HCAHPS Update Training February 2009. 2 HCAHPS Update Training February 2009 Welcome! In the HCAHPS...

144
HCAHPS Update Training February 2009

Transcript of HCAHPS Update Training February 2009. 2 HCAHPS Update Training February 2009 Welcome! In the HCAHPS...

Page 1: HCAHPS Update Training February 2009. 2 HCAHPS Update Training February 2009 Welcome! In the HCAHPS Update Training sessions, we will: Explain purpose.

HCAHPS Update Training

February 2009

Page 2: HCAHPS Update Training February 2009. 2 HCAHPS Update Training February 2009 Welcome! In the HCAHPS Update Training sessions, we will: Explain purpose.

2

HCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update Training

February 2009

Welcome!In the HCAHPS Update Training sessions, we

will:

• Explain purpose and use of HCAHPS survey

• Provide instruction on managing the survey

• Discuss modes of survey administration

• Instruct on sampling, data preparation, data submission and public reporting

Page 3: HCAHPS Update Training February 2009. 2 HCAHPS Update Training February 2009 Welcome! In the HCAHPS Update Training sessions, we will: Explain purpose.

3

HCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update Training

February 2009

HCAHPS Program Updates

Page 4: HCAHPS Update Training February 2009. 2 HCAHPS Update Training February 2009 Welcome! In the HCAHPS Update Training sessions, we will: Explain purpose.

4

HCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update Training

February 2009

Overview of Presentation

HCAHPS Upcoming events

New for HCAHPS

Participation in HCAHPS

How to Join HCAHPS in 2009

Page 5: HCAHPS Update Training February 2009. 2 HCAHPS Update Training February 2009 Welcome! In the HCAHPS Update Training sessions, we will: Explain purpose.

5

HCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update Training

February 2009

Upcoming for HCAHPSMarch 26, 2009 Fifth public reporting of HCAHPS results;

July 2007-June 2008 discharges; ~3,800 hospitals

April 8 Submission deadline for 4th quarter 2008 data

April 10 - May 9 Preview Period for June public reporting

~ June 18 Sixth public reporting of HCAHPS results

~ September 17 Seventh public reporting of HCAHPS results

~ December 17 Eighth public reporting of HCAHPS results

Page 6: HCAHPS Update Training February 2009. 2 HCAHPS Update Training February 2009 Welcome! In the HCAHPS Update Training sessions, we will: Explain purpose.

6

HCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update Training

February 2009

New for HCAHPS• IPPS hospitals must report HCAHPS

results on Hospital Compare website

• Enhanced oversight

• New languages added for mail mode

• HCAHPS Mode Experiment Two– Testing feasibility of two new candidate

modes:• SE-IVR and Web-based

• New footnotes

Page 7: HCAHPS Update Training February 2009. 2 HCAHPS Update Training February 2009 Welcome! In the HCAHPS Update Training sessions, we will: Explain purpose.

7

HCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update Training

February 2009

New for HCAHPS (cont’d)• HCAHPS Bulletins

• HCAHPS Executive Insight

• HCAHPS Version 3.1 effective for second quarter 2009 discharges

• Hospitals with 5 or fewer HCAHPS-eligible patients need not survey from January 2009– However, still must submit header data

• Congress considering HCAHPS in possible pay-for-performance program

Page 8: HCAHPS Update Training February 2009. 2 HCAHPS Update Training February 2009 Welcome! In the HCAHPS Update Training sessions, we will: Explain purpose.

8

HCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update Training

February 2009

Public Reporting MARCH 2009

– QUARTERS INCLUDED: 3Q07, 4Q07, 1Q08, 2Q08

– PREVIEW PERIOD: January 19 – February 17

– PUBLIC REPORTING: March 26, 2009

– NOTE: First reporting of hospitals that joined HCAHPS in July 2007

– Data from 2Q07 has rolled off

Page 9: HCAHPS Update Training February 2009. 2 HCAHPS Update Training February 2009 Welcome! In the HCAHPS Update Training sessions, we will: Explain purpose.

9

HCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update Training

February 2009

Survey Mode

Second quarter 2008 hospitals (3,866):

•Mail: 2,833 hospitals; 73%•Telephone: 990 hospitals; 26%•Mixed: 8 hospitals; 0.2%• IVR: 35 hospitals; 1%

Page 10: HCAHPS Update Training February 2009. 2 HCAHPS Update Training February 2009 Welcome! In the HCAHPS Update Training sessions, we will: Explain purpose.

10

HCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update Training

February 2009

Participation in HCAHPS

Second quarter 2008:

• 50 Approved survey vendors • 93 Self-administering

hospitals• 5 Multi-site hospitals

Page 11: HCAHPS Update Training February 2009. 2 HCAHPS Update Training February 2009 Welcome! In the HCAHPS Update Training sessions, we will: Explain purpose.

11

HCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update Training

February 2009

Oversight and Compliance

As HCAHPS plays a greater role in hospital payment,

The importance of oversight

and compliance increase

Page 12: HCAHPS Update Training February 2009. 2 HCAHPS Update Training February 2009 Welcome! In the HCAHPS Update Training sessions, we will: Explain purpose.

12

HCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update Training

February 2009

Steps to Join HCAHPS in 2009

1. Submit HCAHPS Participation Form • For self-administering hospitals, hospitals

administering survey for multiple sites and survey vendors

• Form now available online

2. Do an HCAHPS Dry Run• Voluntary, but strongly suggested• Last month of calendar quarter • Contact HCAHPS Project Team for details

[email protected]

3. Collect and submit HCAHPS survey data on continuous basis

Page 13: HCAHPS Update Training February 2009. 2 HCAHPS Update Training February 2009 Welcome! In the HCAHPS Update Training sessions, we will: Explain purpose.

13

HCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update Training

February 2009

More information on HCAHPS

• Registration, applications, background information,

reports, updates and HCAHPS Executive Insight :

www.hcahpsonline.org

• Submitting HCAHPS data:

www.qualitynet.org

• Publicly reported HCAHPS results:

www.hospitalcompare.hhs.gov

Page 14: HCAHPS Update Training February 2009. 2 HCAHPS Update Training February 2009 Welcome! In the HCAHPS Update Training sessions, we will: Explain purpose.

14

HCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update Training

February 2009

Questions?

Page 15: HCAHPS Update Training February 2009. 2 HCAHPS Update Training February 2009 Welcome! In the HCAHPS Update Training sessions, we will: Explain purpose.

15

HCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update Training

February 2009

HCAHPS Participation and

Program Requirements

Page 16: HCAHPS Update Training February 2009. 2 HCAHPS Update Training February 2009 Welcome! In the HCAHPS Update Training sessions, we will: Explain purpose.

16

HCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update Training

February 2009

Participation Overview

• Quality Assurance Guidelines V4.0

• Quality Assurance Plans

• Exceptions Request/Discrepancy Report

• HCAHPS Website

Page 17: HCAHPS Update Training February 2009. 2 HCAHPS Update Training February 2009 Welcome! In the HCAHPS Update Training sessions, we will: Explain purpose.

17

HCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update Training

February 2009

HCAHPS Quality Assurance Guidelines

V4.0• General updates:

– Terminology changes• Web site; My QualityNet; CMS Certification Number

– Updates to Introduction and Overview• Mode Experiment II information• Updated 2009 timeline

– Program Requirements• Reminder that the HCAHPS survey must be administered before

any other survey• Data submission for “zero case” and fewer than 5 eligible

discharges in a month• Maintain counts of ineligible patients and exclusions

Page 18: HCAHPS Update Training February 2009. 2 HCAHPS Update Training February 2009 Welcome! In the HCAHPS Update Training sessions, we will: Explain purpose.

18

HCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update Training

February 2009

HCAHPS Quality Assurance Guidelines V4.0 (cont’d)

• General updates (cont’d):– Additional methodologies approved to

determine HCAHPS service line– Sample Frame must be maintained for 3

years– Two new mail survey translations– Updates to the Telephone and IVR scripts– XML File Layout 3.1– Appendices

Page 19: HCAHPS Update Training February 2009. 2 HCAHPS Update Training February 2009 Welcome! In the HCAHPS Update Training sessions, we will: Explain purpose.

19

HCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update Training

February 2009

Quality Assurance Plan (QAP)

• QAP 2009 submission date March 23, 2009– Appendix N– Revisions must be clearly identified

(track changes)– Must include a discussion of the

results of quality control activities conducted during the prior year

Page 20: HCAHPS Update Training February 2009. 2 HCAHPS Update Training February 2009 Welcome! In the HCAHPS Update Training sessions, we will: Explain purpose.

20

HCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update Training

February 2009

Quality Assurance Plan (QAP) (cont’d)

• QAP 2009 submission date March 23, 2009 (cont’d)

• Include sample(s) of survey and cover letter (Mail Only and Mixed modes)

• Include sample(s) of telephone script (screen shots Telephone Only and Mixed modes)

• Include sample(s) of IVR Script (Active IVR mode)

• All survey languages administered

Page 21: HCAHPS Update Training February 2009. 2 HCAHPS Update Training February 2009 Welcome! In the HCAHPS Update Training sessions, we will: Explain purpose.

21

HCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update Training

February 2009

HCAHPS Exceptions Request

• Exceptions Request required to use a service line determination methodology other than:– V.26 or V.25 MS-DRG codes– V.24 CMS-DRG codes– Mix of V.26, V.25, V.24 codes based on payer

source– ICD-9 codes– Hospital unit– New York State DRGs

Page 22: HCAHPS Update Training February 2009. 2 HCAHPS Update Training February 2009 Welcome! In the HCAHPS Update Training sessions, we will: Explain purpose.

22

HCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update Training

February 2009

HCAHPS Exceptions Request

• Exceptions Request must be submitted online via the HCAHPS Web site

• Survey Vendors must submit Exceptions Request on behalf of their contracted hospital

• Organization submitting the Exceptions Request will receive notification emails

Page 23: HCAHPS Update Training February 2009. 2 HCAHPS Update Training February 2009 Welcome! In the HCAHPS Update Training sessions, we will: Explain purpose.

23

HCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update Training

February 2009

Discrepancy Report• Discrepancy Reports must be submitted

online via the HCAHPS Web site• Survey Vendors must submit Discrepancy

Report on behalf of their contracted hospital• Organization submitting the Discrepancy

Report will receive notification emails• Detailed information and hospital CCN

required• Reviewed each reporting period

Page 24: HCAHPS Update Training February 2009. 2 HCAHPS Update Training February 2009 Welcome! In the HCAHPS Update Training sessions, we will: Explain purpose.

24

HCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update Training

February 2009

Discrepancy Report (cont’d)

• Reviewed each reporting period

• Timing of notification emails

Page 25: HCAHPS Update Training February 2009. 2 HCAHPS Update Training February 2009 Welcome! In the HCAHPS Update Training sessions, we will: Explain purpose.

25

HCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update Training

February 2009

HCAHPS Web site• Regular update items

– HCAHPS Executive Insights

– PMA Tables

– Data Submission Due Date Announcements

– HCAHPS Bulletin

– Online Form Submission

Page 26: HCAHPS Update Training February 2009. 2 HCAHPS Update Training February 2009 Welcome! In the HCAHPS Update Training sessions, we will: Explain purpose.

26

HCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update Training

February 2009

Questions?

Page 27: HCAHPS Update Training February 2009. 2 HCAHPS Update Training February 2009 Welcome! In the HCAHPS Update Training sessions, we will: Explain purpose.

27

HCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update Training

February 2009

Sampling Protocol

Page 28: HCAHPS Update Training February 2009. 2 HCAHPS Update Training February 2009 Welcome! In the HCAHPS Update Training sessions, we will: Explain purpose.

28

HCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update Training

February 2009

Overview

• Steps of Sampling Process

• Population, Sample Frame and Sample

• Sampling Facts

Page 29: HCAHPS Update Training February 2009. 2 HCAHPS Update Training February 2009 Welcome! In the HCAHPS Update Training sessions, we will: Explain purpose.

29

HCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update Training

February 2009

Steps of Sampling Process

1. Population (All Patient Discharges)2. Identify Eligible Patients3. Remove Exclusions4. De-Duplication Process5. HCAHPS Sample Frame6. Draw Sample

See Quality Assurance Guidelines V4.0, Flowchart of HCAHPS Sampling Protocol

Page 30: HCAHPS Update Training February 2009. 2 HCAHPS Update Training February 2009 Welcome! In the HCAHPS Update Training sessions, we will: Explain purpose.

30

HCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update Training

February 2009

Step 1: Population(All Patient Discharges)

Page 31: HCAHPS Update Training February 2009. 2 HCAHPS Update Training February 2009 Welcome! In the HCAHPS Update Training sessions, we will: Explain purpose.

31

HCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update Training

February 2009

Step 1: Population (cont’d)

• Patients of all payer types are eligible for sampling

• Hospitals contracting with survey vendors are strongly encouraged to provide entire patient discharge list (excluding no-publicity patients and patients excluded because of state regulations) to their survey vendor

Page 32: HCAHPS Update Training February 2009. 2 HCAHPS Update Training February 2009 Welcome! In the HCAHPS Update Training sessions, we will: Explain purpose.

32

HCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update Training

February 2009

Step 2: Identify Eligible Patients

All Eligible Patients

• 18 years or older at the time of admission

• Admission includes at least one overnight stay in the hospital

• Non-psychiatric MS-DRG/principal diagnosis at discharge

• Alive at the time of discharge

Ineligible Patients

Record count of Ineligible patients

Page 33: HCAHPS Update Training February 2009. 2 HCAHPS Update Training February 2009 Welcome! In the HCAHPS Update Training sessions, we will: Explain purpose.

33

HCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update Training

February 2009

Step 2: Identify Eligible Patients Eligibility Criteria

(cont’d)• V.26 MS-DRGs effective October 1, 2008

– To classify into Medical and Surgical service lines

• The Federal Register Notice – most recent August 19, 2008 (updated approximately twice per year)

– To classify into Maternity Care service line• Use MS-DRGs 765 – 768, 774, 775

• Current Service Line-MS-DRG Crosswalk Table– Quality Assurance Guidelines V4.0

Page 34: HCAHPS Update Training February 2009. 2 HCAHPS Update Training February 2009 Welcome! In the HCAHPS Update Training sessions, we will: Explain purpose.

34

HCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update Training

February 2009

Step 2: Identify Eligible Patients Eligibility Criteria

(cont’d)• Effective with Version 3.1 2Q 2009 patient discharges - accepted methodologies for determination of service line (Exceptions Request not required)– V.26 or V.25 MS-DRG codes– V.24 CMS-DRG codes– Mix of V.26, V.25, V.24 codes based on payer source– ICD-9 codes– Hospital unit– New York State DRGs

Hospitals/Survey vendors must submit an Exceptions Request Form online for approval to use other means.

Page 35: HCAHPS Update Training February 2009. 2 HCAHPS Update Training February 2009 Welcome! In the HCAHPS Update Training sessions, we will: Explain purpose.

35

HCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update Training

February 2009

Step 2: Identify Eligible Patients Eligibility Criteria

(cont’d)• Include patients unless have positive

evidence that a patient is ineligible– Missing or incomplete MS-DRG, address

and/or telephone number does not exclude patient from being sampled

– Nursing home patients must not be excluded

Page 36: HCAHPS Update Training February 2009. 2 HCAHPS Update Training February 2009 Welcome! In the HCAHPS Update Training sessions, we will: Explain purpose.

36

HCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update Training

February 2009

Step 2: Identify Eligible Patients

Eligibility Criteria (cont’d)• Do not include patients with

discharge dates beyond the 42-day initial contact period in the sample frame– Discrepancy Report must be filed to

account for patient information received beyond the 42-day initial contact protocol

Page 37: HCAHPS Update Training February 2009. 2 HCAHPS Update Training February 2009 Welcome! In the HCAHPS Update Training sessions, we will: Explain purpose.

37

HCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update Training

February 2009

Step 3: Remove Exclusions

All Eligible Patients

Ineligible Patients

Exclusions• “No-Publicity” patients• Court/Law enforcement patients

(i.e., prisoners)• Patients with a foreign home

address Patients discharged to hospice care

• Patients who are excluded because of state regulations

Page 38: HCAHPS Update Training February 2009. 2 HCAHPS Update Training February 2009 Welcome! In the HCAHPS Update Training sessions, we will: Explain purpose.

38

HCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update Training

February 2009

Step 3: Remove Exclusions (cont’d)

• Record count of patients by each exclusions category

• Hospitals/Survey vendors must retain documentation that verifies all exclusions

Page 39: HCAHPS Update Training February 2009. 2 HCAHPS Update Training February 2009 Welcome! In the HCAHPS Update Training sessions, we will: Explain purpose.

39

HCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update Training

February 2009

Step 4: De-Duplication Process

All Eligible Patients

Ineligible Patients

Exclusions

De-Duplication• Household• Multiple Discharges

Page 40: HCAHPS Update Training February 2009. 2 HCAHPS Update Training February 2009 Welcome! In the HCAHPS Update Training sessions, we will: Explain purpose.

40

HCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update Training

February 2009

Step 4: De-Duplication Process

De-Duplication by Household• Sample only one patient per

household in a given calendar month– De-duplicate address and/or telephone

number from medical records and patient unique IDs within each month

– Do not de-duplicate address and/or telephone number for nursing homes, long-term care facilities, etc., unless residents are family members

Page 41: HCAHPS Update Training February 2009. 2 HCAHPS Update Training February 2009 Welcome! In the HCAHPS Update Training sessions, we will: Explain purpose.

41

HCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update Training

February 2009

• Sample patient only once in a given calendar month– For continuous sampling, only use the

first discharge date– For weekly sampling, use the last

discharge during the week – For end of the month sampling, de-

duplicate across all discharges in the month and only use the last discharge

Patients are eligible to be included in the sample in consecutive months.

Step 4: De-Duplication Process

De-Duplication by Multiple Discharges

Page 42: HCAHPS Update Training February 2009. 2 HCAHPS Update Training February 2009 Welcome! In the HCAHPS Update Training sessions, we will: Explain purpose.

42

HCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update Training

February 2009

Step 5: HCAHPS Sample Frame

All HCAHPS Eligible Patients(Sample Frame)

Ineligible Patients

Exclusions

De-Duplication• Household• Multiple Discharges

Page 43: HCAHPS Update Training February 2009. 2 HCAHPS Update Training February 2009 Welcome! In the HCAHPS Update Training sessions, we will: Explain purpose.

43

HCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update Training

February 2009

Step 5: HCAHPS Sample Frame Sample Frame

Creation1. Survey vendor generates sample frame (Recommended)

– Contracted hospital submits their entire patient discharge list, excluding no-publicity patients and patients excluded because of state regulations

– Survey vendor applies Eligible Population criteria and removes Exclusions and generates the sample frame before sampling

Page 44: HCAHPS Update Training February 2009. 2 HCAHPS Update Training February 2009 Welcome! In the HCAHPS Update Training sessions, we will: Explain purpose.

44

HCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update Training

February 2009

Step 5: HCAHPS Sample Frame

Sample Frame Creation (cont’d)2. Hospital generates sample frame

– File contains all patients that meet Eligible Population criteria

– Hospital provides all required data file elements• Total count of ineligible patients• Total count of patients by each exclusions category

– Survey vendor validates the integrity of the sample frame before sampling

Page 45: HCAHPS Update Training February 2009. 2 HCAHPS Update Training February 2009 Welcome! In the HCAHPS Update Training sessions, we will: Explain purpose.

45

HCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update Training

February 2009

Step 5: HCAHPS Sample Frame Sample Frame

Creation (cont’d)• Include all patients:

– Who meet eligible population criteria – Discharged between first and last days

of month• Include patients even if:

– Missing or incomplete address/telephone number

– Missing eligibility criteria

Page 46: HCAHPS Update Training February 2009. 2 HCAHPS Update Training February 2009 Welcome! In the HCAHPS Update Training sessions, we will: Explain purpose.

46

HCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update Training

February 2009

Step 5: HCAHPS Sample Frame Sample Frame

Creation(cont’d)• Do not include patients if:

– Discharge dates beyond the 42-day initial contact period if known before sample drawn

• Discrepancy Report must be filed to account for patient information received beyond the 42-day initial contact protocol

• Include these patients towards the count in the Eligible Discharge field

Page 47: HCAHPS Update Training February 2009. 2 HCAHPS Update Training February 2009 Welcome! In the HCAHPS Update Training sessions, we will: Explain purpose.

47

HCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update Training

February 2009

• Must maintain sample frame for a minimum of three years

• Updated sample frame layout (Appendix K)– File Content (i.e., All Patient Discharges or HCAHPS

Sample Frame)– Total Number of Ineligibles– Total Number of Exclusions and by Exclusions

Category– Total Number of Patient Discharges

Step 5: HCAHPS Sample Frame

HCAHPS Sample Frame

Page 48: HCAHPS Update Training February 2009. 2 HCAHPS Update Training February 2009 Welcome! In the HCAHPS Update Training sessions, we will: Explain purpose.

48

HCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update Training

February 2009

Step 6: Draw SampleEligible Patients

Not Selected for Sample

Ineligible Patients

Exclusions

De-Duplication

Sample1. Simple Random Sample

(SRS)2. Proportionate Stratified

Random Sample (PSRS)3. Disproportionate Stratified

Random Sample (DSRS)

Page 49: HCAHPS Update Training February 2009. 2 HCAHPS Update Training February 2009 Welcome! In the HCAHPS Update Training sessions, we will: Explain purpose.

49

HCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update Training

February 2009

Population, Sample Frame and Sample

A + B + C + D + E= Hospital Population (All Patient Discharges)

A + B = HCAHPS Sample Frame: generated by hospital/survey vendor. Contains entire Eligible Population

A = Sample: randomly selected

C

DE

A

B

A B C D E

Population (All Patient Discharges)

Sample Drawn

Page 50: HCAHPS Update Training February 2009. 2 HCAHPS Update Training February 2009 Welcome! In the HCAHPS Update Training sessions, we will: Explain purpose.

50

HCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update Training

February 2009

Sampling Facts• Same sampling type must be

maintained throughout the quarter • Sample must include discharges from

each month in the 12-month reporting period

• HCAHPS random sample drawn first if multiple surveys administered

• Do not stop sampling/surveying if 300 completes attained

Page 51: HCAHPS Update Training February 2009. 2 HCAHPS Update Training February 2009 Welcome! In the HCAHPS Update Training sessions, we will: Explain purpose.

51

HCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update Training

February 2009

Questions?

Page 52: HCAHPS Update Training February 2009. 2 HCAHPS Update Training February 2009 Welcome! In the HCAHPS Update Training sessions, we will: Explain purpose.

52

HCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update Training

February 2009

Survey Administration

Page 53: HCAHPS Update Training February 2009. 2 HCAHPS Update Training February 2009 Welcome! In the HCAHPS Update Training sessions, we will: Explain purpose.

53

HCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update Training

February 2009

Overview

• Survey Translations and Materials

• Survey Management

• Modes of Survey Administration

Page 54: HCAHPS Update Training February 2009. 2 HCAHPS Update Training February 2009 Welcome! In the HCAHPS Update Training sessions, we will: Explain purpose.

54

HCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update Training

February 2009

Survey Translations and Materials

• Mail survey materials availability—questionnaires, alternative survey instructions (circle responses), cover letters, and OMB language – English language materials (Appendix A)– Spanish language materials (Appendix B)– Chinese language materials (Appendix C)– Russian language materials (Appendix D)– Vietnamese language materials (Appendix E)

Page 55: HCAHPS Update Training February 2009. 2 HCAHPS Update Training February 2009 Welcome! In the HCAHPS Update Training sessions, we will: Explain purpose.

55

HCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update Training

February 2009

Survey Translations and Materials (cont’d)

• Telephone and IVR survey materials availability—scripts – English telephone script (Appendix F)– Spanish telephone script (Appendix G)– English IVR script (Appendix H)

Page 56: HCAHPS Update Training February 2009. 2 HCAHPS Update Training February 2009 Welcome! In the HCAHPS Update Training sessions, we will: Explain purpose.

56

HCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update Training

February 2009

Survey Management • Personnel training and oversight

– Project staff and subcontractors• Training• Ongoing oversight • Performance evaluation

– Volunteer staff must not be used

Page 57: HCAHPS Update Training February 2009. 2 HCAHPS Update Training February 2009 Welcome! In the HCAHPS Update Training sessions, we will: Explain purpose.

