or participants of training sessions or educational courses, seminars, or workshops;

• focus groups, cognitive interviews, or any other qualitative data collection activities;

• surveys of fewer than 600 individuals;

• surveys conducted that did not involve using statistical sampling methods;

• Internet or Web-based surveys; and

• interactive Voice Recognition Surveys.



Survey Capabilities and CapacityThe following section describes the capabilities and capacity which vendors must possess to be approved for OAS CAHPS. There are specific requirements pursuant to Personnel, Facilities and Systems, Security Policies, mail administration, telephone administration, mixed-mode administration, data processing, and file submission. The OAS CAHPS Survey Coordination Team will— through its review of Vendor Applications, through its review of QAPs, and through site visits—confirm that vendors meet these requirements. These requirements are the following.

PersonnelVendors must designate a Project Director with relevant survey experience, designate a Sampling Manager with sample frame development and sample selection experience, and designate a programmer capable of processing data and preparing data files for electronic submission.

Facilities and SystemsVendors must currently have the following facilities and systems:

• a secure commercial work environment,

• meet all local commercial code requirements, and

• physical facilities, electronic equipment, and software to receive sample files from participating facilities and upload OAS CAHPS data to the Data Center.

Vendors must conduct all of their OAS CAHPS business operations within the United States. This requirement applies to all staff and subcontractors. Home-based or virtual interviewers or mail survey staff may not be used to administer the OAS CAHPS survey nor may they conduct any survey administration process.

Security PoliciesVendor and all subcontractors must have and implement systems and security policies which protect the security of PII as defined by the Health Insurance Portability and Accountability Act. This includes sample data and survey data. Vendors will be required to submit policies. Submissions must describe in sufficient detail policies and procedures for:

• authorizing and de-authorizing individuals to access PII and survey data (including background checks, training, signed agreements);

• preventing unauthorized individuals from accessing PII and survey data in physical format (including key card/locked access, locked file cabinets);



• preventing unauthorized individuals from accessing data in electronic format (including password protections, firewalls, data encryption software, personnel access limitation procedures, and virus and spyware protection);

• safeguarding PII and survey data in physical format against loss or destruction (including fire and building safety codes);

• safeguarding PII and survey data in electronic format against loss or destruction (e.g., offsite daily backups); and

• destroying PII and survey data when specified.

Further information on security policies is presented in Chapter VIII.

Mail-Only Survey AdministrationVendors who are using mail-only survey administration must have the capability to:

• assign a random, unique, de-identified identification number to each sampled patient;

• obtain and verify addresses of sampled patients;

• print according to formatting guidelines professional-quality survey questionnaires (containing single-coded questions, code-all-that-apply questions) and materials;

• merge and print sample patient name and address, and the name of the outpatient facility on personalized mail survey cover letters and print unique sample identification on the survey questionnaire;

• track fielded surveys throughout the protocol, avoiding respondent burden and losing respondents;

• receive and process (key entry or scanning) completed questionnaires received;

• track and identify nonrespondents for follow-up mailing;

• provide a toll-free customer support line and respond to calls from sample members within 48 hours; and

• assign final status codes in accordance with OAS CAHPS coding requirements to describe the final result of work on each sampled case (see Chapter IX).



Telephone-Only Survey AdministrationVendors who are using telephone-only survey administration must have the capability to:

• assign a random, unique, de-identified identification number to each sampled patient;

• verify telephone numbers;

• develop computer programs for electronically administering the survey (for CATI);

• collect data using CATI which allows seamless administration of single-coded questions, code-all-that-apply questions;

• track fielded surveys throughout the protocol, avoiding respondent burden and losing respondents;

• schedule callbacks to nonrespondents at varying times of the day and week;

• provide a toll-free customer support line and respond to calls within 48 hours;

• assign final status codes in accordance with OAS CAHPS coding guidelines to reflect the results of attempts to obtain completed interview with sampled cases; and

• conduct monitoring of interviewers.

Mixed-Mode Survey AdministrationVendors that apply for administering the OAS CAHPS Survey as a mixed-mode survey (mail with telephone follow-up of non-respondents) must have the capability to adhere to all mail-only and telephone-only survey administration requirements described above. In addition, they must have an electronic tracking system that can track cases from the mail survey through telephone follow-up activities.

Data Processing and File SubmissionVendors must have the capability to:

• Scan or key responses to single coded questions, code-all-that-apply questions from completed surveys.

• Develop data files and edit and clean data according to standard protocols.

• Follow all data cleaning and data submission rules, including verifying that data files are de-identified and contain no duplicate cases.



• Export data from the electronic data collection system to an XML template, confirm that the data were exported correctly and that the XML files are formatted correctly and contain the correct data headers and data records.

• Submit data electronically in the specified format (XML) to the OAS CAHPS secured website.

◦ Vendors must work with the OAS CAHPS Survey Coordination Team to quickly resolve data problems and data submission problems. As stated above with regard to the Discrepancy Notification Report, vendors must inform the OAS CAHPS Survey Coordination Team promptly (within 24 hours after the discrepancy has been identified, when possible) of any deviation from the protocol. Vendors are encouraged to submit their test data files early so as to reveal any potential problems, and afford time to address them prior to submission.

Adherence to Quality Assurance GuidelinesVendors must have prior experience, facilities, equipment and software to enable them to:

• Incorporate well-documented quality control procedures (as applicable) for:

◦ in-house training of staff involved in survey operations

◦ printing, mailing, and recording of receipt of survey questionnaires

◦ telephone administration of survey

◦ coding and editing of survey data and survey-related materials

◦ scanning or keying in survey data

◦ preparation of final person-level data files for submission

◦ all other functions and processes that affect the administration of the OAS CAHPS Survey

• Participate in any conference calls and site visits requested by the Coordination Team as part of overall quality monitoring activities. Site visits will be conducted with all approved vendors.

• Provide documentation as requested for site visits and conference calls, including but not limited to staff training records, telephone interviewer monitoring records, and file construction documentation.



Participation in Training and Quality Assurance ActivitiesSurvey vendors must participate in all required training and quality assurance activities necessary to ensure the successful implementation of the OAS CAHPS Survey. This includes the following requirements:

• Review and follow all procedures described in the OAS CAHPS Protocols and Guidelines Manual that are applicable to the selected survey data collection mode.

• Attend all CMS Introduction and Vendor Update training sessions. (Failure to complete all required vendor training will result in withdrawal of approved vendor status.)

• Participate in any conference calls and site visits requested by the OAS CAHPS Survey Coordination Team as part of overall quality monitoring activities. Site visits will be conducted with all approved vendors. Vendors must provide documentation as requested for site visits and conference calls, including but not limited to staff training records, telephone interviewer monitoring records, sample frame development documentation, and file construction documentation.

Subcontractor RequirementsAny survey vendor using a subcontractor in any capacity on the OAS CAHPS Survey is required to complete the relevant sections of the Vendor Application Form (Appendix A) about each of its subcontractors. Information requested on the Vendor Application about subcontractor capabilities is similar to that requested for vendors. Details must be provided about the capabilities and capacity of the subcontractor to handle mail, telephone, and mixed-mode survey activities. Further, specific information must also be provided about the subcontractor’s quality assurance practices, data security policies, and facilities and systems.

If a vendor applicant organization’s subcontractor will conduct substantive work to support the implementation of the OAS CAHPS Survey, that subcontractor is strongly encouraged to attend the Introduction to OAS CAHPS Webinar Training Session and all OAS CAHPS Update Training Sessions. For purposes of this survey, “substantive work” is defined as follows:

• ANY statistical function, including sample selection,

• telephone survey data collection (i.e., if an approved vendor is subcontracting telephone data collection activities),

• mail or questionnaire receipt and processing, and

• construction or submission of XML data files.



If an applicant vendor will be using a subcontractor to conduct any substantive work as defined above, the subcontractor organization will be subject to the same or similar requirements as the applicant vendor.

Additional RequirementsCMS and its OAS CAHPS Survey Coordination Team reserve the right to request additional information from applicant organizations to help determine whether approval status should be granted. Information requested may include the following:

• Taxpayer Identification Number;

• website address;

• detailed description of surveys conducted that demonstrate statistical sampling and data collection capabilities;

• photographs of applicant organization’s facilities and systems;

• resumes of key staff, demonstrating experience with data collection, sampling, and computer programming; and

• additional descriptions of processes, including treatment of confidential data, control or tracking systems, quality assurance practices, and XML file construction.


IV. SAMPLING PROCEDURES

OverviewThis chapter describes the procedures survey vendors should use for sample selection. The process includes requesting a file of patients for the hospital outpatient departments or ambulatory surgery centers (HOPDs or ASCs), identifying patients and procedures eligible for the survey, constructing a sampling frame, and selecting a patient sample each month. The sampling procedures described in this chapter were developed to ensure standardized administration of the OAS CAHPS Survey by all survey vendors and to ensure comparability of the data and survey results that are publicly reported.

Before explaining patient sampling steps, it is necessary to explain facility eligibility and how the OAS CAHPS is constructed for analysis and reporting. See the text box for a review of the definition of a facility that is eligible for OAS CAHPS. When this chapter refers to “facilities” or “HOPDs or ASCs” it is referring to HOPDs and ASCs that meet this definition. The unit of analysis in OAS CAHPS is the CCN, not the individual ACS and HOPD. Implications are as follows:

• For HOPDs: Every HOPD that is under this hospital’s CCN needs to participate in OAS CAHPS for the sample to be valid. Vendors should work with their client hospital to learn what HOPDs it contains and include all HOPDs in OAS CAHPS.

• For ASCs: Every department or location within the ASC that is under their CCN needs to participate in OAS CAHPS for the sample to be valid. Vendors should work with their client ASCs to learn what locations or departments their CCN comprises and include all of them in OAS CAHPS.

The remaining sections in this chapter on sampling are organized in the general chronological order in which the corresponding tasks will take place.

• Step 1: Obtain a monthly patient information file from each client HOPD or ASC under the same CCN.


Definition of OAS CAHPS-eligible facility(For further detail see Chapter II)

HOPD: A unit of a hospital whose primary focus is to perform outpatient surgeries and procedures, is Medicare-certified, has a CMS Certification Number (CCN), and bills CMS under the Outpatient Prospective Payment System (OPPS).ASC: A freestanding medical facility that performs outpatient surgeries and procedures, is Medicare-certified, has a CCN, and meets the general conditions and requirements in accordance with 42 CFR 416 subpart B.

IV. Sampling Procedures October 2015

• Step 2: Examine the monthly patient information file for completeness and work with the HOPD or ASC to obtain missing data elements. Process and check the file for duplicate information.

• Step 3: Identify eligible patients and surgeries/procedures and construct a sampling frame.

• Step 4: Determine the sampling method most appropriate for the OAS CAHPS survey for this CCN.

• Step 5: Determine the sample size and sampling rate and select the sample.

• Step 6: Verify or update contact information for sampled patients.

• Step 7: Assign a unique sample identification number to each selected sampled patient.

• Step 8: Finalize the monthly sample file and initiate data collection activities.

Step 1: Obtain a Monthly Patient Information File from Each Client HOPD or ASC Under the Same CCNSchedule for Receiving the Monthly Patient Information FileHOPDs or ASCs administering the OAS CAHPS Survey must submit a monthly patient information file to their contracted OAS CAHPS Survey vendor each time they conduct the survey. Sampling on OAS CAHPS is monthly. Some HOPDs and ASCs may prefer to deliver patient records to their survey vendors more frequently than monthly (e.g., weekly, biweekly) per their convenience. This is acceptable, provided that sampling is done using a monthly patient information file. If there is a reason the vendor and facility wish to sample more frequently than monthly, survey vendors must complete and submit an Exceptions Request Form that explains their reasons and proposed procedures. They may receive approval from CMS for more frequent sampling. Information about the Exceptions Request Form and process is provided in Chapter XV of this manual.

Survey vendors select samples each month from the frame of patients who meet survey eligibility criteria. Survey vendors also initiate the survey on a monthly basis. It is critical that client HOPDs and ASCs provide monthly patient information in a timely manner, leaving vendors enough time to conduct sampling and quality control checks before the monthly survey is initiated. For each monthly set of sampled patients, the survey must be initiated within 21 days after the sample month ends. CMS recognizes that on rare occasions an HOPD or ASC may have a situation that may prevent it from providing the monthly patient information in time for the vendor to initiate the survey within 21 days after the sample month ends. Therefore, the vendor can initiate the survey within 26 days after the sample month ends. These exceptions are described in Chapters V, VI, and VII pursuant to each mode of data collection.


October 2015 IV. Sampling Procedures

Patient Eligibility Requirements—12 Criteria1. Patients who had at least one outpatient surgery/procedure during the sample month

(including outpatient surgeries and procedures when the patient had an overnight stay for observation but was not admitted to the hospital);

2. Patients who were at least 18 years of age when they received their outpatient surgery or procedure;

3. Patients regardless of insurance or method of payment;

4. Patients whose outpatient surgery or procedure was given in an HOPD or ASC as defined by the project;

5. Patient’s surgery or procedure meets project eligibility definitions, which are as follows:

5a. A procedure is OAS CAHPS-eligible if it has a G-Code3 of G0104, G0105, G0121 or G0260, or

5b.A surgery, diagnostic procedure, or other type of procedure is OAS CAHPS-eligible if it has a CPT-44 code in the 10021– 69990 range, was performed in an outpatient surgery department or ambulatory surgery center, was not billed as Laboratory, Radiology, Physical Therapy, Respiratory Therapy, or Diagnostic studies and if it has no accompanying modifier of 53 (discontinued procedure)5,6

5c. Also note that a facility may assign more than one code to a surgery or procedure. The presence of one eligible G-code or CPT code is all that is needed to make it OAS CAHPS-eligible.

6. Patients who have a domestic U.S. mailing address;

7. Patients who are not deceased;

8. Patients who do not reside in a nursing home;

9. Patients who were not discharged to hospice care following their surgery;

10. Patients who are not identified as prisoners;

11. Patients who did not request that the HOPDs or ASCs not release their name and contact information to anyone other than facility personnel, hereafter referred to in this manual as “no publicity” patients; and

3 G Codes (HCPCS Level II) are alphanumeric medical procedure codes for temporary procedures and professional services. HCPCS Level II codes are maintained by CMS.4 Current Procedural Terminology (CPT).5 Modifier 53 (discontinued procedure) indicates that a procedure or surgery did not take place. CPT-4 codes with Modifier 53 should be excluded.6 Vendors with HOPD clients should note that hospitals perform procedures within these codes across a variety of departments in a hospital. OAS CAHPS is only surveying patients who received these procedures in a HOPD which focuses on outpatient procedures and bills under OPPS (as defined in Chapter II.)



12. Some states have regulations and laws governing the release of patient information for patients with specific illnesses or conditions, and for other special patient populations, including patients with HIV/AIDS. It is the ASC’s or HOPD’s responsibility to identify any applicable state laws and regulations and exclude state-regulated patients from the survey as required by law or regulation.

Construction of Monthly Patient Information FilesWhen the HOPD or ASC provides the files, it must include the following:

• all patients whose outpatient surgery or procedure was given in an HOPD or ASC as defined by the project (eligibility criterion #4)

• all patients who had at least one outpatient surgery/procedure during the sample month (including outpatient surgeries and procedures when the patient had an overnight stay for observation but was not admitted to the hospital) (eligibility criterion #1)

• all patients regardless of insurance or method of payment (eligibility criterion #3)

and they must exclude the following

• patients who cannot be surveyed because of state regulations (eligibility criterion #12)

• no-publicity patients (eligibility criterion #11)

• prisoners if known (eligibility criterion #10)

• nursing home residents if known (eligibility criterion #8)

• patients discharged to hospice if known (eligibility criterion #9), and

• deceased patients if known (eligibility criterion #7).

The HOPD/ASC and their vendor should reach a mutually acceptable arrangement as to whether the facility, or the vendor, should be responsible for excluding patients who fail eligibility criteria 2 [age], 5 [surgical code], and 6 [domestic address].

With the exception of these categories of patients to exclude, facilities must supply all patients served monthly. No patients may be held back for any other reason.

It is the survey vendor’s responsibility to ensure that

• the facility understands which patients to include and exclude from the files, and



• the facility provides the vendor with sufficient information to identify and exclude patients who do not meet eligibility requirements.

Survey vendors must retain the monthly patient information files supplied by their clients for a minimum of 18 months. This information is subject to review during site visits.

Monthly HOPD and ASC files must contain information at both the patient and the facility level, as described below.

Information Needed From HOPDs and ASCs for Each Patient on the Monthly Patient Information FileHOPDs and ASCs are required to provide all of the information shown in Table 4.1 for each patient in the monthly patient information file. The information the HOPD or ASC provides will be used by the survey vendor to survey sampled patients and will be used by the OAS CAHPS Survey Coordination Team for data analysis.

Table 4.1Information Needed From ASCs/HOPDs or Patient Served During Sample Month

Data Element Required Reason NeededPatient’s full name (First Name, Middle Initial, and Last Name as separate fields)

Survey administration

Gender Survey administration and analysisPatient’s date of birth (MMDDYYYY) Survey eligibilityMailing address (Patient Mailing Address 1, Patient Mailing Address 2, Address City, Address State, and Address Zip Code as separate data fields)

Survey administration

Patient’s telephone number including area code Survey administrationIndication whether telephone number is a cell phone Telephone survey administration (ensuring

compliance with FCC Regulations)Medical Record Number (Patient’s HOPD or ASC medical record number)

Deduplication of patients before sampling

Procedure code(s) (CPT or G code) Survey eligibilityDate of procedure Survey administrationName of location where surgery occurred Survey administration (to use facility name that

will be familiar to the sampled patient)

Information Needed From Each HOPD or ASC at the Facility LevelHOPDs and ASCs are required to submit several facility-level data elements along with their monthly patient information file. These elements are the CCN, the name associated with the CCN, the Sample Month, Sample Year, Mode of Survey, Type of Sampling Method, Number of Patients Served, and Number of Patients on the File Submitted to the Vendor. The “Number of



Patients Served” is the total number of patients the HOPD or ASC served during the sample month. This total should include patients who had at least one outpatient surgery or procedure at any point during the sample month, regardless of whether the patient is OAS CAHPS-eligible. Further explanation of these required numbers is found in Chapter XI and in Appendix K (XML File Layout for Standard Header Record).

Definition and Explanation of Some of the Data Elements Required From HOPDs and ASCsThis section provides more explanation on some of the variables on the monthly patient information file.

• Patient’s date of birth . Patients must be 18 years of age on the day of their outpatient surgery/ procedure to be eligible for participation in the OAS CAHPS Survey.

• Vendors should ensure that their client HOPDs and ASCs include each patient’s mailing address, even if a telephone survey is planned for that HOPD or ASC. For facilities planning telephone surveys, the mailing address for each patient is needed so that the vendor can obtain or verify the sample patient’s telephone number. The facilities provide the initial contact information; however, survey vendors are strongly encouraged to use address verification or telephone number look-up services to obtain updated contact information.

• Patient telephone phone number is needed for mixed-mode and phone-only surveys. It is strongly recommended for mail-only modes because the telephone can be used to validate or update the patient’s address information.

• Indication of cell phone is needed for mixed-mode and phone-only surveys. FCC regulations prohibit auto-dialing of cell phone numbers. Therefore, cell phone numbers need to be identified in advance to allow the vendor to treat cell phone numbers in a way that complies with FCC regulations. Vendors are advised to familiarize themselves with all applicable state and federal laws. If the facility is unable to advise the survey vendor as to which telephone numbers provided are cell phone numbers, it is the vendor’s responsibility to obtain from an external source an up-to-date list of cell phone numbers and land line numbers which have been ported to cell phone from an external source. The external source must be compared to the phone numbers of the sampled patients to identify any phone numbers which are cell phones.

• The patient’s medical record number is the unique identifier that the HOPD or ASC assigns to the patient that allows the HOPD or ASC to track and document the care provided to the patient. This number, along with other data elements, will allow the vendor to keep track of whether each patient has been recently sampled.



• CPT-4 codes are a standardized set of five-digit codes developed by the American Medical Association. The CPT codes relevant to OAS CAHPS are divided into the following categories:

◦ 10021–10022 general

◦ 10040–19499 integumentary system

◦ 20000–29999 musculoskeletal system

◦ 30000–32999 respiratory system

◦ 33010–37799 cardiovascular system

◦ 38100–38999 hemic and lymphatic systems

◦ 39000–39599 mediastinum and diaphragm

◦ 40490–49999 digestive system

◦ 50010–53899 urinary system

◦ 54000–55899 male genital system

◦ 55920–55980 reproductive system and intersex

◦ 56405–58999 female genital system

◦ 59000–59899 maternity care and delivery

◦ 60000–60699 endocrine system

◦ 61000–64999 nervous system

◦ 65091–68899 eye and ocular adnexa

◦ 69000–69979 auditory system

Vendors should work closely with facilities to ensure that only eligible surgeries and procedures are included in the sample. Some HOPDs and ASCs perform additional procedures that would not be inappropriate for the OAS CAHPS Survey because of the limited involvement of the doctors and nurses or the fact that the CPT code represents preadmission testing, postsurgery follow-up testing, physical therapy, respiratory therapy, laboratory, or radiology testing only. For example, the following CPT codes fall within the range for Codes for Surgery but are not considered to be eligible for OAS CAHPS:

• 16020, 16025, 16030: Dressings or debridement of partial-thickness burns, initial or subsequent

• 29581: Application of multilayer compression system; leg (below knee), including ankle and foot



• 36600: Arterial puncture, withdrawal of blood for diagnosis

• 36416: Collection of capillary blood specimen

• 36415: Collection of venous blood by venipuncture

Additional CPT codes within the eligible range may also be excluded; however, the vendor must submit an Exception Request form to document the codes to be excluded.

• G Codes or HCPCS Level II codes are alphanumeric medical procedure codes for temporary procedures and professional services. HCPCS Level II codes are maintained by CMS. At this time, only four G-codes are OAS CAHPS-eligible: G0104, G0105, G0121, and G0260.

Name of location where surgery occurred. Some HOPDs or ASCs are part of larger, multisite institutions. The monthly patient information file should state the name of the location where each patient received his or her surgery. This name is included on the cover letter so that the patient recognizes the name of this location. It may not be the official name of the facility. If there is only one location for all patients, then this value will be identical for all patients. Although location where surgery occurred is part of the monthly patient information file, OAS CAHPS does not report survey results for individual locations or units within the CCN. OAS CAHPS reports only at the CCN level.

Protocol for No Eligible Patients Served in the Sample MonthIf the HOPD or ASC did not perform any outpatient surgeries/procedures or did not serve any patients who met survey eligibility criteria during the sample month, the HOPD or ASC must still submit a monthly patient information file or an e-mail notification to its survey vendor stating that no survey-eligible patients were served during that sample month.

Vendors are still required to submit data to the OAS CAHPS Data Center for a month when there are no eligible cases. The vendor submits a Zero Eligible File in this situation. The vendor must indicate on the file that there were zero eligible cases in data element for “Eligible Patients” and enter all other information required in the Header Record Section of the XML file (refer to Chapter XI in this manual for more information about data file preparation and submission). If the vendor does not submit a zeroeligible file in this case, CMS and the OAS CAHPS Survey Coordination Team will view the HOPD or ASC as having “missed” a sample month. HOPDs or ASCs for which an OAS CAHPS Survey data file is not submitted for a month in the reporting period may be considered as being noncompliant with OAS CAHPS Survey participation requirements.



Protocol for Administering Other Surveys in Conjunction With the OAS CAHPS SurveySome HOPDs and ASCs may wish to administer other surveys of their patients. The following guidelines should be used if the HOPD or ASC is planning to administer other surveys in addition to the OAS CAHPS Survey.

If an HOPD or ASC will be fielding another survey of its patients, it must provide a file of all OAS CAHPS-eligible patients to its survey vendor for the OAS CAHPS Survey first, prior to selecting patients for any other survey. Patients who were not randomly selected into the OAS CAHPS Survey sample for the sample month may be included in a sample for a separate survey that the vendor conducts on the HOPD’s or ASC’s behalf that month. This secondary survey sample must be selected after the OAS CAHPS Survey sample has been drawn. This means the secondary survey must use the unused OAS CAHPS sample. The vendor cannot provide the list of sampled patients for OAS CAHPS to the HOPD or ASC because this would be a violation of the patient’s confidentiality. Because of the coordination required between surveys, both surveys must be administered by the same vendor.

Facilities that are conducting patient surveys in parallel with OAS CAHPS are reminded that they are allowed to add up to 10 questions of their own to the OAS CAHPS questionnaire. Subsuming the questions from their other survey into OAS CAHPS and discontinuing the other survey may be more efficient than administering both surveys simultaneously.

Approved OAS CAHPS Survey vendors are expected to work closely with their client HOPDs and ASCs to identify patients who are eligible for inclusion in other surveys the facilities conduct. It is very important to avoid burdening patients with both OAS CAHPS and other surveys. If the other survey is CMS-sponsored, vendors should contact the OAS CAHPS Survey Coordination Team to make arrangements for both surveys.

Step 2: Examine the Monthly Patient Information File for Completeness and Possible DuplicationSurvey vendors should examine each monthly patient information file provided by their client facilities to ensure that information they need for determining survey eligibility for all patients and surgeries on the file has been provided. These include CPT or G code(s) classifying the surgery, patient date of birth, and date of surgery/procedure. If patient information needed for sample selection is missing, the vendor should work with the HOPD or ASC to obtain all missing data before selecting the sample.

Survey vendors should check the monthly patient information file to ensure that it does not include duplicate information—that is, to ensure that a patient does not appear more than once on this month’s file. If duplicate information is included on the file received, the vendor should



make a copy of the monthly patient information file and remove the duplicate information on the new file. Note that vendors are required to retain the original monthly patient information files submitted by their client HOPDs and ASCs, and any new copies made, for possible audits by CMS and the OAS CAHPS Survey Coordination Team.

When checking the monthly patient information files to identify “duplicate” patients or patients who may have been listed on the file more than once, vendors should use the patient’s Medical Record Number (MRN) and at least one other patient data element to check for duplicate cases. Data elements that will be useful for identifying duplicates include the surgery code(s), patient’s name, date of birth, telephone number, etc. Using the MRN in conjunction with other patient data elements will help ensure that patients identified as duplicate patients on the file are indeed “duplicate” records. If a patient had more than one surgery/procedure in the sample month, it is to be expected that he or she will have more than one record in the monthly patient information file. Vendors should remove the patient’s record associated with a surgery code that is not OAS CAHPS-eligible. If the patient received procedures on different dates in the month and the procedures on all dates are OAS CAHPS-eligible, the vendor should remove the records for the earlier procedures and keep only the latest procedure on the sample frame.

The vendor should have a different staff member conduct a QC check on these two processes (completeness check, removal of duplicates) before proceeding to Step 3.

Step 3: Identify Eligible Patients and Construct a Sampling FrameAfter the completeness check and the duplicate patient removal, the survey vendor should verify the eligibility of the patients. As stated above, HOPDs and ASCs may elect to remove ineligible patients and surgeries before supplying the monthly patient information file, or may elect to have their vendor do it on their behalf. Either way, the vendor should do the following:

1. Compute patient age at the time of surgery by use of the date of birth and surgery date. Verify that the patient was 18 years of age or older at the time of his or her surgery.

2. Verify that the surgery or procedure for each patient is OAS CAHPS-eligible according to its CPT code(s) or G code(s) and that the procedure was performed in an ASC/HOPD and not billed as Laboratory, Radiology, Physical Therapy, Respiratory Therapy, or Diagnostic Studies.

3. Verify that patients have a U.S. domestic address.

4. Verify that the date of the surgery/procedure is within the sample month.

These four checks align with the Patient Eligibility Requirements listed in Step 1. Patients who fail any of these verifications are not OAS CAHPS-eligible and should be removed from the sample frame.



After the completeness and duplication review in Step 2 and the removal of ineligible patients in Step 3, there is another step that must be performed before creating a definitive sample frame for the month. That step is to remove all patients who were sampled for OAS CAHPS in the previous 5 months.

To reduce respondent burden, outpatient surgical patients can only be sampled by OAS CAHPS once in a 6-month period. Therefore, the survey vendor must also exclude from the sample frame patients who were included in the OAS CAHPS Survey sample during the 5 months preceding the sample month. Vendors must compare all eligible patients on the new month’s file to all patients selected for the survey in the past 5 months and identify any repeats. Such repeating patients are ineligible and must be removed from the sample frame. This determination must be made before sampling from the sample frame begins.

For purposes of audit and quality assurance, survey vendors must keep the monthly patient information files submitted by all HOPDs and ASCs and the sampling frame created for each sample month for 18 months. Vendors must record and retain documentation showing the reasons patients were excluded from the sample frame created for each HOPD and ASC for each sample month, and provide documentation of all staff quality control checks that were completed during the sampling process. This documentation will be subject to review by the OAS CAHPS Survey Coordination Team during site visits.

Step 4: Determine the Sampling Method Most Appropriate for the OAS CAHPS Survey for This CCNAs a reminder, OAS CAHPS participation within the CCN must be comprehensive. As stated in Step 1, all components within the CCN which are OAS CAHPS-eligible are to be included in OAS CAHPS. When this chapter mentions the term “components” it refers to the definition in the text box.

The components present in the CCN, the volume of eligible patients in each, and analytic goals of the client CCN dictate which sampling method is most appropriate. There are four acceptable sampling methods for OAS CAHPS:

• Simple random sampling method

• Stratified systematic sampling method


Definition of “Component” Used in This Chapter

Components of an HOPD: Any departments, locations, or other divisions which meet the definition of an OAS CAHPS-eligible HOPD and which bill under the hospital’s CCN.Components of an ASC: Any departments, locations, or centers which are within or associated with the eligible ASC and which bill under the ASC’s CCN.For sampling purposes, components are considered sampling strata.


• Proportionate stratified random sampling method

• Disproportionate stratified random sampling method

Simple Random Sampling (SRS) MethodAppropriate use: When there is a single component within the CCN.

Example: Northshore Ambulatory Surgery Center sees about 400 patients per month. It does not share the CCN with any other surgery centers and has only one location.

Stratified Systematic Sampling (SSS) MethodAppropriate use: There are two or more components (strata) within the CCN and patients from all components need to be included in the OAS CAHPS sample proportionally to their volume in the CCN to make a valid sample. However, the strata are small or the facility does not wish to track results at the strata level.

Example: ABC Surgery Center comprises three locations (strata). They all bill under the same CCN. Location A served 100 eligible patients in the sample month, Location B, 140, and Location C, 80 eligible patients in the sample month, for a total of 320 eligible patients.

Proportionate Stratified Random Sampling (PSRS) MethodAppropriate use: There are two or more components (strata) within the CCN and patients from all components need to be included in the OAS CAHPS sample proportionally to their volume in the CCN to make a valid sample. Additionally:

• the HOPD or ASC would like to keep track of samples and results for each stratum, or

• the HOPD or ASC would like to designate other aggregates of operating units for tracking while using the same sampling rate for each.

Example: Any-City Best Care Surgical Center comprises three locations (strata) but they all bill under the same CCN. These patients were located in Facility A, which serves 200 patients/month, Facility B, which serves 150 patients/month, and Facility C, which serves 180 patients/month. Facility A has been in operation for 10 years, but Facilities B and C were opened in the last 2 years. Any-City Best Surgical Center wants the survey estimates from each location to have statistical precision and would like to track them separately over time.

Additional requirements and limitations: A minimum of 10 eligible patients must be in each stratum for PSRS sampling to be used. The statistical precision of survey results at the stratum level will not be very good unless the stratum sample size is about the size of the overall sample requirements (25 completed surveys per month).



Disproportionate Stratified Random Sampling (DSRS) MethodAppropriate use: There are two or more components (strata) within the CCN and the CCN wishes to achieve statistically precise survey estimates for the component facilities.

Example: Memorial Hospital includes three eligible outpatient departments (strata): Same Day Surgery (120/month), Outpatient (100/month), and Endoscopy (40/month). Memorial wants each department’s survey estimate to have statistical precision.

Additional requirements and limitations: A minimum of 10 eligible patients must be in each stratum for DSRS sampling to be used. The goal of the DSRS is to obtain sufficient statistical power to detect differences at the stratum level. Vendors wishing to use DSRS must submit an Exceptions Request Form to the OAS CAHPS Survey Coordination Team.

Deciding Which Method to UseThe facility, in conjunction with the vendor, should determine which of the four OAS CAHPS- approved sampling methods described above is most appropriate for their CCN and meets the analytic needs of the facility. Unless disproportionate stratified random sampling has been approved for use, if there are two or more components with the CCN either stratified systematic sampling or proportionate stratified random sampling must be used. Simple random sampling may not be used if there are two or more components.

The same sampling method must be used for all sample months in the quarter. Vendors may switch to a different sampling method only at the beginning of a new quarter.

Step 5: Determine the Sample Size and Sampling Rate, and Select the SampleSelect an Appropriate Sample Size Each MonthThe target for the statistical precision of OAS CAHPS Survey results that will be publicly reported is based on a reliability criterion. The reliability target for the OAS CAHPS Survey ratings and most of the composites is 0.8 or higher. For reasons of statistical precision, a target minimum of 300 completed OAS CAHPS Surveys has been set for each HOPD or ASC over each 12-month reporting period. This is an average of 25 completed surveys per month.

The mode of administration of the survey will be an important factor in determining sample size and response rates. Table 4.2 shows response rates by mode which are anticipated for OAS CAHPS and the sample sizes needed based on these rates.



Table 4.2Response Rates Obtained by Mode Anticipated for OAS CAHPS

Mode Expected Response Rate

Sample Size for 25 Responses/Month

Mail only 32% 77Phone only 32% 77Mixed 40% 62

The sample size estimates above were derived using the following formula:

Sample size = (number of responses needed) (response rate) = 25 (response rate)

where the value used for the number of responses needed is 25. These sample size estimates have been rounded up to the nearest integer. Each vendor should work with its client HOPD or ASC and use experience on other surveys with similar populations to determine the appropriate data collection mode and expected response rate to use as a guide for calculating monthly sample sizes.

Determine the Sampling RateSurvey vendors must determine a sampling rate and use that rate to ensure that an even distribution of patients is sampled over a 12-month period. To determine the sampling rate, vendors will need to have a good estimate of the size of the sample frame. The typical frame size will depend on the number of patients served by the HOPD or ASC and the percentage of these patients and surgeries/procedures that are OAS CAHPS-eligible.

Vendors should expect that there will be variability in the number of patients the HOPD or ASC serves and the number eligible for the survey because these characteristics vary over time. In some cases there could be seasonality to surgeries, depending on the mix of patients served by different HOPDs or ASCs. The number of patients to be selected each month to yield a minimum of 300 annual completed surveys will ultimately be determined by trial and error.

The sampling rate must be approximately the same for each month in a quarter. The first month that an HOPD or ASC participates in the OAS CAHPS Survey the facility might have an atypically high number of patients eligible for the survey because none of the patients will have been sampled in the preceding sample months. Therefore, the vendor should adjust the sampling rate for the first sample month to make the sample for that month about equal to subsequent sample months. The rate may be increased in subsequent months to achieve the target of 300 annual completed surveys, but should not be decreased simply to avoid exceeding 300 completed surveys.



The survey vendor should estimate a sampling rate by working with their client HOPDs and ASCs to understand the number of patients served and how many of them will typically be eligible. This is described below.

Using Prior Months From the HOPD or ASC in the Determination of the Sampling RateThe vendor should work with the HOPD or ASC prior to the first sample month that the HOPD or ASC begins its participation in the OAS CAHPS Survey to estimate the sample frame size. This sample frame size should be estimated from the number of patients served monthly and the percentage of those patients and surgeries/procedures which are OAS CAHPS-eligible. The HOPD or ASC should supply to the vendor monthly patient information files with all the required data elements (see Table 4.1) for each of the preceding 3 to 6 months. The more months the facility provides, the better the vendor will be able to estimate sample frame size and its variability. A single month can be nonrepresentative of an ASC’s or HOPD’s patient size or surgeries/procedures performed, so consider a range of months to guard against estimating sampling rates that will yield a sampling frame that is either too large or too small.

In looking at the sample frame information for the 3 to 6 months that precede the first sample month of participation, the vendor should apply the same sample frame construction criteria for each month that it would apply for the first sample month. Note that in the first month’s sample file, the rule that a patient cannot be sampled more than once in the 6-month period will not be a constraint. In the second month of the 3- to 6-month test period, all patients sampled in the first month will be excluded from the frame. Only patients not sampled the previous sample month can be included on the sample frame for the second (and subsequent) month(s).

Once the vendor has a good understanding of the average monthly frame size, the vendor should calculate the sampling rate using the formula

Sampling rate = (Required sample size) (frame size)

The required sample size, as explained above, is

Required sample size = (number of responses needed) (response rate)

Adjustments to the sampling rate may be needed over time to reach the annual target of 300 completes over each of the rolling four quarter periods. However, sampling rate should not fluctuate wildly between months. All patients sampled in a sample month must be surveyed. The target of 300 completed surveys is not a quota after which surveying or processing can stop.



Sampling Rates That Yield Above and Below the Minimum Number of PatientsThe targeted number of completed surveys for OAS CAHPS is 300 over a 12-month period. Some HOPDs and ASCs may want to survey more of their patients. Reasons for doing so include having more patients represented in the survey results or achieving a reliability target for a component within the CCN, a type of patient or a surgical procedure. There is no upper limit to the number of patients who may be surveyed for OAS CAHPS. However, the vendor should still use a sampling rate and select a sample (rather than surveying all eligible patients each month) so that the sample is evenly distributed across a 12-month period. As a reminder, samples that are selected disproportionately―that is, with a different sampling rate for different strata―require approval from the OAS CAHPS Survey Coordination team via an Exceptions Request Form.

As stated previously, the survey vendor should determine a sampling rate and select the sample so that there is an even distribution of patients over a 12-month period. For some facilities with low patient volumes, in some sample months the number of survey-eligible patients served may be less than the number required by the sampling rate. In this case, it is acceptable to sample, and then survey, all survey-eligible patients served during that sample month.

Generation of Random Numbers Needed for Sample SelectionAll four methods of sampling approved for OAS CAHPS described in Step 4 require the use of random numbers. Survey vendors should use a random number generator that is generally accepted as having satisfied criteria of randomness. The random numbers should be generated from the uniform distribution―each number having an equal probability of selection. Most random number generators are pseudo-random number generators that repeat numbers after some specified period. An acceptable random number generator will repeat only after many billions of numbers are produced. An important feature of the random number generator is the “seed” number used to start the cycle. The seed number must be known and retained as part of the documentation vendors keep so that the sampling process can be reproduced for OAS CAHPS Survey Coordination Team site visits. The selection of the seed number should be such that it cannot be manipulated.

Survey vendors should use a reputable statistical program like SAS v9 either to select a sample from a frame using its procedures for survey sample selection or to generate random numbers that can be applied as described above. An appropriate seed often used is the clock time as measured by the computer. This seed varies each fraction of a second but the value used is documented by the program and is part of the output that can be retained.



Another reliable program, which runs under Windows, is RAT-STATS, developed by the Department of Health and Human Service (DHHS) Inspector General’s Office. Survey vendors can download this program at no cost from https://oig.hhs.gov/compliance/rat-stats/index.asp.

In addition to the RAT-STATS program, survey vendors may download a detailed user’s guide and comprehensive manual describing how this program operates. There are many sampling tools in the program. One module can simply produce a sample size, n, random integers between 1 and the frame size, using the computer clock to generate the seed, which is retained and reported.

Both SAS and RAT-STATS are examples of readily available, high-quality, rigorously tested tools for selecting samples randomly. Commonly available spreadsheet programs also have random number generators; however, do not use these random number generators when selecting monthly samples for the OAS CAHPS Survey because they do not generate a report of the seed used. Note, however, that a spreadsheet is an acceptable way to present and manipulate the sample frame.

It is also especially critical to document how the random start number was generated and how the sample frame was sorted for survey oversight purposes. During oversight telephone calls or site visits the OAS CAHPS Survey Coordination Team will check each vendor’s sampling procedures and documentation, including documentation of all quality control checks conducted by vendor staff.

The following are two acceptable ways to choose a random sample of patients from the sample frame for the OAS CAHPS Survey.

Method 1—Generate N Random NumbersSort the sample frame of N eligible patients by any replicable method.

• Generate the N random numbers.

• Assign the random numbers in the order generated to each element in the frame.

• Re-sort the elements as ordered by the random numbers.

• Select the first n, the sample size required for the mode used.

In this way, the initial sort of the data does not affect the result, although a standard sort order should always be used so that it does not appear that a frame has been altered. This method requires generating as many random numbers as there are patients on the frame.



Method 2—Generate n random numbersIf the random number generator is able to produce integers from a range of values, given that N is the size of the sample frame of eligible patients, we can use the following steps to select our sample.

• Generate n distinct random integers whose values range from 1 to N, where n is the sample size required for the mode used.

• Select the element of the frame that corresponds to the random number generated. For example, if the random number 10 is generated then select the 10th element on the frame for the sample.

• Continue selection of elements according to the random numbers generated until all n distinct elements have been selected.

For Method 2, the initial sort of the data does affect the result and the vendor should clearly document any sorting or file manipulation that occurred prior to random number generation.

Either Method 1 or Method 2 may be used for Simple Random Sampling (SRS), Proportionate Stratified Random Sampling (PSRS) or Disproportionate Stratified Random Sampling (DSRS).

Method of Simple Random Sampling (SRS)Appropriate Use: Simple random sampling can be used when there is a single component within the CCN. For example, if there is only one eligible HOPD in the hospital’s CCN or only one location in the ASC’s CCN, simple random sampling can be used.

Example: Northshore Ambulatory Surgery Center sees about 400 patients per month. It does not share the CCN with any other surgery centers. From looking over the past 3-6 months it is revealed that on average 350 patients per month are OAS CAHPS-eligible. Northshore is required to obtain 25 completed surveys per month (300 completed surveys / 12 months = 25 completed surveys per month). Because the surgery center will be doing mixed-mode data collection to which a 40% response rate is expected, it will need to sample 62.5 patients per month (25 completes / .40 response rate = 62.5 selected patients), which is rounded up to 63. Northshore’s sampling rate is 62.5/350, or 17.8%.

