1. HCAHPS Update Training February 2009

2. 2 HCAHPS 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

3. 3 HCAHPS Update Training February 2009 HCAHPS Program Updates

4. 4 HCAHPS Update Training February 2009 Overview of Presentation HCAHPS Upcoming events New for HCAHPS Participation in HCAHPS How to Join HCAHPS in 2009

5. 5 HCAHPS Update Training February 2009 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 4 th 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. 6 HCAHPS 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

7. 7 HCAHPS 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

8. 8 HCAHPS 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

9. 9 HCAHPS 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%

10. 10 HCAHPS Update Training February 2009 Participation in HCAHPS Second quarter 2008: 50 Approved survey vendors 93 Self-administering hospitals 5 Multi-site hospitals

11. 11 HCAHPS Update Training February 2009 Oversight and Compliance As HCAHPS plays a greater role in hospital payment, The importance of oversight and compliance increase

12. 12 HCAHPS 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 − HCAHPS@azqio.sdps.org HCAHPS@azqio.sdps.org 3.Collect and submit HCAHPS survey data on continuous basis

13. 13 HCAHPS 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

14. 14 HCAHPS Update Training February 2009 Questions?

15. 15 HCAHPS Update Training February 2009 HCAHPS Participation and Program Requirements

16. 16 HCAHPS Update Training February 2009 Participation Overview Quality Assurance Guidelines V4.0 Quality Assurance Plans Exceptions Request/Discrepancy Report HCAHPS Website

17. 17 HCAHPS 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

18. 18 HCAHPS 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

19. 19 HCAHPS 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

20. 20 HCAHPS 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

21. 21 HCAHPS 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

22. 22 HCAHPS 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

23. 23 HCAHPS 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

24. 24 HCAHPS Update Training February 2009 Discrepancy Report (cont’d) Reviewed each reporting period Timing of notification emails

25. 25 HCAHPS 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

26. 26 HCAHPS Update Training February 2009 Questions?

27. 27 HCAHPS Update Training February 2009 Sampling Protocol

28. 28 HCAHPS Update Training February 2009 Overview Steps of Sampling Process Population, Sample Frame and Sample Sampling Facts

29. 29 HCAHPS Update Training February 2009 Steps of Sampling Process 1.Population (All Patient Discharges) 2.Identify Eligible Patients 3.Remove Exclusions 4.De-Duplication Process 5.HCAHPS Sample Frame 6.Draw Sample See Quality Assurance Guidelines V4.0, Flowchart of HCAHPS Sampling Protocol

30. 30 HCAHPS Update Training February 2009 Step 1: Population (All Patient Discharges)

31. 31 HCAHPS 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

32. 32 HCAHPS 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

33. 33 HCAHPS 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

34. 34 HCAHPS 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.

35. 35 HCAHPS 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

36. 36 HCAHPS 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

37. 37 HCAHPS 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

38. 38 HCAHPS 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

39. 39 HCAHPS Update Training February 2009 Step 4: De-Duplication Process All Eligible Patients Ineligible Patients Exclusions De-Duplication Household Multiple Discharges

40. 40 HCAHPS 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

41. 41 HCAHPS 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

42. 42 HCAHPS Update Training February 2009 Step 5: HCAHPS Sample Frame All HCAHPS Eligible Patients (Sample Frame) Ineligible Patients Exclusions De-Duplication Household Multiple Discharges

43. 43 HCAHPS Update Training February 2009 Step 5: HCAHPS Sample Frame Sample Frame Creation 1.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. 44 HCAHPS 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

45. 45 HCAHPS 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

46. 46 HCAHPS 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

47. 47 HCAHPS 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

48. 48 HCAHPS Update Training February 2009 Step 6: Draw Sample Eligible Patients Not Selected for Sample Ineligible Patients Exclusions De-Duplication Sample 1.Simple Random Sample (SRS) 2.Proportionate Stratified Random Sample (PSRS) 3.Disproportionate Stratified Random Sample (DSRS)

49. 49 HCAHPS 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 A B C D E Population (All Patient Discharges) Sample Drawn

50. 50 HCAHPS 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

51. 51 HCAHPS Update Training February 2009 Questions?