57

HCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update Training

February 2009

Modes of Administration • Data collection begins within 48 hours to 6 weeks

(42 days) after discharge from hospital– Lag time = the number of days between the patient’s

discharge from the hospital and the return of the mail survey, or the final disposition of the telephone or IVR survey

• If a patient is found to be ineligible, discontinue survey administration for that patient

• No changes are permitted to the order of the questions or answer categories for the Core or “About You” questions

• The “About You” questions must remain as one block of questions

Page 58: HCAHPS Update Training February 2009. 2 HCAHPS Update Training February 2009 Welcome! In the HCAHPS Update Training sessions, we will: Explain purpose.

58

HCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update Training

February 2009

Mail Only Mode

• Questionnaire formatting requirement– Name and return address of

hospital/survey vendor must be printed on the questionnaire• Hospital/Survey vendor must add this

requirement to their survey templates as they update them

Page 59: HCAHPS Update Training February 2009. 2 HCAHPS Update Training February 2009 Welcome! In the HCAHPS Update Training sessions, we will: Explain purpose.

59

HCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update Training

February 2009

Mail Only Mode (cont’d)

• Mail Out - Requirements– Addresses acquired from hospital record– Addresses updated using

commercial software– Mailings sent to patients by name

Page 60: HCAHPS Update Training February 2009. 2 HCAHPS Update Training February 2009 Welcome! In the HCAHPS Update Training sessions, we will: Explain purpose.

60

HCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update Training

February 2009

Mail Only Mode (cont’d) • Quality control guidelines

– Hospitals/Survey vendors must:• Provide ongoing oversight of staff and

subcontractors

• Conduct seeded mailings to project staff for timeliness and accuracy of delivery

• Check for accuracy of mailing contents

Page 61: HCAHPS Update Training February 2009. 2 HCAHPS Update Training February 2009 Welcome! In the HCAHPS Update Training sessions, we will: Explain purpose.

61

HCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update Training

February 2009

Telephone/IVR Mode• Protocol

– Initiate systematic telephone contact with sampledpatient(s) between 48 hours and 6 weeks (42 days) after discharge

– Complete telephone sequence within 42 days of initiation so that a total of 5 telephone calls are attempted• at different times of day• on different days of the week• and in more than one week

– Submit data to CMS via My QualityNet by the data submission deadline

Page 62: HCAHPS Update Training February 2009. 2 HCAHPS Update Training February 2009 Welcome! In the HCAHPS Update Training sessions, we will: Explain purpose.

62

HCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update Training

February 2009

Telephone/IVR Mode (cont’d)

• Obtaining telephone numbers– Main source of telephone numbers is

hospital discharge records– Must attempt to update missing or

incorrect telephone numbers using • commercial software • internet directories• directory assistance • other tested methods

Page 63: HCAHPS Update Training February 2009. 2 HCAHPS Update Training February 2009 Welcome! In the HCAHPS Update Training sessions, we will: Explain purpose.

63

HCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update Training

February 2009

Telephone/IVR ScriptINTRO1 Hello, may I please speak to [SAMPLED PATIENT NAME]? (Appendices F & G)

<1> YES [GO TO INTRO2]<2> NO [REFUSAL]<3> NO, NOT AVAILABLE RIGHT NOW [SET CALLBACK]

IF ASKED WHO IS CALLING: This is [INTERVIEWER NAME] calling from [DATA COLLECTION CONTRACTOR]. We are conducting a survey about healthcare. I am calling to talk to [SAMPLED PATIENT NAME] about a recent healthcare experience.

IF ASKED WHETHER PERSON CAN SERVE AS PROXY FOR SAMPLED PATIENT:For this survey, we need to speak directly to [SAMPLED PATIENT NAME]. Is [SAMPLED PATIENT NAME] available?

IF THE SAMPLED PATIENT IS NOT AVAILABLE:Can you tell me a convenient time to call back to speak with (him/her)?

IF THE SAMPLED PATIENT SAYS THIS IS NOT A GOOD TIME:If you don’t have the time now, when is a more convenient time to call you back?

Page 64: HCAHPS Update Training February 2009. 2 HCAHPS Update Training February 2009 Welcome! In the HCAHPS Update Training sessions, we will: Explain purpose.

64

HCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update Training

February 2009

Telephone/IVR ScriptINTRO2 Hi, this is [INTERVIEWER NAME] calling on behalf of [HOSPITAL NAME].

[HOSPITAL NAME] is participating in a survey about the care people receive in the hospital. This survey is part of a national initiative to measure the quality of care in hospitals. Survey results can be used by people to choose a hospital. Your answers may be shared with the hospital for purposes of quality improvement.

Participation in the survey is completely voluntary and will not affect your health care or your benefits. It should take about 7 minutes to answer. NOTE: THE NUMBER OF MINUTES WILL DEPEND ON WHETHER HCAHPS IS INTEGRATED WITH HOSPITAL-SPECIFIC QUESTIONS.

This call may be monitored [recorded] for quality improvement purposes.

OPTIONAL QUESTION TO INCLUDE:I’d like to begin the survey now, is this a good time for us to

continue?

Page 65: HCAHPS Update Training February 2009. 2 HCAHPS Update Training February 2009 Welcome! In the HCAHPS Update Training sessions, we will: Explain purpose.

65

HCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update Training

February 2009

Telephone/IVR Script• “About You” questions introduction

Q23_INTRO This last set of questions is about you. Please listen to all response choices before you answer the following questions.

Q23 In general, how would you rate your overall health? Would you say that it is…

<1> Excellent,<2> Very good,<3> Good,<4> Fair, or<5> Poor?<M> MISSING/DK

Page 66: HCAHPS Update Training February 2009. 2 HCAHPS Update Training February 2009 Welcome! In the HCAHPS Update Training sessions, we will: Explain purpose.

66

HCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update Training

February 2009

Telephone/IVR Script (cont’d)

• Race questions instruction[FOR TELEPHONE INTERVIEWING THIS QUESTION IS BROKEN INTO PARTS A-E.]

READ ALL RACE CATEGORIES PAUSING AT EACH RACE CATEGORY TO ALLOW RESPONDENT TO REPLY TO EACH RACE CATEGORY.

Q26 When I read the following list, please tell me if the category describes your race. You may choose one or more.

Q26A Are you White?<1> YES/WHITE<0> NO/NOT WHITE<M> MISSING/DK

Q26B Are you Black or African-American?<1> YES/BLACK OR AFRICAN-AMERICAN<0> NO/NOT BLACK OR AFRICAN-AMERICAN <M> MISSING/DK

Read Questions A through E to capture multiple races. Do not stop reading the list when you get a Yes answer.

Page 67: HCAHPS Update Training February 2009. 2 HCAHPS Update Training February 2009 Welcome! In the HCAHPS Update Training sessions, we will: Explain purpose.

67

HCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update Training

February 2009

Telephone Script

• Race questions probe

IF THE RESPONDENT REPLIES “I ALREADY TOLD YOU MY RACE”:

I understand, however the survey requires me to ask about all races so results can include people who are multiracial. If the race does not apply to you please answer no. Thanks for your patience.

Page 68: HCAHPS Update Training February 2009. 2 HCAHPS Update Training February 2009 Welcome! In the HCAHPS Update Training sessions, we will: Explain purpose.

68

HCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update Training

February 2009

Telephone Only Mode (cont’d)

• Quality control guidelines

– Formal interviewer training to ensure standardized, non-directive interviews

– Telephone monitoring and oversight of staff and subcontractors

• At least 10% of interviews are monitored

Page 69: HCAHPS Update Training February 2009. 2 HCAHPS Update Training February 2009 Welcome! In the HCAHPS Update Training sessions, we will: Explain purpose.

69

HCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update Training

February 2009

Questions?

Page 70: HCAHPS Update Training February 2009. 2 HCAHPS Update Training February 2009 Welcome! In the HCAHPS Update Training sessions, we will: Explain purpose.

70

HCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update Training

February 2009

Data Coding, Preparation and

Submission

Page 71: HCAHPS Update Training February 2009. 2 HCAHPS Update Training February 2009 Welcome! In the HCAHPS Update Training sessions, we will: Explain purpose.

71

HCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update Training

February 2009

Overview

• File Specifications Version 3.1• File Layout Version 3.1

– Header Record– Patient Administrative Data Record– Patient Response/Survey Results Record

• Preparing the Data File• Data Submission Timeline

Page 72: HCAHPS Update Training February 2009. 2 HCAHPS Update Training February 2009 Welcome! In the HCAHPS Update Training sessions, we will: Explain purpose.