Use either Method 1 or Method 2 for selecting the patients from the sample frame.

If Method 1 is used, sort the month’s eligible patient list by the random number and select the first 63 patients. If Method 2 is used, generate 63 random numbers between 1 and 350. Select the elements from the frame that correspond to the random numbers generated.



Method of Stratified Systematic Sampling (SSS)Appropriate Use: Vendors may use Stratified Systematic Sampling when a CCN is comprised of two or more strata and patients from all strata need to be included in the OAS CAHPS sample proportionally to their volume in the CCN, to make a valid sample. SSS is appropriate when the strata are small and/or the facility does not wish to track results at the strata level.

Example ABC Surgery Center comprises three locations but they all bill under the same CCN. Location A served 100 eligible patients in the sample month. Location B served 140 eligible patients in the sample month. Location C served 80 eligible patients in the sample month. There are 320 eligible patients in this sample month. Assume the vendor expects a 40% response rate. The vendor will want to sample 63 patients each month to ensure about 25 completed surveys each month to total approximately 300 completed surveys in a 12-month period.

63 patients * 40% response rate = 25 completed surveys

25 completed surveys *12 months = 300 completes in a year

The vendor needs to sample 63 patients in total from ABC Regional Medical Center, but the locations A, B, and C should be representative (proportionate) in this total. The vendor should calculate the proportion of patients from each location, as shown in Column B. The vendor should then allocate the 63 patients proportionally to each location, as shown in Column C.

A.

Patient Count

B.Proportion of Patients on

Frame(Column A/320)

C.Number of Patients to be

Sampled(63 x Column B/100) (numbers

rounded up)Location A 100 31.25 19.69 (round to 20)Location B 140 43.75 27.56 (round to 28)Location C 80 25 15.75 (round to 16)Total 320 100 64

Although the vendor’s goal was to get 63 patients, it is important to round up to the next highest integer. In this example, the sum in column C shows the total sample size ends up being 64 patients. Rounding down could result in not achieving the target of 300 completed interviews in a 12-month period.

Once the vendor knows how many patients to sample from each location, the vendor will apply the Systematic Sampling Process to the sample frame for each location. First, the vendor will need to select a starting observation. To do this the vendor should use a random number generator to apply random numbers to all frame members. Then the vendor should find the



lowest random number and the corresponding frame member will be the first sample member and be the starting point of the systemic sample. Next, the vendor needs to calculate the size of the interval. For Location A, the frame has 100 patients and 20 need to be sampled. The interval will be 100 / 20 = 5. The vendor will take Sample Member #1 based on the random number generation. Let’s say Patient #19 had the lowest random number and was the first patient selected. Using the interval of 5, the vendor will go down the list and select Patient #24, then Patient #29, Patient #34, and so on until 20 patients are selected. If the starting number is toward the bottom of the list (e.g., Patient #90), the vendor would go to the top of the list and continue down again, considering the list to be circular.

Vendors should not allow a patient to be selected multiple times. No sorting should occur. After selecting the 20 patients from Location A, the vendor should repeat this process on the list of eligible patients from Location B, and on the list of eligible patients from Location C. The interval will always be 5.

Method of Proportionate Stratified Random Sampling (PSRS)Appropriate use: There are two or more components (strata) within the CCN and patients from all components need to be included in the OAS CAHPS sample proportionally to their volume in the CCN to be a valid sample. Additionally,

• the HOPD or ASC would like to keep track of samples and results for each stratum, or

• the HOPD or ASC would like to designate other aggregates of operating units for tracking while using the same sampling rate for each.

In PSRS, the same sampling rate must be applied to each stratum included in the sample. The strata created must be large enough to support the same sampling rate in each stratum.

Example: Any-City Best Care Surgical Center comprises three locations (strata) but they all bill under the same CCN. The surgical center serves 530 patients per month, across Facility A, which serves 200 patients/month, Facility B, which serves 150 patients/month, and Facility C, which serves 180 patients/month. Facility A has been in operation for 10 years, but Facilities B and C were opened in the last 2 years. Any-City Best Surgical Center wants the survey estimates from each location to have statistical precision and would like to track them separately over time. These facilities each serves as a stratum for sampling. The vendor for this ASC selected a sampling rate of approximately 45%, based on its prior experience with this client facility.

The sampling rate for the CCN as a whole is 45%, to get 239 sampled patients in the sample month. Then the vendor will apply that same sampling rate to each stratum, as demonstrated below:

• Location A: 200 eligible patients * 45% sampling rate = 90 patients sampled



• Location B: 150 eligible patients * 45% sampling rate = 68 patients sampled

• Location C: 180 eligible patients * 45% sampling rate = 81 patients sampled

The vendor would round any fractions of a patient up to the next largest whole number. For example, a sample of 67.5 patients should become 68 sampled patients. The vendor should use Method 1 or 2 to select the sample of 90 patients in Location A, 68 patients in Location B, and 81 patients in Location C.

This vendor uses mixed-mode administration and expects a response of rate of 40% (see Table 4.2). If the vendor achieves a response rate of 40% the number of completed surveys will be as follows:

• Location A: 62 patients sampled * 40% Response Rate = 36 completed surveys

• Location B: 68 patients sampled * 40% Response Rate = 28 completed surveys

• Location C: 81 patients sampled * 40% Response Rate = 33 completed surveys

The total number of completed surveys from this CCN in the sample month is 97, which greatly exceeds the number of responses needed to get 300 completed interviews in a 12-month period. Additionally, each stratum (location) has 25 or more completed surveys and is on target to achieve 300 completed surveys in the 12-month period. There will be adequate statistical precision to track estimates for each location.

Even if a facility does not have a large number of eligible patients in each stratum, it may still use PSRS. It may not achieve enough completed surveys in a stratum to have good statistical precision, but may still proceed so long as each stratum has a minimum of 10 sampled patients each month.

Method of Disproportionate Stratified Random Sampling (DSRS)Appropriate use: DSRS is another appropriate sampling option if a hospital, for example, with multiple HOPDs wishes to achieve statistically precise numbers for each HOPD. To achieve as good a level of precision for the separate units (in this example, the HOPDs) as required for the CCN as a whole, each unit would have to have the same number of completed surveys as the CCN as a whole. In this case, the sampling rate may be different for each stratum. To allow the separate strata to be recombined to represent the HOPD or ASC as a whole the sampling rate for each stratum must be reported in the data submitted to the OAS CAHPS Survey Coordination Team. This will permit appropriate weighting of the respondents in computing results. Different sampling rates in strata with particularly high or low ratings could otherwise distort the ratings.



If an HOPD or ASC chooses to use DSRS, its survey vendor must do the following:

• Complete and submit an Exceptions Request Form;

• Use the same name for each stratum in each month in the quarter;

• Make sure that each stratum has a minimum of 10 patients eligible to be included in the survey during the sample month; and

• Provide to the OAS CAHPS Survey Data Center additional information about each stratum, including the following:

◦ The name of the stratum;

◦ The total number of patients sampled in each stratum during the sample month;

◦ The total number of patients on the file submitted by the HOPD or ASC for that stratum;

◦ The number of patients in the stratum who were eligible for the survey during the sample month; and

◦ The total number of patients sampled during each sample month.

Example: Memorial Hospital includes three eligible outpatient departments (strata): Same Day Surgery (120/month), Outpatient (100/month), and Endoscopy (40/month). Memorial wants statistically precise survey estimates for each department. Assume that the target for each stratum is the same as for the CCN as a whole, that 25 is the target number of responses, and that the expected response rate is 40 percent. Therefore, to get the same precision for each stratum the sample size would be 62 for each of the three strata in this example. Because of the differing patient volumes for these departments, the vendor’s sampling rate to achieve a sample size of 62 varies, as shown below:

• Same Day Surgery: 120 eligible patients * 51% sampling rate = 62 sampled patients of whom 40% respond to get 25 completed interviews.

• Outpatient: 100 eligible patients * 62% sampling rate = 62 sampled patients of whom 40% respond to get 25 completed interviews.

• Endoscopy : 40 eligible patients * 100% sampling rate = 40 sampled patients of whom 40% respond to get 16 completed interviews.

Note that the survey vendor will report the number of patients eligible for the survey and the number sampled to the OAS CAHPS Survey Data Center for use in computing weights for the HOPD or ASC when the data are combined (this information is provided in the vendor’s data



submission, see Appendix L, XML File Layout for DSRS Header Record). Patients in Location A had a lower probability of selection than those in Location B and C, and that will be accounted for when the data from sample members in the strata are combined. Survey vendors should keep in mind that a minimum of 10 eligible patients must be in each stratum for DSRS sampling to be used.

The goal of the DSRS process is to obtain about 300 completed interviews for each stratum (e.g., location) in the 12-month period. This will provide sufficient statistical power to detect differences at the stratum level. In this example, Location C will have lower statistical power because the number of completes (only 16 are expected) will probably not reach 300 in the 12-month period because of the lower number of eligible patients.

Step 6: Verify or Update Contact Information For Sampled PatientsWe strongly recommend that survey vendors send patient mailing addresses of sampled patients through an outside address service, such as the National Change of Address (NCOA) or a similar provider, to confirm or update patient contact information. In addition, vendors conducting either a telephone-only or mixed-mode data collection are urged to send the most updated mailing addresses through a telephone number–provider service to attempt to obtain an updated telephone number. Performing these quality control activities prior to the start of data collection will result in fewer surveys returned as undeliverable and fewer unproductive telephone call attempts.

Vendors are also reminded that in Step 2 they were to request contact information for all patients. If an HOPD or ASC does not provide an address or telephone number for a patient on the monthly patient information file and this omission was not rectified in Step 2, the vendor should recontact the HOPD or ASC for the missing information for all patients contained on the ASC’s or HOPD’s original data file. Asking for the information for all patients is important because the vendor may not reveal to the facility which patients were selected for OAS CAHPS.

The vendor should also attempt to find an address and phone number for the sampled patients who lack it. In most cases an HOPD or ASC will have the patient’s telephone number which was obtained for the purpose of calling them to follow up on their recovery.

Vendors should also note that even if an address or telephone number cannot be obtained for a patient, the patient is still eligible for inclusion on the sample frame (and in the survey if sampled) if he or she meets all other survey eligibility criteria. That is, patients with missing mailing addresses are considered eligible for the survey and can be sampled. If a patient sampled for a Mail Only survey lacks an address the patient should be assigned the survey disposition code of 330—Bad Address/Undeliverable Mail or No Address. If a patient sampled for a telephone-only survey lacks a telephone number the patient should be assigned the survey disposition code of 340—Wrong, Disconnected, or No Telephone Number. If a patient sampled



for a mixed-mode survey has a telephone phone number or an address he or she should proceed with the survey; if the patient has neither he or she should be assigned the survey disposition code of 340—Wrong, Disconnected, or No Telephone Number.

Step 7: Assign Unique Sample Identification NumbersSurvey vendors are responsible for assigning a unique alphanumeric sample identification (SID) number to every sample member selected into each monthly sample. Procedures for assigning unique SID numbers are described in Chapter IX and are repeated here in summary form only. Vendors will track the status of a sampled patient/case throughout the data collection process using the SID. Note that this number is different from the medical record number that HOPDs and ASCs will provide to the survey vendor with other information needed to construct the sample frame. The SID number cannot contain any combination of letters, numbers, or any information that could link it with a particular sampled patient. For example, no part of the patient’s name, address, date of birth, telephone number, Social Security number, visit dates, or Medicare Number can be used or included in the SID number under any circumstances. The SID number also cannot include any information that would identify the HOPD or ASC that served the patient (i.e., ASC’s or HOPD’s name, address, CCN). Each month, vendors must use a new set of unique SID numbers for the new set of patients sampled that month. Vendors must not reuse the same SID numbers—that is, once a SID number is assigned, it should never be assigned again to any sampled patient, either in the current quarter or in subsequent quarters.

Step 8: Finalize the Monthly Sample File and Initiate Data Collection ActivitiesAlthough OAS CAHPS Survey data will be analyzed on a quarterly basis, sample frame construction, sample selection, and data collection are conducted monthly. As soon as the sampling activities described above have been completed, data collection for the sample month should begin. Survey vendors must initiate the survey for each monthly sample within 3 weeks (21 days) after the end of the sample month. Exceptions to this start date are noted earlier in this chapter. All data collection for each monthly sample must be completed within 6 weeks (42 days) after data collection begins. For mail-only and mixed-mode surveys, data collection for a monthly sample must end 6 weeks after the first questionnaire is mailed. For telephone-only surveys, data collection must end 6 weeks following the first telephone attempt.

As noted earlier in this chapter, HOPDs and ASCs must provide the patient information file for each sample month in time for the survey vendor to initiate the survey within 21 days after the sample month closes. The HOPD or ASC can choose to submit the data needed on two separate files. The first file must contain all patient information that the vendor will need to determine the patients’ eligibility for the survey and for fielding the survey. The second file, which will include the facility-level data needed for analysis, must be submitted to the vendor no later than the end of the second month after the sample month ends. The survey vendor must receive the



second file in time to add the data needed for analysis to the data file that will be submitted to the OAS CAHPS Data Center.

Sampling Issues and ErrorsBased on national implementation of other CAHPS Surveys, CMS and the OAS CAHPS Survey Coordination Team have observed some common misconceptions and problems with the sampling process. The following is a list of some of these common misconceptions, paired with the proper implementation method that survey vendors should use to avoid these issues during the sampling process.

Patient Eligibility Criteria1. Misconception: Patients with missing or incomplete mailing addresses or telephone

numbers are considered ineligible for the OAS CAHPS Survey.

Correct Implementation: Patients whose address is not a U.S. domestic address are ineligible, but if they have an address which is missing or incomplete, or if their telephone number is missing or incomplete, they are eligible to be included in the OAS CAHPS Survey if they meet all other survey eligibility criteria. Vendors should attempt to obtain complete contact information. We also recommend that survey vendors use address or telephone-lookup services to confirm or obtain sample patients’ mailing address or telephone number. If an address cannot be obtained the case should be finalized as a noncomplete of 330—Bad Address/Undeliverable Mail or No Address, not as ineligible.

2. Misconception: If the HOPD or ASC did not serve any patients who met survey eligibility criteria, the HOPD or ASC does not need to submit a sample file to its OAS CAHPS Survey vendor for that sample month or notify them in any way.

Correct Implementation: HOPDs and ASCs participating in the OAS CAHPS Survey should submit a monthly patient information file to their survey vendors for each sample month or send an e-mail notification if no survey eligible patients were served in a particular sample month. The survey vendor must, in turn, submit an OAS CAHPS data file to the OAS CAHPS Survey Data Center for each sample month. Otherwise the HOPD or ASC will be considered to have “missed” a month of survey participation.

3. Misconception: There is a variable called “number of eligible patients” that is part of vendors’ data submission to the OAS CAHPS Data Center. In determining the value for that variable, vendors should count patients who were identified as deceased or reported during the survey that they did not receive care from the HOPD or ASC.

Correct Implementation: The “number of eligible patients” variable on the XML file must reflect the number of presumed eligible patients who were included on the monthly patient information file. Patients who were later identified as ineligible for the survey during the



data collection period should be noted by their final survey disposition code and should not be removed from the “number of eligible patients” count.

4. Misconception. Patient age can be calculated based on their age as of the beginning of the sample month.

Correct Implementation: Patient’s age must be calculated based on their age on the date of surgery.

Sampling Procedures and Documentation Requirements1. Misconception: It is acceptable for a survey vendor to use only the patient’s medical record

number (MRN) to identify patients who may have been listed more than once on a monthly patient information file or to identify patients who have been sampled in the last 5 months.

Correct Implementation: Survey vendors are urged to use more than one variable to identify patients for whom duplicate information is provided on the monthly patient information file and to identify patients who have been sampled in the last 5 months. Using the MRN together with another variable, including surgical code, date of procedure, patient name, date of birth, telephone number, or address will ensure that the correct patient is identified. Vendors may choose to perform the de-duplication process in multiple steps. However, the MRN should never be applied as the sole variable in any of the steps; that is, it should always be combined with another patient variable.

2. Misconception: SID number can be assigned more than once.

Correct Implementation: Once a SID number is assigned, it must never be used again. If a patient is sampled more than once, a new SID number must be assigned to that patient each time he or she is sampled. During the sampling process, all vendors should check the sample file to make sure the same SID number is not assigned to two different patients and that the SID has not been assigned in a preceding sample month.

3. Misconception: A survey vendor can conduct a census survey of all eligible patients during the first sample month that an HOPD or ASC administers the OAS CAHPS Survey; therefore, the survey vendor does not have to conduct the survey for the next 5 months.

Correct Implementation: As described in this chapter, survey vendors must select and survey a sample of patients each sample month, including for very small HOPDs and ASCs. Using a sampling rate and selecting a sample of patients each sample month will ensure that an even distribution of patients is surveyed across a 12-month period.

4. Misconception: The sampling rate should be adjusted each month.

Correct Implementation: Survey vendors should adjust the sampling rate at the beginning of a quarter unless the number of patients served is dramatically different (either lower or



higher) than for the preceding months in the quarter. The sampling rate should remain constant during a quarter. If there is a huge difference in the number of patients served in a month within a quarter, the survey vendor should follow up with the HOPD or ASC to make sure that the information on the file is correct and determine the reason for the difference.

5. Misconception: The seed number (or random numbers generated) do not need to be saved.

Correct Implementation: Documentation of the seed number and the random number generation and application process is a critical component of the OAS CAHPS sampling protocols, as samples must be replicable for OAS CAHPS site visit team review.

6. Misconception: It is not necessary to retain documentation of ineligible sample members.

Correct Implementation: Vendors should retain a separate file or list of each patient deemed ineligible and the reason the patient did not meet the eligibility criteria. This information allows someone other than the person who selected the sample to conduct quality control of the sample, checking to make sure the right patients were excluded. This information is also subject to review during site visits.

Processing Patient Administrative Data1. Misconception: If an HOPD or ASC changes/switches vendors, the current OAS CAHPS

Survey vendor must provide a file containing patient information about all patients sampled in the preceding sample months so the new vendor can exclude those patients from the sample frame.

Correct Implementation: OAS CAHPS Survey vendors are not required to provide the new vendor with a file containing information about patients sampled in the last 5 months.

Sampling Quality Control Procedures1. Misconception: Survey vendors who have automated the receipt and processing of monthly

patient information files and the sample selection process do not need to implement any quality control procedures, because the programs and algorithms used for these processes were fully tested after they were developed.

Correct Implementation: All survey vendors must have in place and implement quality control procedures on the entire sampling process, including receipt and processing of the monthly patient information files and sample selection for each sample month for each HOPD or ASC client. This includes vendors who use automated systems/procedures for sampling. One way to identify problems with the receipt or processing of a monthly patient information file is to look at the history of the numbers of patients served and who met survey eligibility requirements in preceding sample months.If the numbers of patients served or eligible on the monthly patient information file is very different from the numbers provided on files submitted in preceding months, this may be a



good indication that there may be a problem with the monthly patient information file received. If there is an extreme variation in the number of patients served/eligible from one month to the next, vendors are encouraged to contact the HOPD or ASC to determine the reason for the extreme difference in numbers.

2. Misconception: Survey vendors may use the same staff who conduct the sampling process to conduct quality control checks of the sample.

Correct Implementation: The quality control of each sample file should be performed by someone other than the person who performed each task associated with the sample selection process. Vendors are also encouraged to apply appropriate quality control checks on and test all of the computer programs/systems the vendor uses to receive and process monthly files.


V. MAIL-ONLY ADMINISTRATION PROCEDURES

OverviewThis chapter describes the requirements and guidelines for implementing the mail-only mode of survey administration for the Outpatient and Ambulatory Surgery CAHPS Survey (OAS CAHPS). The chapter begins with a discussion of the mail survey protocol and schedule, followed by a discussion of the requirements for producing all mailing materials, including questionnaires, cover letters, and envelopes. Guidelines on how the questionnaire packages should be mailed and data processing guidelines, including optical scanning and data entry, are provided in this chapter. This chapter also provides suggestions for incorporating quality control activities into the mail-only mode of survey administration. In this manual, patients included in the sample are usually referred to as “sample members” or “patients.” However, in discussions of survey processing and systems they may be referred to as “cases.”

Data Collection ScheduleData collection for each sample member must be initiated no later than 3 weeks (21 days) after the close of the sample month. The timing of a mail-only administration process is shown in Table 5.1.

Questionnaires returned after the 6-week data collection period has ended should be considered nonresponses and coded as such. Data collection must be closed for a sampled patient by six weeks (42 calendar days) following the initiation of the survey.

Table 5.1Mail-Only Administration Schedule and Protocol

Activity TimingMail initial questionnaire with cover letter to sample members

No later than 3 weeks (21 days) after the close of the sample month

Mail second questionnaire with cover letter to all sample members who do not respond to first questionnaire mailing

Approximately 3 weeks (21 days) after the first questionnaire is mailed

Complete data collection Six weeks (42 days) after the first questionnaire is mailed

Submit data files to the Centers for Medicare & Medicaid Services (CMS) via the OAS CAHPS Survey website

The second Wednesday of January, April, July, and October.


V. Mail-Only Administration Procedures October 2015

If the 21st day of the month falls on a weekend or holiday, vendors should make every attempt to begin the survey on the business day prior to that weekend or holiday. However, it is acceptable to mail the questionnaire on the first business day following the weekend or holiday if necessary.

If for some reason the survey cannot be initiated within 21 days after the sample month ends, the vendor can initiate the survey within 26 days after the sample month ends. Vendors who are initiating the survey between 21 and 26 days must complete and submit a Discrepancy Notification Report (Chapter XV) to the OAS CAHPS Survey Coordination Team.

If the survey cannot be initiated within 26 days after the close of the sample month, CMS may allow it to be initiated more than 26 days after the sample month ended. However, survey vendors must first request permission to do so via e-mail to the OAS CAHPS Survey Coordination Team. The e-mailed request should explain the reason for the delay, state when the vendor will (if approved) initiate the survey, and request CMS’s approval. As noted in Table 5.1, data collection must be closed 42 calendar days after the first questionnaire is mailed. Note as well that the deadline for data submission is constant. This deadline will not shift later if the vendor starts data collection late.

Questionnaires, Letters, and EnvelopesThe mail survey version of the instrument is available in English, Spanish, and Chinese. At a future date, the questionnaire will also be provided in one additional language, to be determined based on the language needs of the sample members. All versions of the survey materials are available on the OAS CAHPS Survey website at https://oascahps.org/.

Copies of the mail survey instrument and sample mail survey cover letters in English, Spanish, and Chinese are also included in the appendices to this manual:

• sample mail survey cover letters, questionnaire and questionnaire in scannable format in English, Appendix B;

• sample mail survey cover letters, questionnaire and questionnaire in scannable format in Spanish, Appendix C;

• sample mail survey cover letters, questionnaire and questionnaire in scannable format in Chinese, Appendix D; and

• Office of Management and Budget (OMB) Disclosure Notice in English, Spanish, and Chinese in Appendix G.



October 2015 V. Mail-Only Administration Procedures

Outpatient and Ambulatory Surgery CAHPS Survey QuestionnaireThe OAS CAHPS Survey questionnaire contains 37 questions. The survey can be administered as a standalone survey or can be combined with facility-specific questions as explained in Chapter III. Questions 1 to 24 are considered the “core” OAS CAHPS Survey questions and must be placed at the beginning of the questionnaire. Questions 25 to 37 are the “About You” OAS CAHPS Survey questions and must be administered as a unit.

The OAS CAHPS Survey Questionnaire is available in Appendix B, and available in both Microsoft Word and PDF formats on the OAS CAHPS Survey website at https://oascahps.org/.

Questionnaire Printing Requirements and RecommendationsThe following are formatting and content requirements and recommendations for the OAS CAHPS Survey Questionnaire. Survey vendors cannot deviate from questionnaire requirements.

Requirement Recommendation

Questions Every questionnaire must begin with the core OAS CAHPS survey questions. n/a

No changes in wording are allowed to either the OAS CAHPS Survey questions or to the response (answer) choices.

n/a

If hospital outpatient departments (HOPDs) and ambulatory surgery centers (ASCs) elect to add their own questions they must follow the guidelines in Chapter III. In terms of placement of supplemental questions in the questionnaire, they must be placed after the “core” OAS CAHPS questions. They may either be placed before or after the unit of “About You” questions.

n/a

Formatting Questions and associated responses choices may not be split across pages. n/a

Vendors must be consistent throughout the questionnaire in formatting response options either vertically or horizontally. If a vendor elects to list the response options vertically, this must be done for every question in the questionnaire. Vendors may not format some response options vertically and some horizontally.

n/a


https://www.oascahps.org/



No matrix formatting of the questions is allowed. Matrix formatting means formatting a set of questions as a table, with responses listed across the top of a page and individual questions listed in a column on the left.

n/a

Font size should be no smaller than size 10. We strongly recommend that size 12 or larger be used.

Use a two-column format, so there are two columns of

questions per page.Vendors should use best survey practices when formatting the questionnaire, such as maximizing the use of white space and using simple fonts like Arial.

If data entry keying is being used as the data entry method, small coding

numbers next to the response choices may be used.

ID number A unique, randomly generated sample identification (SID) number must be assigned and appear on at least the first page of the survey, for tracking purposes. Additional identifiers are permitted. However, the sample member’s name or other identifying information must not be printed anywhere on the survey.

n/a

Translation Only CMS-approved translations of the OAS CAHPS Survey are permitted. If facilities choose to add their own supplemental questions, vendors will be responsible for translating these questions.

n/a

Logo and other information about the HOPD or ASC

The HOPD or ASC name or logo must appear on the survey or the cover letter. Note that survey vendors cannot include any promotional messages or materials on the OAS CAHPS cover letter, questionnaire, or outgoing or incoming mailing envelopes. This includes indications that either the facility or the survey vendor has been approved by the Better Business Bureau.

n/a

The vendor’s name and mailing address must be printed at the bottom of the last page of the OAS CAHPS Survey questionnaire, in case the respondent does not use the enclosed business reply envelope.

n/a




OMB Number The OMB number shown in Appendix G must be printed on the questionnaire cover. If there is no cover, then the OMB number must be printed on the first page of the questionnaire.

n/a

Cover Letters (First and Second Questionnaire Mailings) Requirements and RecommendationsExamples of cover letters in English, Spanish, and Chinese are provided in the appendices with the survey instruments (see Appendices B–D). Vendors may choose to develop their own cover letters as well, provided that the following requirements are met:


Personalization Cover letters must be personalized with the name and address of the sample member. n/a

Cover letters must contain the date of the surgery/procedure and the name of the location where the surgery was received. (The monthly patient information file must contain the date of surgery, facility name, and location name because the name recognized by the patient may differ from the facility’s official name.)

n/a

Separate from questionnaire

Cover letters must be separate from the questionnaire, so that no personally identifiable information is returned with the questionnaire when the respondent sends it back to the vendor.

n/a

Content of letters

The OMB disclosure notice (see Appendix G) must be printed either on the questionnaire or in the cover letters.

n/a

Vendors may not offer sample members the opportunity to complete the survey over the telephone if the vendor is implementing the mail-only mode.

n/a

Must contain language describing the purpose of the survey. n/a

Must contain a statement that participation is voluntary and will not affect any benefits the sample member receives or expects to receive.

n/a




Must contain language indicating that responses from all survey participants will be grouped together and these grouped data may be shared with the HOPD or ASC, for purposes of quality improvement.

n/a

Must contain language stating that if the respondent needs help in reading the questions or marking responses, a friend or family member can assist them.

n/a

Must contain a toll-free customer support telephone number, which will be staffed by the survey vendor.

n/a

Printing The HOPD or ASC name (or logo) must appear on the letters or the survey. Note that survey vendors cannot include any promotional messages or materials on the OAS CAHPS cover letter, questionnaire, or outgoing or incoming mailing envelopes. This includes indications that either the facility or the survey vendor has been approved by the Better Business Bureau.

n/a

Signature on the letters

A signature is required. We recommend that the signature of an

appropriate official from the HOPD or ASC be printed on each cover

letter If this is not possible, the signature from an appropriate official at the survey vendor is acceptable.

Requests for Survey in Other Language

n/a Survey vendors offering an English, Spanish, and Chinese version of the questionnaire may add language to the English

cover letter indicating that a version of the

questionnaire is available in those languages.



Mailing Requirements and RecommendationsRequirements and recommendations are described below. Vendors are expected to follow these requirements to maximize response rates and ensure consistency in how the mail-only mode of administration is implemented.


Questionnaire contents

Each questionnaire mailing must contain a personalized cover letter, questionnaire, and postage-paid business reply envelope.

n/a

Envelopes Vendors are responsible for supplying both the outgoing envelopes for the questionnaire mailings and business-reply envelopes that sample members will use to return their completed surveys (i.e., they cannot be supplied by the HOPD or ASC).

n/a

Mailing We recommend mailings are sent with first-class postage or indicia, to ensure timely delivery and maximize response rates

Addresses Patients must have a U.S. domestic address to be eligible to participate in the OAS CAHPS Survey.

n/a

If the sample member’s address is missing or incomplete, the vendor must follow up with the HOPD or ASC to obtain the address. If an address cannot be found, or the address that is found is too incomplete for mailing, the vendor should treat the patient as eligible and assign the applicable final disposition code to the case: 330 – Bad Address/Undeliverable Mail, or No Address (see Chapter IX).

To reduce the number of missing addresses, we recommend vendors verify mailing addresses obtained from the facilities using commercial address update services, such as the National Change of Address (NCOA) or the U.S. Postal Service Zip+4 software.




We recommend vendors attempt to identify a new or updated address using commercial address vendors or the Internet for any mail returned as undeliverable in time to include the sample member in the second mailing.

Schedule Mailings must follow the schedule specified for the mail-only mode of administration—the first questionnaire package must be mailed no later than 3 weeks after the close of the sample month; the second questionnaire to sample members who do not respond to the first questionnaire mailing must be mailed approximately 3 weeks after the first questionnaire mailing.

n/a

Data collection must end 6 weeks after the first questionnaire has been mailed.

n/a

Incentives The use of incentives is not permitted. This includes monetary and nonmonetary incentives.

n/a

Data Receipt, Data Entry, and Optical Scanning RequirementsThe following guidelines are provided for receiving and tracking returned questionnaires and entering the data using either data entry or optical scanning.

Requirement

Receipting The date the questionnaire was received from each sample member must be entered into the data record created for each case on the data file.Completed questionnaires should be logged into the tracking system in a timely manner to ensure that sample members who respond to the first mailing are excluded from the second questionnaire mailing.Mailings that are returned in the mail as undeliverable must also be logged into the tracking system. Although not required, we recommend vendors attempt to identify a new or updated address using commercial address vendors or the Internet for any mail returned as undeliverable in time to include the sample member in the second mailing.



Requirement

If two questionnaires are received from the same sample member, vendors should keep and use the questionnaire that has the more complete data, regardless of which questionnaire is received first. If the two questionnaires received contain the same amount of data (are equally complete), the vendor should retain and use the first one received.A final OAS CAHPS Survey disposition code (see Table 9.1 in Chapter IX) must be assigned to each case.

Reviewing received questionnaires for problems

Questionnaires should be visually reviewed prior to scanning or data entry for notes/comments. Vendors should have more than one person who can code or review comments and attach notes for proper disposition code assignment.We recommend that vendors attempt to identify a new or updated address using commercial address vendors or the Internet for any mail returned as undeliverable in time to include the sample member in the second mailing.If a completed mail survey questionnaire is returned and the vendor realizes that it was completed by proxy (i.e., there is a note written on the questionnaire that a family member completed the questionnaire because the patient had died, had moved to a nursing home, or had been incarcerated) vendors should not scan a questionnaire for that sample member. This is because proxy respondents are not permitted on OAS CAHPS. Vendors should instead assign the applicable final disposition code to the case.If a sample member were to die or become ineligible after completing the questionnaire (vendors might learn of this through a comment written by a family member on the questionnaire) that questionnaire is still an eligible complete survey. Vendors should scan the questionnaire and assign the applicable final disposition code indicating the completed survey.

Duplicate questionnaires

The key entry process should not permit keying of duplicate questionnaires.The scanning program should not permit scanning of duplicate questionnaires.

Out-of-range or invalid responses

The key entry program should not permit out-of-range or invalid responses.The scanning program should not permit out-of-range or invalid responses

Quality control For keying: All questionnaires should be 100 percent rekeyed for quality control purposes. That is, for every questionnaire, a different keyer should rekey the questionnaire and the data entry files of the two keyers should be systematically compared. If any discrepancies between the two data entry files are detected, a supervisor should resolve the discrepancy and ensure that the correct value is stored in the data.



Requirement

For optical scanning: A sample of questionnaires (minimum of 10 percent) should be systematically compared with the original hardcopy survey. Any discrepancies between the scan and the hardcopy should be reconciled by a supervisor. This serves as a quality control measure that the scanning program is capturing the hardcopy correctly.Additionally, the survey responses captured in the database for a sample of questionnaires (minimum of 10 percent) should be systematically compared to scanned image for that case. This can be done either by visually examining the scanned image and the data to reveal inconsistencies, or by rescanning and noting whether the data from the original matches the data from the rescan. This serves as a quality control measure that the scanning program is translating the response marks in the scanned image to the data file consistently and correctly.

Interpreting blanks and ambiguous survey responses

The following apply for both keying and optical scanning:If a response mark falls between two answer choices but is clearly closer to one answer choice than to another, select the response that is closest to the marked response.If two responses are checked for the same question, select the one that appears darkest. If it is not possible to make a determination, leave the response blank and code as “missing” rather than guessing.If a mark is between two answer choices but is not clearly closer to one answer choice, code as “missing.”If a response is missing, leave the response blank and code as “missing.”

Open-ended responses

The decision on whether to key or scan the responses to open-ended survey items, specifically, the “Other language” (response option 2) in Q35 and the “Helped in some other way” (response option 5) in Q37, is up to each individual HOPD or ASC. Vendors will not be required to key or scan and include responses to open-ended survey items on the data files submitted to the OAS CAHPS Survey Data Center.CMS, however, encourages survey vendors to review the open-ended entries so they can provide feedback to the Coordination Team about adding additional preprinted response options to these survey items if needed.It follows that if the vendor includes the Consent to Share Identifying Information question in the mail survey questionnaire, we do not require that the vendor key or scan the response to that question. However, we do recommend it for the vendor’s own documentation.Answers to the Consent to Share Identifying Information question will not be included on the data files submitted to the OAS CAHPS Survey Data Center.



Staff TrainingAll staff involved in the mail survey implementation, including support staff, must be thoroughly trained on the survey specifications and protocols. A copy of relevant chapters of this manual should be made available to all staff as needed. In particular, staff involved in questionnaire assembly and mailout, data receipt, and data entry must be trained on:

• use of relevant equipment (case management systems for entering questionnaire receipts, scanning equipment, data entry programs);

• OAS CAHPS Survey protocol specific to their role (for example, contents of questionnaire package, how to document or enter returned questionnaires into the tracking system);

• decision rules and coding guidelines for returned questionnaires (see Chapter IX); and

• proper handling of hardcopy and electronic data, including data storage requirements (see Chapter VIII).

Staff involved in providing customer support via the toll-free telephone number should also be trained on the accurate responses to commonly asked questions, how to respond to questions when customer support does not know the answer, and the rights of survey respondents. If the OAS CAHPS Survey is being offered in a language other than English, customer support staff should also be able to handle questions via the toll-free telephone number in that language. Telephone interviewer training requirements are described in more detail in Chapter VI of this manual. Please refer to that chapter for more information on training customer support staff.

Quality Control Guidelines for Mail-only SurveyThe following steps are required or recommended as a means of incorporating quality control into the mail-only survey administration procedures. Quality control checks should be conducted by a different staff person than the one who completed the task. Some of these are mentioned earlier in the chapter.

Required• Check a minimum of 10 percent of all printed materials to ensure the quality of the printing

—that is, make sure there is no smearing, misaligned pages, duplicate pages, or stray marks on pages.

• Check a minimum of 10 percent of all outgoing questionnaire packages to ensure that all package contents are included and the same unique SID number appears on both the cover letter and the questionnaire.



• For vendors that are scanning: a sample of questionnaires (minimum of 10 percent) should be compared with the original hardcopy survey as a quality control measure. Additionally, for a sample of questionnaires (minimum of 10 percent) the response data resulting from the scanning program should be compared to the scanned image for that case. Any discrepancies from either of these should be reconciled by a supervisor.

• For vendors who are keying: all questionnaires should be 100 percent rekeyed for quality control purposes. That is, for every questionnaire, a different keyer should rekey the questionnaire and the data entry files from the two keyers should be systematically compared to ensure that all entries are accurate. If any discrepancies are observed, a supervisor should resolve the discrepancy and ensure that the correct value is stored in the data.

Recommended• Verify that sample members’ mailing addresses provided by the HOPD or ASC are correct

by using commercial address update services, such as the National Change of Address or the U.S. Postal Service Zip+4 software. Cases with incomplete mailing addresses must remain in the sample.

• “Seed” each mailing. That is, include the name and address of designated vendor staff in each mailing file to assess the completeness of the questionnaire package and timeliness of package delivery.

• Before submitting XML data to the OAS CAHPS Data Center, we highly recommend vendors review a sample of cases comparing responses recorded on the hardcopy questionnaire to responses scanned to the response codes which appear in the XML files. This quality control step will ensure that the responses included in the XML files accurately reflect the patients’ responses to the survey questions.

• Vendors are urged to develop a way to measure error rates for their data receipt staff (in terms of recognizing marginal notes and passing these on to someone for review), for data entry or scanning operators, and for coders. Vendors should then work with their staff to minimize error rates. The Coordination Team will request information about data receipt and processing error rates during site visits to survey vendors.


VI. TELEPHONE-ONLY ADMINISTRATION PROCEDURES

OverviewThis chapter describes the requirements and guidelines for implementing the telephone-only mode of survey administration for the Outpatient and Ambulatory Surgery CAHPS (OAS CAHPS) Survey. The chapter begins with a discussion of the telephone-only data collection schedule, followed by a discussion of the requirements for producing all telephone interviewing materials and systems. It includes guidelines on how the telephone interview should be developed and administered, including general interviewing guidelines and frequently asked questions that interviewers may encounter. This chapter also provides suggestions for data processing procedures and incorporating quality control activities into the telephone-only mode of survey administration.

Note that in most cases in this and subsequent chapters of this manual, patients included in the sample are referred to as “sample members” or “sample patients”; in discussions of survey processing and systems they may be referred to as “cases.”

Data Collection ScheduleIf the OAS CAHPS Survey is being administered as a telephone-only survey, data collection must be initiated no later than 3 weeks (21 days) after the close of the sample month.

Table 6.1 shows the prescribed order of activities and timing for an all-telephone OAS CAHPS Survey.

Table 6.1Prescribed Order of Activities and Timing for an All-Telephone OAS CAHPS Survey

Activity TimingBegin telephone contact with sample members


Complete telephone data collection Six weeks (42 days) after initial telephone contact beginsSubmit data files to the Centers for Medicare & Medicaid Services (CMS) via the OAS CAHPS Survey website


If the 21st day of the month falls on a weekend or holiday, vendors should make every attempt to begin the survey on the business day prior to that weekend or holiday. However, it is acceptable to begin telephone calls on the first business day following the weekend or holiday if necessary.


VI. Telephone-Only Administration Procedures October 2015

OAS CAHPS Survey vendors must make a concerted effort to initiate the survey for each sample month within 21 days after the sample month ends. This means that phone contacting should begin by the 21st day after the end of the sample month.

If for some reason the survey cannot be initiated within 21 days after the sample month ends, the vendor can initiate the survey within 26 days after the sample month ends. Vendors that are initiating the survey between 21 and 26 days must complete and submit a Discrepancy Notification Report (Chapter XV) to the OAS CAHPS Survey Coordination Team.

CMS may allow the survey to be initiated more than 26 days after the sample month ended. However, survey vendors must first request permission to do so via e-mail to the OAS CAHPS Survey Coordination Team. The e-mailed request should explain the reason for the delay, state when the vendor will (if approved) initiate the survey, and request CMS’s approval.

As noted in Table 6.1, data collection must be closed 42 calendar days after the telephone survey begins. Note as well that the deadline for data submission is constant. This deadline will not shift later if the vendor starts data collection late.

Telephone Interview Development ProcessThe following paragraphs describe the requirements for producing all materials and systems needed for the telephone-only survey. The telephone interview script in English, Spanish, and Chinese in both Microsoft Word and PDF formats are available on the OAS CAHPS Survey website at https://oascahps.org/.

A list of questions that are frequently asked by sample members and suggested answers to those questions are included in Appendix H (English) and Appendix J (Spanish). Some general guidelines for telephone interviewer training and monitoring are provided in Appendix I.

Specific requirements and guidelines associated with the telephone survey administration are discussed below.

Telephone Interviewing SystemsAn electronic telephone interviewing system means that the interviewer reads from and enters responses into a computer program. Using an electronic system encourages standardized interviewing and monitoring of interviewers. Survey vendors using a telephone-only survey mode must use an electronic system to administer the OAS CAHPS Survey. Paper-and-pencil administration is not permitted for telephone surveys. To ensure that sample members are called at different times of the day and across multiple days of the week, vendors must also have a survey management system. Ideally, the electronic system will be linked to the survey management system so that cases can be tracked, appointments set and called back at appropriate times, and pending and final case status easily accessed for any case.



October 2015 VI. Telephone-Only Administration Procedures

Predictive or automatic dialers are permitted, as long as they are compliant with Federal Trade Commission and Federal Communications Commission regulations, and as long as respondents can easily interact with a live interviewer. For more information about Federal Trade Commission and Federal Communications Commission regulations please visit https://www.ftc.gov/ and https://www.fcc.gov/.

