Protocols and Guidelines Manual · “OAS CAHPS Survey.” The OAS CAHPS Survey measures the experiences of patients who receive outpatient or ambulatory services from hospital outpatient

Outpatient and Ambulatory Surgery CAHPS

® Survey

Protocols and Guidelines Manual

Version 3.0

November 2018

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Centers for Medicare & Medicaid Services i Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual

COMMUNICATIONS AND TECHNICAL SUPPORT FOR THE OUTPATIENT AND

AMBULATORY SURGERY CAHPS SURVEY

Hospital outpatient departments, ambulatory surgery centers, and survey vendors may use

the following resources to obtain information or technical support with any aspect of the

Outpatient and Ambulatory Surgery CAHPS Survey.

For general information, important news, updates, and all materials to support implementation of

the Outpatient and Ambulatory Surgery CAHPS Survey:

https://oascahps.org/

For technical assistance, contact the Outpatient and Ambulatory Surgery CAHPS Survey

Coordination Team as noted below.

By e-mail: [email protected]

By telephone: (866) 590-7468

Hospital outpatient departments, ambulatory surgery centers and Outpatient and Ambulatory

Surgery CAHPS (OAS CAHPS) Survey vendors must provide the facility’s name and CMS

Certification Number (CCN) when contacting the OAS CAHPS Survey Coordination Team by

e-mail or telephone for technical assistance.


mailto:[email protected]

ii Centers for Medicare & Medicaid Services Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual


Centers for Medicare & Medicaid Services iii Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual

LIST OF ABBREVIATIONS AND ACRONYMS

OUTPATIENT AND AMBULATORY SURGERY CAHPS SURVEY PROTOCOLS AND

GUIDELINES MANUAL

Abbreviation/ Acronym Term/Phrase

AAPOR American Association for Public Opinion Research

AHRQ Agency for Healthcare Research and Quality

ASC Ambulatory surgery center

CAH Critical access hospital

CAHPS Consumer Assessment of Healthcare Providers and Systems

CATI Computer-assisted telephone interview

CCN CMS Certification Number (formerly known as the Medicare Provider

Number)

CMS Centers for Medicare & Medicaid Services

CPT Current Procedural Terminology1

DHHS Department of Health and Human Services

DSRS Disproportionate stratified random sampling

FAQ Frequently Asked Questions (a list of frequently asked questions and

suggested responses)

HCPCS Healthcare Common Procedure Coding System

HIPAA Health Insurance Portability and Accountability Act

HOPD Hospital outpatient department

IRB Institutional Review Board

MRN Medical Record Number

NCOA National Change of Address

NQF National Quality Forum

OAS CAHPS Outpatient and Ambulatory Surgery CAHPS Survey

OMB Office of Management and Budget

OPPS Outpatient Prospective Payment System

PHI Private health information

PII Personally identifiable information

PSRS Proportionate stratified random sampling

1 CPT only copyright 2019 American Medical Association. All rights reserved.

iv Centers for Medicare & Medicaid Services Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual

Abbreviation/ Acronym Term/Phrase

QAP Quality Assurance Plan

RAT-STATS Regional Advanced Techniques Staff Statistics Program

SAS Statistical Analysis System

SID Sample identification (number)

SRS Simple random sampling

SSS Stratified systematic sampling

XML Extensible Markup Language

Centers for Medicare & Medicaid Services v Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual

OUTPATIENT AND AMBULATORY SURGERY CAHPS SURVEY PROTOCOLS AND GUIDELINES MANUAL

TABLE OF CONTENTS

Communications and Technical Support for the Outpatient and Ambulatory

Surgery CAHPS Survey i

List of Abbreviations and Acronyms Outpatient and Ambulatory Surgery

CAHPS Survey Protocols and Guidelines Manual iii

I. Overview of the Contents of the Protocols and Guidelines Manual 1 Overview 1

Section-by-Section Contents of the Outpatient and Ambulatory Surgery CAHPS

Survey Protocols and Guidelines Manual 1

II. Introduction and Background 5 Overview of CAHPS Survey 5

Development of the OAS CAHPS Survey 7 Office of Management and Budget and Public Comment Process 7 OAS CAHPS Survey Instrument 7

OAS CAHPS Survey Data Collection and Public Reporting 8 Sources of Information About the OAS CAHPS Survey 9

III. Survey Participation Requirements 13

Overview 13 Roles and Responsibilities 13 Responsibilities of Both HOPDs/ASCs and Survey Vendors 20

Vendor Business Requirements 23

IV. Sampling Procedures 31

Overview 31 Step 1: Obtain a Monthly Patient Information File From Each Client HOPD or ASC

Under the Same CCN 34 Step 2: Examine the Monthly Patient Information File for Completeness and

Possible Duplication 44

Step 3: Identify Eligible Patients and Construct a Sampling Frame 45 Step 4: Determine the Sampling Method Most Appropriate for the OAS CAHPS

Survey for This CCN 47 Step 5: Determine the Ideal Sample Size, Calculate the Sampling Rate, and Select

the Sample 49 Step 6: Verify or Update Contact Information for Sampled Patients 59 Step 7: Assign Unique Sample Identification Numbers 60

Step 8: Finalize the Monthly Sample File and Initiate Data Collection Activities 60 Sampling Issues and Errors 61


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vi Centers for Medicare & Medicaid Services Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual

V. Mail-Only Administration Procedures 67 Overview 67 Data Collection Schedule 67 Questionnaires, Letters, and Envelopes 68 Mailing Requirements and Recommendations 73

Data Receipt, Data Entry, and Optical Scanning Requirements 75 Staff Training 77 Quality Control Guidelines for Mail-Only Survey 78

VI. Telephone-Only Administration Procedures 81

Overview 81

Data Collection Schedule 81

Telephone Interview Development Process 82 Telephone Interviewing Requirements 84

Telephone Interviewer Training 88 Telephone Data Processing Procedures 89 Telephone-Only Quality Control Guidelines 90

VII. Mail with Telephone Follow-Up (Mixed-Mode) Survey Administration

Procedures 93

Overview 93 Data Collection Schedule 93

Questionnaires, Letters, and Envelopes 94 Data Receipt, Data Entry, and Optical Scanning Requirements 100

Staff Training 102 Telephone Interview Development Process 103 Telephone Interviewing Requirements and Recommendations 105

Interviewer Training 109

Telephone Data Processing Procedures 110 Mixed-Mode Quality Control Guidelines 111

VIII. Confidentiality and Data Security 115 Overview 115 Safeguarding Patient Data 115

Confidentiality Agreements 119 Physical and Electronic Data Security 119 Communicating With Sample Members About Confidentiality and Security 120

IX. Data Processing and Coding 123 Overview 123 Sample Identification Numbers 123 Data Processing Decision Rules and Coding Guidelines – Mail Surveys 124


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Centers for Medicare & Medicaid Services vii Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual

Data Processing Decision Rules and Coding Guidelines – Telephone Surveys 128 Survey Disposition Codes 129 Definition of a Completed Survey or Survey Completion Criteria 129

Handling Blank Questionnaires 134 Handling Proxy Cases 134 Quality Control Measures 135 Computing the Response Rate 138

X. The OAS CAHPS Survey Website 141

Overview 141

The OAS CAHPS Website 141 System and Security Requirements for the OAS CAHPS Website 159

XI. File Preparation and Data Submission 165 Overview 165

Quarterly Data Submission Deadlines 165 Data File Preparation 165 Step 1: Format and Clean Survey Data Following the XML File Specifications 166

XML Data File Specifications 166 Step 2: Data File Submission 173

Step 3: Review and Follow Up on Data Upload Reports 175 Potential Situations When Vendors Will Not Submit Data 175

Data Submission Quality Control 177

XII. Website Reports 181

Overview 181 Reports for Survey Vendors 181 Reports for HOPDs and ASCs 184

XIII. Oversight Activities 187

Overview 187 Quality Assurance Plan 187 Data Review 188 Communication Between Survey Vendors and the OAS CAHPS Survey

Coordination Team 189

Site Visits to Survey Vendors 189 Corrective Action Plans 191

XIV. Public Reporting 193 Overview 193

OAS CAHPS Survey Measures 193 Adjustment and Reporting of Results 195 Star Ratings 197


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viii Centers for Medicare & Medicaid Services Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual

Facility Preview Reports 198 Public Reporting Periods 198

XV. Exceptions Request Process and Discrepancy Notification Report 201

Overview 201 Exceptions Request Process 201

Displaying HOPD/ASC’s Name and/or Logo on Outgoing Envelopes 205 Review Process 206 Discrepancy Notification Report 206 Discrepancy Report Review Process 209


TABLE OF CONTENTS

Centers for Medicare & Medicaid Services ix Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual

Appendix A: Vendor Application Form

Appendix B: English: Mail Survey Cover Letters, Mail Questionnaires,

Instructions for Scannable Mail Questionnaire, Telephone

Interview Script

Appendix C: Spanish: Mail Survey Cover Letters, Mail Questionnaires,

Instructions for Scannable Mail Questionnaire, Telephone

Interview Script

Appendix D: Chinese: Mail Survey Cover Letters, Mail Questionnaires,

Instructions for Scannable Mail Questionnaire

Appendix E: Korean: Mail Survey Cover Letters, Mail Questionnaire, and

Instructions for Scannable Mail Questionnaire

Appendix F: Consent to Share Identifying Information Question

Appendix G: OMB Paperwork Reduction Act Language

Appendix H: Frequently Asked Questions for Telephone Interviewers

(English)

Appendix I: Frequently Asked Questions for Telephone Interviews

(Spanish)

Appendix J: General Guidelines for Telephone Interviewers

Appendix K: XML Data File Layout for Standard Header Record

Appendix L: XML Data File Layout for Disproportionate Stratified

Random Sampling (DSRS) Header Record

Appendix M: XML Data File Layout for Zero Sampled File

Appendix N: Model Quality Assurance Plan (QAP) Outline

Appendix O: Exceptions Request Form

Appendix P: Discrepancy Notification Report

Appendix Q: Excluded Procedural Codes

Appendix R: Example Patient File Layout


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x Centers for Medicare & Medicaid Services Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual

Exhibits

Exhibit 9.1 Steps for Determining Whether a Questionnaire Meets Completeness

Criteria 130

Exhibit 9.2 How to Determine a Proxy Case 135

Exhibit 9.3 How Response Rates Are Calculated 139

Exhibit 10.1 OAS CAHPS Website Diagram 142

Exhibit 10.2 OAS CAHPS Home Page (Public Website) 143

Exhibit 10.3 Announcements Page on the OAS CAHPS Website 145

Exhibit 10.4 Recent Announcements Section on the OAS CAHPS Website Home Page 146

Exhibit 10.5 Facility Administrator Registration Form 148

Exhibit 10.6 Facility CCN Registration Form 149

Exhibit 10.7 Manage Users Console 151

Exhibit 10.8 User Details Form 151

Exhibit 10.9 Pending Access Requests from Facility Dashboard 152

Exhibit 10.10 Vendor Registration Form 156

Exhibit 10.11 Facility Dashboard Page 158

Exhibit 10.12 Vendor Dashboard Page 159

Exhibit 11.1 Link to Data Submission Tool 174

Exhibit 11.2 Uploading Multiple Files 175


TABLE OF CONTENTS

Centers for Medicare & Medicaid Services xi Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual

Tables

Table 4.1 Information Needed From HOPDs/ASCs for Patient Served During Sample

Month 36

Table 4.2 Response Rates Obtained by Mode Anticipated for OAS CAHPS 49

Table 5.1 Mail-Only Administration Schedule and Protocol 67

Table 6.1 Telephone-Only Administration Schedule and Protocol 81

Table 7.1 Tasks and Schedule of Activities for Mail with Telephone Follow-Up 93

Table 9.1 OAS CAHPS Survey Disposition Codes 130

Table 14.1 Crosswalk of Composite Measures and Global Ratings 197

Table 14.2 Data Submission Deadlines Linked to the Public Reporting Period 199

Table 15.1 Example Scenarios of Various Discrepancy Reasons 208


TABLE OF CONTENTS

xii Centers for Medicare & Medicaid Services Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual


Centers for Medicare & Medicaid Services 1 Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual

I. OVERVIEW OF THE CONTENTS OF THE PROTOCOLS AND GUIDELINES MANUAL

Overview

The Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual has

been developed by the Centers for Medicare & Medicaid Services (CMS) to provide guidance

and standard protocols for conducting the Outpatient and Ambulatory Surgery Consumer

Assessment of Healthcare Providers and Systems (CAHPS®) Survey, hereafter referred to as the

“OAS CAHPS Survey.” The OAS CAHPS Survey measures the experiences of patients who

receive outpatient or ambulatory services from hospital outpatient departments (HOPDs) and

ambulatory surgery centers (ASCs). This section provides survey vendors, HOPDs, and ASCs

with a top-level view of the contents of this manual. Each section is briefly described below,

along with an explanation of the contents of the appendices.

Section-by-Section Contents of the Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual

II. Introduction and Background

The Introduction and Background chapter provides information about the purpose of the OAS

CAHPS Survey and history of the OAS CAHPS Survey initiative, including a discussion of the

instrument development and pilot test activities. It also includes information about the public

reporting timeline and sources for more information about the OAS CAHPS Survey.

III. OAS CAHPS Survey Participation Requirements

This chapter describes the roles and responsibilities of CMS, the OAS CAHPS Survey

Coordination Team, HOPDs and ASCs, and approved survey vendors. It also includes

information on the vendor rules of participation and business requirements for becoming an

approved survey vendor. Information about how to communicate with and obtain technical

assistance from the Coordination Team is also provided in the OAS CAHPS Survey Participation

Requirements chapter.

IV. Sampling Procedures

This chapter describes the sampling process for the OAS CAHPS Survey. It includes

requirements for developing the sample frame of eligible patients from HOPDs and ASCs and

the method to be followed in selecting the sample of patients.

I. Overview of the Contents of the Protocols and Guidelines Manual November 2018

2 Centers for Medicare & Medicaid Services Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual

V. Mail-Only Administration Procedures

The Mail-Only Administration Procedures chapter contains the protocols and guidelines for

administering the OAS CAHPS Survey as a mail-only survey. The data collection schedule,

production and mailing requirements, data receipt and processing requirements, and quality

control guidelines associated with conducting a mail-only mode survey are covered in detail.

VI. Telephone-Only Administration Procedures

Procedures and guidelines for administering the OAS CAHPS Survey as a telephone-only survey

are provided in the Telephone-Only Administration Procedures chapter. The data collection

schedule, electronic data collection and tracking system, telephone interviewing requirements,

and quality control guidelines associated with conducting a telephone-only mode survey are

covered in detail.

VII. Mixed-Mode Administration Procedures

The Mixed-Mode Administration Procedures chapter contains the protocols and guidelines for

administering the OAS CAHPS Survey as a mixed-mode survey—that is, mail survey with

telephone follow-up of nonrespondents. The data collection schedule, production and mailing

requirements, electronic data collection and tracking system, telephone interviewing

requirements, data receipt and processing requirements, and quality control for conducting a

mixed-mode survey are covered in detail.

VIII. Confidentiality and Data Security

The requirements and guidelines for protecting the identity of sample members, confidentiality

of respondent data, ensuring data security, instructions for handling confidential data, and the

importance of confidentiality agreements are covered in this chapter. The importance of

establishing and maintaining physical and electronic data security, and explaining these measures

to sample members, is also covered.

IX. Data Processing and Coding

Data processing procedures, including the assignment of a unique sample identification number

to each sampled case, decision rules for assigning survey disposition codes, quality control

measures, and the definition of a completed survey are described in the Data Processing and

Coding chapter.

X. OAS CAHPS Survey Website

The OAS CAHPS Survey Website chapter provides detailed information about the OAS CAHPS

Survey website and the data submission process, including screenshots of the data submission

tool and instructions for data submission.

November 2018 I. Overview of the Contents of the Protocols and Guidelines Manual


XI. File Preparation and Submission

The File Preparation and Submission chapter provides an overview of the purpose and functions

of the OAS CAHPS Survey website and a summary description of how to prepare and submit

data files following OAS CAHPS Survey data file preparation and submission guidelines. More

detailed information about the OAS CAHPS Survey website and the data submission process,

including screenshots of the data submission tool and instructions for data submission, is

included in the OAS CAHPS Survey Website User and Data Submission Manual, Version 2.0.

XII. OAS CAHPS Survey Website Reports

The OAS CAHPS Survey Website Reports chapter provides an overview of the reports available

to vendors and HOPDs and ASCs through the OAS CAHPS Survey website. The reports are

briefly described, with an emphasis on the intended audience for each report and how the reports

should be used.

XIII. Oversight Activities

The Oversight Activities chapter provides information about the quality assurance activities that

the OAS CAHPS Survey Coordination Team and CMS take to ensure the successful

administration of the OAS CAHPS Survey by survey vendors. The chapter begins with a

discussion of the vendor Quality Assurance Plan and reviews the various activities that the

Coordination Team conducts to ensure compliance with OAS CAHPS Survey protocols and

guidelines.

XIV. Public Reporting

The Public Reporting chapter presents an overview of the public reporting of OAS CAHPS

Survey results, including the composite measures and global items that are publicly reported,

patient-mix adjustments, preview reports, and public reporting periods.

XV. Exceptions Request Process and Discrepancy Notification Report

The Exceptions Request Process and Discrepancy Notification Report chapter describes the

process used to request an exception to the OAS CAHPS Survey protocols, including guidelines

for submitting an Exceptions Request Form. This section also covers the process for alerting the

OAS CAHPS Survey Coordination Team of an unplanned discrepancy in data collection

procedures.

Appendices

The appendices contain copies of the Vendor Application, questionnaires, cover letters and

telephone interview script (in English and other languages), the optional Consent to Share

Identifying Information Question, Office of Management and Budget (OMB) approval

statement, frequently asked questions for telephone interviewers, general guidelines for

I. Overview of the Contents of the Protocols and Guidelines Manual November 2018


telephone interviewers, XML data file layout for standard Header Record, XML data file layout

for disproportionate stratified random sampling, XML data file layout for zero sampled patient

file, Quality Assurance Plan instructions, Exception Request Form, Discrepancy Notification

Report, list of procedural codes excluded from the OAS CAHPS Survey, and example patient

file layout.

The Outpatient and Ambulatory Surgery CAHPS Survey Protocols and

Guidelines Manual

An electronic file of the Outpatient and Ambulatory Surgery CAHPS Survey Protocols and

Guidelines Manual and its appendices are available on the project website at

https://oascahps.org/ . Organizations can request a hardcopy manual by sending an e-mail to the

Coordination Team at [email protected].




II. INTRODUCTION AND BACKGROUND

Overview of CAHPS Survey

The Centers for Medicare & Medicaid Services (CMS) has partnered with the Agency for

Healthcare Research and Quality (AHRQ), another agency within the United States Department

of Health and Human Services, to develop surveys measuring patient perspectives of care.

Beginning in 1995 as part of the Consumer Assessment of Healthcare Providers and Systems

(CAHPS) initiative, AHRQ and its CAHPS grantees began to develop surveys focusing on

patient experiences with their healthcare. Since 1995, the initiative has expanded to cover a range

of surveys of health care services at multiple levels of the delivery system, including patients

receiving care from both ambulatory and institutional settings. The intent of the CAHPS

initiative is to provide a standardized survey instrument and data collection methodology for

measuring patients’ perspectives on patient care. CAHPS is meant to complement the data that

providers collect to support improvements in internal customer services and quality-related

activities.

The Outpatient and Ambulatory Surgery CAHPS (OAS CAHPS) Quality

Initiative

In November 2002, the Quality Initiative was launched to ensure quality health care for all

Americans through accountability and public disclosure. The initiative aims to (a) empower

consumers with quality of care information to help them make more informed decisions about

their health care, and (b) stimulate and support providers and clinicians to improve the quality of

health care.2 The Quality Initiative was launched nationally in November 2002 for nursing

homes (the Nursing Home Quality Initiative) and expanded in 2003 to the nation’s home health

care facilities (the Home Health Quality Initiative) and hospitals (the Hospital Quality Initiative).

This Quality Initiative is continuing for hospital outpatient departments (HOPDs) and

ambulatory surgery centers (ASCs) through the national implementation of OAS CAHPS.3

2 Centers for Medicare & Medicaid Services. http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-

Instruments/QualityInitiativesGenInfo/index.html. Also http://www.cms.gov/Research-Statistics-Data-and-

Systems/Research/CAHPS/index.html 3 http://cms.hhs.gov/Research-Statistics-Data-and-Systems/Research/CAHPS/OAS-CAHPS.html

http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/QualityInitiativesGenInfo/index.html

http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/QualityInitiativesGenInfo/index.html

http://www.cms.gov/Research-Statistics-Data-and-Systems/Research/CAHPS/index.html

http://www.cms.gov/Research-Statistics-Data-and-Systems/Research/CAHPS/index.html

http://cms.hhs.gov/Research-Statistics-Data-and-Systems/Research/CAHPS/OAS-CAHPS.html

II. Introduction and Background November 2018


Definition of HOPD and ASC

An HOPD is an outpatient surgery department or specialized department of a hospital that

performs outpatient surgeries and procedures. A hospital is eligible to participate in the OAS

CAHPS Survey if it has an HOPD or any department that meets all of the following criteria:

• performs procedures that are within the OAS CAHPS–eligible range of CPT-44 Codes for

Surgery (i.e., CPT codes between 10021 and 69990) or one of the following G-codes:

G0104, G0105, G0121, or G0260;

• is Medicare-certified and has a CMS Certification Number (CCN);

• bills under the Outpatient Payment Prospective System (OPPS) using CMS-1450 claim

form for provider-based offices (not CMS-1500 claim form used for the Physician Fee

Schedule), with the exclusion of emergency department procedures; and

• has an agreement with CMS and meets the general conditions and requirements in

accordance with 42 CFR 419 subpart B.

Critical access hospitals (CAHs) are also eligible for OAS CAHPS even though CAHs do not

bill under OPPS; however, participation for CAHs is voluntary.

An ASC is a freestanding medical facility that performs outpatient surgeries and procedures.

CMS specifically defines eligible ASCs as distinct entities that operate exclusively for the

purpose of furnishing outpatient services to patients. An ASC is eligible to participate in the

OAS CAHPS Survey if it meets all of the following criteria:

• performs procedures that are within the OAS CAHPS–eligible range of CPT-45 Codes for

Surgery (i.e., CPT codes between 10021 and 69990) or one of the following G-codes:

G0104, G0105, G0121, or G0260;

• is Medicare-certified and has a CCN;

• bills under ASC Payment System; and

• has an agreement with CMS and meets the general conditions and requirements in

accordance with 42 CFR 416 subpart B.

4 Current Procedural Terminology (CPT) is a registered trademark of the American Medical Association. CPT only

copyright 2019 American Medical Association. All rights reserved. 5 CPT only copyright 2019 American Medical Association. All rights reserved.

November 2018 II. Introduction and Background


Some ASCs have more than one location, typically in a geographic region.

Development of the OAS CAHPS Survey

The OAS CAHPS Survey seeks to provide information about patients’ perception of the care

they receive from Medicare-certified HOPDs and ASCs. The OAS CAHPS development began

in 2012. The survey development process followed the principles and guidelines outlined by

AHRQ and its CAHPS® Consortium in developing a patient experience of care survey.

Development included reviewing surveys submitted as a result of a public call for measures,

reviewing existing literature, conducting focus groups with patients who had recent outpatient

surgery, conducting cognitive interviews with patients to test their understanding and ability to

answer the questions, obtaining stakeholder input on the draft survey and other issues that may

affect implementation, and conducting a field test. The goal of the survey development contract

was to identify and include dimensions of care that patients and other consumers want or need to

inform their choice of an outpatient surgery department/center.

A field test was conducted in the summer of 2014 with 36 facilities (18 HOPDs and 18 ASCs) to

test the reliability and validity of the survey items and implementation procedures. Based on the

field test findings, the survey instrument was revised and finalized.

After the survey instrument was finalized, a mode experiment was conducted in 2015. The

objective of the mode experiment was to test the effect on survey responses using three data

collection modes: mail only, telephone only, and mixed mode (mail with telephone follow-up of

nonrespondents). CMS also used data from the mode experiment to determine whether and to

what extent characteristics of patients participating statistically influence OAS CAHPS Survey

results. Statistical models were developed to adjust or control for these patient characteristics

before the survey results were reported to participating facilities. Data from the mode experiment

were also analyzed to detect potential nonresponse bias; the results of these analyses determined

whether applicable nonresponse statistical adjustments must be made on the OAS CAHPS

Survey data.

Office of Management and Budget and Public Comment Process

CMS received approval of the OAS CAHPS Survey from the United States Office of

Management and Budget with control number 0938-1240.

OAS CAHPS Survey Instrument

The OAS CAHPS Survey instrument contains 37 items that cover topics such as access to care,

communications, and experience of the facility and interactions with facility staff. There are two

global items: one asks the patient to rate the care provided by the HOPD or ASC, and the second

asks the patient about his or her willingness to recommend the HOPD or ASC to family and

friends. The survey also contains items that ask for self-reported health status and basic



demographic information (race/ethnicity, education attainment level, language spoken in the

home, etc.).

The OAS CAHPS Survey is currently available in English, Spanish, Chinese, and Korean. A

version is provided for both mail and telephone survey administration modes on the OAS

CAHPS Survey website. HOPDs and ASCs and their survey vendors will not be permitted to

translate the OAS CAHPS Survey into any other languages. CMS will provide additional

translations over time based on the language needs of patients. Please check the OAS CAHPS

Survey website, https://oascahps.org/ , for announcements about additional translations.

OAS CAHPS Survey Data Collection and Public Reporting

Starting in January 2016, Medicare-certified HOPDs and ASCs were invited to submit data on a

voluntary basis for national implementation of the OAS CAHPS Survey. Interested facilities

contract with survey vendors to conduct the survey on their behalf. Survey vendors interested in

administering the OAS CAHPS Survey must meet a set of minimum business requirements,

complete and submit an application, attend OAS CAHPS Survey training sessions, complete and

pass a Training Certification, and participate in all update trainings sponsored by CMS. Survey

vendors cannot collect and submit data to CMS until they receive approval to conduct the survey.

Following each quarter of survey data collection, vendors submit the survey data they collected

using the data submission tool function on the OAS CAHPS Survey website

(https://oascahps.org/ ). The data submitted are reviewed, cleaned, scored, and adjusted by the

OAS CAHPS Survey Coordination Team. Survey results are compiled for each HOPD and ASC.

Public reporting includes four rolling quarters of data; the publicly available results during

voluntary participation are published on Hospital Compare and data.medicare.gov. Before the

data are publicly reported a “preview” report containing the individual results is made available

to each facility for review through the OAS CAHPS Survey website.

The Proposed Rule for the Hospital Outpatient Prospective Payment and Ambulatory Surgical

Center Payment Systems and Quality Reporting Programs was published in the Federal Register

on July 30, 2018 (Federal Register/Vol. 83, No. 147/Tuesday, July 30, 2018/ Pages 33558–

33724). It indicates that the implementation of the OAS CAHPS Survey will remain voluntary

until further action in future rulemaking. Therefore, voluntary implementation of the OAS

CAHPS Survey will continue in 2019. Confirmation of plans will be published in the CY 2019

Final Rule in November 2018.

After the voluntary reporting period concludes, Medicare-certified hospitals and ASCs that

treated 60 or more survey-eligible patients in the year preceding the data collection period are

eligible to participate in the OAS CAHPS Survey. Medicare-certified hospitals and ASCs that

treat fewer than 60 survey-eligible patients during the same 12-month eligibility period have the

option to submit a request for exemption from participating in the OAS CAHPS Survey. The





Participation Exemption Request form will be available on the OAS CAHPS website in the

future for these exemption requests.

As per the CY 2017 Final Rule (Federal Register/Vol. 81, No. 219/Monday, November 14,

2016/Page 79810), an ASC that qualifies for the exemption from the ASCQR Program because

it had fewer than 240 Medicare claims (Medicare primary and secondary payer) in the year prior

to the data collection year for the applicable payment determination would also qualify for the

exemption from the OAS CAHPS Survey for the same time period. In accordance with the CY

2017 Final Rule, these ASCs are not required to submit a participation exemption request form

for the OAS CAHPS Survey for the same time period.

Sources of Information About the OAS CAHPS Survey

More information about the OAS CAHPS Survey and ambulatory and outpatient surgical care is

available at the two websites described below.

The OAS CAHPS Survey Website (https://oascahps.org/ )

The OAS CAHPS Survey Coordination Team maintains a website, which is available at

https://oascahps.org/ and hereafter in this chapter referred to as the OAS CAHPS website or

simply as the “website.” This website provides general information about the OAS CAHPS

Survey, contains the protocols and materials needed for survey implementation, and is one of the

main vehicles for communicating information about the survey to HOPDs, ASCs, and survey

vendors. The website has both public and secure pages.

The public access pages contain the following:

• general information about the OAS CAHPS Survey;

• announcements about updates or changes in the survey protocols or materials and

participation requirements;

• requirements for becoming an OAS CAHPS Survey vendor;

• data collection materials, protocols, and guidelines for administration of the OAS

CAHPS Survey;

• a list of approved OAS CAHPS Survey vendors;

• quality assurance plan requirements;

• training information and materials;

• data submission deadlines, resources, and requirements;





• instructional documents about OAS CAHPS participation and the OAS CAHPS website

for hospitals and ASCs; and

• information about how to obtain technical assistance.

The Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual is

updated annually to reflect changes to participation requirements and changes in survey

protocols, materials, and procedures. However, CMS and the OAS CAHPS Survey Coordination

Team use the OAS CAHPS website to disseminate important interim updates and news about the

OAS CAHPS Survey, including information related to participation requirements, updates and

changes to survey protocols or survey materials, information about upcoming events (e.g., data

submission deadlines, vendor training sessions), and public reporting. Announcements posted on

the OAS CAHPS Survey website may clarify or supersede existing protocols.

Therefore, it is critically important that survey vendors, HOPDs, and ASCs check the OAS

CAHPS Survey website frequently for updates. To view announcements, go to the website at

https://oascahps.org/ and click on “Recent Announcements” at the bottom of the home page or

the “Announcement” link under “General Information.” The announcements are listed in

chronological order with the most recent announcement listed first.

The secure or restricted-access sections of the OAS CAHPS Survey website are accessible only

to OAS CAHPS Survey vendors and HOPDs and ASCs that have registered to access the links

on the private sections of the website. The links provided within this section of the website will

enable HOPDs and ASCs to:

• grant access to additional users within the HOPD or ASC;

• authorize a survey vendor to submit OAS CAHPS Survey data on their behalf, switch

vendors, or view the facility’s authorization history;

• view data submission reports for data submitted by their respective survey vendors; and

• “preview” their OAS CAHPS Survey results before the results are publicly reported.

Additional secured links on the OAS CAHPS Survey website are accessible to survey vendors

that have been given access credentials. These private secured links allow survey vendors to:

• view the current list of HOPDs and ASCs that have authorized the vendor to submit data

on their behalf;

• access the Exceptions Request Form and the DSRS Excel template file, and Discrepancy

Notification Report to report deviations from the standardized survey protocols;




• access the Quality Assurance Plan submission tool; and

• access the OAS CAHPS Survey data submission tool and reports containing information

about submitted data.

More detailed information about the OAS CAHPS Survey website is included in Chapter X of

this manual.

The Medicare Website (http://www.medicare.gov )

This website is maintained by CMS and contains information on the services Medicare provides.

The Medicare website provides information to the public on various quality measures. Viewers

can obtain comparative information about HOPDs and ASCs by state, ZIP code, and county.

OAS CAHPS Survey results are based on survey response data from the four quarters for which

OAS CAHPS Survey data are available and are “refreshed” each calendar year quarter.

http://www.medicare.gov/





III. SURVEY PARTICIPATION REQUIREMENTS

Overview

This chapter describes participation requirements for the Outpatient and Ambulatory Surgery

CAHPS Survey (OAS CAHPS), including the roles and responsibilities of the Centers for

Medicare & Medicaid Services (CMS) and its OAS CAHPS Survey Coordination Team, hospital

outpatient departments (HOPDs) and ambulatory surgery centers (ASCs), and survey vendors

that administer the OAS CAHPS Survey for HOPDs and ASCs. This chapter also discusses the

rules of participation and outlines the business requirements that survey vendors must meet to be

approved to administer the OAS CAHPS Survey. Information about obtaining technical

assistance from the Coordination Team is also provided in this chapter.

Roles and Responsibilities

CMS is responsible for ensuring that the OAS CAHPS Survey is administered using

standardized survey protocols and data collection and processing methods. CMS works very

closely with its OAS CAHPS Survey Coordination Team to provide training, technical

assistance, and oversight to approved survey vendors. Technical assistance is also provided to

HOPDs and ASCs because they are responsible for contracting with an approved survey vendor

to conduct the OAS CAHPS Survey on their behalf and for providing a patient information file

to their survey vendor each month. Survey vendors are responsible for conducting the OAS

CAHPS Survey on behalf of their client HOPDs and ASCs following the standard protocols and

guidelines described in this manual.

The roles and responsibilities of each of these participating organizations are described below.

CMS and the OAS CAHPS Survey Coordination Team Responsibilities

CMS and the OAS CAHPS Survey Coordination Team are responsible for the following

activities on the OAS CAHPS Survey:

• disseminate information about OAS CAHPS Survey administration;

• train survey vendors on OAS CAHPS Survey protocols and requirements;

• monitor data integrity of OAS CAHPS Survey administration to ensure the quality and

comparability of the data;

III. Survey Participation Requirements November 2018


• provide technical assistance to HOPDs and ASCs and approved OAS CAHPS Survey

vendors via a toll-free telephone number, e-mails, and the OAS CAHPS website at

https://oascahps.org/ ;

• conduct oversight and quality assurance of survey vendors;

• receive and conduct final processing of OAS CAHPS Survey data submitted by all

approved survey vendors;

• calculate and adjust OAS CAHPS Survey data for mode and patient-mix effects prior to

publicly reporting survey results; and

• generate preview reports containing OAS CAHPS Survey results for participating

HOPDs and ASCs to review prior to public reporting.

Hospital Outpatient Departments’ and Ambulatory Surgery Centers’

Responsibilities

Participating HOPDs or ASCs must:

• Contract with an approved OAS CAHPS Survey vendor to conduct their survey on a

monthly basis.

• Authorize the contracted survey vendor to collect and submit OAS CAHPS Survey data

to the OAS CAHPS Data Center on the facility’s behalf.

• Work with their approved vendor to determine a date each month by which the vendor

will need the monthly patient information file allowing adequate time for vendor

sampling and fielding the survey by the 21st day following the sample month.

• By the agreed-upon date, compile and deliver to the survey vendor a complete and

accurate list of patients (i.e., the monthly patient information file) and information that

will enable the vendor to sample patients and administer the survey.

• Use a secure method to transmit monthly patient information files to the survey vendor,

ensuring that data are encrypted prior to sending to the vendor.

• Work with their approved vendor to determine a date each month or quarter by which the

vendor will submit data to the OAS CAHPS Data Center.

• Review the online Data Submission Report to ensure that their survey vendor has

submitted data to the OAS CAHPS Data Center on time and without data problems

(allow ample time for this prior to the quarterly data submission deadlines because data

cannot be corrected after the deadline has passed).


November 2018 III. Survey Participation Requirements


• Review OAS CAHPS Survey results prior to public reporting.

• Avoid influencing patients in any way about how to answer the OAS CAHPS Survey.

For example, HOPDs and ASCs may not hand out any information to patients about how

to answer the survey. (Please refer to the section below titled Communications With

Patients About the OAS CAHPS Survey.)

When participation in the OAS CAHPS Survey is linked to HOPDs’ and ASCs’ payment

determination, it will be the responsibility of Medicare-certified HOPDs and ASCs to participate

every month in the OAS CAHPS Survey to obtain the full payment reimbursement from CMS. If

an HOPD or ASC served fewer than 60 survey eligible patients during the year preceding the

data collection period, the facility can request an exemption. To request an exemption, an HOPD

or ASC must submit a Participation Exemption Request (PER) form for that payment

determination period. This PER form will be available on the OAS CAHPS website in the future.

HOPDs and ASCs will need to submit a PER for every year for which they qualify and wish to

seek an exemption from participation. HOPDs and ASCs are encouraged to monitor the OAS

CAHPS website for announcements regarding the availability of the OAS CAHPS Survey PER

form.

As per the CY 2017 Final Rule (Federal Register/Vol. 81, No. 219/Monday, November 14,

2016/Page 79810), an ASC that qualifies for the exemption from the ASCQR Program because

it had fewer than 240 Medicare claims (Medicare primary and secondary payer) in the year prior

to the data collection year for the applicable payment determination would also qualify for the

exemption from the OAS CAHPS Survey for the same time period. In accordance with the CY

2017 Final Rule, these ASCs are not required to submit a PER form for the OAS CAHPS Survey

for the same time period.

Each payment determination period has an associated reference count period and participation

period that corresponds to a calendar year (January to December). The reference count period

(which HOPDs and ASCs should use to determine eligibility for the payment determination

period) is the year preceding the data collection period. More information on participation

requirements for the payment determination will be available on the OAS CAHPS website at a

later date.

If an HOPD or ASC is eligible to participate, it must follow the participation requirements listed

directly under this section’s header. In addition, the HOPD or ASC must understand the payment

determination periods, including key date ranges and deadline dates. Information about payment

determination periods and other participation requirements will be provided in the Final Rule

published for the Hospital Outpatient Prospective Payment and Ambulatory Surgical Center

Payment Systems and Quality Reporting Programs for each calendar year.



Communications With Patients About the OAS CAHPS Survey

It is important to avoid influencing patient responses to the OAS CAHPS Survey. Any

information or communication about the survey from HOPDs and ASCs may introduce bias to

the survey. It is acceptable for HOPDs and ASCs to inform patients that they may be asked to

respond to a patient experience survey. This information can be provided in writing or verbally

with discharge instructions or with paperwork provided to the patient in advance of the surgery

or procedure. Information to patients about the survey can include the following messaging:

• The HOPD or ASC is participating in the survey to learn more about the quality of health

care that patients receive.

• Patients may be selected to participate in a survey about their experience at the HOPD or

ASC.

• Indicate the mode of the survey that the patient should anticipate receiving (telephone or

mail).

It is not acceptable for HOPDs or ASCs to do any of the following:

• Provide a copy of the OAS CAHPS Survey questionnaire or cover letters to the patients.

• Ask any OAS CAHPS or similar questions of patients prior to administration of the

survey or after discharge.

• Include words or phrases verbatim from the OAS CAHPS Survey in marketing or

promotional materials.

• Attempt to influence their patients’ answers to the OAS CAHPS Survey questions.

• Tell the patients the facility hopes or expects their patients will give them the best or

highest rating or to respond in a certain way to the survey questions.

• Imply that the HOPD or ASC or its staff will be rewarded for positive feedback from

patients.

• Offer incentives of any kind to the patients for participating (or not) in the survey.

• Help the patient answer the survey questions, even if the patient asks for the provider’s

help.

• Ask patients why they gave a certain response or rating to any of the OAS CAHPS

Survey questions.



• Include any messages or materials promoting the HOPD or ASC or the services it

provides in survey materials, including mail survey cover letters, questionnaires, and

telephone interview scripts.

HOPDs and ASCs should never ask their patients if they would like to be included in the survey.

All patients selected to participate in the OAS CAHPS Survey must be able to decide on their

own whether they wish to participate and will be provided an opportunity to do so as part of the

survey process.

Survey Vendor Responsibilities

The list below provides a synopsis of the responsibilities of survey vendors on the OAS CAHPS

Survey.

• Complete the Vendor Application, which is available on the OAS CAHPS Survey

website approximately 6 weeks prior to the annual Introduction to the OAS CAHPS

Survey Webinar Training.