72

HCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update Training

February 2009

File Specifications Version 3.1

• Effective with patient discharges beginning 2Q 2009– Appendix L – Data File Structure Version

3.1– Appendix M – XML File Layout Version 3.1

• XML Filenames increased to 50 characters

• Anticipated release of File Specifications 3.1 in early April 2009

Page 73: HCAHPS Update Training February 2009. 2 HCAHPS Update Training February 2009 Welcome! In the HCAHPS Update Training sessions, we will: Explain purpose.

73

HCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update Training

February 2009

File Specifications Version 3.1 (cont’d)

• Do not submit April 2009 and forward discharge data until HCAHPS Version 3.1 release is announced

• Monitor HCAHPS Web site for notification of release

Page 74: HCAHPS Update Training February 2009. 2 HCAHPS Update Training February 2009 Welcome! In the HCAHPS Update Training sessions, we will: Explain purpose.

74

HCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update Training

February 2009

Header Record Version 3.1

Field Name Description

Provider Name Name of the hospital

Provider ID CMS Certification Number (CCN), formerly known as the Medicare Provider Number

NPI National Provider Identifier (optional)

Discharge Year Year of discharge

Discharge Month Month of discharge

Survey Mode Mode of survey administration

Determination of Service Line

Methodology used by a facility to determine whether a patient falls into one of the three service line categories eligible for HCAHPS survey

Eligible Discharges Number of eligible discharges in sample frame in the month

Sample Size Number of sampled discharges in the month

Type of Sampling Type of sampling utilized

DSRS Strata Name If sampling type is DSRS, the name of strata

DSRS Eligible If sampling type is DSRS, the number of eligible patients within the stratum

DSRS Sample Size If sampling type is DSRS, the number of sampled patients within the stratum

Page 75: HCAHPS Update Training February 2009. 2 HCAHPS Update Training February 2009 Welcome! In the HCAHPS Update Training sessions, we will: Explain purpose.

75

HCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update Training

February 2009

File Layout Version 3.1

1. Header Record (Updated Version 3.1)– Complete once per monthly file per CCN

2. Patient Administrative Data Record (Updated Version 3.1)− Complete for every patient in the sample

3. Patient Response/Survey Results Record– Complete for patients who responded to the

survey• “Final Survey Status” of “1 - Completed Survey” or

“6 – Non-response: Break-off”– Enter missing responses as “M - Missing/Don’t

Know” or “8 - Not Applicable”

Page 76: HCAHPS Update Training February 2009. 2 HCAHPS Update Training February 2009 Welcome! In the HCAHPS Update Training sessions, we will: Explain purpose.

76

HCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update Training

February 2009

Header Record Version 3.1 (cont’d)

• All fields in the Header Record must have a valid value

• Exceptions:– NPI (optional)– DSRS Strata Name (required only if DSRS)– DSRS Eligible (required only if DSRS)– DSRS Sample Size (required only if DSRS)

Page 77: HCAHPS Update Training February 2009. 2 HCAHPS Update Training February 2009 Welcome! In the HCAHPS Update Training sessions, we will: Explain purpose.

77

HCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update Training

February 2009

Header Record Version 3.1 (cont’d)

• CMS Certification Number (CCN)– Valid 6 digit CCN (formerly known as

Medicare Provider Number)– Sample per unique CCN– Hospitals that share a common CCN

must obtain a combined total of at least 300 completes per CCN per 12-month reporting period

Page 78: HCAHPS Update Training February 2009. 2 HCAHPS Update Training February 2009 Welcome! In the HCAHPS Update Training sessions, we will: Explain purpose.

78

HCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update Training

February 2009

Header Record Version 3.1 (cont’d)

• Discharge Year and Month– Use of Version 3.1 requires April 2009 or greater

• Survey Mode– Code with the approved survey mode for the hospital

• If the hospital is using IVR survey mode and have patients who opt to complete the survey by telephone, the “Survey Mode” field must still be coded as “4 – IVR”

• If the hospital is using Mixed survey mode and have patients who complete the survey by telephone, the “Survey Mode” field must still be coded as “3 – Mixed Mode”

– Must be the same for all three months within a quarter– Cannot be coded as “5 - Exception” as it is an invalid

value

Page 79: HCAHPS Update Training February 2009. 2 HCAHPS Update Training February 2009 Welcome! In the HCAHPS Update Training sessions, we will: Explain purpose.

79

HCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update Training

February 2009

Header Record Version 3.1 (cont’d)

• Methodology for Determination of Service Line1. V.26 MS-DRG codes or V.25 MS-DRG codes2. V.24 CMS-DRG codes3. Mix of V.26, V.25, V.24 codes based on payer

source4. ICD-9 codes5. Hospital unit6. New York State DRGs7. Other - Approved Exceptions Request only

• Note: Hospitals/Survey vendors must submit an Exceptions Request Form online for approval to use other means

Page 80: HCAHPS Update Training February 2009. 2 HCAHPS Update Training February 2009 Welcome! In the HCAHPS Update Training sessions, we will: Explain purpose.

80

HCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update Training

February 2009

Header Record Version 3.1 (cont’d)

• Eligible Discharges– Number of eligible discharges in the

sample frame• All eligible discharges are included even if the

patient’s information is received from the hospital with discharge dates that are beyond the 42-day initial contact period

– Note: A Discrepancy Report must be filed to account for patient information received beyond the 42-day initial contact protocol

Page 81: HCAHPS Update Training February 2009. 2 HCAHPS Update Training February 2009 Welcome! In the HCAHPS Update Training sessions, we will: Explain purpose.

81

HCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update Training

February 2009

Header Record Version 3.1 (cont’d)

• Eligible Discharges (cont’d)– Hospitals with 5 or few eligible HCAHPS

patient discharges in a month may choose to not survey those patients for that given month, beginning with January 2009 patient discharges

• If patients are not surveyed, an HCAHPS Header Record (Survey Month Data) must still be submitted online via My QualityNet

Page 82: HCAHPS Update Training February 2009. 2 HCAHPS Update Training February 2009 Welcome! In the HCAHPS Update Training sessions, we will: Explain purpose.

82

HCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update Training

February 2009

Header Record Version 3.1 (cont’d)

• Eligible Discharges (cont’d)– In calculating the “Eligible Discharges”

field, do not include patients later determined to be ineligible or excluded, regardless of whether they are selected for the survey sample

Page 83: HCAHPS Update Training February 2009. 2 HCAHPS Update Training February 2009 Welcome! In the HCAHPS Update Training sessions, we will: Explain purpose.

83

HCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update Training

February 2009

Header Record Version 3.1 (cont’d)

• Eligible Discharges (cont’d)– If a patient was selected for the survey sample and later

determined to be ineligible (i.e., “Final Survey Status” code of “3 – Ineligible: Not in eligible population”), the patient must be subtracted when reporting the “Eligible Discharges” field (number of eligible discharges in sample in the month)

– Does NOT apply to “Final Survey Status” codes of “2 – Ineligible: Deceased,” “4 – Ineligible: Language barrier,” or “5 – Ineligible: Mental/Physical incapacity.”

– “Sample Size” can therefore be larger than the number of “Eligible Discharges”

Page 84: HCAHPS Update Training February 2009. 2 HCAHPS Update Training February 2009 Welcome! In the HCAHPS Update Training sessions, we will: Explain purpose.

84

HCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update Training

February 2009

Header Record Version 3.1 (cont’d)

• Eligible Discharges (cont’d)– If a patient was not selected for the

survey sample and later determined to be ineligible (i.e., received an update with an ineligible MS-DRG code for the patient), the patient must be subtracted when reporting the “Eligible Discharges” field

Page 85: HCAHPS Update Training February 2009. 2 HCAHPS Update Training February 2009 Welcome! In the HCAHPS Update Training sessions, we will: Explain purpose.

85

HCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update Training

February 2009

Patient Administrative Data Record Version 3.1

Field Name Description

Provider ID CMS Certification Number (CCN), formerly known as the Medicare Provider Number

Discharge Year Year of discharge

Discharge Month Month of discharge

Patient ID Random, unique, de-identified, assigned patient ID by hospital/survey vendor

Point of Origin for Admission or Visit

Source of inpatient admission for the patient (same as UB-04 field location 15)

Reason Admission Service line

Discharge Status Patient’s discharge status (same as UB-04 field location 17)

Strata Name If sampling type is DSRS, name of the stratum the patient belongs to

Page 86: HCAHPS Update Training February 2009. 2 HCAHPS Update Training February 2009 Welcome! In the HCAHPS Update Training sessions, we will: Explain purpose.