Telephone Interview ScriptSurvey vendors are provided with standardized telephone scripts in Appendix B (English) and Appendix C (Spanish). These scripts include the introductory screens in addition to the survey questions.

The OAS CAHPS Survey questionnaire script contains 35 questions. The survey can be administered as a standalone survey or can be combined with facility-specific questions as explained in Chapter III. Questions 1 to 24 are considered the “core” OAS CAHPS Survey questions and must be placed at the beginning of the questionnaire. Questions 25 to 35 are the “About You” OAS CAHPS Survey questions and must be administered as a unit.

Note that the OAS CAHPS telephone interview script contains only 35 questions and the mail survey contains 37 questions. The mail survey questionnaire contains questions that ask if anyone helped the sample member to complete the survey (Questions 36 and 37). These two questions are not applicable if the survey is administered by telephone.

The following are content and programming requirements and recommendations for the OAS CAHPS Survey Questionnaire. Note that survey vendors cannot deviate from questionnaire requirements.

• Every questionnaire must begin with the core OAS CAHPS questions. They must be administered in the order in which they appear.

• No changes in wording are allowed for either the OAS CAHPS Survey questions or to the response choices.

• Hospital outpatient departments (HOPDs) and ambulatory surgery centers (ASCs) may add their own questions, following the guidelines in Chapter III. In terms of placement of supplemental questions in the questionnaire, note that they must be placed after the “core” OAS CAHPS questions. They may either be placed before or after the unit of “About You” questions.

• Only CMS-approved translations of the OAS CAHPS Survey are permitted, although if facilities choose to add their own supplemental questions, vendors will be responsible for translating these questions.


https://www.fcc.gov/

https://www.ftc.gov/


Telephone Interviewing RequirementsTelephone interviewing requirements and recommendations for the OAS CAHPS Survey interview are described below. Vendors are expected to follow these requirements to maximize response rates and to ensure consistency in how the telephone-only mode of administration is implemented. Vendors are also advised to keep an eye on response rates, to assess whether calls are being scheduled optimally across the data collection period. A low response rate may be indicative of calls being spaced too closely together, rather than spread across a number of weeks

Telephone Contact• Vendors must attempt to contact every patient in the sample. Vendors must make a

minimum of five telephone contact attempts for each sampled case, unless the sample member refuses or the vendor learns that the sample member is ineligible to participate in the survey.

• A telephone contact attempt is defined as one of the following:

◦ the telephone rings six times with no answer or an answering machine is reached;

◦ the interviewer reaches a household member and is told that the sample member is not available to take the call;

◦ the interviewer reaches the sample member and is asked to schedule a call-back at a later date; or

◦ the interviewer gets a busy signal on each of three consecutive phone call attempts, spaced at least 20 minutes apart.

• Vendors may make more than one phone call in one 7-day period but cannot make all five attempts in one 7-day period. Scheduling calls to take place over a longer period of time could reach patients who may be unavailable the first week of the data collection period.

• Contact with a sample member may be continued after five attempts if the fifth attempt results in a scheduled appointment with the sample member, as long as the appointment is within the data collection period.

• Phone calls must be made at different times of the day (i.e., morning, afternoon, and evening) and different days of the week throughout the data collection period.

• Interviewers may not leave voicemail messages on answering machines or leave messages with household members.

• Interviewers may tell household members that they are calling about “a study on health care.”



• Vendors must be able to provide a phone call log that keeps track of the date and time phone calls were made for each sample member.

• If the vendor finds out that a sample member is ineligible for the OAS CAHPS Survey, the vendor must immediately stop further contact attempts with that sample member.

• Telephone survey data collection for each monthly sample must begin no later than 3 weeks from the close of the sample month and must be completed within 6 weeks from the initial telephone attempt.

• The use of incentives—monetary or nonmonetary—is not permitted.

• Proxy respondents are not permitted on OAS CAHPS. If a sample member is incapable of responding to the telephone interview because of mental or physical impairments such as difficulty hearing, the case should be closed using code 240 or “Mentally/Physically Incapable” and end the interview. If a sample member is capable of responding but just needs some help to do so, a friend or family member may help, but cannot respond on his or her behalf.

• If a respondent begins the interview but cannot complete it during the call for a reason other than a refusal, the vendor should follow up with the respondent to complete the entire interview. The interviewer should follow up even if the respondent answered enough questions in the interview for the case to pass the completeness criteria. It is especially important to complete the questions in the “About You” section of the questionnaire, because data from some of those questions will be used in patient-mix adjustment.

• The vendor must be able to offer the interview in any of the approved languages for which an HOPD or ASC has contracted, even if the language is different from the language that the HOPD or ASC believes the sample member will require. That is, the vendor must be able to easily switch to accommodate a respondent’s language preference. For example, if the initial contact is in English but the respondent prefers to conduct in Spanish, the vendor must be able to switch to Spanish.

• Sample members are still eligible even if they have missing, incomplete, or foreign phone numbers. The vendor should contact the HOPD or ASC to obtain the telephone number for the address of the patient. If the HOPD or ASC cannot provide this number, the vendor should attempt to obtain a telephone number for the patient from other sources (directory assistance, Internet directories, etc.). If the vendor still cannot obtain a telephone number, the vendor should code the case as code 340–wrong, disconnected, no telephone number.

• If a respondent decides after he or she has answered some of the questions in the telephone interview that he or she does not wish to participate in the survey any longer, the vendor should code the case as a refusal. The vendor should not use the partial data that were



obtained before the interview was ended.. This protocol applies even if the respondent answered enough questions in the interview for the case to pass the completeness criteria. Note that this situation is different from the respondent saying that he or she does not wish to continue an interview. If the respondent breaks off the interview but does not state that he or she does not wish to participate in the survey, the data may be used as long as the interview meets the completeness criteria. The vendor may then code the case as a completed interview if the case passes the completeness criteria; otherwise it should be coded as a breakoff/partial data.

Contacting Difficult-to-Reach Sample Members• Although not required, we strongly recommend that survey vendors verify telephone

numbers obtained from HOPDs and ASCs, using a commercial address/telephone database service or directory assistance.

• We recommend that vendors attempt to identify a new or updated telephone number for any sample member whose telephone number is no longer in service when called and for any sample members who have moved so that the sample members can be contacted prior to the end of the data collection period.

• If the sample member’s telephone number is incorrect, the interviewer may ask the person who answers the phone for the sample member’s phone number.

• If the sample member is temporarily ill, on vacation, or unavailable during initial contact, the interviewer should attempt to recontact the sample member before the data collection period ends. If the sample member cannot be reached before the data collection period ends, code the case as 350, “No Response After Maximum Attempts.”

• If the sample member does not speak a language that has an approved translation for OAS CAHPS, the interviewer should thank the sample member for his or her time, end the interview, and code the case as 230, “Ineligible: Language Barrier.”

• If a sample member is physically or mentally incapable of responding by telephone, the case should be finalized and coded as 240.

• For sample members who are living in institutions (assisted living, group homes, etc.), OAS CAHPS Survey vendors should contact the HOPD or ASC to obtain a direct-dial telephone number. If the HOPD or ASC cannot provide a direct-dial telephone number for the patient, try to obtain the sample member’s telephone number using other sources, such as a telephone number lookup service, directory assistance, or Internet telephone survey directories. If vendors cannot obtain a telephone number for the patient, they should assign a disposition code of Missing/Disconnected Number to the case. As a reminder, sample members living in nursing homes are ineligible.



Distressed Respondent ProceduresIt is critically important that survey vendors develop a “distressed respondent protocol,” to be incorporated into all interviewer and help desk training. Handling distressed respondent situations requires balancing keeping personally identifiable information and private health information confidential and helping a person who needs assistance. For survey research organizations, best interviewing practices recommend having a distressed respondent protocol in place for handling distressed respondents, which balances the respondent’s right to confidentiality and privacy and providing assistance, if the situation indicates that the respondent’s health and safety are in jeopardy.

Therefore, each approved OAS CAHPS Survey vendor is expected to have procedures in place for handling distressed respondent situations and to follow those procedures. CMS and the OAS CAHPS Survey Coordination Team cannot provide guidelines on how to evaluate or handle distressed respondents. However, survey vendors are urged to consult with their organization’s Committee for the Protection of Human Subjects Institutional Review Board for guidance. In addition, professional associations for researchers, such as the American Association of Public Opinion Researchers (AAPOR), may be able to provide guidance regarding this issue. The following is an excerpt from AAPOR’s website that lists resources for the protection of human subjects. More information about protection of human subjects is available at AAPOR’s website at http://www.aapor.org.7

• The Belmont Report (guidelines and recommendations that gave rise to current federal regulations)

• Federal Regulations Regarding Protection of Human Research Subjects (45 CFR 46) (also known as the Common Rule)

• Federal Office for Human Research Protections

• National Institutes of Health Human Participant Investigator Training (although the site appears to be for cancer researchers, it is the site for the general investigator training used by many institutions)

• University of Minnesota Web-Based Instruction on Informed Consent

Telephone Interviewer TrainingVendors must provide training to all telephone interviewing and customer support staff prior to starting telephone survey data collection activities. Telephone interviewer and customer support staff training must include the following:

7 The American Association of Public Opinion Researchers website at http://www.aapor.org/Additional_IRB_Resources.htmt, July 2010.


http://www.aapor.org/Additional_IRB_Resources.htmt

http://www.aapor.org/


• teaching interviewers how to establish rapport with the respondent;

• teaching interviewers the content and purpose of the interview so that they can effectively communicate this information to the sampled patients;

• teaching interviewers to administer the interview in a standardized format, which includes reading the questions as they are worded, not providing the respondent with additional information that is not scripted, maintaining a professional manner, and adhering to all quality control standards;

• teaching interviewers how to use effective neutral probing techniques;

• teaching interviewers to use the frequently asked questions document so that they can answer questions in a standardized format; and

• teaching multilingual customer support staff how to handle questions in English and the other language(s) in which the survey is being offered.

Survey vendors should also provide telephone survey supervisors with an understanding of effective quality control procedures to monitor and supervise interviewers.

Vendors must conduct an interviewer certification process of some kind—either oral, written, or both—for each interviewer and customer service staff member prior to permitting that person to make or take calls on the OAS CAHPS Survey. The certification should be designed to assess the interviewer’s level of knowledge and comfort with the OAS CAHPS Survey instrument and ability to respond to sample members’ questions about the survey. Documentation of training and certification of all telephone interviewers and customer support staff and outcomes will be subject to review during oversight visits by the OAS CAHPS Survey Coordination Team.

Telephone Data Processing ProceduresThe following guidelines are provided for ensuring that the telephone interview data are properly processed and managed.

Telephone Data Processing Requirements• A unique sample identification number (SID) must be assigned to each case and included in

the case management system and on the final data file for each sample member.

• Vendors must enter the date of the interview with each sample member in the survey management system or in the interview data.

• Vendors must be able to link each telephone interview to their survey management system, so that appropriate variables, such as the language in which the survey was conducted, can be pulled into the final data file.



• Vendors must de-identify all telephone interview data when the data are transferred into the final data file for delivery. Identifiable data include respondent names and contact information.

• Vendors must assign a final OAS CAHPS Survey status or disposition code to each case (see Chapter IX for a list of these codes) and include a final disposition code for each sampled case in the final data file. It is up to the vendor to develop and use a set of pending disposition codes to track actions on a case before it is finalized appropriately—pending disposition codes are not specified in the OAS CAHPS Survey protocol.

Telephone-Only Quality Control GuidelinesThe following activities are methods to incorporate quality control into the telephone-only survey administration procedures. Quality control of telephone interviewers and customer support staff should include the following activities:

• OAS CAHPS requires that survey vendors thoroughly test the electronic telephone interviewing system before beginning the OAS CAHPS survey. Testing will vary from system to system, but includes at a minimum comparing each screen to the Telephone Script to verify that the questions and answer choices are faithful to the script, checking each question to ensure that the answers input match the data exported, and checking that a respondent is automatically routed to the next appropriate question.

• Vendors are required to keep written documentation that all telephone interviewing and customer support staff have been properly trained prior to interviewing. Copies of interviewer certification exam scores should be retained as well. Documentation should be maintained for any retraining required and will be subject to review during oversight visits.

• Although not required, we recommend that vendors conduct regular Quality Circle meetings with telephone interviewing and customer support staff to obtain feedback on issues related to telephone survey administration or handling inbound calls.

• Survey vendors must establish and communicate clear telephone interviewing quality control guidelines for their staff to follow. These guidelines should be used to conduct the monitoring and feedback process, and should include clear explanations of the consequences of not following protocols, including actions such as removal from the project or termination of employment.

• Vendors are required to silently monitor a minimum of 10 percent of all telephone interviews to ensure that correct administration procedures are being followed.



• Supervisory staff monitoring telephone interviewers should use the electronic system to observe the interviewer conducting the interview while listening to the audio of the call at the same time.

• Monitoring staff or supervisors should provide performance feedback to interviewers as soon as possible after the monitoring session has been completed.

• Interviewers should be given the opportunity to correct deficiencies in their administration through additional practice or retraining; however, interviewers who receive consistently poor monitoring scores should be removed from the project.

• There are federal and state laws and regulations relating to the monitoring/recording of telephone calls. In certain states, consent must be obtained from every party or conversation if it involves more than two people (“two-party consent”). When calling sample members who reside in these states, survey vendors should not begin either monitoring or recording the telephone calls until after the interviewer has read the following statement: “This call may be monitored or recorded for quality improvement purposes.”8

• All OAS CAHPS Survey vendors are responsible for identifying and adhering to federal and state laws and regulations in the states in which they will be administering the OAS CAHPS Survey.

• Vendors should conduct periodic reviews of their XML data files by comparing at least 50 completed telephone interview responses directly from their computer-assisted telephone interviewing system to the values output in the XML file. Doing this monthly review will ensure that the responses are being accurately captured and output to the XML file.

8 The following states currently require two-party or all-party consent when telephone calls are monitored or audiotaped: California, Connecticut, Delaware, Florida, Illinois, Maryland, Massachusetts, Michigan, Montana, New Hampshire, Pennsylvania, and Washington.


VII. MAIL WITH TELEPHONE FOLLOW-UP (MIXED-MODE) SURVEY ADMINISTRATION PROCEDURES

OverviewThis chapter describes the requirements and guidelines for implementing a mixed-mode survey administration for the Outpatient and Ambulatory Surgery CAHPS (OAS CAHPS) Survey. For the OAS CAHPS Survey, “mixed mode” is defined as a mail survey followed by a telephone follow-up of nonrespondents.

This chapter begins with a discussion of the data collection schedule that should be followed when a mixed-mode design is used. The mail survey protocols are described next, followed by a discussion of the protocols for implementing the telephone follow-up of nonrespondents. The chapter ends with quality control guidelines that should be implemented throughout the mixed-mode data collection process and describes data storage requirements.

Note that in most cases in this and subsequent chapters of this manual, patients included in the sample are referred to as “sample members” or “patients”; in discussions of survey processing and systems they may be referred to as “cases.”

Data Collection ScheduleSurvey vendors using mail with telephone follow-up of nonrespondents must initiate the mail survey for each monthly sample no later than 3 weeks (21 days) after the close of the sample month. Table 7.1 shows the basic tasks and timing of activities when conducting the OAS CAHPS Survey using a mixed-mode survey administration.

Table 7.1Tasks and Schedule of Activities for Mail with Telephone Follow-Up

Activity TimingMail questionnaire with cover letter to sample members


Initiate telephone follow-up contact for all mail survey nonrespondents

Approximately 3 weeks (21 days) after the questionnaire is mailed

Complete data collection Six weeks (42 days) after the questionnaire is mailedSubmit data files to the Centers for Medicare & Medicaid Services (CMS) via the OAS CAHPS Survey website



VII. Mail with Telephone Follow-Up (Mixed-Mode)Survey Administration Procedures October 2015

If the 21st day of the month falls on a weekend or holiday, vendors should make every attempt to complete the survey mailout on the business day prior to that weekend or holiday. However, it is acceptable to mail the questionnaires on the first business day following the weekend or holiday if necessary.

OAS CAHPS Survey vendors must make a concerted effort to complete the survey mailout for each sample month within 21 days after the sample month ends. If for some reason the survey mailout cannot be completed within 21 days after the sample month ends, the vendor can conduct the mailout within 26 days after the sample month ends. Regarding the telephone survey, vendors must make a concerted effort to initiate the telephone survey 21 days after the mailout. If for some reason the telephone survey cannot be begun by this time, the vendor can initiate the telephone survey within 26 days after the mailout. Vendors must complete and submit a Discrepancy Notification Report (Chapter XV) to the OAS CAHPS Survey Coordination Team if the mailout is initiated within 26 days after the sample month closes or if the telephone survey is initiated within 26 days after the mailout.

If the mailout cannot be conducted within 26 days after the close of the sample month or if the telephone survey cannot be initiated within 26 days of the mailout, CMS may allow these activities to be conducted more than 26 days after the sample month ended. However, survey vendors must submit a request via e-mail to the OAS CAHPS Survey Coordination Team. The e-mailed request should explain the reason for the delay, state when the vendor will (if approved) initiate the mail and telephone survey, and request CMS’s approval. As noted in Table 7.1, data collection must be closed 42 calendar days after the questionnaire is mailed. Note as well that the deadline for data submission is constant. This deadline will not shift later if the vendor starts data collection late.

As explained in Chapter IX, all cases that are not finalized as a result of the mail survey component of the mixed-mode survey must be assigned for telephone follow-up, including both cases that are returned blank and undeliverable mail. This means that unless the case was a refusal or the patient was determined to be ineligible for the survey during the mail survey data collection phase of the survey, survey vendors should follow up with the patient by telephone.

The data collection period for mixed-mode data collection is 6 weeks long, just as it is in mail-only and telephone-only modes. All telephone contact should be initiated and completed within the specified 3-week period noted above in Table 7.1. Questionnaires may be received through the mail after the case has been referred for telephone follow-up. If these questionnaires arrived before the 6-week data collection period ended they should be processed and telephone efforts with this case should be halted. If these questionnaires arrived after 6-week data collection period ended they should be considered nonresponses and coded as such.


VII. Mail with Telephone Follow-Up (Mixed-Mode)October 2015 Survey Administration Procedures

Questionnaires, Letters, and EnvelopesVendors who will be using a mixed-mode design must be able to offer the mail and telephone versions of the instrument in each language in which the survey is being administered. Vendors may not offer a mail questionnaire in one of the non-English languages and conduct the telephone follow-up only in English. For this reason, the mixed-mode design cannot be used in conjunction with the Chinese versions of the mail questionnaire, because there is no corresponding OAS CAHPS–approved telephone interview in Chinese. All versions of these survey materials in the approved languages are available on the OAS CAHPS Survey website at https://oascahps.org/.

Copies of the mail survey instrument and sample mail survey cover letters in English, Spanish, and Chinese are also included in the appendices to this manual:

• sample mail survey cover letters, questionnaire, and questionnaire in scannable format in English, Appendix B;

• sample mail survey cover letters, questionnaire, and questionnaire in scannable format in Spanish, Appendix C;

• sample mail survey cover letters, questionnaire, and questionnaire in scannable format in Chinese, Appendix D and

• Office of Management and Budget (OMB) Disclosure Notice in English, Spanish, and Chinese in Appendix G.

Outpatient and Ambulatory Surgery CAHPS Survey QuestionnairesThe OAS CAHPS Survey Questionnaire used in the mail mode contains 37 questions. The survey can be administered as a standalone survey or can be combined with facility-specific questions as explained in Chapter III. Questions 1 to 24 are considered the core OAS CAHPS Survey questions and must be placed at the beginning of the questionnaire. Questions 25 to 37 are the “About You” OAS CAHPS Survey questions and must be administered as a unit.

The OAS CAHPS Survey Questionnaire are available in both Microsoft Word and PDF formats on the OAS CAHPS Survey website at https://oascahps.org/.

Questionnaire Printing Requirements and RecommendationsThe following are formatting and content requirements and recommendations for the OAS CAHPS Survey Questionnaire. Survey vendors cannot deviate from questionnaire requirements.






Questions Every questionnaire must begin with the core OAS CAHPS survey questions. n/a

No changes in wording are allowed to either the OAS CAHPS Survey questions or to the response (answer) choices.

n/a

If hospital outpatient departments (HOPDs) and ambulatory surgery centers (ASCs) elect to add their own questions they must follow the guidelines in Chapter III. In terms of placement of supplemental questions in the questionnaire, they must be placed after the “core” OAS CAHPS questions. They may either be placed before or after the unit of “About You” questions.

n/a

Formatting Questions and associated responses choices may not be split across pages. n/a

Vendors must be consistent throughout the questionnaire in formatting response options either vertically or horizontally. If a vendor elects to list the response options vertically, this must be done for every question in the questionnaire. Vendors may not format some response options vertically and some horizontally.

n/a

No matrix formatting of the questions is allowed. Matrix formatting means formatting a set of questions as a table, with responses listed across the top of a page and individual questions listed in a column on the left.

n/a

Font size should be no smaller than size 10. We strongly recommend that size 12 or larger be used.

Vendors should use best survey practices when formatting the questionnaire, such as maximizing the use of white space and using simple fonts like Arial.

If data entry keying is being used as the data entry method, small coding numbers next

to the response choices may be used.




ID number A unique, randomly generated sample identification (SID) number must be assigned and appear on at least the first page of the survey, for tracking purposes. Additional identifiers are permitted. However, the sample member’s name or other identifying information must not be printed anywhere on the survey.

n/a

Translation Only CMS-approved translations of the OAS CAHPS Survey are permitted. If facilities choose to add their own supplemental questions, vendors will be responsible for translating these questions.

n/a

Logo and other information about the HOPD or ASC

The HOPD or ASC name or logo must appear on the survey or the cover letter. Note that survey vendors cannot include any promotional messages or materials on the OAS CAHPS cover letter, questionnaire, or outgoing or incoming mailing envelopes. This includes indications that either the facility or the survey vendor has been approved by the Better Business Bureau.

n/a

The vendor’s name and mailing address must be printed at the bottom of the last page of the OAS CAHPS Survey questionnaire, in case the respondent does not use the enclosed business reply envelope.

n/a

OMB Number The OMB number shown in Appendix G must be printed on the questionnaire cover. If there is no cover, then the OMB number must be printed on the first page of the questionnaire.

n/a

Cover Letter Requirements and RecommendationsExamples of cover letters in English, Spanish, and Chinese are provided in the appendices with the survey instruments (see Appendices C–F). Vendors may choose to develop their own cover letters as well, provided that the following requirements are met:




Personalization Cover letters must be personalized with the name and address of the sample member. n/a

Cover letters must contain the date of the surgery/procedure and the name of the location where the surgery was received. (The monthly patient information file must contain the date of surgery, facility name, and location name because the name recognized by the patient may differ from the facility’s official name.)

n/a

Separate from Questionnaire

Cover letters must be separate from the questionnaire, so that no personally identifiable information (PII) is returned with the questionnaire when the respondent sends it back to the vendor.

n/a

Content of letters

The OMB disclosure notice (see Appendix G) must be printed either on the questionnaire or in the cover letters.

n/a

Vendors may not offer sample members the opportunity to complete the survey over the telephone. Telephone interviews may only be conducted as part of the nonresponse follow-up.

n/a

Must contain language describing the purpose of the survey. n/a

Must contain a statement that participation is voluntary and will not affect any benefits the sample member receives or expects to receive.

n/a

Must contain language indicating that responses from all the survey participants will be grouped together and these grouped data may be shared with the HOPD or ASC, for purposes of quality improvement.

n/a

Must contain language stating that if the respondent needs help in reading the questions or marking responses, a friend or family member can assist them.

n/a

Must contain a toll-free customer support telephone number, which will be staffed by the survey vendor.

n/a




Printing The HOPD or ASC name (or logo) must appear on the letters or the survey. Note that survey vendors cannot include any promotional messages or materials on the OAS CAHPS cover letter, questionnaire, or outgoing or incoming mailing envelopes. This includes indications that either the facility or the survey vendor has been approved by the Better Business Bureau.

n/a

Signature on the letters

A signature is required. We recommend that the signature of an appropriate official from the HOPD or

ASC be printed on each cover letter If this is not

possible, the signature from an appropriate official at the survey vendor is acceptable.

Requests for Survey in Other Languages

n/a Survey vendors offering an English, Spanish, and Chinese version of the questionnaire may add language to the English

cover letter indicating that a version of the questionnaire

is available in those languages.

MailingRequirements and recommendations are described below. Vendors are expected to follow these requirements to maximize response rates and ensure consistency in how the mail survey portion of the mixed-mode administration is implemented.


Questionnaire contents

Each questionnaire mailing must contain a personalized cover letter, questionnaire, and postage-paid business reply envelope.

n/a

Envelopes Vendors are responsible for supplying both the outgoing envelopes for the questionnaire mailings and business-reply envelopes that sample members will use to return their completed surveys (i.e., they cannot be supplied by the HOPD or ASC).

n/a




Addresses Patients must have a U.S. domestic address to be eligible to participate in the OAS CAHPS Survey.

n/a

If the sample member’s address is missing or incomplete, the vendor must follow up with the HOPD or ASC to obtain the address. If an address cannot be found, or the address that is found is too incomplete for mailing, the vendor should treat the patient as eligible and proceed to the telephone follow-up survey.

To reduce the number of missing

addresses, we recommend that vendors verify

mailing addresses obtained from the

facilities using commercial address update services, such

as the National Change of Address or

the U.S. Postal Service Zip+4

software.Schedule Mailings must follow the schedule specified for the

mail-only mode of administration—the questionnaire package must be mailed no later than 3 weeks after the close of the sample month; the phone calls for telephone follow-up must begin approximately 3 weeks after the questionnaire mailing.

n/a

Data collection must end 6 weeks after the questionnaire has been mailed.

n/a

Incentives The use of incentives is not permitted. This includes monetary and nonmonetary incentives.

n/a

Data Receipt, Data Entry, and Optical Scanning RequirementsThe following guidelines are provided for receiving and tracking returned questionnaires and entering the data using either data entry or optical scanning.

Requirement

Receipting The date the questionnaire was received from each sample member must be entered into the data record created for each case on the data file.Mailings that are returned in the mail as undeliverable must also be logged into the tracking system. They should then be followed up by telephone.A final OAS CAHPS Survey disposition code (see Table 9.1 in Chapter IX) must be assigned to each case.



Requirement

Reviewing received questionnaires for problems

Questionnaires should be visually reviewed prior to scanning or data entry for notes/comments. Vendors should have more than one person who can code or review comments and attach notes for proper disposition code assignment.If a completed mail survey questionnaire is returned and the vendor realizes that it was completed by proxy (i.e., there is a note written on the questionnaire that a family member completed the questionnaire because the patient had died, had moved to a nursing home, or had been incarcerated) vendors should not scan a questionnaire for that sample member. They should instead assign the applicable final disposition code to the case.If a sample member were to die or become ineligible after completing the questionnaire (vendors might learn of this through a comment written by a family member on the questionnaire) that questionnaire is still an eligible completed survey. Vendors should scan the questionnaire and assign the applicable final disposition code indicating the completed survey.

Out-of-range or invalid responses

The key entry program should not permit out-of-range or invalid responses.The scanning program should not permit out-of-range or invalid responses

Quality control For keying: All questionnaires should be 100 percent rekeyed for quality control purposes. That is, for every questionnaire, a different keyer should rekey the questionnaire and the data entry files of the two keyers should be systematically compared. If any discrepancies between the two data entry files are detected, a supervisor should resolve the discrepancy and ensure that the correct value is stored in the data.For optical scanning: A sample of questionnaires (minimum of 10 percent) should be systematically compared with the original hardcopy survey. Any discrepancies between the scan and the hardcopy should be reconciled by a supervisor. This serves as a quality control measure that the scanning program is capturing the hardcopy correctly.Additionally, the survey responses captured in the database for a sample of questionnaires (minimum of 10 percent) should be systematically compared to scanned image for that case. This can be done either by visually examining the scanned image and the data to reveal inconsistencies, or by rescanning and noting whether the data from the original matches the data from the rescan. This serves as a quality control measure that the scanning program is translating the response marks in the scanned image to the data file consistently and correctly.

Interpreting blanks and ambiguous

The following apply for both keying and optical scanning:If a response mark falls between two answer choices but is clearly closer to one answer choice than to another, select the response that is closest to the marked response.



Requirement

survey responses

If two responses are checked for the same question, select the one that appears darkest. If it is not possible to make a determination, leave the response blank and code as “missing” rather than guessing.If a mark is between two answer choices but is not clearly closer to one answer choice, code as “missing.”If a response is missing, leave the response blank and code as “missing.”

Open-ended responses

The decision on whether to key or scan the responses to open-ended survey items, specifically, the “Other language” (response option 2) in Q35 and the “Helped in some other way” (response option 5) in Q37, is up to each individual HOPD or ASC. Vendors will not be required to key or scan and include responses to open-ended survey items on the data files submitted to the OAS CAHPS Survey Data Center.CMS, however, encourages survey vendors to review the open-ended entries so they can provide feedback to the Coordination Team about adding additional preprinted response options to these survey items if needed.

It follows that if the vendor includes the Consent to Share Identifying Information question in the mail survey questionnaire, we do not require that the vendor key or scan the response to that question. However, we do recommend it for the vendor’s own documentation.Responses to the Consent to Share Identifying Information question will not be included on the data files submitted to the OAS CAHPS Survey Data Center.

Staff TrainingAll staff involved in the mail survey implementation, including support staff, must be thoroughly trained on the survey specifications and protocols. A copy of relevant chapters of this manual should be made available to all staff as needed.

In particular, staff involved in questionnaire assembly and mailout, data receipt, and data entry must be trained on:

• use of relevant equipment (case management systems for entering questionnaire receipts, scanning equipment, data entry programs);

• the OAS CAHPS Survey protocol specific to their role (for example, contents of questionnaire package, how to document or enter returned questionnaires into the tracking system);

• decision rules and coding guidelines for returned questionnaires (see Chapter IX); and

• proper handling of hardcopy and electronic data, including data storage requirements (see Chapter VIII).



Staff involved in providing customer support via the toll-free telephone number should also be trained on the accurate responses to common respondent questions, how to respond to questions when customer support does not know the answer, and the rights of survey respondents. If the OAS CAHPS Survey is being offered in a language other than English, customer support staff should also be able to handle questions via the toll-free telephone number in that language. Telephone interviewer training requirements are described in more detail in Chapter VI of this manual. Please refer to that chapter for more information on training customer support staff.

Telephone Interview Development ProcessThe following paragraphs describe the requirements for producing all materials and systems needed for the telephone survey. The telephone interview script in English and Spanish are available on the OAS CAHPS Survey website at https://oascahps.org/.

Copies of the telephone interview script can also be found in Appendix B (in English) and Appendix C (in Spanish). A list of frequently asked interview questions is included in Appendix H (English) and Appendix J (Spanish). Some general guidelines for telephone interviewer training and monitoring are provided in Appendix I.

Specific requirements and guidelines associated with the telephone interview administration are discussed below.

Telephone Interviewing SystemsIn electronic interviewing systems, the interviewer reads from and enters responses into a computer program. Using an electronic interviewing system or some other type of electronic data collection system encourages standardized interviewing and monitoring of interviewers. The OAS CAHPS Survey mixed-mode administration requires vendors use an electronic interviewing system to administer the follow-up telephone OAS CAHPS Survey. Paper-and-pencil administration of the OAS CAHPS Survey is not permitted. To ensure that sample members are called at different times of the day and across multiple days of the week, vendors must also have a survey management system. Ideally, the electronic interviewing system will be linked to the survey management system so that cases can be tracked, appointments set and called back at appropriate times, and pending and final case status easily accessed for any case.

Predictive or automatic dialers are permitted, as long as they are compliant with Federal Trade Commission and Federal Communications Commission regulations, and as long as respondents can easily interact with a live interviewer. For more information about Federal Trade Commission and Federal Communications Commission regulations please visit https://www.ftc.gov/ and https://www.fcc.gov/.


https://www.fcc.gov/

https://www.ftc.gov/



Telephone Interview ScriptSurvey vendors are provided with standardized telephone scripts in Appendix B English and Appendix C, Spanish. These scripts include the introductory screens, in addition to the survey questions.

The OAS CAHPS Telephone Survey questionnaire script contains 35 questions. The survey can be administered as a standalone survey or can be combined with facility-specific questions as explained in Chapter III. Questions 1 to 24 are considered the “core” OAS CAHPS Survey questions and must be placed at the beginning of the questionnaire. Questions 25 to 35 are the “About You” OAS CAHPS Survey questions and must be administered as a unit.

Note the OAS CAHPS telephone interview script contains only 35 questions and the mail survey contains 37 questions, because the mail survey questionnaire contains questions that ask if anyone helped the sample member to complete the survey (Questions 36 and 37). These two questions are not applicable if the survey is administered by telephone.

The following are content and programming requirements and recommendations for the OAS CAHPS Survey Questionnaire. Survey vendors cannot deviate from questionnaire requirements.

• Every questionnaire must begin with the core OAS CAHPS questions. They must be administered in the order in which they appear.

• No changes in wording are allowed for either the OAS CAHPS Survey questions or to the response choices.

• HOPDs and ASCs may add their own questions, following the guidelines in Chapter III. In terms of placement of supplemental questions in the questionnaire, note that they must be placed after the “core” OAS CAHPS questions. They may either be placed before or after the unit of “About You” questions.

• Only CMS-approved translations of the OAS CAHPS Survey are permitted, although if facilities choose to add their own supplemental questions, vendors will be responsible for translating these questions.

Telephone Interviewing Requirements and RecommendationsTelephone interviewing requirements and recommendations for the OAS CAHPS Survey interview are described below. Vendors are expected to follow these requirements to maximize response rates and ensure consistency in how the telephone follow-up is implemented in the mixed mode of administration.



Telephone Contact• Vendors must attempt to contact every sample member included in the sample. Vendors

must make a minimum of five contact attempts for each nonrespondent to the mail survey, unless the sample member refuses or the vendor learns that the sample member is ineligible for the survey.

• A telephone contact attempt is defined as one of the following:

◦ the telephone rings six times with no answer;

◦ the interviewer reaches a household member and is told that the sample member is not available to take the call;

◦ the interviewer reaches the sample member and is asked to schedule a call-back at a later date; or

◦ the interviewer gets a busy signal on each of three consecutive phone call attempts, spaced at least 20 minutes apart.

• Vendors may make more than one phone call in one 7-day period but cannot make all five attempts in one 7-day period. Scheduling calls to take place over a longer period of time may reach patients who may be unavailable the first week of the data collection period.

• Contact with a sample member may be continued after five attempts if the fifth attempt results in a scheduled appointment with the sample member, as long as the appointment is within the data collection period.

• Phone calls must be made at different times of the day (i.e., morning, afternoon, and evening) and different days of the week throughout the data collection period.

• Interviewers may not leave voicemail messages on answering machines or leave messages with household members.

• Vendors must be able to provide a phone call log that keeps track of the date and time phone calls were made for each sample member.

• If the vendor finds out that a sample member is ineligible for the OAS CAHPS Survey, the vendor must immediately stop further contact attempts with that sample member.

• Telephone interviewing must follow the schedule specified for the mixed mode of administration, with the first phone contact initiated approximately 3 weeks after the questionnaire is mailed and all phone contacts ending 3 weeks after phone contact begins.



• The use of incentives is not permitted in the telephone follow-up portion of the mixed-mode survey administration. This includes monetary and nonmonetary incentives.

• Proxy respondents are not permitted on OAS CAHPS for any reason. If a sample member is incapable of responding to the telephone interview because of mental or physical impairments such as difficulty hearing, the case should be closed using code 240 or “Mentally/Physically Incapable” and end the interview. If a sample member is capable of responding but needs some help to do so, a friend or family member may help, but cannot respond on his or her behalf.

• Proxies are also not permitted for deceased respondents. If a sample member is found to be deceased, the case should be closed using code 210.

• If a respondent begins the interview but cannot complete it during the call for a reason other than a refusal, the vendor should follow up with the respondent to complete the entire interview. This follow-up should be done even if the respondent answered enough questions in the interview for the case to pass the completeness criteria. It is especially important to complete the questions in the “About You” section of the questionnaire, because data from some of those questions will be used in patient-mix adjustment.

• The vendor must be able to offer the interview in any of the approved languages for which an HOPD or ASC has contracted, even if the language is different from the language that the HOPD or ASC believes the sample member will require. That is, the vendor must be able to easily switch to accommodate a respondent’s language preference. For example, if the initial contact is in English but the respondent prefers to conduct in Spanish, the vendor must be able to switch to Spanish.

• Sample members are still eligible even if they have missing, incomplete, or foreign phone numbers. The vendor should contact the HOPD or ASC to obtain the telephone number(s) they have on record for the sample member. If the HOPD or ASC cannot provide this number, the vendor should attempt to obtain a telephone number for the patient from other sources (directory assistance, Internet directories, etc.). If the vendor still cannot obtain a telephone number, the vendor should code the case as code 340—wrong, disconnected, no telephone number.

• If a respondent decides after he or she has answered some of the questions in the telephone interview that he or she does not wish to participate in the survey any longer, the vendor should code the case as a refusal. The interviewer should not use the partial data that were obtained before the interview was ended. This protocol applies even if the respondent answered enough questions in the interview for the case to pass the completeness criteria. Note that this is different from the respondent saying that he or she does not wish to continue an interview. If the respondent breaks off the interview but does not state that he or she does



not wish to participate in the survey, the data may be used as long as the interview meets the completeness criteria. The vendor may then code the case as a completed interview if the case passes the completeness criteria; otherwise it should be coded as a breakoff/partial data.

Contacting Difficult-to-Reach Sample Members• Although not required, we strongly recommend that survey vendors verify telephone

numbers obtained from the HOPD or ASC, using a commercial address/telephone database service or directory assistance.

• We recommend that vendors attempt to identify a new or updated telephone number for any sample member whose telephone number is no longer in service when called and for patients who have moved so that the sample members can be contacted prior to the end of the data collection period.

• If the sample member’s telephone number is incorrect, the interviewer may ask the person who answers the phone for the sample member’s phone number.

• If the sample member is temporarily ill, on vacation, or unavailable during initial contact, the interviewer should attempt to recontact the sample member before the data collection period ends. If the sample member cannot be reached before the data collection period ends, code the case as 350, “No Response After Maximum Attempts.”

• If the sample member does not speak a language which has an approved translation for OAS CAHPS, the interviewer should thank the sample member for his or her time, end the interview, and code the case as 230, “Ineligible: Language Barrier.”

• If a sample member is physically or mentally incapable of responding by telephone, the case should be coded as a 240.

• For sample members who are living in institutions (group homes, assisted living, residential care facilities, etc.), OAS CAHPS Survey vendors should contact the HOPD or ASC to obtain a direct-dial telephone number for the patients who live in those facilities. If the HOPD or ASC cannot provide a direct-dial telephone number for the patient, try to obtain the sample member’s telephone number using other sources, such as a telephone number lookup service, directory assistance, or Internet telephone survey directories. If vendors cannot obtain a telephone number for the patient, they should assign a disposition code of “Missing/Disconnected Number” to the case. As a reminder, sample members living in nursing homes or prisons are ineligible.



Distressed Respondent ProceduresIt is critically important that survey vendors develop a “distressed respondent protocol,” to be incorporated into all interviewer and help desk training. Handling distressed respondent situations requires balancing keeping personally identifiable information and private health information confidential and helping a person who needs assistance. For survey research organizations, best interviewing practices recommend having a distressed respondent protocol in place for handling distressed respondents, which balances the respondent’s right to confidentiality and privacy and providing assistance, if the situation indicates that the respondent’s health and safety are in jeopardy.

Therefore, each approved OAS CAHPS Survey vendor is expected to have procedures in place for handling distressed respondent situations and to follow those procedures. CMS and the OAS CAHPS Survey Coordination Team cannot provide guidelines on how to evaluate or handle distressed respondents. However, survey vendors are urged to consult with their organization’s Committee for the Protection of Human Subjects Institutional Review Board for guidance. In addition, professional associations for researchers, such as the American Association of Public Opinion Researchers (AAPOR), may be able to provide guidance regarding this issue. The following is an excerpt from AAPOR’s website that lists resources for the protection of human subjects. More information about protection of human subjects is available at AAPOR’s website at http://www.aapor.org.9

• The Belmont Report (guidelines and recommendations that gave rise to current federal regulations)

• Federal Regulations Regarding Protection of Human Research Subjects (45 CFR 46) (also known as the Common Rule)

• Federal Office for Human Research Protections

• National Institutes of Health Human Participant Investigator Training (although the site appears to be for cancer researchers, it is the site for the general investigator training used by many institutions)

• University of Minnesota Web-Based Instruction on Informed Consent

Interviewer TrainingVendors must provide training to all telephone interviewing and customer support staff prior to starting telephone survey data collection activities. The telephone interview training must include the following:

9 The American Association of Public Opinion Researchers website at http://www.aapor.org/Additional_IRB_Resources.htm l , July 2010.


http://www.aapor.org/Additional_IRB_Resources.htmt

http://www.aapor.org/


• teaching interviewers how to establish rapport with the respondent;

• teaching interviewers the content and purpose of the interview so that they can effectively communicate this information to the sample members;

• teaching interviewers to administer the interview in a standardized format (reading the questions as they are worded, not providing the respondent with additional information that is not scripted, maintaining a professional manner, and adhering to all quality control standards);

• teaching interviewers how to use effective neutral probing techniques;

• teaching interviewers to use the frequently asked questions document so that they can answer questions in a standardized format; and

• teaching multilingual customer support staff how to handle questions in English and the other language(s) in which the survey is being offered.

Survey vendors should also provide telephone survey supervisors with an understanding of effective quality control procedures to monitor and supervise interviewers.

Vendors must conduct an interviewer certification process of some kind—either oral, written, or both—for each interviewer and customer service staff member prior to permitting that person to make or take calls on the OAS CAHPS Survey. The certification should be designed to assess the interviewer’s level of knowledge and comfort with the OAS CAHPS Survey instrument and ability to respond to sample members’ questions about the survey. Documentation of training and certification of all telephone interviewers and customer support staff and outcomes will be subject to review during oversight visits by the OAS CAHPS Survey Coordination Team.