• Participate in and successfully complete the two-part Introduction to the OAS CAHPS

Survey Webinar Training and in all Update Training sessions.

• The survey vendor’s designated OAS CAHPS Project Director must also complete and

pass a Training Certification after participating in the two-part Introduction to the OAS

CAHPS Survey Webinar Training.

• Ensure that all survey vendor staff who work on the OAS CAHPS Survey are trained and

follow the standard OAS CAHPS Survey protocols and guidelines.

• Report any deviations from the protocols and guidelines to the OAS CAHPS Survey

Coordination Team within 24 hours after the discrepancy has been discovered, either

through a Discrepancy Notification Report (see Chapter XV) or other e-mail or telephone

contact with the Coordination Team.

• Follow the participation requirements listed in the “Survey Vendor Requirements” tab of

the Vendor Application and also repeated in the following chapters in this manual.

• Work with appropriate HOPD or ASC staff to create monthly patient information files,

including data elements needed and file format specifications (see Appendix R, Example

Patient File Layout) and decide on a date each month by which the HOPD or ASC must

provide each monthly patient information file.



• Receive and perform checks on the monthly patient information files provided by HOPDs

and ASCs to ensure that they include the entire eligible population and all required data

elements.

• Sample patients, following the sampling protocols described in this manual (see

Chapter IV).

• Administer the OAS CAHPS Survey in accordance with the protocols specified in

Chapters V–VII of this manual and oversee the quality of work performed by staff and

any subcontractors, if applicable.

• Verify that each client HOPD or ASC has authorized the vendor to submit data on the

facility’s behalf.

• Prepare and submit data files to the OAS CAHPS Data Center following the guidelines

specified in Chapters IX and X of this manual and in the OAS CAHPS Survey Website

User and Data Submission Manual, Version 2.0.

• Review all data submission reports for client HOPDs and ASCs to ensure that data have

been successfully uploaded and received.

Survey Vendor Participation Requirements

Survey organizations interested in becoming an approved survey vendor for the OAS CAHPS

Survey must agree to the following requirements of participation.

• Participate in both the Introduction to the OAS CAHPS Survey Training Sessions and in

any subsequent Update Trainings. The vendor’s staff member designated as the OAS

CAHPS Project Director must attend these trainings; we strongly advise that the vendor’s

sampling and data managers also attend. All training sessions will be conducted via

Webinar and require that the survey vendor register in advance. The survey vendor’s

designated OAS CAHPS Project Director must complete and pass a post-training

certification exercise, also referred to as a Training Certification Form, after attending

the Introduction to the OAS CAHPS Survey Training. The Introduction to the OAS

CAHPS Survey Training will be provided in two 4-hour sessions. Each Update Training

session, when offered, will usually consist of one 2- to 3-hour session.

• Review the Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines

Manual and follow the protocols and procedures described in this manual during survey

administration. This manual is the main resource for survey vendors to use in

implementing all stages of the OAS CAHPS Survey—from sampling and data collection

to file development and submission. It is expected that vendors will refer to this manual



frequently and adhere to all protocols contained within it. Protocol and policy updates

will be posted on the OAS CAHPS Survey website.

• Check the OAS CAHPS website frequently to review announcements and protocol

updates, and review and respond as appropriate to e-mails from the OAS CAHPS Survey

Coordination Team (e-mails will be from [email protected]).

• Communicate in a timely manner (within 24 hours when possible) with the OAS CAHPS

Survey Coordination Team any instances when the survey is not following the protocols

and guidelines in this manual. As explained in Chapter XV, there are two forms that are

used in this regard: the Exception Request (regarding a planned deviation) and the

Discrepancy Notification Report (regarding an unplanned deviation). For situations when

these two forms are not appropriate, contact the Coordination Team.

• Develop and submit a Quality Assurance Plan (QAP), following guidelines described in

Chapter XIII of this manual and the QAP instructions provided in the Model QAP

Outline (Appendix N). Survey vendors must complete and submit a QAP within 6 weeks

after the vendor’s first quarterly OAS CAHPS Survey data submission. The QAP must be

updated annually or as needed whenever changes are made to key personnel, survey

modes being administered, or protocols. The QAP must include the following elements:

◦ organizational background and staff experience;

◦ initial communications with HOPDs and ASCs;

◦ work plan for each approved mode of data collection;

◦ sampling protocols and quality assurance procedures;

◦ survey administration protocols and quality assurance procedures;

◦ data security, confidentiality, and privacy protocols; and

◦ copies of the survey instrument (questionnaire or computer-assisted telephone

interview [CATI] script) and cover letters.

• Participate and cooperate in all oversight activities conducted by the OAS CAHPS

Survey Coordination Team, including but not limited to conference calls and site visits,

as deemed necessary. Additionally, the Coordination Team may request teleconference

calls with vendors to review sampling protocols, file submissions, or any other aspect of

the data collection process. Documentation and requirements that vendors are expected to

follow in light of these oversight activities are described in the Vendor Application

(Appendix A) and in Chapter XIII of this manual. All vendors must also correct any




issues identified by the Coordination Team, whether they are identified at a site visit, in

the QAP document, or during the course of data collection.

• As noted on the Vendor Application, all survey vendors seeking approval to conduct the

OAS CAHPS Survey must review and agree to the participation requirements listed in

the “Survey Vendor Requirements” tab of the Vendor Application and described in the

bullets above. Vendors that fail to adhere to or comply with the participation

requirements risk losing their status as an approved OAS CAHPS Survey vendor.

• If interim approval is denied to a vendor applicant, the survey vendor will be notified by

the OAS CAHPS Survey Coordination Team and provided documentation regarding the

requirements that have not been met. The vendor applicant has the option to formally

appeal the application denial by submitting an online Appeals form and providing

sufficient documentation that addresses the unmet requirements within 10 business days

of the denial notification.

Responsibilities of Both HOPDs/ASCs and Survey Vendors

Administering the OAS CAHPS Survey in Conjunction With Other Surveys

Some HOPDs and ASCs may wish to conduct other patient surveys to support internal quality

improvement activities. A “survey,” for purposes of this project, is defined as a formal, patient

experience or satisfaction survey. A formal survey, regardless of the data collection mode

employed, is one in which the primary goal is to ask standardized questions of a sample of the

patient population. Contacting patients to assess their care at any time or calling a patient to

check on services received are both considered to be routine patient contacts, not surveys.

HOPDs and ASCs that are administering other outpatient surveys must follow the guidelines

below.

With regard to sampling and ensuring that patients are not overburdened by multiple surveys:

• For each sample month, the survey vendor must select the OAS CAHPS Survey sample

prior to selecting the samples for any other HOPD or ASC survey.

• The HOPDs and ASCs cannot select the sample for the other facility survey. The vendor

must select the sample because the sample selection for OAS CAHPS cannot be

disclosed to the facility.

• If another CMS- or other federally sponsored effort is also conducting a survey of

patients in the HOPD or ASC that month, the facility must contact the OAS CAHPS

Survey Coordination Team to make arrangements for both surveys.



With regard to questionnaire content of other outpatient surveys:

• In other surveys that an HOPD or ASC conducts, the facility can include any of the OAS

CAHPS questions or similar questions.

• They can also include questions that ask for more in-depth information about OAS

CAHPS issues.

It is permissible for HOPDs or ASCs that are participating in the American College of Surgeons’

National Surgical Quality Improvement Program (NSQIP) to administer the OAS CAHPS

Survey in conjunction with the NSQIP post-operative survey to patients such that each survey

can be administered independently. In other words, the OAS CAHPS Survey vendor can sample

OAS CAHPS patients as they normally would and the NSQIP follow-ups can be administered as

required.

Adding Supplemental Questions to the OAS CAHPS Questionnaire

The OAS CAHPS Survey mail questionnaire contains 37 questions, and the OAS CAHPS

Survey telephone script 35 questions. The survey can be administered as a standalone survey or

can be combined with supplemental questions as explained in this section. Questions 1 to 24 are

considered the “core” OAS CAHPS Survey questions and must be placed at the beginning of the

questionnaire. Questions 25 to 37 (or 35 in the telephone script) are the “About You” OAS

CAHPS Survey questions and must be administered as a unit.

Survey vendors and their client HOPDs and ASCs may elect to add up to 15 questions per

respondent to the OAS CAHPS Survey. These could be questions they develop themselves or

use from an existing survey.

• All supplemental questions must be placed after the “core” OAS CAHPS Survey

questions (Q1-Q24). Supplemental questions may be placed either before or after the

OAS CAHPS Survey “About You” questions. (Refer to the Questionnaire in

Appendix B.)

• We strongly recommend avoiding sensitive questions or lengthy additions, because these

will likely reduce expected response.

• Supplemental questions cannot ask patients why they gave a certain response or rating to

any of the OAS CAHPS Survey questions.

• Supplemental questions do not need to be approved by or reported to CMS. However,

survey vendors should review the appropriateness of supplemental questions added to the

OAS CAHPS Survey and share any concerns they have directly with the HOPD or ASC,

or the OAS CAHPS Survey Coordination Team.



• Survey vendors must not include responses to the supplemental questions on the data

files that will be submitted to the OAS CAHPS Data Center.

• Supplemental questions cannot repeat any of the survey items in the OAS CAHPS

Survey, even if the response scale is different.

• Supplemental questions cannot be used with the intention of marketing or promoting

services provided by the HOPD, ASC, or any other organization. An example of a

question for marketing or promotion is “Can you provide the names and contact

information of any friends or family members who are interested in learning about the

services we provide?”

• Supplemental questions cannot ask sample patients to identify other individuals who may

need outpatient surgical services because of privacy and confidentiality issues they raise

if personally identifiable information (PII) was shared with the HOPD or ASC without

that person’s knowledge and permission.

• The Consent to Share Identifying Information question (Appendix F), if vendors elect to

include it, is considered one of the 15 allowable supplemental questions. The Consent to

Share Identifying Information question asks sample members if they will permit the

survey vendor to link their name and identifying information (responses to the About

You questions) to their survey responses. If the sample member answers “No” or the

response is “Missing” to the Consent to Share Identifying Information question, the

vendor cannot link the sample member’s name to their survey responses. However, the

vendor is permitted to share responses to the sample member’s About You questions in

aggregate form and only if a minimum of 11 responses were provided for each response

option (see Chapter VIII for more information on providing response data to HOPDs and

ASCs). If an HOPD or ASC would like these identifying data, their survey vendor must

include the Consent to Share Identifying Information question. This question is typically

placed at the end of the questionnaire, as the last question. The Consent to Share

Identifying Information question is currently available in English, Spanish, Chinese, and

Korean. Additional languages may be added in the future.

• Vendors and their client facilities cannot ask supplemental questions that would reveal

the patient’s identity without the Consent to Share Identifying Information question

affirmatively answered.

Depending on the placement of the supplemental questions in the OAS CAHPS Survey, it is

acceptable to replace the skip instruction currently provided in Q36 of the OAS CAHPS mail

survey, “Go to END,” with the skip instruction, “Go to Q38,” if the vendor adds the Consent to

Share Identifying Information question or any supplemental questions to the mail survey starting

with Q38. If adding supplemental questions to the end of the OAS CAHPS telephone script, it is



also permissible to revise the programmable skip logic in Q35, “GO TO Q_END,” to instead

skip to Q36.

If a survey vendor, HOPD, or ASC wishes to add more than 15 supplemental questions per

sampled patient, the vendor should submit an Exceptions Request Form (ERF) (see

Chapter XV). The ERF should include the questions, the reason for including more than 15

supplemental questions, and an estimate of the additional time required for sample members to

respond to them.

Vendor Business Requirements

An organization that owns, operates, or provides staffing for an HOPD or ASC is not permitted

to administer its own OAS CAHPS Survey or administer the survey on behalf of any other

HOPDs and ASCs. If any vendor personnel are affiliated with a healthcare provider (hospital,

ambulatory surgery center [ASC], management company, etc.), the vendor cannot be contracted

to conduct OAS CAHPS for that provider as long as the vendor personnel maintain the

affiliation. CMS believes an independent third party (survey vendor) will be better able to solicit

unbiased responses to the OAS CAHPS Survey; therefore, CMS requires that HOPDs and ASCs

contract with an independent, approved OAS CAHPS Survey vendor to administer the OAS

CAHPS Survey on their behalf.

The following types of survey organizations will not be eligible to administer the OAS CAHPS

Survey:

• organizations or divisions within organizations that own or operate an HOPD or ASC, or

provide outpatient or ambulatory surgical services, even if the division is run as a

separate entity to the HOPD or ASC;

• organizations that provide telehealth, monitoring of outpatient or ambulatory surgery

patients, or teleprompting services for HOPDs and ASCs; and

• organizations that provide staffing to HOPDs and ASCs for providing care to outpatient

or ambulatory surgery patients.

Survey vendors seeking approval as an OAS CAHPS Survey vendor must have proven

experience in conducting mail-only, telephone-only, and/or mixed-mode surveys, depending on

which mode(s) they are seeking approval for. They also must have the capability and capacity to

collect and process all survey-related data for the survey administration mode they intend to use

on the OAS CAHPS Survey following standardized procedures and guidelines. The business

requirements that survey vendors must meet are described in the following sections.



Relevant Business Experience

The following section describes the business experience a vendor must possess. Vendors should

submit the online Vendor Application (Appendix A) only if they meet these requirements.

Vendors will also need to document details of this experience in their QAP. The OAS CAHPS

Survey Coordination Team will—through its review of Vendor Applications, through its review

of QAPs, and through site visits—confirm that vendors meet these requirements. These

requirements are the following.

A vendor must have relevant business experience, including a minimum of 3 years in business, a

minimum of 2 years conducting surveys with individuals, and a minimum of 2 years conducting

surveys in the selected data collection mode. A “survey of individuals” is defined as the

collection of data from individuals selected by statistical sampling methods and the data

collected are used for statistical purposes. An applicant organization must:

• Have conducted surveys of individuals responding about their own experiences.

• Be able to demonstrate that a statistical sampling process (e.g., simple random sampling,

proportionate stratified random sampling, or disproportionate stratified random sampling)

was used in the previously conducted survey(s). This means that the organization has to

have conducted surveys where a sample of individuals was selected.

• Be able to demonstrate that it has conducted surveys of individuals as an organization for

at least 2 years. If someone within the applicant organization has relevant experience

obtained while in the employment of a different organization, that experience will not

count toward the 2-year minimum of survey experience.

• Currently possess all required facilities and systems to implement the OAS CAHPS

Survey. CMS and its OAS CAHPS Survey Coordination Team reserve the right to

request photographs of the applicant organization’s telephone call center for

organizations applying for the telephone-only and mixed modes, scanning and data

processing systems if applying for the mail-only or mixed modes, and other relevant

equipment and facilities.

The following are examples of data collection activities that do not satisfy the requirement of

experience conducting surveys of individuals, as defined for the OAS CAHPS Survey, and will

not be considered as part of the experience that OAS CAHPS requires:

• polling questions administered to trainees or participants of training sessions or

educational courses, seminars, or workshops;

• focus groups, cognitive interviews, or any other qualitative data collection activities;



• surveys of fewer than 600 individuals;

• surveys conducted that did not involve using statistical sampling methods;

• Internet or Web-based surveys; and

• interactive Voice Recognition surveys.

Survey Capabilities and Capacity

The following section describes the capabilities and capacity that vendors must possess to be

approved for OAS CAHPS. There are specific requirements pursuant to Personnel, Facilities and

Systems, Security Policies, mail administration, telephone administration, mixed-mode

administration, data processing, and file submission. The OAS CAHPS Survey Coordination

Team will—through its review of Vendor Applications and follow-up correspondence, through

its review of QAPs, and through site visits—confirm that vendors meet these requirements.

These requirements are the following.

Personnel

Vendors must designate a Project Director with relevant survey experience, designate a

Sampling Manager with sample frame development and sample selection experience, and

designate a programmer capable of processing data and preparing data files for electronic

submission.

Facilities and Systems

Vendors must currently:

• have a secure commercial work environment;

• meet all local commercial code requirements; and

• have physical facilities, electronic equipment, and software to receive sample files from

participating facilities and upload OAS CAHPS data to the OAS CAHPS Data Center.

Vendors must conduct all of their OAS CAHPS business operations within the United States.

This requirement applies to all staff and subcontractors. Home-based or virtual interviewers or

mail survey staff may not be used to administer the OAS CAHPS Survey nor may they conduct

any survey administration process.

Security Policies

Vendor and all subcontractors must have and implement systems and security policies that

protect the security of PII as defined by the Health Insurance Portability and Accountability Act.



This includes sample data and survey data. Vendors will be required to submit policies.

Submissions must describe in sufficient detail policies and procedures for:

• authorizing and de-authorizing individuals to access PII and survey data (including

background checks, training, signed agreements);

• preventing unauthorized individuals from accessing PII and survey data in physical

format (including key card/locked access, locked file cabinets);

• preventing unauthorized individuals from accessing data in electronic format (including

password protections, firewalls, data encryption software, personnel access limitation

procedures, and virus and spyware protection);

• safeguarding PII and survey data in physical format against loss or destruction (including

fire and building safety codes);

• safeguarding PII and survey data in electronic format against loss or destruction (e.g.,

offsite daily backups);

• establishing a disaster recovery plan for survey data in the event of a disaster; and

• destroying PII and survey data when specified.

Further information on security policies is presented in Chapter VIII.

Mail-Only Survey Administration

Vendors that are using mail-only survey administration must demonstrate prior experience and

have commercial facilities, equipment, and software to enable them to:

• assign a random, unique, de-identified identification number to each sampled patient;

• obtain and verify addresses of sampled patients;

• print according to OAS CAHPS formatting guidelines professional-quality survey

questionnaires (containing single-coded questions, code-all-that-apply questions) and

materials;

• merge and print sample patient name and address, the name of the outpatient facility, and

the date of procedure or surgery on personalized mail survey cover letters and print

unique sample identification on the survey questionnaire;

• track fielded surveys throughout the protocol, avoiding respondent burden and losing

respondents;



• receive and process (key entry or scanning) completed questionnaires;

• track and identify nonrespondents for follow-up mailing;

• provide a toll-free customer support line and respond to calls within 48 hours; and

• assign final status codes in accordance with OAS CAHPS coding requirements to reflect

the results of the attempt(s) to obtain a completed interview with each sampled patient

(see Chapter IX).

Telephone-Only Survey Administration

Vendors that are using telephone-only survey administration must demonstrate prior experience

and have commercial facilities, equipment, and software to enable them to:

• assign a random, unique, de-identified identification number to each sampled patient;

• obtain and verify telephone numbers of sampled patients;

• develop computer programs for electronically administering the survey (for CATI);

• collect data using CATI, which allows seamless administration of single-coded questions,

code-all-that-apply questions;

• track fielded surveys throughout the protocol, avoiding respondent burden and losing

respondents;

• schedule callbacks to nonrespondents at varying times of the day and week;

• provide a toll-free customer support line and respond to calls within 48 hours;

• assign final status codes in accordance with OAS CAHPS coding guidelines to reflect the

results of attempt(s) to obtain a completed interview with each sampled patient; and

• conduct monitoring of interviewers.

Mixed-Mode Survey Administration

Vendors that apply for administering the OAS CAHPS Survey as a mixed-mode survey (mail

with telephone follow-up of nonrespondents) must demonstrate prior experience and have

commercial facilities, equipment, and software to enable them to adhere to all mail-only and

telephone-only survey administration requirements described above. In addition, they must have

an electronic tracking system that can track cases from the mail survey through telephone follow-

up activities.



Data Processing and File Submission

Vendors must demonstrate prior experience and have facilities, equipment, and software to

enable them to:

• Scan or key responses to single coded questions and code-all-that-apply questions from

completed surveys.

• Develop data files and edit and clean data according to standard protocols.

• Follow all data cleaning and data submission rules, including verifying that data files are

de-identified and contain no duplicate patient records.

• Export data from the electronic data collection system to an XML template, confirm that

the data were exported correctly, and that the XML files are formatted correctly and

contain the correct data headers and data records.

• Submit data electronically in the specified format (XML) via the OAS CAHPS secured

website.

◦ Vendors must work with the OAS CAHPS Survey Coordination Team to quickly

resolve data problems and data submission problems. As stated above with regard to

the Discrepancy Notification Report, vendors must inform the Coordination Team

promptly (within 24 hours after the discrepancy has been identified, when possible)

of any deviation from the protocol. Vendors are encouraged to submit their test data

files early so as to reveal any potential problems, and afford time to address them

prior to submission.

Adherence to Quality Assurance Guidelines

Vendors must have prior experience, facilities, equipment, and software to enable them to:

• Incorporate well-documented quality control procedures (as applicable) for:

◦ in-house training of staff involved in survey operations;

◦ printing, mailing, and recording of receipt of survey questionnaires;

◦ telephone administration of survey;

◦ coding and editing of survey data and survey-related materials;

◦ scanning or keying in survey data;

◦ preparation of final person-level data files for submission; and



◦ all other functions and processes that affect the administration of the OAS CAHPS

Survey.

• Participate in any conference calls and site visits requested by the Coordination Team as

part of overall quality monitoring activities. Site visits will be conducted with all

approved vendors.

• Provide documentation as requested for site visits and conference calls, including but not

limited to staff training records, telephone interviewer monitoring records, and file

construction documentation.

Participation in Training and Quality Assurance Activities

Survey vendors must participate in all required training and quality assurance activities necessary

to ensure the successful implementation of the OAS CAHPS Survey. This includes the following

requirements:

• Review and follow all procedures described in the OAS CAHPS Survey Protocols and

Guidelines Manual that are applicable to the selected survey data collection mode.

• Attend all CMS Introduction and Update training sessions. (Failure to complete all

required vendor training will result in withdrawal of approved vendor status.)

• Participate in any conference calls and site visits requested by the OAS CAHPS Survey

Coordination Team as part of overall quality monitoring activities. Site visits will be

conducted with all approved vendors. Vendors must provide documentation as requested

for site visits and conference calls, including but not limited to staff training records,

telephone interviewer monitoring records, sample frame development documentation,

and file construction documentation.

Subcontractor Requirements

Any survey vendor using a subcontractor in any capacity on the OAS CAHPS Survey is required

to complete the relevant sections of the Vendor Application (Appendix A) about each of its

subcontractors. Information requested on the Vendor Application about subcontractor capabilities

is similar to that requested for vendors. Details must be provided about the capabilities and

capacity of the subcontractor to handle mail, telephone, and mixed-mode survey activities (as

appropriate). Further, specific information must also be provided about the subcontractor’s

quality assurance practices, data security policies, and facilities and systems.

If a vendor applicant’s subcontractor will conduct substantive work to support the

implementation of the OAS CAHPS Survey, that subcontractor is strongly encouraged to attend

relevant portions of the Introduction to OAS CAHPS Webinar Training Session and all OAS



CAHPS Update Training Sessions. For purposes of this survey, “substantive work” is defined as

follows:

• ANY statistical function, including sample selection,

• telephone survey data collection (i.e., if an approved vendor is subcontracting telephone

data collection activities),

• mail or questionnaire receipt and processing, and

• construction or submission of XML data files.

If an applicant vendor will be using a subcontractor to conduct any substantive work as defined

above, the subcontractor organization will be subject to the same or similar requirements as the

applicant vendor.

Additional Requirements

CMS and its OAS CAHPS Survey Coordination Team reserve the right to request additional

information from applicant organizations to help determine whether approval status should be

granted. Information requested may include the following:

• Taxpayer Identification Number;

• website address;

• detailed description of surveys conducted that demonstrate statistical sampling and data

collection capabilities;

• photographs of applicant organization’s facilities and systems;

• resumes of key staff, demonstrating experience with data collection, sampling, and

computer programming; and

• additional descriptions of processes, including treatment of confidential data, control or

tracking systems, quality assurance practices, and XML file construction.


IV. SAMPLING PROCEDURES

Overview

This chapter describes the procedures survey vendors should use for sample selection. The

process includes requesting a file of patients for the hospital outpatient departments or

ambulatory surgery centers (HOPDs or ASCs), identifying patients and procedures eligible for

the survey, constructing a sampling frame, and selecting a patient sample each month. The

sampling procedures described in this chapter were developed to ensure standardized

administration of the OAS CAHPS Survey by all survey vendors and to ensure comparability of

the data and survey results that are publicly reported.

Before explaining patient sampling steps, it is

necessary to explain facility eligibility and

how the OAS CAHPS Survey is constructed

for analysis and reporting. See the text box for

a review of the definition of a facility that is

eligible for OAS CAHPS. When this chapter

refers to “facilities” or “HOPDs or ASCs” it

is referring to HOPDs and ASCs that meet

this definition.

The unit of analysis in OAS CAHPS is the

CCN, not the individual HOPD or ASC.

Implications of this fact are as follows:

• For HOPDs: Every HOPD that reports

under the hospital’s CCN needs to

participate in OAS CAHPS for the sample to be valid. Vendors should work with their

client hospitals to determine all HOPDs and other departments or units that perform

outpatient surgeries and procedures and include all of them in OAS CAHPS.

• For ASCs: Every location or unit within the ASC that is under their CCN needs to

participate in OAS CAHPS for the sample to be valid. Vendors should work with their

client ASCs to determine all locations or units that report under the same CCN and

include all of them in OAS CAHPS.

Definition of OAS CAHPS-eligible facilities

(For further detail see Chapter II)

HOPD: A unit of a hospital that performs

outpatient surgeries and procedures, is Medicare-

certified, has a CMS Certification Number (CCN),

bills CMS under the Outpatient Prospective

Payment System (OPPS); and meets the general

conditions and requirements in accordance with 42

CFR 419 subpart B.

ASC: A freestanding medical facility that performs

outpatient surgeries and procedures, is Medicare-

certified, has a CCN, bills under the ASC Payment

System, and meets the general conditions and

requirements in accordance with 42 CFR 416

subpart B.

IV. Sampling Procedures November 2018


Determining Eligibility of Surgeries and Procedures

For OAS CAHPS, the primary criterion for determining

eligible surgeries and procedures is the Current

Procedural Terminology (CPT-4)6 codes. HOPDs and

ASCs use CPT-4 codes for billing purposes. CPT codes

are composed of three categories: Category I (services,

procedures, and surgeries), Category II (performance

measurement), and Category III (emerging technology).

Category I codes are divided into the following

subcategories:

• Codes for anesthesia: 00100–01999; 99100–99150

• Codes for surgery: 10021–69990

• Codes for radiology: 70010–79999

• Codes for pathology and laboratory: 80047–89398

• Codes for medicine: 90281–99099; 99151–99199; 99500–99607

• Codes for evaluation and management: 99201–99499

OAS CAHPS-eligible surgeries and procedures fall within the Category I CPT-4 range Codes for

Surgery (i.e., CPT codes between 10021 and 69990) or one of the following Category II G-

codes: G0104, G0105, G0121, or G0260. All other CPT codes are considered ineligible for OAS

CAHPS. For more information about other patient eligibility requirements, see the section titled

Patient Eligibility Requirements—12 Criteria). Detailed explanations of each data element that

HOPDs and ASCs will provide to their vendor are covered in the section titled Definition and

Explanation of Some of the Data Elements Required From HOPDs and ASCs and Appendix R

(Example Patient File Layout).

6 CPT is a registered trademark of the AMA.

Use of CPT-4 Codes for OAS CAHPS

CPT-4 codes are a standardized set of 5-

digit codes developed by the American

Medical Association (AMA).

Participating facilities have appropriate

licensure agreements with the AMA to

use CPT codes. CMS-approved vendors

for OAS CAHPS will use the CPT-4

codes to determine eligibility of patient

records provided by the facilities.

November 2018 IV. Sampling Procedures


Patient Eligibility Requirements—12 Criteria

1. Patients who had at least one outpatient surgery/procedure during the sample month

(including outpatient surgeries and procedures when the patient had an overnight stay for

observation but was not transferred or admitted to the hospital);

2. Patients who were at least 18 years of age when they received their outpatient surgery or

procedure;

3. Patients regardless of insurance or method of payment;

4. Patients whose outpatient surgery or procedure was given in an HOPD or ASC as defined

by the project;

5. Patient’s surgery or procedure meets project eligibility definitions, which are as follows:

5a. A procedure is OAS CAHPS-eligible if it has a G-Code7 of G0104, G0105, G0121,

or G0260, or

5b. A surgery, diagnostic procedure, or other type of procedure is OAS CAHPS-eligible

if it has a CPT-48 code in the 10021–69990 range, was performed in an outpatient

surgery department or ambulatory surgery center, and if it has no accompanying

modifier of 73 or 74 (discontinued procedure)9

5c. Note that a facility may assign more than one code to a surgery or procedure. The

presence of one eligible G-code or CPT code is all that is needed to make it OAS

CAHPS-eligible.

6. Patients who have a domestic U.S. mailing address;

7. Patients who are not deceased;

8. Patients who do not reside in a nursing home;

7 G-Codes (HCPCS Level II) are alphanumeric medical procedure codes for temporary procedures and professional

services. HCPCS Level II codes are maintained by CMS. 8 CPT only copyright 2019 American Medical Association. All rights reserved.

9 Modifiers 73 and 74 (discontinued procedure) indicate that a procedure or surgery did not take place. CPT-4 codes

with Modifier 73 or 74 should be excluded.

Licensure Issues Associated With the Use of CPT-4 Codes

CMS has entered into an agreement with the American Medical Association (AMA), to use CPT data

in print and on the web. Fee schedules, relative value units, conversion factors, or related components

are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The

AMA does not directly or indirectly practice medicine or dispense medical services. The AMA

assumes no liability for the data contained or not contained herein. Applicable FARS/DFARS apply to

government use.



9. Patients who were not discharged to hospice care following their surgery;

10. Patients who are not identified as prisoners;

11. Patients who did not request that the HOPDs or ASCs protect their identity (that is, not

release their name and contact information to anyone other than facility personnel),

hereafter referred to in this manual as “no publicity” patients; and

12. Some states have regulations and laws governing the release of patient information for

patients with specific illnesses or conditions, and for other special patient populations,

including patients with HIV/AIDS. It is the HOPD’s or ASC’s responsibility to identify

any applicable state laws and regulations and exclude state-regulated patients from the

survey as required by law or regulation.

The remaining sections in this chapter on sampling are organized chronologically corresponding

to the sampling steps listed below.

• Step 1: Obtain a monthly patient information file from each client HOPD or ASC under

the same CCN.

• Step 2: Examine the monthly patient information file for completeness and work with the

HOPD or ASC to obtain missing data elements. Process and check the file for duplicate

patient records.

• Step 3: Identify eligible patients and surgeries/procedures and construct a sampling

frame.

• Step 4: Determine the sampling method most appropriate for the OAS CAHPS Survey for

this CCN.

• Step 5: Determine the ideal sample size, calculate the sampling rate, and select the

sample.

• Step 6: Verify or update contact information for sampled patients.

• Step 7: Assign a unique sample identification number to each selected sampled patient.

• Step 8: Finalize the monthly sample file and initiate data collection activities.

Step 1: Obtain a Monthly Patient Information File From Each Client HOPD or ASC Under the Same CCN

Schedule for Receiving the Monthly Patient Information File

HOPDs or ASCs administering the OAS CAHPS Survey must submit a monthly patient

information file to their contracted OAS CAHPS Survey vendor each time they conduct the



survey. Appendix R is an example of a patient file layout that includes the data variables that

vendors need from participating facilities to sample and field the OAS CAHPS Survey.

Survey vendors select samples each month from the frame of patients who meet survey eligibility

criteria. Survey vendors also initiate the survey on a monthly basis. It is critical that client

HOPDs and ASCs provide monthly patient information in a timely manner, leaving vendors

enough time to conduct sampling and quality control checks before the monthly survey is

initiated. For each monthly set of sampled patients, the survey must be initiated within 21 days

after the sample month ends. CMS recognizes that on rare occasions an HOPD or ASC may have

a situation that may prevent it from providing the monthly patient information in time for the

vendor to initiate the survey within 21 days after the sample month ends. Therefore, the vendor

can initiate the survey within 26 days after the sample month ends. These exceptions are

described in Chapters V, VI, and VII pursuant to each mode of data collection.

Construction of Monthly Patient Information Files

When the HOPD or ASC construct the file, it must include the following:

• all patients whose outpatient surgery or procedure was given in an HOPD or ASC as

defined by the project (eligibility criterion #4);

• all patients who had at least one outpatient surgery or procedure during the sample month

(including outpatient surgeries and procedures when the patient had an overnight stay for

observation but was not transferred or admitted to the hospital) (eligibility criterion #1).

If multiple survey-eligible surgeries or procedures were performed during the sample

month for a patient, all of these surgeries or procedures should be included in the sample

file;

• all patients regardless of insurance or method of payment (eligibility criterion #3);

and must exclude the following:

• patients who cannot be surveyed because of state regulations (eligibility criterion #12);

• no-publicity patients10

(eligibility criterion #11);

• prisoners if known (eligibility criterion #10);

10 Facilities or software vendors cannot exclude patients who indicated that they do not participate in surveys. These

patients must be included in the monthly patient information file. If selected, they have the right to refuse to

participate.



• nursing home residents if known (eligibility criterion #8);

• patients discharged to hospice if known (eligibility criterion #9); and

• deceased patients if known (eligibility criterion #7).

The HOPD or ASC and its vendor should reach a mutually acceptable arrangement as to whether

the facility, or the vendor, should be responsible for excluding patients who fail eligibility

criteria 2 [age], 5 [surgical code], and 6 [domestic address].

It is the survey vendor’s responsibility to ensure that

• the facility understands which patients to include and exclude from the files, and

• the facility provides the vendor with sufficient information to identify and exclude

patients who do not meet eligibility requirements.

Monthly HOPD and ASC files must contain information at both the patient and the facility level,

as described below.

Information Needed From HOPDs and ASCs for Each Patient in the Monthly

Patient Information File

HOPDs and ASCs are required to provide all of the information shown in Table 4.1 for each

patient in the monthly patient information file. The information the HOPD or ASC provides will

be used by the survey vendor to survey sampled patients and will be used by the OAS CAHPS

Survey Coordination Team for data analysis. Appendix R is an example of a patient file layout

and can be used by survey vendors as an example template of patient data needed from a client

HOPD or ASC to sample and field the OAS CAHPS Survey.

Table 4.1 Information Needed From HOPDs/ASCs for Patient Served During Sample Month

Data Element Required Reason Needed

Patient’s full name (First Name, Middle Initial, and Last Name as separate fields)

Survey administration

Gender Survey administration and analysis

Patient’s date of birth (MMDDYYYY) Survey eligibility

Mailing address (Patient Mailing Address 1, Patient Mailing Address 2, Address City, Address State, and Address Zip Code as separate data fields)

Survey administration

Patient’s telephone number including area code Survey administration

Indication whether telephone number is a cell phone Telephone survey administration (ensuring compliance with FCC Regulations)

Medical Record Number (Patient’s HOPD or ASC medical record number)

Deduplication of patients before sampling



(continued) Table 4.1 (continued)

Information Needed From HOPDs/ASCs for Patient Served During Sample Month

Data Element Required Reason Needed

Procedure code(s) (CPT11

or G-code) Survey eligibility

Date of procedure (MMDDYYYY) Survey administration

Name of location where surgery occurred Survey administration (to use facility name that will be familiar to the sampled patient)

Information Needed From Each HOPD or ASC at the Facility Level

HOPDs and ASCs are required to submit several facility-level data elements along with their

monthly patient information file. These elements are the CCN, the name associated with the

CCN, the Sample Month, Sample Year, and Number of Patients Served. Further explanation of

these required numbers is found in Chapter XI and in Appendix K (XML File Layout for

Standard Header Record).

Removing Non-eligible Patients From Monthly Files

Some HOPDs and ASCs may want to provide their contracted vendor with a monthly patient

information file that contains information only about patients who meet the survey eligibility

criteria. If the facility is making the exclusions, it is the vendor’s responsibility to make sure that

the facility understands and correctly applies the patient eligibility criteria. And, the survey

vendor must still examine the file for completeness and to make sure that all patients on the file

meet all of the eligibility criteria.

Other facilities may opt to provide a file containing information about all patients served during

the sample month so that the vendor can make the exclusions. If the survey vendor is making the

exclusions, it is the survey vendor’s responsibility to stress to its client facilities that all patients

must be represented in the file they submit. The facility must provide the vendor with sufficient

information for the vendor to identify and exclude patients who do not meet eligibility

requirements. And, even if the survey vendor is making the exclusions, the facility must exclude

state-regulated and no publicity patients.




Definition and Explanation of Some of the Data Elements Required From

HOPDs and ASCs

This section provides more explanation on some of the variables on the monthly patient

information file.

• Patient’s date of birth. Patients must be 18 years of age on the day of their outpatient

surgery or procedure to be eligible for participation in the OAS CAHPS Survey.

• Vendors should ensure that their client HOPDs and ASCs include each patient’s mailing

address, even if a telephone survey is planned for that HOPD or ASC. For facilities

planning telephone surveys, the mailing address for each patient is needed so that the

vendor can obtain or verify the sample patient’s telephone number. The facilities provide

the initial contact information; however, survey vendors are strongly encouraged to use

address verification or telephone number look-up services to obtain updated contact

information.

• Patient telephone phone number is needed for mixed-mode and telephone-only surveys. It

is strongly recommended for mail-only modes because the telephone can be used to

validate or update the patient’s address information.

• Indication of cell phone is needed for mixed-mode and phone-only surveys. FCC

regulations prohibit auto-dialing of cell phone numbers. Therefore, cell phone numbers

need to be identified in advance to allow the vendor to treat cell phone numbers in a way

that complies with FCC regulations. Vendors are advised to familiarize themselves with

all applicable state and federal laws. If the facility is unable to identify which telephone

numbers are cell phone numbers, it is the vendor’s responsibility to use an external

source to obtain an up-to-date list of cell phone numbers and landline numbers that have

been ported to cell phone. The external source must be compared to the phone numbers of

the sampled patients to identify any phone numbers that are cell phones.

• The patient’s medical record number is the unique identifier that the HOPD or ASC

assigns to the patient that allows the HOPD or ASC to track and document the care

provided to the patient. This number, along with other data elements, will allow the

vendor to keep track of whether each patient has been recently sampled.

• CPT-4 codes12

relevant to OAS CAHPS are divided into the following categories:




◦ 10021–10022 general

◦ 10030–19499 integumentary system

◦ 20000–29999 musculoskeletal system

◦ 30000–32999 respiratory system

◦ 33010–37799 cardiovascular system

◦ 38100–38999 hemic and lymphatic systems

◦ 39000–39599 mediastinum and diaphragm

◦ 40490–49999 digestive system

◦ 50010–53899 urinary system

◦ 54000–55899 male genital system

◦ 55920–55980 reproductive system and intersex

◦ 56405–58999 female genital system

◦ 59000–59899 maternity care and delivery

◦ 60000–60699 endocrine system

◦ 61000–64999 nervous system

◦ 65091–68899 eye and ocular adnexa

◦ 69000–69979 auditory system

◦ 69990 microsurgery

• G-Codes or HCPCS Level II codes are alphanumeric medical procedure codes for

temporary procedures and professional services. HCPCS Level II codes are maintained

by CMS. At this time, only four G-codes are OAS CAHPS-eligible: G0104, G0105,

G0121, and G0260.

http://en.wikipedia.org/wiki/Integumentary_system

http://en.wikipedia.org/wiki/Musculoskeletal_system

http://en.wikipedia.org/wiki/Respiratory_system

http://en.wikipedia.org/wiki/Cardiovascular_system

http://en.wikipedia.org/wiki/Hemic

http://en.wikipedia.org/wiki/Lymphatic_system

http://en.wikipedia.org/wiki/Mediastinum

http://en.wikipedia.org/wiki/Thoracic_diaphragm

http://en.wikipedia.org/wiki/Digestive_system

http://en.wikipedia.org/wiki/Urinary_system

http://en.wikipedia.org/wiki/Human_male_genitalia

http://en.wikipedia.org/wiki/Reproductive_system

http://en.wikipedia.org/wiki/Intersex

http://en.wikipedia.org/wiki/Human_female_genitalia

http://en.wikipedia.org/wiki/Maternity_care

http://en.wikipedia.org/wiki/Childbirth

http://en.wikipedia.org/wiki/Endocrine_system

http://en.wikipedia.org/wiki/Nervous_system

http://en.wikipedia.org/wiki/Human_eye

http://en.wikipedia.org/wiki/Ocular_adnexa

http://en.wikipedia.org/wiki/Auditory_system



• Vendors should work closely with facilities to ensure that only eligible surgeries and

procedures are included in the sample. Some HOPDs and ASCs perform additional

procedures that would be inappropriate for the OAS CAHPS Survey because of the

limited involvement of the doctors and nurses or the fact that the CPT code13

represents

preadmission testing, postsurgery follow-up testing, physical therapy, respiratory therapy,

laboratory, or radiology testing only. For the majority of these types of ineligible

procedures, the CPT code provides the exclusion criteria. As noted previously in this

chapter, codes for anesthesia, radiology, pathology, laboratory, medicine, and evaluation

and management would not fall within the range of eligible CPT codes for surgery

(10021–69990).