86

HCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update Training

February 2009

Patient AdministrativeData Record Version 3.1

(cont’d)Field Name Description

Final Survey Status Disposition of survey

Survey Language Identify whether survey was completed in English Spanish, Chinese, Russian or Vietnamese

Lag Time Number of days between the patient’s discharge from the hospital and the return of the mail survey, or the final disposition of the telephone or IVR survey.

Gender Patient’s gender (same as UB-04 field location 11)

Age at Admission Patient’s age at hospital admission

Page 87: HCAHPS Update Training February 2009. 2 HCAHPS Update Training February 2009 Welcome! In the HCAHPS Update Training sessions, we will: Explain purpose.

87

HCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update Training

February 2009

Patient AdministrativeData Record Version 3.1

(cont’d)• All fields in the Patient Administrative Data

Record must have a valid value • Use code “M - Missing/Don’t Know” for all

missing fields, with the following exceptions:– “Point of Origin for Admission or Visit”—code as

“9 - Information not available”– “Survey Language”—code as “8 – Not applicable”– “Lag Time”—code as “888 – Not applicable”

Page 88: HCAHPS Update Training February 2009. 2 HCAHPS Update Training February 2009 Welcome! In the HCAHPS Update Training sessions, we will: Explain purpose.

88

HCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update Training

February 2009

Patient AdministrativeData Record Version 3.1

(cont’d)• Service Line (Reason Admission)

– Based on one of the accepted methodologies for Determination of Service Line in Header Record

• Discharge Status– Updated code “5 – Discharge/transfer to a

designated cancer center or children’s hospital”– Added code “70 - Discharge/transfer to a health

care institution not defined elsewhere in the code list”

Page 89: HCAHPS Update Training February 2009. 2 HCAHPS Update Training February 2009 Welcome! In the HCAHPS Update Training sessions, we will: Explain purpose.

89

HCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update Training

February 2009

Patient AdministrativeData Record Version 3.1

(cont’d)• Survey Language

– Based on the language survey was completed and not the patient’s language

– Added Russian and Vietnamese languages for Mail only

Page 90: HCAHPS Update Training February 2009. 2 HCAHPS Update Training February 2009 Welcome! In the HCAHPS Update Training sessions, we will: Explain purpose.

90

HCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update Training

February 2009

Patient AdministrativeData Record Version 3.1

(cont’d)• Lag Time

– Number of days between the patient’s discharge from the hospital and the return of the mail survey, or the final disposition of the telephone or IVR survey

– “Final Survey Status” code of 1 – Completed survey” or “6 – Non-response: Break-off” must contain the actual lag time

• These surveys should NOT be coded “888 – Not Applicable” for lag time

– “Final Survey Status” code of 2, 3, 4, 5, 7, 8, 9, 10, or M (that is, any “Final Survey Status” code OTHER THAN 1 or 6) need not contain the actual lag time

• Such surveys MAY use either the actual lag time or “888 – Not Applicable”

Page 91: HCAHPS Update Training February 2009. 2 HCAHPS Update Training February 2009 Welcome! In the HCAHPS Update Training sessions, we will: Explain purpose.

91

HCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update Training

February 2009

Patient AdministrativeData Record Version 3.1

(cont’d)• Patient administrative information must be

submitted for all patients selected in the survey sample

• If a patient is later found to be ineligible or excluded, the patient administrative information must be submitted and the patient should be assigned a “Final Survey Status” code of “3-Ineligible: Not in eligible population”

Page 92: HCAHPS Update Training February 2009. 2 HCAHPS Update Training February 2009 Welcome! In the HCAHPS Update Training sessions, we will: Explain purpose.

92

HCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update Training

February 2009

Patient Response/Survey Results Record Version

3.1• Required when “Final Survey Status”

in the Patient Administrative Data Record is coded as “1 - Completed Survey” or “6 – Non-response: Break-off”

• All fields must have a valid value, including “M - Missing/Don’t Know” or “8 - Not Applicable”

Page 93: HCAHPS Update Training February 2009. 2 HCAHPS Update Training February 2009 Welcome! In the HCAHPS Update Training sessions, we will: Explain purpose.

93

HCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update Training

February 2009

File Layout Structure• Header Record completed once per

monthly file• Patient Administrative Data Record

completed for every patient in the sample• Patient Response/Survey Results Record

completed for patients who responded to the survey – “Final Survey Status” codes of “1 - Completed

Survey” or “6 – Non-response: Break-off”– Enter missing responses as “M - Missing/Don’t

Know” or “8 - Not Applicable”

Page 94: HCAHPS Update Training February 2009. 2 HCAHPS Update Training February 2009 Welcome! In the HCAHPS Update Training sessions, we will: Explain purpose.

94

HCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update Training

February 2009

Preparing the Data File• Check data file

– Check for (no) out of range values– Check for consistency

• Male patients should not be reported in the “Maternity Care” service line

• Patients with a “Discharge Status” of “Expired” (codes 20 or 41) must not have “Final Survey Status” coded as “1 - Completed Survey” or “6 – Non-response: Break-off”

– Check frequency distributions of values• Survey responses coded as all “M – Missing”

Page 95: HCAHPS Update Training February 2009. 2 HCAHPS Update Training February 2009 Welcome! In the HCAHPS Update Training sessions, we will: Explain purpose.

95

HCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update Training

February 2009

Data Submission Timeline

Data Submission Deadline

Month of Patient DischargesFile

Specifications Version

April 8, 2009 October, November and December 2008

Version 3.0

July 8, 2009 January, February and March 2009 Version 3.0

October 14, 2009 April, May and June 2009 Version 3.1

Page 96: HCAHPS Update Training February 2009. 2 HCAHPS Update Training February 2009 Welcome! In the HCAHPS Update Training sessions, we will: Explain purpose.

96

HCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update Training

February 2009

Questions?

Page 97: HCAHPS Update Training February 2009. 2 HCAHPS Update Training February 2009 Welcome! In the HCAHPS Update Training sessions, we will: Explain purpose.

97

HCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update Training

February 2009

Data Submission via My QualityNet

Page 98: HCAHPS Update Training February 2009. 2 HCAHPS Update Training February 2009 Welcome! In the HCAHPS Update Training sessions, we will: Explain purpose.

98

HCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update Training

February 2009

Data Submission Deadlines

• Hospitals and survey vendors may revise their files up to the data submission deadline Revised XML files completely overwrite previous file Final submission of each file must contain all

records for that month

• Recommend submitting final data, including corrections, no later than 48 hours prior to deadline

• Review HCAHPS Reports

Page 99: HCAHPS Update Training February 2009. 2 HCAHPS Update Training February 2009 Welcome! In the HCAHPS Update Training sessions, we will: Explain purpose.

99

HCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update Training

February 2009

Feedback Reports• Feedback reports available to

Vendors and Healthcare Systems– Report Authorization– Feedback reports roles

Page 100: HCAHPS Update Training February 2009. 2 HCAHPS Update Training February 2009 Welcome! In the HCAHPS Update Training sessions, we will: Explain purpose.

100

HCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update Training

February 2009

Notifications• Submission Deadline reminder• APU submission reminders

Page 101: HCAHPS Update Training February 2009. 2 HCAHPS Update Training February 2009 Welcome! In the HCAHPS Update Training sessions, we will: Explain purpose.

101

HCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update Training

February 2009

QualityNet Training and Users Guides

• Web-Ex available to the public– www.qualtynet.org

• Training – QualityNet Training

• QualityNet users guides available on the secure pages of MyQualityNet “Help” link– QualityNet– QualityNet Reports

Page 102: HCAHPS Update Training February 2009. 2 HCAHPS Update Training February 2009 Welcome! In the HCAHPS Update Training sessions, we will: Explain purpose.

102

HCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update Training

February 2009

QualityNet Exchange Resources

• Website: www.qualitynet.org

• QualityNet Help Desk:Phone: (866) 288-8912Email: [email protected]: 8 a.m. – 8 p.m. ET Monday - Friday

Page 103: HCAHPS Update Training February 2009. 2 HCAHPS Update Training February 2009 Welcome! In the HCAHPS Update Training sessions, we will: Explain purpose.

103

HCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update Training

February 2009

Questions?