Telephone Data Processing ProceduresThe following guidelines are provided for ensuring that the telephone interview data are properly processed and managed.

Telephone Data Processing Requirements• A unique SID number must be assigned to each sampled case and included in the case

management system and on the final data file for each sample member.

• Vendors must enter the date the interview was conducted with each sample member in the survey management system or in the interview data.



• Vendors must be able to link each telephone interview to their survey management system, so that appropriate variables, such as the language in which the survey was conducted, can be pulled into the final data file.

• Vendors must de-identify all telephone interview data when the data are transferred into the final data file for delivery. Identifiable data include respondent name and contact information.

• Vendors must assign a final OAS CAHPS Survey status or disposition code to each case (see Chapter IX for a list of these codes) and include a final disposition code for each sampled case in the final data file. It is up to the vendor to develop and use a set of pending disposition codes to track actions on a case before it is finalized appropriately—pending disposition codes are not specified in the OAS CAHPS Survey protocol.

Mixed-Mode Quality Control GuidelinesThe following steps are required or recommended as a means of incorporating quality control into the mixed-mode survey administration procedures. Quality control checks should be conducted by a different staff person than the one who completed the task.

Mail Protocol• Vendors are required to check a minimum of 10 percent of all printed materials to ensure the

quality of the printing—that is, make sure that there is no smearing, misaligned pages, duplicate pages, or stray marks on pages.

• Vendors are required to check a minimum of 10 percent of all outgoing questionnaire packages to ensure that all package contents are included and that the same unique SID number appears on both the cover letter and the questionnaire.

• For vendors who are scanning: a sample of questionnaires (minimum of 10 percent) should be compared with the original hardcopy survey as a quality control measure. Additionally, for a sample of questionnaires (minimum of 10 percent) the response data resulting from the scanning program should be compared to the scanned image for that case. Any discrepancies from either of these should be reconciled by a supervisor.

• For vendors who are keying: all questionnaires should be 100 percent rekeyed for quality control purposes. That is, for every questionnaire, a different keyer should rekey the questionnaire and the data entry files from the two keyers should be systematically compared to ensure that all entries are accurate. If any discrepancies are observed, a supervisor should resolve the discrepancy and ensure that the correct value is stored in the data.

Although not required, vendors are urged to develop a way to measure error rates for their data receipt staff (in terms of recognizing marginal notes and passing these on to someone for



review), for data entry or scanning operators, and for coders. Vendors should then work with their staff to minimize error rates. The Coordination Team will request information about data receipt and processing error rates during site visits to survey vendors.

Telephone ProtocolThe following activities are methods to incorporate quality control into the survey administration procedures for the telephone follow-up portion of the mixed-mode survey administration. Quality control of telephone interviewers and customer support staff should include the following activities:

• OAS CAHPS requires that survey vendors thoroughly test the electronic telephone interviewing system before beginning the OAS CAHPS survey. Testing will vary from system to system, but includes at a minimum comparing each screen to the Telephone Script to verify that the questions and answer choices are faithful to the script; checking each question to ensure that the answers input match the data exported, and checking that a respondent is automatically routed to the next appropriate question.

• Vendors are required to keep written documentation that all telephone interviewing and customer support staff have been properly trained prior to interviewing. Copies of interviewer certification exam scores should be retained as well. Documentation should be maintained for any retraining required and will be subject to review during oversight visits.

• Although not required, we recommend that vendors conduct regular Quality Circle meetings with telephone interviewing and customer support staff to obtain feedback on issues relating to telephone survey administration or handling inbound calls.

• Survey vendors must establish and communicate clear telephone interviewing quality control guidelines for their staff to follow. These guidelines should be used to conduct the monitoring and feedback process and should include clear explanations of the consequences of not following protocols, including actions such as removal from the project or termination of employment.

• Vendors are required to silently monitor a minimum of 10 percent of all telephone interviews to ensure that correct administration procedures are being followed.

• Supervisory staff monitoring telephone interviewers should use the computer-assisted telephone interviewing (CATI) or alternative electronic system to observe the interviewer conducting the interview while listening to the audio of the call at the same time.

• Monitoring staff or supervisors should provide performance feedback to interviewers as soon as possible after the monitoring session has been completed.



• Interviewers should be given the opportunity to correct deficiencies in their administration through additional practice or retraining; however, interviewers who receive consistently poor monitoring scores should be removed from the project.

• There are federal and state laws and regulations relating to the monitoring/recording of telephone calls. In certain states, consent must be obtained from every party or conversation if it involves more than two people (“two-party consent”). When calling sample members who reside in these states, survey vendors should not begin either monitoring or recording the telephone calls until after the interviewer has read the following statement:

“This call may be monitored or recorded for quality improvement purposes.”10

• All OAS CAHPS Survey vendors are responsible for identifying and adhering to federal and state laws and regulations in the states in which it will be administering the OAS CAHPS Survey.

• Vendors should conduct periodic reviews of their XML data files by comparing at least 50 completed telephone interview responses directly from their CATI system to the values output in the XML file. Doing this monthly review will ensure that the responses are being accurately captured and output to the XML file.

10 The following states currently require two-party or all-party consent when telephone calls are monitored or audiotaped: California, Connecticut, Delaware, Florida, Illinois, Maryland, Massachusetts, Michigan, Montana, New Hampshire, Pennsylvania, and Washington.


VIII. CONFIDENTIALITY AND DATA SECURITY

OverviewThis chapter describes the requirements and guidelines for (1) protecting the identity of sample members included in the survey sample, (2) ensuring confidentiality of respondent data, and (3) ensuring data security. The chapter begins with a discussion of how confidential data should be handled and the importance of confidentiality agreements. The last section provides information about the importance of establishing and maintaining physical and electronic data security.

Safeguarding Patient DataThe Health Insurance Portability and Accountability Act of 1996 (HIPAA) is legislation intended to protect private medical information and to improve the efficiency of the health care system. This law went into effect April 14, 2003.

The type of information protected under HIPAA is called “protected health information,” or PHI. PHI is defined as personally identifiable information that relates to a person’s past, present, or future health or medical treatment. If the health information is completely de-identified, it is no longer PHI and can be released. HIPAA also applies to electronic records, whether they are being stored or transmitted. All vendors approved to implement Outpatient and Ambulatory Surgery CAHPS (OAS CAHPS) survey must adhere to HIPAA requirements. That is, vendors must safeguard any and all data collected from sample members as required by HIPAA. Vendors should therefore stress to their hospital outpatient department (HOPD) and ambulatory surgery center (ASC) clients the importance of sending the monthly patient information files in a manner which adheres to HIPAA guidelines, at a minimum encrypting the patient information files prior to sending them to their vendor.

Vendors must adhere to the following requirements when conducting OAS CAHPS. Each of these is discussed in more detail in the paragraphs that follow.

• Confidential data must be kept secure as described in this chapter.

• Access to confidential data must be limited to authorized staff members.

• Vendors must develop procedures for identifying and handling breaches of confidential data.


VIII. Confidentiality and Data Security October 2015

• No data that can identify a sample member can be included on OAS CAHPS data files submitted to the OAS CAHPS Data Center. That is, all file submissions must contain de-identified data.

State Regulations and Laws Protecting Patients With Specific Conditions/IllnessesAs indicated in Chapter IV of this manual, some states have additional regulations and laws governing the release of patient information for patients with specific illnesses or conditions, and for other special patient populations, including patients with HIV. It is the HOPD’s or ASC’s responsibility to identify any applicable state laws and regulations and exclude patients from the survey as required by the law or regulation.

Confidential Data Must Be Kept SecureAny identifying information associated with a patient should be considered private and must be protected. When the sample frame information is received from an HOPD or ASC, it will contain private information, such as the name and address or telephone number of the patient, and other information such as outpatient surgeries or procedures performed and the date on which the surgeries or procedures were performed. HOPDs and ASCs must provide the monthly patient information files in a manner which adheres to HIPAA guidelines and regulations, at a minimum encrypting the patient information files prior to sending them to their vendor.

From the moment the vendor receives sample frame information, the data must be handled in a way to ensure that the patient information is kept confidential and that only authorized personnel have access to it. Examples of ways to keep confidential data secure include storing the data electronically in password-protected locations and limiting the number of staff with access to the password. For confidential information that is obtained on hard copy, data should be kept in a locked room or file cabinet, with access restricted to authorized staff. Confidential data should not, under any circumstances, be removed from the survey vendor’s place of business, either in electronic or hardcopy form, even by survey vendor staff. Confidential data should not be stored on laptop computers unless those laptops have data encryption software to protect the information should the laptop be lost or stolen.

Limit Access to Confidential Data to Authorized StaffSurvey vendors should consider carefully who needs access to confidential OAS CAHPS data and then ensure that only those staff have access. For example, the sampling manager will need access to the facility sample frame to select the sample. However, information on the frame does not need to be included in every data file—although names and addresses need to be provided in the file used to create cover letters, other PHI does not have to be on that file.


October 2015 VIII. Confidentiality and Data Security

Any staff who will be working with data about outpatient surgery patients should sign a confidentiality agreement specific to OAS CAHPS implementation (see the paragraph on Confidentiality Agreements for more information).

Develop Procedures for Identifying and Handling Breaches of Confidential DataSurvey vendors are required to develop protocols for identifying when there has been a breach of security with OAS CAHPS data, including when an unauthorized individual has gained access to confidential information and when an authorized individual has distributed confidential data in an unauthorized manner. The vendor’s plans must include a system to notify the vendor’s OAS CAHPS Project Director in a timely manner of a security breach, a means to detect the level of risk represented by the breach in security, and a means to take corrective action against the individual who created the breach and any persons affected by the breach, including sample members.

Provide Only De-identified Data Files to the OAS CAHPS Data CenterAlthough vendors will have access to confidential information about outpatient surgery patients, none of the data files submitted to the OAS CAHPS Data Center may contain any confidential information (i.e., any information that would identify a sample member). All files submitted to the OAS CAHPS Data Center must contain de-identified data only. Therefore, only the unique patient sample identification (SID) number that the survey vendor assigns to each sample member should be included on the file for each data record. (There will be a data record for each patient sampled.)

Providing De-Identified OAS CAHPS Response Data to ASCs and HOPDsOAS CAHPS–approved vendors can provide responses linked to a sample member’s name and other identifying information only if the sample member gives his or her consent on the “Consent to Share Identifying Information” question (Appendix F). In the absence of this explicit consent, only de-identified response data can be provided.

Additional rules govern whether vendors may provide response data on the “About You” questions (Questions 25-37). If there are a minimum of 10 patients who responded to a question, the response data may be provided. For example, if 10 or more respondents provided an answer to Q27, it is acceptable to provide de-identified results for Q27 to the HOPD or ASC. Similarly, if nine or fewer patients provided a response to Q31, it is not acceptable to provide de-identified results (even aggregated) for Q31 to the HOPD or ASC.

Confidentiality AgreementsSurvey vendors are required to obtain a signed affidavit of confidentiality from all staff, including subcontractors, who will work on the OAS CAHPS implementation. This includes



individuals who will be working as telephone interviewers or staffing the customer support line and individuals working in data receipt or data entry positions. Copies of the signed agreements should be retained by the project director as documentation of compliance with this requirement. Vendors will be asked to provide this documentation during site visits by the OAS CAHPS Survey Coordination Team.

Physical and Electronic Data SecurityVendors must take appropriate actions to safeguard both the hardcopy and electronic data obtained during the course of implementing OAS CAHPS, including data obtained from ASCs and HOPDs and data provided by survey respondents.

The following are measures vendors should take to ensure physical and electronic data security:

• Paper copies of questionnaires or sample frame information must be stored in a secure location, such as a locked file cabinet or within a locked room. At no time should paper copies be removed from the vendor’s premises, even temporarily.

• At no time should electronic data be removed from the survey vendor’s or subcontractor’s premises, even temporarily.

• Electronic data must be protected. Electronic security measures may include firewalls, restricted access levels, or password-protected access.

• Access to confidential data must be limited to authorized staff members.

• Data stored electronically must be backed up nightly or more frequently to minimize data loss.

• Electronic images of paper questionnaires or keyed data, including computer-assisted telephone interview or alternative electronic system data, should be retained for 3 years in a secure location at the vendor’s facility.

• Paper copies of questionnaires must be stored in a secure location at the vendor’s facility, such as a locked room or file cabinet, for 3 years. Paper copies of questionnaires do not need to be kept if electronic images of the questionnaires are being kept instead.

• Destroy all paper and electronic copies of questionnaire and surveys that contain personally identifiable information once the proper time has elapsed.

• Protocols for secure file transmission must be established. E-mailing of PHI via unsecure e-mail is prohibited.


October 2015 VIII. Confidentiality and Data Security

• Confidential data should not be stored on laptop computers unless those laptops have data encryption software to protect the information should the laptop be lost or stolen.

• Vendors must develop procedures for identifying if breaches of confidential data have occurred, informing the OAS CAHPS Survey Coordination Team, and implementing a corrective action plan.

• No data that can identify a patient or a sample of patients can be included on OAS CAHPS Survey data files submitted to the OAS CAHPS Data Center. That is, all file submissions must contain de-identified data.

Communicating With Sample Members About Confidentiality and SecuritySample members may wish to understand how the OAS CAHPS survey keeps information about them confidential and secure. It is important that survey vendors on OAS CAHPS clearly and succinctly communicate this information to sample members, when asked. The following are guidelines of what to convey:

• the purposes of the survey and how the survey results will be used, specifically that all patients’ survey responses will be reported at the aggregate level and absolutely no response will be linked to an individual patient respondent;

• participation in the study will not affect the care they receive or health care benefits they currently receive or expect to receive in the future;

• participation in the OAS CAHPS Survey is voluntary;

• they can skip or refuse to answer any question they do not want to answer;

• all information they provide is protected by the Federal Privacy Act of 1974 and HIPAA (most patients are familiar with HIPAA);

• all OAS CAHPS project staff have signed affidavits of confidentiality and are prohibited by law from using survey information for anything other than this research study; and

• no facility personnel will see an individual patient’s answers unless the patient explicitly gives consent to share their answers.


IX. DATA PROCESSING AND CODING

OverviewThis chapter describes the requirements and guidelines for creating and assigning a unique sample identification (SID) number to each sample member, decision rules related to processing returned mail survey questionnaires, assignment of survey disposition codes, and quality control measures. In addition, procedures and steps for determining whether a returned survey meets the definition of a completed survey and information about how survey response rates are calculated are provided in this chapter.

Sample Identification NumbersA unique numeric or alphanumeric SID number must be assigned to each patient included in the Outpatient and Ambulatory Surgery CAHPS (OAS CAHPS) Survey sample. Vendors will use the SID to track efforts to complete the survey with each sample member throughout the data collection period. When creating and assigning SID numbers to sampled cases, follow the guidelines listed below.

• The SID number assigned to a sample member cannot contain any combination of letters or numbers that could link the SID with a particular sample member. For example, no part of a sample member’s name, address, date of birth, telephone number, Social Security number, or dates of outpatient surgeries or procedures can be included in the unique SID created and assigned to the sample member.

• The SID number also cannot link a particular sample member with a particular hospital outpatient department (HOPD) or ambulatory surgery center (ASC). The vendor should not embed within the SID any items identifying the source HOPD or ASC, such as its CMS Certification Number (CCN), its initials, or its location. Vendors with multiple OAS CAHPS clients wishing to track the source should establish a variable distinct from the SID in which to identify the source HOPD or ASC of the patient.

• The SID can be a numeric or alphanumeric variable. The SID must have a minimum length of 6 and a maximum length of 16 characters.

• Vendors must assign new SID numbers to the new set of patients sampled each month. Vendors must not reuse the same SID number.

• If a patient is sampled more than once in a calendar year or across multiple calendar years, the vendor must assign a new SID number to that patient each time he or she is sampled.


Data Processing Decision Rules and Coding GuidelinesGuidelines and procedures for handling ambiguous, missing, or inconsistent survey responses from returned mail survey questionnaires are provided below. Note that these guidelines should be followed regardless of whether the vendor is using optical scanning or data entry to enter data from completed questionnaires.

Mail SurveysIn mail surveys, some respondents may choose not to answer particular questions, and others may not clearly mark their answer choices. Use the following rules to handle missing or ambiguous responses when processing completed questionnaires from the OAS CAHPS mail survey respondents.

• If a response mark falls between two answer choices but is clearly closer to one answer choice than to another, select the response that is closest to the marked response.

• If two responses are checked for the same question, select the one that appears darkest. If it is not possible to make a determination, leave the response blank and code as “missing” rather than guess.

• If a mark is between two answer choices but is not clearly closer to one answer choice, code as “missing.”

• Note that the only survey items in the OAS CAHPS Survey where two or more answers are acceptable are Questions 32 and 37, which ask the sample member to check all answer choices that are applicable to him or her. For both of these questions, enter responses for all of the categories that the respondent marked.

• If a response is missing, leave the response blank and code it as “Missing.”

Skip PatternsSome of the questions included in the OAS CAHPS Survey instrument are “screening” questions—that is, they are designed to determine whether one or more follow-up questions about the same topic are applicable to the respondent. The respondent is directed to the next applicable question by a “skip” instruction printed beside the answer choice that he or she marks.

In mail surveys, some respondents may answer the screening question but leave applicable follow-up questions blank. In other cases, some respondents will mark an answer to follow-up questions that are not applicable to them (based on the answer to the screening question). Yet in other cases, some respondents will answer both the screening and follow-up questions with responses that contradict each other. Use the following rules for completed OAS CAHPS Questionnaires.


October 2015 IX. Data Processing and Coding

Decision Rules for Coding Screening Questions (Qs. 10, 30, 34, and 36)• Key or scan the response provided by the respondent.

• If the screener question is left blank, code it as “Missing (Code M).”

Decision Rules for Coding Follow-Up Questions (Qs. 11, 12, 31, 35, and 37*)*Please note: Q. 37 is included in the mail survey only.

• Key or scan the response provided by the respondent whenever one is given, regardless of whether the response agrees with the screener question. For example, if the respondent answers “No” to the screener question and then marks a response to the follow-up question instead of skipping it, that is acceptable—the response must still be keyed or scanned.

• If the follow-up question is left blank (correctly) because the respondent correctly followed the skip instruction in the screener question, assign Code 8 (“Not Applicable”) to the follow-up question.

• If the follow-up question is left blank (incorrectly) because the respondent skipped it rather than answering it, enter Code M (“Missing”) for the follow-up question.

To summarize, when follow-up questions are appropriately skipped, the follow-up question response should be coded as “Not Applicable,” which is Code 8. When follow-up questions are incorrectly answered, scan or key the response that the respondent provides. If a screener or follow-up question should have been answered but was not, code the response as “Missing,” which is Code M. Note that in OAS CAHPS, survey vendors will key or scan the response to every question that the respondent provides.

Decision Rules for Coding Survey Responses Marked Outside of the Response BoxAlthough OAS CAHPS mail questionnaires use response bubbles or boxes, vendors may receive surveys where a response is marked outside the response box. CMS and the OAS CAHPS Survey Coordination Team acknowledge that there are some instances where it is acceptable to consider a response “marked,” even if the response box itself is not marked. However, to minimize the opportunity for coding interpretation errors among vendors, OAS CAHPS requests that all responses or response boxes that are not circled, checked, underlined, or in some other way clearly designated by the respondent (i.e., the respondent writes the exact wording of a response to the right of the response options) be coded as “Missing.”

Although some text or marks to the right of the response options may seem to point to a particular response, many times the respondent’s intent is not clear. This opens the door to nonstandardized interpretations from vendor to vendor. To provide some visual guidance on


IX. Data Processing and Coding October 2015

what is expected, we have offered three examples below of when it is acceptable to code a response and two examples of when it is not acceptable to code a response.

When it is Acceptable to Code a Response

Example 1:

In this first example, the respondent has circled a response. The respondent’s intention is clear and the vendor should code the answer to Q3 as “No.”

Example 2:

In this second example, the respondent has underlined a response. The respondent’s intention is clear and the vendor should code the answer to Q6 as “Yes, definitely.”

Example 3:In this third example, the respondent has placed a check mark very close to a response. Again, the respondent’s intention is clear, and the vendor should code the answer to Q22 as “Yes.”



When it is NOT Acceptable to Code a Response

Example 1:

In this example, the respondent has placed a check mark to the right of the response boxes. It is not clear which response was intended. Therefore, the correct procedure for a question presenting like Q10 is to code the response as “M” which stands for “missing.”

Example 2:

In this example, the respondent has placed a check mark to the right of the response boxes. It is not clear which response was intended. Therefore, the correct procedure for a question presenting like Q9 is to code the response as “M.”



Survey Disposition CodesSurvey disposition codes, which are also referred to as status codes, are used to track the current status of a sampled case as it moves through the survey process. For example, a disposition code is used to designate that the first questionnaire has been mailed, and another disposition code is used to indicate that the questionnaire has been received. Disposition codes can be interim (meaning that they are expected to change as the case moves through the rest of the survey process) or final (meaning that no further action will be taken with that case). Understanding and appropriately using OAS CAHPS disposition codes is required for successful administration and completion of OAS CAHPS. This section provides a list and description of the final disposition codes that are to be used on OAS CAHPS, for mail-only, telephone-only, and mixed-mode surveys.

Survey vendors should apply pending disposition codes to OAS CAHPS cases for internal tracking purposes only—that is, to describe the result of the most recent work or action on the case that did not result in a final disposition. Because survey vendors may have already developed a set of designated pending dispostion codes for tracking the pending status of a case, survey vendors may use their own set of pending codes on OAS CAHPS.

Definition of a Completed Survey or Survey Completion CriteriaAs is seen below in the description of all OAS CAHPS status codes, one of the criteria in determining the correct code is whether the survey is “complete.” A survey is considered to be “complete” and should be assigned a survey disposition code of 110 or 120 if at least 50 percent of the questions applicable to all sample members (Questions 1–10 and 13–24) are answered.

• Survey items that are part of skip patterns and the items in the “About You” section of the questionnaire (Questions 10 and 25–37) are not included in this calculation of percentage complete.

• Responses of “Don’t Know” and “Refuse” should be recoded to missing “M” and should not be counted as responses.

• Use the steps in Exhibit 9.1 to determine whether a survey can be considered “complete.”



Exhibit 9.1Steps for Determining Whether a Questionnaire Meets Completeness Criteria

Sum the number of questions that have been answered by the respondent that are applicable to all patients. These include questions 1–10 and 13–24.

R = total number of questions answered

Divide the total number of questions answered by 22, which is the total number of questions applicable to all patients, and then multiple by 100 to determine the percentage.

Percentage Complete = (R / 22) x 100

If the Percentage Complete is greater than or equal to 50 percent, then assign the applicable survey completed disposition code (code 110 or 120) to indicate that the case meets the definition of a completed survey. Otherwise, assign the disposition code for breakoff (code 310) to the case.

The vendor must select and assign the applicable code from the disposition codes shown in Table 9.1 for each sampled case included on the data file submitted to the OAS CAHPS Data Center.

Table 9.1OAS CAHPS Survey Disposition Codes

Code Description110 Completed Mail Survey

See Definition of a Completed Survey (above)Assign this code for mail-only cases and for mixed-mode cases if the sample member responded by mail.

Note that respondents may receive assistance completing the mail survey and such respondents should be included in Code 110. If they are capable of understanding and answering the questions someone else can provide assistance. For example, someone could read the questions and record their answers to help a blind respondent.

120 Completed Telephone InterviewSee Definition of Completed Survey (above)Assign this code if the interview was completed by telephone and for mixed-mode cases if the sample member responded by telephone.

Note that respondents may receive assistance in completing the telephone survey and such respondents should be included in Code 120. For example, someone could translate the computer-assisted telephone interview (CATI) interviewer’s questions into sign language and state a deaf respondent’s replies to the CATI interviewer.

210 Ineligible: DeceasedAssign this code if the sample member is reported as deceased during the course of the survey period.

(continued)




Code Description220 Ineligible: Does Not Meet Eligible Population Criteria11

Assign this code if it is determined during the data collection period that the sample member does not meet all of the required eligibility criteria for being included in the survey sample. Exclude the sample member if:

• The sample member is under age 18 (note: sampling procedures direct vendors to remove such patients from the sample frame based on their birthdate).

• The sample member does not have a domestic U.S. address (note: sampling procedures direct vendors to remove these patients from the sample frame based on their address).

• The sample member resides in a nursing home or in a prison/jail (note: sampling procedures direct vendors to remove these patients from the sampling frame if this residence information is known).

• The sample member reports that he or she did not receive an outpatient surgery/procedure from the named HOPD or ASC.

• The sample member reports that he or she did not receive surgery/procedure on the sample date.

• It is reported that the sample member was discharged to hospice care following his or her surgery during the sample month.

A full listing of eligibility criteria is provided in Chapter IV of this manual.230 Ineligible: Language Barrier

Assign this code to sample members who do not speak one of the languages which are approved for the OAS CAHPS survey.

240 Ineligible: Mentally or Physically IncapacitatedAssign this code if it is determined that the sample member is unable to complete the survey because he or she is mentally or physically incapable.

310 Break-OffThis code should be assigned if the sample member completes some responses but does not meet the definition of a completed survey (see above).

320 RefusalThis code should be assigned if the sample member indicates either in writing or verbally (for telephone administration) that he or she does not wish to participate in the survey.

330 Bad Address/Undeliverable Mail, or No AddressThis code should be assigned only when using the mail-only mode. It should be assigned if it is determined that the sample member’s address is bad (e.g., the questionnaire is returned by the Post Office as undeliverable with no forwarding address).

340 Wrong, Disconnected, or No Telephone NumberThis code will be used in telephone-only or mixed-mode survey administration. In the telephone-only mode, this code should be assigned if it is determined the telephone number is bad (disconnected, no telephone number available, etc.). In the mixed mode, this code should be assigned because the telephone follow-up represents the last attempt to reach the sample member even if it is determined the mailing address is also bad.

(continued)

11 See Chapter IV for eligibility rules for OAS CAHPS.




Code Description

350 No Response After Maximum AttemptsThis code can be used in all three approved data collection modes. It should be assigned when the contact information for the sample member is assumed to be viable, but the sample member does not respond to the survey/cannot be reached during the data collection period.

This code should also be assigned to completed surveys received after the data collection period ends. As explained earlier, the data collection period ends 42 calendar days after the initial mailout (for mail-only and mixed mode) or 42 calendar days after the initiation of the telephone survey (for telephone-only mode) for telephone surveys.

Mail-Only Mode• This code should be assigned if the sample member’s address is viable but he or

she does not respond to either the first or second questionnaire mailing during the data collection period. This code should be assigned if the initial questionnaire is returned blank and the second questionnaire is never returned.

Telephone-Only Mode• This code should be assigned if it is determined that the telephone number is

viable but the minimum number of telephone attempts (five) did not result in a completed interview or other final disposition code.

Mixed Mode• This code should be assigned if it is determined that the address and telephone

number are viable but the maximum number of contact attempts (i.e., the questionnaire mailing and five telephone attempts) did not result in a completed survey or another final disposition code.

Differentiating Between Disposition Codes 330 (Nonresponse: Bad Address), 340 (Bad/No Telephone Number), and 350 (No Response after Maximum Attempts)Code 330: Nonresponse: Bad Address should be assigned only if there is evidence that the patient’s address is not viable. Evidence that the address is not viable includes the following:

• the HOPD or ASC does not provide an address for the sample member and the vendor has attempted but failed to obtain an address;

• the questionnaire is returned as “undeliverable, no forwarding address”; and

• the questionnaire is returned as “address or addressee unknown” or some other reason the mail was not delivered.

The vendor is strongly encouraged to use an outside address update service prior to mailing questionnaires to ensure that the most accurate mailing address is used. Survey vendors are permitted to ask HOPDs and ASCs to provide updated address information for all patients



treated within the sample month, if needed. The survey vendors cannot, however, give a list of sample members to the HOPD or ASC to request this information. Similarly, if a questionnaire is returned as undeliverable, the vendor is strongly encouraged to attempt to locate a new address prior to the second questionnaire mailing.

Code 340: Nonresponse: Bad or No Telephone Number should be assigned only if there is evidence that the sample member’s telephone number is not viable. This applies to both telephone-only and mixed-mode administration. Evidence that the telephone number is not viable includes the following:

• the HOPD or ASC does not provide a telephone number for the sample member and the vendor has attempted and failed to obtain a telephone number;

• on calling, the telephone interviewer learns that the telephone number on file is disconnected, nonworking, or out of order, and no new telephone number is provided; and

• on calling, the telephone interviewer reaches a person and learns that the telephone number is the wrong number for the sample member and no new number is provided.

To ensure that the most accurate telephone number is used, the vendor is strongly encouraged to use an outside telephone number update service prior to initiating telephone contact. Similarly, if the vendor learns that a telephone number is not viable, the vendor is strongly encouraged to attempt to locate a new telephone number for the sample member prior to the end of the data collection period. Survey vendors are permitted to ask HOPDs and ASCs to provide updated telephone number information for all patients treated within the sample month, if needed. The survey vendors cannot, however, give a list of sample members to the HOPD or ASC to request this information.

Code 350: Nonresponse: No Response After Maximum Attempts should be assigned if there is evidence that the sample member’s address or telephone number is viable but the sample member has not responded after all questionnaire mailings or telephone attempts appropriate for the given mode have been implemented.

Handling Blank QuestionnairesIn handling questionnaires that are returned blank, vendors should differentiate between mail survey questionnaires that are returned blank because the United States Postal Service could not deliver the mail (referred to as undeliverables) and those returned blank by the sample member or the sample member’s family or friend. The procedures described below are for surveys that are returned blank and are not marked as undeliverable.

For the mail-only mode it is appropriate to send a second questionnaire to the sample member if the first questionnaire is returned blank, as long as it is mailed before the end of the data



collection period. If the second questionnaire is also returned blank, the vendor should assign a final survey disposition code “320 – refusal.” If the first survey for the mail-only mode is never returned and the second survey is returned blank, then that case should also be assigned a final disposition code of “320 – refusal.” Finally, if the first survey for the mail-only mode is never returned or returned blank and the second questionnaire is not returned at all, the vendor should assign the final survey disposition code “350 – no response after maximum attempts.”

Note that all cases that are not finalized as a result of the mail survey component of the mixed-mode survey must be assigned for telephone follow-up, including both cases that are returned blank and undeliverable mail. This means that unless the case was a refusal or the sample member was determined to be ineligible for the survey during the mail survey data collection phase of the survey, survey vendors should follow up with the sample member by telephone. This includes cases for which the questionnaire was returned blank and those for which the questionnaire was undeliverable.

Quality Control MeasuresVendors are strongly encouraged to implement quality control measures for every aspect of mail and telephone data processing activities. Required and recommended quality control measures are described in detail in the mail, telephone, and mixed-mode data collection chapters of this manual; however, we have repeated key measures here as well. Quality control measures are listed by topic in the paragraphs that follow. Vendors should conduct additional quality control measures as warranted, based on their individual processes. All quality control checks should be conducted by a different person than the one who completed the task.

Quality Control for Mail Survey Data Processing Activities• Vendors should review at least 10 percent of the printed questionnaires for each batch of

questionnaires that are printed each sample month to ensure the quality of the printed questionnaires. The questionnaires should be examined to make sure there are no bleed-throughs, which can impact or cause problems when scanning the data from completed surveys, and to make sure all pages are included in the questionnaire.

• Vendors should check to make sure the number of mail survey packages to be mailed matches the number of sampled cases.

• Vendors should check a sample of at least 10 percent of mail survey packages before they are sealed and mailed. In this check, make sure that the SID number on the questionnaire matches the SID number on the cover letter.

• For vendors that use scanning software for data capture procedures, select a sample of questionnaires (minimum of 10 percent), rescan, and compare the scanned images against the original hardcopy survey as a quality control measure. For vendors that use data keying as



their data capture process, all questionnaires should be 100 percent rekeyed by a different keyer to ensure all entries are accurate. If any discrepancies are observed, a supervisor should resolve the discrepancy and ensure the correct value is keyed.

• For coding, vendors should select and review a sample of cases coded by each coder to make sure coding rules were followed correctly.

• We highly recommend before submitting data to the OAS CAHPS Data Center that vendors compare the responses coded on the hardcopy questionnaire for a sample of at least 10 percent of cases with the responses that were actually scanned or keyed and with the responses entered on the XML file. This quality control step will ensure that the responses included in the XML files accurately reflect the sample members’ responses to the survey questions.

• We highly recommend vendors calculate and review the response rates periodically for each of their client ASCs or HOPDs. If a sample was selected for an HOPD or ASC but there is no response or a very low response rate, this could be an indicator that incoming mail was not processed, scanned data were not exported to the XML file, or other problems occurred with the mail survey. In instances where the number of cases sampled was very small (e.g., 10 or fewer), it is possible that all of the sample members decided not to return a completed survey. For HOPDs and ASCs with larger sample sizes, no response from any of the sample members could be indicative of a data collection or data processing problem.

• Vendors are urged to develop a way to measure error rates of both their data receipt staff (in terms of recognizing marginal notes and passing these on to someone for review) and in terms of data entry or scanning verification. Vendors should then work with their staff to minimize error rates. The OAS CAHPS Survey Coordination Team will request information about data receipt and processing error rates during site visits to survey vendors.

Quality Control for Telephone Survey Data Processing Activities• Vendors must silently monitor a minimum of 10 percent of all telephone interviews to ensure

that correct administration and coding procedures are being followed. Supervisory staff monitoring telephone interviewers should use the electronic system to observe the interviewer conducting the interview while listening to the audio of the call at the same time.

• We highly recommend that vendors calculate and review the response rates on a periodic basis for each of their client HOPDs and ASCs. If a sample was selected for an HOPD or ASC but there is no response or a very low response rate, this could be an indication of a data collection or data processing problem. In cases where the number of cases sampled was very small (e.g., 10 or fewer), it is possible all of the sample members decided not to participate in



the survey. For HOPDs and ASCs with larger sample sizes, it is highly unlikely that 100 percent of the sample cases will refuse to participate in the survey.

• Vendors should conduct periodic reviews of their XML data files by comparing at least 50 completed telephone interview responses directly from their CATI system to the values output in the XML file. Doing this review monthly will ensure that the responses are being accurately captured and output to the XML file.

• Vendors should generate and review frequencies of cases at the various interim and final disposition codes for each ASC and HOPD and perhaps by telephone interviewer. For instance, a high percentage of cases coded as “not available” after maximum attempts could indicate that call attempts are not scheduled appropriately.

Quality Control on XML Files• Vendors should use the XML validation tool to conduct an initial quality control of their

XML file formatting. The XML Schema Validation Tool is available on the OAS CAHPS website under the “Data Submission” tab.

• We highly recommend that vendors conduct some additional quality control measures on the data included on XML files to ensure that the data from completed mail and telephone surveys are being captured accurately. This includes running frequencies of distributions on both the patient administrative data and the patient response data to look for outliers or anomalies, including missing values.

Examples of frequencies vendors could run include the race variable (are all respondents coded as Alaska Native, for example) or the age variable (is there a reasonable distribution of age categories across sample members, or do the ages lean heavily toward the very young or very old?). By reviewing frequencies of both the patient administrative data and the patient response data, vendors may be able to identify problems in the data they receive from HOPDs and ASCs, their own facility data file processing, or their XML coding operations.

• Vendors should periodically check their data processing programs to confirm that variables on the XML files are coded properly on the XML file.

• Vendors should conduct a final check of the disposition code assigned to all sampled cases before submitting XML files to the OAS CAHPS Data Center. If the vendor identifies a case assigned either an ineligible or noncomplete final disposition code AND there are data included in the Patient Response Record section of the XML file, they should


The Patient Response Record section of the XML file is the patient response record, which contains the responses to the OAS CAHPS Survey from every patient who answered the survey during the sample month.


check their records to determine why code 110 or 120 was not assigned to the case. If it is determined that the case is indeed ineligible or was a noncomplete, remove the survey response data from the XML file.

• Vendors should select a random sample of cases on the XML file and compare the variables in the Patient Administrative Record against the patient information that was provided by the HOPD or ASC on the monthly patient information file to make sure the information was exported to the XML file correctly.

Computing the Response RateSurvey vendors are not required to compute a response rate for each monthly sample. However, CMS will compute and report a response rate for each ASC and HOPD when survey results are publicly reported. For a given public reporting period (i.e., the last four quarters of collected data), a response rate for each ASC and HOPD will be calculated as described in Exhibit 9.2. The information below is provided for illustrative purposes only.

Exhibit 9.2How Response Rates Are Calculated

Response Rate =

Total number of Completed Surveys is the number of surveys assigned a final survey disposition code of 110 or 120.

Total Number of Surveys Fielded is the total number of patients selected for the survey in the sample month. This includes all cases with a final survey disposition code of 110 through 350.

Total Number of Ineligible Surveys is the number of sample cases assigned a final survey disposition code of 210, 220, 230, or 240. No other cases will be removed from the denominator.


The Patient Administrative Record section of the XML file contains data about each patient who was sampled for the sample month, including both those who responded to the survey and nonrespondents.

X. THE OAS CAHPS SURVEY WEB PORTAL

OverviewThis chapter presents an overview of the Outpatient and Ambulatory Surgery CAHPS Survey (OAS CAHPS) website and the web portal within the website. The website is the official site for the OAS CAHPS Survey with public and private sections. The private section, called the “web portal”, is an interactive site which supports the functionality needed by survey vendors, HOPDs and ASCs participating in the OAS CAHPS Survey. For example, it contains procedural documents, survey materials, online submissions and authorizations, and reports for vendors, hospital outpatient departments (HOPDs), ambulatory surgery centers (ASCs).

The OAS CAHPS Web PortalThe OAS CAHPS Data Center is maintained by RTI International, which is assisting the Centers for Medicare & Medicaid Services (CMS) with OAS CAHPS. RTI also developed and maintains the OAS CAHPS web portal, available at https://oascahps.org/. This web portal is the main vehicle for communicating and updating information about OAS CAHPS to ASCs, HOPDs, and survey vendors. The web portal has both public and secure (restricted-access) sections to ensure the security and privacy of selected interactions. On the public page, a link to a login allows authorized users (survey vendor, HOPD or ASC staff) access to the restricted private sections of the web portal, where they can carry out administrative functions according to their role. Access to the secure sections will be restricted and controlled through user identification and password.

Specifically, survey vendors will use the web portal to submit OAS CAHPS data to the Data Center. It will also allow Medicare-certified HOPDs and ASCs to authorize their contracted survey vendor to submit OAS CAHPS data on their behalf, access their data submission reports, and review their OAS CAHPS survey results before the results are publicly reported. Exhibit 10.1 provides an overview of both the public and private links and information available on the web portal. In the diagram private links are shown in red text and public links are shown in black text.


October 2015 X. The OAS CAHPS Survey Web Portal

Exhibit 10.1OAS CAHPS Web Portal

OAS CAHPS Web Portal Diagram

· About OAS CAHPS Survey· National Implementation· Mode Experiment· Registration and Application Process· Announcements· Contact Us

General Information

· Schedule· Agenda· Registration· Training Slides

Training

· Vendor Registration· Minimum Business Requirements· Vendor Application *· Exceptions Request Form *· Discrepancy Notification Form *· Model QA Plan· Submit QA Plan *· Survey Vendor Authorization Report *· Manage Users *

For Vendors

oascahps.org

· OAS CAHPS Procedures Manual· Questionnaire· Sample Letters and Phone Scripts· FAQs and OMB Disclosure Notice

Survey Materials

· Data Submission Deadlines· Data Submission Resources · Data Submission Tool *· Data Submission Reports *

Data Submission

· Facility User Registration· Registered CCNs Report *· Manage Users *· Vendor Authorization *· View Data Submission History *

For Facilities

· Vendor Approval Process *· Training Summary *· Vendor Authorization Status *· User Access Summary *· Data Submission Summary *

Vendor Dashboard

Login

· Required Action Items *· Registration Status *· Authorization Status *· User Access Summary *· Recent Announcements *· Data Submission Summary *

Facilities Dashboard

- Publicly Available Pages and Links - Private Pages and Links requiring Login Authentication *

Legend

Public Links on the OAS CAHPS Web PortalThe public side of the OAS CAHPS web portal is located at https://oascahps.org/. This address defaults to the public Home page, which is shown in Exhibit 10.2. Note that this is a secured web portal; therefore, users should be sure to include the “s” in the “http” when accessing the site.



X. The OAS CAHPS Survey Web Portal October 2015

Exhibit 10.2OAS CAHPS Home Page (Public Web portal)

On the Home page, there is a welcome message that includes brief information about OAS CAHPS. In that message, there are hyperlinks embedded in the underlined text that lead to other pages that provide more specific information.

The OAS CAHPS web portal uses navigation features that include standard dropdown menus and other navigation tools. A horizontal menu bar is displayed near the top of the Home page. The bar has different tabs, each with its own dropdown options to allow users to perform various functions and access more information. The navigation tabs include the following:

• General Information;

• Training;

• For Vendors;

• Survey Materials;

• Data Submission; and

• For Facilities.

The public pages on the OAS CAHPS web portal contain numerous links and information including the following:

• Background information about OAS CAHPS, including information about the mode experiment, national implementation and public reporting;



• Requirements and a description of the application process for survey vendors interested in becoming a CMS-approved OAS CAHPS Survey vendor;

• Contact information for the OAS CAHPS Survey Coordination Team (e-mail address and toll-free telephone number);

• Survey questionnaires and related survey administration materials in English, Spanish, and Chinese (forthcoming);

• Survey administration protocols, guidelines for data submission, and information about the data submission tool (including this manual);

• Model Quality Assurance Plan, which is a sample QAP outline that approved survey vendors should use as a guide when completing their own initial QAP or annual QAP update;

• Vendor Registration Form, to be completed by the survey vendor’s designated Survey Administrator; the Survey Administrator must complete this form so that he or she can access and submit a Vendor Application to become a CMS-approved OAS CAHPS Survey vendor;

• HOPD/ASC User Registration Form, to be completed by the HOPD’s or ASC’s designated Survey Administrator to create an account and credentials for accessing links in the secure section of the web portal;

• Continuous updates in the Announcements section (shown in Exhibit 10.3) which is under General Information. An These updates will provide vendors, HOPDs, and ASCs with any new policies or changes in survey administration protocols and procedures, announcements about updates to the procedures manual, a data submission schedule, and reminders of upcoming data submission deadlines;

• A recent announcements section also appears on the home page box (shown in Exhibit 10.4);

• Forthcoming, a list of survey vendors that have been approved to administer OAS CAHPS;

• Helpful documents that are targeted for HOPDs and ASCs, including information about OAS CAHPS participation guidelines and instructions on steps that facilities should take to participate in OAS CAHP); and

• Training information and materials for each Introduction to the OAS CAHPS Training Session and all vendor update training sessions, including training registration form.



Exhibit 10.3Announcements Page on the OAS CAHPS Web Portal

Exhibit 10.4Recent Announcements on the OAS CAHPS Web Portal home page



How to Obtain Access to the Private side of the OAS CAHPS Web Portal

All Users (Survey Vendors, HOPDs, and ASCs)Designate an OAS CAHPS Survey Administrator. Before any participating HOPD, ASC, or survey vendor can access the restricted portion of the web portal, the organization first must decide which staff member it will designate to serve as its OAS CAHPS Survey Administrator. The designated OAS CAHPS Survey Administrator’s roles and responsibilities are listed below.

• Register as the Survey Administrator for the HOPD, ASC or survey vendor;

• Designate another individual within the organization to serve as the backup OAS CAHPS Survey Administrator;

• Remove access or approve the removal of access for users who are no longer authorized to access the private side of the web portal;

• Serve as the main point of contact with the OAS CAHPS Survey Coordination Team and Data Center; and

• Notify the OAS CAHPS Survey Coordination Team if your role as the OAS CAHPS Survey Administrator will no longer be valid and identify a successor.

HOPD and ASC UsersStep 1: The individual designated as the HOPD’s/ASC’s OAS CAHPS Survey Administrator will complete and submit the Facility Website User Registration Form. This online form is located on the public side of the web portal. It is used to establish an account and obtain credentials for accessing the secured sections of the web portal. To do this, click on the “Facility Registration” link under the “For Facilities” navigation tab on the OAS CAHPS web portal (as shown in Exhibit 10.5).

The form will collect the OAS CAHPS Survey Administrator’s name, e-mail address, and telephone number. The Survey Administrator will also be instructed to create a username and password that will be used to access the secured links and forms on the private side of the web portal. Once all information is correct, click the “Submit” button.

The OAS CAHPS Data Center staff will activate an account for the HOPD’s or ASC’s OAS CAHPS Survey Administrator immediately after the online registration form has been submitted. Once the registration form is submitted, users will be routed to a dashboard created specifically for their HOPD(s) or ASC(s), where they can find the other forms required to complete the registration process. Additional links to important functions and forms, including the CCN Registration Form and the Authorize a Vendor Form, are also available on the dashboard.



Exhibit 10.5Facility User Registration Form

Step 2: The OAS CAHPS Survey Administrator will complete and submit the CCN Registration Form. This online form is located on the private side of the web portal. Therefore, the OAS CAHPS Survey Administrator will enter the established username and password to log in. See Exhibit 10.6. The OAS CAHPS Survey Administrator will type the CCN or CCNs for which they are an administrator into the box. Multiple CCNs can be separated by commas and entered into the box. After the CCN(s) are entered click the “Lookup Facility Names” button and the system will automatically display the facility or facilities name(s) in the display window.

The person filling out this form will be presented the list of roles and responsibilities of the OAS CAHPS Survey Administrator. The OAS CAHPS Survey Administrator needs to personally acknowledge that that he/she is the OAS CAHPS Survey Administrator for the listed HOPD or ASC, and acknowledge that he/she accepts the roles and responsibilities for the listed HOPD or ASC. Once all information is entered correctly click “Submit.”

Step 3: The OAS CAHPS Survey Administrator will designate a backup OAS CAHPS Survey Administrator and create an account for him or her. The backup OAS CAHPS Survey Administrator will have all of the same permissions as the primary OAS CAHPS Survey Administrator. Having a backup Survey Administrator will ensure continued system use if the primary Survey Administrator is unavailable or terminates employment with the HOPD or ASC. The Survey Administrator or the backup Survey Administrator must notify the Data Center immediately if the primary Survey Administrator will no longer serve in that role.



Exhibit 10.6CCN Registration Form

The form to designate a backup survey administrator is also available under the Facility Dashboard, under the menu item “Manage User Console.” This is shown in Exhibit 10.7. The Survey Administrator can add a new user, delete a user, or edit a user. User Details collects contact information for the user and allows them to linked with, or unlinked from, any of the CCNs associated with the primary Survey Administrator.



Exhibit 10.7Manage User Console

Step 4: The OAS CAHPS Survey Administrator or backup completes the Vendor Authorization Form. After an HOPD or ASC has entered into a contract with a survey vendor, the facility must authorize a survey vendor to submit data on its behalf before the survey vendor can successfully submit OAS CAHPS data for that facility. Facilities should note that survey vendors must submit their clients’ survey data to the OAS CAHPS Data Center by the following deadlines: the 2 nd Wednesday in July, October, January and April. For further details, see Table 14.2 in Chapter XIV, Public Reporting.

To authorize a vendor, facility’s OAS CAHPS Survey Administrator must log in to the secure web portal and proceed to the ‘Vendor Authorization” sub menu under the “For facilities” tab. The sub menu provides three options for users:

• Start an Authorization (for new authorizations or to change an existing authorization);

• Change the start date for the current vendor;

• Vendor Authorization Report.

A brief description and the steps in each of these actions on the Vendor Authorization Form are provided below. Note that an automatic e-mail will be sent to the HOPD and/or ASC OAS CAHPS Survey Administrator confirming that the vendor has been authorized soon after the authorization has been submitted.



1. Start an Authorization. This is used both by an HOPD or ASC that is just beginning to participate in OAS CAHPS, as well as by an HOPD or ASC which is switching to another vendor. The OAS CAHPS Survey Administrator will:

◦ Select an approved vendor from the dropdown list (note that the list of approved vendors will be available beginning in December 2015 and updated on a flow basis);

◦ Select the “Start Date,” which is the first day of the first calendar year quarter (either January 1, April 1, July 1, or October 1) for which the vendor is being authorized to submit OAS CAHPS data. For example, if a vendor is authorized to submit data beginning January, February or March, the Survey Administrator should choose a Start Date of January;

◦ Select the CCN or CCNs to which the authorization applies; and

◦ Click the “Submit” button.

To change or switch to a different survey vendor, the HOPD or ASC will follow the same process in above. The system will automatically assign and end date for the existing authorization, based on the start date of the new authorization. This will ensure that there are no gaps in authorization time periods.

The system will allow an HOPD/ASC to change a start date for multiple CCNs. This would be useful for someone who is serving as the OAS CAHPS Survey Administrator for example for several ASCs which are under different CCNs but are linked organizationally. To select multiple CCNs, the OAS CAHPS Survey Administrator should check the box next to the name of each CCN for which this vendor is authorized to submit data. The administrator should click to Submit button to save the entries selected.

HOPDs and ASCs should note the following details regarding switching vendors:

◦ HOPDs/ASCs may switch vendors only at the beginning of a quarter. This is because data for every month in a quarterly submission must come from a single vendor. Consider the three months below.

Sample month Survey takes placeData submitted to the

OAS CAHPS Data Center

January February through April JulyFebruary March through May JulyMarch April through June July



These sample months all go into the same quarterly delivery to the OAS CAHPS DATA Center. One vendor cannot supply January data and a second vendor supply February and March data because that will mean that there must be two vendors for a single submission. That is why vendors may only be switched for the beginning month of a data delivery quarter

◦ Survey vendors may not submit data files after the data submission deadline passes for a quarter; therefore, it is critically important that HOPDs/ASCs make sure the End Data for their old vendor and Start date for the new vendor are correct, well in advance of the data submission deadlines.

◦ The Authorize a Vendor form is an authorization to submit data, not an authorization to conduct the survey. More than one vendor at a time may collect data (in the chart below, note the overlapping times for Vendors A and B to conduct the survey). However, only one vendor at a time can submit data. Vendor A who is collecting data through 6/2 needs to be authorized to submit that data in the July 13 submission―which falls within quarter 3 (quarter 3 dates are 7/1 through 9/30). Vendor B who is collecting data beginning 5/21 needs to be authorized to submit data in the October 10 submission ― which falls within quarter 4 (quarter 4 dates are 10/1 through 12/31).

Sample month

Begin conducting

survey

End conducting

survey

Quarterly data submission deadline to

OAS CAHPS Data Center

Authorization begin date

(starting day of first calendar

quarter)

Authorization end date

(ending day of final calendar

quarter)

Vendor A Feb–March 3/21/2016 6/2/2016 7/13/2016 1/1/2016 9/30/2016Vendor B April-and on 5/21/2016 No end date 10/10/2016 10/1/2016 No end date

2. Change the Start Date for the Current Vendor. This function will allow an HOPD/ASC to change the start date for an existing vendor, if for instance, they make a mistake when they originally set the start date.

The system will allow an HOPD/ASC to change a start date for multiple CCNs. This would be useful for someone who is serving as the OAS CAHPS Survey Administrator for example for several ASCs which are under different CCNs but are linked organizationally. To select multiple CCNs, the OAS CAHPS Survey Administrator should check the box next to the name of each CCN for which this vendor is authorized to submit data. The administrator should click to Submit button to save the entries selected.

3. View current authorization status. This function will allow HOPDs/ASCs to view the list of facilities for which a vendor has been authorized, and the current vendor’s name, and the



Start Date for each vendor. If the HOPD/ASC entered an End Date for the vendor currently authorized, the End Date will also show.

Survey Vendors UsersStep 1: The individual designated as the survey vendor’s OAS CAHPS Survey Administrator will complete an online Vendor Registration Form. This form is located on the public side of the web portal. To locate this form, click on the “Vendor Registration Form” link under the “Forms for Vendors” navigation tab on the OAS CAHPS web portal (as shown in Exhibit 10.8). When completing the Vendor Registration Form, the vendor’s OAS CAHPS Survey Administrator will establish an account and create credentials for accessing the secure sections of the web portal.

The form will collect the vendor’s OAS CAHPS Survey Administrator’s name, e-mail address, and telephone number. The Survey Administrator will also be instructed to create a username and password that will be used to access the secured links and forms on the private side of the web portal, including the Vendor Application. Once all information is entered and correct, click the “Submit” button.

Once it is submitted, the Survey Administrator will be routed to a dashboard created specifically for that survey vendor.

Exhibit 10.8Vendor Registration Form Link



Step 2: Complete the Vendor Application Form. This form is located on the private side of the OAS CAHPS Survey web portal. It is divided into four pages. Vendors need to save each page in order to proceed to the next. The application will time out after 60 minutes of inactivity. The OAS CAHPS Survey Administrator can save and return to it as many times as needed to edit responses input into the page. When the application is complete and accurate, click “Submit” to submit the application. The vendor application form appears in Appendix A.

After the application has been completed, a new window will appear with a copy of the OAS CAHPS Survey Vendor Consent Form, customized for the registering survey vendor.

The OAS CAHPS Survey Vendor Consent Form is a document on which the person designated as the OAS CAHPS Survey Administrator will acknowledge that he or she accepts the roles and responsibilities of the Survey Administrator for the listed survey vendor. The Survey Administrator will print a hardcopy version of the Consent Form. Then, review, sign and date this form in the presence of a Notary Public, and obtain the notary’s signature and seal on the form. Mail the notarized OAS CAHPS Survey Vendor Consent Form to the OAS CAHPS Data Center at the address provided at the top of the form.

Step 3: Periodically check their Vendor Authorization Status. As explained above in Step 4 for HOPDs and ASCs, the HOPD’s/ASC’s OAS CAHPS Survey Administrator is required to authorize a survey vendor to submit OAS CAHPS data on their behalf. Survey vendors should check periodically to ensure that each client HOPD and/or ASC with which they have contracted has accurately completed the online Authorize a Vendor Form and that the Start Date the facility entered is the first day of the first quarter in which the vendor is authorized to submit data on the facility’s behalf. ASCs, HOPDs, and survey vendors should note that CMS will not allow OAS CAHPS vendors to submit data files after the data submission deadline passes for a quarter; therefore, it is critically important that facilities authorize the vendor and make sure that the Start Date is correct well in advance of a data submission deadline.

The Vendor Authorization Status report is available under the vendor’s customized dashboard.

User Dashboards and Secure (Access-Restricted) LinksThe private OAS CAHPS web portal menu options differ slightly from those on the public web portal. In Exhibit 10.1, the items with an asterisk are accessible only on the private pages of the web portal and with proper login credentials and authorization. Access to the secure sections will be restricted and controlled through a user identification and password, created by the survey vendor, HOPD or ASC Survey Administrator during the registration process. Once logged into the secure side of the web portal, OAS CAHPS Survey Administrators will be routed to a dashboard created specifically for their organization.



Each of the “Dashboard” views (Facility Dashboard and Vendor Dashboard) provides the user with links to key items on the web portal, depending on the user.

• Vendors are provided with the status of key elements of the Vendor Approval Process—including the status of and links to their vendor application, consent form, and overall approval status; a User console, showing administrative users within the organization; and links to both data submission reports and reports showing the HOPDs and ASCs that have authorized them.

• HOPDs and ASCs are provided with links to all of the documents required for the registration and vendor authorization process, including links to the vendor authorization form; a User console, showing administrative users within the organization; recent announcements; and links to their data submission and latest preview reports.

Facility DashboardEach time the ASC’s or HOPD’s OAS CAHPS Survey Administrator logs into the web portal, he or she will be taken to the Facility Dashboard (see Exhibit 10.9). The dashboard will guide the Survey Administrator through the rest of the registration process, including printing out and completing the OAS CAHPS Survey Administrator Consent Form. Survey Administrators should note that they can register additional HOPDs or ASCs at any time using the dashboard.

The Facility Dashboard also includes:

• An Authorize a Vendor link that allows the HOPD’s or ASC’s OAS CAHPS Survey Administrator to select a CMS-approved survey vendor to submit data on behalf of the facility.

• A Manage Users Console link, where the Survey Administrator can add or delete authorized users for certain functions on the web portal.

• Reports, including data submission and latest preview reports.

• Recent announcements posted on the web portal.

HOPDs and ASCs are responsible for checking the web portal announcements displayed both on their dashboard and the OAS CAHPS web portal homepage regularly for updates.



Exhibit 10.9Facility Dashboard

Vendor DashboardEach time the survey vendor’s OAS CAHPS Survey Administrator logs into the web portal with the login credentials created during the registration process, he or she will be taken to the Vendor Dashboard (see Exhibit 10.10). From the dashboard, survey vendors can complete and submit the Vendor Application and Vendor Survey Administrator Consent Form during periods in which the Coordination Team is accepting vendor applications. The Vendor Application must be completed to be considered for approval as a CMS-approved survey vendor.

Exhibit 10.10Vendor Dashboard



The Vendor Dashboard also includes the following tools or links:

• Manage Users Console, where the Survey Administrator can add or delete authorized users on the web portal;

• Data Submission Tool, where the Survey Administrator can upload and submit survey data on behalf of his or her client HOPDs and/or ASCs; and

• Reports, including Vendor Authorization Status reports and data submission reports.

System and Security Requirements for the OAS CAHPS Web PortalApproved survey vendors will submit or upload OAS CAHPS Survey data to the OAS CAHPS Data Center through a link on the OAS CAHPS web portal. The security level for users’ browser Internet zone must be set to the equivalent of medium or lower, at least during the time that they are working in the project web portal.

Data SecurityOAS CAHPS survey vendors are required to submit only de-identified data files to the OAS CAHPS web portal. This means that no personally identifiable patient information can be included in the data files that are submitted to the OAS CAHPS Data Center. Vendors are required to assign a unique sample identification (SID) number to each sampled patient included in the survey. The data submitted must include an SID for each patient included in the sample, regardless of whether the sample member completed the survey. More information about assigning a unique SID to each sampled patient is included in Chapter IV.

Even though only de-identified data will be submitted to the OAS CAHPS Data Center, every measure will be taken to protect and secure OAS CAHPS data. Ensuring data security was a concern and consideration during the design and development of the OAS CAHPS web portal. The web portal balances a straightforward and flexible design with the need to protect the privacy and security of OAS CAHPS data. Data are encrypted whenever vendors upload their data files. The OAS CAHPS Survey Coordination Team has implemented a number of policies and procedures to ensure that all communications and transfers are secure. Among these measures are the following:

• requiring that each individual provided access to the private links on the web portal must have a secure login;

• requiring users to create and use a strong password;

• using Secure Sockets Layer (SSL) technology to encrypt files for transmission; and

• carefully monitoring uploads, upload attempts, and web portal use in general.



When users log into the private links on the web portal, the system will automatically check and authenticate their credentials before allowing access. This ensures that only authorized users log into the system.

In addition to allowing only credentialed users access to the private links on the web portal, all electronic data are stored behind a firewall in a password-protected network. All data traffic between the vendor’s network and the Internet pass through this single connection point. This process provides the same level of protection and monitoring to all systems connected to the vendor’s network. The web portal firewall is programmed to allow or prevent access to the network by using a set of rules to determine whether attempted network access is in compliance with the OAS CAHPS Data Center’s network security policy. In addition, the firewall logs all incoming traffic to help detect and analyze any problems or suspicious activity.

Survey Vendor’s Web Portal Security ResponsibilitiesAll OAS CAHPS survey vendors must go through an application and certification process to participate in the survey. In addition, vendors must agree to strict requirements to continue their participation. By following the security procedures identified for the project, survey vendors will protect their client HOPDs’ and ASCs’ data and those of other vendors participating in OAS CAHPS.

All OAS CAHPS survey vendors must also abide by all requirements set forth in the Health Insurance Portability and Accountability Act of 1996 (HIPAA), legislation intended to protect private health information and to improve the efficiency of the health care system. The type of patient information that is protected under HIPAA is called “Protected Health Information” or PHI. PHI is defined as personally identifiable information (PII) that relates to a person’s past, present, or future health or medical treatment. If the health information is completely de-identified, it is no longer considered PHI and can be released. HIPAA applies to all electronic and hardcopy records whether they are being stored or transmitted.

OAS CAHPS survey vendors must safeguard all data collected from patients as required by HIPAA. However, survey vendors will not submit any confidential information to the OAS CAHPS Data Center as all of data file submissions will contain only de-identified data. Even with de-identified data files, vendors must still use security measures to keep the data as safe as possible. This means that when issued credentials to access the private links on the project web portal, survey vendors also must follow all safeguards to prevent an unauthorized person from entering the private side of the web portal. Therefore, the OAS CAHPS Data Center has password protected the private side of the web portal and requires that approved survey vendors, HOPDs and ASCs use the following guidelines when creating and maintaining their password:

• When an OAS CAHPS survey vendor, HOPD’s or ASC’s account is approved, the user will be able to log into the system and change the password on first login.



• Each account will be locked out after five successive incorrect password entries. If the account is locked, the user will need to contact the OAS CAHPS Survey Coordination Team to have the account unlocked.

If a user’s password is compromised or lost, contact the OAS CAHPS Survey Coordination Team immediately to ask that the account be deactivated. The Coordination Team will then issue new credentials to the user.

Web Portal Password Generation and ProtectionAs indicated, data security is of utmost concern to the OAS CAHPS Survey Coordination Team. When survey vendors, HOPDs, and ASCs generate a password to access the private links on the project web portal, they must develop a strong password. A strong password is defined as one that contains at least nine (9) characters. These nine characters must include the following:

• one upper-case alphabet letter,

• one numeral, and

• one special character (&,%,#,!).

An example of a strong password is Mgh0721$&; it meets the required criteria shown above.

These password rules and guidelines are designed to minimize the chance that automated password-cracking routines used by unauthorized personnel can gain access to the web portal. In addition to the above rules, the following guidelines will help create a strong password:

• Combine two or more related words with punctuation, such as Radio-Cook.

• Use a password that looks like nonsense but allows an easy way to remember it, such as “Thaawtsom.” for “The hills are alive with the sound of music.” (Note the end punctuation.)

• Think in terms of vanity license plates, such as “I8myfood.”

The following should be avoided when creating a password; therefore, do not use:

• a single English word;

• a scientific name, biological term, geographic name;

• a person’s name or part of name, even with slight modifications like an added character at the end or beginning;

• known combinations (e.g., NLRB 1234, attorney1, judge111);



• words found in a dictionary, including names, obscene words, or well-known phrases;

• a password with a repeating series of characters;

• reverse spellings of dictionary words;

• a name associated with the user in any way (middle name, family names, pet’s name, sports team name, films, etc.);

• portions of a User ID on the current or other systems; or

• simple keyboard patterns (e.g., “asdfjkl.”).

In addition, a user should never write down his or her password. If the user needs to store passwords, there are free applications that can be downloaded and used. An application like this can be very helpful because another password safety rule is to never use the same password across applications or computers. Finally, do not share or give the password to anyone. OAS CAHPS survey vendors, HOPDs, and ASCs are responsible for all access to the private links on the project web portal that are made under their credentials.

What To Do If a User Forgets the PasswordIf a user forgets his or her password, simply click on the Forgot Password link on the Login screen on the OAS CAHPS web portal. Survey vendors, HOPDs, and ASCs can request a password by providing the username. OAS CAHPS Data Center project staff will send the user’s password to him or her via e-mail at the e-mail address provided on the registration form. When the e-mail containing the password is received, promptly delete it, then log in and change the password immediately.


XI. FILE PREPARATION AND DATA SUBMISSION

OverviewSurvey vendors will construct and submit a data file containing three sections; 1) a header record, 2) a patient administrative record for every sampled case, 3) a response record for every completed survey in each monthly Outpatient and Ambulatory Surgery CAHPS (OAS CAHPS) Survey sample. Vendors will submit data files for each of their client hospital outpatient surgery departments (HOPDs) and ambulatory surgery centers (ASCs). Data for all three monthly samples in a calendar quarter must be submitted by a specific data submission deadline for each quarter. Data will be submitted to the OAS CAHPS Data Center through the OAS CAHPS web portal.

Data File PreparationOAS CAHPS vendors will submit XML data files for each HOPD or ASC that has authorized the vendor to submit data on the facility’s behalf. All OAS CAHPS data files must contain a record for each patient who was sampled at the HOPD or ASC for each month of the quarterly submission period. Survey vendors will submit data at least once each quarter by uploading individual .xml files or a zipped file of multiple XML files. During the data file upload process, the survey vendor’s data are encrypted (scrambled so that they are unreadable) until they are received by the Coordination Team and checked for errors. This means that an OAS CAHPS vendor’s data will remain secure from the beginning of the upload process onward.

The data file submission steps that OAS CAHPS vendors will follow to submit OAS CAHPS data files are shown below.

3. Format and prepare survey data following the XML file specifications.

4. Submit data file(s) via the OAS CAHPS web portal.

5. Review and follow -up on Data Upload Reports.

Each of these steps is described in the following sections.

Step 1: Format and Clean Survey Data Following the XML File SpecificationsEach XML file should contain only 1 month of survey data for all HOPD or ASC locations under a specific CMS Certification Number CCN. The OAS CAHPS XML file structure is included in Appendix K. The specifications in that document contain details about the data to be submitted

XI. File Preparation and Data Submission October 2015

such as data type, field sizes, and order. The format of each OAS CAHPS data file must match the specification provided in that Appendix. Survey vendors can also download the XML data file template from the OAS CAHPS web portal. The XML templates were developed based on data elements needed for analysis and on the OAS CAHPS questionnaire.

The XML file format will allow data for all patients sampled during a given sample month to be submitted in one file. Survey vendors should note that if a data file for a sample month is submitted more than once, the most recent data submission will overwrite the file previously submitted for that sample month, even if those files “passed” all checks. Therefore, the final file submission must contain data for all patients who were sampled in that sample month for all HOPD or ASC locations under a specific CCN. OAS CAHPS vendors should note that a data file must pass both validation checks before the file is accepted. One check is completed immediately upon upload and the second validation check is completed within 10 minutes of upload. We highly recommend that vendors submit data submission files as early as possible to allow time for any errors detected during the validation checks to be corrected and to resubmit the file.

The data file specifications for OAS CAHPS XML files are described below and included in Appendix K. If disproportionate stratified random sampling (DSRS) is used, approved survey vendors must use the XML for DSRS. The DSRS data file specifications are provided in Appendix L.

XML Data File SpecificationsOAS CAHPS survey vendors must submit data using the XML format only. Survey vendors that need assistance with the XML format should contact the OAS CAHPS Survey Coordination Team for technical assistance at 1-866-590-7468 or by sending an e-mail to [email protected].

Each XML file will consist of three sections: a Header Record, a Patient Administrative Data Record, and the Patient Response Record. Each of these sections is described below. There should be only one header record for each OAS CAHPS XML file. Each patient within the XML file should have an administrative data record. A survey response record must be included for every sampled patient who completed the survey questionnaire (via mail or telephone).

HOPDs, ASCs, and their survey vendor should keep in mind that an OAS CAHPS data file must be submitted for each sample month.



October 2015 XI. File Preparation and Data Submission

Header RecordThe Header Record contains the following data elements:

• Header Type

• Provider Name. This is the HOPD’s or ASC’s Provider Name

• Provider Number This is the HOPD’s or ASC’s CCN.

• Sample Year. This is the calendar year in which the survey is conducted.

• Sample Month. Survey vendors will select a sample of patients who meet survey eligibility criteria for each calendar month. The Sample Month is the month for which the sample was selected.

• Mode of Survey Administration. The survey mode, either mail only, phone only, or mixed mode, must be the same for all sample members in each sample month in the calendar quarter for all of the HOPD or ASC locations under the same CCN. HOPDs, ASCs, and their survey vendors cannot change survey administration modes until a new quarter begins. Also note that the survey mode indicated in the Header Record must be one of the modes that the survey vendor is approved to use. If the mode is not one of the modes for which the vendor is approved, the Data Center will not accept the data file when the vendor attempts to submit it.

• Type of Sampling. This is the sampling method that was used to select the sample—these include census, simple random sampling (SSS), stratified systematic sampling, proportionate stratified random sampling (PSRS), and disproportionate stratified random sampling (DSRS). See Chapter IV for information about each of these methods.

• Number of Patients Served. This is the total number of patients who had at least one outpatient surgery or procedure during the sample month at the ASC or HOPD. This number should reflect all patients who received outpatient care in the sample month regardless of eligibility of that surgery, or of that patient, for OAS CAHPS. CCNs which contain multiple HOPD or ASC locations should note that this value should reflect the total number of patients served across all eligible HOPD/ASC locations. If the eligible ASC(s) or HOPD(s) served no patients during the sample month, enter zero for this variable on the data file for this sample month.

• Number of Patients on the File Submitted by the HOPD(s) or ASC(s). As was explained in Chapter IV, the facility should withhold various categories of patients from the monthly patient information file that it supplies to vendor. These types of patients are: patients who are deceased, are not 18 years old or older, were discharged after their procedure to hospice,



currently reside in a nursing home, are prisoners, or who requested that the facility not release their name to anyone outside that facility. This vendor should count the number of patients which the facility supplies and indicate that number on the data file for this sample month. As stated regarding Number of Patients Served, this value should reflect patients across all eligible HOPD or ASC locations in the CCN; if no patients were served during the sample month zero should be entered.

• Number of Eligible Patients. This is the number of patients in the file submitted by the HOPD or ASC which meet survey eligibility criteria in the sample month. As explained in Chapter IV, patients whose CPT codes are not within the eligible range are ineligible. It is acceptable for either the facility or the vendor to remove these ineligible patients. As stated regarding Number of Patients Served, and Number of Patients on the File Submitted by the HOPD(s) or ASC(s), this value should reflect patients across all eligible HOPD or ASC locations in the CCN. This value can be zero only if none of the patients on the file provided by the HOPD or ASC for the sample month was eligible for the survey.

• Number of Patients Sampled. This is the number of patients selected for the survey during the sample month. This value can be zero only if all of the patients included on the file that the HOPD or ASC provided for the sample month were ineligible for the survey. If a value of zero is entered for this variable, the value for the Number of Eligible Patients variable must also be zero.

If DSRS is used, the survey vendor must use the specific DSRS header. The DSRS has these extra data elements in the Header Record:

• DSRS Stratum Name (note that there must be at least two strata identified for DSRS sampling).

• DSRS Number of Patients on file submitted to vendor, which is the number of patients included on the file that all of the HOPD or ASC locations that share a CCN provided for this stratum.

• DSRS Number of Patients eligible in stratum, which is the number of patients who meet survey eligibility criteria within each stratum.

• DSRS Number of Patients sampled in stratum, which is the number of patients sampled within the stratum.

Please remember that approved OAS CAHPS vendors must complete and submit an Exceptions Request Form to the Coordination Team prior to sampling if their HOPD or ASC chooses to use DSRS (see Chapter XV for more information about the Exceptions Request Form). If a vendor submits a data file with a DSRS Header record and does not have prior approval for using DSRS,



the data file will be rejected. More information about DSRS and requirements for DSRS sample selection and file construction is provided in Chapter IV.

Patient Administrative Data RecordThe second section of the XML file contains data about each patient who was sampled for the sample month, including both those who responded to the survey and nonrespondents. In this section of the file, some of the information provided in the Header Record is repeated, including the HOPD’s or ASC’s CCN and the Sample Year and Sample Month. All other information included in this section of the file is about the patients included in the sample. There must be a Patient Administrative Record for every patient sampled in the sample month. The sample identification (SID) number assigned to each sample member must be included. Only de-identified data will be submitted to the OAS CAHPS Data Center; however, the unique SID number that the survey vendor assigned to the sample member must be included on the file. Files submitted with missing and/or duplicate SID numbers will be rejected.

Most of the information required in the Patient Administrative Data Record is provided by the HOPD or ASC on the monthly patient information file that is submitted to the vendor. This information includes the patient’s age (the survey vendor will calculate the sample member’s age based on the date of birth provided by the HOPD or ASC), the patient’s gender, and surgical/procedural code information. The survey vendor will classify each patient’s surgery as either gastrointestinal, orthopedic, opthamologic, or other according to the CPT or G code.

The information in the last part of this section is survey administration data compiled by the survey vendor. This information includes the Final Survey Status (also known as disposition code) assigned to each case and survey language.

Patient Response RecordThe third section of the XML file is the patient response record, which contains the responses to the OAS CAHPS survey from every patient who answered the survey during the sample month. Note that only the OAS CAHPS survey questions should be submitted. Do not submit responses to non-OAS CAHPS questions (i.e., supplemental questions) that were added by the HOPD or ASC. The only records that should be included are those with a final Survey Status code for a completed survey (Codes 110 and 120) and those with Code 310 (Break-Off). For all patient response records that are included on the file, all response fields must have a legitimate value, which can include “Missing,” or “Not Applicable.”

The decision whether to key the responses to the two open-ended survey items―“Other language” (response option 2) in Q35 and “Helped in some other way” (response option 5) in Q37―is up to each individual HOPD or ASC. Vendors should not include responses to open-ended survey items on the data files submitted to the OAS CAHPS Data Center. CMS, however, encourages survey vendors to review the open-ended entries so that they can provide feedback to



the Coordination Team about adding additional preprinted response options to these survey items, if needed.

Step 2: Data File SubmissionOAS CAHPS vendors should follow the steps outlined below for submitting data via the OAS CAHPS web portal:

1. Login to the OAS CAHPS web portal; when logged in, the system will display the vendor’s dashboard.

2. Click the “Submit Data” link under “Data Submission” The data submission tool page will display (as shown in Exhibit 11.1)

3. Click the “Select” button to select the file to upload. The Select button permits users to locate and directly upload a file that has been saved in their own computer system. Survey vendors can select either a single XML file or a single ZIP file that contains multiple XML files.

4. After selecting the file to be uploaded, click “Upload XML” to submit the file. The Data Submission Summary Report based on the file selected will appear. A link to this report will also be e-mailed to the vendor’s OAS CAHPS Survey Administrator.

5. To upload more than one file at a time, click the “Add” button on the same screen. Additional file selection rows will be added. Repeat Step 3 above for each file to be uploaded.

6. To remove rows that have been added, click the “Remove” button to the right of the row to be deleted.

Exhibit 11.1Link to Data Submission Tool



Exhibit 11.2 shows how the screen looks when submitting multiple files for uploading to the private side of the web portal.

As the upload begins, the XML file will undergo validation checks. The first check will determine whether the CCN(s) in the header record and the patient administrative file are aligned for the client ASC’s or HOPD’s authorized survey vendor and the facility’s CCN. The next validation checks will determine the quality and completeness of the data.

If the file fails any of the validation checks, the survey vendor will receive an error message within seconds after a file error is detected noting that the file upload failed, giving details on why the file failed to upload. For example, the message may indicate that there is no authorization from the HOPD or ASC for the survey vendor to submit data on its behalf or that the number of patient records listed in the Header Record does not match the number of sample members for which data are provided in the Patient Administrative Record section of the file.

If a file does not pass the upload validations, none of the data on the file are accepted and stored in the Data Center. Survey vendors must review data submission reports (discussed in Chapter XII) and correct any data errors on the XML file and resubmit the file. CMS will not accept data files that are submitted after the quarterly data submission deadline. We strongly encourage survey vendors to submit their data files well in advance of the data submission deadline for a survey period. Survey vendors can resubmit a data file for an HOPD or ASC client as many times as needed prior to the data submission deadline. However, survey vendors must keep in mind that each time a data file for an HOPD or ASC is submitted, it overwrites any data for that same facility that were previously submitted for that survey period.

Exhibit 11.2Uploading Multiple Files



Step 3: Review and Follow -Up on Data Upload ReportsThere are three reports that are available to survey vendors via the OAS CAHPS web portal. These reports serve to inform survey vendors about the outcome of each of the vendor’s data file upload attempts, and they also provide the vendor with a history of upload efforts, successful or unsuccessful. The three reports are listed below:

• Data Submission Summary Report;

• Data Submission History Report; and

• Data Submission History by Upload Date.

Each of these reports is described in detail in Chapter XII.

Quarterly Data Submission DeadlinesSurvey vendors have the option of submitting a data file to the OAS CAHPS Data Center as data collection and processing activities for each monthly sample are completed or on a quarterly basis. However, the data file for all months in a specific quarter for each client HOPD or ASC must be submitted before the submission deadline for that quarter.

Data Center staff will check all data files immediately after they are submitted to ensure that they pass the initial verification checks. Any files in which problems are detected or that do not comply with file specification requirements will not be accepted by the Data Center. Survey vendors are also reminded again that all data files undergo validation checks immediately upon upload and the second validation check is completed within 10 minutes of upload. OAS CAHPS data files must pass both validation checks before they are accepted. Survey vendors are strongly encouraged to submit data files well in advance of a data submission deadline in case there are problems that must be corrected before the data file is accepted. Survey vendors are also strongly encouraged to check the Data Submission Summary reports that are posted on the web portal (these reports are discussed in the next chapter) to ensure that the files are accepted.

Potential Situations When Vendors Will Not Submit DataIf there is a Survey Vendor Authorization in effect (explained in Chapter X, Step 4) the OAS CAHPS Data Center will expect the survey vendor to submit data for the contract HOPD or ASC for every quarter. If the survey vendor fails to submit, the HOPD/ASC is considered noncompliant for that quarter, with respect to CMS National Implementation.

However, there are situations when a survey vendor will not be able to submit data. The paragraphs below describe those situations and instruct survey vendors how to proceed so as not to be noncompliant



Survey Not Yet in EffectSurvey vendor authorizations (described in Chapter X) are put into effect on a quarterly basis, and remain in effect until they reach the end date (if any) of the authorization period. Should an HOPD/ASC authorize a vendor for Quarter 1 beginning in January, yet begin collecting data mid-quarter (for example, March) the elapsed months between quarter start and survey start (in this example, January and February) will not have survey data. Survey vendors must submit a Exceptions Request Form (ERF) to the OAS CAHPS Survey Coordination Team to explain this situation. Once this ERF is on record and approved, the survey vendor and their client ASC/HOPD will not be considered non-compliant.

Closed CCN or Closed Location Within a CCNIf an HOPD or ASC closes or is no longer active while its OAS CAHPS vendor is still contracted to conduct and provide survey data on its behalf, the vendor authorization that that HOPD or ASC submitted will remain in effect for the entire authorization period. It remains in effect until either the facility’s OAS CAHPS Survey Administrator modifies the end date of the authorization, or, alternatively until the OAS CAHPS Survey Coordination team marks the CCN as inactive/closed. Survey vendors should contact the OAS CAHPS Survey Coordination team to inform them if a client facility closes or becomes inactive. The Survey Coordination team will mark this CCN as inactive. Inactive HOPDs or ASCs are viewable on the Vendor Authorization Report and are designated with an asterisk (*) symbol.

If the CCN remains active but one of the HOPD or ASC locations or entities within it closes, the remaining active HOPD(s)’ or ASC(s)’ location(s) should continue participating in OAS CAHPS.

Data Submission Quality ControlThe following issues and guidelines are provided to assist vendors in making sure that XML files are prepared properly and that quality control measures are conducted on each file before the vendor attempts to submit the file to the OAS CAHPS Data Center. Implementing adequate quality control on XML files, and submitting each file well in advance of the data submission deadline, will help ensure that each HOPD’s or ASC’s monthly data files are accepted and that high-quality data are submitted. Quality control checks should be conducted by a different staff person than the one who completed the task.

Verify that the vendor is authorized to submit data. Vendors should check the Survey Vendor Authorization Report regularly to make sure that each of their clients has authorized the vendor to submit data on their behalf and that the Start Date the HOPD or ASC entered represents the first month of the quarter for which the vendor collected data on the HOPD’s or ASC’s behalf.



Help ensure proper file format by using the validation tools on the OAS CAHPS website. The following can be downloaded from the OAS CAHPS website:

• Templates for the XML files

• XML schemas

• Schema validation tool

• Data submission tips

Vendors should apply the validation schema posted on the OAS CAHPS web portal on each data file. This validation tool contains some of the same validation checks that are applied when the data file is submitted to the Data Center. Using the validation schema to identify file problems and correcting any problems detected will reduce the number of attempts to submit the data file.

Perform additional quality control checks. In addition to using the validation schema, survey vendors are encouraged to make additional quality control checks on the data files before they attempt to submit the files to the Data Center. Some suggested quality checks are listed below.

a. Check the sample month entered on the XML file to verify that the sample month is correct. The OAS CAHPS Data Center will not accept a data file for a sample month in a previous data submission quarter, but it will accept files for months in the current and upcoming data submission quarters. Similarly, make sure that the sample month on the file correctly indicates the month in which the sample patients received their outpatient surgery or procedure.

b. Select a sample of patients for whom data are entered on the XML file and compare the data on the XML file for those patients with the data for that patient on the original (raw) data source. For example, compare the variables entered in the Patient Administrative Data Record section of the XML with the information that the HOPD or ASC provided for the sample patient on the monthly patient information file. Similarly, compare the entries in the Patient Survey Response Record section of the XML with the hardcopy questionnaire or scanned image of the patient’s completed survey or, if the survey was completed by phone, with the original CATI or telephone survey data file. Implementing this quality control check on a sample of the data records will ensure that data are correctly exported from the data source onto the XML file.

c. After the XML file is prepared, generate data distributions (frequencies of responses/variables) on selected variables and inspect the output for data anomalies. A visual inspection of data frequencies is a quick way to identify data problems. For example, if the race variable for all patients entered on the XML file is American Indian, this could be an indication that the race variable is incorrect. Similarly, response option 2



is coded for the overall rating of care variable for all patients on the file, this is likely an indication that there is a problem with the file.

d. Check that a valid response code has been entered for all variables in the XML file. Note if data are missing for a variable, either the missing code (“M”) or the code for not applicable (“8”) must be entered for the variable.

e. Confirm that there have not been any assigned duplicate SID numbers assigned in the XML files across months in the data submission period or across prior data submission periods. An SID number can only be assigned to one patient and cannot be reused within quarters, across quarters, or across years.

f. Verify that all final disposition codes are correct. Vendors must make sure that no data are submitted for non-interview cases that are coded as deceased, ineligible, refusals, etc. The reverse check – confirming that there is response data present for all patients whose final disposition code is complete – should also be performed.

g. Vendors should change the disposition code for a completed survey that does not pass the OAS CAHPS completeness criteria to 310 (breakoff). Also, make sure that code 340 is being appropriately assigned to cases only when the vendor could not obtain a “working” telephone number for the sample patient.

h. Conduct quality checks of mail survey coders’ work by having a different person recheck a sample of each coder’s cases to make sure that they are following and applying correct coding guidelines.

i. Check the file to make sure that all patient data the HOPD or ASC provided for a patient on the monthly patient information file exported correctly to the XML file.

j. Check the XML file name to make sure that it conforms to OAS CAHPS file naming conventions.

k. Confirm that an XML file has been accepted for each sample month for each HOPD or ASC.

Survey vendors should check the XML data files for internal logic and consistency prior to submitting them to the OAS CAHPS Data Center. Some examples of items to check are provided below:

a. The number of eligible patients included in the variable on the header record should always be equal to or smaller than the number of patients the facility served during the sample month. It should never be more than the number of patients served.

b. The number of patients eligible must be equal to or larger than the number of patients sampled.



c. The number of patients sampled must be equal to or less than the number of patients served.

d. The total number of patients for which the vendor has included administrative information in the patient administrative section of the XML file must equal the number of patients sampled.