52. 52 HCAHPS Update Training February 2009 Survey Administration

53. 53 HCAHPS Update Training February 2009 Overview Survey Translations and Materials Survey Management Modes of Survey Administration

54. 54 HCAHPS 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)

55. 55 HCAHPS 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)

56. 56 HCAHPS 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

57. 57 HCAHPS 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

58. 58 HCAHPS 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

59. 59 HCAHPS 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

60. 60 HCAHPS 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

61. 61 HCAHPS Update Training February 2009 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. 62 HCAHPS 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

63. 63 HCAHPS Update Training February 2009 Telephone/IVR Script INTRO1 Hello, may I please speak to [SAMPLED PATIENT NAME]? (Appendices F & G) YES [GO TO INTRO2] NO [REFUSAL] 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?

64. 64 HCAHPS Update Training February 2009 Telephone/IVR Script INTRO2Hi, 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?

65. 65 HCAHPS Update Training February 2009 Telephone/IVR Script “About You” questions introduction Q23_INTROThis last set of questions is about you. Please listen to all response choices before you answer the following questions. Q23In general, how would you rate your overall health? Would you say that it is… Excellent, Very good, Good, Fair, or Poor? MISSING/DK

66. 66 HCAHPS 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. Q26AAre you White? YES/WHITE NO/NOT WHITE MISSING/DK Q26BAre you Black or African-American? YES/BLACK OR AFRICAN-AMERICAN NO/NOT BLACK OR AFRICAN-AMERICAN MISSING/DK Read Questions A through E to capture multiple races. Do not stop reading the list when you get a Yes answer.

67. 67 HCAHPS 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.

68. 68 HCAHPS 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

69. 69 HCAHPS Update Training February 2009 Questions?

70. 70 HCAHPS Update Training February 2009 Data Coding, Preparation and Submission

71. 71 HCAHPS 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

72. 72 HCAHPS 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

73. 73 HCAHPS 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

74. 74 HCAHPS Update Training February 2009 Header Record Version 3.1 Field NameDescription Provider NameName of the hospital Provider IDCMS Certification Number (CCN), formerly known as the Medicare Provider Number NPINational Provider Identifier (optional) Discharge YearYear of discharge Discharge MonthMonth of discharge Survey ModeMode 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 DischargesNumber of eligible discharges in sample frame in the month Sample SizeNumber of sampled discharges in the month Type of SamplingType of sampling utilized DSRS Strata NameIf sampling type is DSRS, the name of strata DSRS EligibleIf sampling type is DSRS, the number of eligible patients within the stratum DSRS Sample SizeIf sampling type is DSRS, the number of sampled patients within the stratum

75. 75 HCAHPS 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”

76. 76 HCAHPS 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)

77. 77 HCAHPS 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

78. 78 HCAHPS 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

79. 79 HCAHPS Update Training February 2009 Header Record Version 3.1 (cont’d) Methodology for Determination of Service Line 1.V.26 MS-DRG codes or V.25 MS-DRG codes 2.V.24 CMS-DRG codes 3.Mix of V.26, V.25, V.24 codes based on payer source 4.ICD-9 codes 5.Hospital unit 6.New York State DRGs 7.Other - Approved Exceptions Request only Note: Hospitals/Survey vendors must submit an Exceptions Request Form online for approval to use other means

80. 80 HCAHPS 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

81. 81 HCAHPS 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

82. 82 HCAHPS 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

83. 83 HCAHPS 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”

84. 84 HCAHPS 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

85. 85 HCAHPS Update Training February 2009 Patient Administrative Data Record Version 3.1 Field NameDescription Provider IDCMS Certification Number (CCN), formerly known as the Medicare Provider Number Discharge YearYear of discharge Discharge MonthMonth of discharge Patient IDRandom, 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 AdmissionService line Discharge StatusPatient’s discharge status (same as UB-04 field location 17) Strata NameIf sampling type is DSRS, name of the stratum the patient belongs to

86. 86 HCAHPS Update Training February 2009 Patient Administrative Data Record Version 3.1 (cont’d) Field NameDescription Final Survey StatusDisposition of survey Survey LanguageIdentify whether survey was completed in English Spanish, Chinese, Russian or Vietnamese Lag TimeNumber 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. GenderPatient’s gender (same as UB-04 field location 11) Age at AdmissionPatient’s age at hospital admission

87. 87 HCAHPS Update Training February 2009 Patient Administrative Data 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”