• However, some outpatient procedures that fall within the Codes for Surgery range could

be considered ineligible for OAS CAHPS based on a number of criteria, including

whether the procedure was significant enough for the survey questions to be relevant.

• See Appendix Q, Excluded Procedural Codes, for a list of CPT codes that have been

approved for exclusion by CMS. Some examples of ineligible CPT codes represent

procedures, such as the application of a compression system, collection of blood for

testing, application of casts, and bladder catheterization.

Additional CPT codes within the eligible range may also be excluded; however, the vendor

must submit an Exceptions Request Form (ERF) to document the codes to be excluded.

Name of location where surgery occurred. Some HOPDs or ASCs are part of larger, multisite

institutions. The monthly patient information file should state the name of the location where

each patient received his or her surgery. This name is included on the cover letter so that the

patient recognizes the name of this location. It may not be the official name of the facility. If

there is only one location for all patients, then this value will be identical for all patients.

Although location where surgery occurred is part of the monthly patient information file, OAS

CAHPS does not report survey results for individual locations or units within the CCN. OAS

CAHPS reports only at the CCN level.

Protocol for Missing Procedural Codes (CPT-4 Codes14 and G-Codes)

Occasionally, procedural codes (CPT-4 and G-codes) may be missing for some patient records

included in the monthly patient data file that the survey vendor receives from an HOPD/ASC.





Guidance on how to handle this missing data is based on the percentage of procedural codes that

are determined to be missing.

• If vendors determine that the percentage of patient records with missing procedural codes

is 3% or less, they are permitted to assume that the records with missing procedural codes

are eligible and continue with sampling and data collection. During file preparation, these

records should be coded into surgical category 5 (Missing).

• If vendors determine that the percentage of patient records with missing procedural codes

is higher than 3%, they are required to follow up with their client facilities to obtain the

missing procedural codes by the vendor’s deadline, which will allow them to initiate data

collection within the acceptable window of time.

If the facility cannot provide procedural codes for all of the patient records by the vendor’s

sampling deadline, vendors should work with the HOPD/ASC to determine whether the

procedural codes can be provided at a later date. After making this determination, the vendor

should follow the guidance below.

Guidelines for when missing procedural codes >3% can be provided at a later date

• If the updated monthly patient data file is received by the 26th day of the month

following the sample month, the vendor should follow the guidance provided in either

option a or b below.

a. If the vendor has been approved to conduct continuous sampling for the affected

facility, the vendor may conduct an additional round of sampling on the updated

records. If data collection for the newly sampled cases is initiated between 22 and 26

days after the end of the sample month, the vendor is required to submit a

Discrepancy Notification Report (DNR). Additional information about DNRs can be

found in Chapter XV.

b. If the vendor is conducting monthly sampling for the affected facility, the vendor

should wait until all patient records are updated to conduct sampling activities. If data

collection is initiated between 22 and 26 days after the end of the sample month, the

vendor is required to submit a DNR.

• If the updated monthly patient data file is received after the 26th day of the month

following the sample month, the vendor must first obtain CMS approval to initiate data

collection by submitting a Late Start Request e-mail to the OAS CAHPS Survey

Coordination Team, copying the HOPD or ASC client. The e-mail request should explain

the reason for the delay, state when the vendor will initiate the survey (if approved),

specify the affected sample month, and request CMS’ approval, regardless of the



sampling method or frequency (continuous, monthly, etc.). If the request is approved, the

vendor should proceed with data collection activities. Note that monthly sampling cannot

be done on a partial file so if updates are expected for some cases, the vendor must wait

to select the sample.

Guidelines for when missing procedural codes >3% cannot be provided at a later date

• If the facility cannot provide an update to records with missing procedural codes, the

vendor should do the following:

a. Work with the facility to identify an alternative method of determining eligibility for

these cases and submit the proposed alternative method in an ERF. If the proposed

alternative method is approved, then initiate sampling and data collection.

b. Work with the facility to identify a way to code the “Surgical Category” variable,

which must be included in the XML file.

• If the facility cannot provide an update to records with missing procedural codes, and the

facility is unable to determine an alternate method of determining eligibility, the vendor

should do the following:

a. Verify with the facility that they confirm that the patient records with missing

procedural codes are eligible. If they meet all of the other eligibility criteria, include

them in the sample frame. Follow the protocols described under the “Guidelines for

when missing procedural codes >3% can be provided at a later date” header to initiate

data collection.

b. Work with the affected facility to determine how the cases should be coded for the

“Surgical Category” variable, which must be included in the XML file. For example,

if the facility can determine that the cases with missing procedural codes were pulled

from the Orthopedics department, then assign the cases to “surgical category 2

(orthopedic).” If the facility cannot identify a department or another method that

would determine how the cases should be classified, assign the cases to “surgical

category 5 (Missing).”

Once sampling is complete, submit a DNR reporting that sampled cases with missing procedural

codes were fielded for a given sample month. Be sure to include the number of affected cases

and the reason that the procedural codes are missing. Also include a description of the method

used to determine each of the case’s “Surgical Category” for the XML file and for how many

cases.



If the facility cannot confirm that the patient records with missing procedural codes are eligible,

the vendor should not select the sample from facilities with missing procedural codes above

10%. In this case, submit a DNR documenting that the vendor could not conduct sampling for a

given sample month, the number of affected cases, the percentage of cases with missing

procedural codes, and the reason that the procedural codes are missing.

Sampling More Frequently Than Monthly

Some HOPDs and ASCs may prefer to deliver patient records to their survey vendors more

frequently than monthly (e.g., weekly, biweekly) per their convenience. This is acceptable,

provided that sampling is done using a monthly patient information file.

However, if the survey vendor wishes to perform sampling on a continuous basis it must

complete and submit an ERF that explains its reasons and proposed procedures. It may receive

approval from CMS for more frequent sampling. Information about the ERF and process is

provided in Chapter XV of this manual.

Protocol for No Eligible Patients Served in the Sample Month

If the HOPD or ASC did not perform any outpatient surgeries or procedures or did not serve any

patients who met survey eligibility criteria during the sample month, the facility must still submit

a monthly patient information file or an e-mail notification to its survey vendor stating that no

survey-eligible patients were served during that sample month.

Vendors are still required to submit data to the OAS CAHPS Data Center for a month when there

are no eligible cases. The vendor submits a Zero Eligible File in this situation. The vendor must

indicate on the file that there were zero eligible cases in data element for “Eligible Patients” and

enter all other information required in the Header Record Section of the XML file (refer to

Chapter XI in this manual for more information about data file preparation and submission). If

the vendor does not submit a zero-eligible file in this case, CMS and the OAS CAHPS Survey

Coordination Team will view the HOPD or ASC as having “missed” a sample month. HOPDs or

ASCs for which an OAS CAHPS Survey data file is not submitted for a month in the reporting

period may be considered as being noncompliant with OAS CAHPS Survey participation

requirements.

Protocol for Administering Other Surveys in Conjunction With the OAS

CAHPS Survey

Some HOPDs and ASCs may wish to administer other surveys of their patients. The following

guidelines should be used if the HOPD or ASC is planning to administer other surveys in

addition to the OAS CAHPS Survey.



If an HOPD or ASC will be fielding another survey of its patients, it must provide a file of all

OAS CAHPS-eligible patients to its survey vendor for the OAS CAHPS Survey first, prior to

selecting patients for any other survey. Patients who were not randomly selected into the OAS

CAHPS Survey sample for the sample month may be included in a sample for a separate survey

that the vendor conducts on the HOPD’s or ASC’s behalf that month. This secondary survey

sample must be selected after the OAS CAHPS Survey sample has been drawn. The vendor

cannot provide the list of sampled patients for OAS CAHPS to the HOPD or ASC because this

would be a violation of the patient’s confidentiality. Because of the coordination required

between surveys, both surveys must be administered by the same vendor.

Facilities that are conducting patient surveys in parallel with OAS CAHPS are reminded that they

are allowed to add up to 15 supplemental questions of their own to the OAS CAHPS

questionnaire. Subsuming the questions from their other survey into OAS CAHPS and

discontinuing the other survey may be more efficient than administering both surveys

simultaneously.

It is permissible for HOPDs or ASCs that are participating in the American College of Surgeons’

National Surgical Quality Improvement Program (NSQIP) to administer the OAS CAHPS

Survey in conjunction with the NSQIP post-operative survey to patients such that each survey

can be administered independently. In other words, the OAS CAHPS Survey vendor can sample

OAS CAHPS patients as they normally would and the NSQIP follow-ups can be administered as

required.

Approved OAS CAHPS Survey vendors are expected to work closely with their client HOPDs

and ASCs to identify patients who are eligible for inclusion in other surveys the facilities

conduct. It is very important to avoid burdening patients with both OAS CAHPS and other

surveys. If the other survey is federally sponsored, vendors should contact the OAS CAHPS

Survey Coordination Team to make arrangements for both surveys.

Step 2: Examine the Monthly Patient Information File for Completeness and Possible Duplication

Survey vendors should examine each monthly patient information file provided by their client

facilities to ensure that information they need for determining survey eligibility for all records in

the file has been provided. This includes CPT15

or G-code(s) classifying the surgery, patient date

of birth, and date of surgery or procedure. If patient information needed for sample selection is

missing, the vendor should work with the HOPD or ASC to obtain all missing data before




selecting the sample. Additional guidance on handling missing procedural codes is provided

earlier in this chapter.

Survey vendors should check the monthly patient information file to ensure that it does not

include duplicate information—that is, to ensure that a patient does not appear more than once on

the file. If duplicate information is included, the vendor should review the patient information

provided to determine whether multiple survey-eligible surgeries or procedures were performed

for a patient. Unique surgery or procedure entries for each patient should be retained to conduct

Step 3 below. For all other duplicated patient information, make a copy of the monthly patient

information file and remove the duplicate information on the new file. Note that vendors are

required to retain the original monthly patient information files submitted by their client HOPDs

and ASCs, and any new copies made, for possible audits by CMS and the OAS CAHPS Survey

Coordination Team.

When checking the monthly patient information files to identify “duplicate” patients or patients

who may have been listed on the file more than once, vendors should use the patient’s Medical

Record Number (MRN) and at least one other patient data element to check for duplicate cases.

Data elements that will be useful for identifying duplicates include the surgery code(s), patient’s

name, date of birth, telephone number, etc. Using the MRN in conjunction with other patient data

elements will help ensure that patients identified as duplicate patients on the file are indeed

“duplicate” records.

If a patient had more than one surgery or procedure in the sample month, it is to be expected that

he or she will have more than one record in the monthly patient information file. Vendors should

remove the patient’s record associated with a surgery code that is not OAS CAHPS-eligible. If

the patient received procedures on different dates in the month and the procedures on all dates are

OAS CAHPS-eligible, the vendor should remove the records for the earlier procedures and keep

only the latest (most recent) procedure on the sample frame.

The vendor should have a different staff member conduct a QC check on these two processes

(completeness check, removal of duplicates) before proceeding to Step 3.

Step 3: Identify Eligible Patients and Construct a Sampling Frame

After the completeness check and the duplicate patient removal, the survey vendor should verify

the eligibility of the patients. As stated above, HOPDs and ASCs may elect to remove ineligible

patients and surgeries before supplying the monthly patient information file, or may elect to have

their vendor do it on their behalf. Either way, the vendor should do the following:

1. Compute patient age at the time of surgery by use of the date of birth and surgery date.

Verify that the patient was 18 years of age or older at the time of his or her surgery.



2. Verify that at least one surgery or procedure for each patient is OAS CAHPS-eligible

according to its CPT code(s)16

or G-code(s), the procedures was billed through OPPS, and

that the procedure was not performed in an emergency department.

Note: If a patient record has both eligible and ineligible procedural codes associated with

it, that patient could be eligible for the OAS CAHPS Survey if at least one CPT code or

G-code is eligible.

3. If a patient record has more than one procedural code, determine the primary code.

4. If there are patients with more than one OAS CAHPS-eligible procedure, retain the most

recent patient record (based on the visit date) only.

5. Verify that patients have a U.S. domestic address.

6. Verify that the date of the surgery or procedure is within the sample month.

These six checks align with the Patient Eligibility Requirements listed in Step 1. Patients who fail

any of these verifications are not OAS CAHPS-eligible and should be removed from the sample

frame.

After the completeness and duplication review in Step 2 and the removal of ineligible patients in

Step 3, there is another step that must be performed before creating a definitive sample frame for

the month. That step is to remove all patients who were sampled for OAS CAHPS in the

previous 5 months.

To reduce respondent burden, outpatient surgical patients can only be sampled for OAS CAHPS

once in a 6-month period. Therefore, the survey vendor must also exclude from the sample frame

patients who were included in the OAS CAHPS Survey sample during the 5 months preceding

the sample month. Vendors must compare all eligible patients on the new month’s file to all

patients selected for the survey in the past 5 months and identify any repeats. Such

repeating patients are ineligible and must be removed from the sample frame. This determination

must be made before sampling from the sample frame begins.

For purposes of audit and quality assurance, survey vendors must keep the original monthly

patient information files submitted by all HOPDs and ASCs and the sampling frame created for

each sample month for 18 months. Vendors must record and retain documentation showing the

reasons patients were excluded from the sample frame for each sample month and the quality




control checks completed during the sampling process. This documentation will be subject to

review by the OAS CAHPS Survey Coordination Team during site visits.

Step 4: Determine the Sampling Method Most Appropriate for the OAS CAHPS Survey for This CCN

As a reminder, OAS CAHPS

participation within the CCN must be

comprehensive. As stated in Step 1, all

components within the CCN that are OAS

CAHPS-eligible are to be included in

OAS CAHPS. When this chapter

mentions the term “components” it refers

to the definition in the text box.

The components present in the CCN, the volume of eligible patients in each, and analytic goals

of the client CCN dictate which sampling method is most appropriate. There are four acceptable

sampling methods for OAS CAHPS:

• Simple random sampling method;

• Stratified systematic sampling method;

• Proportionate stratified random sampling method; and

• Disproportionate stratified random sampling method.

Simple Random Sampling (SRS) Method

Appropriate use: When there is a single component within the CCN.

Example: Northshore Ambulatory Surgery Center sees about 400 patients per month. It does not

share the CCN with any other surgery centers and has only one location.

Stratified Systematic Sampling (SSS) Method

Appropriate use: There are two or more components (strata) within the CCN and patients from

all components need to be included in the OAS CAHPS sample proportionally to their volume in

the CCN to make a valid sample. However, the strata are small or the facility does not wish to

track results at the strata level.

Example: ABC Surgery Center comprises three locations (strata). They all bill under the same

CCN. Location A served 100 eligible patients in the sample month, Location B, 140, and

Location C, 80 eligible patients in the sample month, for a total of 320 eligible patients.

Definition of “Component” Used in This Chapter

Components of an HOPD: Any departments,

locations, or other divisions that meet the definition of

an OAS CAHPS-eligible HOPD and that bill under the

hospital’s CCN.

Components of an ASC: Any departments, locations,

or centers that are within or associated with the eligible

ASC and that bill under the ASC’s CCN.

For sampling purposes, components are considered

sampling strata.



Proportionate Stratified Random Sampling (PSRS) Method



the CCN to make a valid sample. Additionally:

• the HOPD or ASC would like to keep track of samples and results for each stratum, or

• the HOPD or ASC would like to designate other aggregates of operating units for tracking

while using the same sampling rate for each.

Example: Any-City Best Care Surgical Center comprises three locations (strata) but they all bill

under the same CCN. These patients were located in Facility A, which serves 200

patients/month, Facility B, which serves 150 patients/month, and Facility C, which serves 180

patients/month. Facility A has been in operation for 10 years, but Facilities B and C were opened

in the last 2 years. Any-City Best Surgical Center wants the survey estimates from each location

to have statistical precision and would like to track them separately over time.

Additional requirements and limitations: A minimum of 10 eligible patients must be in each

stratum for PSRS sampling to be used. The statistical precision of survey results at the stratum

level will not be very good unless the stratum sample size is about the size of the overall sample

requirements (25 completed surveys per month).

Disproportionate Stratified Random Sampling (DSRS) Method

Appropriate use: There are two or more components (strata) within the CCN and the CCN

wishes to achieve statistically precise survey estimates for the component facilities.

Example: Memorial Hospital includes three eligible outpatient departments (strata): Same Day

Surgery (120/month), Outpatient (100/month), and Endoscopy (40/month). Memorial wants each

department’s survey estimate to have statistical precision.

Additional requirements and limitations: A minimum of 10 eligible patients must be in each

stratum for DSRS sampling to be used. The goal of the DSRS is to obtain sufficient statistical

power to detect differences at the stratum level. Vendors wishing to use DSRS must submit an

Exceptions Request Form to the OAS CAHPS Survey Coordination Team and receive approval

from CMS prior to using this method.

Deciding Which Method to Use

The facility, in conjunction with the vendor, should determine which of the four OAS CAHPS-

approved sampling methods described above is most appropriate for their CCN and meets the

analytic needs of the facility. Unless DSRS has been approved for use, if there are two or more



components with the CCN either SSS or PSRS must be used. SRS may not be used if there are

two or more components.

The same sampling method must be used for all sample months in the quarter. Vendors may

switch to a different sampling method only at the beginning of a new quarter.

Step 5: Determine the Ideal Sample Size, Calculate the Sampling Rate, and Select the Sample

Determine the Ideal Sample Size

The target for the statistical precision of OAS CAHPS Survey results that will be publicly

reported is based on a reliability criterion. The reliability target for the OAS CAHPS Survey

ratings and most of the composites is 0.8 or higher. For reasons of statistical precision, a target

minimum of 300 completed OAS CAHPS Surveys has been set for each HOPD or ASC over

each 12-month reporting period. This is an average of 25 completed surveys per month.

The mode of survey administration will be an important factor in determining sample size and

response rates. Table 4.2 shows response rates by mode that are anticipated for OAS CAHPS and

the sample sizes needed based on these rates.

Table 4.2 Response Rates Obtained by Mode Anticipated for OAS CAHPS

Mode Expected Response Rate Sample Size for 25 Responses/Month

Mail only 28% 90

Phone only 24% 105

Mixed 38% 66

The sample size estimates above were derived using the following formula:

Sample size = (number of responses needed) (response rate) = 25 (response rate)

where the value used for the number of responses needed is 25. These sample size estimates have

been rounded up to the nearest integer. Each vendor should work with its client HOPD or ASC

and use experience on other surveys with similar populations to determine the appropriate data

collection mode and expected response rate to use as a guide for calculating monthly sample

sizes.

Calculate the Sampling Rate

Survey vendors must calculate a sampling rate and use that rate to ensure that an even

distribution of patients is sampled over a 12-month period. To calculate the sampling rate,

vendors will need to have a good estimate of the size of the sample frame. The typical frame size



will depend on the number of patients served by the HOPD or ASC and the percentage of these

patients and surgeries and procedures that are OAS CAHPS-eligible.

Vendors should expect that there will be variability in the number of patients the HOPD or ASC

serves and the number eligible for the survey because these characteristics vary over time. In

some cases there could be seasonality to surgeries, depending on the mix of patients served by

different HOPDs or ASCs. The number of patients to be selected each month to yield a minimum

of 300 annual completed surveys will vary from month to month depending on the number of

eligible patients submitted to the vendor and the sampling rate that is applied.

The sampling rate must be approximately the same for each month in a quarter. The rate may be

increased in subsequent months to achieve the target of 300 annual completed surveys, but

should not be decreased simply to avoid exceeding 300 completed surveys.

The survey vendor should estimate a sampling rate by working with its client HOPDs and ASCs

to understand the number of patients served and how many of them will typically be eligible, as

described below.

Using Prior Months From the HOPD or ASC in the Calculation of the

Sampling Rate

The vendor should work with the HOPD or ASC prior to the first sample month that the HOPD

or ASC begins its participation in the OAS CAHPS Survey to estimate the sample frame size.

This sample frame size should be estimated from the number of patients served monthly and the

percentage of those patients, and surgeries and procedures that are OAS CAHPS-eligible. The

HOPD or ASC should supply to the vendor monthly patient information files with all the

required data elements (see Table 4.1) for each of the preceding 3 to 6 months. The more months

the facility provides, the better the vendor will be able to estimate sample frame size and its

variability. A single month can be nonrepresentative of an HOPD’s or ASC’s patient size or

surgeries and procedures performed, so consider a range of months to guard against estimating

sampling rates that will yield a sampling frame that is either too large or too small.

In looking at the sample frame information for the 3 to 6 months that precede the first sample

month of participation, the vendor should apply the same sample frame construction criteria for

each month that it would apply for the first sample month. Note that in the first month’s sample

file, the rule that a patient cannot be sampled more than once in the 6-month period will not be a

constraint. In the second month of the 3- to 6-month test period, all patients sampled in the first

month will be excluded from the frame. Only patients not sampled the previous sample months

can be included on the sample frame for the second (and subsequent) month(s).

Once the vendor has a good understanding of the average monthly frame size, it should calculate

the sampling rate using the formula



Sampling rate = (Required sample size) (frame size)

The required sample size, as explained above, is

Required sample size = (number of responses needed) (response rate)

Adjustments to the sampling rate may be needed over time to reach the annual target of 300

completes over each of the rolling four quarter periods. However, sampling rate should not

fluctuate wildly between months. All patients sampled in a sample month must be surveyed. The

target of 300 completed surveys is not a quota after which surveying or processing can stop.

The Purpose of Using a Sampling Rate

Using a sampling rate, instead of a fixed number of patients each month (i.e., target sample size),

helps smooth out the influence of patient characteristics over time. This ensures that patients’

perspective of the care at various points in time is proportionately captured. There is variability

in HOPD and ASC activities over time including the patients served, surgeries performed,

facility staff, and general operations.

Example: Center City Surgical Center is a new participating facility. It provides information

about its historical patient counts to its vendor. The vendor determines Center City Surgical

Center has about 100 eligible patients each month. Based on past experience on the OAS

CAHPS Survey or other work the vendor expects a 30% response rate from these patients. Using

the sample size formula above for this facility, the ideal sample size for a month is:

Required sample size = (number of responses needed) (response rate)

83 patients = (25 completes) (30% response rate)

For a typical month of 100 eligible patients, the vendor would select 83 patients.

In reality, Center City Surgical Center will not have exactly 100 eligible patients each month.

Therefore, the vendor will not select 83 patients each month. Months where there are fewer

eligible patients will yield fewer sampled patients. If the January monthly patient information file

has only 90 eligible patients, the vendor will apply the 83% sampling rate to 90 patients and

sample 75 patients. For a month when the facility has more eligible patients, the sample will be

larger.

Sampling Rates That Yield Above and Below the Minimum Number of

Patients

The targeted number of completed surveys for OAS CAHPS is 300 over a 12-month period.

Some HOPDs and ASCs may want to survey more of their patients. Reasons for doing so include

having more patients represented in the survey results or achieving a reliability target for a



component within the CCN, a type of patient, or a surgical procedure. There is no upper limit to

the number of patients who may be surveyed for OAS CAHPS. However, the vendor should still

use a sampling rate and select a sample (rather than surveying all eligible patients each month) so

that the sample is evenly distributed across a 12-month period. As a reminder, samples that are

selected disproportionately―that is, with a different sampling rate for different strata―require

approval from the OAS CAHPS Survey Coordination Team via an ERF. As stated previously,

the survey vendor should determine a sampling rate and select the sample so that there is an even

distribution of patients over a 12-month period.

For small facilities with low patient volumes, the number of survey-eligible patients served may

be less than the number required by the sampling rate. In this case, it is acceptable to sample, and

then survey, all survey-eligible patients served during that sample month. For small facilities that

sample all eligible patients (i.e., conducting a census), the survey measures the true value of the

patient population. The survey measures the true value because all patients were selected for the

survey. Large facilities target 300 completed surveys to achieve sufficient statistical precision to

reflect their population of patients. Thus, the ratings for large facilities and the ratings for small

facilities both achieve the statistical precision for the OAS CAHPS Survey results based on the

reliability criterion targeted.

Generation of Random Numbers Needed for Sample Selection

All four methods of sampling approved for OAS CAHPS described in Step 4 require the use of

random numbers. Survey vendors should use a random number generator that is generally

accepted as having satisfied criteria of randomness. The random numbers should be generated

from the uniform distribution―each number having an equal probability of selection. Most

random number generators are pseudo-random number generators that repeat numbers after some

specified period. An acceptable random number generator will repeat only after many billions of

numbers are produced. An important feature of the random number generator is the “seed”

number used to start the cycle. The seed number must be known and retained as part of the

documentation vendors keep so that the sampling process can be reproduced for OAS CAHPS

Survey Coordination Team site visits. The selection of the seed number should be such that it

cannot be manipulated.

Survey vendors should use a reputable statistical program like SAS v9 either to select a sample

from a frame using its procedures for survey sample selection or to generate random numbers

that can be applied as described above. An appropriate seed often used is the clock time as

measured by the computer. This seed varies each fraction of a second but the value used is

documented by the program and is part of the output that can be retained.

Another reliable program, which runs under Windows, is RAT-STATS, developed by the

Department of Health and Human Service Inspector General’s Office. Survey vendors can

download this program at no cost from https://oig.hhs.gov/compliance/rat-stats/index.asp.

https://oig.hhs.gov/compliance/rat-stats/index.asp



In addition to the RAT-STATS program, survey vendors may download a detailed user’s guide

and comprehensive manual describing how this program operates. There are many sampling

tools in the program. One module can simply produce a sample size, n, random integers between

1 and the frame size, using the computer clock to generate the seed, which is retained and

reported.

Both SAS and RAT-STATS are examples of readily available, high-quality, rigorously tested

tools for selecting samples randomly. Commonly available spreadsheet programs also have

random number generators; however, they do not use these random number generators when

selecting monthly samples for the OAS CAHPS Survey because they do not generate a report of

the seed used. Note, however, that a spreadsheet is an acceptable way to present and manipulate

the sample frame.

It is also especially critical to document how the random start number was generated and how the

sample frame was sorted for survey oversight purposes. During oversight telephone calls or site

visits, the OAS CAHPS Survey Coordination Team will check each vendor’s sampling

procedures and documentation, including documentation of all quality control checks conducted

by vendor staff.

The following are two acceptable ways to choose a random sample of patients from the sample

frame for the OAS CAHPS Survey.

Method 1—Generate N Random Numbers

Sort the sample frame of N eligible patients by any replicable method.

• Generate the N random numbers.

• Assign the random numbers in the order generated to each element in the frame.

• Re-sort the elements as ordered by the random numbers.

• Select the first n, the sample size required for the mode used.

In this way, the initial sort of the data does not affect the result, although a standard sort order

should always be used so that it does not appear that a frame has been altered. This method

requires generating as many random numbers as there are patients on the frame.

Method 2—Generate n Random Numbers

If the random number generator is able to produce integers from a range of values, given that N

is the size of the sample frame of eligible patients, we can use the following steps to select our

sample.



• Generate n distinct random integers whose values range from 1 to N, where n is the

sample size required for the mode used.

• Select the element of the frame that corresponds to the random number generated. For

example, if the random number 10 is generated then select the 10th element on the frame

for the sample.

• Continue selection of elements according to the random numbers generated until all n

distinct elements have been selected.

For Method 2, the initial sort of the data does affect the result, and the vendor should clearly

document any sorting or file manipulation that occurred prior to random number generation.

Either Method 1 or Method 2 may be used for SRS, PSRS, or DSRS.

Method of Simple Random Sampling

Appropriate Use: SRS can be used when there is a single component within the CCN. For

example, if there is only one eligible HOPD in the hospital’s CCN or only one location in the

ASC’s CCN, SRS can be used.

Example: Northshore Ambulatory Surgery Center sees about 400 patients per month. It does not

share the CCN with any other surgery centers. From looking over the past 3–6 months it is

revealed that on average 350 patients per month are OAS CAHPS-eligible. Northshore is

required to obtain 25 completed surveys per month (300 completed surveys / 12 months = 25

completed surveys per month). Because the surgery center will be doing mixed-mode data

collection to which a 38% response rate is expected, it will need to sample 65.8 patients per

month (25 completes / .38 response rate = 65.8 selected patients), which is rounded up to 66.

Northshore’s sampling rate is 65.8/350, or 18.8%.

Use either Method 1 or Method 2 for selecting the patients from the sample frame.

If Method 1 is used, sort the month’s eligible patient list by the random number and select the

first 66 patients. If Method 2 is used, generate 66 random numbers between 1 and 350. Select the

elements from the frame that correspond to the random numbers generated.

Method of Stratified Systematic Sampling

Appropriate Use: Vendors may use SSS when a CCN comprises two or more strata and patients

from all strata need to be included in the OAS CAHPS sample proportionally to their volume in

the CCN to make a valid sample. SSS is appropriate when the strata are small or the facility does

not wish to track results at the strata level.

There are two variations to implement the SSS sampling method:



• Variation 1 (SSS1): The same sampling rate is applied to each stratum; it is equivalent to

PSRS. In SSS1, a same skip pattern (for example, picking one and skipping 4) is applied

in each stratum; in PSRS, first calculate the number of patients selected from each

stratum proportionally to eligible patient volumes, then select patients independently

within each stratum. Both methods may yield exactly the same number of patients

selected but may be slightly different because of rounding.

• Variation 2 (SSS2): Different sampling rates are applied to different strata; it is

equivalent to DSRS. Similar to SSS1, both methods may yield exactly the same number

of patients selected but may be slightly different because of rounding.

Example: ABC Surgery Center comprises three locations but they all bill under the same CCN.

Location A served 100 eligible patients in the sample month. Location B served 140 eligible

patients in the sample month. Location C served 80 eligible patients in the sample month. There

are 320 eligible patients in this sample month. Assume the vendor expects a 40% response rate.

The vendor will want to sample 63 patients each month to ensure about 25 completed surveys

each month to total approximately 300 completed surveys in a 12-month period.

63 patients * 40% response rate = 25 completed surveys

25 completed surveys *12 months = 300 completes in a year

The vendor needs to sample 63 patients in total from ABC Regional Medical Center, but the

locations A, B, and C should be representative (proportionate) in this total. The vendor should

calculate the proportion of patients from each location, as shown in Column B. The vendor

should then allocate the 63 patients proportionally to each location, as shown in Column C.

A.

Patient Count

B. Proportion of Patients on

Frame (Column A/320)

C. Number of Patients to be

Sampled (63 x Column B/100)

(numbers rounded up)

Location A 100 31.25 19.69 (round to 20)

Location B 140 43.75 27.56 (round to 28)

Location C 80 25.00 15.75 (round to 16)

Total 320 100.00 64.00

Although the vendor’s goal was to get 63 patients, it is important to round up to the next highest

integer. In this example, the sum in column C shows the total sample size ends up being 64

patients. Rounding down could result in not achieving the target of 300 completed interviews.



Once the vendor knows how many patients to sample from each location, it will apply the

systematic sampling process to the sample frame for each location. First, the vendor will need to

select a starting observation. To do this the vendor should use a random number generator to

apply random numbers to all frame members. Then the vendor should find the lowest random

number, and the corresponding frame member will be the first sample member and be the starting

point of the systemic sample. Next, the vendor needs to calculate the size of the interval. For

Location A, the frame has 100 patients and 20 need to be sampled. The interval will be 100 / 20

= 5. The vendor will take Sample Member #1 based on the random number generation. Say

Patient #19 had the lowest random number and was the first patient selected. Using the interval

of 5, the vendor will go down the list and select Patient #24, then Patient #29, Patient #34, and so

on until 20 patients are selected. If the starting number is toward the bottom of the list (e.g.,

Patient #90), the vendor would go to the top of the list and continue down again, considering the

list to be circular.

Vendors should not allow a patient to be selected multiple times. No sorting should occur. After

selecting the 20 patients from Location A, the vendor should repeat this process on the list of

eligible patients from Location B and on the list of eligible patients from Location C. The interval

will always be 5.

Method of Proportionate Stratified Random Sampling



the CCN to be a valid sample. Additionally,

• the HOPD or ASC would like to keep track of samples and results for each stratum, or

• the HOPD or ASC would like to designate other aggregates of operating units for tracking

while using the same sampling rate for each.

In PSRS, the same sampling rate must be applied to each stratum included in the sample. The

strata created must be large enough to support the same sampling rate in each stratum.

Example: Any-City Best Care Surgical Center comprises three locations (strata) but they all bill

under the same CCN. The surgical center serves 530 patients per month, across Facility A, which

serves 200 patients/month, Facility B, which serves 150 patients/month, and Facility C, which

serves 180 patients/month. Facility A has been in operation for 10 years, but Facilities B and C

were opened in the last 2 years. Any-City Best Surgical Center wants the survey estimates from

each location to have statistical precision and would like to track them separately over time.

These facilities each serve as a stratum for sampling. The vendor for this ASC selected a

sampling rate of approximately 45%, based on its prior experience with this client facility.



The sampling rate for the CCN as a whole is 45%, to get 239 sampled patients in the sample

month. Then the vendor will apply that same sampling rate to each stratum, as demonstrated

below:

• Location A: 200 eligible patients * 45% sampling rate = 90 patients sampled

• Location B: 150 eligible patients * 45% sampling rate = 68 patients sampled

• Location C: 180 eligible patients * 45% sampling rate = 81 patients sampled

The vendor would round any fractions of a patient up to the next largest whole number. For

example, a sample of 67.5 patients should become 68 sampled patients. The vendor should use

Method 1 or 2 to select the sample of 90 patients in Location A, 68 patients in Location B, and 81

patients in Location C.

This vendor uses mixed-mode administration and expects a response of rate of 40% (see

Table 4.2). If the vendor achieves a response rate of 40% the number of completed surveys will

be as follows:

• Location A: 62 patients sampled * 40% Response Rate = 36 completed surveys

• Location B: 68 patients sampled * 40% Response Rate = 28 completed surveys

• Location C: 81 patients sampled * 40% Response Rate = 33 completed surveys

The total number of completed surveys from this CCN in the sample month is 97, which greatly

exceeds the number of responses needed to get 300 completed interviews. Additionally, each

stratum (location) has 25 or more completed surveys and is on target to achieve 300 completed

surveys in the 12-month period. There will be adequate statistical precision to track estimates for

each location.

Even if a facility does not have a large number of eligible patients in each stratum, it may still

use PSRS. It may not achieve enough completed surveys in a stratum to have good statistical

precision, but may still proceed so long as each stratum has a minimum of 10 sampled patients

each month.

Method of Disproportionate Stratified Random Sampling

Appropriate use: DSRS is another appropriate sampling option if a hospital, for example, with

multiple HOPDs wishes to achieve statistically precise numbers for each HOPD. To achieve as

good a level of precision for the separate units (in this example, the HOPDs) as required for the

CCN as a whole, each unit would have to have the same number of completed surveys as the

CCN as a whole. In this case, the sampling rate may be different for each stratum. To allow the



separate strata to be recombined to represent the HOPD or ASC as a whole the sampling rate for

each stratum must be reported in the data submitted to the OAS CAHPS Survey Coordination

Team. This will permit appropriate weighting of the respondents in computing results. Different

sampling rates in strata with particularly high or low ratings could otherwise distort the ratings.

If an HOPD or ASC chooses to use DSRS, its survey vendor must do the following:

• Complete and submit an ERF;

• Use the same name for each stratum in each month in the quarter;

• Make sure that each stratum has a minimum of 10 patients eligible to be included in the

survey during the sample month; and

• Provide to the OAS CAHPS Data Center additional information about each stratum,

including the following:

◦ The name of the stratum;

◦ The total number of patients sampled in each stratum during the sample month;

◦ The total number of patients on the file submitted by the HOPD or ASC for that

stratum;

◦ The number of patients in the stratum who were eligible for the survey during the

sample month; and

◦ The total number of patients sampled during each sample month.

Example: Memorial Hospital includes three eligible outpatient departments (strata): Same Day

Surgery (120/month), Outpatient (100/month), and Endoscopy (40/month). Memorial wants

statistically precise survey estimates for each department. Assume that the target for each stratum

is the same as for the CCN as a whole, that 25 is the target number of responses, and that the

expected response rate is 40%. Therefore, to get the same precision for each stratum the sample

size would be 62 for each of the three strata in this example. Because of the differing patient

volumes for these departments, the vendor’s sampling rate to achieve a sample size of 62 varies,

as shown below:

• Same Day Surgery: 120 eligible patients * 51% sampling rate = 62 sampled patients of

whom 40% respond to get 25 completed interviews.

• Outpatient: 100 eligible patients * 62% sampling rate = 62 sampled patients of whom

40% respond to get 25 completed interviews.



• Endoscopy: 40 eligible patients * 100% sampling rate = 40 sampled patients of whom

40% respond to get 16 completed interviews.

Note that the survey vendor will report the number of patients eligible for the survey and the

number sampled to the OAS CAHPS Data Center for use in computing weights for the HOPD or

ASC when the data are combined (this information is provided in the vendor’s data submission,

see Appendix L, XML File Layout for DSRS Header Record. Patients in Location A had a

lower probability of selection than those in Locations B and C, and that will be accounted for

when the data from sample members in the strata are combined. Survey vendors should keep in

mind that a minimum of 10 eligible patients must be in each stratum for DSRS sampling to be

used.

The goal of the DSRS process is to obtain about 300 completed interviews for each stratum (e.g.,

location) in the 12-month period. This will provide sufficient statistical power to detect

differences at the stratum level. In this example, Location C will have lower statistical power

because the number of completes (only 16 are expected) will probably not reach 300 in the 12-

month period because of the lower number of eligible patients.

Step 6: Verify or Update Contact Information for Sampled Patients

We strongly recommend that survey vendors send patient mailing addresses of sampled patients

through an outside address service, such as the National Change of Address or a similar provider,

to confirm or update patient contact information. In addition, vendors conducting either a

telephone-only or mixed-mode data collection are urged to send the most updated mailing

addresses through a telephone number provider service to attempt to obtain an updated telephone

number. Performing these quality control activities prior to the start of data collection will result

in fewer surveys returned as undeliverable and fewer unproductive telephone call attempts.

Vendors are also reminded that in Step 2 they were to request contact information for all patients.

If an HOPD or ASC does not provide an address or telephone number for a patient on the

monthly patient information file and this omission was not rectified in Step 2, the vendor should

recontact the HOPD or ASC for the missing information for all patients contained on the

HOPD’s or ASC’s original data file. Asking for the information for all patients is important

because the vendor may not reveal to the facility which patients were selected for OAS CAHPS.

The vendor should also attempt to find an address and phone number for the sampled patients

who lack it. In most cases an HOPD or ASC will have the patient’s telephone number that was

obtained for the purpose of calling them to follow up on their recovery.

