1. Educational Seminar – Q415
J. L. Morgan
Educational Seminar – Q415
January 26, 2016
Finding the pulse of your business

2. Outline Latest CMS HCAHPS Top Box Results OAS CAHPS ED PEC
New JLM Website
Q & A

3. CMS HCAHPS Summary – Apr14 – Mar15
Released December 2015
4,193 Hospitals reported
No changes in national averages for last three quarters
Two composites increased from prior quarter
Overall Rating – 75th (76% to 77%)
Would Recommend – 90th (83% to 84%)
One composite decreased from prior quarter
Care Transition – 90th (61% to 60%)

4. CMS HCAHPS Percentile Tables Summary October 2013 – March 2015*

5. 90th
75th
50th

16. CMS OAS CAHPS Survey

17. INTRODUCTION TO OAS CAHPS
The Outpatient and Ambulatory Services CAHPS® (OAS CAHPS) survey
Developed by the Agency for Healthcare Research and Quality (AHRQ) and its Consumer Assessment of Health Providers and Systems (CAHPS®) Consortium in 2012.
Developed to provide a standardized survey instrument to assess patient experience
Outpatient surgical care who visited a Medicare-certified hospital outpatient departments (HOPDs)
Ambulatory surgery centers (ASCs) for a surgery or procedure.
Critical Access Hospital
Survey will be available on a voluntary basis beginning January 2016.

18. OAS CAHPS GOALS
Produce comparable data on the patient’s perspective that allows objective and meaningful comparisons between HOPDs and free-standing ASCs on domains that are important to consumers.
Public reporting will allow consumers to make more informed choices when choosing an HOPD or ASC.
Public reporting of survey results will be used by HOPDs and ASCs for quality improvement initiatives.
After four quarterly submissions to CMS
Report overall average for each section

19. Reporting Measures and Results
Three Composite Measures
Did the HOPD or ASC staff give care in a professional way?
Did the HOPD or ASC staff communicate with patients about what to expect during and after the procedure?
Preparations for Discharge and Recovery – “Pain, nausea or vomiting, bleeding, or possible signs of infection…”
Two Global Items
How do patients rate the overall care from the HOPD or ASC?
Would patients recommend the HOPD or ASC to friends and family?
Responses on a 3-point scale
“Yes, definitely”, “Yes, somewhat”, “No”
The final composite score reported averages the proportion of those responding to each answer choice in all questions in the composite.

20. OAS CAHPS METHODOLOGY Methodology follows closely along with HCAHPS
Target of 300 annual submissions per CCN
ANYONE submitting < 300 will be reported noted with an “*” footnote
Data submitted monthly to vendor for sampling
Vendor must attempt to contact every patient in the sample
Minimum of five calls attempted
Calls at different times of the day and different days of the week
Proxy’s are not permitted
J. L. Morgan will use telephone mode only

21. Roles and Responsibilities – HOPD or ASC
Contract with an approved OAS CAHPS survey vendor to conduct their survey on a monthly basis.
Authorize the contracted survey vendor to collect and submit OAS CAHPS Survey data to the OAS CAHPS Survey Data Center on the facility’s behalf.
Work with their approved vendor to determine a date each month by which the vendor will need the monthly patient information file allowing adequate time for vendor sampling and fielding the survey by the 21st of the month.
Use a secure method to transmit monthly patient information files to the survey vendor, ensuring that data are encrypted prior to sending to the vendor.
Review data submission reports to ensure that their survey vendor has submitted data to the OAS CAHPS Data Center on time and without data problems (allow ample time for this prior to the quarterly data submission deadlines because data cannot be corrected after the deadline has passed).
Review OAS CAHPS Survey results prior to public reporting.
Avoid influencing patients in any way about how to answer the OAS CAHPS Survey. For example, HOPDs and ASCs may not hand out any information to patients about how to answer the survey. (Please refer to the section below titled Communications With Patients About the OAS CAHPS Survey.)