Page 104: HCAHPS Update Training February 2009. 2 HCAHPS Update Training February 2009 Welcome! In the HCAHPS Update Training sessions, we will: Explain purpose.

104

HCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update Training

February 2009

Data Adjustmentand Public Reporting

Page 105: HCAHPS Update Training February 2009. 2 HCAHPS Update Training February 2009 Welcome! In the HCAHPS Update Training sessions, we will: Explain purpose.

105

HCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update Training

February 2009

Overview• Reporting HCAHPS Results• Hospitals with 5 or fewer HCAHPS

Eligible Patients• Footnotes• Forms for Public Reporting• Hospital Preview Reports• Suppression of Results

Page 106: HCAHPS Update Training February 2009. 2 HCAHPS Update Training February 2009 Welcome! In the HCAHPS Update Training sessions, we will: Explain purpose.

106

HCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update Training

February 2009

Reporting HCAHPS Results

• Results reported for the six composites, two individual items, two global items

• Number of completed surveys and response rate also reported

• The user is able to drill down for more detailed results

• Results aggregated into rolling four quarters (12 months) by hospital

• Footnotes are applied as applicable

• Each hospital’s results is displayed with national and state averages

• Results are updated quarterly

Page 107: HCAHPS Update Training February 2009. 2 HCAHPS Update Training February 2009 Welcome! In the HCAHPS Update Training sessions, we will: Explain purpose.

107

HCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update Training

February 2009

Reporting HCAHPS Results (cont’d)

• On Hospital Compare website at www.hospitalcompare.hhs.gov

• Hospitals will be able to view a preview report of their results

Page 108: HCAHPS Update Training February 2009. 2 HCAHPS Update Training February 2009 Welcome! In the HCAHPS Update Training sessions, we will: Explain purpose.

108

HCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update Training

February 2009

Hospital Preview Reports

• Preview Report data will encompass:-Aggregate of rolling 4 quarters (12

months)– All information that will be publicly

reported for each hospital

• Preview period is 30 days via My QualityNet

Page 109: HCAHPS Update Training February 2009. 2 HCAHPS Update Training February 2009 Welcome! In the HCAHPS Update Training sessions, we will: Explain purpose.

109

HCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update Training

February 2009

Hospital Compare Screenshot

Page 110: HCAHPS Update Training February 2009. 2 HCAHPS Update Training February 2009 Welcome! In the HCAHPS Update Training sessions, we will: Explain purpose.

110

HCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update Training

February 2009

Hospital Compare Screenshot

Page 111: HCAHPS Update Training February 2009. 2 HCAHPS Update Training February 2009 Welcome! In the HCAHPS Update Training sessions, we will: Explain purpose.

111

HCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update Training

February 2009

Hospital Compare Screenshot

Page 112: HCAHPS Update Training February 2009. 2 HCAHPS Update Training February 2009 Welcome! In the HCAHPS Update Training sessions, we will: Explain purpose.

112

HCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update Training

February 2009

Hospitals with 5 or Fewer HCAHPS Eligible Patients in a

Given Month• Starting with January 2009 discharges,

these hospitals are no longer required to collect and submit HCAHPS data for that month– A header record must be submitted to My

QualityNet through the on-line tool or XML file submission

• These hospitals can voluntarily collect and submit data for these months

Page 113: HCAHPS Update Training February 2009. 2 HCAHPS Update Training February 2009 Welcome! In the HCAHPS Update Training sessions, we will: Explain purpose.

113

HCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update Training

February 2009

Public Reporting: Footnote 6

• Fewer than 100 patients completed the HCAHPS survey. Use these rates with caution, as the number of surveys may be too low to reliably assess hospital performance.

The number of completed surveys the hospital or its vendor provided to CMS is less than 100.

Page 114: HCAHPS Update Training February 2009. 2 HCAHPS Update Training February 2009 Welcome! In the HCAHPS Update Training sessions, we will: Explain purpose.

114

HCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update Training

February 2009

March 2009 Public Reporting: Footnote 7

• Survey results are based on less than 12 months of data, or there were discrepancies in the data collection process.

Footnote 7 is applied when HCAHPS results are based on less than 12 months of survey data, or when there have been deviations from HCAHPS data collection protocols. CMS is working with survey vendors and/or hospitals to correct any discrepancies.

Page 115: HCAHPS Update Training February 2009. 2 HCAHPS Update Training February 2009 Welcome! In the HCAHPS Update Training sessions, we will: Explain purpose.

115

HCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update Training

February 2009

Public Reporting: Footnote 8

• Survey results are not available for this period.

This footnote is applied when a hospital did not participate in HCAHPS, or chose to suppress their HCAHPS results.

Page 116: HCAHPS Update Training February 2009. 2 HCAHPS Update Training February 2009 Welcome! In the HCAHPS Update Training sessions, we will: Explain purpose.

116

HCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update Training

February 2009

Public Reporting: Footnote 9

• No patients were eligible for the HCAHPS Survey.

This footnote is applied when a hospital has no patients eligible to participate in the HCAHPS survey.

Page 117: HCAHPS Update Training February 2009. 2 HCAHPS Update Training February 2009 Welcome! In the HCAHPS Update Training sessions, we will: Explain purpose.

117

HCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update Training

February 2009

Changes in Footnotes for June 2009 Public Reporting:

Footnote 7• Survey results are based on less than 12

months of data.

Footnote 7 is applied when HCAHPS results are based on less than 12 months of survey data.

Page 118: HCAHPS Update Training February 2009. 2 HCAHPS Update Training February 2009 Welcome! In the HCAHPS Update Training sessions, we will: Explain purpose.

118

HCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update Training

February 2009

Changes in Footnotes for June 2009 Public Reporting:

Footnote 11• There were discrepancies in the data

collection process.

Footnote 11 is applied when there have been deviations from HCAHPS data collection protocols. CMS is working with survey vendors and/or hospitals to correct any discrepancies.

Page 119: HCAHPS Update Training February 2009. 2 HCAHPS Update Training February 2009 Welcome! In the HCAHPS Update Training sessions, we will: Explain purpose.

119

HCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update Training

February 2009

Forms for Public Reporting

• Hospitals must have either a Hospital Quality Alliance (HQA) Pledge or a RHDQAPU Notice of Participation Form submitted to have their data displayed on www.Hospitalcompare.hhs.gov

• Forms are accessible on My QualityNet (www.qualitynet.org)

Page 120: HCAHPS Update Training February 2009. 2 HCAHPS Update Training February 2009 Welcome! In the HCAHPS Update Training sessions, we will: Explain purpose.

120

HCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update Training

February 2009

Suppression of Results: IPPS Hospitals

• IPPS hospitals can not suppress their results for 2009 public reporting periods

– Must withdraw from RHQDAPU program to suppress

Page 121: HCAHPS Update Training February 2009. 2 HCAHPS Update Training February 2009 Welcome! In the HCAHPS Update Training sessions, we will: Explain purpose.

121

HCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update Training

February 2009

Suppression of Results: CAHs

• CAHs may suppress their results– Must suppress complete set of HCAHPS results

• Will receive footnote 8

• To suppress, the CAH must complete the HQA Request for Withholding Data from Public Reporting Form (found on the My QualityNet www.qualitynet.org) and submit it to the QIO

Page 122: HCAHPS Update Training February 2009. 2 HCAHPS Update Training February 2009 Welcome! In the HCAHPS Update Training sessions, we will: Explain purpose.

122

HCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update Training

February 2009

Questions?

Page 123: HCAHPS Update Training February 2009. 2 HCAHPS Update Training February 2009 Welcome! In the HCAHPS Update Training sessions, we will: Explain purpose.

123

HCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update Training

February 2009

Oversight Activities and

Compliance

Page 124: HCAHPS Update Training February 2009. 2 HCAHPS Update Training February 2009 Welcome! In the HCAHPS Update Training sessions, we will: Explain purpose.

124

HCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update Training

February 2009

Overview

• Purpose of Oversight

• Description of Oversight activities

• Quality Assurance Plan (QAP) requirements

• On-Site visits and Conference calls

• Oversight and Compliance

Page 125: HCAHPS Update Training February 2009. 2 HCAHPS Update Training February 2009 Welcome! In the HCAHPS Update Training sessions, we will: Explain purpose.

125

HCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update Training

February 2009

Purpose of Oversight

• Ensure compliance with HCAHPS protocols

• Ensure that survey data collected and submitted are complete, valid and timely

• Ensure standardization and transparency of publicly reported HCAHPS results

Page 126: HCAHPS Update Training February 2009. 2 HCAHPS Update Training February 2009 Welcome! In the HCAHPS Update Training sessions, we will: Explain purpose.

126

HCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update Training

February 2009

Description of Oversight Activities

The HCAHPS Project Team:

• Reviews Quality Assurance Plans

• Reviews survey materials

• Analyzes submitted data

• Conducts on-site visits & conference calls

Page 127: HCAHPS Update Training February 2009. 2 HCAHPS Update Training February 2009 Welcome! In the HCAHPS Update Training sessions, we will: Explain purpose.

127

HCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update Training

February 2009

Quality Assurance Plan• Provides documentation of

understanding, application and compliance with HCAHPS protocols

– Sufficient detail to administer survey without prior knowledge of the survey process

– See “Tips” in QAG v4.0, Appendix N

Page 128: HCAHPS Update Training February 2009. 2 HCAHPS Update Training February 2009 Welcome! In the HCAHPS Update Training sessions, we will: Explain purpose.

128

HCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update Training

February 2009

Quality Assurance Plan (cont’d)

• Serves as organization-specific guide for administering and training project staff to conduct HCAHPS surveys

• Must reflect actual survey processes and practices

• Provides a guide for the on-site visit

• Ensures high quality data collection and continuity in survey processes

Page 129: HCAHPS Update Training February 2009. 2 HCAHPS Update Training February 2009 Welcome! In the HCAHPS Update Training sessions, we will: Explain purpose.

129

HCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update Training

February 2009

Quality Assurance Plan (cont’d)

• New QAP submitted after participation approval by CMS as self-administering hospital, hospital administering multiple sites, or survey vendor– New QAP submissions due on March 23

• QAP must be updated annually and when changes in key events or key project staff occur – Annual QAP update due by March 23

• HCAHPS Project Team “accepts” QAP– Acceptance does not imply approval of data collection

processes

Page 130: HCAHPS Update Training February 2009. 2 HCAHPS Update Training February 2009 Welcome! In the HCAHPS Update Training sessions, we will: Explain purpose.

130

HCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update Training

February 2009

Quality Assurance Plan (cont’d)

• To produce the QAP– Follow the outline and specifications in

Appendix N, QAG v4.0

• Submit to HCAHPS Project Team through the HCAHPS Technical Assistance email ([email protected])

Page 131: HCAHPS Update Training February 2009. 2 HCAHPS Update Training February 2009 Welcome! In the HCAHPS Update Training sessions, we will: Explain purpose.

131

HCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update Training

February 2009

Quality Assurance Plan (cont’d)

• Submitted QAP documentation includes:

– Organizational background and structure for the project

– Work plan for survey administration

– Survey and data management system and quality controls

Page 132: HCAHPS Update Training February 2009. 2 HCAHPS Update Training February 2009 Welcome! In the HCAHPS Update Training sessions, we will: Explain purpose.

132

HCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update Training

February 2009

Quality Assurance Plan (cont’d)

• QAP documentation includes:

– Confidentiality/privacy and security procedures in accordance with HIPAA

– QAP Annual Update: discussion of recent quality control activities

• Including resolution of any issues identified by HCAHPS Project Team

Page 133: HCAHPS Update Training February 2009. 2 HCAHPS Update Training February 2009 Welcome! In the HCAHPS Update Training sessions, we will: Explain purpose.

133

HCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update Training

February 2009

Analysis of Submitted Data

• Examine survey data submitted to the HCAHPS data warehouse –Outliers, anomalies, unusual patterns, etc.

• Contact hospitals/survey vendors regarding submitted data, as needed

Page 134: HCAHPS Update Training February 2009. 2 HCAHPS Update Training February 2009 Welcome! In the HCAHPS Update Training sessions, we will: Explain purpose.

134

HCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update Training

February 2009

On-Site Visits/Conference Calls

• Purpose: ensure compliance with survey protocols

• Review of survey systems

• Discussions with project staff, including subcontractors

• All materials related to survey administration are subject to review

– Includes survey forms, letters, scripts, etc.

Page 135: HCAHPS Update Training February 2009. 2 HCAHPS Update Training February 2009 Welcome! In the HCAHPS Update Training sessions, we will: Explain purpose.

135

HCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update Training

February 2009

On-Site Visits/Conference Calls (cont’d)

• On-site visit feedback report will include HCAHPS Project Team’s observations of the visit

– Survey administration– Customer support – Data preparation, specifications, coding & submission– Action items for follow-up

• Documentation of corrections will be required

• Further review and conference calls may occur

Page 136: HCAHPS Update Training February 2009. 2 HCAHPS Update Training February 2009 Welcome! In the HCAHPS Update Training sessions, we will: Explain purpose.

136

HCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update Training

February 2009

On-Site Visits/Conference Calls (cont’d)

• Conference calls– Held with survey vendors, self-

administering hospitals, and multi-site hospitals

– May cover same topics as on-site visits

– Conference calls may also be conducted as a follow-up to on-site visits

Page 137: HCAHPS Update Training February 2009. 2 HCAHPS Update Training February 2009 Welcome! In the HCAHPS Update Training sessions, we will: Explain purpose.

137

HCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update Training

February 2009

Oversight and Compliance

As HCAHPS results play a greater role in

hospital payment,

the importance of oversight and compliance increase

Page 138: HCAHPS Update Training February 2009. 2 HCAHPS Update Training February 2009 Welcome! In the HCAHPS Update Training sessions, we will: Explain purpose.

138

HCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update Training

February 2009

HCAHPS Compliance (cont’d)

A participating hospital should:

• Work closely with its survey vendor (if using one)• Regularly monitor QualityNet Exchange

Feedback Reports• Read Quality Assurance Guidelines V4.0 and

monitor HCAHPS website for updates and announcements

• Comply with all HCAHPS oversight activities, as requested

Page 139: HCAHPS Update Training February 2009. 2 HCAHPS Update Training February 2009 Welcome! In the HCAHPS Update Training sessions, we will: Explain purpose.

139

HCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update Training

February 2009

Non-Compliance with Program Requirements

• If hospital (or its survey vendor) fails to adhere to HCAHPS protocols, it must develop and implement corrective actions– Footnotes may be applied to publicly reported

results, as appropriate

• If problems persist, hospital may not qualify as meeting the APU requirements for HCAHPS

• Hospital’s APU may be jeopardized

Page 140: HCAHPS Update Training February 2009. 2 HCAHPS Update Training February 2009 Welcome! In the HCAHPS Update Training sessions, we will: Explain purpose.

140

HCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update Training

February 2009

Non-Compliance with Program Requirements

(cont’d)If a survey vendor or self-

administering hospital does not fix persistent problems, it may lose its “approved” status for conducting HCAHPS

Page 141: HCAHPS Update Training February 2009. 2 HCAHPS Update Training February 2009 Welcome! In the HCAHPS Update Training sessions, we will: Explain purpose.

141

HCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update Training

February 2009

Communicating with Patients about the HCAHPS

Survey• Hospital/Survey vendors are not allowed to:

– Attempt to influence or encourage patients to answer HCAHPS questions a particular way

– Ask patients to explain why they didn’t rate a hospital with most favorable rating possible

– Indicate the hospital’s goal is for all patients to rate them as an “Always” or other top response

Page 142: HCAHPS Update Training February 2009. 2 HCAHPS Update Training February 2009 Welcome! In the HCAHPS Update Training sessions, we will: Explain purpose.

142

HCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update Training

February 2009

Advertising Guidelines• The Hospital Compare website is the

official source of HCAHPS results

• CMS does not endorse hospitals or survey vendors

• Hospital Compare is designed to provide objective information to help consumers make informed decisions about health care providers

Page 143: HCAHPS Update Training February 2009. 2 HCAHPS Update Training February 2009 Welcome! In the HCAHPS Update Training sessions, we will: Explain purpose.

143

HCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update Training

February 2009

Contact Us

HCAHPS Information and Technical Support

• Website: www.hcahpsonline.org• E-mail: [email protected]• Telephone: 1-888-884-4007

Page 144: HCAHPS Update Training February 2009. 2 HCAHPS Update Training February 2009 Welcome! In the HCAHPS Update Training sessions, we will: Explain purpose.

144

HCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update TrainingHCAHPS Update Training

February 2009

Questions?