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
1
? 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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47
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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23
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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5
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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