Self-Administering Participation Form
     
CAHPS® Hospital Survey Participation Form for Hospitals Self-Administering Survey
This participation form is to be completed only by hospitals self-administering the CAHPS® Hospital Survey (HCAHPS) (without using a survey vendor).

Indicate whether this report is a New Participation Form or an Updated Participation Form.
06/24/2018
I. General Participation Information

This section is to be completed with general information for participation in HCAHPS Data Collection and Public Reporting.

1. Applicant Organization
The Name of the Organization is required.
The Medicare Provider Number is required.
The Address is required.
The City is required.
The State is required.
The Zip Code is required.
Telephone is required.
Fax must at least 10 digits.
2. Applicant Primary Contact Person
First Name is required.
Last Name is required.
Title is required.
Mailing Address 1 is required.
City is required.
State is required.
Zip Code is required.
Telephone is required.
Fax must at least 10 digits.
Email is required.

3. Type(s) of Mode of Survey Administration Fielding for the CAHPS® Hospital Survey (Check all that apply)1
1No alternative modes of survey administration will be permitted for use other than those prescribed for the survey (Mail Only, Telephone Only, Mixed Mode, and IVR).
At least one Type(s) of mode of Survey Administration Fielding is required.

II. CAHPS® Hospital Survey Minimum Business Requirements

Hospitals self-administering the HCAHPS Survey (and their subcontractors if applicable) must meet the following Minimum Business Requirements. In addition, approved HCAHPS self-administering hospitals must fully comply with the HCAHPS oversight activities. The FY 2014 IPPS Final Rule states: “Approved HCAHPS self-administering hospitals must fully comply with all HCAHPS oversight activities, including allowing CMS and its HCAHPS Project Team to perform site visits at the hospitals’ and survey vendors’ company locations.” Federal Register/Vol. 78, No. 160/Monday, August 19, 2013/Rules and Regulations, Section. 412.140.

Please check Yes or No for each item below to indicate that the organization has read and meets the following Minimum Business Requirements, if applicable.

Note: Hospitals conducting the HCAHPS Survey for more than one site, must complete the HCAHPS Participation Form for Hospital Conducting Survey for Multiple Sites.

1. Relevant Survey Experience

Demonstrated recent experience in fielding patient-specific surveys in the requested mode (i.e., mail, and/or telephone, and/or IVR)

Hospital has experience in conducting patient-specific surveys as an
organization within the most recent two-year time period for the requested
mode(s) of survey administration (mail, telephone, mixed and/or IVR).

Answer Required.

Hospital has been in business a minimum of three years.

Answer Required.

Hospital has conducted patient-specific surveys a minimum of two years in each
of the requested mode(s) of survey administration within the most recent
two-year time period.

Answer Required.

Hospital has one year prior experience selecting random sample based on
specific eligibility criteria within the most recent one-year time period. Note:
Hospitals are responsible for conducting the sampling process and must not
subcontract this activity
.

Answer Required.
2. Organizational Survey Capacity

Capability and capacity to handle a required volume of mail questionnaires, and/or to conduct standardized telephone interviewing, and/or IVR in specified time frame.

Hospital has a designated HCAHPS Project Manager with minimum one year prior experience conducting patient-specific surveys in the requested mode. Hospital must have appropriate organizational back-up staff for coverage of key staff. Note: Hospitals must not use volunteers in any capacity for HCAHPS Survey administration.

Answer Required.

Hospital has physical plant resources available to handle the volume of surveys being administered; a systematic process to track fielded surveys through the protocol, avoiding respondent burden and losing respondents. Hospital has the ability to assign random, unique, de-identified patient IDs and to track each sampled patient. In order for the HCAHPS Project Team to perform the required oversight activities, organizations that are approved to administer the HCAHPS Survey must conduct all of their business operations within the United States. This requirement applies to all staff and subcontractors. Note: All System Resources are subject to oversight activities including on-site visits to physical locations.

Answer Required.

Hospital has one year prior experience selecting sample based on specific eligibility criteria. Hospital has the ability to generate the sampling frame data file that contains all discharged patients who meet the eligible population criteria and to draw the sample of discharges to be surveyed.

Answer Required.

Hospital has the capability and capacity to obtain and update addresses; produce and print survey instruments and materials; mail survey materials; process survey data (including key entry or scanning); and track non-respondents for follow-up mailing. Mail survey administration is not to be conducted from a residence.

Answer Required.

Hospital has the capability and capacity to obtain and update all telephone numbers; collect telephone interview data for the survey; identify non-respondents for follow-up telephone calls; and ability to schedule and conduct callback appointments. Telephone interviews are not to be conducted from a residence and cannot be conducted by staff who provide direct patient care.

Answer Required.

Hospital has the capability and capacity to perform both of the above referenced Mail Only Mode of Survey Administration and Telephone Only Mode of Survey Administration requirements. Mail survey administration and telephone interviews are not to be conducted from a residence and cannot be conducted by staff who provide direct patient care.

Answer Required.

Hospital has the capability and capacity to obtain and update telephone numbers; collect touch-tone key pad responses to pre-recorded questions; allow respondents to choose or switch to a live operator to complete the survey; identify non-respondents for follow-up telephone calls; and ability to schedule and conduct callback appointments. Telephone interviews are not to be conducted from a residence and cannot be conducted by staff who provide direct patient care.

Answer Required.

Hospital has one year prior experience transmitting data via secure methods (HIPAA-compliant); the capability and capacity to become a registered user of the QualityNet Secure Portal and access and submit data electronically via the QualityNet Secure Portal; and have the capability to prepare final patient-level data files for submission. Note: Hospitals are responsible for data submission and must not subcontract this process.

Answer Required.

Hospital has taken the following actions to secure electronic data: use a firewall and/or other mechanisms for preventing unauthorized access to the electronic files; implement access levels and security passwords so that only authorized users have access to sensitive data; implement daily data backup procedures that adequately safeguard system data; test backup files at a minimum on a quarterly basis to make sure the files are easily retrievable and working; and perform frequent saves to media to minimize data losses in the event of power interruption. Hospital has developed a disaster recovery plan for conducting ongoing business operations in the event of a disaster.

Answer Required.

Hospital has taken the following actions to securely store all survey administration related data: store HCAHPS-related data files, including patient discharge files and de-identified electronic data files (e.g., HCAHPS sample frame, XML files, etc.), for all survey modes for a minimum of three years. Archived electronic data files must be easily retrievable; store de-identified returned mail questionnaires in a secure and environmentally safe location. Paper copies or optically scanned images of the questionnaires must be retained for a minimum of three years and be easily retrievable, when needed; and store returned mail paper questionnaires and/or electronically scanned questionnaires in a secure and environmentally safe location.

Answer Required.

Hospital has one year prior experience providing telephone customer support, and the capability and capacity to provide a customer support line.

Answer Required.

Hospital has developed confidentiality agreements which include language related to HIPAA regulations and the protection of patient information, and obtained signatures from all personnel with access to survey information, including staff and all subcontractors involved in survey administration and data collection; executed Business Associate Agreement(s) in accordance with HIPAA regulations; confirmed that staff and subcontractors are compliant with HIPAA regulations in regard to patient protected health information (PHI); and established protocols for secure file transmission. Emailing of PHI via unsecure email is prohibited.

Answer Required.
3. Quality Control Procedures

Personnel training and quality control mechanisms employed to collect valid, reliable survey data and achieve, on average, a 32 percent response rate.

Hospital has established systems for conducting and documenting quality control activities including: in-house training of staff and subcontractors involved in survey operations; printing, mailing and recording of receipt of survey information; telephone administration of survey, IVR administration of survey, coding and editing; scanning or keying in survey data; preparation of final patient-level data files for submission; and all other functions and processes that affect the administration of the HCAHPS Survey.

Answer Required.

Hospital has developed a QAP for survey administration in accordance with the HCAHPS Quality Assurance Guidelines and updates the QAP on an annual basis and at the time of process and/or key personnel changes as part of retaining participation status.

Answer Required.
4. Explanation

Please explain any "NO" responses above or updates to the Participation Form.

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III. List of Key Project Staff
Project Director is required. A valid Email is required. Telephone is required.
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A valid Email is required. Telephone is required.
{{200 - model.ProjectManagerAddress.length}} characters remaining Address is required.
IV. List of Subcontractors
Answer Required.
LIST OF SUBCONTRACTORS AND ANY OTHER ORGANIZATION(S) that are responsible for major functions of HCAHPS Survey administration.
Hospitals should promptly update the List of Subcontractors as subcontractors are added or deleted.
Name of Subcontractor is required.
Role is required.
Add
Please add all additional subcontractors before submitting the form.
At least one subcontractor is required.
(click on a row in the grid to edit it)
V. Rules of Participation

Any organization participating in the CAHPS Hospital Survey (HCAHPS) must adhere to the following Rules of Participation. To be eligible, the organization must:

  1. Participate in both the Introduction to HCAHPS Training and all subsequent HCAHPS Update Trainings. At a minimum, the organization's Project Manager must participate in training as a representative of the organization. The organization's subcontractors and any other organizations that are responsible for major functions of HCAHPS Survey administration (e.g., mail/telephone/IVR operations) must also participate in training.
  2. Participate in teleconference call(s) with the HCAHPS Project Team to discuss relevant survey experience, organizational survey capability and capacity, and quality control procedures.
  3. Review and adhere to the HCAHPS Quality Assurance Guidelines and policy updates.
  4. Attest to the accuracy of the organization's data collection activities in accordance with HCAHPS protocols; the accuracy of data submission(s) and that data quality checks will be conducted.
  5. Develop and submit an HCAHPS Quality Assurance Plan (QAP) by due date. In addition, submit materials relevant to HCAHPS Survey administration (as determined by CMS), including mailing materials (e.g., cover letters, questionnaires and outgoing envelopes) and/or telephone/IVR scripts.
  6. Become a registered user of the QualityNet Secure Portal for Data Collection.
  7. Participate and cooperate (including subcontractors and any other organization(s) that are responsible for major functions of HCAHPS Survey administration) in all oversight activities conducted by the HCAHPS Project Team.
  8. Comply with all requirements of the HIPAA Security and Privacy Rules in conducting all survey administration and data collection processes
  9. Meet all HCAHPS due dates including data submission.
  10. Acknowledge that review of and agreement with the Rules of Participation is necessary for participation and public reporting of results through the Centers for Medicare & Medicaid Services Hospital Compare Web site.
VI. Applicant Organization Certification and Acceptance

I certify that:

  • I have reviewed and agree to meet the Rules of Participation for participating in the CAHPS Hospital Survey (HCAHPS).

  • The statements herein are true, complete and accurate to the best of my knowledge, and I accept the obligation to comply with the CAHPS Hospital Survey (HCAHPS) Minimum Survey Requirements.
AUTHORIZED REPRESENTATIVE
The Representative's Name is required.
The Representative's Title is required.
The Representative's Organization is required.
06/24/2018
Note: Please print completed Participation Form before submitting.