Quality Assurance Guidelines - Centers for Medicare ...

CAHPS? Hospital Survey

(HCAHPS)

Quality Assurance

Guidelines

Version 15.0

March 2020

CAHPS? Hospital Survey (HCAHPS)

Quality Assurance Guidelines

ACKNOWLEDGMENTS

These Quality Assurance Guidelines were prepared under contract to the Centers for Medicare &

Medicaid Services (CMS). The primary author is the Health Services Advisory Group, ably

assisted by the National Committee for Quality Assurance, expert consultants and CMS.

CMS is pleased to acknowledge the role of the Agency for Healthcare Research and Quality, its

CAHPS grantees, and Westat in developing and testing the HCAHPS Survey, and that of the

Hospital Quality Alliance and the National Quality Forum in supporting the HCAHPS initiative.

CMS would like to acknowledge that the ¡°Point of Origin for Admission¡± and ¡°Visit and Patient

Discharge Status¡± codes are reprinted from the National Uniform Billing Committee Official UB04, Data Specifications Manual by permission, Copyright 2019, by the American Hospital

Association.

Centers for Medicare & Medicaid Services

HCAHPS Quality Assurance Guidelines V15.0

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Centers for Medicare & Medicaid Services

HCAHPS Quality Assurance Guidelines V15.0

HCAHPS

Quality Assurance Guidelines

Table of Contents

I. Reader¡¯s Guide

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? Purpose of Quality Assurance Guidelines

? Quality Assurance Guidelines V15.0 Contents

II. Introduction and Overview

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III. Program Requirements

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Overview

HCAHPS Information and Technical Assistance

QualityNet Help Desk

Hospital Value-Based Purchasing (Hospital VBP)

General Information, Announcements and Updates

V. Survey Management

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Overview

Purpose of the HCAHPS Survey

Communicating with Patients about the HCAHPS Survey

Roles and Responsibilities

Hospital/Survey Vendor HCAHPS Rules of Participation

Hospital/Survey Vendor HCAHPS Minimum Survey Requirements to

Administer the HCAHPS Survey (Minimum Business Requirements)

IV. Communications and Technical Support

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New for 2020

Overview of the CAHPS Hospital Survey (HCAHPS)

HCAHPS Survey Instrument

HCAHPS Development, Data Collection and Public Reporting

Timeline

49

Overview

System Resources

Personnel Training

Monitoring and Quality Oversight

Safeguarding Patient Confidentiality

Data Security

Data Retention and Storage

Centers for Medicare & Medicaid Services

HCAHPS Quality Assurance Guidelines V15.0

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Table of Contents

March 2020

VI. Sampling Protocol

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New for 2020

Overview

Eligibility for the HCAHPS Survey

Survey Timing

Sampling Procedure

Methods of Sampling

? MS-DRG Codes and Service Line Categories

VII. Mail Only Survey Administration

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VIII.

New for 2020

Overview

Production of Questionnaire and Related Materials

Mailing of Materials

Data Receipt and Retention

Quality Control Guidelines

Telephone Only Survey Administration

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New for 2020

Overview

Telephone Interviewing Systems

Telephone Attempts

Obtaining and Updating Telephone Numbers

Data Receipt and Retention

Electronic Telephone Interviewing System

Quality Control Guidelines

IX. Mixed Mode Survey Administration

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New for 2020

Overview

Mail Protocol

Data Receipt and Retention of Mailed Questionnaires

Quality Control Guidelines for Mail Data

Telephone Protocol

Telephone Interviewing Systems

Receipt and Retention of Telephone Data

Electronic Telephone Interviewing System

Quality Control Guidelines for Telephone Data Collection

Centers for Medicare & Medicaid Services

HCAHPS Quality Assurance Guidelines V15.0

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