Survey vendors are reminded that if none of the patients for whom information is provided on the monthly patient information file is eligible for OAS CAHPS, the vendor must still prepare and submit an XML file for that sample month (see Appendix M). The vendor must indicate on the file that there were zero eligible cases in the number eligible variable, and enter all other information required in the Header Record Section of the XML file. Note that OAS CAHPS vendors are not required to submit a Discrepancy Notification Report for situations where there are zero eligible cases; however, they are required to submit a Discrepancy Notification Report if the HOPD or ASC did not submit a file at all (see Potential Situations When Vendors Will Not Submit Data, above.)


XII. WEB PORTAL REPORTS

OverviewThe Outpatient and Ambulatory Surgery CAHPS (OAS CAHPS) Survey Data Center will generate and provide via the OAS CAHPS web portal a number of reports to indicate the status of data submissions and the quality of the data submitted. These reports are described in the following sections.

Reports for Survey VendorsSurvey vendors will be able to access a number of reports via the secured section of the web portal. The most important of these is tied to the data submission and file review process—the Data Submission Summary Report. Another important report is the Survey Vendor Authorization Report, which allows the survey vendor to view all ambulatory surgery centers (ASCs) and hospital outpatient departments (HOPDs) that have authorized the vendor to collect and submit data on their behalf. Each of these reports is discussed separately below.

The Data Submission Summary ReportThis report is generated at two points in time. First, it is immediately available to survey vendors after they upload data via the Data Submission Tool. Once the vendor submits data, the system will check for the correct file layout, missing data, duplicate patient ID numbers, invalid responses, etc. After successful file upload, the Data Center conducts a more thorough edit of the data, which is done within an hour of the file submission. This second validation check is also referred to as the “secondary validation.” The Data Submission Summary Report is updated after the secondary validation checks have been made.

The first check (during upload) of the submitted data file is to make sure that the XML template has been used and is properly formatted. If the survey vendor has an incorrectly formatted template, the data upload process will stop immediately and display an error message to the vendor that describes the problem detected. After the system verifies that a properly formatted template has been used, it will begin a series of data checks. It will look for any fields in the Header Record with missing data. If any data are missing, the file will be rejected, and the data submission report will let the vendor know what data fields are missing. The system will also check for any duplicate sample identification (SID) numbers to make sure a vendor has not used an SID more than once for a given HOPD or ASC in a given quarter. If a vendor has used a duplicate SID, the file will be rejected and the data submission report will let the vendor know where the error is so it can be corrected. Finally, the report will check that the vendor is authorized to upload data for the particular ASC or HOPD.

XII. Web Portal Reports October 2015

If the data file successfully passes the initial checks, the system will display a message saying that the upload was successful. This screen will also provide the vendor with a count of records received for each facility. The message will also indicate that the file will be sent through a more formal data processing step within an hour, and that the data submission report will be updated to show the results of this data processing step.

Files that have successfully passed the upload validation process are then subjected to a secondary validation process. The system will check for missing data fields required for patient eligibility determination. Each patient response record included on the file will be checked to ensure that all entries are within the acceptable range. In addition, a completeness algorithm will be run to verify that all patient response records included on the file meet survey completeness criteria (although this step will be used to ensure that the appropriate cases are included as “complete” and will not be a reason for rejecting a file).

The results of the secondary validation are appended to the Data Submission Summary Report for each file that was uploaded. This report will provide sufficient detail, by CMS Certification Number (CCN), of data file errors that caused data files to be rejected so that the vendor can fix those errors and resubmit the file(s). Following the edit checks, the system will generate and send an e-mail to the vendor indicating that the data processing step has been completed, and the vendor can view the results on the Data Submission Summary Report. The e-mail will be generated immediately after the secondary validation process has been completed. Survey vendors can access this report at any time from the website by going to the “Data Submission” menu and selecting the “Data Submission Reports” link. Survey vendors can select to view a history of all reports, or history by upload date.

Files that successfully pass both stages of validation will be accepted and processed for public reporting. If any problems are detected in the data file, this information will be displayed on the Data Submission Summary Report, and the vendor will be expected to correct the errors and resubmit the file.

As explained in Chapter XI, each XML file contains a single CCN for a single month. However, vendors can upload a zip file containing XML files for several CCNs and several months. Files will be accepted or rejected based on CCN. The vendor will only need to resubmit the XML file with incorrect records.

Because of the two-part nature of the Data Center’s data processing steps, vendors are strongly advised to submit files far enough in advance of the quarterly submission deadline to allow for both the initial upload file check and the secondary validation checks, if they have to resubmit a file. The OAS CAHPS Data Center will not accept files after 8:00 PM EST on the data submission deadline date for each quarter.


October 2015 XII. Web Portal Reports

Below is an example Data Submission Summary Report.

The Data Submission History Summary ReportsOAS CAHPS Survey vendors can view a history of their data submission activities via two reports under the Data Submission Report menu option: Data Submission History and Data Submission History by Upload Date. The Data Submission History report allows vendors to see a summary or detailed list of all data submission activity. The Data Submission History by Upload Date allows vendors to search for a data submission report by the actual upload date. Below is an example of what a vendor would see upon selecting a particular file upload date.

Survey Vendor Authorization ReportThe Survey Vendor Authorization Report allows survey vendors to view a list of ASCs and HOPDs that have authorized the vendor to collect and submit data on their behalf. A survey vendor under contract with an HOPD or ASC that has not yet been formally authorized by the facility to submit data on the facility’s behalf should contact the facility and ask it to do so. Any files a vendor submits for an HOPD or ASC that has not formally authorized the vendor to submit data on its behalf will be rejected during data submission. It is the vendor’s responsibility to ensure that any HOPD or ASC with which it is contracted to conduct the OAS



CAHPS Survey completes the authorization process. The OAS CAHPS Data Center will reject data files if the form is out of date. Below is an example Survey Vendor Authorization Report.

If a facility closes or is no longer active while its survey vendor is still contracted to conduct and provide survey data on its behalf, any vendor authorizations will remain in effect for the entire authorization period. The authorized vendor must submit the data that were collected for the closed HOPD or ASC to the OAS CAHPS Data Center.

Reports for Ambulatory Surgery Centers and Hospital Outpatient DepartmentsHOPDs and ASCs will be able to access two reports via the secured section of the OAS CAHPS Survey website. The first report, the Data Submission Summary Report, is intended to provide a means for the facility to monitor its vendor’s data submission activities and should be reviewed on a monthly or quarterly basis, depending on the agreement that the facility has worked out with the vendor in terms of frequency of data submission. The second report available to HOPDs and ASCs is the OAS CAHPS Survey Results for Public Reporting―this report is a preview of the OAS CAHPS Survey results that are compiled for each facility on a quarterly basis prior to being publicly reported. These reports are discussed below.

Data Submission Summary ReportThe Data Submission Summary Report is available to HOPDs and ASCs from the “For facilities” menu on the OAS CAHPS Survey website. HOPDs and ASCs that have contracted with a survey vendor will be able to log into the website and view, print, and download a report that includes information on the number of submissions and the submission status of their contracted vendor’s monthly or quarterly file submissions. HOPDs and ASCs are strongly advised to review these reports on a regular basis.

The Data Submission Summary Report displays all of the dates on which the Data Center accepted the data files the vendor submitted for the HOPD or ASC. Only files that passed both the initial edit checks implemented during file upload and those that passed the secondary set of edit checks will be listed on this report. The purpose of this report is to allow an HOPD or ASC to monitor whether its vendor is successfully submitting data files by the required quarterly data submission deadlines. An HOPD or ASC can use this report for reference when it follows up with its vendor if expected data submissions do not appear. The Data Submission Summary Report also includes a hyperlink embedded in the date of each submission that takes the user to


October 2015 XII. Web Portal Reports

the data validation checks that were performed on the uploaded files for that date. This report will give users the ability to view a list of successful data file transmissions.

To protect the confidentiality of each HOPD or ASC and the vendor it has selected, only the facility and its authorized vendor will be able to view the submission history relating to that facility’s data.

OAS CAHPS Survey Results for Public ReportingThe OAS CAHPS Survey Preview Reports provide HOPDs and ASCs with a preview of their own survey results that will be publicly reported on the CMS website. The preview report is made available approximately 2 weeks before the OAS CAHPS Survey results are publicly reported. HOPDs and ASCs are able to access their Preview Report(s) via the secure side of the OAS CAHPS portal. To access the reports, HOPDs and ASCs must login to the OAS CAHPS web portal and then select the “Preview Reports” link under the “For facilities” menu. HOPDs and ASCs participating in the OAS CAHPS Survey will have access to their own reports. The Preview Report will not be available to the OAS CAHPS Survey vendor or to anyone other than the HOPD or ASC.


XIII. OVERSIGHT ACTIVITIES

OverviewThis chapter describes oversight activities that will be conducted by the Outpatient and Ambulatory Surgery CAHPS (OAS CAHPS) Survey Coordination Team to ensure that the survey is being administered according to required OAS CAHPS Survey protocols. Requirements for vendor Quality Assurance Plans (QAPs), data review activities to be conducted by the Coordination Team, communication between the Coordination Team and the vendors, and site visit procedures are described in the following sections.

Quality Assurance PlanAll vendors seeking approval to conduct the OAS CAHPS Survey must submit a QAP, a document that describes how the vendor will implement, comply with, and provide oversight of all sampling, survey, and data processing activities associated with the OAS CAHPS Survey.

The first QAP must be submitted within 6 weeks of the data submission deadline date after the vendor’s first quarterly data submission. It must be updated and submitted annually thereafter and at any time that changes occur in staff or vendor capabilities or systems.

A QAP Outline is included in Appendix N to assist vendors in the development of their own QAP. The vendor’s QAP should include the following sections:

• Organization Background and Staff Experience

• Identifying and Recruiting hospital outpatient departments (HOPDs) and ambulatory surgery centers (ASCs)

• Work Plan

• Sampling Plan

• Survey Implementation Plan

• Data Security, Confidentiality, Privacy Plan

• Discrepancy Report and Corrective Action Plan

• Questionnaire Attachments

XIII. Oversight Activities October 2015

Within each section, the vendor must specify all key staff responsible for implementing or overseeing the activity or activities, procedures, and methods being used, and quality assurance activities that will be implemented. Changes to key staff must be reported to the OAS CAHPS Survey Coordination Team. There should be sufficient detail provided for all of these components so that the Centers for Medicare & Medicaid Services (CMS) can evaluate whether the vendor is complying with all approved protocols. If CMS and the Coordination Team do not feel that the vendor’s QAP has sufficient detail to make this determination, the Coordination Team will request that the vendor make additions or edits to its QAP and resubmit it. Vendors will also be required to submit either a copy of the mail questionnaire (for mail and mixed-mode surveys) or the screen shots from their electronic telephone interview (for telephone surveys) as part of their QAP. Note that the submission of a completed QAP is one of the components of the vendor approval process.

When preparing the QAP, vendors should review and refer to the QAP Outline provided on the OAS CAHPS website to ensure that they provide all information requested, including detailed information about systems, protocols, and processes, so that the OAS CAHPS Survey Coordination Team can assess how the survey is being implemented. The Coordination Team will request that the vendor provide more information if the information provided is not adequate. Vendors should also organize the information in their QAPs to conform to the sections included in the QAP Outline, and make sure that the QAP is paginated for ease of reference and review by CMS and the Coordination Team.

Data ReviewThe OAS CAHPS Survey Coordination Team will conduct ongoing reviews of the data submitted by each survey vendor. As discussed in Chapter XI of this manual, data files are reviewed immediately upon submission for proper formatting, completeness, accuracy of record count, and out-of-range and missing values. In addition, the Coordination Team will run a series of edits on the data to check for such issues as outlier response rate patterns or unusual data elements.

The Coordination Team will attempt to resolve data issues with the vendor through the use of conference calls or e-mail exchanges. If the Coordination Team believes that there are any significant issues with a vendor’s data, or if repeated discussions and contact with a vendor fail to result in cleaner data submissions, a more thorough review of the vendor’s data processing and survey implementation activities may be initiated. At that time, the Coordination Team may request copies of documentation associated with whatever the data issue is—for example, if out-of-range values are found repeatedly, the Coordination Team may request copies of documents showing the training program used to train Data Entry keying staff, training records, and documentation that recommended quality assurance practices associated with keying data were followed. Vendors are expected to comply with all such requests for documentation.


October 2015 XIII. Oversight Activities

Communication Between Survey Vendors and the Coordination TeamThe OAS CAHPS Survey Coordination Team welcomes communication from vendors related to any part of the OAS CAHPS Survey implementation process. Vendors may communicate with the Coordination Team via telephone or e-mail. The Coordination Team is also available to participate in teleconference calls as needed to ensure vendors’ successful implementation of the OAS CAHPS Survey. As noted in a preceding section of this manual, the vendor must provide the facility name and CMS Certification Number (CCN) in all communications with the OAS CAHPS Survey Coordination Team and OAS CAHPS Survey Data Center.

The Coordination Team expects that in addition to communication with vendors about technical assistance issues, it will also schedule conference calls with selected vendors to review vendor procedures and ensure adherence to the OAS CAHPS Survey protocols and guidelines. The Coordination Team will make periodic calls to vendors to assess the status of sampling, data collection, and file processing issues in general. These calls will be scheduled in advance so that appropriate members of the vendor’s project team can participate.

Requirement for ClientsSurvey vendors receive approval to conduct the OAS CAHPS Survey after their designated OAS CAHPS Survey Project Director/Survey Administrator 1) successfully completes an online training certification after participating in both sessions of the Introduction Training, and 2) attends and successful completes all mandatory Update Trainings.

This status of “approved to conduct OAS CAHPS Survey” will be withdrawn if the survey vendor does not have any clients on OAS CAHPS for two years from the Introductory Training. If they wish to re-instate this approval status, they will need to obtain clients or repeat the Introductory Training.

Site Visits to Survey VendorsThe OAS CAHPS Survey Coordination Team will conduct site visits to all approved vendors. The purpose of the site visits is to allow the Coordination Team to observe the entire OAS CAHPS Survey implementation process, from the sampling stage through file preparation and submission.

The Coordination Team expects at a minimum to accomplish the following on each site visit:

• To review the process the survey vendor followed to determine the eligibility of their clients, and specifically how the vendor

◦ identified the hospital/CCN, worked with the hospital management to determine the eligible HOPDs within the CCN or within other CCNs, and gained the participation of the eligible HOPDs within CCNs; and



◦ identified the ASC, worked with the ASC management to understand the CCN number or numbers of their facilities, including different sites, and gained the participation of the eligible locations within each CCN.

• A “walk through” of the systems and processes used from the point of obtaining a sample frame from an HOPD or ASC to preparation of a final data file, including but not limited to a review of:

◦ software/programs used to select and store the sample; how patient contact information (name and address) and sample identification (SID) number are printed on letters accompanying questionnaire mailings or provided to a call center for telephone survey data collection; questionnaire production, mailout, and receipt facilities/processes; telephone survey operation facilities/processes, including listening to interviews;

◦ all data processing activities, including how final status codes are assigned; and

◦ file preparation and submission activities and file storage facilities.

• A review of documentation associated with any of the above steps, as applicable. The documentation to be reviewed includes but is not limited to:

◦ signed confidentiality forms for all applicable staff, including subcontractors;

◦ training records, such as for data entry or telephone interviewing staff;

◦ monitoring logs, with dates and times telephone interviewers were monitored, and the results of those monitoring sessions;

◦ telephone interview scripts, including introductory scripts and responses to frequently asked questions; and

◦ verification records, for either data entry or scanning processes, showing the level of quality control for keyed questionnaires.

• Interviews with the vendor’s key OAS CAHPS Survey project staff, including the project manager, sampling manager, and data manager.

The Coordination Team may make either scheduled or unscheduled visits to the vendor’s site. Scheduled visits will be planned far enough in advance to ensure that all appropriate vendor staff are able to participate in the site visit review process. For unscheduled visits, the Coordination Team will give the vendor a 3-day window during which the team may conduct the onsite review.


October 2015 XIII. Oversight Activities

Generally, the site visit team will consist of two to three individuals, although the size of the team may vary and may include representatives from CMS. All discussions, observations, and materials reviewed during the site visit will remain confidential. Thus, although the Coordination Team appreciates that certain systems or processes may be proprietary to a vendor, full cooperation with the site visit team is expected so that the team may adequately assess vendor compliance with all OAS CAHPS Survey protocols and guidelines.

After each site visit, the Coordination Team will prepare and submit to CMS a Site Visit Report, which will summarize the findings from each site visit, including any systems and data issues. The Site Visit Report will also describe corrective actions that the vendor will be required to take to correct any deficiencies or problems noted. The Coordination Team will provide the vendor with the Site Visit Report after it has been reviewed with CMS project staff. The Coordination Team may request clarification, additional documentation, or changes to any aspect of the implementation process, if needed. The vendor will then be given a specified period of time in which to provide the additional information or submit documentation showing that it has implemented the requested process or system change. The Coordination Team will follow up with the vendor by teleconference or with additional site visits as needed.

Corrective Action PlansIf a vendor fails to demonstrate adherence to the OAS CAHPS Survey protocols and guidelines, as evidenced by ongoing problems with its submitted data or as observed in its implementation process during a site visit, CMS may ask the Coordination Team to either increase oversight of the vendor’s activities (or submitted data files) or, if necessary, put the vendor on a corrective action plan.

If the vendor is put on a corrective action plan, the Coordination Team will work out a schedule with CMS by which the vendor must comply with the tasks set forth in the corrective action plan. These will include interim monitoring dates, where the Coordination Team and the vendor will meet via teleconference to discuss the status of the plan and what changes the vendor has made or is in the process of making. The nature of the requested changes that the vendor is asked to implement will dictate the kind of “deliverables” the vendor will be expected to provide and the dates by which the deliverable must be provided.

Survey vendors that fail to comply with the oversight activities described above or whose implementation of the OAS CAHPS Survey is found to be unsatisfactory after the opportunity is given to correct deficiencies may be subject to having their “approved” status rescinded. Further, any HOPD or ASC survey responses collected by the vendor may be withheld from public reporting. The affected facilities will be notified by the OAS CAHPS Survey Coordination Team of their vendor’s failure to comply with oversight activities or unsatisfactory implementation so that the facilities will have the opportunity to contract with another approved vendor.


XIV. PUBLIC REPORTING

OverviewThis chapter describes the public reporting activities associated with the Outpatient and Ambulatory Surgery CAHPS (OAS CAHPS) Survey. All publicly reported data are available on the CMS website. Results from the OAS CAHPS Survey are published quarterly and include each hospital outpatient department’s (HOPD’s) and ambulatory surgery center’s (ASC’s) most recent four quarters of data.

The chapter begins with a list of the measures that are reported and explains how the results are adjusted and reported. The chapter concludes with a discussion of Outpatient and Ambulatory Surgery Preview Reports and a table showing the quarters included in each public reporting period.

Measures That Are ReportedOAS CAHPS Survey results are reported for three composites and two global items:

Composite Measures• About Facilities and Staff (Q3, Q4, Q5, Q6, Q7, and Q8)

• Communications About Your Procedure (Q1, Q2, Q9, Q10/Q11, and Q12)

• Preparations for Discharge and Recovery (Q13, Q14, Q15/Q16, Q17/Q18, Q19/Q20, and Q21/Q22)

Global Items• Overall rating of facility (Q23)

• Patient willingness to recommend HOPD or ASC to family or friends (Q24)

Each of the three composite measures consists of five or more questions from the survey that are about related topics. The results from the questions that comprise a composite are reported as one score. Composite scores are created by first determining the proportion of answers to each response option for all questions in the composite. The final composite score averages the proportion of those responding to each answer choice in all questions in the composite. Only questions that are answered by survey respondents are included in the calculation of composite scores.

XIV. Public Reporting October 2015

Adjustment and Reporting of ResultsIn 2015, the OAS CAHPS Survey Coordination Team conducted a mode experiment to test the effects of using three data collection modes: mail only, telephone only, and mixed mode (mail with telephone follow-up of nonrespondents).

Because some patients’ assessment of the care they received from HOPDs and ASCs may be influenced by patient characteristics that are beyond the facilities’ control, CMS used the data from the mode experiment to determine whether and to what extent characteristics of patients participating in the OAS CAHPS Survey statistically affect survey results. Statistical models were developed to adjust or control for these patient characteristics. These statistical adjustments are applied before survey results are publicly reported. Also, some patients may not respond to the survey, and this may impact the accuracy and comparability of results. Therefore, the data from the mode experiment were analyzed to detect potential nonresponse bias. The results of these analyses determined applicable statistical adjustments that are made on each quarter of the OAS CAHPS Survey data.

OAS CAHPS Survey results are published on the CMS website. The URL of the OAS CAHPS public reporting will be announced in 2016. Results are reported for a rolling four quarters of data that are updated quarterly by replacing the oldest quarter of data with data from the most recent quarter. Table 14.1 shows a crosswalk of the composite measures and global ratings mapped to the text that is displayed on the CMS website.

Table 14.1Crosswalk of Composite Measures and Global Ratings

OAS CAHPS Composite Measurements/Global Ratings

OAS CAHPS Questions Included in Composite/

Global Rating Text Displayed on CMS WebsiteCare of Patients Q3, Q4, Q5, Q6, Q7, and Q8 Did the HOPD or ASC staff give care in a

professional way?Communications About Your Procedure

Q1, Q2, Q9, Q10/Q11, and Q12

Did the HOPD or ASC staff communicate with patients about what to expect during and after the procedure?

Preparations for Discharge and Recovery

Q13, Q14, Q15/Q16, Q17/Q18, Q19/Q20, and Q21/Q22

If after leaving the facility the patient reported having pain, nausea or vomiting, bleeding, or possible signs of infection as a result of the procedure or the anesthesia, had the HOPD or ASC staff given the patient information about what to do?

Overall rating of care Q23 How do patients rate the overall care from the HOPD or ASC?

Patient willingness to recommend HOPD or ASC to family or friends

Q24 Would patients recommend the HOPD or ASC to friends and family?


October 2015 XIV. Public Reporting

Facility Preview ReportsPrior to publishing the results on the CMS website, the OAS CAHPS Survey Coordination Team makes available a preview report posted on the OAS CAHPS website so that each HOPD and ASC can review the results that will be publicly reported. We anticipate that OAS CAHPS Survey data will be publicly reported for the first time in January 2018, based on survey results from data collected for the sample months July 2016 through June 2017 (see Table 14.2). Each subsequent quarterly public reporting period includes survey results from data collected for the prior 12 months, as the oldest quarter’s data are dropped and the newest quarter’s data are added.

Public Reporting PeriodsTable 14.2 shows the quarters included in each public reporting period.

Table 14.2Data Submission Deadlines linked to the (Anticipated) Public Reporting Period

Vendors Data Submission

Deadline to (1)

Includes Sample

Months in….Public Reporting

Period (#)Public Reporting Period

Covers

Date posted on CMS.gov

(2) (3)

July 13, 2016 Qtr. 1, 2016 October 2016 (1) Qtr. 1, 2016 Not posted

Oct. 11, 2016 Qtr. 2, 2016 January 2017 (2) Qtr. 1, 2016–Qtr. 2, 2016 Not posted

Jan. 11, 2017 Qtr. 3, 2016 April 2016 (3) Qtr. 1, 2016–Qtr. 3, 2016 Not posted

April 12, 2017 Qtr. 4, 2016 July 2017 (4) Qtr. 1, 2016–Qtr. 4, 2016 Not posted

July 12, 2017 Qtr. 1, 2017 October 2017 (5) Qtr. 2, 2016–Qtr. 1, 2017 Not posted

Oct. 11, 2017 Qtr. 2, 2017 January 2018 (6) Qtr. 3, 2016–Qtr. 2, 2017 Jan. 2018

Jan. 10, 2018 Qtr. 3, 2017 April 2018 (7) Qtr. 4, 2016–Qtr. 3, 2017 April 2018

April 11, 2018 Qtr. 4, 2017 July 2018 (8) Qtr. 1, 2017–Qtr. 4, 2017 July 2018

July 11, 2018 Qtr. 1, 2018 October 2018 (11) Qtr. 2, 2017–Qtr. 1, 2018 Oct. 2018

Oct. 10, 2018 Qtr. 2, 2018 January 2019 (12) Qtr. 3, 2017–Qtr. 2, 2018 Jan. 2019

Jan. 9, 2019 Qtr. 3, 2018 April 2019 (13) Qtr. 4, 2017–Qtr. 3, 2018 April 2019

April 10, 2019 Qtr. 4, 2018 July 2019 (14) Qtr. 1, 2018–Qtr. 4, 2018 July 2019

NOTES : (1) Data submissions will be second Wednesday of month. (2) Exact location within CMS.gov of public reporting of OAS CAHPS to be announced at a future date. (3) Data are publicly released for a facility when that facility has four consecutive quarters of data.


XIV. Public Reporting October 2015



XV. EXCEPTIONS REQUEST PROCESS AND DISCREPANCY NOTIFICATION REPORT

OverviewThis chapter describes the process to be used to request an exception to the Outpatient and Ambulatory Surgery CAHPS (OAS CAHPS) Survey Protocols, including guidelines for submitting an Exceptions Request Form. This chapter also covers the process for alerting the OAS CAHPS Survey Coordination Team of an unplanned discrepancy in the collected or submitted survey data. Vendors are expected to submit a Discrepancy Notification Report whenever there has been an inadvertent or temporary deviation from the standard OAS CAHPS Survey Protocols. The vendor is expected to notify the OAS CAHPS Survey Coordination Team within 24 hours after the discovery of the discrepancy.

Exceptions Request ProcessThe Exceptions Request Form (see Appendix O) is designed to allow the survey vendor to request a planned deviation from the standard OAS CAHPS Survey protocols. Vendors are asked to submit an Exceptions Request Form for any exceptions to the OAS CAHPS Survey protocol. The Coordination Team will make a determination after reviewing each request whether to approve the exception. The OAS CAHPS Survey Coordination Team has identified three allowable exceptions on the OAS CAHPS Survey at this time: the use of disproportionate stratified random sampling (see Chapter IV), more frequent than monthly sampling (see Chapter IV), and survey not yet in effect (Chapter XI). Vendors must complete and submit an Exceptions Request Form to obtain approval to implement these exceptions.

The Exceptions Request form is designed to allow the survey vendor to request the same exception for multiple hospital outpatient departments (HOPDs) or ambulatory surgery centers (ASCs) for which it is responsible for collecting data. The Exceptions Request Form can be accessed and submitted online (https://oascahps.org/).

Review ProcessThe Coordination Team will review the vendor’s exceptions request, evaluating the methodological strengths and weaknesses of the proposed approach. The Coordination Team will let the survey vendor know whether the exceptions request has been approved or denied. If denied, the vendor will have 5 business days to appeal the decision. To submit an appeal, the vendor needs to check “Appeal of Exception Denial” in Box 1b on the Exceptions Request Form and update the form to provide further information about the exception being requested. The


XV. Exceptions Request Process and Discrepancy Notification Report October 2015

Coordination Team will review the appeal and return a final decision to the survey vendor within 10 business days.

Discrepancy Notification ReportThe Discrepancy Notification Report (DNR) (see Appendix P) is designed to allow the survey vendor to notify the OAS CAHPS Survey Coordination Team of an unplanned deviation from the OAS CAHPS Survey protocols that will require some form of corrective action on the part of the survey vendor. Examples of instances when a Discrepancy Notification Report is required include the following:

• the vendor or facility inadvertently omitted from the sample frame patients who were eligible for the survey;

• the vendor is unable to initiate the survey by the 21st day after the sample month ended and needs to initiate it from the 22nd through the 26th day after the sample month ended;

• a variable was incorrectly coded and submitted on the XML file;

• there has been a natural disaster or event that has interrupted data collection in such a way as to adversely affect survey outcomes; and

• the HOPD or ASC was unable to provide the vendor with a file for the sample month. The reason the HOPD or ASC was unable to provide the monthly patient information file must be specified in the Discrepancy Notification Report.

The DNR can be accessed and submitted online via the OAS CAHPS Survey website (https://oascahps.org/).

The vendor is expected to notify the OAS CAHPS Survey Coordination Team within 24 hours after the discovery of the discrepancy. The vendor must also notify all affected HOPDs and ASCs that a DNR has been submitted to the Coordination Team on their behalf. The report must clearly describe the discrepancy and the action proposed by the vendor to correct the discrepancy, along with a proposed timeline to correct the discrepancy. At a minimum, the following information must be included on the report form:

• the HOPD’s or ASC’s CMS Certification Number;

• sample month and year;

• number of affected patients;

• a description of the discrepancy and whether the deviation from OAS CAHPS Survey protocol was caused by the vendor or facility;



October 2015 XV. Exceptions Request Process and Discrepancy Notification Report

• remediation plan for the affected month and the timeline for the remediation activity; and

• corrective actions to be taken to avoid the situation in the future.

Vendors are required to submit a DNR if an HOPD or ASC client does not submit a monthly patient information file for a sample month. However, survey vendors do not need to continue submitting these reports for facilities that are not submitting monthly patient information files once the facility has failed to submit a monthly patient information file for 3 consecutive sample months. It is the responsibility of the OAS CAHPS Survey vendor to track the number of months the HOPD or ASC has failed to submit a monthly patient information file and to submit a DNR for the first 3 months that this occurs.

Vendors are reminded that no DNR is needed if a facility has notified the vendor via submission of a zero eligible file or an e-mail that it has no eligible patients in a given sample month. If an HOPD or ASC submits a file to its vendor with no eligible patients, the vendor must submit an XML file for that facility for that sample month indicating there were no eligible patients.

Discrepancy Report Review ProcessThe Coordination Team will review the vendor’s DNR and evaluate the impact of the discrepancy on the publicly reported data. Depending on the type of discrepancy, a footnote may be added to the publicly reported data. The Coordination Team will let the survey vendor know whether additional information is required to document or correct the discrepancy.


XV. Exceptions Request Process and Discrepancy Notification Report October 2015



APPENDIX A:

VENDOR APPLICATION FORM

Centers for Medicare & Medicaid ServicesOutpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual

Centers for Medicare & Medicaid Services A-1Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual

October 2015 Appendix A: Vendor Application Form


Appendix A: Vendor Application Form October 2015

A-4 Centers for Medicare & Medicaid ServicesOutpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual

APPENDIX B :

ENGLISH: MAIL SURVEY COVER LETTERS,

MAIL QUESTIONNAIRES, INSTRUCTIONS FOR SCANNABLE MAIL QUESTIONNAIRE ,

TELEPHONE INTERVIEW SCRIPT


Appendix B: English: Mail Survey Cover Letters, Mail Questionnaires,Instructions for Scannable Mail Questionnaire, Telephone Interview Script October 2015



Appendix B: English: Mail Survey Cover Letters, Mail Questionnaires,October 2015 Instructions for Scannable Mail Questionnaire, Telephone Interview Script

SAMPLE COVER LETTER FOR FIRST QUESTIONNAIRE MAILING

Outpatient and Ambulatory Surgery CAHPS SurveyTo be Printed on Ambulatory Surgery Center or Hospital Outpatient Department or Vendor

Letterhead

«FirstName» «LastName»«Address1» «Address2»«City_Name», «State_Code» «Zip_Zip4»

Dear «FirstName» «LastName»:

The enclosed survey asks for your experiences with the outpatient surgery or procedure you had on [DATE OF SURGERY]. We hope that you will take a few minutes to complete and return the questionnaire to [VENDOR] in the enclosed, postage-paid envelope.

When answering the questions, please consider your visit to [FACILITY] on [DATE OF SURGERY]. Do not answer questions based on any other surgeries or procedures you might have had at either this facility or another.

All information you provide will be confidential and is protected by the Privacy Act. Your answers to the survey will be grouped with answers from all other survey participants; your name and identifying information will not be linked to your answers when the data are analyzed. The overall survey results for [FACILITY NAME] and other facilities will be publically reported on the Internet at https://www.medicare.gov/. These results will help people make more informed decisions when choosing an outpatient or ambulatory surgery facility. Your participation is voluntary and will not affect any health care benefits you currently receive or will receive in the future.

If you have any questions about the survey, please call NAME toll-free at 1-800-XXX-XXXX. If you need help in reading the questions or marking responses, a friend or family member can assist you. Thank you in advance for your participation. Si desea recibir la versión de la encuesta en español, por favor llame al 1-800-XXX-XXXX.

Sincerely,

NAMETitleEnclosures [PRINT UNIQUE SAMPLE ID NUMBER HERE]

SAMPLE COVER LETTER FOR SECOND QUESTIONNAIRE MAILING TO MAIL SURVEY NONRESPONDENTS

Outpatient and Ambulatory Surgery CAHPS Survey

Centers for Medicare & Medicaid Services B-1Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual

https://www.medicare.gov/


To be Printed on Ambulatory Surgery Center or Hospital Outpatient Department or Vendor Letterhead


Dear «FirstName» «LastName»:

Recently, we sent you a letter asking for your help on a survey to provide [FACILITY] with information about the quality of health care provided to patients who receive an outpatient surgery or procedure in our facility. As of today, we have not yet received your completed questionnaire. If you have already completed and returned the questionnaire, please accept our thanks. If you have not completed it, please take a few minutes to do so now. Then return the questionnaire in the enclosed, postage-paid envelope.

When answering the questions, please consider your visit to [FACILITY] on [DATE OF SURGERY]. Do not answer questions based on any other surgeries or procedures you might have had at either our facility or another.

The results of this survey will be used to help us understand more about patient experiences in our facility. All information you provide will be confidential and is protected by the Privacy Act. Your participation is voluntary and will not affect any health care benefits you currently receive or will receive in the future.

If you have any questions about the survey, please call NAME toll-free at 1-800-XXX-XXXX. If you need help in reading the questions or marking responses, a friend or family member can assist you. Thank you in advance for your participation. Si desea recibir la versión de la encuesta en español, por favor llame al 1-800-XXX-XXXX.

Sincerely,

NAMETitle

B-2 Centers for Medicare & Medicaid ServicesOutpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual

Consumer Assessment of Healthcare Providers and Systems

Outpatient and Ambulatory Surgery Survey

(OAS CAHPS)A PATIENT EXPERIENCE OF CARE SURVEY ABOUT OUTPATIENT AND AMBULATORY

SURGERIES AND PROCEDURES

2015

ACCORDING TO THE PAPERWORK REDUCTION ACT OF 1995, NO PERSONS ARE REQUIRED TO RESPOND TO A COLLECTION OF INFORMATION UNLESS IT DISPLAYS A VALID OMB CONTROL NUMBER. THE VALID OMB CONTROL NUMBER FOR THIS INFORMATION COLLECTION IS 0938-1240. THE TIME REQUIRED TO COMPLETE THIS INFORMATION COLLECTION IS ESTIMATED TO AVERAGE 8 MINUTES PER RESPONSE, INCLUDING THE TIME TO REVIEW INSTRUCTIONS, SEARCH EXISTING DATA RESOURCES, GATHER THE DATA NEEDED, AND COMPLETE AND REVIEW THE INFORMATION COLLECTION. IF YOU HAVE COMMENTS CONCERNING THE ACCURACY OF THE TIME ESTIMATE(S) OR SUGGESTIONS FOR IMPROVING THIS FORM, PLEASE WRITE TO: CMS, 7500 SECURITY BOULEVARD, ATTN: PRA REPORTS CLEARANCE OFFICER, MAIL STOP C4-26-05, BALTIMORE, MARYLAND 21244-1850.


SURVEY INSTRUCTIONS

Answer all the questions by checking the box to the left of your answer.

You are sometimes told to skip over some questions in this survey. When this happens you will see an arrow with a note that tells you what question to answer next, like this:

YesNo If No, go to #1.

This survey asks about your experience at the facility named in the cover letter. For this survey, we use the term “procedure” for diagnostic, surgical or other procedures. We refer to “facility” as the place where you had your procedure.

Please answer these questions only for the procedure(s) you had on the date included in the cover letter. Do not include any other procedures in your answers.

I. BEFORE YOUR PROCEDURE

The first few questions are about getting ready for your procedure. Include any information you received before and on the day of your procedure.

1. Before your procedure, did your doctor or anyone from the facility give you all the information you needed about your procedure?1 Yes, definitely2 Yes, somewhat3 No

2. Before your procedure, did your doctor or anyone from the facility give you easy to understand instructions about getting ready for your procedure?1 Yes, definitely2 Yes, somewhat3 No

II. ABOUT THE FACILITY AND STAFF

The next questions ask about the day of your procedure.

3. Did the check-in process run smoothly?1 Yes, definitely2 Yes, somewhat3 No

4. Was the facility clean?1 Yes, definitely2 Yes, somewhat3 No

5. Were the clerks and receptionists at the facility as helpful as you thought they should be?1 Yes, definitely2 Yes, somewhat3 No

6. Did the clerks and receptionists at the facility treat you with courtesy and respect?1 Yes, definitely2 Yes, somewhat3 No



7. Did the doctors and nurses treat you with courtesy and respect?1 Yes, definitely2 Yes, somewhat3 No

8. Did the doctors and nurses make sure you were as comfortable as possible?1 Yes, definitely2 Yes, somewhat3 No

III. COMMUNICATIONS ABOUT YOUR PROCEDURE

As a reminder, please include any information you received before and on the day of the procedure.

9. Did the doctors and nurses explain your procedure in a way that was easy to understand?1 Yes, definitely2 Yes, somewhat3 No

10. Anesthesia is something that would make you feel sleepy or go to sleep during your procedure. Were you given anesthesia?1 Yes2 No If No, go to #13

11. Did your doctor or anyone from the facility explain the process of giving anesthesia in a way that was easy to understand?1 Yes, definitely2 Yes, somewhat3 No

12. Did your doctor or anyone from the facility explain the possible side effects of the anesthesia in a way that was easy to understand?1 Yes, definitely2 Yes, somewhat3 No

13. Discharge instructions include things like symptoms you should watch for after your procedure, instructions about medicines, and home care. Before you left the facility, did you get written discharge instructions?1 Yes2 No

IV. YOUR RECOVERY

14. Did your doctor or anyone from the facility prepare you for what to expect during your recovery?1 Yes, definitely2 Yes, somewhat3 No



15. Some ways to control pain include prescription medicine, over-the-counter pain relievers or ice packs. Did your doctor or anyone from the facility give you information about what to do if you had pain as a result of your procedure?1 Yes, definitely2 Yes, somewhat3 No

16. At any time after leaving the facility, did you have pain as a result of your procedure?1 Yes2 No

17. Before you left the facility, did your doctor or anyone from the facility give you information about what to do if you had nausea or vomiting?1 Yes, definitely2 Yes, somewhat3 No

18. At any time after leaving the facility, did you have nausea or vomiting as a result of either your procedure or the anesthesia?1 Yes2 No

19. Before you left the facility, did your doctor or anyone from the facility give you information about what to do if you had bleeding as a result of your procedure?1 Yes, definitely2 Yes, somewhat3 No

20. At any time after leaving the facility, did you have bleeding as a result of your procedure?1 Yes2 No

21. Possible signs of infection include fever, swelling, heat, drainage or redness. Before you left the facility, did your doctor or anyone from the facility give you information about what to do if you had possible signs of infection?1 Yes, definitely2 Yes, somewhat3 No

22. At any time after leaving the facility, did you have any signs of infection?1 Yes2 No



V. YOUR OVERALL EXPERIENCE

23. Using any number from 0 to 10, where 0 is the worst facility possible and 10 is the best facility possible, what number would you use to rate this facility?

0 Worst facility possible12345678910 Best facility possible

24. Would you recommend this facility to your friends and family?1 Definitely no2 Probably no3 Probably yes4 Definitely yes

VI. ABOUT YOU

25. In general, how would you rate your overall health?1 Excellent2 Very good3 Good4 Fair5 Poor

26. In general, how would you rate your overall mental or emotional health?1 Excellent2 Very good3 Good4 Fair5 Poor

27. What is your age?1 18 to 242 25 to 343 35 to 444 45 to 545 55 to 646 65 to 747 75 to 798 80 to 849 85 or older

28. Are you male or female?1 Male2 Female

29. What is the highest grade or level of school that you have completed?1 8th grade or less2 Some high school, but did not

graduate3 High school graduate or GED4 Some college or 2-year degree5 4-year college graduate6 More than 4-year college

degree



30. Are you of Hispanic, Latino/a, or Spanish origin?1 Yes, Hispanic, Latino/a, or

Spanish2 No, not Hispanic, Latino/a, or

Spanish If No, go to #32

31. Which group best describes you?1 Mexican, Mexican American,

Chicano/a2 Puerto Rican3 Cuban4 Another Hispanic, Latino/a, or

Spanish origin

32. What is your race? You may select one or more categories.1 White2 Black or African American3 American Indian or Alaska

Native4 Asian Indian5 Chinese6 Filipino7 Japanese8 Korean9 Vietnamese

10 Other Asian11 Native Hawaiian12 Guamanian or Chamorro13 Samoan14 Other Pacific Islander

33. How well do you speak English?1 Very well2 Well3 Not well4 Not at all

34. Do you speak a language other than English at home?1 Yes2 No If No, go to #36

35. What is that language?1 Spanish2 Other Language

(PLEASE SPECIFY):_________________________(Please print.)

36. Did someone help you complete this survey?1 Yes2 No If No, go to END.

37. How did that person help you? Check all that apply.1 Read the questions to me2 Wrote down the answers I

gave3 Answered the questions for me4 Translated the questions into

my language5 Helped in some other way:

(EXPLAIN):_________________________(Please print.)

6 No one helped me complete this survey

END



(Alternative Instructions for Scannable Forms)

SURVEY INSTRUCTIONS

· Answer all the questions by completely filling in the circle to the left of your answer.

· You are sometimes told to skip over some questions in this survey. When this happens you will see an arrow with a note that tells you what question to answer next, like this:

Yes

No If Yes, go to #1.

This survey asks about your experience at the facility named in the cover letter. For this survey, we use the term “procedure” for diagnostic, surgical or other procedures. We refer to “facility” as the place where you had your procedure.

Please answer these questions only for the procedure(s) you had on the date included in the cover letter. Do not include any other procedures in your answers.



TELEPHONE INTERVIEW SCRIPTFOR THE OUTPATIENT AND AMBULATORY SURGERY CAHPS SURVEY

INTRO1 Hello, may I please speak to [SAMPLED MEMBER’S NAME]?

