Multi-Site Participation Form
     
CAHPS® Hospital Survey Participation Form for Hospitals Administering Survey for Multiple Sites
This participation form is to be completed only by hospitals conducting the CAHPS® Hospital Survey (HCAHPS) for more than one hospital site.

Indicate whether this report is a New Participation Form or an Updated Participation Form.
09/23/2018
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 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 conducting the HCAHPS Survey for more than one site and their subcontractors, and any other organization(s) that are responsible for major functions of HCAHPS Survey administration, if applicable, must meet the following Minimum Business Requirements. In addition, approved HCAHPS Multi Sites must fully comply with the HCAHPS oversight activities. The FY 2014 IPPS Final Rule states: “Approved HCAHPS Multi Sites 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.

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 three-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 four years.

Answer Required.

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

Answer Required.

Hospital has two years prior experience selecting random sample based on specific eligibility criteria within the most recent two-year time period. Hospital must have the ability to work with contracted client hospital(s) to obtain patient data for sampling via HIPAA-compliant electronic data transfer processes. Hospital must adequately document the sampling process. Note: Hospital is 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 designated HCAHPS personnel, including a Project Manager with a minimum two years prior experience conducting patient-specific surveys in the requested mode, staff with minimum one year prior experience in sample frame development and sample selection, Programmer (subcontractor designee, if applicable) with minimum one year prior experience processing data and preparing data files and Call Center/Mail Center Supervisor (subcontractor designee, if applicable) with minimum one year prior experience in role. In addition, hospital has appropriate organizational staff back-up for coverage of key staff. Note: Hospitals Administering Survey for Multiple Sites 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, including computer and technical equipment and an electronic survey management system 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 two years prior experience selecting sample based on specific eligibility criteria and has the ability to generate the sampling frame data file that contains all 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; use electronic or alternative interviewing system to collect telephone interview data for the survey; identify non-respondents for follow-up telephone calls; and has the 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 who uses an electronic telephone or alternative interviewing system to complete the survey; identify non-respondents for follow-up telephone calls; and has the 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 two years prior experience transmitting data via secure methods (HIPAA-compliant) transmission and; will obtain registered user status from contracted hospitals for the QualityNet Secure Portal and access and submit data electronically via the QualityNet Secure Portal. Hospital will not be listed on the HCAHPS Web site until this step is completed. Note: Hospitals Administering Survey for Multiple Sites 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 two years prior experience providing telephone customer support and has capacity to provide a toll-free 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. CMS - Sponsored and CAHPS® Survey Experience
1. Have you been approved as a vendor to implement other CMS or CAHPS® Surveys in the past five years?
Answer Required.
Please provide the name of the survey(s) for which you have been approved as a vendor.
{{500 - model.SurveysApprovedFor.length}} characters remaining Please provide the sureveys you have been approved for.

2. Have you been a subcontractor to an approved vendor for other CMS or CAHPS® Surveys in the past five years?
Answer Required.
Please provide the name of survey(s) for which you have been approved as a subcontractor to a vendor.
{{500 - model.PreviousSubContractorSurveys.length}} characters remaining Please provide the sureveys you have been approved as a subcontractor for.

In reviewing the HCAHPS Participation Form, CMS will take into consideration any prior experience the applicant organization may have with administering CMS-sponsored CAHPS® Surveys, whether as a survey vendor or subcontractor.

IV. List of Key Project Staff
Project Director is required. A valid Email is required. Telephone is required.
{{200 - model.ProjectDirectorAddress.length}} characters remaining Address is required.

A valid Email is required. Telephone is required.
{{200 - model.ProjectManagerAddress.length}} characters remaining Address is required.

A valid Email is required. Telephone is required.
{{200 - model.SamplingManagerAddress.length}} characters remaining Address is required.

A valid Email is required. Telephone is required.
{{200 - model.ProgrammerAddress.length}} characters remaining Address is required.

A valid Email is required. Telephone is required.
{{200 - model.MailCallCenterSupervisorAddress.length}} characters remaining Address is required.
V. Total Number and List of Affiliated/Contracted Hospitals
Answer Required.
The Number of Contracted Hospitals is required.
List of Contracted Hospitals
Please add all additional hospitals before submitting the form.
Name of Hospital is required.
CCN is required.
Mailing Address 1 is required.
City is required.
State is required.
Zip Code is required.
At least one Survey Mode is Required.
Add
At least one contracted hospital is required.
(click on a row in the grid to edit it)
VI. 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)
VII. 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. Participate in the HCAHPS Dry Run and/or successfully submit one quarter's data to the QualityNet Secure Portal.
  4. Review and adhere to the HCAHPS Quality Assurance Guidelines and policy updates.
  5. 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.
  6. 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.
  7. Become a registered user of the QualityNet Secure Portal for Data Collection.
  8. 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.
  9. Comply with all requirements of the HIPAA Security and Privacy Rules in conducting all survey administration and data collection processes
  10. Meet all HCAHPS due dates including data submission.
  11. 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.
VIII. 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.
09/23/2018
Note: Please print completed Participation Form before submitting.