22. Patient Eligibility Requirements
Upon receipt of the data, JLM will apply the following CMS eligibility requirements
At least one outpatient surgery/procedure;
At least 18 years of age when they received their outpatient surgery or procedure;
Patients regardless of insurance or method of payment;
Patients whose outpatient surgery or procedure was given in an HOPD or ASC as defined by the project;
Patient’s surgery or procedure meets project eligibility definitions, which are as follows:
A procedure is OAS CAHPS-eligible if it has a G-Code of G0104, G0105, G0121 or G0260, or
A surgery, diagnostic procedure, or other type of procedure is OAS CAHPS-eligible if it has a CPT-4 code in the 10021– range, was performed in an outpatient surgery department or ambulatory surgery center
Was not billed as Laboratory, Radiology, Physical Therapy, Respiratory Therapy, or Diagnostic studies and if it has no accompanying modifier 53 (d/c procedure)
Also note that a facility may assign more than one code to a surgery or procedure. The presence of one eligible G-code or CPT code is all that is needed to make it OAS CAHPS-eligible.
Patients must have a domestic U.S. mailing address; not deceased; do not reside in a nursing home or hospice
“No publicity” patients and certain diagnosis such as HIV/AIDS are removed

23. Surgical Categories Assigned
Surgical Category Assigned
Type
Description
Category 1
Gastrointestinal
CPT code(s) in range 40000–49999 or G-code(s) G0105, G0121, or G0104
Category 2
Orthopedic
CPT code(s) in range 20000–29999 or G-code is G0260
Category 3
Ophthalmology
CPT code(s) in range 65000–68899
Category 4
Other
CPT code(s) or G codes not in the range for surgical categories 1, 2 or 3

24. Next Steps?
Work with vendor to determine monthly sample they want to use (if greater than the minimum of 25).
Data department will work with hospital on standardized data file submissions protocols.
Approve J. L. Morgan as their OAS CAHPS vendor (
Surveys for January patients must be received by the 10th of each month
Data will be sampled and surveyed
Results will be available in real-time via eMedsurvey
Submitted quarterly to CMS (publically reported after 4 submission in succession – January 2018)

25. IN SUMMARY
New CAHPS® survey to evaluate patient experience for Outpatient Surgery and Ambulatory Services.
Voluntary in 2016, 2017 undetermined
Will follow methodology closely with HCAHPS
Will be publically reported in 2018

26. Emergency Department Patient Experience of Care (EDPEC)
Updated January 2016

27. ED PEC Formerly EDCAHPS (Now Patient Experience of Care or EDPEC)
Will provide patient experience data that enables comparison of EDs across the nation and promotes effective communication and coordination.
A field test is currently underway for the first quarter (Jan- Mar) 2016 discharges.
Test the impact on response rates of four novel data collection methods compared to standard data collection strategies.
There is no fee to participate in the test.

28. Survey Instruments
Discharged to Community: 35 questions regarding ED experience, plus 18 questions regarding the respondent’s characteristics
Admitted Stand Alone: 29 questions regarding ED experience, plus 18 questions regarding the respondent’s characteristics
Admitted HCAHPS Add-on: 10 questions regarding ED experience that should be inserted into a full HCAHPS instrument, using the most recently available version of the instrument, immediately preceding the “About You”

29. Participation Hospitals can NOT volunteer for field test
CMS field testing included approximately hospitals
JLM expects EDPEC update by 3rd quarter 2016.
Visit and-Systems/Research/CAHPS/ed.html

30. J. L. Morgan Website Update

31. J. L. Morgan has a New Website!

33. Jay Bishop, MSHA, CPHQ, COO (Preventative Care / Pat Sat)
Contact Us:
Jeff Morgan, President
Office
Jay Bishop, MSHA, CPHQ, COO
Office
Tanya Harris-Haynes
HCAHPS Manager
Office
Wendy Dew
Programs Director
(Preventative Care / Pat Sat)
Office
Latrice Lawson
Data Manager
Office
DeAnna Bagwell
Marketing / Sales
J. L. Morgan & Associates
7057 Meadowlark Drive| Birmingham, Al 35242
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