1. YES Go to INTRO 22. NO, NOT AVAILABLE RIGHT NOW [SET CALLBACK]3. NO [REFUSAL] Go to TERMINATE Screen,4. MENTALLY/PHYSICALLY INCAPABLE

IF ASKED WHO IS CALLING:This is [INTERVIEWER NAME] calling from [VENDOR] on behalf of [FACILITY NAME]. I’d like to speak to [SAMPLE MEMBER’S NAME] about a health care survey.

INTRO2 [Hello, this is [INTERVIEWER NAME] calling on behalf of [FACILITY NAME] [FACILITY NAME] is participating in a survey about patients’ experiences with outpatient surgeries and procedures. The results will be used to help [FACILITY NAME] understand patient experiences in their facilities.

Your participation in this survey is completely voluntary and will not affect any health care or benefits you receive. All information you provide is confidential and is protected by the Privacy Act. The interview will take about 8 minutes to complete. This call may be monitored or recorded for quality improvement purposes.

[ADDRESS ANY QUESTIONS/CONCERNS THEN CONTINUE.]

INTRO3 This survey asks about your experience at [FACILITY NAME]. For this survey, we use the term “procedure” for diagnostic, surgical or other procedures. We refer to “facility” as the place where you had your procedure. Please answer these questions only for the procedure you had on [DATE]. Do not include any other procedures in your answers.

[ADDRESS ANY QUESTIONS/CONCERNS THEN SELECT RESPONSE OPTION.]



1 BEGIN INTERVIEW [GO TO Q1_INTRO]2 NO, NOT RIGHT NOW [SET CALLBACK]3 DID NOT RECEIVE SURGERY/PROCEDURE FROM THIS FACILITY

DURING [MONTH] [GO TO Q_INELIGIBLE SCREEN]4 NO [REFUSAL] [GO TO Q_REF SCREEN]

Q1_INTRO The first few questions are about getting ready for your procedure. Include any information you received before and on the day of your procedure.

Q1. Before your procedure, did your doctor or anyone from the facility give you all the information you need about your procedure? Would you say…1 Yes, definitely2 Yes, somewhat3 No

M MISSING/DK

Q2. Before your procedure, did your doctor or anyone from the facility give you easy to understand instructions about getting ready for your procedure? Would you say…1 Yes, definitely2 Yes, somewhat3 No

M MISSING/DK

Q3_INTRO The next questions ask about the day of your procedure.

Q3. Did the check-in process run smoothly? Would you say…1 Yes, definitely2 Yes, somewhat3 No

M MISSING/DK



Q4. Was the facility clean? Would you say…1 Yes, definitely2 Yes, somewhat3 No

M MISSING/DK

Q5. Were the clerks and receptionists at the facility as helpful as you thought they should be? Would you say…1 Yes, definitely2 Yes, somewhat3 No

M MISSING/DK

Q6. Did the clerks and receptionists at the facility treat you with courtesy and respect? Would you say…1 Yes, definitely2 Yes, somewhat3 No

M MISSING/DK

Q7. Did the doctors and nurses treat you with courtesy and respect? Would you say…1 Yes, definitely2 Yes, somewhat3 No

M MISSING/DK

Q8. Did the doctors and nurses make sure you were as comfortable as possible? Would you say…1 Yes, definitely2 Yes, somewhat3 No

M MISSING/DK

Q9_INTRO As a reminder, please include any information you received before and on the day of the procedure.



Q9. Did the doctors and nurses explain your procedure in a way that was easy to understand? Would you say…1 Yes, definitely2 Yes, somewhat3 No

M MISSING/DK

Q10. Anesthesia is something that would make you feel sleepy or go to sleep during your procedure. Were you given anesthesia?1 Yes2 No [GO TO Q#13]

M MISSING/DK

Q11. Did your doctor or anyone from the facility explain the process of giving anesthesia in a way that was easy to understand? Would you say…1 Yes, definitely2 Yes, somewhat3 No

M MISSING/DK

Q12. Did your doctor or anyone from the facility explain the possible side effects of anesthesia in a way that was easy to understand? Would you say…1 Yes, definitely2 Yes, somewhat3 No

M MISSING/DK

Q13. Discharge instruction include things like symptoms you should watch for after your procedure, instructions about medicines, and home care. Before you left the facility, did you receive written discharge instructions?1 Yes2 No

M MISSING/DK



Q14. Did your doctor or anyone from the facility prepare you for what to expect during your recovery? Would you say…1 Yes, definitely2 Yes, somewhat3 No

M MISSING/DK

Q15. Some ways to control pain can include prescription medicine, over-the-counter pain relievers or ice packs. Did your doctor or anyone from the facility give you information about what to do if you had pain as a result of your procedure? Would you say…1 Yes, definitely2 Yes, somewhat3 No

M MISSING/DK

Q16. At any time after leaving the facility did you have pain as a result of your procedure?1 Yes2 No

M MISSING/DK

Q17. Before you left the facility, did your doctor or anyone from the facility give you information about what to do if you had nausea or vomiting?1 Yes, definitely2 Yes, somewhat3 No

M MISSING/DK

Q18. At any time after leaving the facility, did you have nausea or vomiting as a result of either your procedure or the anesthesia?1 Yes2 No

M MISSING/DK



Q19. Before you left the facility, did your doctor or anyone from the facility give you information about what to do if you had bleeding as a result of your procedure? Would you say…1 Yes, definitely2 Yes, somewhat3 No

M MISSING/DK

Q20. At any time after leaving the facility, did you have bleeding as a result of your procedure?1 Yes2 No

M MISSING/DK

Q21. Possible signs of infection include fever, swelling, heat, drainage or redness. Before you left the facility, did your doctor or anyone from the facility give you information about what to do if you had possible signs of infection? Would you say…1 Yes, definitely2 Yes, somewhat3 No

M MISSING/DK

Q22. At any time after leaving the facility, did you have signs of infection?1 Yes2 No

M MISSING/DK

Q23_INTRO The next two questions ask about your overall experience.



Q23. Using any number from 0 to 10, where 0 is the worst facility possible and 10 is the best facility possible, what number would you use to rate this facility?

0 WORST FACILITY POSSIBLE12345678910 BEST FACILITY POSSIBLE

M MISSING/DK

Q24. Would you recommend this facility to your friends and family? Would you say…1 Definitely no2 Probably no3 Probably yes4 Definitely yes

M MISSING/DK

Q25. In general, how would you rate your overall health? Would you say …1 Excellent,2 Very good,3 Good,4 Fair, or5 Poor?

M MISSING/DK



Q26. In general, how would you rate your overall mental or emotional health? Would you say …1 Excellent,2 Very good,3 Good,4 Fair, or5 Poor?

M MISSING/DK

Q27. What is your age?1 18 TO 242 25 TO 343 35 TO 444 55 TO 645 65 TO 746 75 TO 797 80 TO 848 85 OR OLDER

M MISSING/DK

Q28. Are you male or female?1 MALE2 FEMALE

M MISSING/DK

Q29. What is the highest grade or level of school that you have completed? Would you say…1 8th grade or less,2 Some high school, but did not graduate,3 High school graduate or GED,4 Some college or 2-year degree,5 4-year college graduate, or6 More than 4-year college degree?

M MISSING/DK



Q30. Are you of Hispanic or Latino/Latina, or Spanish origin?1 YES2 NO [GO TO Q32]

M MISSING/DK

Q31. Which group best describes you?1 Mexican, Mexican American, Chicano/a2 Puerto Rican3 Cuban4 Another Hispanic, Latino/a, or Spanish origin

M MISSING/DK

Q32. What is your race? You may select one or more categories. Are you…1 White2 Black or African American3 American Indian or Alaska Native4 Asian Indian5 Chinese6 Filipino7 Japanese8 Korean9 Vietnamese10 Other Asian11 Native Hawaiian12 Guamanian or Chamorro13 Samoan14 Other Pacific Islander

M MISSING/DK

Q33. How well do you speak English? Would you say…1 Very well2 Well3 Not well4 Not at all

M MISSING/DK



Q34. Do you speak a language other than English at home?1 YES2 NO [GO TO END]

M MISSING/DK

Q35. What is that language?1 Spanish (GO TO Q_END)2 Other Language (GO TO Q35b)

M MISSING/DK

Q35b. What is that language? (ENTER RESPONSE BELOW. ALLOW UP TO 50 CHARACTERS)

M MISSING/DK

Q_END These are all the questions I have for you. Thank you for your time. Have a good (day/evening).

INELIGIBLE SCREEN:

Q_INELIG Thank you for your time. Have a good (day/evening).

REFUSAL SCREEN:

Q_REF Thank you for your time. Have a good (day/evening).


APPENDIX C:

SPANISH: MAIL SURVEY COVER LETTERS,

MAIL QUESTIONNAIRES, INSTRUCTIONS FOR SCANNABLE MAIL QUESTIONNAIRE ,

TELEPHONE INTERVIEW SCRIPT


Appendix C: Spanish: Mail Survey Cover Letters, Mail Questionnaires,Instructions for Scannable Mail Questionnaire, Telephone Interview Script October 2015



Appendix C: Spanish: Mail Survey Cover Letters, Mail Questionnaires,October 2015 Instructions for Scannable Mail Questionnaire, Telephone Interview Script

SAMPLE COVER LETTER FOR FIRST QUESTIONNAIRE MAILING


Letterhead


Estimado(a) «FirstName» «LastName»:

[FACILITY NAME] participará en una encuesta nacional para saber más sobre la calidad de la atención médica que reciben los pacientes. [VENDOR], una organización independiente que realiza estudios, está ayudando a realizar esta encuesta. Nuestros registros muestran que usted se hizo un procedimiento o cirugía en [FACILITY NAME]. Los resultados se usarán para ayudar a comprender las experiencias de los pacientes de nuestro centro.

La encuesta que adjuntamos hace preguntas sobre sus experiencias con el procedimiento o la cirugía que recibió el [Date of Procedure]. Esperamos que tome unos cuantos minutos para completar y devolver el cuestionario a [VENDOR], en el sobre adjunto con franqueo postal pagado.

Al contestar las preguntas, tenga en cuenta su visita a [FACILITY NAME] el [Date of Procedure]. No responda las preguntas acerca de otras cirugías o procedimientos que haya tenido en este centro de cirugía o en otro lugar.

Toda la información que proporcione será confidencial y estará protegida por la Ley de Privacidad. Sus respuestas a la encuesta se agruparán con las de otros participantes del estudio. Su nombre y su información de identidad no se asociarán a sus respuestas cuando se analicen los datos. Los resultados generales de la encuesta de [FACILITY NAME] y de otras instalaciones se reportará públicamente en internet en https://www.medicare.gov/. Estos resultados ayudarán a las personas a tomar decisiones más informadas cuando eligen un centro para cirugía externa o ambulatoria. Su participación es voluntaria y no afectará a ningún beneficio de atención médica que usted reciba ahora o en el futuro.

Atentamente,

NAMETitleEnclosures [PRINT UNIQUE SAMPLE ID NUMBER HERE]

Centers for Medicare & Medicaid Services C-1Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual

https://www.medicare.gov/


SAMPLE COVER LETTER FOR SECOND QUESTIONNAIRE MAILING TO MAIL SURVEY NONRESPONDENTS


Letterhead


Estimado(a) «FirstName» «LastName»:

Hace poco, le enviamos una carta pidiéndole su ayuda en una encuesta para dar información a [FACILITY] sobre la calidad de la atención médica que reciben los pacientes de cirugía para pacientes externos o ambulatorios. Al día de hoy, no hemos recibido el cuestionario con sus respuestas. Si usted ya completó el cuestionario y lo regresó, se lo agradecemos. Si no lo ha completado, por favor dedique unos minutos para hacerlo ahora. Luego envíe el cuestionario en el sobre adjunto con franqueo postal pagado.

Los resultados de la encuesta se usarán para ayudar a comprender las experiencias de los pacientes del centro. Toda la información que proporcione será confidencial y estará protegida por la Ley de Privacidad. Su participación es voluntaria y no afectará a ningún beneficio de atención médica que usted reciba ahora o en el futuro.

Si tiene alguna pregunta sobre la encuesta, puede llamar al personal de la encuesta a la línea gratuita 1-800-XXX-XXXX. Si necesita ayuda para leer las preguntas o marcar respuestas, una amistad o miembro de la familia puede ayudarle. Le agradecemos de antemano por su participación.

Atentamente,

NAMETitle

C-2 Centers for Medicare & Medicaid ServicesOutpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual

Encuesta CAHPS sobre la cirugía externa o ambulatoria

(OAS CAHPS®)UNA ENCUESTA DE PACIENTES SOBRE LA EXPERIENCIA CON LA ATENCIÓN DE CIRUGÍAS Y

PROCEDIMIENTOS AMBULATORIOS

2015

DE ACUERDO A LA LEY DE REDUCCIÓN DE TRABAJO ADMINISTRATIVO DE 1995 (PAPERWORK REDUCTION ACT OF 1995), NINGUNA PERSONA TIENE LA OBLIGACIÓN DE RESPONDER A UN CUESTIONARIO QUE SOLICITE INFORMACIÓN, A MENOS QUE LLEVE UN NÚMERO DE CONTROL DE OMB (OFICINA DE ADMINISTRACIÓN Y PRESUPUESTO) VÁLIDO. EL NÚMERO DE CONTROL OMB VÁLIDO PARA ESTE CUESTIONARIO ES 0938-1240. SE ESTIMA QUE EL TIEMPO PROMEDIO NECESARIO PARA COMPLETAR ESTE CUESTIONARIO ES DE 8 MINUTOS POR RESPUESTA, INCLUYENDO EL TIEMPO PARA REVISAR LAS INSTRUCCIONES, BUSCAR EN LAS FUENTES DE DATOS EXISTENTES, RECOPILAR LOS DATOS NECESARIOS, COMPLETAR Y REVISAR LA INFORMACIÓN RECOPILADA. SI TIENE ALGÚN COMENTARIO SOBRE LA EXACTITUD DEL TIEMPO ESTIMADO O SUGERENCIAS PARA MEJORAR ESTE FORMULARIO, POR FAVOR ESCRIBA A: CMS, 7500 SECURITY BOULEVARD, ATTN: PRA REPORTS CLEARANCE OFFICER, MAIL STOP C4-26-05, BALTIMORE, MARYLAND 21244-1850.


INSTRUCCIONES PARA LA ENCUESTA

Conteste todas las preguntas marcando el cuadrito que aparece a la izquierda de su respuesta.

A veces se le pide que salte algunas preguntas en esta encuesta. Cuando esto ocurra, verá una flecha con una nota que le indicará cuál es la siguiente pregunta a la que tiene que ir, de esta manera:

SíNo Si contestó “No”,

pase a la pregunta 1Esta encuesta pregunta acerca de sus experiencias en el centro ambulatorio que se menciona en la carta de presentación. Para esta encuesta, usamos el término “procedimiento” para procedimientos de diagnóstico, cirugías u otros procedimientos. Nos referimos al “centro ambulatorio” como el lugar en donde se realizó su procedimiento.

Por favor, responda las preguntas solo para el/los procedimiento(s) que tuvo en la fecha que se incluye en la carta de presentación. No incluya ningún otro procedimiento en sus respuestas.

I. ANTES DEL PROCEDIMIENTO

Las primeras preguntas son acerca de la preparación para su procedimiento. Incluya cualquier información que haya recibido antes o en el día del procedimiento.

1. Antes del procedimiento, ¿le dio un doctor o alguien del centro ambulatorio toda la información que necesitaba acerca de su procedimiento?

1 Sí, definitivamente2 Sí, algo3 No

2. Antes del procedimiento, ¿le dio un doctor o alguien del centro ambulatorio instrucciones fáciles de entender sobre lo que necesitaba para prepararse para su procedimiento?


II. ACERCA DEL CENTRO AMBULATORIO Y EL PERSONAL

Las siguientes preguntas se refieren al día de su procedimiento.

3. ¿Fue fácil el proceso de registro?1 Sí, definitivamente2 Sí, algo3 No

4. ¿Estaba limpio el centro ambulatorio?




5. ¿Le ayudó el personal administrativo y de recepción del centro ambulatorio tanto como usted pensaba que debían hacerlo?


6. ¿Le trató el personal administrativo y de recepción del centro ambulatorio con cortesía y respeto?


7. ¿Le trataron los doctores y enfermeras con cortesía y respeto?


8. ¿Se aseguraron los doctores y enfermeras que usted estuviera tan cómodo como fuera posible?


III. COMUNICACIÓN SOBRE SU PROCEDIMIENTO

Le recordamos que por favor incluya cualquier información que haya recibido ya sea antes o en el día del procedimiento.

9. ¿Le explicaron los doctores u enfermeras el procedimiento de tal manera que fue fácil de entender?


10.La anestesia es algo que le haría sentir sueño o dormir durante el procedimiento. ¿Le dieron anestesia?

1 Sí2 No Si contestó “No”,

pase a la pregunta 13

11.¿Le explicó el doctor o alguien del centro ambulatorio el proceso de dar anestesia de tal manera que fue fácil de entender?


12.¿Le explicó el doctor o alguien del centro ambulatorio los posibles efectos secundarios de la anestesia de tal manera que fuera fácil de entender?


13.Las instrucciones al ser dado de alta incluyen observar los síntomas después de su procedimiento, instrucciones sobre los medicamentos y cuidado en el hogar. Antes de salir del centro ambulatorio, ¿recibió instrucciones por escrito al darle de alta?

1 Sí2 No



IV. SU RECUPERACIÓN

14.¿Le preparó el doctor o alguien del personal del centro ambulatorio sobre qué esperar durante su recuperación?


15.Algunas maneras para controlar el dolor incluyen medicamentos recetados, medicamentos para el dolor de venta libre o bolsas de hielo. ¿Su doctor o alguien del centro ambulatorio le dio información sobre qué hacer si tenía dolor como resultado de su procedimiento?


16.En algún momento después de salir del centro ambulatorio, ¿tuvo dolor debido al procedimiento?

1 Sí2 No

17.Antes de salir del centro ambulatorio, ¿su doctor o alguien del personal del centro ambulatorio le dio información sobre qué hacer si tenía náusea o vómitos?


18.En algún momento después de salir del centro ambulatorio, ¿tuvo náusea o vómitos como resultado del procedimiento o la anestesia?

1 Sí2 No

19.Antes de salir del centro ambulatorio, ¿su doctor o alguien del personal del centro ambulatorio le dio información sobre qué hacer si sangraba como resultado del procedimiento?


20.En algún momento después de salir del centro ambulatorio, ¿tuvo sangrado como resultado del procedimiento?

1 Sí2 No

21.Posibles señales de infección incluyen fiebre, hinchazón, calor, secreción o enrojecimiento. Antes de salir del centro ambulatorio, ¿su doctor o alguien del personal del centro ambulatorio le dio información sobre qué hacer si tuviera señales de infección?


22.En algún momento después de salir del centro ambulatorio, ¿tuvo señales de infección?

1 Sí2 No



V. SU EXPERIENCIA GENERAL

23.Usando un número del 0 al 10, en donde 0 es el peor centro ambulatorio posible y 10 es el mejor centro ambulatorio posible, ¿qué número usaría para calificar éste centro ambulatorio?

0 Peor centro ambulatorio posible

12345678910 Mejor centro ambulatorio

posible

24.¿Recomendaría este centro ambulatorio a sus amistades y familia?

1 Definitivamente no2 Probablemente no3 Probablemente sí4 Definitivamente sí

VI. ACERCA DE USTED

25.En general, ¿cómo calificaría su salud general?

1 Excelente2 Muy buena3 Buena4 Regular5 Mala

26.En general, ¿cómo calificaría su salud mental o emocional?

1 Excelente2 Muy buena3 Buena4 Regular5 Mala

27.¿Qué edad tiene usted?1 18 a 24 años2 25 a 34 años3 35 a 44 años4 45 a 54 años5 55 a 64 años6 65 a 74 años7 75 a 79 años8 80 a 84 años9 85 años o más

28.¿Es usted hombre o mujer?1 Hombre2 Mujer



29.¿Cuál es el nivel o año escolar más avanzado que usted ha completado?

1 8o años de escuela o menos2 9-12 años de escuela, pero

sin graduarse3 Graduado de la escuela

secundaria, Diploma de escuela secundaria, preparatoria o su equivalente (o GED)

4 Algunos cursos universitarios o un título universitario de un programa de 2 años

5 Título universitario de 4 años6 Título universitario de más de

4 años

30.¿Es usted de origen hispano, latino o español?

1 Sí, soy de origen hispano, latino o español

2 No, no soy de origen hispano, latino o español Si contestó “No”, pase a la pregunta 32

31.¿Cuál grupo lo(a) describe mejor?1 Mexicano, mexicano

americano, chicano2 Puertorriqueño3 Cubano4 Otro origen hispano, latino o

español

32.¿Cuál es su raza? Puede seleccionar una o más categorías.

1 Blanca2 Negra o afro americana3 Indígena americana o nativa

de Alaska4 India asiática5 China6 Filipina7 Japonesa8 Coreana9 Vietnamita10 Otra raza asiática11 Nativa de Hawai12 Procedente de Guam o

Chamorro13 Samoana14 Otra raza de las islas del

Pacífico

33.¿Qué tan bien habla usted inglés?1 Muy bien2 Bien3 No bien4 Nada

34.¿Habla usted algún otro idioma que no sea inglés en casa?

1 Sí2 No Si contestó “No”, pase

a la pregunta 36

35.¿Qué idioma habla en su casa?1 Español2 Otro idioma

(FAVOR DE ESPECIFICAR):_________________________(Favor de usar letra tipo imprenta.)



36.¿Le ayudó alguien a completar esta encuesta?

1 Sí2 No Si contestó No, vaya

al FINAL.

37.¿De qué manera le ayudó esa persona? Marque todas las respuestas que correspondan.

1 Me leyó las preguntas2 Anotó las respuestas que le di3 Contestó las preguntas por mi4 Me tradujo las preguntas a mi

idioma5 Me ayudó de alguna otra

manera:(EXPLIQUE):_________________________(Favor de usar letra tipo imprenta.)

6 Nadie me ayudó a completar esta encuesta

FINAL



(This version contains alternative Instructions for Scannable Forms)

INSTRUCCIONES PARA LA ENCUESTA

· Responda todas las preguntas llenando por completo el círculo a la izquierda de su respuesta.

· A veces se le indica que debe saltarse algunas preguntas de esta encuesta. Cuando ocurra, verá una flecha con una nota que le indica qué pregunta es la siguiente, de esta manera:

Sí

No Si contestó “No”, pase a la pregunta 1

Esta encuesta pregunta acerca de sus experiencias en el centro ambulatorio que se menciona en la carta de presentación. Para esta encuesta, usamos el término “procedimiento” para procedimientos de diagnóstico, cirugías u otros procedimientos. Nos referimos al “centro ambulatorio” como el lugar en donde se realizó su procedimiento.

Por favor, responda las preguntas solo para el/los procedimiento(s) que tuvo en la fecha que se incluye en la carta de presentación. No incluya ningún otro procedimiento en sus respuestas.



TELEPHONE INTERVIEW SCRIPTFOR THE OUTPATIENT AND AMBULATORY SURGERY CAHPS SURVEY

INTRO1 [Buenos días/Buenas tardes/Buenas noches], ¿puedo hablar con [SAMPLE MEMBER’S NAME]?

1. YES Go to INTRO 22. NO, NOT AVAILABLE RIGHT NOW [SET CALLBACK]3. NO [REFUSAL] Go to TERMINATE Screen,4. MENTALLY/PHYSICALLY INCAPABLE [CODE AS INCAPABLE]

IF ASKED WHO IS CALLING:Mi nombre es [INTERVIEWER NAME], y estoy llamando de [VENDOR] en nombre de [FACILITY NAME]. Me gustaría hablar con [SAMPLE MEMBER’S NAME] sobre una encuesta sobre la atención médica.

INTRO2 [Buenos días/Buenas tardes/Buenas noches], mi nombre es [INTERVIEWER NAME] y estoy llamando de parte de [FACILITY NAME]. [FACILITY NAME] está participando en una encuesta sobre las experiencias de los pacientes que han tenido una cirugía o un procedimiento ambulatorio. Los resultados se usarán para ayudar a [FACILITY NAME] a comprender las experiencias de los pacientes en su centro ambulatorio.

Su participación en esta encuesta es completamente voluntaria y no afectará a ningún beneficio de atención médica que usted recibe. Toda la información que proporcione es confidencial y está protegida por la Ley de Privacidad. La entrevista se puede completar como en 8 minutos. Esta llamada puede ser escuchada o grabada con propósitos de mejorar la calidad.

[ADDRESS ANY QUESTIONS/CONCERNS THEN CONTINUE.]

INTRO3 La encuesta hace preguntas sobre sus experiencias con [FACILITY NAME]. Para esta encuesta, usamos el término “procedimiento” para procedimientos de diagnóstico, cirugías u otros procedimientos. Nos referimos al “centro ambulatorio” como el lugar en donde se realizó su procedimiento. Por favor, responda a estas preguntas solo para el procedimiento que se realizó el [DATE]. No incluya ningún otro procedimiento en sus respuestas.



[ADDRESS ANY QUESTIONS/CONCERNS THEN SELECT RESPONSE OPTION.]

1 BEGIN INTERVIEW [GO TO Q1_INTRO]2 NO, NOT RIGHT NOW [SET CALLBACK]3 DID NOT RECEIVE SURGERY/PROCEDURE FROM THIS FACILITY

DURING [MONTH] [GO TO Q_INELIGIBLE SCREEN]4 NO [REFUSAL] [GO TO Q_REF SCREEN]

Q1_INTRO Las primeras preguntas son acerca de la preparación para su procedimiento. Incluya cualquier información que haya recibido antes o en el día del procedimiento.

Q1. Antes del procedimiento, ¿le dio un doctor o alguien del centro ambulatorio toda la información que necesitaba acerca de su procedimiento? ¿Diría usted que…?1 Sí, definitivamente2 Sí, algo3 No

M MISSING/DK

Q2. Antes del procedimiento, ¿le dio un doctor o alguien del centro ambulatorio instrucciones fáciles de entender sobre lo que necesitaba para prepararse para su procedimiento? ¿Diría que…?1 Sí, definitivamente2 Sí, algo3 No

M MISSING/DK

Q3 INTRO Las siguientes preguntas se refieren al día de su procedimiento.

Q3. ¿Fue fácil el proceso de registro? ¿Diría que…?1 Sí, definitivamente2 Sí, algo3 No

M MISSING/DK



Q4. ¿Estaba limpio el centro ambulatorio? ¿Diría que…?1 Sí, definitivamente2 Sí, algo3 No

M MISSING/DK

Q5. ¿Le ayudó el personal administrativo y de recepción del centro ambulatorio tanto como usted pensaba que debían hacerlo? ¿Diría que…?1 Sí, definitivamente2 Sí, algo3 No

M MISSING/DK

Q6. ¿Le trató el personal administrativo y de recepción del centro ambulatorio con cortesía y respeto? ¿Diría que…?1 Sí, definitivamente2 Sí, algo3 No

M MISSING/DK

Q7. ¿Le trataron los doctores y enfermeras con cortesía y respeto? ¿Diría que…?1 Sí, definitivamente2 Sí, algo3 No

M MISSING/DK

Q8. ¿Se aseguraron los doctores y enfermeras que usted estuviese tan cómodo como fuera posible? ¿Diría que…?1 Sí, definitivamente2 Sí, algo3 No

M MISSING/DK



Q9_INTRO Le recordamos que por favor incluya cualquier información que haya recibido ya sea antes o en el día del procedimiento.

Q9. ¿Le explicaron los doctores u enfermeras el procedimiento de tal manera que fue fácil de entender? ¿Diría usted que…?1 Sí, definitivamente2 Sí, algo3 No

M MISSING/DK

Q10. La anestesia es algo que le haría sentir sueño o dormir durante el procedimiento. ¿Le dieron anestesia?1 SÍ2 NO [GO TO Q13]

M MISSING/DK

Q11. ¿Le explicó el doctor o alguien del centro ambulatorio el proceso de dar anestesia de tal manera que fue fácil de entender? ¿Diría usted que…?1 Sí, definitivamente2 Sí, algo3 No

M MISSING/DK

Q12. ¿Le explicó el doctor o alguien del centro ambulatorio los posibles efectos secundarios de la anestesia de tal manera que fuera fácil de entender? ¿Diría usted que…?1 Sí, definitivamente2 Sí, algo3 No

M MISSING/DK



Q13. Las instrucciones al ser dado de alta incluyen observar los síntomas después de su procedimiento, instrucciones sobre los medicamentos y cuidado en el hogar. Antes de salir del centro ambulatorio, ¿recibió instrucciones por escrito al darle de alta?1 SÍ2 NO

M MISSING/DK

Q14. ¿Le preparó el doctor o alguien del personal del centro ambulatorio sobre qué esperar durante su recuperación? ¿Diría que…?1 Sí, definitivamente2 Sí, algo3 No

M MISSING/DK

Q15. Algunas maneras para controlar el dolor incluyen medicamentos recetados, medicamentos para el dolor de venta libre o bolsas de hielo. ¿Su doctor o alguien del centro ambulatorio le dio información sobre qué hacer si tenía dolor como resultado de su procedimiento? ¿Diría que…?1 Sí, definitivamente2 Sí, algo3 No

M MISSING/DK

Q16. En algún momento después de salir del centro ambulatorio, ¿tuvo dolor debido al procedimiento?1 SÍ2 NO

M MISSING/DK



Q17. Antes de salir del centro ambulatorio, ¿su doctor o alguien del personal del centro ambulatorio le dio información sobre qué hacer si tenía náusea o vómitos? ¿Diría que…?1 Sí, definitivamente2 Sí, algo3 No

M MISSING/DK

Q18. En algún momento después de salir del centro ambulatorio, ¿tuvo náusea o vómitos como resultado del procedimiento o la anestesia?1 SÍ2 NO

M MISSING/DK

Q19. Antes de salir del centro ambulatorio, ¿su doctor o alguien del personal del centro ambulatorio le dio información sobre qué hacer si sangraba como resultado del procedimiento? ¿Diría que…?1 Sí, definitivamente2 Sí, algo3 No

M MISSING/DK

Q20. En algún momento después de salir del centro ambulatorio, ¿tuvo sangrado como resultado del procedimiento?1 SÍ2 NO

M MISSING/DK



Q21. Posibles señales de infección incluyen fiebre, hinchazón, calor, secreción o enrojecimiento. Antes de salir del centro ambulatorio, ¿su doctor o alguien del personal del centro ambulatorio le dio información sobre qué hacer si tuviera señales de infección? ¿Diría que…?1 Sí, definitivamente2 Sí, algo3 No

M MISSING/DK

Q22. En algún momento después de salir del centro ambulatorio, ¿tuvo señales de infección?1 SÍ2 NO [GO TO Q34]

M MISSING/DK

Q23_INTRO Las siguientes preguntas se refieren a su experiencia en general.

Q23. Usando un número del 0 al 10, en donde 0 es el peor centro ambulatorio posible y 10 es el mejor centro ambulatorio posible, ¿qué número usaría para calificar éste centro ambulatorio?

0 PEOR CENTRO AMBULATORIO POSIBLE12345678910 MEJOR CENTRO AMBULATORIO POSIBLE

M MISSING/DK



Q24. ¿Recomendaría este centro ambulatorio a sus amistades y familia? ¿Diría usted que…?1 Definitivamente no2 Probablemente no3 Probablemente sí4 Definitivamente sí

M MISSING/DK

Q25. En general, ¿cómo calificaría su salud general? ¿Diría que es…1 Excelente2 Muy buena3 Buena4 Regular o5 Mala?

M MISSING/DK

Q26. En general, ¿cómo calificaría su salud mental o emocional? ¿Diría que es…1 Excelente2 Muy buena3 Buena4 Regular o5 Mala?

M MISSING/DK

Q27. ¿Qué edad tiene usted?1 18 A 24 AÑOS2 25 A 34 AÑOS3 35 A 44 AÑOS4 45 A 54 AÑOS5 55 A 64 AÑOS6 65 A 74 AÑOS7 75 A 79 AÑOS8 80 A 84 AÑOS9 85 AÑOS O MÁS

M MISSING/DK



Q28. ¿Es usted hombre o mujer?1 HOMBRE2 MUJER

M MISSING/DK

Q29. ¿Cuál es el nivel o año escolar más avanzado que usted ha completado? ¿Diría que…?1 8o grado de escuela o menos2 9-12 años de escuela, pero sin graduarse3 Graduado(a) de escuela secundaria, diploma de escuela secundaria,

preparatoria o su equivalente o 'GED'4 Algunos cursos universidarios o un título universitario de un programa de 2

años5 Título universitario de 4 años o6 Título universitario de más de 4 años

M MISSING/DK

Q30. ¿Es usted de origen hispano, latino o español?1 SÍ,2 NO [GO TO Q32]

M MISSING/DK

Q31. ¿Cuál grupo lo(a) describe mejor? ¿Diría que usted es…?1 Mexicano(a), mexicano(a) americano(a), chicano(a)2 Puertorriqueño(a)3 Cubano(a)4 Otro origen hispano, latino o español

M MISSING/DK



Q32. ¿Cuál es su raza? Puede seleccionar una o más categorías. ¿Es usted…?1 Blanco(a)2 Negro(a) o africano(a) americano(a)3 Indígeno(a) americano(a) o nativo(a) de Alaska4 Indio(a) asiático(a)5 Chino(a)6 Filipino(a)7 Japones(a)8 Coreano(a)9 Vietnamita10 Otra raza asiática11 Nativo(a) de Hawai12 Procedente de Guam o Chamorro13 Samoano(a)14 Otra raza de las islas del Pacífico

M MISSING/DK

Q33. ¿Qué tan bien habla usted inglés? ¿Diría que…?1 Muy bien2 Bien3 No bien4 Nada

M MISSING/DK

Q34. ¿Habla usted algún otro idioma que no sea inglés en casa?1 SÍ2 NO [GO TO Q_END]

M MISSING/DK

Q35. ¿Qué idioma habla en su casa?1 Español [GO TO Q_END]2 Otro idioma (GO TO Q35b)

M MISSING/DK



Q35b. ¿Qué idioma habla en su casa? (ENTER RESPONSE BELOW)

{ALLOW UP TO 50 CHARACTERS}

M MISSING/DK

Q_END Estas son todas las preguntas que tengo para usted. Muchas gracias por su tiempo. Le deseo que tenga (un buen día/buenas noches).

INELIGIBLE SCREEN:

Q_INELIG Muchas gracias por su tiempo. Le deseo que tenga (un buen día/buenas noches).

REFUSAL SCREEN:

Q_REF Muchas gracias por su tiempo. Le deseo que tenga (un buen día/buenas noches).


APPENDIX D:

CHINESE COVER LETTERS AND QUESTIONNAIRE (FORTHCOMING)


Appendix D: Chinese Cover Letters and Questionnaire October 2015



APPENDIX E:

ADDITIONAL LANGUAGE COVER LETTERS AND QUESTIONNAIRE (FORTHCOMING)


Appendix E: Additional Language Cover Letters and Questionnaire October 2015



APPENDIX F :

CONSENT TO SHARE IDENTIFYING INFORMATION QUESTION


October 2015 Appendix F: Consent to Share Identifying Information Question

HOPDs or ASCs may request that their survey vendor provide survey responses linked to a sample member’s name. If they wish to do so, they must ask for and receive consent from the sample member using the Consent to Share Identifying Information question (below). This question should be placed at the end of the questionnaire as the last question.

English Mail Questionnaire VersionThe facility where you received your surgery or procedure may want to review your survey responses so that they can decide how to address any concerns that you have.

Do you give your permission to link your name with your survey responses that will be shared with the facility where you received your surgery or procedure?

1 Yes, I give my permission to link my name with my survey responses.2 No, I do not give permission to link my name with my survey responses.

English Telephone Interview VersionThe facility where you received your surgery or procedure may want to review your survey responses so that they can decide how to address any concerns that you have.

Do you give your permission to link your name with your survey responses that will be shared with the facility where you received your surgery or procedure?

1 Yes2 No

Centers for Medicare & Medicaid ServicesOutpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual F-1

Appendix F: Consent to Share Identifying Information Question October 2015

Spanish Mail Questionnaire VersionEs posible que el centro ambulatorio en donde se realizó su cirugía o procedimiento desee revisar sus respuestas para encontrar la manera de aclarar sus preocupaciones.

¿Nos da usted permiso de asociar su nombre con las respuestas a la encuesta que se compartirá con el centro ambulatorio en donde se realizó su cirugía o procedimiento?

1 Sí, doy permiso para asociar mi nombre con mis respuestas a la encuesta.2 No, no doy permiso para asociar mi nombre con mis respuestas a la encuesta.

Spanish Telephone Interview VersionEs posible que el centro ambulatorio en donde se realizó su cirugía o procedimiento desee revisar sus respuestas para encontrar la manera de aclarar sus preocupaciones.

¿Nos da usted permiso de asociar su nombre con las respuestas a la encuesta que se compartirá con el centro ambulatorio en donde se realizó su cirugía o procedimiento?

1 Sí2 No

Centers for Medicare & Medicaid ServicesF-2 Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual

APPENDIX G :

OMB PAPERWORK REDUCTION ACT LANGUAGE


Appendix G: OMB Paperwork Reduction Act Language October 2015


The Office of Management and Budget (OMB) Paperwork Reduction Act language below must be included in the Outpatient and Ambulatory Surgery CAHPS Survey mailings. It can be included in the cover letter or on the front or back of the questionnaire. It does not need to be included in both the cover letter and the questionnaire.

ENGLISH

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1240. The time required to complete this information collection is estimated to average 8 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

Centers for Medicare & Medicaid ServicesOutpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual G-1

October 2015 Appendix G: OMB Paperwork Reduction Act Language


The Office of Management and Budget (OMB) Paperwork Reduction Act language below must be included in the Outpatient and Ambulatory Surgery CAHPS Survey mailings. It can be included in the cover letter or on the front or back of the questionnaire. It does not need to be included in both the cover letter and the questionnaire.

SPANISH

De acuerdo a la Ley de Reducción de Trabajo Administrativo de 1995 (Paperwork Reduction Act of 1995), ninguna persona tiene la obligación de responder a un cuestionario que solicite información, a menos que lleve un número de control de OMB (Oficina de Administración y Presupuesto) válido. El número de control OMB válido para este cuestionario es 0938-1240. Se estima que el tiempo promedio necesario para completar este cuestionario es de 8 minutos por respuesta, incluyendo el tiempo para revisar las instrucciones, buscar en las fuentes de datos existentes, recopilar los datos necesarios, completar y revisar la información recopilada. Si tiene algún comentario sobre la exactitud del tiempo estimado o sugerencias para mejorar este formulario, por favor escriba a: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

Centers for Medicare & Medicaid ServicesG-2 Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual

APPENDIX H:

FREQUENTLY ASKED QUESTIONS FOR TELEPHONE INTERVIEWERS (ENGLISH)


October 2015 Appendix H: Frequently Asked Questions for Telephone Interviewers (English)

FREQUENTLY ASKED QUESTIONSOUTPATIENT/AMBULATORY SURGERY PATIENT EXPERIENCE OF CARE SURVEY

What is the purpose of this survey?

The purpose of this survey is to learn about your experiences with the care you received for your recent outpatient surgery or procedure. The survey results will help other patients make more informed choices when choosing an outpatient surgery facility and help facilities in the study to improve the quality of care provided to their patients.

I’ve already completed a mail survey. Do I need to complete this survey again?

Thank you for completing the survey and mailing it back in. However, we have not yet received the survey and so we are following up to gather your feedback by phone. If you have some time right now we could go through the questions. Or I can call you back in a few days if we still have not received the survey by mail.

I lost the mail survey. Would you please mail me another one?

We are nearing the end of the survey data collection period and are not allowed to send out any additional surveys. Because the feedback you provide will help improve the quality of the outpatient surgery care you and others like you receive, we are asking that you please complete the survey with us over the phone. If now is okay, let’s get started!

I already completed/received a survey about this.

Sometimes hospitals and surgeons conduct surveys of their recent patients, and you may have received one of those surveys. The survey we are asking you to do is about your experience at the outpatient facility where your surgery or procedure was performed. The results will be used to help people make more informed decisions when choosing an outpatient surgery facility. The facilities will also use survey results to help improve the quality of care they give to their patients.

How are the results from the study going to be used?

Results from this survey will be used to help people make more informed decisions when choosing an outpatient surgery facility. The facilities will also use survey results to help improve the quality of care they give to their patients.

Do I have to take part in this survey?

Your participation in this survey is voluntary. All information that you give in this survey will be held in confidence and is protected by the Privacy Act. Please know that none of your individual answers will be shared with [facility name], nor will they know whether or not you participated.

Centers for Medicare & Medicaid Services H-1Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual

Appendix H: Frequently Asked Questions for Telephone Interviewers (English) October 2015

It is also important that you know that your decision to participate in this survey and your answers to the questions will not affect any health care benefits you receive now or expect to receive in the future.

You can also skip or refuse to answer any question you don’t feel comfortable with. But, we hope you will participate because the feedback you provide will help improve the quality of the care you, and others like you, receive.

I did not have surgery. This survey does not apply to me.

This survey is applicable to you if you had a medical or diagnostic procedure at [Facility Name] in [Month, Year]. Examples of these types of procedures include colonoscopy, endoscopy, biopsy and injection for pain management. [NOTE: IF NEEDED, EXPLAIN TO RESPONDENT HOW THEY WERE SELECTED: You were randomly selected to participate in this survey because our records show that you had a procedure at (Facility Name).]

I can’t remember any specific procedure/I didn’t have surgery on that date.

For privacy reasons, we do not have access to the procedures you had at this facility during [MONTH]. Please try to answer the questions as best as you can for the procedure you remember the most in [MONTH].

My surgery was not outpatient/ambulatory because I stayed overnight at the hospital/facility. This survey does not apply to me.

