This section is to be completed with general information for participation in HCAHPS Data Collection and Public Reporting.
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.
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 a minimum of two years within the most recent two-year time period for the requested mode(s) of survey administration (mail, telephone, mixed and/or IVR).
Hospital has been in business a minimum of three years.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
Hospital has one year prior experience providing telephone customer support, and the capability and capacity to provide a customer support line.
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.
Personnel training and quality control mechanisms employed to collect valid, reliable survey data and achieve, on average, a 26 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.
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.
Please explain any "NO" responses above or updates to the Participation Form.
Any organization participating in the CAHPS Hospital Survey (HCAHPS) must adhere to the following Rules of Participation. To be eligible, the organization must:
I certify that: