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HCAHPS Update Training February 2009

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Title: HCAHPS Update Training February 2009


1
HCAHPS Update TrainingFebruary 2009
2
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

3
HCAHPS Program Updates
4
Overview of Presentation
  • HCAHPS Upcoming events
  • New for HCAHPS
  • Participation in HCAHPS
  • How to Join HCAHPS in 2009

5
Upcoming for HCAHPS
  • March 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

6
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

7
New for HCAHPS (contd)
  • 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

8
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

9
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

10
Participation in HCAHPS
  • Second quarter 2008
  • 50 Approved survey vendors
  • 93 Self-administering hospitals
  • 5 Multi-site hospitals

11
Oversight and Compliance
  • As HCAHPS plays a greater role in hospital
    payment,
  • The importance of oversight and compliance
    increase

12
Steps to Join HCAHPS in 2009
  • Submit HCAHPS Participation Form
  • For self-administering hospitals, hospitals
    administering survey for multiple sites and
    survey vendors
  • Form now available online
  • Do an HCAHPS Dry Run
  • Voluntary, but strongly suggested
  • Last month of calendar quarter
  • Contact HCAHPS Project Team for details
  • HCAHPS_at_azqio.sdps.org
  • Collect and submit HCAHPS survey data on
    continuous basis

13
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

14
Questions?
15
HCAHPS Participation and Program Requirements
16
Participation Overview
  • Quality Assurance Guidelines V4.0
  • Quality Assurance Plans
  • Exceptions Request/Discrepancy Report
  • HCAHPS Website

17
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

18
HCAHPS Quality Assurance Guidelines V4.0 (contd)
  • General updates (contd)
  • 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

19
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

20
Quality Assurance Plan (QAP) (contd)
  • QAP 2009 submission date March 23, 2009 (contd)
  • 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

21
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

22
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

23
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

24
Discrepancy Report (contd)
  • Reviewed each reporting period
  • Timing of notification emails

25
HCAHPS Web site
  • Regular update items
  • HCAHPS Executive Insights
  • PMA Tables
  • Data Submission Due Date Announcements
  • HCAHPS Bulletin
  • Online Form Submission

26
Questions?
27
Sampling Protocol
28
Overview
  • Steps of Sampling Process
  • Population, Sample Frame and Sample
  • Sampling Facts

29
Steps of Sampling Process
  • Population (All Patient Discharges)
  • Identify Eligible Patients
  • Remove Exclusions
  • De-Duplication Process
  • HCAHPS Sample Frame
  • Draw Sample
  • See Quality Assurance Guidelines V4.0, Flowchart
    of HCAHPS Sampling Protocol

30
Step 1 Population(All Patient Discharges)
31
Step 1 Population (contd)
  • 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

32
Step 2 Identify Eligible Patients
Ineligible Patients Record count of Ineligible
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

33
Step 2 Identify Eligible Patients Eligibility
Criteria (contd)
  • 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

34
Step 2 Identify Eligible Patients Eligibility
Criteria (contd)
  • 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.

35
Step 2 Identify Eligible Patients Eligibility
Criteria (contd)
  • 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

36
Step 2 Identify Eligible Patients Eligibility
Criteria (contd)
  • 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

37
Step 3 Remove Exclusions
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

All Eligible Patients
38
Step 3 Remove Exclusions (contd)
  • Record count of patients by each exclusions
    category
  • Hospitals/Survey vendors must retain
    documentation that verifies all exclusions

39
Step 4 De-Duplication Process
Ineligible Patients
Exclusions
All Eligible Patients
  • De-Duplication
  • Household
  • Multiple Discharges

40
Step 4 De-Duplication ProcessDe-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

41
Step 4 De-Duplication ProcessDe-Duplication by
Multiple Discharges
  • 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.
42
Step 5 HCAHPS Sample Frame
Ineligible Patients
Exclusions
All HCAHPS Eligible Patients (Sample Frame)
  • De-Duplication
  • Household
  • Multiple Discharges

43
Step 5 HCAHPS Sample Frame Sample Frame Creation
  • 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

44
Step 5 HCAHPS Sample FrameSample Frame Creation
(contd)
  • 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

45
Step 5 HCAHPS Sample Frame Sample Frame Creation
(contd)
  • 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

46
Step 5 HCAHPS Sample Frame Sample Frame
Creation(contd)
  • 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

47
Step 5 HCAHPS Sample FrameHCAHPS Sample Frame
  • 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

48
Step 6 Draw Sample
Eligible Patients Not Selected for Sample
Ineligible Patients
Exclusions
De-Duplication
  • Sample
  • Simple Random Sample (SRS)
  • Proportionate Stratified Random Sample (PSRS)
  • Disproportionate Stratified Random Sample (DSRS)

49
Population, Sample Frame and Sample
Population (All Patient Discharges)
  • 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

A B C D E
Sample Drawn
50
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

51
Questions?
52
Survey Administration
53
Overview
  • Survey Translations and Materials
  • Survey Management
  • Modes of Survey Administration

54
Survey Translations and Materials
  • Mail survey materials availabilityquestionnaires,
    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)

55
Survey Translations and Materials (contd)
  • Telephone and IVR survey materials
    availabilityscripts
  • English telephone script (Appendix F)
  • Spanish telephone script (Appendix G)
  • English IVR script (Appendix H)

56
Survey Management
  • Personnel training and oversight
  • Project staff and subcontractors
  • Training
  • Ongoing oversight
  • Performance evaluation
  • Volunteer staff must not be used

57
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
    patients 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

58
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

59
Mail Only Mode (contd)
  • Mail Out - Requirements
  • Addresses acquired from hospital record
  • Addresses updated using commercial software
  • Mailings sent to patients by name

60
Mail Only Mode (contd)
  • 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

61
Telephone/IVR Mode
  • Protocol
  • Initiate systematic telephone contact with
    sampled
  • patient(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

62
Telephone/IVR Mode (contd)
  • 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

63
Telephone/IVR Script
  • INTRO1 Hello, may I please speak to SAMPLED
    PATIENT NAME? (Appendices F G)
  • lt1gt YES GO TO INTRO2
  • lt2gt NO REFUSAL
  • lt3gt 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 dont have the time now, when is a
    more convenient time to call you back?

64
Telephone/IVR Script
  • INTRO2 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
  • Id like to begin the survey now, is this a
    good time for us to continue?

65
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
  • lt1gt Excellent,
  • lt2gt Very good,
  • lt3gt Good,
  • lt4gt Fair, or
  • lt5gt Poor?
  • ltMgt MISSING/DK

66
Telephone/IVR Script (contd)
  • 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?
  • lt1gt YES/WHITE
  • lt0gt NO/NOT WHITE
  • ltMgt MISSING/DK
  • Q26B Are you Black or African-American?
  • lt1gt YES/BLACK OR AFRICAN-AMERICAN
  • lt0gt NO/NOT BLACK OR AFRICAN-AMERICAN
  • ltMgt MISSING/DK
  • Read Questions A through E to capture multiple
    races. Do not stop reading the list when you get
    a Yes answer.

67
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.

68
Telephone Only Mode (contd)
  • 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

69
Questions?
70
Data Coding, Preparation and Submission
71
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

72
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

73
File Specifications Version 3.1 (contd)
  • 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

74
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
75
File Layout Version 3.1
  • Header Record (Updated Version 3.1)
  • Complete once per monthly file per CCN
  • Patient Administrative Data Record (Updated
    Version 3.1)
  • Complete for every patient in the sample
  • 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/Dont
    Know or 8 - Not Applicable

76
Header Record Version 3.1 (contd)
  • 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)

77
Header Record Version 3.1 (contd)
  • 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

78
Header Record Version 3.1 (contd)
  • 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

79
Header Record Version 3.1 (contd)
  • Methodology for Determination of Service Line
  • V.26 MS-DRG codes 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
  • Other - Approved Exceptions Request only
  • Note Hospitals/Survey vendors must submit an
    Exceptions Request Form online for approval to
    use other means

80
Header Record Version 3.1 (contd)
  • Eligible Discharges
  • Number of eligible discharges in the sample frame
  • All eligible discharges are included even if the
    patients 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

81
Header Record Version 3.1 (contd)
  • Eligible Discharges (contd)
  • 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

82
Header Record Version 3.1 (contd)
  • Eligible Discharges (contd)
  • 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

83
Header Record Version 3.1 (contd)
  • Eligible Discharges (contd)
  • 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

84
Header Record Version 3.1 (contd)
  • Eligible Discharges (contd)
  • 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

85
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 Patients discharge status (same as UB-04 field location 17)
Strata Name If sampling type is DSRS, name of the stratum the patient belongs to
86
Patient AdministrativeData Record Version 3.1
(contd)
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 patients discharge from the hospital and the return of the mail survey, or the final disposition of the telephone or IVR survey.
Gender Patients gender (same as UB-04 field location 11)
Age at Admission Patients age at hospital admission
87
Patient AdministrativeData Record Version 3.1
(contd)
  • All fields in the Patient Administrative Data
    Record must have a valid value
  • Use code M - Missing/Dont Know for all missing
    fields, with the following exceptions
  • Point of Origin for Admission or Visitcode as
    9 - Information not available
  • Survey Languagecode as 8 Not applicable
  • Lag Timecode as 888 Not applicable

88
Patient AdministrativeData Record Version 3.1
(contd)
  • 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 childrens hospital
  • Added code 70 - Discharge/transfer to a health
    care institution not defined elsewhere in the
    code list

89
Patient AdministrativeData Record Version 3.1
(contd)
  • Survey Language
  • Based on the language survey was completed and
    not the patients language
  • Added Russian and Vietnamese languages for Mail
    only

90
Patient AdministrativeData Record Version 3.1
(contd)
  • Lag Time
  • Number of days between the patients 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

91
Patient AdministrativeData Record Version 3.1
(contd)
  • 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

92
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/Dont Know or 8 - Not Applicable

93
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/Dont
    Know or 8 - Not Applicable

94
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

95
Data Submission Timeline
Data Submission Deadline Month of Patient Discharges File 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
96
Questions?
97
Data Submission via My QualityNet
98
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

99
Feedback Reports
  • Feedback reports available to Vendors and
    Healthcare Systems
  • Report Authorization
  • Feedback reports roles

100
Notifications
  • Submission Deadline reminder
  • APU submission reminders

101
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

102
QualityNet Exchange Resources
  • Website www.qualitynet.org
  • QualityNet Help Desk
  • Phone (866) 288-8912
  • Email qnetsupport_at_ifmc.sdps.org
  • Availability 8 a.m. 8 p.m. ET Monday - Friday

103
Questions?
104
Data Adjustmentand Public Reporting
105
Overview
  • Reporting HCAHPS Results
  • Hospitals with 5 or fewer HCAHPS Eligible
    Patients
  • Footnotes
  • Forms for Public Reporting
  • Hospital Preview Reports
  • Suppression of Results

106
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 hospitals results is displayed with
    national and state averages
  • Results are updated quarterly

107
Reporting HCAHPS Results (contd)
  • On Hospital Compare website at www.hospitalcompare
    .hhs.gov
  • Hospitals will be able to view a preview report
    of their results

108
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

109
Hospital Compare Screenshot
110
Hospital Compare Screenshot
111
Hospital Compare Screenshot
112
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

113
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.

114
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.

115
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.

116
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.

117
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.

118
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.

119
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)

120
Suppression of Results IPPS Hospitals
  • IPPS hospitals can not suppress their results for
    2009 public reporting periods
  • Must withdraw from RHQDAPU program to suppress

121
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

122
Questions?
123
Oversight Activities and Compliance
124
Overview
  • Purpose of Oversight
  • Description of Oversight activities
  • Quality Assurance Plan (QAP) requirements
  • On-Site visits and Conference calls
  • Oversight and Compliance

125
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

126
Description of Oversight Activities
  • The HCAHPS Project Team
  • Reviews Quality Assurance Plans
  • Reviews survey materials
  • Analyzes submitted data
  • Conducts on-site visits conference calls

127
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

128
Quality Assurance Plan (contd)
  • 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

129
Quality Assurance Plan (contd)
  • 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

130
Quality Assurance Plan (contd)
  • 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 (hcahps_at_azqio.sdps.org)

131
Quality Assurance Plan (contd)
  • Submitted QAP documentation includes
  • Organizational background and structure for the
    project
  • Work plan for survey administration
  • Survey and data management system and quality
    controls

132
Quality Assurance Plan (contd)
  • 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

133
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

134
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.

135
On-Site Visits/Conference Calls (contd)
  • On-site visit feedback report will include HCAHPS
    Project Teams 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

136
On-Site Visits/Conference Calls (contd)
  • 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

137
Oversight and Compliance
  • As HCAHPS results play a greater role in
  • hospital payment,
  • the importance of oversight and compliance
    increase

138
HCAHPS Compliance (contd)
  • 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

139
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
  • Hospitals APU may be jeopardized

140
Non-Compliance with Program Requirements (contd)
  • If a survey vendor or self-administering hospital
    does not fix persistent problems, it may lose its
    approved status for conducting HCAHPS

141
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 didnt rate a
    hospital with most favorable rating possible
  • Indicate the hospitals goal is for all patients
    to rate them as an Always or other top response

142
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

143
Contact Us
  • HCAHPS Information and Technical Support
  • Website www.hcahpsonline.org
  • E-mail hcahps_at_azqio.sdps.org
  • Telephone 1-888-884-4007

144
Questions?
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