Vendors should also note that even if an address or telephone number cannot be obtained for a

patient, the patient is still eligible for inclusion on the sample frame (and in the survey if

sampled) if he or she meets all other survey eligibility criteria. That is, patients with missing



mailing addresses are considered eligible for the survey and can be sampled. If a patient sampled

for a mail-only survey lacks an address the patient should be assigned the survey disposition

code of 330—Bad Address/Undeliverable Mail or No Address. If a patient sampled for a

telephone-only survey lacks a telephone number the patient should be assigned the survey

disposition code of 340—Wrong, Disconnected, or No Telephone Number. If a patient sampled

for a mixed-mode survey has a telephone phone number or an address, the vendor should

proceed with the survey; if the patient has neither, survey disposition code of 340—Wrong,

Disconnected, or No Telephone Number should be assigned.

Step 7: Assign Unique Sample Identification Numbers

Survey vendors are responsible for assigning a unique alphanumeric sample identification (SID)

number to every sample member selected into each monthly sample. Detailed procedures for

assigning unique SID numbers are described in Chapter IX.

Vendors will track the status of a sampled patient/case throughout the data collection process

using the SID. Note that this number is different from the medical record number that HOPDs

and ASCs will provide to the survey vendor with other information needed to construct the

sample frame. The SID number cannot contain any combination of letters, numbers, or any

information that could link it with a particular sampled patient. For example, no part of the

patient’s name, address, date of birth, telephone number, Social Security number, visit dates, or

Medical Record Number can be used or included in the SID number under any circumstances.

The SID number also cannot include any information that would identify the HOPD or ASC that

served the patient (i.e., HOPD’s or ASC’s name, address, CCN). Each month, vendors must use

a new set of unique SID numbers for the new set of patients sampled that month. Vendors must

not reuse the same SID numbers—that is, once the SID number is assigned, it should never be

assigned again to any sampled patient, either in the current quarter or in subsequent quarters.

Step 8: Finalize the Monthly Sample File and Initiate Data Collection Activities

As soon as the sampling activities described above have been completed, data collection for the

sample month should begin. Survey vendors must initiate the survey for each monthly sample

within 3 weeks (21 days) after the end of the sample month. Exceptions to this start date are

noted earlier in this chapter. All data collection for each monthly sample must be completed

within 6 weeks (42 days) after data collection begins. For mail-only and mixed-mode surveys,

data collection for a monthly sample must end 6 weeks after the first questionnaire is mailed. For

telephone-only surveys, data collection must end 6 weeks following the first telephone attempt.

As noted earlier in this chapter, HOPDs and ASCs must provide the patient information file for

each sample month in time for the survey vendor to initiate the survey within 21 days after the

sample month closes. The HOPD or ASC can choose to submit the data needed on two separate



files. The first file must contain all patient information that the vendor will need to determine the

patients’ eligibility for the survey and for fielding the survey. The second file may contain

information needed at the facility level for analysis, and it must be submitted to the vendor in

time for the vendor’s data submission to the OAS CAHPS Data Center.

Requirement That the First File Contain All Patient Information

The survey vendor needs to receive all patient and patient procedure information in the first file

and follow the process (described in Step 1) to remove known ineligible patients and procedures

from the frame so they are not sampled. Survey vendors should not initiate the OAS CAHPS

Survey to all patients and determine at a later date which patients had a procedure that was OAS

CAHPS-eligible. Consultations, preadmission tests, or follow-up tests are examples of ineligible

procedures. In general, vendors should use CPT17

codes and G-codes as described in Step 1 to

determine if the surgery is OAS CAHPS-eligible but other methods may suffice. An example of

another method that could suffice is if a facility performed a limited set of procedures and all

were eligible. Please consult the OAS CAHPS Survey Coordination Team for guidance about the

method you would like to use in lieu of CPT coding to determine procedure eligibility.

If procedure ineligibility is revealed during data collection, a sampled patient can be given a

status code of ineligible. Nevertheless, survey vendors must have a process that excludes known

ineligible patients and procedures before the survey is initiated with them.

Preventing patient confusion is one reason for this policy. The OAS CAHPS Survey directs

sample patients to think about the procedure that they had on a particular date. Experience shows

that patients whose reference date was for a secondary visit (e.g., preadmission test) and not a

procedure, or patients whose procedure was not OAS CAHPS-eligible, were confused by the

questionnaire topics.

The second main reason for this policy is that it ensures that the OAS CAHPS data reflect patient

experience with a surgery or procedure itself. If a patient is sampled for an ineligible procedure

his or her questionnaire data will fail to reflect the desired measures. Furthermore, patients may

only be sampled once every 6 months. If they are sampled for a visit that is later found out to be

ineligible, it is no longer possible to sample the eligible procedure visit.

Sampling Issues and Errors

Based on national implementation of other CAHPS Surveys and the OAS CAHPS Survey, CMS

and the OAS CAHPS Survey Coordination Team have observed some common misconceptions




and problems with the sampling process. The following is a list of some of these common

misconceptions, paired with the proper implementation method that survey vendors should use to

avoid these issues during the sampling process.

Patient Eligibility Criteria

1. Misconception: Patients with missing or incomplete mailing addresses or telephone numbers

are considered ineligible for the OAS CAHPS Survey.

Correct Implementation: Patients whose address is not a U.S. domestic address are

ineligible, but if they have an address that is missing or incomplete, or if their telephone

number is missing or incomplete, they are eligible to be included in the OAS CAHPS Survey

if they meet all other survey eligibility criteria. Vendors should attempt to obtain complete

contact information. We also recommend that survey vendors use address or telephone-

lookup services to confirm or obtain sample patients’ mailing address or telephone number. If

an address cannot be obtained the case should be finalized as a noncomplete of 330—Bad

Address/Undeliverable Mail or No Address, not as ineligible.

2. Misconception: If the HOPD or ASC did not serve any patients who met survey eligibility

criteria, it does not need to submit a sample file to its OAS CAHPS Survey vendor for that

sample month or notify the vendor in any way.

Correct Implementation: HOPDs and ASCs participating in the OAS CAHPS Survey

should submit a monthly patient information file to their survey vendors for each sample

month or send an e-mail notification if no survey eligible patients were served in a particular

sample month. The survey vendor must, in turn, submit an OAS CAHPS data file to the OAS

CAHPS Data Center for each sample month. Otherwise the HOPD or ASC will be considered

to have “missed” a month of survey participation.

3. Misconception: There is a variable called “number of eligible patients” that is part of

vendors’ data submission to the OAS CAHPS Data Center. To determine the value for that

variable, vendors should remove patient records that were later identified as deceased or

reported that they did not receive care from the HOPD or ASC.

Correct Implementation: The “number of eligible patients” variable on the XML file must

reflect the number of presumed eligible patients who were included on the monthly patient

information file. Patients who were later identified as ineligible for the survey during the data

collection period should be noted by their final survey disposition code and should not be

removed from the “number of eligible patients” count.

4. Misconception: Patient age can be calculated based on their age as of the beginning of the

sample month.



Correct Implementation: Patient’s age must be calculated based on their age on the date of

surgery.

5. Misconception: If a patient record has multiple procedural codes that are both eligible and

ineligible for the OAS CAHPS Survey, the patient is ineligible for the survey.

Correct Implementation: If a patient record has both eligible and ineligible procedural

codes associated with it, it could be eligible for the OAS CAHPS Survey if at least one

procedural code is eligible and the record meets all other eligibility criteria. In other words,

the presence of an ineligible procedural code in a series of codes for a patient record does not

make that patient record ineligible for OAS CAHPS.

Sampling Procedures and Documentation Requirements

1. Misconception: It is acceptable for a survey vendor to use only the patient’s medical record

number (MRN) to identify patients who may have been listed more than once on a monthly

patient information file or to identify patients who have been sampled in the last 5 months.

Correct Implementation: Survey vendors are urged to use more than one variable to

identify patients for whom duplicate information is provided on the monthly patient

information file and to identify patients who have been sampled in the last 5 months. Using

the MRN together with another variable, including surgical code, date of procedure, patient

name, date of birth, telephone number, or address will ensure that the correct patient is

identified. Vendors may choose to perform the de-duplication process in multiple steps.

However, the MRN should never be applied as the sole variable in any of the steps; that is, it

should always be combined with another patient variable.

2. Misconception: SID number can be assigned more than once.

Correct Implementation: Once the SID number is assigned, it must never be used again. If a

patient is sampled more than once, a new SID number must be assigned to that patient each

time he or she is sampled. During the sampling process, all vendors should check the sample

file to make sure the same SID number is not assigned to two different patients and that the

SID has not been assigned in a preceding sample month.

3. Misconception: A survey vendor can conduct a census survey of all eligible patients during

the first sample month that an HOPD or ASC administers the OAS CAHPS Survey;

therefore, the survey vendor does not have to conduct the survey for the next 5 months.

Correct Implementation: As described in this chapter, survey vendors must select and

survey a sample of patients each sample month, including for very small HOPDs and ASCs.

Using a sampling rate and selecting a sample of patients each sample month will ensure that

an even distribution of patients is surveyed across a 12-month period.



4. Misconception: The sampling rate should be adjusted each month.

Correct Implementation: Survey vendors should adjust the sampling rate at the beginning

of a quarter unless the number of patients served is dramatically different (either lower or

higher) than for the preceding months in the quarter. The sampling rate should remain

constant during a quarter. If there is a huge difference in the number of patients served in a

month within a quarter, the survey vendor should follow up with the HOPD or ASC to make

sure that the information on the file is correct and determine the reason for the difference.

5. Misconception: The seed number (or random numbers generated) do not need to be saved.

Correct Implementation: Documentation of the seed number and the random number

generation and application process is a critical component of the OAS CAHPS sampling

protocols, as samples must be replicable for OAS CAHPS site visit team review.

6. Misconception: It is not necessary to retain documentation of ineligible sample members.

Correct Implementation: Vendors should retain a separate file or list of each patient

deemed ineligible and the reason the patient did not meet the eligibility criteria. This

information allows someone other than the person who selected the sample to conduct quality

control of the sample, checking to make sure the right patients were excluded. This

information is also subject to review during site visits.

Processing Patient Administrative Data

1. Misconception: If an HOPD or ASC changes or switches vendors, the current OAS CAHPS

Survey vendor must provide a file containing patient information about all patients sampled

in the preceding sample months so the new vendor can exclude those patients from the

sample frame.

Correct Implementation: OAS CAHPS Survey vendors are not required to provide the new

vendor with a file containing information about patients sampled in the last 5 months.

Sampling Quality Control Procedures

1. Misconception: Survey vendors that have automated the receipt and processing of monthly

patient information files and the sample selection process do not need to implement any

quality control procedures, because the programs and algorithms used for these processes

were fully tested after they were developed.

Correct Implementation: All survey vendors must have in place and implement quality

control procedures on the entire sampling process, including receipt and processing of the

monthly patient information files and sample selection for each sample month for each

HOPD or ASC client. This includes vendors that use automated systems/procedures for

sampling. One way to identify problems with the receipt or processing of a monthly patient



information file is to look at the history of the numbers of patients served and who met

survey eligibility requirements in preceding sample months.

If the numbers of patients served or eligible on the monthly patient information file is very

different from the numbers provided on files submitted in preceding months, this may be a

good indication that there may be a problem with the monthly patient information file

received. If there is an extreme variation in the number of patients served/eligible from one

month to the next, vendors are encouraged to contact the HOPD or ASC to determine the

reason for the extreme difference in numbers.

2. Misconception: Survey vendors may use the same staff who conduct the sampling process to

conduct quality control checks of the sample.

Correct Implementation: The quality control of each sample file should be performed by

someone other than the person who performed each task associated with the sample selection

process. Vendors are also encouraged to apply appropriate quality control checks on and test

all of the computer programs and systems the vendor uses to receive and process monthly

files.





V. MAIL-ONLY ADMINISTRATION PROCEDURES

Overview

This chapter describes the requirements and guidelines for implementing the mail-only mode of

survey administration for the Outpatient and Ambulatory Surgery CAHPS (OAS CAHPS)

Survey. The chapter begins with a discussion of the mail survey protocol and schedule, followed

by a discussion of the requirements for producing all mailing materials, including questionnaires,

cover letters, and envelopes. Guidelines on how the questionnaire packages should be mailed and

data processing guidelines, including optical scanning and data entry, are provided in this

chapter. This chapter also provides suggestions for incorporating quality control activities into

the mail-only mode of survey administration. In this manual, patients included in the sample are

usually referred to as “sample members” or “patients.” However, in discussions of survey

processing and systems they may be referred to as “cases.”

Data Collection Schedule

Data collection for each sample member must be initiated no later than 3 weeks (21 days) after

the close of the sample month. The timing of a mail-only administration process is shown in

Table 5.1.

Questionnaires returned after the 6-week data collection period has ended should be considered

nonresponses and coded as such. Data collection must be closed for a sampled patient by six

weeks (42 calendar days) following the initiation of the survey.

Table 5.1 Mail-Only Administration Schedule and Protocol

Activity Timing

Mail initial questionnaire with cover letter to sample members

No later than 3 weeks (21 days) after the close of the sample month

Mail second questionnaire with cover letter to all sample members who do not respond to first questionnaire mailing

Approximately 3 weeks (21 days) after the first questionnaire is mailed

Complete data collection Six weeks (42 days) after the first questionnaire is mailed

Submit data files to the OAS CAHPS Data Center via the OAS CAHPS Survey website

The second Wednesday of January, April, July, and October

If the 21st day of the month falls on a weekend or holiday, vendors should make every attempt to

begin the survey on the business day prior to that weekend or holiday. However, it is acceptable

to mail the questionnaire on the first business day following the weekend or holiday if necessary.

V. Mail-Only Administration Procedures November 2018


If for some reason the survey cannot be initiated within 21 days after the sample month ends, the

vendor can initiate the survey within 26 days after the sample month ends. Vendors that initiate

the survey between 22 and 26 days after the sample month ends must complete and submit a

Discrepancy Notification Report (Chapter XV) to the OAS CAHPS Survey Coordination Team.

If the survey cannot be initiated within 26 days after the close of the sample month, CMS may

allow it to be initiated more than 26 days after the sample month ended. However, survey

vendors must first request permission and obtain approval from CMS to do so via an e-mail to

the OAS CAHPS Survey Coordination Team, copying their hospital outpatient department

(HOPD) or ambulatory surgery center (ASC) client. The e-mailed request should include the

HOPD or ASC’s name and CCN, explain the reason for the delay, state when the vendor will (if

approved) initiate the survey, specify the affected sample month, and request CMS’ approval.

As noted in Table 5.1, data collection must be closed 42 calendar days after the first

questionnaire is mailed. Note as well that the deadline for data submission is constant. This

deadline will not shift later if the vendor starts data collection late.

Questionnaires, Letters, and Envelopes

Currently, the mail survey version of the instrument is available in English, Spanish, Chinese,

and Korean. All versions of the survey materials are available on the OAS CAHPS Survey

website at https://oascahps.org/ .

Copies of the mail survey instrument and sample mail survey cover letters in English, Spanish,

Chinese, and Korean are also included in the appendices to this manual:

• sample mail survey cover letters, questionnaire and questionnaire in scannable format in

English, Appendix B;


Spanish, Appendix C;


Chinese, Appendix D;


Korean, Appendix E;

• Office of Management and Budget (OMB) Disclosure Notice in English, Spanish,

Chinese, and Korean in Appendix G.


November 2018 V. Mail-Only Administration Procedures


Outpatient and Ambulatory Surgery CAHPS Survey Questionnaire

The OAS CAHPS Survey questionnaire contains 37 questions. It is available in Appendix B, C,

D and E and available on the OAS CAHPS Survey website at https://oascahps.org/ . Additional

information about content of the OAS CAHPS Survey instrument is provided in Chapter III and

in the table below.

Questionnaire Printing Requirements and Recommendations

The following are formatting and content requirements and recommendations for the OAS

CAHPS Survey Questionnaire. Survey vendors cannot deviate from questionnaire requirements.

Requirement Recommendation

Questions Every questionnaire must begin with the

“core” OAS CAHPS Survey questions

(Questions 1 to 24).

n/a

No changes in wording are allowed to either

the OAS CAHPS Survey questions or to the

response options.

n/a

If HOPDs and ASCs elect to add their own

questions they must follow the guidelines in

Chapter III. In terms of placement of

supplemental questions in the questionnaire,

they must be placed after the “core” OAS

CAHPS questions. They may either be

placed before or after the unit of “About

You” questions. It is acceptable to replace

the skip instruction currently provided in

Q36 of the OAS CAHPS mail survey, “Go to

END,” with the skip instruction, “Go to

Q38,” if the vendor adds the Consent to

Share Identifying Information question or

any supplemental questions to the mail

survey starting with Q38.

n/a

Formatting Questions and associated responses options

may not be split across pages. n/a

Vendors must be consistent throughout the

questionnaire in formatting response options

either vertically or horizontally. If a vendor

elects to list the response options vertically,

this must be done for every question in the

questionnaire. Vendors may not format some

response options vertically and some

horizontally.

n/a





No matrix formatting of the questions is

allowed. Matrix formatting means formatting

a set of questions as a table, with responses

listed across the top of a page and individual

questions listed in a column on the left.

n/a

Font size should be no smaller than size 10. We strongly recommend that

size 12 or larger be used.

n/a

Use a two-column format, so

there are two columns of

questions per page.

Vendors should use best survey practices

when formatting the questionnaire, such as

maximizing the use of white space and using

simple fonts like Arial.

If data entry keying is being

used as the data entry

method, small coding

numbers next to the response

options may be used.

ID number A unique, randomly generated sample

identification (SID) number must be

assigned and appear on at least the first page

of the survey, for tracking purposes.

Additional identifiers are permitted.

However, the sample member’s name or

other identifying information must not be

printed anywhere on the survey.

n/a

Translation Only CMS-approved translations of the OAS

CAHPS Survey are permitted. If facilities

choose to add their own supplemental

questions, vendors will be responsible for

translating these questions.

n/a




Logo and other

information

about the

HOPD or ASC

The HOPD or ASC name or logo should

appear on the survey or the cover letter but

cannot appear on the envelopes (for privacy),

unless vendors receive prior approval from

CMS via the submission of an Exceptions

Request Form indicating that they have the

facility’s approval to display the name or

logo on the outgoing envelope and the

facility believes there are no HIPAA risks.

Note that survey vendors cannot include any

promotional messages or materials on the

OAS CAHPS cover letter, questionnaire, or

outgoing or incoming mailing envelopes.

This includes indications that either the

facility or the survey vendor has been

approved by the Better Business Bureau.

n/a

The vendor’s name and mailing address

must be printed at the bottom of the last page

of the OAS CAHPS Survey questionnaire, in

case the respondent does not use the

enclosed business reply envelope.

n/a

OMB Number The OMB number shown in Appendix G

must be printed on the questionnaire cover.

If there is no cover, then the OMB number

must be printed on the first page of the

questionnaire.

n/a

Cover Letters (First and Second Questionnaire Mailings) Requirements and

Recommendations

Examples of cover letters in English, Spanish, Chinese, and Korean are provided in the

appendices with the survey instruments (see Appendices B–D). Vendors may choose to develop

their own cover letters as well, provided that the following requirements are met:


Personalization Cover letters must be personalized with the

name and address of the sample member. n/a




Cover letters must contain the date of the

surgery or procedure and the name of the

location where the surgery was received. (The

monthly patient information file must contain

the date of surgery, facility name, and location

name because the name recognized by the

patient may differ from the facility’s official

name.)

n/a

ID Number A unique, randomly generated SID number

must be assigned and appear on the cover letter,

for tracking purposes. Additional identifiers are

permitted.

Separate from

questionnaire

Cover letters must be separate from the

questionnaire, so that no personally identifiable

information is returned with the questionnaire

when the respondent sends it back to the

vendor.

n/a

Content of

letters

The OMB disclosure notice (see Appendix G)

must be printed either on the questionnaire or

in the cover letters.

n/a

Vendors may not offer sample members the

opportunity to complete the survey over the

telephone if the vendor is implementing the

mail-only mode.

n/a

Must contain language describing the purpose

of the survey. n/a

Must contain a statement that participation is

voluntary and will not affect any benefits the

sample member receives or expects to receive.

n/a

Must contain language indicating that responses

from all survey participants will be grouped

together and these grouped data may be shared

with the HOPD or ASC, for purposes of quality

improvement.

n/a

Must contain language stating that if the

respondent needs help in reading the questions

or marking responses, a friend or family

member can assist them.

n/a

Must contain a toll-free customer support

telephone number that will be staffed by the

survey vendor.

n/a




Must include a statement that all information

the sampled patient provides will be

confidential and is protected by the Privacy

Act. This sentence is included in all of the

sample cover letters in Appendices B (English),

C (Spanish), D (Chinese), and E (Korean).

n/a

Printing The HOPD or ASC name (or logo) must appear

on the letters or the survey, but cannot appear

on the envelopes (for privacy). Note that survey

vendors cannot include any promotional

messages or materials on the OAS CAHPS

cover letter, questionnaire, or outgoing or

incoming mailing envelopes. This includes

indications that either the facility or the survey

vendor has been approved by the Better

Business Bureau.

n/a

Signature on

the letters

A signature is required. We recommend that the

signature of an

appropriate official from

the HOPD or ASC be

printed on each cover

letter If this is not

possible, the signature

from an appropriate

official at the survey

vendor is acceptable.

Requests for

Survey in

Other

Language

n/a

Survey vendors offering

an English, Spanish,

Chinese, and Korean

version of the

questionnaire may add

language to the English

cover letter indicating that

a version of the

questionnaire is available

in those languages.

Mailing Requirements and Recommendations

Requirements and recommendations are described below. Vendors are expected to follow these

requirements to maximize response rates and ensure consistency in how the mail-only mode of

administration is implemented.




Questionnaire

contents

Each questionnaire mailing must contain a

personalized cover letter, questionnaire, and

postage-paid business reply envelope.

n/a

Envelopes Vendors are responsible for supplying both the

outgoing envelopes for the questionnaire

mailings and business-reply envelopes that

sample members will use to return their

completed surveys (i.e., they cannot be supplied

by the HOPD or ASC).

n/a

Mailing

n/a

We recommend that

mailings be sent with

first-class postage or

indicia, to ensure timely

delivery and maximize

response rates.

Addresses Patients must have a U.S. domestic address to be

eligible to participate in the OAS CAHPS

Survey.

n/a

If the sample member’s address is missing or

incomplete, the vendor must follow up with the

HOPD or ASC to obtain the address. If an

address cannot be found, or the address that is

found is too incomplete for mailing, the vendor

should treat the patient as eligible (i.e., the case

should remain in the sample) and assign the

applicable final disposition code to the case:

330 – Bad Address/Undeliverable Mail, or No

Address (see Chapter IX).

To reduce the number of

missing addresses, we

recommend that vendors

verify mailing addresses

obtained from the

facilities using

commercial address

update services, such as

the National Change of

Address or the U.S.

Postal Service Zip+4

software.

n/a

We recommend that

vendors attempt to

identify a new or updated

address using

commercial address

vendors or the Internet

for any mail returned as

undeliverable in time to

include the sample

member in the second

mailing.




Schedule Mailings must follow the schedule specified for

the mail-only mode of administration—the first

questionnaire package must be mailed no later

than 3 weeks after the close of the sample

month; the second questionnaire to sample

members who do not respond to the first

questionnaire mailing must be mailed

approximately 3 weeks after the first

questionnaire mailing.

n/a

Data collection must end 6 weeks after the first

questionnaire has been mailed. n/a

Incentives The use of incentives is not permitted. This

includes monetary and nonmonetary incentives. n/a

Data Receipt, Data Entry, and Optical Scanning Requirements

The following guidelines are provided for receiving and tracking returned questionnaires and

entering the data using either data entry or optical scanning.

Requirement

Receipting The date the questionnaire was received from each sample member must be

entered into the data record created for each case on the data file.

Completed questionnaires should be logged into the tracking system in a

timely manner to ensure that sample members who respond to the first

mailing are excluded from the second questionnaire mailing.

Mailings that are returned in the mail as undeliverable must also be logged

into the tracking system. Although not required, we recommend that vendors

attempt to identify a new or updated address using commercial address

vendors or the Internet for any mail returned as undeliverable in time to

include the sample member in the second mailing.

If two questionnaires are received from the same sample member, vendors

should keep and use the questionnaire that has the more complete data,

regardless of which questionnaire is received first. If the two questionnaires

received contain the same amount of data (are equally complete), the vendor

should retain and use the first one received.

A final OAS CAHPS Survey disposition code (see Table 9.1 in Chapter IX)

must be assigned to each case.

Reviewing

received

questionnaires

for problems

Questionnaires should be visually reviewed prior to scanning or data entry

for notes and comments. Vendors should have more than one person who

can code or review comments and attach notes for proper disposition code

assignment.



Requirement

If a completed mail survey questionnaire is returned and the vendor realizes

that it was completed by proxy (i.e., response option “3 – Answered the

questions for me” is selected for Q37 alone or in combination with other

response options for that question, or there is a note written on the

questionnaire that a family member completed the questionnaire because the

patient had died, had moved to a nursing home, had been incarcerated)

vendors should not key or scan a questionnaire for that sample member. This

is because proxy respondents are not permitted on OAS CAHPS. Vendors

should instead assign the applicable final disposition code to the case based

on the information provided in the handwritten note, or disposition code 320

(Refusal) if no note is included and Q37’s response option “3” is selected.

Proxies are also not permitted for deceased respondents. If a sample member

is found to be deceased, the case should be closed using code 210 –

Deceased.

If a sample member were to die or become ineligible after completing the

questionnaire (vendors might learn of this through a comment written by a

family member on the questionnaire) that questionnaire is still an eligible

complete survey. Vendors should scan the questionnaire and assign the

applicable final disposition code indicating the completed survey.

Duplicate

questionnaires

The key entry process should not permit keying of duplicate questionnaires.

The scanning program should not permit scanning of duplicate

questionnaires.

Out-of-range

or invalid

responses

The key entry program should not permit out-of-range or invalid responses.

The scanning program should not permit out-of-range or invalid responses

Interpreting

blanks and

ambiguous

survey

responses

The following apply for both keying and optical scanning (additional

information about handling blank and ambiguous responses can be found in

Chapter IX):

If a response mark falls between two answer choices but is clearly closer to

one answer choice than to another, select the response that is closest to the

marked response.

If two responses are checked for the same question, select the one that

appears darkest. If it is not possible to make a determination, leave the

response blank and code as “missing” rather than guessing.

If a mark is between two answer choices but is not clearly closer to one

answer choice, code as “missing.”

If a response is missing, leave the response blank and code as “missing.”



Requirement

Open-ended

responses

The decision on whether to key or scan the responses to open-ended survey

items, specifically, the “Other language” (response option 2) in Q35 and the

“Helped in some other way” (response option 5) in Q37, is up to each

individual HOPD or ASC. Vendors will not be required to key or scan and

include responses to open-ended survey items on the data files submitted to

the OAS CAHPS Data Center.

CMS, however, encourages survey vendors to review the open-ended entries

so they can provide feedback to the OAS CAHPS Survey Coordination

Team about adding additional preprinted response options to these survey

items if needed.

If the vendor includes the Consent to Share Identifying Information question

in the mail survey questionnaire, the vendor is not required to key or scan the

response to that question. However, we do recommend vendors review the

responses to this question for the vendor’s own documentation.

Answers to the Consent to Share Identifying Information question will not

be included on the data files submitted to the OAS CAHPS Data Center.

Staff Training

All staff involved in the mail survey implementation, including support staff, must be thoroughly

trained on the survey specifications and protocols. A copy of relevant chapters of this manual

should be made available to all staff as needed. In particular, staff involved in questionnaire

assembly and mailout, data receipt, and data entry must be trained on:

• use of relevant equipment (case management systems for entering questionnaire receipts,

scanning equipment, data entry programs);

• OAS CAHPS Survey protocol specific to their role (for example, contents of

questionnaire package, how to document or enter returned questionnaires into the

tracking system);

• decision rules and coding guidelines for returned questionnaires (see Chapter IX); and

• proper handling of hardcopy and electronic data, including data storage requirements (see

Chapter VIII).

Staff involved in providing customer support via the toll-free telephone number should also be

trained on the accurate responses to commonly asked questions, how to respond to questions

when customer support does not know the answer, and the rights of survey respondents. If the

OAS CAHPS Survey is being offered in a language other than English, customer support staff

should also be able to handle questions via the toll-free telephone number in that language.



Telephone interviewer training requirements are described in more detail in Chapter VI of this

manual. Please refer to that chapter for more information on training customer support staff.

Quality Control Guidelines for Mail-Only Survey

The following steps are required or recommended as a means of incorporating quality control

into the mail-only survey administration procedures. Quality control checks should be conducted

by a different staff person than the one who completed the task. Some of these are mentioned

earlier in the chapter.

Required for Mail Protocol

• Check a minimum of 10% of all printed materials to ensure the quality of the printing—

that is, make sure there is no smearing, misaligned pages, duplicate pages, or stray marks

on pages.

• Check a minimum of 10% of all outgoing questionnaire packages to ensure that all

package contents are included and the same unique SID number appears on both the

cover letter and the questionnaire.

• For vendors that are scanning: a sample of questionnaires (minimum of 10 percent)

should be compared with the original hardcopy survey. This serves as a quality control

measure that the scanning program is capturing the hard copy correctly. Any

discrepancies between the scan and the hard copy should be reconciled by a supervisor.

Additionally, the survey responses captured in the database for a sample of

questionnaires (minimum of 10 percent) should be systematically compared to scanned

image for that case. This can be done either by visually examining the scanned image and

the data to reveal inconsistencies or by rescanning and noting whether the data from the

original match the data from the rescan. This serves as a quality control measure that the

scanning program is translating the response marks in the scanned image to the data file

consistently and correctly. Any discrepancies should be reconciled by a supervisor.

• For vendors that are keying: all questionnaires should be 100% rekeyed for quality

control purposes. That is, for every questionnaire, a different keyer should rekey the

questionnaire and the data entry files from the two keyers should be systematically

compared to ensure that all entries are accurate. If any discrepancies are observed, a

supervisor should resolve the discrepancy and ensure that the correct value is stored in

the data.



Recommended for Mail Protocol

• “Seed” each mailing. That is, include the name and address of designated vendor staff in

each mailing file to assess the completeness of the questionnaire package and timeliness

of package delivery.

• Before submitting XML data to the OAS CAHPS Data Center, we highly recommend

vendors review a sample of cases comparing responses recorded on the hardcopy

questionnaire to responses scanned to the response codes that appear in the XML files.

This quality control step will ensure that the responses included in the XML files

accurately reflect the patients’ responses to the survey questions.

• Vendors are urged to develop a way to measure error rates for their data receipt staff (in

terms of recognizing marginal notes and passing these on to someone for review), for

data entry or scanning operators, and for coders. Vendors should then work with their

staff to minimize error rates. The OAS CAHPS Survey Coordination Team will request

information about data receipt and processing error rates during site visits to survey

vendors.





VI. TELEPHONE-ONLY ADMINISTRATION PROCEDURES

Overview

This chapter describes the requirements and guidelines for implementing the telephone-only

mode of survey administration for the Outpatient and Ambulatory Surgery CAHPS (OAS

CAHPS) Survey. The chapter begins with a discussion of the telephone-only data collection

schedule, followed by a discussion of the requirements for producing all telephone interviewing

materials and systems. It includes guidelines on how the telephone interview should be

developed and administered, including general interviewing guidelines and frequently asked

questions that interviewers may encounter. This chapter also provides suggestions for data

processing procedures and incorporating quality control activities into the telephone-only mode

of survey administration.

Note that in most cases in this and subsequent chapters of this manual, patients included in the

sample are referred to as “sample members” or “sample patients”; in discussions of survey

processing and systems they may be referred to as “cases.”


If the OAS CAHPS Survey is being administered as a telephone-only survey, data collection

must be initiated no later than 3 weeks (21 days) after the close of the sample month.

Table 6.1 shows the prescribed order of activities and timing for telephone-only OAS CAHPS

Survey administration.

Table 6.1 Telephone-Only Administration Schedule and Protocol

Activity Timing

Begin telephone contact with sample members No later than 3 weeks (21 days) after the close of the sample month

Complete telephone data collection Six weeks (42 days) after initial telephone contact begins

Submit data files to OAS CAHPS Data Center via the OAS CAHPS Survey website




to begin telephone calls on the first business day following the weekend or holiday if necessary.

VI. Telephone-Only Administration Procedures November 2018


OAS CAHPS Survey vendors must make a concerted effort to initiate the survey for each sample

month within 21 days after the sample month ends. This means that phone contacting should

begin by the 21st day after the end of the sample month.


vendor can initiate the survey within 26 days after the sample month ends. Vendors that initiate

the survey between 22 and 26 days after the sample month ends must complete and submit a

Discrepancy Notification Report (Chapter XV) to the OAS CAHPS Survey Coordination Team.

CMS may allow the survey to be initiated more than 26 days after the sample month ended.

However, survey vendors must first request permission and approval from CMS to do so via an

e-mail to the OAS CAHPS Survey Coordination Team, copying its hospital outpatient

department (HOPD) or ambulatory surgery center (ASC) client. The e-mailed request should

include the HOPD or ASC’s name and CCN, explain the reason for the delay, state when the

vendor will (if approved) initiate the survey, specify the affected sample month, and request

CMS’ approval.

As noted in Table 6.1, data collection must be closed 42 calendar days after the telephone survey

begins. Note as well that the deadline for data submission is constant. This deadline will not shift

later if the vendor starts data collection late.

Telephone Interview Development Process

The following paragraphs describe the requirements for producing all materials and systems

needed for the telephone-only survey. The telephone interview script in English and Spanish is

available on the OAS CAHPS Survey website at https://oascahps.org/ .

A list of questions that are frequently asked by sample members and suggested answers to those

questions are included in Appendix H (English) and Appendix I (Spanish). Some general

guidelines for telephone interviewer training and monitoring are provided in Appendix J.

Specific requirements and guidelines associated with the telephone survey administration are

discussed below.

Telephone Interviewing Systems

An electronic telephone interviewing system means that the interviewer reads from and enters

responses into a computer program. Using an electronic system encourages standardized

interviewing and monitoring of interviewers. Survey vendors administering the OAS CAHPS

Survey in telephone-only survey mode must use an electronic system. Paper-and-pencil

administration is not permitted for telephone surveys. To ensure that sample members are

called at different times of the day and across multiple days of the week, vendors must also have

a survey management system. Ideally, the electronic system will be linked to the survey


November 2018 VI. Telephone-Only Administration Procedures


management system so that cases can be tracked, appointments set and called back at appropriate

times, and pending and final case status easily accessed for any case.

Predictive or automatic dialers are permitted, as long as they are compliant with Federal Trade

Commission and Federal Communications Commission regulations, and as long as respondents

can easily interact with a live interviewer. For more information about Federal Trade

Commission and Federal Communications Commission regulations, please visit

https://www.ftc.gov/ and https://www.fcc.gov/.

Telephone Interview Script

Survey vendors are provided with standardized telephone scripts in Appendix B (English) and

Appendix C (Spanish). These scripts include the introductory screens in addition to the survey

questions.

Note that the OAS CAHPS telephone interview script contains only 35 questions and the mail

survey contains 37 questions. The mail survey questionnaire contains questions that ask if

anyone helped the sample member to complete the survey (Questions 36 and 37). These two

questions are not applicable if the survey is administered by telephone. Additional information

about content of the OAS CAHPS Survey instrument is provided in Chapter III.

The following are content and programming requirements and recommendations for the OAS

CAHPS Survey questionnaire. Survey vendors cannot deviate from questionnaire requirements.

• Every questionnaire must begin with the “core” OAS CAHPS questions (Questions 1 to

24). They must be administered in the order in which they appear.

• No changes in wording are allowed for either the OAS CAHPS Survey questions or to

the response options.

• HOPDs and ASCs may add their own questions, following the guidelines in Chapter III.

In terms of placement of supplemental questions in the questionnaire, note that they must

be placed after the “core” OAS CAHPS questions. They may either be placed before or

after the unit of “About You” questions. If adding the Consent to Share Identifying

Information or supplemental questions to the end of the OAS CAHPS telephone script, it

is permissible to revise the programmable skip logic in Q35, “GO TO Q_END,” to

instead skip to Q36.

• Only CMS-approved translations of the OAS CAHPS Survey are permitted, although if

facilities choose to add their own supplemental questions, vendors will be responsible for


https://www.ftc.gov/

https://www.fcc.gov/



Telephone Interviewing Requirements

Telephone interviewing requirements and recommendations for the OAS CAHPS Survey

interview are described below. Vendors are expected to follow these requirements to maximize

response rates and to ensure consistency in how the telephone-only mode of administration is

implemented. Vendors are also advised to keep an eye on response rates, to assess whether calls

are being scheduled optimally across the data collection period. A low response rate may be

indicative of calls being spaced too closely together, rather than spread across a number of

weeks.

Telephone Contact

• Vendors must attempt to contact every patient in the sample. Vendors are required to

make five telephone contact attempts for each sampled case, unless the sample member

refuses or the vendor learns that the sample member is ineligible to participate in the

survey.

• A telephone contact attempt is defined as one of the following:

◦ the telephone rings six times with no answer or an answering machine is reached;

◦ the interviewer reaches a household member and is told that the sample member is

not available to take the call;

◦ the interviewer reaches the sample member and is asked to schedule a call-back at a

later date; or

◦ the interviewer gets a busy signal on each of three consecutive phone call attempts,

spaced at least 20 minutes apart.

• Vendors may make more than one phone call in one 7-day period but cannot make all

five attempts in one 7-day period. Scheduling calls to take place over a longer period of

time could reach patients who may be unavailable the first week of the data collection

period.

• Contact with a sample member may be continued after five attempts if the fifth attempt

results in a scheduled appointment with the sample member, as long as the appointment

is within the data collection period.

• Phone calls must be made at different times of the day (i.e., morning, afternoon, and

evening) and different days of the week throughout the data collection period.

• Interviewers may not leave voicemail messages on answering machines or leave

messages with household members.



• Interviewers may tell household members that they are calling about “a study on health

care.”

• Vendors must maintain a phone call log that keeps track of the date and time phone calls

were made for each sample member.

• If the vendor finds out that a sample member is ineligible for the OAS CAHPS Survey,

the vendor must immediately stop further contact attempts with that sample member.

• Telephone survey data collection for each monthly sample must begin no later than 3

weeks from the close of the sample month and must be completed within 6 weeks from

the initial telephone attempt.

• The use of incentives—monetary or nonmonetary—is not permitted.

• Proxy respondents are not permitted on OAS CAHPS. If a sample member is incapable

of responding to the telephone interview because of mental or physical impairments such

as difficulty hearing, the interviewer must end the interview and apply code 240 –

Mentally or Physically Incapacitated. If a sample member is capable of responding but

just needs some help to do so, a friend or family member may help, but cannot respond

on his or her behalf.

• Proxies are also not permitted for deceased respondents. If a sample member is found to

be deceased, the case should be closed using code 210 – Deceased.

• If a respondent begins the interview but cannot complete it during the call for a reason

other than a refusal, the vendor should follow up with the respondent to complete the

entire interview. The interviewer should follow up even if the respondent answered

enough questions in the interview for the case to pass the completeness criteria. It is

especially important to complete the questions in the “About You” section of the

questionnaire, because data from some of those questions will be used in patient-mix

adjustment.

• The vendor must be able to offer the interview in any of the approved languages for

which an HOPD or ASC has contracted, even if the language is different from the

language that the HOPD or ASC believes the sample member will require. That is, the

vendor must be able to easily switch to accommodate a respondent’s language

preference. For example, if the initial contact is in English but the respondent prefers to

conduct the interview in Spanish, the vendor must be able to switch to Spanish.