This survey is for people who had outpatient surgeries, including those who went home on the same day and those who stayed overnight for observation. As long as you went home after observation and a doctor did not write an order to admit you to a hospital as an inpatient, then this survey is for you.

What do I have to do/What kinds of questions are there?

I would like to ask you some questions about your experiences with your recent outpatient surgery or procedure at [facility name]. For example, the questions will ask for your experience with the check-in process, the facility itself, the communication you had with the facility’s staff, the information you received on your procedure, and your overall experience. This survey takes on average about 8 minutes to complete, and I will move through the questions as quickly as possible.

Is it okay for RESPONDENT’S wife, husband, child, legal guardian, etc.) to answer these questions?

Because you were chosen at random to participate in this important study, and because you were the one who received care for an outpatient surgery or procedure, no other person can take your place. But, you may skip or refuse to answer any question you’re uncomfortable with.

H-2 Centers for Medicare & Medicaid ServicesOutpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual

October 2015 Appendix H: Frequently Asked Questions for Telephone Interviewers (English)

How do I know this is confidential?

Your individual answers will only be seen by research staff, who have signed statements of confidentiality. All personal identifying information, such as names and addresses, will be removed from data records before they are analyzed. And, everyone’s answers will be combined to produce a summary report.

Why do you want to know all this personal stuff about me (RACE, AGE, GENERAL HEALTH, etc.) if this is a survey about my outpatient surgery care experiences?

I understand your concern with the questions about your general health and background. We have found that people’s experiences may differ based on their current health status and other characteristics. This is a very important survey. If a question bothers you, just tell me you’d rather not answer it, and I’ll move on to the next question.

I’m on the Do Not Call list. Why are you calling me?

The Do Not Call list stops sales and telemarketing calls. We are conducting survey research on behalf of [Facility Name]. We are not calling to sell or market a product or service.

I’m not going to answer a lot of questions over the phone!

Your cooperation is very important to us. The information that you provide in this survey will help others make more informed choices about an outpatient surgery center and will help the facility you visited to improve the care they give. Please know that you can skip or refuse to answer any question you don’t feel comfortable with, and that all of your answers will be kept completely confidential since they are protected by the Federal Privacy Act of 1974. Let me start and you can see what the questions are like…[READ FIRST QUESTION]

How did you get my name? How was I chosen for the survey?

Your name was randomly selected from a list of patients at [Facility Name] who received an outpatient surgery or procedure in [TBD based on when patient was sampled].

I did not like my outpatient surgery center!

I understand. Your opinions are very important and will help your outpatient surgery center understand how to improve its care. Let’s start now. [NOTE: DO NOT ARGUE BACK. MAKE SHORT, NEUTRAL COMMENTS TO LET THEM KNOW THAT YOU ARE LISTENING AND IMMEDIATELY ASK THE FIRST QUESTION.]

How long will this take?

This survey takes on average about 8 minutes to complete. I’ll move through the questions as quickly as possible.

Centers for Medicare & Medicaid Services H-3Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual

Appendix H: Frequently Asked Questions for Telephone Interviewers (English) October 2015


H-4 Centers for Medicare & Medicaid ServicesOutpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual

APPENDIX I :

GENERAL GUIDELINES FOR TELEPHONE INTERVIEWERS


Appendix I: General Guidelines for Telephone Interviewers October 2015



October 2015 Appendix I: General Guidelines for Telephone Interviewers

OUTPATIENT AND AMBULATORY SURGERY CAHPS SURVEYGENERAL GUIDELINES FOR TELEPHONE INTERVIEWING

Overview

The Outpatient and Ambulatory Surgery (OAS) CAHPS Survey will be administered as an electronic system telephone interview. As a telephone interviewer on the OAS CAHPS, you will use the system to conduct each interview. The questions you ask are programmed into a computer. The phone number is provided by the computer for you to make the call. You will read the questions from the computer screen and enter the answer to each question into the computer. Based on the answer you enter, the computer will automatically take you to a screen with the next applicable question.

You play an extremely important role in the overall success of this study. You are the link to the hundreds of respondents who will provide valuable information to the project team. You are the person who develops rapport with the respondents, assures them that their participation is important, and obtains their full cooperation and informed consent.

As a professional interviewer, your job is to help each respondent feel at ease and comfortable with the interview. Key to accomplishing this goal is to be fully informed about the survey, the interview, and the data collection procedures.

General Interviewing Techniques

The process of asking questions, probing, and entering responses correctly is crucial to obtaining high-quality data for the OAS CAHPS Survey. General techniques and procedures you should follow when conducting the OAS CAHPS Survey interviews are provided below.

Administering Survey Questions

• Ask the questions exactly as they are presented. Do not change the wording or condense any question when reading it to the respondent.

• Emphasize all words or phrases that appear in bold, are underlined, or appear in italics.

• Ask every question specified, even when a respondent has seemingly provided the answer as part of the response to a preceding question. The answer received in the context of one question may not be the same answer that will be received when the other question is asked. If it becomes cumbersome to the respondent, remind him or her gently that you must ask all questions of all respondents.

• If the answer to a question indicates that the respondent did not understand the intent of the question, or if the respondent requests that any part of the question be clarified, even if it is only one word, repeat the question.

Centers for Medicare & Medicaid Services I-1Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual


• Read the questions slowly, at a pace that allows them to be readily understood. Remember that the respondent has not heard these questions before and will not have had the exposure that you have had to the questionnaire.

• Transition statements are designed to inform the respondent of the nature of an upcoming question or a series of questions, to define a word, or to describe what is being asked for in the question. Read transition statements just as they are presented. Don’t create “transition statements” of your own, because these may unintentionally introduce bias into the interview.

• Give the respondent plenty of time to recall past events.

• Do not suggest answers to the respondent. Your job as an interviewer is to read the questions exactly as they are printed, make sure the respondent understands the question, and then enter the responses. Do not help the respondent answer the questions.

• Ask questions in the exact order in which they are presented.

• Do not read words that appear in ALL CAPITAL LETTERS to the respondent. This includes both questions and response categories.

• Read all questions including those which may appear to be sensitive to the respondent in the same manner with no hesitation or change in inflection.

• Thoroughly familiarize yourself with the Frequently Asked Questions list before you conduct interviews so that you are knowledgeable about the OAS CAHPS Survey.

• At the end of the interview, tell the sample member that the survey is completed and thank him or her for taking part in the survey.

Introducing the Survey

The introduction is of the utmost importance to successfully completing a telephone interview. Most people hang up in the first few minutes of the interview, so if you can convince the respondent to remain on the line long enough to hear the purpose of the study and begin asking the questions, the chances that your respondent will complete the interview increase dramatically.

• When reading the introduction, sound confident and pronounce the words as clearly as you can.

• Respondents are typically not expecting survey research calls, so they may need your help to clarify the nature of the call.

I-2 Centers for Medicare & Medicaid ServicesOutpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual


• Practice the introduction until you can present it in such a manner that your presentation sounds confident, sincere, and natural.

• Deliver the introduction at a conversational pace. Rushing through the introduction gives an impression of lack of confidence and may also cause the listener to misunderstand.

• Try not to pause too long before asking the first question in the survey following the introduction. A pause tends to indicate that you are waiting for approval to continue.

Avoiding Refusals

The first and most critical step in avoiding refusals is your effort to establish rapport with reluctant sample members, therefore minimizing the incidence of refusals. Remember, you will not be able to call back and convert a refusal―your initial contact with the sample member is the only chance you will have to create a successful interview. The following are some tips to follow to avoid refusals.

• Make sure you are mentally prepared when you start each call, and have a positive attitude.

• Treat respondents the way you would like to be treated.

• Always use an effective/positive/friendly tone and maintain a professional outlook.

• Pay careful attention to what the respondent says during the interview.

• Listen to the respondent completely rather than assuming you know what he or she is objecting to.

• Listen before evaluating and entering a response code.

• Be accommodating to the respondents’ needs.

• Always remain in control of the interaction.

• Understand the reason for reluctance/refusal at the start of the call, or figure it out as quickly as possible.

• Listen as an ally, not an adversary, and do not debate or argue with the respondent.

• Be prepared to address one (or more) reason(s) for reluctance/refusal.

• Focus your comments to sample members on why they specifically are important to the study.

• Paraphrase what you hear and repeat this back to the respondent.

• Remember that you are a professional representative of your survey organization and the health care facility whose patients you are contacting.



General Interviewing Guidance

The following sections provide guidance on the use of probes, avoiding bias, and entering responses accurately. By following these rules, interviewers will help ensure that the OAS CAHPS Survey interviews are conducted in a standardized manner.

Probing

At times, it will be necessary for you to probe to obtain a more complete or more specific answer from a respondent. To elicit an acceptable response, you will often need to use an appropriate neutral or nondirective probe. The important thing to remember is not to suggest answers or lead the respondent. Some general rules for probing follow:

• Repeat the question if the respondent misunderstood or misinterpreted the question. After hearing the question the second time, the respondent will probably understand what information is expected.

• Use a silent probe, which is pausing or hesitating to indicate to the respondent that you need additional or better information. This is a good probe to use after you have determined the respondent’s response pattern.

• Use neutral questions or statements to encourage a respondent to elaborate on an inadequate response. Examples of neutral probes include the following: “What do you mean?” “How do you mean?” “Tell me what you have in mind.” “Tell me more about….”

• Use clarification probes when the response is unclear, ambiguous, or contradictory. Be careful not to appear to challenge the respondent when clarifying a statement and always use a neutral probe. Examples of clarification probes are “Can you give me an example?” or “Could you be more specific?”

• Encourage the respondent to give his or her best guess if a respondent gives a “don’t know” response. Let the respondent know that this is not a test and there are no right or wrong answers. We are interested in the respondent’s opinions and assessment of the care that he or she has received at their ambulatory surgery center or hospital outpatient department.

• If the respondent asks you to answer the question for him or her, let the respondent know that you cannot. Instead, ask the respondent if she or he requires clarification on the content or meaning of the question.

Avoiding Bias

One common pitfall of interviewing is unknowingly introducing bias into an interview. Bias occurs when an interviewer says or does something that affects the answers respondents give in



an interview. An interview that has significant bias will not provide accurate data for the research being conducted; such an interview may have to be thrown out.

As a professional interviewer, remaining neutral at all times ensures that bias is not introduced into the interview. There are many things you can do or avoid to help ensure that no bias is introduced. You should

• read all statements and questions exactly as they are written,

• use neutral probes that do not suggest answers,

• not provide your own personal opinions or answers in an effort to “help” respondents, and

• not use nonverbal language, such as a cough, pause or a yawn to influence the interview.

Taking these steps to monitor your own spoken and unspoken language will go a long way to guarantee that the interviews you conduct are completed correctly and efficiently.

Entering Responses

The majority of the questions you will ask have precoded responses. To enter a response for these types of questions, you will simply select the appropriate response option and enter the number corresponding to that response.

The conventions presented below must be followed at all times to ensure that the responses you enter accurately reflect the respondents’ answers and to ensure that questionnaire data are all collected in the same systematic manner.

• You must listen to what the respondent says and enter the appropriate answer if the response satisfies the objective of the question. If the answer does not appear to satisfy the objective, repeat the question.

• In entering answers to open-ended questions or “Other (specify)” categories, enter the response verbatim, exactly as it was given by the respondent.

• Enter the response immediately after it is given.

• If a respondent gives a range in response to a question, probe as appropriate for a more specific answer. For example, if a respondent says, “Oh, 2 or 3 times” and you can enter only one number, ask for clarification: “Would that be closer to 2 or to 3?”

Rules for Successful Telephone Interviewing

Remember, the key to successful interviewing is being prepared for every contact that you make. Have a complete set of the appropriate materials at your work station, organized in such a



manner that you do not have to stop and search for required documents. Some general rules that you should follow every time you place a call are provided below.

1. Be prepared before you place a call . Be prepared to talk to the sample member. You should be able to explain the purpose of your call to the sample member or his or her family and friends. Do not rely on your memory alone to answer questions. Make sure you review and understand the Frequently Asked Questions (FAQs).

2. Act professionally . Convey to sample members that you are a professional who specializes in asking questions and conducting interviews. As a professional interviewer, you have specific tasks to accomplish for this survey.

3. Make the most of your contact . Even though you may not be able to obtain an interview on this call, it is important to make the most of the contact to aid in future attempts. For example, if you are trying to contact the sample member and he or she is not available, gain as much information as you can to help reach the sample member the next time he or she is called. Important questions to ask:

◦ When is the sample member usually home?

◦ What is the best time to reach the sample member?

◦ Can you schedule an “appointment” to reach the sample member at a later time?

4. Don’t be too quick to code a sample member as incapable . Some sample members may be hard of hearing or appear not to fully understand you when you call. Rather than immediately coding these cases as “Incapable,” please attempt to set a call-back for a different time of day and different day of the week. It is possible that reaching the sample member at a different time may result in your being able to conduct the interview with him or her. It is also possible that a friend or family member can assist the sample member with the interview. You cannot allow them to proxy for the sample member, but you can allow them to provide general help.


APPENDIX J:

FREQUENTLY ASKED QUESTIONS FOR TELEPHONE INTERVIEWS (SPANISH)

Preguntas más frecuentes para entrevistas por teléfono


Appendix J: Frequently Asked Questions for Telephone Interviews (Spanish) October 2015



October 2015 Appendix J: Frequently Asked Questions for Telephone Interviews (Spanish)

PREGUNTAS MÁS FRECUENTESENCUESTA CAHPS SOBRE LA CIRUGÍA EXTERNA O AMBULATORIA

(OAS CAHPS®)

¿Cuál es el propósito de esta encuesta?

El objetivo de la encuesta es aprender sobre sus experiencias con los servicios que recibió durante su más reciente cirugía externa o procedimiento ambulatorio. Los resultados de la encuesta ayudarán a otros pacientes a tomar decisiones más informadas al seleccionar un centro de cirugía ambulatoria así como para ayudar a los centros que participan en el estudio a mejorar la calidad de la atención que proporcionan a sus pacientes.

Ya completé una encuesta por correo ¿Tengo que completar esta encuesta otra vez?

Muchas gracias por completar la encuesta y enviarla por correo. Sin embargo, aún no hemos recibido la encuesta, y estamos dándole seguimiento para obtener sus comentarios por teléfono. Si tiene tiempo en este momento puedo hacerle las preguntas. O le puedo volver a llamar en unos días si aún no hemos recibido la encuesta por correo.

Perdí la encuesta que se envía por correo ¿Me puede enviar otra por correo?

Estamos cerca del final del periodo de recolección de datos y no nos permiten enviar ninguna encuesta adicional. Como las opiniones que usted proporcione nos ayudarán a mejorar la calidad de la atención de pacientes de cirugía externa o ambulatoria que usted y otras personas reciben, le estamos pidiendo que por favor complete la encuesta con nosotros por teléfono. Si este es un buen momento, ¡comencemos!

Ya completé/recibí una encuesta como esa.

A veces los hospitales y los cirujanos llevan a cabo encuestas de sus pacientes recientes y usted pudiera haber recibido una de esas encuestas. La encuesta que le estamos pidiendo que haga es sobre su experiencia en la instalación de cirugía externa en donde le realizaron la cirugía o procedimiento. Los resultados se utilizarán para ayudar a las personas a tomar decisiones más informadas cuando eligen un centro para cirugía externa o ambulatoria. Los centros también van a utilizar la encuesta para ayudar a mejorar la calidad de los servicios que dan a sus pacientes.

¿Cómo se utilizarán los resultados del estudio?

Los resultados de esta encuesta se usarán para ayudar a las personas a tomar decisiones más informadas cuando eligen un centro para cirugía externa o ambulatoria. Los centros también van a utilizar la encuesta para ayudar a mejorar la calidad de los servicios que dan a sus pacientes.

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¿Tengo que participar en esta encuesta?

Su participación en esta encuesta es voluntaria. Toda la información que usted proporcione en esta encuesta se mantendrá confidencial y está protegida por la Ley de privacidad. Deseamos que sepa que ninguna de sus respuestas individuales se compartirán con [Facility Name], ni sabrán si usted participó o no.

También es importante que sepa que su decisión de participar en esta encuesta y sus respuestas a las preguntas no afectarán a ningún beneficio de atención médica que usted reciba ahora o que espere recibir en el futuro.

También se puede saltar o rehusar contestar cualquier pregunta que le moleste. Sin embargo, esperamos que participe porque los comentarios que usted nos dé nos ayudarán a mejorar la calidad de los servicios que recibe usted y otras personas como usted.

No tuve una cirugía. Esta encuesta no me corresponde.

Esta encuesta sí le corresponde si le realizaron un procedimiento médico o de diagnóstico en [Facility Name] en [mez, año]. Ejemplos de este tipo de procedimientos incluyen: colonoscopía, endoscopía, biopsia e inyección para control del dolor. [NOTE: IF NEEDED, EXPLAIN TO RESPONDENT HOW THEY WERE SELECTED: Usted fue seleccionado al azar para participar en esta encuesta porque nuestros registros indican que le realizaron un procedimiento en (Facility Name).]

No recuerdo ningún procedimiento/No tuve una cirugía en esa fecha.

Por razones de privacidad, no tenemos acceso a los procedimientos que le realizaron a usted en ese centro durante [MES]. Por favor trate de responder a las preguntas lo mejor que pueda para el procedimiento que mejor recuerde en [MES].

Mi cirugía no fue como paciente externo/ambulatorio porque me tuve que quedar una noche en el hospital/centro. Esta encuesta no me aplica.

Esta encuesta es para personas que tuvieron cirugía como pacientes externos, incluyendo a las personas que se fueron a casa el mismo día y los que se quedaron una noche para observación. Siempre y cuando se fuera a su casa después del periodo de observación y un doctor no le haya ordenado que se le admitiera en un hospital como paciente interno, entonces esto es para usted.

¿Qué tengo que hacer/Qué tipos de preguntas son?

Me gustaría hacerle algunas preguntas sobre sus experiencias con su reciente cirugía externa o procedimiento ambulatorio en [Facility Name]. Por ejemplo, las preguntas le pedirán sus experiencias con el proceso de registro, el centro de cirugía en sí, la comunicación que tuvo con el personal del centro de cirugía, la información que recibió sobre su procedimiento y su

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October 2015 Appendix J: Frequently Asked Questions for Telephone Interviews (Spanish)

experiencia en general. En promedio, esta encuesta se puede completar en unos 10 minutos y voy a avanzar con las preguntas tan rápido como sea posible.

¿Es posible que (la esposa, el esposo, el hijo, el tutor legal, etc.) responda a estas preguntas?

Como usted fue seleccionado(a) al azar para participar en este importante estudio y como usted fue la persona que recibió la atención médica para la cirugía externa o procedimiento ambulatorio, ninguna otra persona puede tomar su lugar. Pero se puede saltar o rehusar contestar cualquier pregunta que le moleste.

¿Cómo sé que esto es confidencial?

Las respuestas que usted dé solo serán vistas por el personal del estudio, quienes han firmado declaraciones de confidencialidad. Toda la información de identidad, como los nombres y las direcciones, serán separados de los registros de datos antes de ser analizados. Y, las respuestas de todas las personas se combinarán para generar un reporte de resumen.

¿Por qué desea saber todos esos datos personales acerca de mi (SALUD, RAZA, EDAD, etc.) si esta encuesta es acerca de mis experiencias sobre la atención médica durante mi cirugía externa o ambulatoria?

Entiendo su preocupación sobre las preguntas sobre su salud en general y antecedentes. Hemos encontrado que las experiencias de las personas pueden variar de acuerdo al estado salud y otras características. Esta es una encuesta muy importante. Si le molesta alguna pregunta, solo dígame que no desea responderla y avanzaré a la siguiente pregunta.

Estoy en la lista de no llamar. ¿Por qué me están llamando?

La lista de No llamar previene las llamadas de ventas y telemercadeo. Estamos llevando a cabo el estudio de encuesta a nombre de [Facility Name]. No le estamos llamando para vender o promover un producto o servicio.

¡No voy a responder a tantas preguntas por teléfono!

Su cooperación es muy importante para nosotros. La información que usted proporcione en esta encuesta ayudará a otras personas a tomar decisiones más informadas sobre un centro de cirugía externo o ambulatorio y ayudará al centro de cirugía, a mejorar sus servicios. Por favor tenga en cuenta que se puede saltar o negar a contestar cualquier pregunta que le moleste y que sus respuestas se mantendrán completamente confidenciales porque están protegidas por la ley federal de privacidad de 1974. Empecemos y usted podrá ver cómo son las preguntas…[READ FIRST QUESTION]

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¿Cómo obtuvo mi nombre? ¿Cómo me seleccionaron para la encuesta?

Su nombre se seleccionado al azar de una lista de pacientes en [Facility Name] que tuvieron una cirugía externa o procedimiento ambulatorio durante el mes de [TBD depende de cuando el paciente fue parte de la muestra].

¡No me agradó el centro de cirugía externa/ambulatoria!

Le entiendo. Sus opiniones son muy importantes y ayudarán a su centro de cirugía externa/ambulatoria a entender como mejorar sus servicios. Comencemos. [NOTE: DO NOT ARGUE BACK. MAKE SHORT, NEUTRAL COMMENTS TO LET THEM KNOW THAT YOU ARE LISTENING AND IMMEDIATELY ASK THE FIRST QUESTION.]

¿Cuánto tiempo va a tomar?

En promedio esta encuesta se puede completar como en 8 minutos. Trataré de hacer las preguntas tan rápido como me sea posible.

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APPENDIX K :

XML DATA FILE LAYOUT FOR STANDARD HEADER RECORD (FORTHCOMING)


Appendix K: XML Data File Layout for Standard Header Record October 2015



APPENDIX L :

XML DATA FILE LAYOUT FOR DSRS HEADER RECORD (FORTHCOMING)


Appendix L: XML Data File Layout for DSRS Header Record October 2015



APPENDIX M :

XML DATA FILE LAYOUT ZERO SAMPLED PATIENT FILE (FORTHCOMING)


Appendix M: XML Data File Layout Zero Sampled Patient File October 2015



APPENDIX N :

INSTRUCTIONS FOR PREPARING A SURVEY VENDOR QUALITY ASSURANCE PLAN


Appendix N: Instructions for Preparing a Survey Vendor Quality Assurance Plan October 2015



October 2015 Appendix N: Instructions for Preparing a Survey Vendor Quality Assurance Plan

INSTRUCTIONS FOR PREPARING A SURVEY VENDOR QUALITY ASSURANCE PLAN

Introduction: OAS CAHPS is a CMS-sponsored standardized survey instrument and data collection methodology for measuring patients’ perspectives on patient care received in HOPDs and ASCs. OAS CAHPS data provides the public with comparative information on HOPDs and ASCs and supports quality-related activities. (A definition of HOPD and ASC can be found in Chapter II – Introduction and Background.) Like other CAHPS programs, HOPDs and ASCs conducting OAS CAHPS contract with survey vendors to conduct data collection on their behalf. Survey data collection can be completed using one of three modes: mail only, telephone only, or mixed mode (mail with telephone follow-up).

Survey vendors must meet minimum business requirements posted on the OAS CAHPS website to become an OAS CAHPS vendor. These requirements include having experience conducting surveys and drawing statistical samples; possessing facilities and systems for survey operations; conducting all survey operations in the United States; and adhering to security and confidentiality procedures. Survey vendors meeting these minimum requirements will receive interim approval once they have (1) submitted their online vendor application, (2) satisfactorily answered follow-up questions about their application from the OAS CAHPS Survey Coordination Team and received CMS approval, (3) participated in the Introduction to the OAS CAHPS Survey training session, and (4) successfully completed a written Training Certification Form. With interim approval, vendors can begin conducting OAS CAHPS on behalf of client facilities. To become fully approved, vendors must complete the final step in the approval process: the submission of an acceptable Quality Assurance Plan (QAP). The QAP must be submitted within 6 weeks of the data submission deadline date after vendor’s first quarterly submission of OAS CAHPS data. It must be updated and resubmitted annually on or before April 30 and whenever the survey vendor makes key staff or protocol changes.

This purpose of this document is to serve as instructions for survey vendors to help them develop a QAP that describes their specific plans for implementation and compliance with all guidelines required to implement the OAS CAHPS Survey.

The vendor’s QAP should include the sections listed below. The specific requirements for these sections are described in the pages that follow.

I. Organization Background and Staff Experience

II. Identifying and Recruiting HOPDs and ASCs

III. Work Plan for Each Mode of Data Collection

IV. Sampling Plan

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V. Survey Implementation Plan

VI. Data Security, Confidentiality, and Privacy Plan

VII. Exceptions Request Process and Discrepancy Notification Reporting

VIII. Questionnaire and Materials Attachments

To facilitate review of the QAP, each vendor should use the outline format noted above.

I. ORGANIZATION BACKGROUND AND STAFF EXPERIENCE

In this section of the QAP, each OAS CAHPS Survey vendor must provide the following information:

• Your organization’s name, address, and telephone number. If your organization has multiple locations, include the address of both the main location and the address of the locations at which the primary operations, including sampling, data collection, and data processing activities, are being conducted.

• Describe the history and affiliation with any other organization (e.g., other company or university affiliation). Include the scope of business, number of years in business, and number of years of survey experience.

• Describe your organization’s survey experience conducting person-level surveys using each approved data collection mode that is allowed for the OAS CAHPS Survey, specifically, mail-only, CATI-only, and mixed mode (mail with CATI follow-up). Describe other CAHPS survey experience if you have it. You must discuss each data collection mode for which you have received approval, regardless of whether you have any HOPD or ASC clients who are using that mode.

• Provide an organizational chart that shows the names and titles of staff members, including subcontractors, who are responsible for each of the following tasks:

a. Overall project management, including tracking and supervision of all tasks below.

b. Explaining the nature of the project to hospitals and ASCs, including determining whether their facility is eligible.

c. Sampling procedures, including creation of the sample frame, selection of the sample, and assignment of a unique identification number to each sampled patient.

d. Data collection procedures, including overseeing implementation of the data collection mode for which your organization has been approved.

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e. Data receipt and data entry/scanning procedures.

f. File development and submission processes.

The organizational chart should also clearly specify all staff reporting relationships, including those staff who are responsible for managing subcontractors. It should designate any individuals who have quality assurance oversight responsibility and indicate which tasks they are responsible for.

• Summarize the background and experience of the individuals who are responsible for the tasks listed in the organizational chart above, including a description of any subcontractors serving in these roles. The description of each individual’s experience should include a discussion of how the person’s qualifications are relevant to the OAS CAHPS Survey tasks that he or she is expected to perform. Resumes should be available upon request.

II. IDENTIFYING AND RECRUITING HOPDS AND ASCS

• Describe your process for identifying hospitals and ASCs whom you will attempt to contract for OAS CAHPS. Clarify if you contact only those institutions with whom you already have a relationship, or if you also contact institutions you have not worked with previously.

• When working with hospitals to explain the study, how do you determine whether a particular hospital has one or more eligible HOPDs? What questions do hospitals have and how do you address these questions?

• When working with ASCs to explain the study, how do you determine which facilities or sites within their institution are eligible? What questions do ASCs have and how do you address these questions?

III.WORK PLAN

• Describe how your organization is implementing the OAS CAHPS Survey for each mode for which your organization has been approved. This section of your QAP must describe the entire process that your organization is following, including:

a. how you are obtaining the sample frame and selecting the sample;

b. how you are fielding the survey, receiving and processing the data;

c. the procedures that you are following to prepare and submit final files; and

d. the type of quality control procedures you are following at each stage to ensure data quality.



• For each step above, you must specify the name of the individual who is responsible for conducting and providing oversight of each specific activity.

• Include a copy of a schedule or timeline that you are following to ensure that you are able to conduct all activities within the timeframes specified in the OAS CAHPS Survey protocols. The timeline must describe when that activity will be completed (for example, x weeks after sample selection, or y weeks after mailing the first questionnaire). The timeline must include receipt of files from HOPDs and ASCs, sample selection, each step of the mailout or telephone implementation, data file cleaning, and data file preparation and submission.

IV. SAMPLING PLAN

• Describe how you are working with your client facilities to ensure that the HOPDs and ASCs understand patient survey eligibility criteria and the measures you take to ensure that all patient information needed for sample selection is included on the file that is submitted and that the monthly patient files are submitted in time for you to select the sample and initiate the survey within 21 days after the sample month ends.

• Describe how HOPDs or ASCs submit the monthly patient files to your organization and how you check those files. That is, describe the steps that you take to ensure that the ASC or HOPD has included all required data on the monthly patient files and the checks you make to ensure that the same patient information is not included more than once on the monthly patient information file. Describe how the transmission is done to ensure security of these HIPAA data.

• Describe how you create the sample frame. This section should describe the process you are using to develop a sampling frame that complies with the OAS CAHPS Survey protocol. Specifically, you must explain how you are creating the frame, what patient survey eligibility criteria you are using, and the types of patients who are being excluded and how those cases are being identified. Please make sure your QAP addresses each of the following questions:

a. How do you check monthly patient information files to determine if any required data for a patients is incomplete?

b. What do you do if information is missing from the monthly patient information files?

c. What are the eligibility and exclusion criteria that you use to determine which patients are eligible and which patients should be excluded from the sample frame? Refer to Chapter IV, Sampling Procedures – Patient Eligibility Criteria.

d. How do you know whether your client HOPDs and ASCS have included all patients on the monthly patient files? Do you obtain and retain documentation from the HOPDs and



ASCs about who was excluded and the reasons those patients were excluded from the monthly patient information files?

e. How do you know whether all eligible ASCs within the CCN, or all eligible HOPDs within the CCN, are submitting patient files?

f. Do you check the monthly patient information files to ensure that patients are only listed once on the file? If so, what information and process do you use to identify and remove patients who may have been listed on the monthly patient information file more than once?

g. What process (system or procedures) do you use to identify and remove patients who have been included in the survey sample in the last 5 months?

h. What process (system, software, or procedure) do you use to assign a unique patient identification number to each sample patient?

i. OAS CAHPS Survey vendors are expected to calculate and use a sample rate for each ASC and HOPD client to ensure that an even distribution of patients is sampled over a 12-month period. How do you determine a sample rate for each ASC and HOPD?

j. How is the sample selected? What software program do you use to generate the seed number and assign random numbers used for sampling?

k. What documentation about sample frame creation do you retain and for how long?

l. If the ASC or HOPD is also conducting other patient experience surveys, what procedures do you follow to ensure that the sample for OAS CAHPS is selected first, and is a random selection that is representative of the monthly patient records?

• Describe the quality control checks that you are performing on the sampling activities, how frequently those checks are being performed, and by whom. Indicate what percentage of the sample frame or sample file is being checked, and describe the documentation that you maintain to verify that the quality control procedures have taken place. Note that this documentation may be requested by the OAS CAHPS Survey Coordination Team at any time.

• If applicable, describe any sampling exceptions that you have requested or for which your firm has been approved. Explain the exceptions request and the specific procedures you are or will be following to implement the approved exception.



V. SURVEY IMPLEMENTATION PLAN

• Describe the system resources that you are using to implement your approved survey mode(s). This includes a description of the relevant hardware or software. For example, describe the electronic telephone interviewing systems, mailing equipment, scanning or data entry equipment, and case management system that you are using.

• Describe training that is being given to all staff working on the OAS CAHPS Survey project, including telephone interviewers (if applicable), mail survey production staff, and data receipt/data processing/data entry staffs. If you are using any subcontractors for any roles, describe how the subcontractor’s staff are being trained. Include a discussion of quality control procedures that you or your subcontractor are implementing during training to ensure compliance with OAS CAHPS Survey protocols. Describe the documentation that is being kept to provide evidence of this quality control.

• Describe the toll-free customer support telephone line that you are offering, including the actual telephone number, how customer support staff are being trained, and who is responsible for training and responding to questions related to the OAS CAHPS Survey. Also include information on the days of the week and times of the day that you are staffing the customer support line and how you are handling after-hours contacts, and include text of any recordings that are being used. Include a discussion of quality control procedures that are being implemented to ensure compliance with OAS CAHPS Survey protocols and describe documentation that is being kept to provide evidence of this quality control. (Reference chapter VI of this manual.)

• Describe the production and mailout process for mail surveys, if applicable, including who is responsible for the process and what quality control checks are being implemented at each stage (for example, monitoring the quality and content of mail survey packages, use of seeded mailings, and frequency of checks). Describe all quality control checks that are being implemented and documented to ensure that the OAS CAHPS Survey protocols are being followed. (Reference chapter V of this manual.)

• Describe the receipt and data entry or scanning process for mail surveys, if applicable, including who is responsible for the process and what quality control checks are being implemented at the questionnaire receipt, data entry, or scanning phase, and how frequently those checks are being made. Describe all quality control checks that are being implemented and documented to ensure that the OAS CAHPS Survey protocols are being followed. (Reference chapter V of this manual.)

• Describe the process for implementing the telephone survey, if applicable, including who is responsible for training and monitoring interviewer performance, how training and monitoring are being documented, and what systems and procedures are being used to ensure



that all interviewing is conducted according to the OAS CAHPS Survey protocols (for example, varying times of day that calls are attempted and tracking the status of call attempts). If you are using a telephone survey subcontractor, describe oversight activities you are conducting to ensure that the subcontractor is in compliance with OAS CAHPS Survey protocols. (Reference chapter VI of this manual.)

• If you are approved for mixed-mode administration, you must address all of the paragraphs above regarding both mail and telephone processes. In addition, you must include a discussion of the control system used to monitor case status as the case transitions from the mail phase of the survey to the telephone follow-up phase. Describe how you keep track of surveys that are returned while the telephone follow-up phase is in effect. Describe the processes that you have in place to ensure that sample members who have returned a completed survey are not called after the completed survey is received. How do you determine which completed survey to retain (mail or telephone interview data) if the sample member returns a completed survey and participates in a telephone interview? (Reference chapter VII of this manual.)

• Describe the processes you are using to create data files and submit them to the OAS CAHPS Survey Data Center through the OAS CAHPS Survey website. Discuss quality control checks that are being implemented during file creation, including how these checks are being documented. (Reference chapter XI of this manual.)

VI. DATA SECURITY, CONFIDENTIALITY, AND PRIVACY PLAN

• Describe the measures that you are taking to ensure data security, including a discussion of the use of passwords, file encryption, backup systems, and any other measures to ensure the security of OAS CAHPS Survey data. Describe how often passwords are changed. For both hardcopy questionnaires and electronic data files, describe how and for how long these materials will be stored and when and how they will be destroyed. (Reference chapter VIII of this manual.)

• Describe how individuals will be authorized and de-authorized to access personally identifiable information (PII). Include information about how confidentiality agreements are being implemented among vendor staff and any subcontractor staff. Describe how affidavits of confidentiality are being documented, background checks are being conducted, and confidentiality training procedures are being implemented. Include a copy of the confidentiality agreement that is being used as an appendix in your QAP. Describe the measures that are being taken to protect respondent privacy and ensure compliance with HIPAA requirements. Include information about how unauthorized individuals are being prevented from accessing PII and the survey data in physical and electronic format. (Reference chapter VIII of this manual.)



• If you are approved for telephone surveys, include a screenshot or text indicating the voluntary nature of the sample member’s participation.

VII. EXCEPTIONS REQUEST PROCESS AND DISCREPANCY NOTIFICATION REPORTING

• Describe any Exceptions Requests that you have or plan to request or document that you have none but agree to comply with the process outlined in chapter XV of this manual.

• Document your understanding of the Discrepancy Notification Reporting protocol outlined in chapter XV of this manual and that you agree to comply with the process.

VIII. QUESTIONNAIRE AND MATERIALS ATTACHMENTS

• Attach a copy of your formatted mail survey questionnaire if you are approved for mail-only or mixed-mode administration. Be sure to include the cover page and back page.

• If you are approved for telephone-only or mixed-mode administration, attach all screen shots from your telephone interview program—beginning with the introductory screens and ending with the last question in the interview. If your interview includes the Consent to Share Identifying Information question, please include a screen shot of this question as well.

• If you are approved for mail-only or mixed-mode administration, include a copy of your cover letter(s).


APPENDIX O:

EXCEPTIONS REQUEST FORM


October 2015 Appendix O: Exceptions Request Form

OUTPATIENT AND AMBULATORY SURGERY CAHPS SURVEYEXCEPTIONS REQUEST FORM

Use the Exceptions Request Form to report a planned deviation from the standard OAS CAHPS protocols. You may request the same exceptions for multiple Hospital Outpatient Departments (HOPDs) or Ambulatory Surgery Centers (ASCs) with which you contract, if applicable.

To submit this form online, please go to https://oascahps.org/.

I. Exception RequestPlease provide today’s date, select an exception request classification, and provide the specific reason for your exception request

1a. Date Submitted _______________________

1b. Exception Request Classification (Select one)

New Exception Request

Update list of applicable hospital outpatient departments and ambulatory surgery centers on a previous Exception Request

Update other information on a previous Exception Request

Appeal of denial of a previous Exception Request

1c. Specify Reason for Exception Request:

For example: “We request 5 additional business days to complete the phone attempts for three of our contracted facilities.”

II. Description of Exception Request2a. Purpose of requested exception (e.g., data issues).

For example: “The purpose is to allow us to complete the required telephone attempts for three of the facilities for which we collect data. A flu epidemic has spread through our area resulting in many telephone interviewers being unable to work for several days in a row.”

2b. How and when will the exception be implemented?

For example: “Instead of the final calling day being Friday, February 6, 2016, we will continue calling Friday, February 6 through Wednesday, February 11. The extension in the data collection period will allow us to finalize all outstanding phone cases.”

2c. Provide evidence that exception will not affect survey results.

For example: “This procedure will not impact survey results because it only applies to the pre-notification letter.” Or “If the extension is granted it will not impact our ability to meet the data submission deadline.”

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Appendix O: Exceptions Request Form October 2015

III. Which hospital outpatient departments and ambulatory surgery centers are impacted by this Exception Request?The vendor should revise the Exception Request if additional facilities (CCNs) need to be added after the initial Exception Request was submitted. If you have multiple CCN numbers, please enter them as a comma-separated list, as shown in the example below. Do not include dashes in the CCN number. After entering your CCN number(s), click on the "Lookup Facility Names" button.

For example: “111111, 222222, 333333”

Lookup Facility Names .

How many facilities are impacted? Enter number . .

To submit this form, visit the Outpatient and Ambulatory Surgery CAHPS Survey website at https://oascahps.org/. If you have any problems completing the online Exceptions Request Form, please e-mail the OAS CAHPS Survey Coordination Team at [email protected] for assistance.

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APPENDIX P:

DISCREPANCY NOTIFICATION REPORT


October 2015 Appendix P: Discrepancy Notification Report

OUTPATIENT AND AMBULATORY SURGERY CAHPS SURVEYDISCREPANCY NOTIFICATION REPORT

Use the Discrepancy Notification Report to notify the OAS CAHPS Survey Coordination Team of any unplanned deviation from the OAS CAHPS protocols that occurred.

To submit this form online, please go to https://oascahps.org/.

Date Submitted: <inserted by system>

I. Discrepancy Notification ReportOne Discrepancy Notification Report (DNR) is required for each discrepancy reason. If you have multiple CCNs with the same discrepancy reason, please include all CCNs on one DNR. If you have more than one discrepancy reason, you will need to submit a DNR for each discrepancy reason. To complete this form, please complete the following sections:

• Section I—Select the affected Survey Period and the reason for the discrepancy from the drop down boxes.

• Section II—Indicate how many facilities, and which CCNs, are impacted by the discrepancy reason.

• Section III—Provide a detailed description of the discrepancy being reported for each CCN and include the number of affected patients. If you do not know the number of affected patients, please enter UNK. If the number of affected patients is not applicable, enter NA.

• Section IV—Include a description of the corrective action your organization has taken to address the discrepancy.

• Section V—Provide any additional information about the discrepancy that you feel the OAS CAHPS Survey Coordination Team will need.

• Section V—Submit.

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Appendix P: Discrepancy Notification Report October 2015

II. Affected Facility or FacilitiesHow many facilities are affected? Enter number: . .

Please enter the CCN number(s) for which you are filing this discrepancy. If you have multiple CCN numbers, please enter them as a comma-separated list, as shown in the example below. Do not include dashes in the CCN number. After entering your CCN number(s), click on the “Lookup Facility Names” button.

Example: 111111, 222222, 333333

Lookup Facility Names .

III. Describe DiscrepancyPlease complete the items below in detail for each facility listed. Include adequate information so the OAS CAHPS team can fully understand this discrepancy and its root cause.

For example: “We had to mail out pre-notification letters after the deadline, because our vendor offices were closed due to inclement weather.” Or “It has come to our attention that an error occurred during data collection and the answers to Q8, Q9, and Q10 were all recorded as “refused” due to a programing error.”

IV Corrective ActionDescribe the corrective action(s) that will be taken to address discrepancy. Include the proposed timeline for the corrective action(s).

For example: “We have increased staff hours ensure that all pre-notification letters are sent no later than 2 days after the deadline.” Or “We have implemented quality control procedures and automated checks to prevent this type of programing error in the future. The CATI system now allows data to be recorded for the Q8, Q9, and Q10. In future survey periods the CATI instrument will be tested in both the development and live survey environments.”

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October 2015 Appendix P: Discrepancy Notification Report

V. Additional informationProvide additional information that will help the OAS CAHPS Survey Coordination Team understand the discrepancy.

For example: “Due to a blizzard the data collection facility was closed for two days before the pre-notification mailing deadline.” Or “This has been corrected for the current survey period. All additional survey data collected will not be impacted by this problem.”

VI. Submit.A Discrepancy Notification form will be submitted for the CCN number(s) listed above when you click the "Submit" button below. Please verify that the list is correct. If it is not correct, please edit your CCN number(s) above and click the Lookup button again.

To submit this form, visit the Outpatient and Ambulatory Surgery CAHPS Survey website at https://oascahps.org/. If you have any problems completing the online Discrepancy Notification Form, please e-mail the OAS CAHPS Survey Coordination Team at [email protected] for assistance.

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Appendix P: Discrepancy Notification Report October 2015


P-4 Centers for Medicare & Medicaid ServicesOutpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual

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