88. 88 HCAHPS Update Training February 2009 Patient Administrative Data 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”

89. 89 HCAHPS Update Training February 2009 Patient Administrative Data 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

90. 90 HCAHPS Update Training February 2009 Patient Administrative Data 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”

91. 91 HCAHPS Update Training February 2009 Patient Administrative Data 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”

92. 92 HCAHPS 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”

93. 93 HCAHPS 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”

94. 94 HCAHPS 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”

95. 95 HCAHPS Update Training February 2009 Data Submission Timeline Data Submission Deadline Month of Patient Discharges File Specifications Version April 8, 2009October, November and December 2008 Version 3.0 July 8, 2009January, February and March 2009Version 3.0 October 14, 2009April, May and June 2009Version 3.1

96. 96 HCAHPS Update Training February 2009 Questions?

97. 97 HCAHPS Update Training February 2009 Data Submission via My QualityNet

98. 98 HCAHPS 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

99. 99 HCAHPS Update Training February 2009 Feedback Reports Feedback reports available to Vendors and Healthcare Systems –Report Authorization –Feedback reports roles

100. 100 HCAHPS Update Training February 2009 Notifications Submission Deadline reminder APU submission reminders

101. 101 HCAHPS Update Training February 2009 QualityNet Training and Users Guides Web-Ex available to the public –www.qualtynet.orgwww.qualtynet.org Training – QualityNet Training QualityNet users guides available on the secure pages of MyQualityNet “Help” link –QualityNet –QualityNet Reports

102. 102 HCAHPS Update Training February 2009 QualityNet Exchange Resources Website: www.qualitynet.org QualityNet Help Desk: Phone: (866) 288-8912 Email: qnetsupport@ifmc.sdps.org Availability : 8 a.m. – 8 p.m. ET Monday - Friday

103. 103 HCAHPS Update Training February 2009 Questions?

104. 104 HCAHPS Update Training February 2009 Data Adjustment and Public Reporting

105. 105 HCAHPS 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

106. 106 HCAHPS 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

107. 107 HCAHPS Update Training February 2009 Reporting HCAHPS Results (cont’d) On Hospital Compare website at www.hospitalcompare.hhs.gov www.hospitalcompare.hhs.gov Hospitals will be able to view a preview report of their results

108. 108 HCAHPS 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

109. 109 HCAHPS Update Training February 2009 Hospital Compare Screenshot

110. 110 HCAHPS Update Training February 2009 Hospital Compare Screenshot

111. 111 HCAHPS Update Training February 2009 Hospital Compare Screenshot

112. 112 HCAHPS 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

113. 113 HCAHPS 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.

114. 114 HCAHPS 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.

115. 115 HCAHPS 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.

116. 116 HCAHPS 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.

117. 117 HCAHPS 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.

118. 118 HCAHPS 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.

119. 119 HCAHPS 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)

120. 120 HCAHPS 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

121. 121 HCAHPS 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 www.qualitynet.org

122. 122 HCAHPS Update Training February 2009 Questions?

123. 123 HCAHPS Update Training February 2009 Oversight Activities and Compliance

124. 124 HCAHPS 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

125. 125 HCAHPS 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

126. 126 HCAHPS 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

127. 127 HCAHPS 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

128. 128 HCAHPS 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

129. 129 HCAHPS 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

130. 130 HCAHPS 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 (hcahps@azqio.sdps.org)hcahps@azqio.sdps.org

131. 131 HCAHPS 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

132. 132 HCAHPS 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

133. 133 HCAHPS 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

134. 134 HCAHPS 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.

135. 135 HCAHPS 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

136. 136 HCAHPS 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

137. 137 HCAHPS Update Training February 2009 Oversight and Compliance As HCAHPS results play a greater role in hospital payment, the importance of oversight and compliance increase

138. 138 HCAHPS 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

139. 139 HCAHPS 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

140. 140 HCAHPS 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

141. 141 HCAHPS 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

142. 142 HCAHPS 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

143. 143 HCAHPS Update Training February 2009 Contact Us HCAHPS Information and Technical Support Website: www.hcahpsonline.org E-mail: hcahps@azqio.sdps.org Telephone:1-888-884-4007

144. 144 HCAHPS Update Training February 2009 Questions?