• Sample members are still eligible even if they have missing, incomplete, or foreign phone

numbers. The vendor should contact the HOPD or ASC to obtain the telephone number



and the address of the patient. If the HOPD or ASC cannot provide the telephone number,

the vendor should attempt to obtain a telephone number for the patient from other sources

(directory assistance, Internet directories, etc.). If the vendor still cannot obtain a

telephone number, the vendor should code the case as code 340 – Wrong, Disconnected,

No Telephone Number.

• If the telephone interviewer dials the sample patient’s telephone number, learns the

telephone number is incorrect, and obtains a new telephone number for the sampled

patient, the number of call attempts for that case should start over with the newly

obtained telephone number.

• Once the interviewer has confirmed that the sample member is on the phone, if the

sample member hangs up (without any comment) before or during the introductory

script, the case should be called again on a different day of the week and at a different

time of day. If the sample member hangs up (without any comment) after the

introductory script, the interviewer should code the case as a refusal. As a reminder, final

disposition code 320 – Refusal can only be assigned if sample members (not a

gatekeeper or other individual) indicate they do not wish to participate in the survey.

• If a respondent decides after answering some of the questions in the telephone interview

that he or she does not wish to participate in the survey any longer, the vendor should

code the case as a Refusal. The vendor should not use the partial data that were obtained

before the interview ended. This protocol applies even if the respondent answered enough

questions in the interview for the case to pass the completeness criteria. Note that this

situation is different from the respondent saying that he or she does not wish to continue

an interview. If the respondent breaks off the interview but does not state that he or she

does not wish to participate in the survey, the data may be used as long as the interview

meets the completeness criteria. In this case, the vendor may code the case as a 120 –

Completed Telephone Interview if the case passes the completeness criteria; otherwise, it

should be coded as a 310 – Breakoff.

Contacting Difficult-to-Reach Sample Members

• Although not required, we strongly recommend that survey vendors verify telephone

numbers obtained from HOPDs and ASCs, using a commercial address or telephone

database service or directory assistance.

• We recommend that vendors attempt to identify a new or updated telephone number for

any sample member whose telephone number is no longer in service when called and for

any sample members who have moved so that the sample members can be contacted prior

to the end of the data collection period.



• If the sample member’s telephone number is incorrect, the interviewer may ask the

person who answers the phone for the sample member’s phone number.

• If the sample member is temporarily ill, on vacation, or unavailable during initial contact,

the interviewer should attempt to recontact the sample member before the data collection

period ends. If the sample member cannot be reached before the data collection period

ends, code the case as 350 – No Response After Maximum Attempts.

• If the sample member does not speak any of the OAS CAHPS Survey language(s) that

the vendor is administering for that facility, the interviewer should thank the sample

member for his or her time, end the interview, and code the case as 230 – Ineligible:

Language Barrier. Note that the language barrier disposition code only applies to the

sample member and should not be assigned until a determination is made that the sample

member cannot speak the language(s) being administered.

• If a sample member is physically or mentally incapable of responding by telephone, the

case should be finalized and coded as 240 – Mentally or Physically Incapacitated.

• For sample members who are living in institutions (assisted living, group homes, etc.),

OAS CAHPS Survey vendors should contact the HOPD or ASC to obtain a direct-dial

telephone number. If the HOPD or ASC cannot provide a direct-dial telephone number

for the patient, try to obtain the sample member’s telephone number using other sources,

such as a telephone number lookup service, directory assistance, or Internet telephone

survey directories. If vendors cannot obtain a telephone number for the patient, they

should assign a disposition code of 340 – Wrong, Disconnected, or No Telephone

Number to the case. As a reminder, sample members living in nursing homes or prisons

are ineligible.

Distressed Respondent Procedures

It is critically important that survey vendors develop a “distressed respondent protocol,” to be

incorporated into all interviewer and help desk training. For survey research organizations, best

interviewing practices recommend having a distressed respondent protocol in place for handling

distressed respondents, which balances the respondent’s right to confidentiality and privacy and

providing assistance, if the situation indicates that the respondent’s health and safety are in

jeopardy.

Therefore, each approved OAS CAHPS Survey vendor is expected to have procedures in place

for handling distressed respondent situations and to follow those procedures. CMS and the OAS

CAHPS Survey Coordination Team cannot provide guidelines on how to evaluate or handle

distressed respondents. However, survey vendors are urged to consult with their organization’s

Committee for the Protection of Human Subjects Institutional Review Board for guidance. In



addition, professional associations for researchers, such as the American Association of Public

Opinion Researchers (AAPOR), may be able to provide guidance regarding this issue. The

following is an excerpt from AAPOR’s website that lists resources for the protection of human

subjects. More information about protection of human subjects is available at AAPOR’s website

at http://www.aapor.org .18

• The Belmont Report (guidelines and recommendations that gave rise to current federal

regulations)

• Federal Regulations Regarding Protection of Human Research Subjects (45 CFR 46)

(also known as the Common Rule)

• Federal Office for Human Research Protections

• National Institutes of Health Human Participant Investigator Training (although the site

appears to be for cancer researchers, it is the site for the general investigator training used

by many institutions)

• University of Minnesota Web-Based Instruction on Informed Consent

Telephone Interviewer Training

Vendors must provide training to all telephone interviewing and customer support staff prior to

starting telephone survey data collection activities. Telephone interviewer and customer support

staff training must include the following:

• teaching interviewers how to establish rapport with the respondent;

• teaching interviewers the content and purpose of the interview so that they can effectively

communicate this information to the sampled patients;

• teaching interviewers to administer the interview in a standardized format, which

includes reading the questions as they are worded, not providing the respondent with

additional information that is not scripted, maintaining a professional manner, and

adhering to all quality control standards;

• teaching interviewers how to use effective neutral probing techniques;

18 The American Association of Public Opinion Researchers website at

http://www.aapor.org/Additional_IRB_Resources.htmt , July 2010.

http://www.aapor.org/

http://www.aapor.org/Additional_IRB_Resources.htmt



• teaching interviewers to use the frequently asked questions document so that they can

answer questions in a standardized format; and

• teaching multilingual customer support staff how to handle questions in English and the

other language(s) in which the survey is being offered.

Survey vendors should also provide telephone survey supervisors with an understanding of

effective quality control procedures to monitor and supervise interviewers.

Vendors must conduct an interviewer certification process of some kind—oral, written, or

both—for each interviewer and customer service staff member prior to permitting that person to

make or take calls on the OAS CAHPS Survey. The certification should be designed to assess

the interviewer’s level of knowledge and comfort with the OAS CAHPS Survey instrument and

ability to respond to sample members’ questions about the survey. Documentation of training

and certification of all telephone interviewers and customer support staff and outcomes will be

subject to review during oversight visits by the OAS CAHPS Survey Coordination Team.

Telephone Data Processing Procedures

The following guidelines are provided for ensuring that the telephone interview data are properly

processed and managed.

Telephone Data Processing Requirements

• A unique sample identification (SID) number must be assigned to each case and included

in the case management system and on the final data file for each sample member.

• Vendors must capture the date of the interview with each sample member in the survey

management system or in the interview data.

• Vendors must be able to link each telephone interview to their survey management

system, so that appropriate variables, such as the language in which the survey was

conducted, can be pulled into the final data file.

• Vendors must de-identify all telephone interview data when the data are transferred into

the final data file for delivery. Identifiable data include respondent names and contact

information.

• Vendors must assign and include a final OAS CAHPS Survey disposition code to each

sampled case in the final data file (see Chapter IX for a list of these codes). It is up to the

vendor to develop and use a set of pending disposition codes to track actions on a case

before it is finalized appropriately—pending disposition codes are not specified in the

OAS CAHPS Survey protocol.



Telephone-Only Quality Control Guidelines

The following activities are methods to incorporate quality control into the telephone-only

survey administration procedures. Quality control checks should be conducted by a different

staff person than the one who completed the task.

Required for Telephone Protocol

• OAS CAHPS requires that survey vendors thoroughly test the electronic telephone

interviewing system before beginning the OAS CAHPS Survey. Testing will vary from

system to system, but includes at a minimum comparing each screen to the telephone

script (in Appendices B and C) to verify that the questions and response options are

faithful to the script, checking each question to ensure that the answers input match the

data exported, and checking that a respondent is automatically routed to the next

appropriate question.

• Vendors are required to keep written documentation that all telephone interviewing and

customer support staff have been properly trained prior to interviewing. Copies of

interviewer certification exam scores should be retained as well. Documentation should

be maintained for any retraining required and will be subject to review during oversight

visits. Survey vendors must establish and communicate clear telephone interviewing

quality control guidelines for their staff to follow. These guidelines should be used to

conduct the monitoring and feedback process, and should include clear explanations of

the consequences of not following protocols, including actions such as removal from the

project or termination of employment.

• Vendors are required to silently monitor a minimum of 10% of all telephone interviews to

ensure that correct administration procedures are being followed.

• There are federal and state laws and regulations relating to the monitoring and/or

recording of telephone calls. In certain states, consent must be obtained from every party

or conversation if it involves more than two people (“two-party consent”). When calling

sample members who reside in these states, survey vendors should not begin either

monitoring or recording the telephone calls until after the interviewer has read the

following statement: “This call may be monitored or recorded for quality improvement

purposes.”19

19 The following states currently require two-party or all-party consent when telephone calls are monitored or

audiotaped: California, Connecticut, Florida, Illinois, Maryland, Massachusetts, Montana, New Hampshire,

Pennsylvania, and Washington.



• All OAS CAHPS Survey vendors are responsible for identifying and adhering to federal

and state laws and regulations in the states in which they will be administering the OAS

CAHPS Survey.

• No revisions or corrections should be made to the OAS CAHPS Survey response data

once a telephone interview has been completed. Corrections can only be made while the

respondent is still on the phone to confirm responses. If survey response errors are

identified through QC measures after the interview, prompt retraining of the interviewer

is required to correct an issue for future interviews.

Recommended for Telephone Protocol

• Vendors are urged to conduct regular Quality Circle meetings with telephone

interviewing and customer support staff to obtain feedback on issues related to telephone

survey administration or handling inbound calls.

• Supervisory staff monitoring telephone interviewers should use the electronic system to

observe the interviewer conducting the interview while simultaneously listening to the

audio of the call.

• Monitoring staff or supervisors should provide performance feedback to interviewers as

soon as possible after the monitoring session has been completed.

• Interviewers should be given the opportunity to correct deficiencies in their

administration through additional practice or retraining; however, interviewers who

receive consistently poor monitoring scores should be removed from the project.

• Vendors should conduct periodic reviews of their XML data files by comparing at least

50 completed telephone interview responses directly from their computer-assisted

telephone interviewing system to the values output in the XML data file. Doing this

monthly review will ensure that the responses are being accurately captured and output to

the XML data file.





VII. MAIL WITH TELEPHONE FOLLOW-UP (MIXED-MODE) SURVEY ADMINISTRATION PROCEDURES

Overview

This chapter describes the requirements and guidelines for implementing a mixed-mode survey

administration for the Outpatient and Ambulatory Surgery CAHPS (OAS CAHPS) Survey. For

the OAS CAHPS Survey, “mixed mode” is defined as a mail survey followed by a telephone

follow-up of nonrespondents.

This chapter begins with a discussion of the data collection schedule that should be followed

when a mixed-mode design is used. The mail survey protocols are described next, followed by a

discussion of the protocols for implementing the telephone follow-up of nonrespondents. The

chapter ends with quality control guidelines that should be implemented throughout the mixed-

mode data collection process and describes data storage requirements.

Note that in most cases in this and subsequent chapters of this manual, patients included in the

sample are referred to as “sample members” or “patients”; in discussions of survey processing

and systems they may be referred to as “cases.”


Survey vendors using mail with telephone follow-up of nonrespondents must initiate the mail

survey for each monthly sample no later than 3 weeks (21 days) after the close of the sample

month. Table 7.1 shows the basic tasks and timing of activities when conducting the OAS

CAHPS Survey using mixed-mode survey administration.

Table 7.1 Tasks and Schedule of Activities for Mail with Telephone Follow-Up

Activity Timing

Mail questionnaire with cover letter to sample members

No later than 3 weeks (21 days) after the close of the sample month

Initiate telephone follow-up contacts for all mail survey nonrespondents

Approximately 3 weeks (21 days) after the questionnaire is mailed

Complete data collection Six weeks (42 days) after the questionnaire is mailed

Submit data files to the OAS CAHPS Data Center via the OAS CAHPS Survey website


VII. Mail with Telephone Follow-Up (Mixed-Mode) Survey Administration Procedures November 2018




to mail the questionnaire on the first business day following the weekend or holiday if necessary.


vendor can initiate the survey within 26 days after the sample month ends. Vendors must

complete and submit a Discrepancy Notification Report (Chapter XV) to the OAS CAHPS

Survey Coordination Team if the survey is initiated between 22 and 26 days after the sample

month ends.

If the survey cannot be initiated within 26 days after the sample month ends, CMS may allow it

to be initiated more than 26 days after the sample month ended. However, survey vendors must

first request permission and approval from CMS to do so via an e-mail to the OAS CAHPS

Survey Coordination Team, copying its hospital outpatient department (HOPD) or ambulatory

surgery center (ASC) client. The e-mailed request should include the HOPD or ASC’s name and

CCN, explain the reason for the delay, state when the vendor will (if approved) initiate the mail

and telephone survey, specify the affected sample month, and request CMS’ approval.

As noted in Table 7.1, data collection must be closed 42 calendar days after the questionnaire is

mailed. Note as well that the deadline for data submission is constant. This deadline will not shift

later if the vendor starts data collection late.

As explained in Chapter IX, all cases that are not finalized as a result of the mail survey

component of the mixed-mode survey must be assigned for telephone follow-up, including both

cases that are returned blank and undeliverable mail. This means that unless the case was a

complete, refusal, or the patient was determined to be ineligible for the survey during the mail

survey data collection phase of the survey, survey vendors should follow up with the patient by

telephone.

All telephone contact should be initiated and completed within the specified 3-week period noted

above in Table 7.1. Questionnaires may be received through the mail after the case has been

referred for telephone follow-up. If these questionnaires arrived before the 6-week data

collection period ended, they should be processed and telephone efforts with this case should be

stopped. If these questionnaires arrived after the 6-week data collection period ended, they

should be considered nonresponses and coded as such.

Questionnaires, Letters, and Envelopes

Vendors administering the OAS CAHPS Survey using mixed-mode must be able to offer the

mail and telephone versions of the instrument in each language in which the survey is being

administered. Vendors may not offer a mail questionnaire in one of the non-English languages

and conduct the telephone follow-up only in English, for example. For this reason, the mixed-

VII. Mail with Telephone Follow-Up (Mixed-Mode) November 2018 Survey Administration Procedures


mode design cannot be used in conjunction with the Chinese or Korean versions of the mail

questionnaire, because there is no corresponding OAS CAHPS–approved telephone interview in

Chinese or Korean. All versions of these survey materials in the approved languages are


Copies of the mail survey instrument and sample mail survey cover letters in English and

Spanish are also included in the appendices to this manual:

• sample mail survey cover letters, questionnaire, and questionnaire in scannable format in

English, Appendix B;

• sample mail survey cover letters, questionnaire, and questionnaire in scannable format in

Spanish, Appendix C;

• Office of Management and Budget (OMB) Disclosure Notice in all languages in

Appendix G.

Outpatient and Ambulatory Surgery CAHPS Survey Questionnaires

The OAS CAHPS Survey Questionnaire used in the mail mode contains 37 questions. It is

available on the OAS CAHPS Survey website at https://oascahps.org/ . Additional information

about content of the OAS CAHPS Survey instrument is provided in Chapter III and in the table

below.

Questionnaire Printing Requirements and Recommendations

The following are formatting and content requirements and recommendations for the OAS

CAHPS Survey Questionnaire. Survey vendors cannot deviate from questionnaire requirements.


Questions Every questionnaire must begin with the “core”

OAS CAHPS Survey questions (Questions 1 to 24). n/a

No changes in wording are allowed to either the

OAS CAHPS Survey questions or to the response

options.

n/a






If HOPDs and ASCs elect to add their own

questions they must follow the guidelines in

Chapter III. In terms of placement of supplemental

questions in the questionnaire, they must be placed

after the “core” OAS CAHPS questions. They may

either be placed before or after the unit of “About

You” questions. It is acceptable to replace the skip

instruction currently provided in Q36 of the OAS

CAHPS mail survey, “Go to end,” with the skip

instruction, “Go to Q38,” if the vendor adds the

Consent to Share Identifying Information question

or any supplemental questions to the mail survey

starting with Q38.

n/a

Formatting Questions and associated responses options may

not be split across pages. n/a

Vendors must be consistent throughout the

questionnaire in formatting response options either

vertically or horizontally. If a vendor elects to list

the response options vertically, this must be done

for every question in the questionnaire. Vendors

may not format some response options vertically

and some horizontally.

n/a

No matrix formatting of the questions is allowed.

Matrix formatting means formatting a set of

questions as a table, with responses listed across

the top of a page and individual questions listed in

a column on the left.

n/a

Font size should be no smaller than size 10. We strongly

recommend that size

12 or larger be used.

Vendors should use best survey practices when

formatting the questionnaire, such as maximizing

the use of white space and using simple fonts like

Arial.

If data entry keying is

being used as the data

entry method, small

coding numbers next

to the response

options may be used.

ID number A unique, randomly generated sample

identification (SID) number must be assigned and

appear on at least the first page of the survey, for

tracking purposes. Additional identifiers are

permitted. However, the sample member’s name

or other identifying information must not be

printed anywhere on the survey.

n/a




Translation Only CMS-approved translations of the OAS

CAHPS Survey are permitted – English and

Spanish only. If facilities choose to add their own

supplemental questions, vendors will be

responsible for translating these questions.

n/a

Logo and other

information

about the

HOPD or ASC

The HOPD or ASC name or logo should appear on

the survey or the cover letter but cannot appear on

the envelopes (for privacy), unless vendors receive

prior approval from CMS via the submission of an

Exceptions Request Form indicating that they have

the facility’s approval to display the name or logo

on the outgoing envelope and the facility believes

there are no HIPAA risks. Note that survey vendors

cannot include any promotional messages or

materials on the OAS CAHPS cover letter,

questionnaire, or outgoing or incoming mailing

envelopes. This includes indications that either the

facility or the survey vendor has been approved by

the Better Business Bureau.

n/a

The vendor’s name and mailing address must be

printed at the bottom of the last page of the OAS

CAHPS Survey questionnaire, in case the

respondent does not use the enclosed business reply

envelope.

n/a

OMB Number The OMB number shown in Appendix G must be

printed on the questionnaire cover. If there is no

cover, then the OMB number must be printed on

the first page of the questionnaire.

n/a

Cover Letter Requirements and Recommendations

Examples of cover letters in English and Spanish are provided in the appendices with the survey

instruments (see Appendices B and C). Vendors may choose to develop their own cover letters as

well, provided that the following requirements are met:




Personalization Cover letters must be personalized with the

name and address of the sample member. n/a

Cover letters must contain the date of the

surgery or procedure and the name of the

location where the surgery was received. (The

monthly patient information file must contain

the date of surgery, facility name, and

location name because the name recognized

by the patient may differ from the facility’s

official name.)

n/a

ID Number A unique, randomly generated SID number

must be assigned and appear on the cover

letter, for tracking purposes. Additional

identifiers are permitted.

Separate from

questionnaire

Cover letters must be separate from the

questionnaire, so that no personally

identifiable information (PII) is returned with

the questionnaire when the respondent sends

it back to the vendor.

n/a

Content of

letters

The OMB disclosure notice (see Appendix G)

must be printed either on the questionnaire or

in the cover letters.

n/a

Vendors may not offer sample members the

opportunity to complete the survey over the

telephone. Telephone interviews may only be

conducted as part of the nonresponse follow-

up.

n/a

Must contain language describing the purpose

of the survey. n/a

Must contain a statement that participation is

voluntary and will not affect any benefits the

sample member receives or expects to

receive.

n/a

Must contain language indicating that

responses from all the survey participants will

be grouped together and these grouped data

may be shared with the HOPD or ASC, for

purposes of quality improvement.

n/a

Must contain language stating that if the

respondent needs help in reading the

questions or marking responses, a friend or

family member can assist them.

n/a




Must contain a toll-free customer support

telephone number that will be staffed by the

survey vendor.

n/a

Must include a statement that all information

the sampled patient provides will be

confidential and is protected by the Privacy

Act. This sentence is included in all of the

sample cover letters in Appendices B

(English) and C (Spanish).

n/a

Printing The HOPD or ASC name (or logo) must

appear on the letters or the survey, but cannot

appear on the envelopes (for privacy). Note

that survey vendors cannot include any

promotional messages or materials on the

OAS CAHPS cover letter, questionnaire, or

outgoing or incoming mailing envelopes. This

includes indications that either the facility or

the survey vendor has been approved by the

Better Business Bureau.

n/a

Signature on

the letters

A signature is required. We recommend that the

signature of an appropriate

official from the HOPD or

ASC be printed on each

cover letter If this is not

possible, the signature from

an appropriate official at the

survey vendor is acceptable.

Requests for

survey in other

languages

n/a

Survey vendors offering the

OAS CAHPS questionnaire

in Spanish may add

language to the English

cover letter indicating that a

version of the questionnaire

is available in Spanish.

Mailing

Requirements and recommendations are described below. Vendors are expected to follow these

requirements to maximize response rates and ensure consistency in how the mail survey portion

of the mixed-mode administration is implemented.




Questionnaire

contents

Each questionnaire mailing must contain a

personalized cover letter, questionnaire, and

postage-paid business reply envelope.

n/a

Envelopes Vendors are responsible for supplying both the

outgoing envelopes for the questionnaire mailings

and business-reply envelopes that sample members

will use to return their completed surveys (i.e., they

cannot be supplied by the HOPD or ASC).

n/a

Addresses Patients must have a U.S. domestic address to be

eligible to participate in the OAS CAHPS Survey. n/a

If the sample member’s address is missing or

incomplete, the vendor must follow up with the

HOPD or ASC to obtain the address. If an address

cannot be found, or the address that is found is too

incomplete for mailing, the vendor should treat the

patient as eligible (i.e., the case should remain in the

sample) and attempt to contact via telephone as part

of the telephone follow-up survey.

To reduce the

number of missing

addresses, we

recommend that

vendors verify

mailing addresses

obtained from the

facilities using

commercial address

update services, such

as the National

Change of Address or

the U.S. Postal

Service Zip+4

software.

Schedule Mailings must follow the schedule specified for the

mixed-mode administration—the questionnaire

package must be mailed no later than 3 weeks after

the close of the sample month; the phone calls for

telephone follow-up must begin approximately 3

weeks after the questionnaire mailing.

n/a

Data collection must end 6 weeks after the

questionnaire has been mailed. n/a

Incentives The use of incentives is not permitted. This includes

monetary and nonmonetary incentives. n/a

Data Receipt, Data Entry, and Optical Scanning Requirements

The following guidelines are provided for receiving and tracking returned questionnaires and

entering the data using either data entry or optical scanning.



Requirement

Receipting The date the questionnaire was received from each sample member must be

entered into the data record created for each case on the data file.

Mailings that are returned in the mail as undeliverable must also be logged

into the tracking system. They should then be followed up by telephone.

A final OAS CAHPS Survey disposition code (see Table 9.1 in Chapter IX)

must be assigned to each case.

If a completed questionnaire is received from the sample member after

telephone follow-up begins and a telephone interview with that sample

member has already been completed, retain the questionnaire or interview

with the more complete data. If both surveys are equally complete, the

vendor should use the first one received or completed.

Reviewing

received

questionnaires

for problems

Questionnaires should be visually reviewed prior to scanning or data entry

for notes and comments. Vendors should have more than one person who

can code or review comments and attach notes for proper disposition code

assignment.

If a completed mail survey questionnaire is returned and the vendor realizes

that it was completed by proxy (i.e., response option “3 – Answered the

questions for me” is selected for Q37 alone or in combination with other

response options for that question, or there is a note written on the

questionnaire that a family member completed the questionnaire because the

patient had died, had moved to a nursing home, had been incarcerated)

vendors should not key or scan a questionnaire for that sample member.

They should instead assign the applicable final disposition code to the case

based on the information provided in the handwritten note, or disposition

code 320 (Refusal) if no note is included and Q37’s response option “3” is

selected.

If a sample member were to die or become ineligible after completing the

questionnaire (vendors might learn of this through a comment written by a

family member on the questionnaire) that questionnaire is still an eligible

completed survey. Vendors should scan the questionnaire and assign the

applicable final disposition code indicating the completed survey.

Out-of-range

or invalid

responses

The key entry program should not permit out-of-range or invalid responses.

The scanning program should not permit out-of-range or invalid responses.



Requirement

Interpreting

blanks and

ambiguous

survey

responses

The following apply for both keying and optical scanning (additional

information about handling blank and ambiguous responses can be found in

Chapter IX):

If a response mark falls between two answer choices but is clearly closer to

one answer choice than to another, select the response that is closest to the

marked response.

If two responses are checked for the same question, select the one that

appears darkest. If it is not possible to make a determination, leave the

response blank and code as “missing” rather than guessing.

If a mark is between two answer choices but is not clearly closer to one

answer choice, code as “missing.”

If a response is missing, leave the response blank and code as “missing.”

Open-ended

responses

The decision on whether to key or scan the responses to open-ended survey

items, specifically, the “Other language” (response option 2) in Q35 and the

“Helped in some other way” (response option 5) in Q37, is up to each

individual HOPD or ASC. Vendors will not be required to key or scan and

include responses to open-ended survey items on the data files submitted to

the OAS CAHPS Data Center.

CMS, however, encourages survey vendors to review the open-ended entries

so they can provide feedback to the OAS CAHPS Survey Coordination

Team about adding additional preprinted response options to these survey

items if needed.

If the vendor includes the Consent to Share Identifying Information question

in the mail survey questionnaire, the vendor is not required to key or scan the

response to that question. However, we do recommend vendors review the

responses to this question for the vendor’s own documentation.

Responses to the Consent to Share Identifying Information question will not

be included on the data files submitted to the OAS CAHPS Data Center.

Staff Training

All staff involved in the mail survey implementation, including support staff, must be thoroughly

trained on the survey specifications and protocols. A copy of relevant chapters of this manual

should be made available to all staff as needed.

In particular, staff involved in questionnaire assembly and mailout, data receipt, and data entry

must be trained on:



• use of relevant equipment (case management systems for entering questionnaire receipts,

scanning equipment, data entry programs);

• the OAS CAHPS Survey protocol specific to their role (for example, contents of

questionnaire package, how to document or enter returned questionnaires into the

tracking system);

• decision rules and coding guidelines for returned questionnaires (see Chapter IX); and

• proper handling of hardcopy and electronic data, including data storage requirements (see

Chapter VIII).

Staff involved in providing customer support via the toll-free telephone number should also be

trained on the accurate responses to common respondent questions, how to respond to questions

when customer support does not know the answer, and the rights of survey respondents. If the

OAS CAHPS Survey is being offered in Spanish, customer support staff should also be able to

handle questions via the toll-free telephone number in Spanish. Telephone interviewer training

requirements are described in more detail in Chapter VI of this manual. Please refer to that

chapter for more information on training customer support staff.

Telephone Interview Development Process

The following paragraphs describe the requirements for producing all materials and systems

needed for the telephone survey. The telephone interview script in English and Spanish are


Copies of the telephone interview script can also be found in Appendix B (in English) and

Appendix C (in Spanish). A list of frequently asked interview questions is included in

Appendix H (English) and Appendix I (Spanish). Some general guidelines for telephone

interviewer training and monitoring are provided in Appendix J.

Specific requirements and guidelines associated with the telephone interview administration are

discussed below.

Telephone Interviewing Systems

In electronic interviewing systems, the interviewer reads from and enters responses into a

computer program. Using an electronic interviewing system or some other type of electronic data

collection system encourages standardized interviewing and monitoring of interviewers. The

OAS CAHPS Survey mixed-mode administration requires vendors use an electronic

interviewing system to administer the follow-up telephone OAS CAHPS Survey. Paper-and-

pencil administration of the OAS CAHPS Survey is not permitted. To ensure that sample

members are called at different times of the day and across multiple days of the week, vendors




must also have a survey management system. Ideally, the electronic interviewing system will be

linked to the survey management system so that cases can be tracked, appointments set and

called back at appropriate times, and pending and final case status easily accessed for any case.

Predictive or automatic dialers are permitted, as long as they are compliant with Federal Trade

Commission and Federal Communications Commission regulations, and as long as respondents

can easily interact with a live interviewer. For more information about Federal Trade

Commission and Federal Communications Commission regulations please visit

https://www.ftc.gov/ and https://www.fcc.gov/.

Telephone Interview Script

Survey vendors are provided with standardized telephone scripts in Appendix B, English, and

Appendix C, Spanish. These scripts include the introductory screens, in addition to the survey

questions.

Note the OAS CAHPS telephone interview script contains only 35 questions and the mail survey

contains 37 questions, because the mail survey questionnaire contains questions that ask if

anyone helped the sample member to complete the survey (Questions 36 and 37). These two

questions are not applicable if the survey is administered by telephone. Additional information

about the content of the OAS CAHPS Survey instrument is provided in Chapter III.

The following are content and programming requirements and recommendations for the OAS

CAHPS Survey questionnaire. Survey vendors cannot deviate from questionnaire requirements.

• Every questionnaire must begin with the “core” OAS CAHPS questions (Questions 1 to

24). They must be administered in the order in which they appear.

• No changes in wording are allowed for either the OAS CAHPS Survey questions or to

the response options.

• HOPDs and ASCs may add their own questions, following the guidelines in Chapter III.

In terms of placement of supplemental questions in the questionnaire, note that they must

be placed after the “core” OAS CAHPS questions. They may either be placed before or

after the unit of “About You” questions. If adding the Consent to Share Identifying

Information or supplemental questions to the end of the OAS CAHPS telephone script, it

is permissible to revise the programmable skip logic in Q35, “go to Q_end,” to instead

skip to Q36.

• Only CMS-approved translations of the OAS CAHPS Survey are permitted, although if

facilities choose to add their own supplemental questions, vendors will be responsible for


https://www.ftc.gov/

https://www.fcc.gov/



Telephone Interviewing Requirements and Recommendations

Telephone interviewing requirements and recommendations for the OAS CAHPS Survey

interview are described below. Vendors are expected to follow these requirements to maximize

response rates and ensure consistency in how the telephone follow-up is implemented in the

mixed-mode administration.

Telephone Contact

• Vendors must attempt to contact every sample member included in the sample. Vendors

are required to make five contact attempts for each nonrespondent to the mail survey,

unless the sample member refuses or the vendor learns that the sample member is

ineligible for the survey.

• A telephone contact attempt is defined as one of the following:

◦ the telephone rings six times with no answer;

◦ the interviewer reaches a household member and is told that the sample member is

not available to take the call;

◦ the interviewer reaches the sample member and is asked to schedule a call-back at a

later date; or

◦ the interviewer gets a busy signal on each of three consecutive phone call attempts,

spaced at least 20 minutes apart.

• Vendors may make more than one phone call in one 7-day period but cannot make all

five attempts in one 7-day period. Scheduling calls to take place over a longer period of

time may reach patients who may be unavailable the first week of the data collection

period.

• Contact with a sample member may be continued after five attempts if the fifth attempt

results in a scheduled appointment with the sample member, as long as the appointment

is within the data collection period.

• Phone calls must be made at different times of the day (i.e., morning, afternoon, and

evening) and different days of the week throughout the data collection period.

• Interviewers may not leave voicemail messages on answering machines or leave

messages with household members.

• Vendors must maintain a phone call log that keeps track of the date and time phone calls

were made for each sample member.



• If the vendor finds out that a sample member is ineligible for the OAS CAHPS Survey,

the vendor must immediately stop further contact attempts with that sample member.

• Telephone interviewing must follow the schedule specified for the mixed-mode

administration, with the first phone contact initiated approximately 3 weeks after the

questionnaire is mailed and all phone contacts ending 3 weeks after phone contact begins.

• The use of incentives is not permitted. This includes monetary and nonmonetary

incentives.

• Proxy respondents are not permitted on OAS CAHPS for any reason. If response option

“3 – Answered questions for me” is selected for Question 37 alone or in combination

with another response option for that question on a returned mail survey and no

handwritten note is provided, do not key or scan the questionnaire for that sample

member. This type of case should be coded a 320 (Refusal). A proxy mail survey can also

be determined through a note written on the questionnaire that a family member

completed the questionnaire because the patient had died, had moved to a nursing home,

or had been incarcerated. Again, vendors should not key or scan a questionnaire. They

should assign the applicable final disposition code to the case based on the information

provided in the handwritten note.

If a sample member is incapable of responding to the telephone interview because of

mental or physical impairments such as difficulty hearing, the interviewer should end the

interview and apply code 240 – Mentally or Physically Incapacitated. If a sample member

is capable of responding but needs some help to do so, a friend or family member may

help, but cannot respond on his or her behalf.

• Proxies are also not permitted for deceased respondents. If a sample member is found to

be deceased, the case should be closed using code 210 – Deceased.

• If a respondent begins the interview but cannot complete it during the call for a reason

other than a refusal, the vendor should follow up with the respondent to complete the

entire interview. This follow-up should be done even if the respondent answered enough

questions in the interview for the case to pass the completeness criteria. It is especially

important to complete the questions in the “About You” section of the questionnaire,

because data from some of those questions will be used in patient-mix adjustment.

• The vendor must be able to offer the interview in any of the approved languages (English

or Spanish) for which an HOPD or ASC has contracted, even if the language is different

from the language that the HOPD or ASC believes the sample member will require. That

is, the vendor must be able to easily switch to accommodate a respondent’s language



preference. For example, if the initial contact is in English but the respondent prefers to

conduct the interview in Spanish, the vendor must be able to switch to Spanish.

• Sample members are still eligible even if they have missing, incomplete, or foreign phone

numbers. The vendor should contact the HOPD or ASC to obtain the telephone

number(s) they have on record for the sample member. If the HOPD or ASC cannot

provide this number, the vendor should attempt to obtain a telephone number for the

patient from other sources (directory assistance, Internet directories, etc.). If the vendor

still cannot obtain a telephone number, the vendor should code the case as code 340 —

Wrong, Disconnected, or No Telephone Number.

• If the telephone interviewer dials the sample patient’s telephone number, learns the

telephone number is incorrect, and obtains a new telephone number for the sampled

patient, the number of call attempts for that case should start over with the newly

obtained telephone number.

• Once the interviewer has confirmed the sample member is on the phone, if the sample

member hangs up (without any comment) before or during the introductory script, the

case should be called again on a different day of the week and at a different time of day.

If the sample member hangs up (without any comment) after the introductory script, the

interviewer should code the case as a refusal. As a reminder, final disposition code 320 –

Refusal can only be assigned if sample members (not a gatekeeper or other

individual) indicate they do not wish to participate in the survey.

• If a respondent decides after answering some of the questions in the telephone interview

that he or she does not wish to participate in the survey any longer, the vendor should

code the case as a Refusal. The interviewer should not use the partial data that were

obtained before the interview ended. This protocol applies even if the respondent

answered enough questions in the interview for the case to pass the completeness criteria.

Note that this is different from the respondent saying that he or she does not wish to

continue an interview. If the respondent breaks off the interview but does not state that he

or she does not wish to participate in the survey, the data may be used as long as the

interview meets the completeness criteria. In this case, the vendor may code the case as a

120 – Completed Telephone Interview if the case passes the completeness criteria;

otherwise, it should be coded as a 310 – Breakoff.

Contacting Difficult-to-Reach Sample Members

• Although not required, we strongly recommend that survey vendors verify telephone

numbers obtained from the HOPD or ASC, using a commercial address or telephone

database service or directory assistance.



• We recommend that vendors attempt to identify a new or updated telephone number for

any sample member whose telephone number is no longer in service when called and for

patients who have moved so that the sample members can be contacted prior to the end of

the data collection period.

• If the sample member’s telephone number is incorrect, the interviewer may ask the

person who answers the phone for the sample member’s phone number.

• If the sample member is temporarily ill, on vacation, or unavailable during initial contact,

the interviewer should attempt to recontact the sample member before the data collection

period ends. If the sample member cannot be reached before the data collection period

ends, code the case as 350 – No Response After Maximum Attempts.

• If the sample member does not speak any of the OAS CAHPS Survey language(s) that

the vendor is administering for that facility, the interviewer should thank the sample

member for his or her time, end the interview, and code the case as 230 – Ineligible:

Language Barrier. Note that the language barrier disposition code only applies to the

sample member and should not be assigned until a determination is made that the sample

member cannot speak the language(s) being administered.

• If a sample member is physically or mentally incapable of responding by telephone, the

case should be coded as a 240 – Mentally or Physically Incapacitated.

• For sample members who are living in institutions (group homes, assisted living,

residential care facilities, etc.), OAS CAHPS Survey vendors should contact the HOPD

or ASC to obtain a direct-dial telephone number for the patients who live in those

facilities. If the HOPD or ASC cannot provide a direct-dial telephone number for the

patient, try to obtain the sample member’s telephone number using other sources, such as

a telephone number lookup service, directory assistance, or Internet telephone survey

directories. If vendors cannot obtain a telephone number for the patient, they should

assign a disposition code of 340 – Wrong, Disconnected, or No Number to the case. As a

reminder, sample members living in nursing homes or prisons are ineligible.

Distressed Respondent Procedures

It is critically important that survey vendors develop a “distressed respondent protocol,” to be

incorporated into all interviewer and help desk training. For survey research organizations, best

interviewing practices recommend having a distressed respondent protocol in place for handling

distressed respondents, which balances the respondent’s right to confidentiality and privacy and

providing assistance, if the situation indicates that the respondent’s health and safety are in

jeopardy.



Therefore, each approved OAS CAHPS Survey vendor is expected to have procedures in place

for handling distressed respondent situations and to follow those procedures. CMS and the OAS

CAHPS Survey Coordination Team cannot provide guidelines on how to evaluate or handle

distressed respondents. However, survey vendors are urged to consult with their organization’s

Committee for the Protection of Human Subjects Institutional Review Board for guidance. In

addition, professional associations for researchers, such as the American Association of Public

Opinion Researchers (AAPOR), may be able to provide guidance regarding this issue. The

following is an excerpt from AAPOR’s website that lists resources for the protection of human

subjects. More information about protection of human subjects is available at AAPOR’s website

at http://www.aapor.org .20

• The Belmont Report (guidelines and recommendations that gave rise to current federal

regulations)

• Federal Regulations Regarding Protection of Human Research Subjects (45 CFR 46)

(also known as the Common Rule)

• Federal Office for Human Research Protections

• National Institutes of Health Human Participant Investigator Training (although the site

appears to be for cancer researchers, it is the site for the general investigator training used

by many institutions)

• University of Minnesota Web-Based Instruction on Informed Consent

Interviewer Training

Vendors must provide training to all telephone interviewing and customer support staff prior to

starting telephone survey data collection activities. The telephone interview training must include

the following:

• teaching interviewers how to establish rapport with the respondent;

• teaching interviewers the content and purpose of the interview so that they can effectively

communicate this information to the sample members;

• teaching interviewers to administer the interview in a standardized format (reading the

questions as they are worded, not providing the respondent with additional information

20 The American Association of Public Opinion Researchers website at

http://www.aapor.org/Additional_IRB_Resources.html , July 2010.

http://www.aapor.org/

http://www.aapor.org/Additional_IRB_Resources.htmt



that is not scripted, maintaining a professional manner, and adhering to all quality control

standards);

• teaching interviewers how to use effective neutral probing techniques;

• teaching interviewers to use the frequently asked questions document so that they can

answer questions in a standardized format; and

• teaching multilingual customer support staff how to handle questions in English and

Spanish if offered.

Survey vendors should also provide telephone survey supervisors with an understanding of

effective quality control procedures to monitor and supervise interviewers.

Vendors must conduct an interviewer certification process of some kind—either oral, written, or

both—for each interviewer and customer service staff member prior to permitting that person to

make or take calls on the OAS CAHPS Survey. The certification should be designed to assess

the interviewer’s level of knowledge and comfort with the OAS CAHPS Survey instrument and

ability to respond to sample members’ questions about the survey. Documentation of training

and certification of all telephone interviewers and customer support staff and outcomes will be

subject to review during oversight visits by the OAS CAHPS Survey Coordination Team.

Telephone Data Processing Procedures

The following guidelines are provided for ensuring that the telephone interview data are properly

processed and managed.

Telephone Data Processing Requirements

• A unique SID number must be assigned to each sampled case and included in the case

management system and on the final data file for each sample member.

• Vendors must capture the date the interview was conducted with each sample member in

the survey management system or in the interview data.

• Vendors must be able to link each telephone interview to their survey management

system, so that appropriate variables, such as the language in which the survey was

conducted, can be pulled into the final data file.

• Vendors must de-identify all telephone interview data when the data are transferred into

the final data file for delivery. Identifiable data include respondent name and contact

information.



• Vendors must include and assign a final OAS CAHPS Survey disposition code to each

sampled case in the final data file (see Chapter IX for a list of these codes). It is up to the

vendor to develop and use a set of pending disposition codes to track actions on a case

before it is finalized appropriately—pending disposition codes are not specified in the

OAS CAHPS Survey protocol.

Mixed-Mode Quality Control Guidelines

The following steps are required or recommended as a means of incorporating quality control

into the mixed-mode survey administration procedures. Quality control checks should be

conducted by a different staff person than the one who completed the task.

Required for Mail Protocol

• Check a minimum of 10% of all printed materials to ensure the quality of the printing—

that is, make sure that there is no smearing, misaligned pages, duplicate pages, or stray

marks on pages.

• Check a minimum of 10% of all outgoing questionnaire packages to ensure that all

package contents are included and that the same unique SID number appears on both the

cover letter and the questionnaire.

• For vendors that are scanning: a sample of questionnaires (minimum of 10 percent)

should be compared with the original hardcopy survey. This serves as a quality control

measure that the scanning program is capturing the hard copy correctly. Any

discrepancies between the scan and the hard copy should be reconciled by a supervisor.

Additionally, the survey responses captured in the database for a sample of

questionnaires (minimum of 10 percent) should be systematically compared to scanned

image for that case. This can be done either by visually examining the scanned image and

the data to reveal inconsistencies, or by rescanning and noting whether the data from the

original match the data from the rescan. This serves as a quality control measure that the

scanning program is translating the response marks in the scanned image to the data file

consistently and correctly. Any discrepancies should be reconciled by a supervisor.

• For vendors that are keying: all questionnaires should be 100% rekeyed for quality

control purposes. That is, for every questionnaire, a different keyer should rekey the

questionnaire and the data entry files from the two keyers should be systematically

compared to ensure that all entries are accurate. If any discrepancies are observed, a

supervisor should resolve the discrepancy and ensure that the correct value is stored in

the data.



Recommended for Mail Protocol

• “Seed” each mailing. That is, include the name and address of designated vendor staff in

each mailing file to assess the completeness of the questionnaire package and timeliness

of package delivery.

• Before submitting XML data to the OAS CAHPS Data Center, we highly recommend

vendors review a sample of cases comparing responses recorded on the hardcopy

questionnaire to responses scanned to the response codes that appear in the XML files.

This quality control step will ensure that the responses included in the XML files

accurately reflect the patients’ responses to the survey questions.

• Vendors are urged to develop a way to measure error rates for their data receipt staff (in

terms of recognizing marginal notes and passing these on to someone for review), for

data entry or scanning operators, and for coders. Vendors should then work with their

staff to minimize error rates. The OAS CAHPS Survey Coordination Team will request

information about data receipt and processing error rates during site visits.

Required for Telephone Protocol

The following activities are methods to incorporate quality control into the survey administration

procedures for the telephone follow-up portion of the mixed-mode survey administration.

Quality control of telephone interviewers and customer support staff should include the

following activities:

• OAS CAHPS requires that survey vendors thoroughly test the electronic telephone

interviewing system before beginning the OAS CAHPS Survey. Testing will vary from

system to system, but includes at a minimum comparing each screen to the telephone

script (in Appendices B and C) to verify that the questions and response options are

faithful to the script; checking each question to ensure that the answers input match the

data exported, and checking that a respondent is automatically routed to the next

appropriate question.

• Vendors are required to keep written documentation that all telephone interviewing and

customer support staff have been properly trained prior to interviewing. Copies of

interviewer certification exam scores should be retained as well. Documentation should

be maintained for any retraining required and will be subject to review during site visits.

• Survey vendors must establish and communicate clear telephone interviewing quality

control guidelines for their staff to follow. These guidelines should be used to conduct the

monitoring and feedback process and should include clear explanations of the

consequences of not following protocols, including actions such as removal from the

project or termination of employment.



• Vendors are required to silently monitor a minimum of 10% of all telephone interviews to

ensure that correct administration procedures are being followed.

• There are federal and state laws and regulations relating to the monitoring and/or

recording of telephone calls. In certain states, consent must be obtained from every party

or conversation if it involves more than two people (“two-party consent”). When calling

sample members who reside in these states, survey vendors should not begin either

monitoring or recording the telephone calls until after the interviewer has read the

following statement: “This call may be monitored or recorded for quality improvement

purposes.”21

• All OAS CAHPS Survey vendors are responsible for identifying and adhering to federal

and state laws and regulations in the states in which it will be administering the OAS

CAHPS Survey.

• No revisions or corrections should be made to the OAS CAHPS Survey response data

once a telephone interview has been completed. Corrections can only be made while the

respondent is still on the phone to confirm responses. If survey response errors are

identified through QC measures after the interview, prompt retraining of the interviewer

is required to correct an issue for future interviews.

Recommended for Telephone Protocol

• Vendors are urged to conduct regular Quality Circle meetings with telephone

interviewing and customer support staff to obtain feedback on issues relating to telephone

survey administration or handling inbound calls.

• Supervisory staff monitoring telephone interviewers should use the electronic system to

observe the interviewer conducting the interview while listening to the audio of the call at

the same time.

• Monitoring staff or supervisors should provide performance feedback to interviewers as

soon as possible after the monitoring session has been completed.

• Interviewers should be given the opportunity to correct deficiencies in their

administration through additional practice or retraining; however, interviewers who

receive consistently poor monitoring scores should be removed from the project.

21 The following states currently require two-party or all-party consent when telephone calls are monitored or

audiotaped: California, Connecticut, Florida, Illinois, Maryland, Massachusetts, Montana, New Hampshire,

Pennsylvania, and Washington.




50 completed telephone interview responses directly from their CATI system to the

values output in the XML data file. Doing this monthly review will ensure that the

responses are being accurately captured and output to the XML data file.


VIII. CONFIDENTIALITY AND DATA SECURITY

Overview

This chapter describes the requirements and guidelines for (1) protecting the identity of sample

members included in the survey sample, (2) ensuring confidentiality of respondent data, and

(3) ensuring data security. The chapter begins with a discussion of how confidential data should

be handled and the importance of confidentiality agreements. The last section provides

information about the importance of establishing and maintaining physical and electronic data

security.

Safeguarding Patient Data

The Health Insurance Portability and Accountability Act of 1996 (HIPAA) is legislation intended

to protect private medical information and to improve the efficiency of the health care system.

This law went into effect April 14, 2003.

The type of information protected under HIPAA is called “protected health information,” or PHI.

PHI is defined as personally identifiable information that relates to a person’s past, present, or

future health or medical treatment. If the health information is completely de-identified, it is no

longer PHI and can be released. HIPAA also applies to electronic records, whether they are

being stored or transmitted. All vendors approved to implement Outpatient and Ambulatory

Surgery CAHPS (OAS CAHPS) Survey must adhere to HIPAA requirements. That is, vendors

must safeguard any and all data collected from hospital outpatient departments (HOPDs) and

ambulatory surgery centers (ASCs) and sample members as required by HIPAA.

Vendors must adhere to the following requirements when conducting OAS CAHPS. Each of

these is discussed in more detail in the paragraphs that follow.

• Confidential data must be kept secure as described in this chapter.

• Access to confidential data must be limited to authorized staff members.

• Vendors must develop procedures for identifying and handling breaches of confidential

data.

• No data that can identify a sample member can be included on OAS CAHPS data files

submitted to the OAS CAHPS Data Center. That is, all file submissions must contain de-

identified data.

VIII. Confidentiality and Data Security November 2018


State Regulations and Laws Protecting Patients With Specific

Conditions/Illnesses

As indicated in Chapter IV, some states have additional regulations and laws governing the

release of patient information for patients with specific illnesses or conditions, and for other

special patient populations, including patients with HIV. It is the HOPD’s or ASC’s

responsibility to identify any applicable state laws and regulations and exclude patients from the

survey as required by the law or regulation.

Confidential Data Must Be Kept Secure

Any identifying information associated with a patient should be considered private and must be

protected. When monthly patient information is received from an HOPD or ASC, it will contain

private information, such as the name and address or telephone number of the patient, and other

information such as outpatient surgeries or procedures performed and the date on which the

surgeries or procedures were performed. HOPDs and ASCs must provide the monthly patient

information files in a manner that adheres to HIPAA guidelines and regulations, at a minimum

encrypting the patient information files prior to sending them to their vendor. Vendors should

stress this important security measure to their client facilities.

From the moment the vendor receives the monthly patient information file, the data must be

handled in a way to ensure that the patient information is kept confidential and that only

authorized personnel have access to it. Examples of ways to keep confidential data secure

include storing the data electronically in password-protected locations and limiting the number of

staff with access to the password. For confidential information that is obtained on hard copy,

data should be kept in a locked room or file cabinet, with access restricted to authorized staff.

Confidential data should not, under any circumstances, be removed from the survey vendor’s

place of business, either in electronic or hardcopy form, even by survey vendor staff.

Confidential data should not be stored on laptop computers unless those laptops have data

encryption software to protect the information should the laptop be lost or stolen. (Additional

guidance on electronic data backup storage and a disaster recovery plan is provided later in this

chapter.)

Limit Access to Confidential Data

Survey vendors should consider carefully who needs access to confidential OAS CAHPS data

and then ensure that only those staff have access. For example, the Sampling Manager will need

access to the facility sample frame to select the sample. However, information on the frame does

not need to be included in every data file—although names and addresses need to be provided in

the file used to create cover letters, other PHI does not have to be on that file.

November 2018 VIII. Confidentiality and Data Security


Any staff who will be working with data about outpatient surgery patients should sign a

confidentiality agreement specific to OAS CAHPS implementation (see the paragraph on

Confidentiality Agreements for more information).

Develop Procedures for Identifying and Handling Breaches of Confidential

Data

Survey vendors are required to develop protocols for identifying when there has been a breach of

security with OAS CAHPS data, including when an unauthorized individual has gained access to

confidential information and when an authorized individual has distributed confidential data in

an unauthorized manner. The vendor’s plans must include a system to notify the vendor’s OAS

CAHPS Project Director in a timely manner of a security breach, a means to detect the level of

risk represented by the breach in security, and a means to take corrective action against the

individual who created the breach and any persons affected by the breach, including sample

members. The OAS CAHPS Survey Coordination Team should also be notified as soon as

possible following the breach.

Provide Only De-Identified Data Files to the OAS CAHPS Data Center

Although vendors will have access to patients’ confidential information, none of the data files

submitted to the OAS CAHPS Data Center may contain any confidential information (i.e., any

information that would identify a sample member). All files submitted to the Data Center must

contain de-identified data only. Therefore, only the unique patient sample identification (SID)

number that the survey vendor assigns to each sample member should be included on the file for

each data record. (There will be a data record for each patient sampled.)

Providing OAS CAHPS Response Data to HOPDs and ASCs

When providing response data to their clients, survey vendors must provide data that are de-

identified. Survey vendors must be aware of the following requirements and exceptions.

“About You” Questions (Questions 25–35)

Vendors can provide de-identified response data for an “About You” question (Questions 25-35)

only if there are a minimum of 11 responses in each response category for that question. For

example, if there are 11 or more responses in each age category of Q27 (“What is your age?”), it

is acceptable to provide response results for Q27. However, if there are 10 or fewer responses in

any or all of the age categories, it is not acceptable to provide response data for Q27.

There are two questions in the About You section (Questions 36 and 37) that do not require this

restriction. Questions 36 and 37 are proxy questions that collect information about who helped

the patient complete the mail survey and how they helped. Response data for these two survey

items can be reported to client HOPDs and ASCs regardless of how many responses for each

response option there are.



Alternative Method for Providing De-Identified Response Data

An acceptable alternative method for vendors to report the “About You” response data to client

HOPDs and ASCs is to combine two or more contiguous response options so that the combined

responses meet the reporting requirement of 11 or more. Below is an illustrative example of how

vendors can implement this alternative method with an “About You” survey question (Q27).

HOPD has 50 completed surveys in a month. The distribution of response categories for Q27 is

as follows:

Response

Category

Number of

Responses

18-24 2

25-34 9

35-44 8

45-54 2

55-64 1

65-74 4

75-79 3

80-84 10

85 + 11

In this example, the data for Q27 cannot be shared with the facility because at least one of the

response categories has fewer than 11 responses.

However, using this alternative method, the vendor could combine response categories to meet

the reporting requirement of 11 or more responses per category:

Response

Category

Number of

Responses

18-34 11

35-64 11

65-84 17

85 + 11

Providing Identified Data

Survey vendors can provide responses linked to a sample member’s name and other identifying

information only if the sample member gives his or her consent on the “Consent to Share



Identifying Information” question (Appendix F). This includes providing this sample member’s

responses to any “About You” questions that do not meet the threshold of 11 that is required for

reporting response data overall.

In the absence of this explicit consent, only de-identified response data can be provided. In this

case, patient-level data cannot be shared with anyone outside of the vendor’s organization,

including, but not limited to, parent organizations (overseeing multiple CCNs) and individual

client facilities.

Confidentiality Agreements

Survey vendors are required to obtain a signed affidavit of confidentiality from all staff,

including subcontractors, who work on the OAS CAHPS implementation. This includes

individuals who will be working as telephone interviewers or staffing the customer support line

and individuals working in data receipt or data entry positions. Copies of the signed agreements

should be retained by the OAS CAHPS Project Director as documentation of compliance with

this requirement. Vendors will be asked to provide this documentation during site visits.

Physical and Electronic Data Security

Vendors must take appropriate actions to safeguard both the hardcopy and electronic data

obtained during the course of implementing OAS CAHPS, including data obtained from HOPDs

and ASCs and data provided by survey respondents.

The following are measures vendors should take to ensure physical and electronic data security:

• Paper copies of questionnaires or sample frame information must be stored in a secure

location, such as a locked file cabinet or within a locked room. At no time should paper

copies be removed from the vendor’s premises, even temporarily.

• At no time should electronic data be removed from the survey vendor’s or

subcontractor’s premises, even temporarily, unless this is done for purpose of backup

storage. If done for this purpose, the data must be encrypted during transmission and

while in storage in a secure commercial work environment. Vendors must have a disaster

recovery plan for the OAS CAHPS Survey data should any natural (floods, hurricanes,

tornadoes, etc.) or man-made (break-in, act of a terrorist, etc.) disasters occur.

• Electronic data must be protected. Electronic security measures may include firewalls,

restricted-access levels, or password-protected access.

• Access to confidential data must be limited to authorized staff members.



• Data stored electronically must be backed up nightly or more frequently to minimize data

loss.

• Electronic images of paper questionnaires or keyed data, including computer-assisted

telephone interview or alternative electronic system data, should be retained for 3 years in

a secure location at the vendor’s facility.

• Paper copies of questionnaires must be stored in a secure location at the vendor’s facility,

such as a locked room or file cabinet, for 3 years. Paper copies of questionnaires do not

need to be kept if electronic images of the questionnaires are being kept instead.

• Destroy all paper and electronic copies of questionnaires and surveys that contain

personally identifiable information once the proper time has elapsed.

• Protocols for secure file transmission must be established. E-mailing of PHI via unsecure

e-mail is prohibited.

• Confidential data should not be stored on laptop computers unless those laptops have data

encryption software to protect the information should the laptop be lost or stolen.

• Vendors must develop procedures for identifying if breaches of confidential data have

occurred, informing the OAS CAHPS Survey Coordination Team, and implementing a

corrective action plan.

• No data that can identify a patient or a sample of patients can be included on OAS

CAHPS Survey data files submitted to the OAS CAHPS Data Center. That is, all file

submissions must contain de-identified data.

Communicating With Sample Members About Confidentiality and Security

Sample members may wish to understand how the OAS CAHPS Survey keeps information about

them confidential and secure. It is important that survey vendors on OAS CAHPS clearly and

succinctly communicate this information to sample members, when asked. The following are

guidelines of what to convey:

• the purposes of the survey and how the survey results will be used, specifically that all

patients’ survey responses will be reported at the aggregate level and no response will be

linked to an individual patient respondent;

• participation in the study will not affect the care they receive or health care benefits they

currently receive or expect to receive in the future;



• participation in the OAS CAHPS Survey is voluntary;

• they can skip or refuse to answer any question they do not want to answer;

• all information they provide is protected by the Federal Privacy Act of 1974 and HIPAA

(most patients are familiar with HIPAA);

• all OAS CAHPS project staff have signed affidavits of confidentiality and are prohibited

by law from using survey information for anything other than this research study; and

• no facility personnel will see an individual patient’s answers unless the patient explicitly

gives consent to share his or her answers.





IX. DATA PROCESSING AND CODING

Overview

This chapter describes the requirements and guidelines for creating and assigning a unique

sample identification (SID) number to each sample member, decision rules related to processing

returned mail survey questionnaires, assignment of survey disposition codes, and quality control

measures. In addition, procedures and steps for determining whether a returned survey meets the

definition of a completed survey and information about how survey response rates are calculated

are provided in this chapter.

Sample Identification Numbers

A unique numeric or alphanumeric SID number must be assigned to each patient included in

the Outpatient and Ambulatory Surgery CAHPS (OAS CAHPS) Survey sample. Vendors will

use the SID to track efforts to complete the survey with each sample member throughout the data

collection period. When creating and assigning SID numbers to sampled cases, follow the

guidelines listed below.

• The SID number assigned to a sample member cannot contain any combination of letters

or numbers that could link the SID with a particular sample member. For example, no

part of a sample member’s name, address, date of birth, telephone number, Social

Security Number, or dates of outpatient surgeries or procedures can be included in the

unique SID created and assigned to the sample member.

• The SID number also cannot link a sample member with a hospital outpatient department

(HOPD) or ambulatory surgery center (ASC). The vendor should not embed within the

SID any items identifying the source HOPD or ASC, such as its CMS Certification

Number (CCN), its initials, or its location. Vendors with multiple OAS CAHPS clients

wishing to track the source should establish a variable distinct from the SID in which to

identify the source HOPD or ASC of the patient.

• The SID can be a numeric or alphanumeric variable. The SID must have a minimum

length of 6 and a maximum length of 16 characters.

• Vendors must assign new SID numbers to the new set of patients sampled each month.

Vendors must not reuse the same SID number.

• If a patient is sampled more than once in a calendar year or across multiple calendar

years, the vendor must assign a new SID number to that patient each time he or she is

sampled.

IX. Data Processing and Coding November 2018


Data Processing Decision Rules and Coding Guidelines – Mail Surveys

Guidelines and procedures for handling ambiguous, missing, or inconsistent survey responses

from returned mail survey questionnaires are provided below. Note that these guidelines should

be followed regardless of whether the vendor is using optical scanning or data keying to enter

data from completed questionnaires.

Decision Rules for Handling Missing or Ambiguous Responses

In mail surveys, some respondents may choose not to answer particular questions, and others

may not clearly mark their answer choices. Use the following rules to handle missing or

ambiguous responses when processing completed questionnaires.

• If a response mark falls between two answer choices but is clearly closer to one answer

choice than to another, select the response that is closest to the marked response.

• If two responses are checked for the same question, select the one that appears darkest. If

it is not possible to make a determination, leave the response blank and code as “missing”

rather than guess.

• If a mark is between two answer choices but is not clearly closer to one answer choice,

code as “missing.”

• Note that the only survey items in the OAS CAHPS Survey where two or more answers

are acceptable are Questions 32 and 37, which ask the sample member to check all

answer choices that are applicable to him or her. For both of these questions, enter

responses for all of the categories that the respondent marked.

• If a response is missing, leave the response blank and code it as “Missing.”

Decision Rules for Coding Survey Responses Marked Outside the

Response Box

Although OAS CAHPS mail questionnaires use response bubbles or boxes, vendors may receive

surveys where a response is marked outside the response box. CMS and the OAS CAHPS

Survey Coordination Team acknowledge that there are some instances where it is acceptable to

consider a response “marked,” even if the response box itself is not marked. However, to

minimize the opportunity for coding interpretation errors among vendors, OAS CAHPS requests

that all responses or response boxes that are not circled, checked, underlined, or in some other

way clearly designated by the respondent (i.e., the respondent writes the exact wording of a

response to the right of the response options) be coded as “Missing.”

November 2018 IX. Data Processing and Coding


Although some text or marks to the right of the response options may seem to point to a

particular response, many times the respondent’s intent is not clear. This opens the door to

nonstandardized interpretations from vendor to vendor. To provide some visual guidance on

what is expected, we offer three examples below of when it is acceptable to code a response and

two examples of when it is not acceptable to code a response.

When it is Acceptable to Code a Response

Example 1:

In this first example, the respondent has

circled a response. The respondent’s

intention is clear and the vendor should code

the answer to Q3 as “No.”

Example 2:

In this second example, the respondent has

underlined a response. The respondent’s

intention is clear and the vendor should code

the answer to Q6 as “Yes, definitely.”

Example 3:

In this third example, the respondent has

placed a check mark very close to a

response. Again, the respondent’s intention

is clear, and the vendor should code the

answer to Q22 as “Yes.”



When it is NOT Acceptable to Code a Response

Example 1:

In this example, the respondent has placed a

check mark to the right of the response

boxes. It is not clear which response was

intended. Therefore, the correct procedure

for a question presenting like Q10 is to code

the response as “M,” which stands for

“missing.”

Example 2:

In this example, the respondent has placed a

check mark to the right of the response

boxes. It is not clear which response was

intended. Therefore, the correct procedure

for a question presenting like Q9 is to code

the response as “M.”



Skip Patterns

Some of the questions included in the OAS CAHPS Survey instrument are “screening”

questions—that is, they are designed to determine whether one or more follow-up questions

about the same topic are applicable to the respondent. The respondent is directed to the next

applicable question by a “skip” instruction printed beside the answer choice that he or she marks.

In mail surveys, some respondents may answer the screening question but leave applicable

follow-up questions blank. In other cases, some respondents will mark an answer to follow-up

questions that are not applicable to them (based on the answer to the screening question). Yet in

other cases, some respondents will answer both the screening and follow-up questions with

responses that contradict each other. Use the following rules for completed OAS CAHPS

questionnaires.

Decision Rules for Coding Screening Questions (Qs. 10, 30, 34, and 36)

• Key or scan the response provided by the respondent.

• If the screener question is left blank, code it as “M” for Missing. If both the screener

question and the follow-up questions are left blank, the screening question should be

coded “M” for Missing and the follow-up questions should be coded “X” for Not

Applicable.

Decision Rules for Coding Follow-Up Questions (Qs. 11, 12, 31, 35, and 37*)

*Please note: Question 37 is included in the mail survey only.

• Key or scan the response provided by the respondent whenever one is given, regardless

of whether the response agrees with the screener question. For example, if the respondent

answers “No” to the screener question and then marks a response to the follow-up

question instead of skipping it, that is acceptable—the response must still be keyed or

scanned.

• If the follow-up question is left blank (correctly) because the respondent correctly

followed the skip instruction in the screener question, assign code “X” for Not Applicable

to the follow-up question.

• If the follow-up question is left blank (incorrectly) because the respondent skipped it (or,

if a telephone interview, he or she responded with Don’t Know or Refuse) rather than

answering it, enter code as “M” for Missing to the follow-up question.

To summarize, when follow-up questions are appropriately skipped, the follow-up question

response should be coded as “Not Applicable,” which is code “X.” When follow-up questions

are incorrectly answered, scan or key the response that the respondent provides. If a screener or

follow-up question should have been answered but was not, code the response as “Missing,”



which is code “M.” Note that in OAS CAHPS, survey vendors will key or scan the response to

every question that the respondent provides.

Data Processing Decision Rules and Coding Guidelines – Telephone Surveys

Guidelines and procedures for handling skip patterns and decision rules for telephone surveys are

provided below.

Skip Patterns

Some of the questions included in the OAS CAHPS Survey instrument are “screening”

questions—that is, they are designed to determine whether one or more follow-up questions

about the same topic are applicable to the respondent. The vendor’s computer-assisted telephone

interview (CATI) system should be programmed such that follow-up questions are skipped if a

screening question is answered in the negative. Therefore, when follow-up questions are skipped,

no response data should be captured by a telephone interviewer.

Decision Rules for Coding Screening Questions (Qs. 10, 30, 34, and 35)

• Key the response provided by the respondent.

• If the response to the screener question is coded as MISSING/DK, code it as “M” for

Missing. If both the screener question and the follow-up questions are left blank, the

screening question should be coded “M” for Missing and the follow-up questions should

be coded “X” for Not Applicable.

Decision Rules for Coding Follow-Up Questions (Qs. 11, 12, 31, 35, and 35a*)

*Please note: Question 35a is included in the telephone survey only.

• If the respondent answered the screening question such that the follow-up question is

skipped, assign code “X” for Not Applicable to the follow-up question.

• If the follow-up question is read to the respondent and coded MISSING/DK, assign code

“M” for Missing to the follow-up question.



Survey Disposition Codes

Survey disposition codes, which are also referred to as status codes, are used to track the current

status of a sampled case as it moves through the survey process. For example, a disposition code

is used to designate that the first questionnaire has been mailed, and another disposition code is

used to indicate that the questionnaire has been received. Disposition codes can be interim

(meaning that they are expected to change as the case moves through the rest of the survey

process) or final (meaning that no further action will be taken with that case). Understanding and

appropriately using OAS CAHPS disposition codes is required for successful administration and

completion of OAS CAHPS. This section provides a list and description of the final disposition

codes that are to be used on OAS CAHPS, for mail-only, telephone-only, and mixed-mode

surveys.

Survey vendors should apply pending disposition codes to OAS CAHPS cases for internal

tracking purposes only—that is, to describe the result of the most recent work or action on the

case that did not result in a final disposition. Because survey vendors may have already

developed a set of designated pending disposition codes for tracking the pending status of a case,

survey vendors may use their own set of pending codes on OAS CAHPS.

Definition of a Completed Survey or Survey Completion Criteria

As is seen below in the description of all OAS CAHPS status codes, one of the criteria in

determining the correct code is whether the survey is “complete.” A survey is considered to be

“complete” and should be assigned a survey disposition code of 110 or 120 if at least 50% of the

questions applicable to all sample members (Questions 1–10 and 13–24) are answered.

• Survey items that are part of skip patterns and the items in the “About You” section of

the questionnaire (Questions 11, 12 and 25–37) are not included in this calculation of

percentage complete.

• Responses of “Don’t Know” and “Refuse” should be recoded to “M” for Missing and

should not be counted as responses.

• Responses to any supplemental questions should not be included in this calculation of

percentage complete and should not be reported to the OAS CAHPS Data Center.

• Use the steps in Exhibit 9.1 to determine whether a survey can be considered “complete.”



Exhibit 9.1 Steps for Determining Whether a Questionnaire Meets Completeness Criteria

Sum the number of questions that have been answered by the respondent that are applicable to all

patients. These include questions 1–10 and 13–24.

R = total number of questions answered

Divide the total number of questions answered by 22, which is the total number of questions applicable to

all patients, and then multiply by 100 to determine the percentage.

Percentage Complete = (R / 22) x 100

If the Percentage Complete is greater than or equal to 50 percent, then assign the applicable survey

completed disposition code (code 110 or 120) to indicate that the case meets the definition of a

completed survey. Otherwise, assign the disposition code for breakoff (code 310) to the case.

The vendor must select and assign the applicable code from the disposition codes shown in

Table 9.1 for each sampled case included on the data file submitted to the OAS CAHPS Data

Center.

Table 9.1 OAS CAHPS Survey Disposition Codes

Code Description

110 Completed Mail Survey

See Definition of a Completed Survey (above)

Assign this code for mail-only cases and for mixed-mode cases if the sample member responded by mail.

Note that respondents may receive assistance completing the mail survey and such respondents should be included in Code 110. If they are capable of understanding and answering the questions someone else can provide assistance. For example, someone could read the questions and record their answers to help a blind respondent.

120 Completed Telephone Interview

See Definition of Completed Survey (above)

Assign this code if the interview was completed for telephone-only cases and for mixed-mode cases if the sample member responded by telephone.

Note that respondents may receive assistance in completing the telephone survey and such respondents should be included in Code 120. For example, someone could translate the CATI interviewer’s questions into sign language and state a deaf respondent’s replies to the CATI interviewer.

210 Ineligible: Deceased

Assign this code if the sample member is reported as deceased during the course of the survey period.

(continued)



Table 9.1 (continued) OAS CAHPS Survey Disposition Codes

Code Description

220 Ineligible: Does Not Meet Eligible Population Criteria22

Assign this code if it is determined during the data collection period that the sample member does not meet all of the required eligibility criteria for being included in the survey sample. Apply this code if:

• The sample member is under age 18 (note: sampling procedures direct vendors to remove such patients from the sample frame based on their birthdate).

• The sample member does not have a domestic U.S. address (note: sampling procedures direct vendors to remove these patients from the sample frame based on their address).

• The sample member resides in a nursing home or in a prison or jail (note: sampling procedures direct vendors to remove these patients from the sampling frame if this residence information is known).

• The sample member reports that he or she did not receive an outpatient surgery or procedure from the named HOPD or ASC.

• The sample member reports that he or she did not receive surgery or procedure on the sample date.

• It is reported that the sample member was discharged to hospice care following his or her surgery during the sample month.

A full listing of eligibility criteria is provided in Chapter IV of this manual.

230 Ineligible: Language Barrier

Assign this code to sample members who do not speak any of the OAS CAHPS language(s) that the vendor is administering for that facility. Note that this code only applies to the sample member and should not be assigned until a determination is made that the sample member cannot speak the language(s) being administered.

240 Ineligible: Mentally or Physically Incapacitated

Assign this code if it is determined that the sample member is unable to complete the survey because he or she is mentally or physically incapable.

310 Break-Off

This code should be assigned if the sample member completes some responses but does not meet the definition of a completed survey (see above).

320 Refusal

This code should be assigned if the sample member indicates either in writing or verbally that he or she does not wish to participate in the survey.

Mail-Only Mode

This code should also be assigned if the first questionnaire mailing is never returned or is returned blank and the second questionnaire is returned blank during the data collection period.

Telephone-Only Mode or Mixed Mode

This code should be assigned if the sample member (not a gatekeeper or other individual) states that he or she does not wish to participate in the survey.

(continued)

22 See Chapter IV for eligibility rules for OAS CAHPS.



Table 9.1 (continued) OAS CAHPS Survey Disposition Codes

Code Description

330 Bad Address/Undeliverable Mail, or No Address

This code should be assigned only when using the mail-only mode. It should be assigned if it is determined that the sample member’s address is bad (e.g., the questionnaire is returned by the Post Office as undeliverable with no forwarding address).

340 Wrong, Disconnected, or No Telephone Number

This code should be used in telephone-only or mixed-mode survey administration. In the telephone-only mode, this code should be assigned if it is determined the telephone number is bad (disconnected, no telephone number available, etc.). In the mixed mode, this code should be assigned because the telephone follow-up represents the last attempt to reach the sample member even if it is determined that the mailing address is also bad.

350 No Response After Maximum Attempts

This code should be used in all three approved data collection modes. It should be assigned when the contact information for the sample member is assumed to be viable, but the sample member does not respond to the survey or cannot be reached during the data collection period.

This code should also be assigned to completed surveys received after the data collection period ends. As explained earlier, the data collection period ends 42 calendar days after the initial mailout (for mail-only and mixed mode) or 42 calendar days after the initiation of the telephone survey (for telephone-only mode).

Mail-Only Mode

• This code should be assigned if the sample member’s address is viable but he or she does not respond to either the first or second questionnaire mailing during the data collection period. This code should be assigned if the initial questionnaire is never returned or returned blank and the second questionnaire is never returned.

Telephone-Only Mode

• This code should be assigned if it is determined that the telephone number is viable but the required number of telephone attempts (five) did not result in a completed interview or other final disposition code.

Mixed Mode

• This code should be assigned if it is determined that the address and telephone number are viable but the maximum number of contact attempts (i.e., the questionnaire mailing and five telephone attempts) did not result in a completed survey or another final disposition code.

Differentiating Between Disposition Codes 330 (Bad/No Address), 340

(Bad/No Telephone Number), and 350 (No Response After Maximum

Attempts)

Code 330: Nonresponse: Bad or No Address should be assigned only if there is evidence that

the patient’s address is not viable. This code is for mail-only mode. Evidence that the address is

not viable includes the following:



• the HOPD or ASC does not provide an address for the sample member and the vendor

has attempted but failed to obtain an address;

• the questionnaire is returned as “undeliverable, no forwarding address”; and

• the questionnaire is returned as “address or addressee unknown” or some other reason the

mail was not delivered.

The vendor is strongly encouraged to use an outside address update service prior to mailing

questionnaires to ensure that the most accurate mailing address is used. Survey vendors are

permitted to ask HOPDs and ASCs to provide updated address information for all patients

treated within the sample month, if needed. The survey vendors cannot, however, give a list of

sample members to the HOPD or ASC to request this information. Similarly, if a questionnaire is

returned as undeliverable, the vendor is strongly encouraged to attempt to locate a new address

prior to the second questionnaire mailing.

Code 340: Nonresponse: Bad or No Telephone Number should be assigned only if there is

evidence that the sample member’s telephone number is not viable. This applies to both

telephone-only and mixed-mode administration. Evidence that the telephone number is not

viable includes the following:

• the HOPD or ASC does not provide a telephone number for the sample member and the

vendor has attempted and failed to obtain a telephone number;

• on calling, the telephone interviewer learns that the telephone number on file is

disconnected, nonworking, or out of order, and no new telephone number is provided;

and

• on calling, the telephone interviewer reaches a person and learns that the telephone

number is the wrong number for the sample member and no new number is provided.

To ensure that the most accurate telephone number is used, the vendor is strongly encouraged to

use an outside telephone number update service prior to initiating telephone contact. Similarly, if

the vendor learns that a telephone number is not viable, the vendor is strongly encouraged to

attempt to locate a new telephone number for the sample member prior to the end of the data

collection period. Survey vendors are permitted to ask HOPDs and ASCs to provide updated

telephone number information for all patients treated within the sample month, if needed. The

survey vendors cannot, however, give a list of sample members to the HOPD or ASC to request

this information.

Code 350: Nonresponse: No Response After Maximum Attempts should be assigned if there is

evidence that the sample member’s address or telephone number is viable but the sample



member has not responded after all questionnaire mailings or telephone attempts appropriate for

the given mode have been implemented.

Handling Blank Questionnaires

In handling questionnaires that are returned blank, vendors should differentiate between mail

survey questionnaires that are returned blank because the United States Postal Service could not

deliver the mail (referred to as undeliverables) and those returned blank by the sample member

or the sample member’s family or friend. The procedures described below are for surveys that

are returned blank and are not marked as undeliverable.

For the mail-only mode, it is appropriate to send a second questionnaire to the sample member if

the first questionnaire is returned blank, as long as it is mailed before the end of the data

collection period. If the second questionnaire is also returned blank, the vendor should assign a

final survey disposition code 320 – Refusal. If the first survey for the mail-only mode is never

returned and the second survey is returned blank, then that case should also be assigned a final

disposition code of 320 – refusal. If the first survey for the mail-only mode is never returned or

returned blank and the second questionnaire is not returned at all, the vendor should assign the

final survey disposition code 350 – No Response After Maximum Attempts. If any survey for the

a mail-only or mixed mode is returned with only supplemental questions marked (i.e., the OAS

CAHPS Survey Questions 1–37 are left blank), it is considered a “blank survey” as response data

for supplemental questions are not reported to the OAS CAHPS Data Center. Such a case should

be coded a 320 – Refusal.

Note that all cases that are not finalized as a result of the mail survey component of the mixed-

mode survey must be assigned for telephone follow-up. This means that unless the case was a

refusal or the sample member was determined to be ineligible for the survey during the mail

survey data collection phase of the survey, survey vendors should follow up with the sample

member by telephone. This includes cases for which the questionnaire was returned blank and

those for which the questionnaire was undeliverable. An exception to this rule is for “blank

surveys” coded a 320 – Refusal because only the supplemental questions have been marked in

the mail survey. Mail surveys meeting this criterion should not be contacted again (i.e., if in the

mail-only mode, a second questionnaire should not be sent to the sample member, and if in the

mixed mode, survey vendors should not follow up with the sample member by telephone).

Handling Proxy Cases

Proxies are not permitted on the OAS CAHPS Survey. However, it is possible someone other

than the sample member completes and returns the OAS CAHPS mail survey questionnaire.

There are two ways to determine a proxy case: the response to Question 37 is response option

“3 - Answered questions for me” (alone or in combination with other response options for that



question) or through a note written on or attached to the questionnaire. Exhibit 9.2 shows when a

case is a proxy based on the response provided for Question 37.

Exhibit 9.2 How to Determine a Proxy Case

Value for Q36 Is response option 3 to Question 37

selected? Proxy?

1 Yes Yes

2 Yes Yes

M Yes Yes

1 No No

2 No No

M No No

If a proxy case is identified, the vendor must not key or scan any of the responses provided

because no data can be accepted for a survey completed by a proxy. A proxy case must not be

assigned a disposition code of 110, 120, or 310. Instead, the vendor’s data receipt or data keying

staff should review the returned questionnaire for any information that could inform an

appropriate final disposition code. This must be based on the information provided in the

handwritten note (e.g., an indication that a family member completed the questionnaire because

the sample member died, moved to a nursing home, is mentally incapable of responding, or is

incarcerated). If there is no note indicating why the mail survey was completed by proxy and

Q37’s response option “3” is selected, the vendor should assign the final disposition code 320 –

Refusal to the case.

Quality Control Measures

Vendors are strongly encouraged to implement quality control measures for every aspect of mail

and telephone data processing activities. Required and recommended quality control measures

are described in detail in the mail, telephone, and mixed-mode data collection chapters of this

manual; however, we have repeated key measures here as well. Quality control measures are

listed by topic in the paragraphs that follow. Vendors should conduct additional quality control

measures as warranted, based on their individual processes. All quality control checks should be

conducted by a different person than the one who completed the task.

Quality Control for Mail Survey Data Processing Activities

• Vendors should review at least 10% of the printed questionnaires for each batch of

questionnaires that are printed each sample month to ensure the quality of the printed

questionnaires. The questionnaires should be examined to make sure there are no bleed-



throughs, which can impact or cause problems when scanning the data from completed

surveys, and to make sure all pages are included in the questionnaire.

• Vendors should check to make sure the number of mail survey packages to be mailed

matches the number of sampled cases.

• Vendors should check a sample of at least 10%of mail survey packages before they are

sealed and mailed. In this check, make sure that the SID number on the questionnaire

matches the SID number on the cover letter.

• For vendors that use scanning software for data capture procedures, select a sample of

questionnaires (minimum of 10 percent), rescan, and compare the scanned images against

the original hardcopy survey as a quality control measure. For vendors that use data

keying as their data capture process, all questionnaires should be 100% rekeyed by a

different keyer to ensure that all entries are accurate. If any discrepancies are observed, a

supervisor should resolve the discrepancy and ensure that the correct value is keyed.

• For coding, vendors should select and review a sample of cases coded by each coder to

make sure coding rules were followed correctly.

• We highly recommend before submitting data to the OAS CAHPS Data Center that

vendors compare the responses coded on the hardcopy questionnaire for a sample of at

least 10% of cases with the responses that were actually scanned or keyed and with the

responses entered on the XML file. This check will ensure that the responses included in

the XML files accurately reflect the sample members’ responses to the survey questions.

• We highly recommend that vendors calculate and review the response rates periodically

for each of their client HOPDs or ASCs. If a sample was selected for an HOPD or ASC

but there is no response or a very low response rate, this could be an indicator that

incoming mail was not processed, scanned data were not exported to the XML data file,

or other problems occurred with the mail survey. In instances where the number of cases

sampled was very small (e.g., 10 or fewer), it is possible that all of the sample members

decided not to return a completed survey. For HOPDs and ASCs with larger sample sizes,

no response from any of the sample members could be indicative of a data collection or

data processing problem.

• Vendors are urged to develop a way to measure error rates of both their data receipt staff

in terms of recognizing marginal notes and passing these on to someone for review and in

terms of data entry or scanning verification. Vendors should then work with their staff to

minimize error rates. The OAS CAHPS Survey Coordination Team will request

information about data receipt and processing error rates during site visits to survey

vendors.



Quality Control for Telephone Survey Data Processing Activities

• Vendors must silently monitor a minimum of 10% of all telephone interviews to ensure

that correct administration and coding procedures are being followed. Supervisory staff

monitoring telephone interviewers should use the electronic system to observe the

interviewer conducting the interview while listening to the audio of the call at the same

time.

• We highly recommend that vendors calculate and review the response rates on a periodic

basis for each of their client HOPDs and ASCs. If a sample was selected for an HOPD or

ASC but there is no response or a very low response rate, this could be an indication of a

data collection or data processing problem. In cases where the number of cases sampled

was very small (e.g., 10 or fewer), it is possible all of the sample members decided not to

participate in the survey. For HOPDs and ASCs with larger sample sizes, it is highly

unlikely that 100% of the sample cases will refuse to participate in the survey.


50 completed telephone interview responses directly from their CATI system to the

values output in the XML file. Doing this review monthly will ensure that the responses

are being accurately captured and output to the XML file.

• Vendors should generate and review frequencies of cases at the various interim and final

disposition codes for each HOPD and ASC and perhaps by telephone interviewer. For

instance, a high percentage of cases coded as “not available” after maximum attempts

could indicate that call attempts are not scheduled appropriately.

Quality Control on XML Files

• Vendors should use the XML validation tool to conduct an initial quality control of their

XML file formatting. The XML Schema Validation Tool is available on the OAS

CAHPS website through the “Data Submission Resources” link, under the “Data

Submission” menu.

• We highly recommend that vendors conduct some additional quality control measures on

the data included on XML files to ensure that the data from completed mail and

telephone surveys are being captured accurately. This includes running frequencies of

distributions on both the patient administrative data and the patient response data to look

for outliers or anomalies, including missing values.

Examples of frequencies vendors could run include the race variable (are all respondents

coded as Alaska Native, for example?) or the age variable (is there a reasonable

distribution of age categories across sample members, or do the ages lean heavily toward

the very young or very old?). By reviewing frequencies of both the patient administrative



data and the patient response data, vendors may be able to identify problems in the data

they receive from HOPDs and ASCs, their own facility data file processing, or their XML

coding operations.

• Vendors should periodically check their data processing programs to confirm that

variables on the XML files are coded properly on the XML file.

• Vendors should conduct a final check of the

disposition code assigned to all sampled

cases before submitting XML files to the

OAS CAHPS Data Center. If the vendor

identifies a case assigned either an

ineligible or noncomplete final disposition

code AND there are data included in the Patient Response Record section of the XML

file, they should check their records to determine why code 110, 120, or 310 was not

assigned to the case. If it is determined that the case is indeed ineligible or was a

noncomplete, remove the survey response data from the XML file.

• Vendors should select a random sample of

cases on the XML file and compare the

variables in the Patient Administrative Data

Record against the patient information that

was provided by the HOPD or ASC on the

original monthly patient information file to

make sure the information was exported to the XML file correctly.

Computing the Response Rate

Survey vendors are not required to compute a response rate for each monthly sample. However,

CMS will compute and report a response rate for each HOPD and ASC when survey results are

publicly reported. For a given public reporting period (i.e., the last four quarters of collected

data), a response rate for each HOPD and ASC will be calculated as described in Exhibit 9.3.

The information below is provided for illustrative purposes only.

The Patient Response Record section of the

XML file contains the responses to the OAS

CAHPS Survey from every patient who

answered the survey during the sample

month.

The Patient Administrative Data Record

section of the XML file contains data about

each patient who was sampled for the sample

month, including both those who responded to

the survey and nonrespondents.



Exhibit 9.3 How Response Rates Are Calculated

Response Rate =

Total number of Completed Surveys is the number of surveys assigned a final survey disposition code of

110 or 120.

Total Number of Surveys Fielded is the total number of patients selected for the survey in the sample

month. This includes all cases with a final survey disposition code of 110 through 350.

Total Number of Ineligible Surveys is the number of sample cases assigned a final survey disposition

code of 210, 220, 230, or 240. No other cases will be removed from the denominator.





X. THE OAS CAHPS SURVEY WEBSITE

Overview

This chapter presents an overview of the Outpatient and Ambulatory Surgery CAHPS Survey

(OAS CAHPS) website and the web portal within the website. This website is the official site for

the OAS CAHPS Survey with public and private sections. The private section is an interactive

site that supports the functionality needed by survey vendors, hospital outpatient departments

(HOPDs) and ambulatory surgery centers (ASCs) participating in the OAS CAHPS Survey. For

example, it contains procedural documents, survey materials, an online tool for data submission

and vendor authorization, and reports for vendors, HOPDs, and ASCs.

The OAS CAHPS Website

The OAS CAHPS Data Center is maintained by RTI International, which is assisting the Centers

for Medicare & Medicaid Services (CMS) with OAS CAHPS. RTI also developed and maintains

the OAS CAHPS website, available at https://oascahps.org/ . This website is the main vehicle

for communicating and updating information about OAS CAHPS to HOPDs, ASCs, and survey

vendors. The website has both public and secure (restricted-access) sections to ensure the

security and privacy of selected interactions. On the public page, a link to a login allows

authorized users (survey vendor, HOPD or ASC staff) access to the restricted private sections of

the website, where they can carry out administrative functions according to their role. Access to

the secure sections will be restricted and controlled through user identification and password.

Specifically, survey vendors will use the website to submit OAS CAHPS data to the OAS

CAHPS Data Center. It will also allow Medicare-certified HOPDs and ASCs to authorize their

contracted survey vendor to submit OAS CAHPS data on their behalf, access their data

submission reports, and review their OAS CAHPS Survey results before the results are publicly

reported. Exhibit 10.1 provides an overview of both the public and private links and information

available on the website. In the diagram, private links are shown in red text and public links are

shown in black text.


X. The OAS CAHPS Survey Website November 2018


Exhibit 10.1 OAS CAHPS Website Diagram

Public Links on the OAS CAHPS Website

The public side of the OAS CAHPS website is located at https://oascahps.org/ . This address

defaults to the public Home page, which is shown in Exhibit 10.2. Note that this is a secured

website; therefore, users should be sure to include the “s” in the “http” when accessing the site.

OAS CAHPS Web Portal Diagram

About OAS CAHPS Survey National Implementation and Public Rpt Mode Experiment Vendor Application Process Announcements Contact Us

General Information

Schedule Agenda Registration Training Slides

Training

Vendor Registration Minimum Business Requirements Vendor Application

* Exceptions Request Form

* Discrepancy Notification Form

* Model QA Plan Submit QA Plan

* Survey Vendor Authorization Report

* Manage Users

*

For Vendors

oascahps . org

OAS CAHPS Procedures Manual Questionnaire Sample Letters and Phone Scripts FAQs and OMB Disclosure Notice

Survey and Protocols

Data Submission Deadlines Sample File Download

* Data Submission Resources

Data Submission Tool

* Data Submission Reports

*

Data Submission

Facility User Registration Registered CCNs Report

* Manage Users

* Authorize a Vendor

* View Data Submission History

* Survey Preview Report

*

For Facilities

Vendor Approval Process

* Training Summary

* Vendor Authorization Status

* User Access Summary

* Data Submission Summary

*

Vendor Dashboard

Login

Required Action Items

* Registration Status

* Authorization Status

* User Access Summary

* Info for Dialysis Facilities

* Recent Announcements

* Data Submission Summary

*

Facilities Dashboard

- Publicly Available Pages and Links - Private Pages and Links requiring Login Authentication

*

Legend


November 2018 X. The OAS CAHPS Survey Website


Exhibit 10.2 OAS CAHPS Home Page (Public Website)

On the Home page, there is a welcome message that includes brief information about OAS

CAHPS. In that message, there are hyperlinks embedded in the underlined text that lead to other

pages that provide more specific information.

The OAS CAHPS website uses navigation features that include standard dropdown menus and

other navigation tools. A horizontal menu bar is displayed near the top of the Home page. The

bar has different tabs, each with its own dropdown options to allow users to perform various

functions and access more information. The navigation tabs include the following:

• General Information;

• Training;

• For Vendors;

• Survey Materials;

• Data Submission; and



• For Facilities.

The public pages on the OAS CAHPS website contain various links and information including

the following:

• Background information about OAS CAHPS, including information about the mode

experiment, national implementation, and public reporting;

• Requirements and a description of the application process for survey vendors interested

in becoming a CMS-approved OAS CAHPS Survey vendor;

• Contact information for the OAS CAHPS Survey Coordination Team (e-mail address and

toll-free telephone number);

• Survey questionnaires and related survey administration materials in English, Spanish,

Chinese, and Korean;

• Survey administration protocols, guidelines for data submission, and information about

the data submission tool (including this manual and the OAS CAHPS Survey Website

User and Data Submission Manual, Version 2.0);

• Vendor Registration Form, to be completed by the survey vendor’s designated Survey

Administrator; the Survey Administrator must complete this form so that he or she can

access and submit a Vendor Application to become a CMS-approved OAS CAHPS

Survey vendor;

• Minimum Business Requirements, a set of requirements survey organizations must meet

to be considered for approval for the OAS CAHPS Survey;

• Facility Administrator Registration Form, to be completed by the HOPD’s or ASC’s

designated OAS CAHPS Survey Administrator to create an account and credentials for

accessing links in the secure section of the website;

• Continuous updates in the Announcements section (shown in Exhibit 10.3), which is

under the “General Information” menu tab. These updates will provide vendors, HOPDs,

and ASCs with any new policies or changes in survey administration protocols and

procedures, announcements about updates to the Protocols and Guidelines Manual, the

Data Submission Manual, reminders of upcoming data submission deadlines, and

information about the annual training sessions;

• A Recent Announcements section also appears on the Home page (shown in Exhibit

10.4);



• A list of Approved Survey Vendors that may administer the OAS CAHPS Survey;

• Helpful documents for HOPDs and ASCs, including information about OAS CAHPS

participation process and guidelines, steps on Getting Started to participate in OAS

CAHPS, instructions on How to Authorize a Vendor on the OAS CAHPS website, and

Frequently Asked Questions (FAQs) for hospitals and ASCs;

• A copy of the most recent Hospital Outpatient Prospective Payment and Ambulatory

Surgical Center Payment Systems and Quality Reporting Programs Proposed or Final

Rule published on the Federal Register that HOPDs, ASCs, and vendors can reference

for OAS CAHPS participation guidelines;

• Information about the patient-mix coefficients and adjustments made for publicly

reported OAS CAHPS Survey Results (updated quarterly when results are refreshed on

data.medicare.gov); and

• Training information and materials for the annual Introduction to the OAS CAHPS

Survey Training and Update Training sessions, including a Training Information page

and Training Registration form.

Exhibit 10.3 Announcements Page on the OAS CAHPS Website



Exhibit 10.4 Recent Announcements Section on the OAS CAHPS Website Home Page

How to Obtain Access to the Private Side of the OAS CAHPS Website

All Users (Survey Vendors, HOPDs, and ASCs)

Designate an OAS CAHPS Survey Administrator. Before any participating HOPD, ASC, or

survey vendor can access the restricted portion of the website, the organization first must

designate a staff member to serve as its OAS CAHPS Survey Administrator. The designated

OAS CAHPS Survey Administrator’s roles and responsibilities are listed below.

• Complete the registration process on the OAS CAHPS website:

◦ For HOPDs and ASCs, this is a two-step process:

Step 1: Register as the Survey Administrator establishing login credentials for this

website; and

Step 2: Register the CCN(s) of the HOPD or ASC the Survey Administrator will be

responsible for;

◦ For vendors, register as the Survey Administrator establishing login credentials for

this website;

• Designate another individual within the organization to serve as the backup OAS CAHPS

Survey Administrator;

• Remove access or approve the removal of access for users who are no longer authorized

to access the private side of the website;

• Serve as the main point of contact with the OAS CAHPS Survey Coordination Team; and



• Notify the OAS CAHPS Survey Coordination Team if your role as the OAS CAHPS

Survey Administrator will no longer be valid and identify a successor.

HOPD and ASC Users

Step 1: The individual designated as the HOPD’s or ASC’s OAS CAHPS Survey

Administrator will complete and submit the Facility Administrator Registration Form. This

online form is located on the public side of the website. It is used to establish an account and

obtain credentials for accessing the secured sections of the website. To do this, click on the

“Register for Login Credentials” link under the “For Facilities” navigation tab on the OAS

CAHPS website (as shown in Exhibit 10.5).

The form will collect the OAS CAHPS Survey Administrator’s name, e-mail address, and

telephone number. The Survey Administrator will also be instructed to create a username and

password that will be used to access the secured links and forms on the private side of the

website. Once all information is correct, click the “Submit” button.

The OAS CAHPS Data Center will activate an account immediately after the online registration

form has been submitted. Once the registration form is submitted, users will be routed to a

personalized dashboard, where they can find the other forms required to complete the registration

process. Additional links to important functions and forms, including the Facility CCN

Registration Form and the Authorize a Vendor Form, are also available on the dashboard.



Exhibit 10.5 Facility Administrator Registration Form

Step 2: The OAS CAHPS Survey Administrator will complete and submit the Facility CCN

Registration Form. This online form is located on the private side of the website. The OAS

CAHPS Survey Administrator will enter their username and password to log in (see

Exhibit 10.6). The OAS CAHPS Survey Administrator will enter the CCN(s) for which they are

an administrator into the box. Multiple CCNs can be separated by commas. After the CCN(s) are

entered, click the “Lookup Facility Names” button and the system will automatically display the

facility or facilities name(s) in the display window.



Exhibit 10.6 Facility CCN Registration Form

The person filling out this form will be presented the list of roles and responsibilities of the OAS

CAHPS Survey Administrator. The OAS CAHPS Survey Administrator needs to personally

acknowledge that that he or she is the OAS CAHPS Survey Administrator for the listed

HOPD(s) or ASC(s), and acknowledge that he or she accepts the roles and responsibilities

for the listed HOPD(s) or ASC(s). Once all information is entered correctly, click “Submit.”

Step 3: The OAS CAHPS Survey Administrator will designate a backup OAS CAHPS

Survey Administrator and create an account for him or her. The backup OAS CAHPS

Survey Administrator will have all of the same permissions on the website as the primary OAS

CAHPS Survey Administrator. Having a backup Survey Administrator will ensure continued

access to the system if the primary Survey Administrator is unavailable or terminates

employment with the HOPD(s) or ASC(s). The Survey Administrator or the backup Survey

Administrator must notify the OAS CAHPS Data Center immediately if the primary Survey

Administrator will no longer serve in that role.

After logging onto the OAS CAHPS website, the form to designate a backup survey

administrator (User Details form) is available on the Facility Dashboard, under the menu item

“Manage Users Console.” Through this console (shown in Exhibit 10.7), the Survey

Administrator can add a new user, delete a user, or edit a user. The User Details form (shown in



Exhibit 10.8) collects contact information for the user and allows them to be linked with, or

unlinked from, any of the CCNs associated with the primary Survey Administrator.

The primary Survey Administrator can navigate to the User Details form by clicking on the

“Add New User” button on the Manage Users page, and then follow the steps described below to

complete the desired action.

To add a user, complete all fields on the form (username, first name, last name, e-mail,

telephone, role, and the CCN(s) this user will have access to).

The Role field is populated with one option: “Backup Administrator.” This will allow the

added user to have the same level of access on the OAS CAHPS website as the primary

Survey Administrator.

When all required fields are completed, click “Add User.”

This action will cause an e-mail notification to be sent to the added user. The e-mail will

contain the username that was entered on the User Details form and a temporary password.

The added user will be prompted to change his or her password the first time he or she logs

into the website.

If the user being added has existing login credentials, it will be important that the username

and e-mail address entered on the form matches the user’s existing account information. This

will link all CCNs for which the person should have access to the single set of credentials.

A message in a red box will appear on the screen indicating that the e-mail entered already

exists in the system. Before clicking “Confirm Add,” we encourage the Survey Administrator

(completing the form) to confirm directly with the user that the username entered matches the

user’s existing username. If it does match, click “Confirm Add.” If it does not match, correct

the username entered and then click “Confirm Add.”

The next time the requestee logs in, there will be a new table in the User Access section of

their Facility Dashboard showing the Pending Access Requests (see Exhibit 10.9). The user

can click on “Accept” or “Reject” for each request. After the user accepts or rejects the

request, an e-mail notification is sent to the original requestor (Survey Administrator) with an

update.



Exhibit 10.7 Manage Users Console

Exhibit 10.8 User Details Form



Exhibit 10.9 Pending Access Requests from Facility Dashboard

To remove a user’s access to the OAS CAHPS website (for all CCNs linked to his or her

account), the primary Survey Administrator will complete the process described here to delete a

user. First, navigate to the Manage Users Console, and then locate the person’s information in

the grid displayed on this page. Next, click on the red “X” ( ) to the left of the person’s

username. A pop-up confirmation message will appear. Click “yes” to confirm deletion.

Another way in which the Survey Administrator can delete a user’s access is by clicking on

the pen and paper icon ( ) in the far-left column of the individual’s row, and then clicking

“Delete” at the bottom of the form. A pop-up confirmation message will appear. Click “yes”

to confirm deletion.

To edit a user’s account, the Survey Administrator will navigate to the Manage Users Console

and then locate the person’s information in the grid displayed on this page. Next, click on the pen

and paper icon ( ) in the far-left column of the individual’s row. This will open a populated

User Details form with the user’s information that was initially entered on this form. All fields,

including the CCN(s) the user has access to, can be edited, except for the username field. Click

“Update” for the updates to be saved in the system.

If the user is granted access to an additional CCN(s), completing this action will cause an e-

mail notification to be sent to the added user requesting him or her to accept or decline access

to each CCN listed on the User Details form.

Step 4: The OAS CAHPS Survey Administrator or backup completes the Vendor

Authorization Form. After an HOPD or ASC has entered into a contract with a survey vendor,

the facility must authorize the survey vendor to submit data on its behalf before the survey

vendor can successfully submit data to the OAS CAHPS Data Center. Facilities should note that

survey vendors must submit their clients’ survey data (at minimum) on a quarterly basis to the

OAS CAHPS Data Center by the following deadlines: the second Wednesday in July, October,

January, and April. For further details, see Table 14.2 in Chapter XIV.



To authorize a vendor, the facility’s OAS CAHPS Survey Administrator must log in to the

secure website and proceed to the “Vendor Authorization” submenu under the “For Facilities”

tab. The sub menu provides three options for users:

• Start an Authorization;

• Delete an Authorization; and

• Authorization Report.

A brief description and the steps in each of these actions are provided below.

1. Start an Authorization. This is used by an HOPD or ASC user that is just beginning to

participate in OAS CAHPS and by an HOPD or ASC that is switching to another vendor.

The OAS CAHPS Survey Administrator will:

◦ Select an approved vendor from the dropdown list;

◦ Select the “Start Date,” which is the first day of the first calendar year quarter (either

January 1, April 1, July 1, or October 1) for which the vendor is being authorized to

submit OAS CAHPS data. For example, if a vendor is authorized to submit data

starting with the January, February, or March sample month, the Survey

Administrator should choose a Start Date of January 1;

◦ Select the CCN(s) to which the authorization applies; and

◦ Click the “Submit” button. The OAS CAHPS Survey Administrator will receive an e-

mail notification after the Start an Authorization form has been submitted.

To change or switch to a different survey vendor, the HOPD or ASC user will follow the

steps described above and assign a start date for the new survey vendor. The system will

automatically assign an end date for the existing authorization, based on the start date of the

new authorization. This will ensure that there are no gaps in authorization time periods.

The system will allow an HOPD or ASC to change a start date for multiple CCNs. To select

multiple CCNs, the OAS CAHPS Survey Administrator should check the box next to the

name of each CCN for which this vendor is authorized to submit data. The user should click

the “Submit” button to save the entries selected.

HOPDs and ASCs should note the following details regarding switching vendors:

◦ Whenever possible, HOPDs and ASCs should only switch vendors at the beginning

of a quarter. This is because data for every month in a quarterly submission must

come from a single vendor. Survey vendors may not submit data files after the data



submission deadline passes for a quarter; therefore, it is critically important that

HOPDs and ASCs make sure the Vendor Authorization form is current with a correct

start date for the new vendor, well in advance of the data submission deadline.

◦ The Vendor Authorization form is an authorization for OAS CAHPS Survey vendors

to submit data, not an authorization to conduct the survey. More than one vendor at a

time may collect data (in the chart below, note the overlapping times for Vendors A

and B to conduct the survey). However, only one vendor at a time can submit data.

Vendor A is collecting data for the February and March sample months, which falls

within the first quarter of 2019. Therefore, Vendor A should be authorized for

Quarter 1, 2019 (with a Start Date of 1/1/2019 and an End Date of 3/31/2019).

Vendor B, who is collecting data starting with the April 2019 sample month and

onward, needs to be authorized to submit data before the October 2019 data

submission deadline. Therefore, Vendor B should be authorized starting with Quarter

2, 2019 (with a Start Date of 4/1/2019 and no end date specified).

Sample month Begin data collection

End data collection

Quarterly data submission deadline to

OAS CAHPS Data Center

Authorization start date

(starting day of first calendar

quarter)

Authorization end date

(ending day of final calendar

quarter)

Vendor A Feb–March 3/21/2019 6/2/2019 7/10/2019 1/1/2019 3/31/2019

Vendor B April-and on 5/21/2019 No end date 10/9/2019 4/1/2019 No end date

2. Delete an Authorization. This function will allow an HOPD or ASC user to delete an existing

authorization. The reasons an HOPD or ASC may want to delete an authorization is to revise

its start date or revise it to show a different vendor. The system will allow an HOPD or ASC

user to delete authorizations for multiple CCNs, if needed. To delete one or more existing

authorizations, the OAS CAHPS Survey Administrator should follow these steps:

◦ Check the box next to each CCN for which the vendor authorization should be

deleted.

◦ Click the “Delete Checked Authorizations” button.

◦ A pop-up box will appear confirming that the selected authorization(s) should be

deleted. To proceed with the deletion, click “Confirm.”

To select a different start date or vendor after deleting the existing authorization(s), follow

the steps in Start an Authorization above.



3. Authorization Report. This function will allow HOPD and ASC users to view the list of

facilities for which a vendor has been authorized, the vendor’s name, and the start date for

each vendor. If, at any point, the HOPD or ASC switched vendors, the Authorization Report

will display the start and end dates for the different vendors.

Survey Vendors Users

Step 1: The individual designated as the survey vendor’s OAS CAHPS Survey

Administrator will complete an online Vendor Registration Form. This form is available

approximately 2 months before the annual OAS CAHPS Survey Vendor Webinar Trainings and

remains available until approximately 6 weeks after the trainings have concluded. During the

time when it is available, the Vendor Registration Form is located on the public side of the

website. To locate this form, click on the “Vendor Registration Form” link under the “For

Vendors” navigation tab on the OAS CAHPS website (as shown in Exhibit 10.10). When

completing the Vendor Registration Form, the vendor’s OAS CAHPS Survey Administrator will

establish an account and create credentials for accessing the secure sections of the website.

The form will collect the vendor’s OAS CAHPS Survey Administrator’s name, e-mail address,

and telephone number. The Survey Administrator will also be instructed to create a username

and password that will be used to access the secured links and forms on the private side of the

website, including the Vendor Application. Once all information is entered and correct, click the

“Submit” button.

Once it is submitted, the Survey Administrator will be routed to a personalized dashboard.



Exhibit 10.10 Vendor Registration Form

Step 2: Complete the Vendor Application. This form is located on the private side of the OAS

CAHPS Survey website. It is divided into four pages (or tabs). Vendors need to save each page

to proceed to the next. The application will time out after 60 minutes of inactivity. The OAS

CAHPS Survey Administrator can save and return to it as many times as needed. When the

application is complete and accurate, click “Submit” on the last page (or tab) to submit the

application. The Vendor Application appears in Appendix A.

After the application has been submitted, a new window will appear with a personalized copy of

the OAS CAHPS Survey: Vendor Survey Administrator Consent Form. This is a document on

which the person designated as the OAS CAHPS Survey Administrator will acknowledge that he

or she accepts the roles and responsibilities of the Survey Administrator for the listed survey

vendor. The Survey Administrator will print, review, sign, and date this form in the presence of a

Notary Public, and obtain the notary’s signature and seal on the form. Mail the notarized Consent

Form to the OAS CAHPS Survey Coordination Team at the address provided at the top of the

form.

Step 3: Periodically check the Survey Vendor Authorization Report. Survey vendors should

periodically check the Survey Vendor Authorization Report to ensure that each client HOPD or

ASC with which they have contracted has accurately completed the online Authorize a Vendor



form and that the Start Date the facility entered is correct. The Survey Vendor Authorization

Report is available on the Vendor Dashboard. HOPDs, ASCs, and survey vendors should note

that CMS will not allow OAS CAHPS vendors to submit data files after the data submission

deadline passes for a quarter; therefore, it is critically important that facilities authorize the

vendor and make sure that the Start Date is correct well in advance of a data submission

deadline.

User Dashboards and Access-Restricted Links

The private OAS CAHPS website menu options differ slightly from those on the public website.

In Exhibit 10.1, the items with an asterisk are accessible only on the private pages of the website.

Access to the secure sections will be restricted and controlled through a user identification and

password, created by the survey vendor, HOPD, or ASC Survey Administrator during the

registration process. Once logged into the website, OAS CAHPS Survey Administrators will be

routed to a personalized dashboard.

Each of the “Dashboard” views (Facility Dashboard and Vendor Dashboard) provides the user

with links to key items on the website, depending on the user.

Facility Dashboard

Each time the HOPD’s or ASC’s OAS CAHPS Survey Administrator logs into the website, he or

she will be taken to the Facility Dashboard (see Exhibit 10.11). Survey Administrators should

note that they can register additional HOPDs or ASCs at any time via the dashboard.



Exhibit 10.11 Facility Dashboard Page

The Facility Dashboard also includes:

• A Facility CCN Registration link that allows the HOPD or ASC to register the facility’s

CMS Certification Number(s) (CCNs);

• An Authorize a Vendor link that allows the selection of a CMS-approved survey vendor

to submit data on behalf of the HOPD or ASC;

• A Manage Users Console link, where the Survey Administrator can add or delete

authorized users for certain functions on the website; and

• Recent announcements posted on the website.

HOPDs and ASCs are responsible for checking the web announcements displayed both on their

dashboard or the OAS CAHPS Home page regularly for updates.

Vendor Dashboard

Each time the survey vendor’s OAS CAHPS Survey Administrator logs into the website with the

login credentials created during the registration process, he or she will be taken to the Vendor

Dashboard (see Exhibit 10.12). From the dashboard, survey vendors can complete and submit



the Vendor Application and OAS CAHPS Survey: Vendor Survey Administrator Consent Form.

A Vendor Application must be completed to be considered for approval as a CMS-approved

survey vendor. The OAS CAHPS training session(s) in which the user registered to attend is also

displayed on the Vendor Dashboard.

The Vendor Dashboard also includes the following tools or links:

• Manage Users Console, where the Survey Administrator can add or delete authorized

users on the website;

• Training Certification Exam, which will be available for a period of time after the OAS

CAHPS training sessions conclude; and

• Survey Vendor Authorization Report.

Exhibit 10.12 Vendor Dashboard Page

System and Security Requirements for the OAS CAHPS Website

Approved survey vendors will submit or upload OAS CAHPS Survey data to the OAS CAHPS

Data Center through a link on the OAS CAHPS website. The security level for users’ browser

Internet zone must be set to the equivalent of medium or lower, at least during the time that they

are working in the project website.



Data Security

OAS CAHPS Survey vendors are required to submit only de-identified data files to the OAS

CAHPS website. This means that no personally identifiable patient information can be included

in the data files that are submitted to the OAS CAHPS Data Center. Vendors are required to

assign a unique sample identification (SID) number to each sampled patient. The data submitted

must include an SID number for each patient included in the sample, regardless of whether the

sample member completed the survey. More information about assigning a unique SID to each

sampled patient is included in Chapter IV.

Even though only de-identified data will be submitted to the OAS CAHPS Data Center, every

measure will be taken to protect and secure OAS CAHPS data. Ensuring data security was a

concern and consideration during the design and development of the OAS CAHPS website. Data

are encrypted whenever vendors upload their data files. The OAS CAHPS Survey Coordination

Team has implemented a number of policies and procedures to ensure that all communications

and transfers are secure. Among these measures are the following:

• requiring that each individual provided access to the private links on the website have a

secure login;

• using Secure Sockets Layer (SSL) technology to encrypt files for transmission; and

• carefully monitoring uploads, upload attempts, and website use in general.

When users log into the private links on the website, the system will automatically check and

authenticate their credentials before allowing access. This ensures that only authorized users are

able to log into the system.

In addition to allowing only credentialed users access to the private links on the website, all

electronic data are stored behind a firewall in a password-protected network. All data traffic

between the vendor’s network and the Internet pass through this single connection point. This

process provides the same level of protection and monitoring to all systems connected to the

vendor’s network. The website firewall is programmed to allow or prevent access to the network

by using a set of rules to determine whether attempted network access is in compliance with the

OAS CAHPS Data Center’s network security policy. In addition, the firewall logs all incoming

traffic to help detect and analyze any problems or suspicious activity.

Survey Vendor’s Website Security Responsibilities

All OAS CAHPS Survey vendors must go through an application and certification process to

participate in the survey. In addition, vendors must agree to strict requirements to continue their

participation. By following the security procedures identified for the project, survey vendors will



protect their client HOPDs’ and ASCs’ data and those of other vendors participating in OAS

CAHPS.

All OAS CAHPS Survey vendors must also abide by all requirements set forth in the Health

Insurance Portability and Accountability Act of 1996 (HIPAA), legislation intended to protect

private health information and to improve the efficiency of the health care system. The type of

patient information that is protected under HIPAA is called “protected health information” or

PHI. PHI is defined as personally identifiable information (PII) that relates to a person’s past,

present, or future health or medical treatment. If the health information is completely de-

identified, it is no longer considered PHI and can be released. HIPAA applies to all electronic

and hardcopy records whether they are being stored or transmitted.

OAS CAHPS Survey vendors must safeguard all data collected from patients as required by

HIPAA. However, survey vendors will not submit any confidential information to the OAS

CAHPS Data Center as all of data file submissions will contain only de-identified data. Even

with de-identified data files, vendors must still use security measures to keep the data as safe as

possible. This means that when issued credentials to access the private links on the project

website, survey vendors also must follow all safeguards to prevent an unauthorized person from

entering the private side of the website. Therefore, the OAS CAHPS Data Center has password

protected the private side of the website and requires that approved survey vendors, HOPDs and

ASCs use the following guidelines when creating and maintaining their password:

• When an OAS CAHPS Survey vendor’s, HOPD’s, or ASC’s account is approved, the

user will be able to log into the system using the username and password submitted on

the online registration form.

• All users are encouraged to create and use a strong password.

• Each account will be locked out after five successive incorrect password entries. If the

account is locked, the user will need to contact the OAS CAHPS Survey Coordination

Team to have the account unlocked.

• If a password reset is initiated (i.e., the user clicks on “Reset Password” on the Login

screen and follows the instructions to have a password reset link sent via e-mail), the user

will have 24 hours to complete the password reset before it becomes inactive.

• If a user’s password is compromised or lost, contact the OAS CAHPS Survey

Coordination Team immediately to ask that the account be deactivated. The Coordination

Team will then issue new credentials to the user.



Website Password Generation and Protection

As indicated, data security is of utmost concern to the OAS CAHPS Survey Coordination Team.

When survey vendors, HOPDs, and ASCs generate a password to access the private links on the

project website, they must develop a strong password. A strong password is defined as one that

contains at least nine (9) characters. These nine characters must include the following:

• one upper-case alphabet letter,

• one numeral, and

• one special character (&,%,#,!).

An example of a strong password is Mgh0721$&; it meets the required criteria shown above.

These password rules and guidelines are designed to minimize the chance that automated

password-cracking routines used by unauthorized personnel can gain access to the website. In

addition to the above rules, the following guidelines will help create a strong password:

• Combine two or more related words with punctuation, such as Radio-Cook.

• Use a password that looks like nonsense but allows an easy way to remember it, such as

“Thaawtsom.” for “The hills are alive with the sound of music.” (Note the end

punctuation.)

• Think in terms of vanity license plates, such as “I8myfood.”

The following should be avoided when creating a password; therefore, do not use:

• a single English word;

• a scientific name, biological term, geographic name;

• a person’s name or part of name, even with slight modifications like an added character at

the end or beginning;

• known combinations (e.g., NLRB 1234, attorney1, judge111);

• words found in a dictionary, including names, obscene words, or well-known phrases;

• a password with a repeating series of characters;

• reverse spellings of dictionary words;



• a name associated with the user in any way (middle name, family names, pet’s name,

sports team name, films, etc.);

• portions of a User ID on the current or other systems; or

• simple keyboard patterns (e.g., “asdfjkl.”).

In addition, a user should never write down his or her password. If the user needs to store

passwords, there are free applications that can be downloaded and used. An application like this

can be very helpful because another password safety rule is to never use the same password

across applications or computers. Finally, do not share or give the password to anyone. OAS

CAHPS Survey vendors, HOPDs, and ASCs are responsible for all access to the private links on

the project website that are made under their credentials.

What To Do If a User Forgets the Password

If a user forgets his or her password, he or she will need to reset his or her password to access the

private side of the OAS CAHPS website. To reset the password, simply click on the “Reset

Password” button on the Login screen on the OAS CAHPS website. The user will need to

provide the registered username and then click “Send Reset Link.” An e-mail with a link to reset

the password will be sent to the user’s registered e-mail address. By clicking on the password

reset link in the e-mail, the user will be taken to a page to create a new password.

For security reasons, a password reset is valid for only 24 hours. Therefore, it is important that

the user attempts to log in and reset his or her password as soon as possible after clicking on the

“Send Reset Link” button.





XI. FILE PREPARATION AND DATA SUBMISSION

Overview

Survey vendors will construct and submit a data file containing three sections: (1) a Header

Record, (2) a Patient Administrative Record for every sampled case, and (3) a Patient Response

Record for every completed survey in each monthly Outpatient and Ambulatory Surgery CAHPS

(OAS CAHPS) Survey sample. Vendors will submit data files for each of their client hospital

outpatient departments (HOPDs) and ambulatory surgery centers (ASCs) through the OAS

CAHPS website. Data for all three monthly samples in a calendar quarter must be submitted by

the data submission deadline.

Quarterly Data Submission Deadlines

Survey vendors have the option of submitting a data file to the OAS CAHPS Data Center as data

collection and processing activities for each monthly sample are completed or on a quarterly

basis. However, the data file for all months in a specific quarter for each client HOPD or ASC

must be submitted before the submission deadline for that quarter.

OAS CAHPS Data Center will check all data files immediately after they are submitted to ensure

that they pass the initial verification checks. Any files in which problems are detected or that do

not comply with file specification requirements will not be accepted. Survey vendors are

strongly encouraged to submit data files well in advance of a data submission deadline in case

there are problems that must be corrected. Survey vendors are also strongly encouraged to check

the Data Submission History Report or the Data Submission History by Upload Date Report that

are posted on the website (these reports are discussed in the next chapter) to ensure that the files

pass all validation checks and are accepted.

Data File Preparation

OAS CAHPS Survey vendors will submit XML data files for each HOPD or ASC that has

authorized the vendor to collect and submit data on its behalf. OAS CAHPS data files must

contain a record for each sampled patient at the HOPD or ASC for each sample month. Survey

vendors will submit data at least once each quarter by uploading individual .xml files or a zipped

file containing multiple XML files on the OAS CAHPS website. During the data file upload

process, the survey vendor’s data are encrypted until they are received by the OAS CAHPS Data

Center and checked for errors. This means that the data will remain secure from the beginning of

the upload process onward.

XI. File Preparation and Data Submission November 2018


The data file submission steps that survey vendors will follow to submit OAS CAHPS data files

are shown below.

1. Format and prepare survey data following the XML file specifications.

2. Submit data file(s) via the OAS CAHPS website.

3. Review and follow up on Data Upload Reports.

Each of these steps is described in the following sections.

Step 1: Format and Clean Survey Data Following the XML File Specifications

Each XML file should contain data for one sample month collected for all HOPD or ASC

locations that operate under a CMS Certification Number (CCN). The standard OAS CAHPS

XML file structure is included in Appendix K. If disproportionate stratified random sampling

(DSRS) is used, survey vendors must use the XML file specifications for DSRS, which are

provided in Appendix L. Both XML file structure templates are also available for download

under “Survey Materials” on the OAS CAHPS website. The specifications in that document

contain details about the data to be submitted such as data type, field sizes, and order. Survey

vendors should format each OAS CAHPS data file to match those specifications. The XML

templates were developed based on data elements needed for analysis and on the OAS CAHPS

questionnaire.

The XML file format will allow data for all patients sampled during a given sample month to be

submitted in one file.

XML Data File Specifications

OAS CAHPS Survey vendors must submit data using the XML format only. Survey vendors that

need assistance with the XML format should contact the OAS CAHPS Survey Coordination

Team for technical assistance at 1-866-590-7468 or by sending an e-mail to [email protected].

Each OAS CAHPS XML file will consist of three sections: a Header Record, a Patient

Administrative Data Record, and the Patient Response Record. Each of these sections is

described below. There should be only one Header Record for each XML file. Each sampled

patient should have an administrative data record, whether they completed the survey or not. A

survey response record must be included for every sampled patient who completed the survey

questionnaire (via mail (with code 110) or telephone (with code 120)) and who partially

completed the survey questionnaire (with code 310).

https://homehealthcahpsstage.rti.org/AppL.pdf


November 2018 XI. File Preparation and Data Submission


Header Record

The Header Record contains the following data elements:

• Header Type. This is the type of Header Record (standard, DSRS, or zero sampled).

• Provider Name. This is the HOPD’s or ASC’s Provider Name.

• Provider Number. This is the HOPD’s or ASC’s CCN.

• Sample Year. This is the calendar year in which the survey is conducted.

• Sample Month. This is the calendar year month for which the sample was selected.

• Mode of Survey Administration. The survey mode—mail-only, telephone-only, or

mixed mode—must be the same for all sample members in each sample month in the

calendar quarter for all of the HOPD or ASC locations under the same CCN. HOPDs,

ASCs, and their survey vendors cannot change survey administration modes until a new

quarter begins. Also note that the survey mode indicated in the Header Record must be

one of the modes that the survey vendor is approved to use. If the mode is not one of the

modes for which the vendor is approved, the OAS CAHPS Data Center will not accept

the data file when the vendor attempts to submit it.

• Type of Sampling. This is the sampling method that was used to select the sample—

these include census, simple random sampling (SRS), stratified systematic sampling

(SSS), proportionate stratified random sampling (PSRS), and DSRS. See Chapter IV for

information about each of these methods.

• Number of Patients Served. The total number of patients served is used to estimate the

sampling rate and for quality control checks. CCNs that contain multiple locations should

note that this value should reflect the total number of patients served across all eligible

locations. If eligible hospitals or ASCs served no patients during the sample month, enter

zero for this variable on the data file. See the following additional criteria for determining

the number of patients served:

◦ Determining Number of Patients Served in Hospitals: This count should be taken

from the hospital outpatient department or other specialized departments that perform

outpatient procedures and surgeries. These departments (1) must perform procedures

that are within the OAS CAHPS-eligible range of CPT-423

Codes for Surgery (i.e.,




CPT codes between 10021- 69990) or one of the following G-codes: G0104, G0105,

G0121 or G0260; (2) must be Medicare-certified and have a CMS Certification

Number (CCN); (3) must bill under the Outpatient Payment Prospective System

(OPPS) using CMS-1450 claim form for provider-based offices (not CMS-1500 claim

form used for the Physician Fee Schedule), with the exclusion of emergency

department procedures; and (4) have an agreement with CMS and meets the general

conditions and requirements in accordance with 42 CFR 419 subpart B.

To calculate the total number of patients served, hospitals should begin by including all

patient records that were billed through OPPS using CMS-1450 claim form but then only

count each patient one time. If a procedure took place in an eligible department, but the

patient was admitted as an inpatient rather than being discharged to home, then the

patient record would not be counted. If a patient has two procedures in a month, only one

patient record should be counted. Patient records come from an eligible department and

only include procedures that fall within the CPT-4 Codes for Surgery range or the G-

codes listed above. This count would also include patient records that could later be

determined to be ineligible, for example, because the patient is deceased or was

discharged to hospice.

◦ Determining Number of Patients Served in ASCs: To calculate the total number of

patients served, ASCs should include all patients who had at least one outpatient

surgery or procedure during the sample month that falls within the CPT-4 Codes for

Surgery range of 10021-69990 or the following G-codes: G0104, G0105, G0121, or

G0260. An ASC must (1) be Medicare-certified and have a CCN; (2) bill under ASC

Payment System; and (3) have an agreement with CMS and meets the general

conditions and requirements in accordance with 42 CFR 416 subpart B. If a patient

has two procedures in a month, only one patient record should be counted. This count

would also include patient records that could later be determined to be ineligible, for

example, because the patient is deceased or was discharged to hospice.

• Number of Patients on the File Submitted by the HOPD(s) or ASC(s). As discussed

in Chapter IV, the HOPD or ASC must provide the survey vendor with a list of all

patients who received at least one outpatient procedure at the HOPD or ASC during the

sample month, with the exception of patients who are deceased, are not 18 years old or

older, were discharged after their procedure to hospice, currently reside in a nursing

home, are prisoners, cannot be surveyed because of state regulations, or requested that the

facility not release their name to anyone outside that facility. The vendor should count the

number of patients that the facility supplies and indicate that number on the data file for

the sample month. This value should reflect patients across all eligible HOPD or ASC

locations under the same CCN. Note that if the HOPD or ASC did not serve any

patients during the sample month, the vendor must still submit a data file for that



sample month using the zero sampled XML data file template (in Appendix M). This

data file template is available for download under “Survey Materials” on the OAS

CAHPS website. The HOPD or ASC must, therefore, still submit a file to its vendor

showing that there were zero eligible patients. If the HOPD or ASC did not serve any

patients during the sample month, enter zero for this data element on the data file.

• Number of Eligible Patients. This is the number of patients in the file submitted by the

HOPD or ASC that meet survey eligibility criteria in the sample month. This value

should reflect patients across all eligible HOPD or ASC locations under the same CCN.

This value can be zero only if none of the patients on the file provided by the HOPD or

ASC for the sample month was eligible for the survey.

• Number of Patients Sampled. This is the number of patients selected for the survey

during the sample month. This value can be zero only if all of the patients included on the

file that the HOPD or ASC provided for the sample month were ineligible for the survey.

If a value of zero is entered for this variable, the value for the Number of Eligible Patients

variable must also be zero.

If DSRS is used, the survey vendor must use the XML file specifications intended for DSRS,

which are included in Appendix L and available for download under “Survey Materials” on the

OAS CAHPS website. The DSRS XML has these extra data elements in the Header Record,

including:

• DSRS Stratum Name (note that there must be at least two strata identified for DSRS

sampling).

• DSRS Number of Patients on file submitted to vendor, which is the number of patients

included on the file that all of the HOPD or ASC locations that share a CCN provided for

this stratum.

• DSRS Number of Patients eligible in stratum, which is the number of patients who

meet survey eligibility criteria within each stratum.

• DSRS Number of Patients sampled in stratum, which is the number of patients

sampled within the stratum.

Please remember that approved OAS CAHPS vendors must complete and submit an Exceptions

Request Form to the Coordination Team prior to conducting DSRS sampling (see Chapter XV

for more information about the Exceptions Request Form). If a vendor submits a data file with a

DSRS Header Record and does not have prior approval for using DSRS, the data file will be

rejected. More information about DSRS and requirements for DSRS sample selection and file

construction is provided in Chapter IV.



Patient Administrative Data Record

The second section of the XML file contains data about each patient who was sampled for the

sample month, including both those who responded to the survey and nonrespondents. Any

patients who were deemed ineligible during the sampling process should not be included in the

XML file. For example, the vendor determines a patient is under 18 when creating the sampling

frame for the May sample month. In this case, that patient record would be flagged as ineligible

for the OAS CAHPS Survey, not included in the sample frame, and not included in the May

XML file to the OAS CAHPS Data Center.

In this section of the data file, some of the information provided in the Header Record is

repeated, including the HOPD’s or ASC’s CCN, the Sample Year, and Sample Month. All other

information included in this section of the file is about the patients included in the sample. There

must be a Patient Administrative Data Record for every patient sampled in the sample month.

Only de-identified data will be submitted to the OAS CAHPS Data Center; however, the unique

sample identification (SID) number that the survey vendor assigned to the sample member must

be included on the file. Files submitted with missing or duplicate SID numbers will be rejected.

Most of the information required in the Patient Administrative Data Record is provided by, or

derived from, information the HOPD or ASC submits to the vendor on the monthly patient

information file. The Patient Administrative Data Record will include the following data

elements for each sampled patient. See Appendix K for instructions and coding specifications for

each element.

• Provider Number. This is the HOPD’s or ASC’s CCN.

• Sample Month. This is the calendar year month for which the sample was selected.

• Sample Year. This is the calendar year in which the survey is conducted.

• Sample ID Number. This is the unique de-identified SID number the survey vendor

assigns to the sampled patient record. Additional information about the guidelines

surrounding a SID can be found in Chapter IX.

• Surgical Category. The survey vendor will classify each patient’s surgery one of the

four surgical categories according to the CPT24

or G-code. The four surgical categories

are gastrointestinal, orthopedic, ophthalmologic, or other. The categories are defined as

follows:




◦ Surgical category 1 (Gastrointestinal) 40000–49999 or G0105, G0121, or G0104

◦ Surgical category 2 (Orthopedic) 20000–29999 or G0260

◦ Surgical category 3 (Ophthalmologic) 65000–68899

◦ Surgical category 4 (Other) 10021–19999, 30000–39999, 50000–64999, and 68900–

69990

OAS CAHPS Survey vendors may receive patient records from their client HOPDs or

ASCs with multiple, survey-eligible CPT codes from different surgical categories. When

this happens, vendors should use the primary code if the facility can identify the primary

code. If not, then the vendor should use the first CPT code that is OAS CAHPS Survey-

eligible to identify the surgical category.

Below are two examples of CPT codes, their corresponding surgical categories, and how

to handle categorizing the record in the XML data file:

◦ 40701 (Gastrointestinal), 69436 (Other) Record as Surgical Category #1.

◦ 69631 (Other), 20926 (Orthopedic) Record as Surgical Category #4.

There may be instances when an HOPD or ASC cannot provide procedural codes (CPT

Codes and G-Codes) for all of the patient records included in the monthly patient file by

the vendor’s sampling deadline. When this happens and an alternative method for

determining eligibility for these cases is identified and approved by CMS (via an

Exceptions Request Form), the vendor should work with the facility to identify how the

cases should be coded for the “Surgical Category” variable. See Chapter IV for

additional information on the protocols for handling missing procedural codes. If the

facility is unable to determine an alternate method of determining eligibility, the vendor

should work with the facility to determine which “Surgical Category” is appropriate. For

example, if the facility can determine that the cases with missing procedural codes were

pulled from the Orthopedics department, then assign the cases to “Surgical category 2

(Orthopedic).” In this example, if the facility cannot identify a department or another

method that would determine how the cases should be classified, assign the cases to

“Surgical category 5 (Missing).”

• Patient Age. The vendor will calculate the sample member’s age based on the date of

birth provided by the HOPD or ASC. If a sampled patient has an unknown date of birth

(because it was not provided by the facility but meets the other eligibility criteria and is

considered eligible), the vendor is unable to calculate the patient’s age and should apply

code “M” (Unknown/Missing) for this variable.



• Gender. This is the patient’s gender as indicated on the facility’s monthly patient

information file. If a sampled patient’s gender is unknown, the vendor should apply code

“M” (Unknown/Missing) for this variable.

• Survey Mode. The Survey Mode included in the Patient Administrative Data Record is

the data collection mode the patient used to complete the survey, either mail (code “1”) or

telephone (code “2”). The Survey Mode variable must only be coded a “1” for mail if one

of the following two criteria are met: the mail questionnaire was returned and is a

completed survey (code 110), or it is considered a breakoff (code 310). The Survey Mode

variable must only be coded a “2” for telephone if one of the following two criteria are

met: the vendor spoke to the sampled patient by phone and the interview resulted in a

completed interview (code 120), or a breakoff (code 310). Because a value is required for

this variable, there may be instances when the code for Not Applicable (“X”) is needed

(i.e., all scenarios where the survey does not result in a complete (code 110 or 120) or a

breakoff (code 310)). For example, if the mail questionnaire is never returned, is received

blank, or if the sample member is never reached by phone, or the telephone interview is

never initiated, the Survey Mode variable should be coded “X” (Not Applicable).

• Lag Time. The survey vendor will also compute and provide the Lag Time, which

reflects the number of days that elapsed between the date of surgery and the date the

survey was initiated for that patient.

• Final Survey Status. This is the 3-digit disposition code, or status code, assigned by the

survey vendor to indicate the final status of the sampled patient record. A list of OAS

CAHPS Survey final disposition codes and code descriptions can be found in Table 9.1.

• Survey Language. The Survey Language included in the Patient Administrative Data

Record is the identified approved language in which the patient completed the survey,

either English (code “1”), Spanish (code “2”), Chinese (code “3”), or Korean (code “4”).

The Survey Language variable must be coded a “1,” “2,” “3,” or “4” if one of the

following two criteria are met: the mail survey or telephone interview resulted in a

completed survey (code 110 or 120, respectively) or a breakoff interview (code 310) in

one of the approved languages. Note: If the survey was administered by telephone, the

Survey Language variable must be coded either a “1” or “2,” since the OAS CAHPS

telephone survey is only available in English and Spanish. Because a value is required for

this variable, there may be instances when the code for Not Applicable (“X”) should be

applied (i.e., all scenarios where the mail survey or telephone interview does not result in

a complete (code 110 or 120, respectively) or a breakoff (code 310)).



Patient Response Record

The third section of the XML file is the Patient Response Record, which contains the responses

to the OAS CAHPS Survey from every patient who answered the survey during the sample

month. Note that only the OAS CAHPS Survey questions should be submitted. Do not

submit responses to non-OAS CAHPS questions (i.e., supplemental questions) that were

added by the HOPD or ASC. The only records that should be included are those with a final

Survey Status code for a completed survey (Codes 110 and 120) and those with Code 310

(BreakOff). For all patient response records that are included on the file, all response fields must

have a legitimate value, which can include “Missing” or “Not Applicable.”

The decision whether to key the responses to the two open-ended survey items―“Other

language” (response option 2) in Q35 and “Helped in some other way” (response option 5) in

Q37―is up to each individual HOPD or ASC. Vendors should not include responses to open-

ended survey items on the data files submitted to the OAS CAHPS Data Center. CMS, however,

encourages survey vendors to review the open-ended entries so that they can provide feedback to

the OAS CAHPS Survey Coordination Team about adding additional preprinted response

options to these survey items, if needed.

Step 2: Data File Submission

OAS CAHPS vendors should follow the steps outlined below for submitting data via the OAS

CAHPS website. Additional information on the data submission tool and process can be found in

the OAS CAHPS Survey Website and Data Submission Manual, Version 2.0.

1. Login to the OAS CAHPS website; when logged in, the system will display the vendor’s

dashboard.

2. Click the “Submit Data” link under “Data Submission.” The data submission tool page

will display (as shown in Exhibit 11.1).

3. Click the “Select” button to select the file to upload. The Select button permits users to

locate and directly upload a file that has been saved in their own computer system.

Survey vendors can select either a single XML file or a single ZIP file that contains

multiple XML files.

4. After selecting the file to be uploaded, click “Upload XML” to submit the file. The

Validation Results Report based on the file selected will appear. A link to this report will

also be e-mailed to the vendor’s OAS CAHPS Survey Administrator.

5. To upload more than one file at a time, click the “Add” button on the same screen.

Additional file selection rows will be added. Repeat Step 3 above for each file to be

uploaded.



6. To remove rows that have been added, click the “Remove” button to the right of the row

to be deleted.

Exhibit 11.1 Link to Data Submission Tool

Exhibit 11.2 shows how the screen looks when submitting multiple files.

As the upload begins, the XML file will undergo validation checks. The first check will

determine whether the CCN(s) in the Header Record and the Patient Administrative Data Record

are aligned for the client HOPD’s or ASC’s authorized survey vendor and the facility’s CCN.

The next validation checks will determine the quality and completeness of the data.

If the file fails any of the validation checks, the survey vendor will receive an error message

within seconds after a file error is detected noting that the file upload failed, giving details on

why the file failed to upload. For example, the message may indicate that there is no

authorization from the HOPD or ASC for the survey vendor to submit data on its behalf or that

the number of patient records listed in the Header Record does not match the number of sample

members for which data are provided in the Patient Administrative Data Record section of the

file.

If a file does not pass the upload validations, none of the data on the file are accepted or stored

by the OAS CAHPS Data Center. Survey vendors must review data submission reports

(discussed in Chapter XII and the OAS CAHPS Survey Website and Data Submission Manual,

Version 2.0) and correct any data errors on the XML file and resubmit the file. CMS will not

accept data files that are submitted after the quarterly data submission deadline. We strongly

encourage survey vendors to submit their data files well in advance of the data submission

deadline for a survey period. Survey vendors can resubmit a data file for an HOPD or ASC client

as many times as needed prior to the data submission deadline However, if a data file for a

sample month is submitted more than once, the most recent submission overwrites the data file

previously submitted for that facility for that month , even if those files “passed” all checks.



Therefore, the final file submission must contain data for all patients who were sampled in

that sample month for all HOPD or ASC locations under a specific CCN.

Exhibit 11.2 Uploading Multiple Files

Step 3: Review and Follow Up on Data Upload Reports

There are three data submission reports that are available to survey vendors via the OAS CAHPS

website. These reports inform survey vendors about the outcome of each of the vendor’s data file

upload attempts, and they also provide the vendor with a history of upload efforts. The three

reports are listed below:

• Validation Results Report;

• Data Submission History Report; and

• Data Submission History by Upload Date Report.

Each of these reports is described in detail in Chapter XII.

Potential Situations When Vendors Will Not Submit Data

If there is an active survey vendor authorization in place (explained in Chapter X, Step 4), the

OAS CAHPS Data Center will expect the survey vendor to submit data for the contract HOPD

or ASC for every quarter. If the survey vendor fails to submit, the HOPD or ASC may be

considered noncompliant for that quarter.

However, there are situations when a survey vendor will not be able to submit data. The

paragraphs below describe those situations and provide guidance to survey vendors on how to

proceed.



Survey Not Yet in Effect or Survey Not Administered

Survey vendor authorizations (described in Chapter X) remain in effect until they reach the end

date (if any) of the authorization period. Should an HOPD or ASC authorize a vendor for Quarter

1 beginning in January, yet begin collecting data mid-quarter (for example, March), the elapsed

months between quarter start and survey start (in this example, January and February) will not

have survey data. Starting data collection mid-quarter is permitted on the OAS CAHPS Survey;

however, HOPDs and ASCs should not switch vendors in the middle of a calendar year quarter,

unless it is a situation of new ownership or other extenuating circumstances. Please note the

following guidelines for starting data collection mid-quarter:

1. If the HOPD or ASC is authorizing a vendor for the first time: The HOPD or ASC

should simply complete the online vendor authorization form by selecting the survey

quarter during which the vendor will start submitting survey data on their behalf. The

authorized vendor will begin collecting data the month that it is instructed to do so by its

client, and within the survey quarter it has been authorized. The vendor will not need to

submit a Discrepancy Notification Report (DNR) for any month(s) it was not authorized

to collect data. For example, if an HOPD or ASC begins participation with the March

sample month, the authorized survey vendor will collect and submit data for that sample

month. The vendor does not need to submit a DNR for January or February (in this

example). This only applies to the quarter for which the vendor was first authorized; after

it is authorized, the vendor will need to submit a DNR for any unplanned deviations

moving forward (i.e., a DNR is required if a CCN is already participating but misses

administering the survey for any month). Additional information on when a DNR should

be submitted can be found in Chapter XV.

2. If the HOPD or ASC is switching vendors mid-quarter: Manual vendor authorization

changes are required when an HOPD or ASC switches vendors mid-quarter. This ensures

that only one vendor is authorized for a CCN and there are no gaps in participation. The

affected facility must contact the OAS CAHPS Survey Coordination Team via e-mail to

formally request a manual vendor authorization change. The facility should include its

name, CCN, reason for the mid-quarter switch, the previous vendor’s name, end date for

its authorization, new vendor’s name, and start date for its authorization. Please note that

HOPDs and ASCs are encouraged to wait until the end of a quarter before switching to a

new vendor.

Closed CCN or Closed Location Within a CCN

If an HOPD or ASC closes or is no longer active while its OAS CAHPS vendor is still contracted

to conduct and provide survey data on its behalf, the vendor authorization that that HOPD or

ASC submitted will remain in effect for the entire authorization period. It remains in effect until

either the facility’s OAS CAHPS Survey Administrator modifies the end date of the vendor



authorization, or, alternatively, until the OAS CAHPS Survey Coordination Team marks the

CCN as inactive. Inactive HOPDs or ASCs are viewable on the Survey Vendor Authorization

Report and are designated with an asterisk (*) symbol.

If the CCN remains active but one of the HOPD or ASC locations or entities within it closes, the

remaining active location(s) should continue participating in OAS CAHPS.

Data Submission Quality Control

The following issues and guidelines are provided to assist vendors in making sure that XML files

are prepared properly and that quality control measures are conducted on each file before the

vendor attempts to submit the file to the OAS CAHPS Data Center. Implementing adequate

quality control on XML files, and submitting each file well in advance of the data submission

deadline, will help ensure that each HOPD’s or ASC’s monthly data files are accepted and that

high-quality data are submitted. Quality control checks should be conducted by a different staff

person than the one who completed the task.

Verify that the vendor is authorized to submit data. Vendors should check the Survey Vendor

Authorization Report regularly to make sure that each of their clients has authorized them to

submit data on their behalf and that the Start Date entered is correct.

Help ensure proper file format by using the validation tools on the OAS CAHPS website.

The following can be downloaded from the OAS CAHPS website:

• Templates for the XML files;

• XML schemas;

• Schema validation tool; and

• Data submission tips.

Vendors should apply the validation schema posted on the OAS CAHPS website on each data

file. This validation tool contains some of the same validation checks that are applied when the

data file is submitted to the OAS CAHPS Data Center. Using the validation schema to identify

file problems and correcting any problems detected will reduce the number of attempts to submit

the data file.

Perform additional quality control checks. In addition to using the validation schema, survey

vendors are encouraged to make additional quality control checks on the data files before they

attempt to submit the files to the OAS CAHPS Data Center. Some suggested quality checks are

listed below.



a. Check the sample month entered on the XML file to verify that the sample month is

correct. The OAS CAHPS Data Center will not accept a data file for a sample month in a

previous data submission quarter, but it will accept files for months in the current and

upcoming data submission quarters. Similarly, make sure that the sample month on the

file correctly indicates the month in which the sample patients received their outpatient

surgery or procedure.

b. Select a sample of patients for whom data are entered on the XML file and compare the

data on the XML file for those patients with the data for that patient on the original (raw)

data source. For example, compare the variables entered in the Patient Administrative

Data Record section of the XML with the information that the HOPD or ASC provided

for the sample patient in the original monthly patient information file. Similarly, compare

the entries in the Patient Survey Response Record section of the XML with the hardcopy

questionnaire or scanned image of the patient’s completed survey or, if the survey was

completed by phone, with the original CATI or telephone survey data file. Implementing

this quality control check on a sample of the data records will ensure that data are

correctly exported from the data source onto the XML file.

c. After the XML file is prepared, generate data distributions (frequencies of responses and

variables) on selected variables and inspect the output for data anomalies. A visual

inspection of data frequencies is a quick way to identify data problems. For example, if

the race variable for all patients entered on the XML file is American Indian, this could

be an indication that the race variable is incorrect. Similarly, response option “2” is coded

for the overall rating of care variable for all patients on the file, this is likely an indication

that there is a problem with the file.

d. Check that a valid response code has been entered for all variables in the XML file. Note

if data are missing for a variable, either the Missing code (“M”) or the code for Not

Applicable (“X”) must be entered for the variable.

e. Confirm that there have not been any assigned duplicate SID numbers in the XML files

across months in the data submission period or across prior data submission periods. The

SID number can only be assigned to one patient and cannot be reused.

f. Confirm that the only patient response records included in the third section of the XML

file are those with a final Survey Status code for a completed survey (codes 110 and 120)

and those with code 310 – Breakoff.

g. Verify that all final disposition codes are correct. Vendors must make sure that no

response data are submitted for non-interview cases that are coded as deceased,

ineligible, refusals, etc.

h. Vendors should change the disposition code for a completed survey that does not pass the

OAS CAHPS completeness criteria to 310 – Breakoff. Also, make sure that code 340 –

Wrong, Disconnected, or No Telephone Number is being appropriately assigned to

telephone-only or mixed-mode cases and only in situations when the vendor could not

obtain a “working” telephone number for the sample patient. Similarly, make sure that



code 330 – Bad Address/Undeliverable Mail, or No Address is being appropriately

assigned to mail-only cases when it is determined that the sample member’s address is

bad and no new address is obtained.

i. Conduct quality checks of mail survey coders’ work by having a different person recheck

a sample of each coder’s cases to make sure that they are following and applying correct

coding guidelines.

j. Check the file to make sure that all patient data the HOPD or ASC provided for a patient

on the monthly patient information file exported correctly to the XML file.

k. Check the XML file name to make sure that it conforms to OAS CAHPS recommended

file naming conventions, which are to include the sample month, year, and CCN or

facility name in the filename.

l. Confirm that an XML file has been accepted for each sample month for each client

HOPD or ASC.

Survey vendors should check the XML data files for internal logic and consistency prior to

submitting them to the OAS CAHPS Data Center. Some examples of items to check are provided

below:

a. The number of eligible patients included in the variable on the Header Record should

always be equal to or smaller than the number of patients the facility served during the

sample month. It should never be more than the number of patients served.

b. The number of patients eligible must be equal to or larger than the number of patients

sampled.

c. The number of patients sampled must be equal to or less than the number of patients

served.

d. The total number of patients for which the vendor has included administrative

information in the patient administrative section of the XML file must equal the number

of patients sampled.

Survey vendors are reminded that if none of the patients for whom information is provided on

the monthly patient information file is eligible for OAS CAHPS, the vendor must still prepare

and submit an XML file for that sample month (see Appendix M). The vendor must indicate on

the file that there were zero eligible cases in the number eligible variable and enter all other

information required in the Header Record section of the XML file. Note that OAS CAHPS

vendors are not required to submit a DNR for situations where there are zero eligible cases;

however, they are required to submit a DNR if the HOPD or ASC did not submit a file at all (see

Potential Situations When Vendors Will Not Submit Data, above).





XII. WEBSITE REPORTS

Overview

The Outpatient and Ambulatory Surgery CAHPS (OAS CAHPS) Data Center will generate and

provide a number of online reports (via the OAS CAHPS website) to indicate the status of data

submissions and the quality of the data submitted. These reports are described in the following

sections.

Reports for Survey Vendors

Survey vendors will be able to access a number of reports via the website, once logged in. The

most important of these are tied to the data submission and file review process—the Validation

Results Report, Data Submission History Report and Data Submission History by Upload Date

Report. Another important report is the Survey Vendor Authorization Report, which allows the

survey vendor to view all hospital outpatient departments (HOPDs) and ambulatory surgery

centers (ASCs) that have authorized the vendor to collect and submit data on their behalf. Each

of these reports is discussed separately below.

The Data Submission Reports

A data submission report (Validation Results Report) is immediately generated and available to

survey vendors after they upload data via the Data Submission Tool. Once the vendor submits

data, the system will check for the correct file layout, missing data, duplicate sample

identification (SID) numbers, invalid responses, etc. After a successful file upload, the OAS

CAHPS Data Center conducts a more thorough review of the data, which is done within an hour

of the file submission. This second validation check is also referred to as the “secondary

validation.” The Data Submission History Report is updated after the secondary validation

checks have been made. The Data Submission History by Upload Date Report is also available

for vendors to search for a data submission report by the actual upload date.

The first check of the submitted data file is to make sure that the XML template has been used

and is properly formatted. If the survey vendor has an incorrectly formatted template, the data

upload process will stop immediately and display an error message (in the Validation Results

Report) that describes the problem detected. After the system verifies that a properly formatted

template has been used, it will begin a series of data checks. It will look for any fields in the

Header Record with missing data. If any data are missing, the file will be rejected, and the

Validation Results Report will inform the vendor what data fields are missing. The system will

also check for any duplicate SID numbers to make sure a vendor has not used an SID more than

once for a given HOPD or ASC in a given quarter. If a vendor has used a duplicate SID, the file

XII. Website Reports November 2018


will be rejected and the Validation Results Report will inform the vendor where the error is so it

can be corrected. Finally, the report will check that the vendor is authorized to upload data for

the CMS Certification Number (CCN).

If the data file successfully passes the initial checks, the Validation Results Report will display a

message saying that the upload was successful. This screen will also provide the vendor with a

count of records received by CCN. The message will also indicate that the file will be sent

through a more formal data processing step within an hour.

Files that have successfully passed the upload validation process are then subjected to a

secondary validation process. The system will check for missing data fields required for patient

eligibility determination. Each Patient Response Record included on the file will be checked to

ensure that all entries are within the acceptable range. In addition, a completeness algorithm will

be run to verify that all patient response records included on the file meet survey completeness

criteria (although this step will be used to ensure that the appropriate cases are included as

“complete” and will not be a reason for rejecting a file).

The results of the secondary validation are updated on the Data Submission History Report for

each file that was uploaded. This report provides sufficient detail, by CCN, of data file errors that

caused data files to be rejected so that the vendor can fix those errors and resubmit the file(s). To

view the XML validation results (and detail about the file errors found), select “Detailed” for the

Report Type field. After the validation checks, the system will generate and send an e-mail to the

vendor after the secondary validation process has been completed indicating that the data

processing step has been completed. Survey vendors can access data submission reports at any

time from the website by going to the “Data Submission” menu and selecting the “Data

Submission Reports” link. Survey vendors can select to view a history of all reports or history by

upload date.

Files that successfully pass both stages of validation will be accepted and processed for public

reporting. If any problems are detected in the data file, this information will be displayed on the

Data Submission History Report (when “Detailed” is selected for Report Type) and the Data

Submission History by Upload Date Report, and the vendor will be expected to correct the errors

and resubmit the file.

As explained in Chapter XI, each XML file contains a single CCN for a single month. However,

vendors can upload a zip file containing XML files for several CCNs and several months. Files

will be accepted or rejected based on CCN.

Because of the two-part nature of the OAS CAHPS Data Center’s data processing steps, vendors

are strongly advised to submit files far enough in advance of the quarterly submission deadline to

allow for both the initial upload file check and the secondary validation checks, if they have to

resubmit a file. The Data Center will not accept files after 8:00 PM EST on the data submission

November 2018 XII. Website Reports


deadline date for each quarter. The quarterly data submission deadlines can be found through the

“Data Submission Deadlines” link under the “Data Submission” menu tab on the website.

Below is an example Data Submission History Report.

Below is an example of what a vendor would see upon selecting a particular file upload date in

the Data Submission History by Upload Date Report.

Survey Vendor Authorization Report

The Survey Vendor Authorization Report allows survey vendors to view a list of HOPDs and

ASCs that have authorized the vendor to collect and submit data on their behalf. Any files a

vendor submits for an HOPD or ASC that has not formally authorized the vendor to submit data

on its behalf will be rejected during data submission. It is the vendor’s responsibility to ensure

that any HOPD or ASC with which it is contracted to conduct the OAS CAHPS Survey completes



the authorization process. The OAS CAHPS Data Center will reject data files if the form is out

of date. Below is an example Survey Vendor Authorization Report.

If a facility closes or is no longer active while its survey vendor is still contracted to conduct and

provide survey data on its behalf, any vendor authorizations will remain in effect for the entire

authorization period. The authorized vendor must submit the data that were collected for the

closed HOPD or ASC to the OAS CAHPS Data Center.

Reports for HOPDs and ASCs

HOPDs and ASCs will be able to access three reports after logging in to the OAS CAHPS

Survey website. The first report HOPD and ASC users can access is a Registered Facilities

Report—this report displays a list of the facilities (by CCN) that the user has access to. The

second report, the Data Submission Summary Report, is intended to provide a means for the

facility to monitor its vendor’s data submission activities and should be reviewed on a monthly

or quarterly basis, depending on the agreement that the facility has worked out with the vendor in

terms of frequency of data submission. The third report available to HOPDs and ASCs is the

Facility Preview Report―this report is a preview of the OAS CAHPS Survey results that are

compiled for each facility on a quarterly basis prior to being publicly reported. These reports are

discussed in more detail below.

Registered Facilities Report

The Registered Facilities Report is available to HOPDs and ASCs from the “Registered CCNs

Report” link in the “For Facilities” menu and via a link on the Facility Dashboard on the OAS

CAHPS Survey website. This report lists all of the facilities (by CCN) affiliated with the user’s

account, regardless of whether the user or someone else from the facility registered the CCN on

the OAS CAHPS website. This report also includes the facility’s name and the date in which it

was registered on the OAS CAHPS website.

November 2018 XII. Website Reports


Data Submission History Report

The Data Submission History Report is available to HOPDs and ASCs from the “Data

Submission Reports” link in the “For Facilities” menu on the OAS CAHPS Survey website.

HOPDs and ASCs that have contracted with a survey vendor will be able to log into the website

and view, print, and download a report that includes information on the number of submissions

and the submission status of their authorized vendor’s monthly or quarterly file submissions.

HOPDs and ASCs are strongly advised to review these reports on a regular basis.

The Data Submission Summary Report displays all of the dates on which the OAS CAHPS Data

Center accepted the data files the vendor submitted for the HOPD or ASC. Only files that passed

both the initial edit checks implemented during file upload and those that passed the secondary

set of edit checks will be listed on this report. The purpose of this report is to allow an HOPD or

ASC to monitor whether its vendor is successfully submitting data files by the required quarterly

data submission deadlines. The Data Submission Summary Report also includes a hyperlink

embedded in the date of each submission that takes the user to the data validation checks that

were performed on the uploaded files for that date. This report will give users the ability to view

a list of successful data file transmissions.

To protect the confidentiality of each HOPD or ASC and the vendor it has selected, only the

facility and its authorized vendor will be able to view the submission history relating to that

facility’s data.

Facility Preview Report

The OAS CAHPS Survey Facility Preview Report provides HOPDs and ASCs with a preview of

their own survey results that will be publicly reported on the CMS website. The preview report is

made available approximately 2 to 3 weeks before the OAS CAHPS Survey results are publicly

reported. HOPDs and ASCs are able to access their Preview Report(s) via the OAS CAHPS

website. To access the reports, HOPDs and ASCs must log into the OAS CAHPS website and

then select the “Preview Reports” link under the “For Facilities” menu. HOPDs and ASCs

participating in the OAS CAHPS Survey can only access their own reports. The Preview Report

is not be available to the OAS CAHPS Survey vendor or to anyone other than the HOPD or

ASC.

“Understanding the Preview Reports” document is available on the OAS CAHPS website, under

the “For Facilities” menu tab. It provides a brief explanation of the information included in the

Facility Preview Report.





XIII. OVERSIGHT ACTIVITIES

Overview

This chapter describes oversight activities that will be conducted by the Outpatient and

Ambulatory Surgery CAHPS (OAS CAHPS) Survey Coordination Team to ensure that the

survey is being administered according to required OAS CAHPS Survey protocols.

Requirements for vendor Quality Assurance Plans (QAPs), data review activities to be conducted

by the Coordination Team, communication between the Coordination Team and the vendors, and

site visit procedures are described in the following sections.

Quality Assurance Plan

All vendors seeking approval to conduct the OAS CAHPS Survey must submit a QAP, a

document that describes how the vendor will implement, comply with, and provide oversight of

all sampling, survey, and data processing activities associated with the OAS CAHPS Survey.

The first QAP must be submitted within 6 weeks after the vendor’s first quarterly data

submission deadline. It must be updated and submitted annually thereafter and at any time that

changes occur in staff or vendor capabilities or systems.

A Model QAP Outline is included in Appendix N to assist vendors in the development of their

own QAP. The vendor’s QAP should include the following sections:

• Organization Background and Staff Experience

• Initial Communications with Hospital Outpatient Departments (HOPDs) and Ambulatory

Surgery Centers (ASCs)

• Work Plan for Each Approved Mode of Data Collection

• Sampling Plan

• Survey Implementation Plan

• Data Security, Confidentiality, Privacy Plan

• Exceptions Request Process and Discrepancy Notification Reporting

• Questionnaire and Materials Attachments (in each language offered to clients)

XIII. Oversight Activities November 2018


Within each section, the vendor must specify all key staff responsible for implementing or

overseeing the activity or activities, procedures, and methods being used, and quality assurance

activities that will be implemented. Changes to key staff must be reported to the OAS CAHPS

Survey Coordination Team. There should be sufficient detail provided for all of these

components so that the Centers for Medicare & Medicaid Services (CMS) can evaluate whether

the vendor is complying with all approved protocols. If CMS and the Coordination Team do not

feel that the vendor’s QAP has sufficient detail to make this determination, the vendor will be

asked to make additions or edits to its QAP and resubmit it. Vendors will also be required to

submit a copy of sample cover letters, and the mail questionnaire (for mail and mixed-mode

surveys), or the screenshots from their electronic telephone interview (for telephone surveys) as

part of their QAP, depending on the mode(s) the vendor is approved to administer. Note that the

submission of a completed QAP is one of the components of the vendor approval process.

When preparing the QAP, vendors should review and refer to the Model QAP Outline available

on the OAS CAHPS website to ensure that they provide all information requested, including

detailed information about systems, protocols, and processes. Vendors should also organize the

information in their QAPs to conform to the sections included in the Model QAP Outline and

make sure that the QAP is paginated for ease of reference and review by CMS and the

Coordination Team.

Data Review

The OAS CAHPS Survey Coordination Team will conduct ongoing reviews of the data

submitted by each survey vendor. As discussed in Chapter XI of this manual, data files are

reviewed immediately upon submission for proper formatting, completeness, accuracy of record

count, and out-of-range and missing values. In addition, the Coordination Team will run a series

of edits on the data to check for such issues as outlier response rate patterns or unusual data

elements.

The OAS CAHPS Survey Coordination Team will attempt to resolve data issues with the vendor

through the use of conference calls or e-mail exchanges. If the Coordination Team believes that

there are any significant issues with a vendor’s data, or if repeated discussions and contact with a

vendor fail to result in cleaner data submissions, a more thorough review of the vendor’s data

processing and survey implementation activities may be initiated. At that time, the Coordination

Team may request copies of documentation associated with whatever the data issue is—for

example, if out-of-range values are found repeatedly, the Coordination Team may request copies

of documents showing the training program used to train data entry keying staff, training records,

and documentation that recommended quality assurance practices associated with keying data

were followed. Vendors are expected to comply with all such requests for documentation.

November 2018 XIII. Oversight Activities


Communication Between Survey Vendors and the OAS CAHPS Survey Coordination Team

The OAS CAHPS Survey Coordination Team welcomes communication from vendors related to

any part of the OAS CAHPS Survey implementation process. Vendors may communicate with

the Coordination Team via telephone or e-mail. The Coordination Team is also available to

participate in teleconference calls as needed to ensure vendors’ successful implementation of the

OAS CAHPS Survey. As noted in a preceding section of this manual, the vendor must provide

the facility name and CMS Certification Number (CCN) in all communications with the

Coordination Team.

The OAS CAHPS Survey Coordination Team expects that, in addition to communication with

vendors about technical assistance issues, it will also schedule conference calls with selected

vendors to review vendor procedures and ensure adherence to the OAS CAHPS Survey protocols

and guidelines. The Coordination Team will make periodic calls to vendors to assess the status of

sampling, data collection, and file processing issues in general. These calls will be scheduled in

advance so that appropriate members of the vendor’s project team can participate.

Site Visits to Survey Vendors

The OAS CAHPS Survey Coordination Team conducts site visits to all approved vendors. The

purpose of the site visits is to allow the Coordination Team to observe the entire OAS CAHPS

Survey implementation process, from the sampling stage through file preparation and

submission.

The OAS CAHPS Survey Coordination Team expects, at a minimum, to accomplish the

following on each site visit:

• Discuss the vendor’s initial communications with the HOPDs and ASCs, review the

process the survey vendor followed to determine the eligibility of their clients, and how

the vendor:

◦ worked with the hospital management to determine whether a particular hospital has

one or more eligible HOPDs or departments that meet the eligibility criteria for

inclusion in the OAS CAHPS Survey. Vendors will be asked to report what types of

questions hospitals have, and what information or specific website links the vendor

provides the hospitals to address their questions; and

◦ worked with the ASC management to understand the CCN(s) of their facilities,

including different sites. Vendors will be asked to report what types of questions

ASCs have and what information or specific website links the vendor provides the

ASCs to address their questions.



• “Walk through” the systems and processes used from the point of obtaining a sample

frame from an HOPD or ASC to preparation of a final data file, including but not limited

to a review of:

◦ software and/or programs used to select and store the sample; how patient contact

information (name and address) and sample identification (SID) number are printed

on letters accompanying questionnaire mailings or provided to a call center for

telephone survey data collection; questionnaire production, mailout, and receipt

facilities and processes; telephone survey operation facilities and processes, including

listening to interviews;

◦ all data processing activities, including how final status codes are assigned;

◦ file preparation and submission activities and file storage facilities;

◦ quality control on all aspects of the survey, including data entry and capture,

sampling, and file construction; and

◦ data security (including discussion of firewalls, passwords, data backup systems) and

adequacy of sample file, data file, and questionnaire storage facilities.

• Review documentation associated with any of the above steps, as applicable. The

documentation to be reviewed includes, but is not limited to:

◦ signed confidentiality forms for all applicable staff, including subcontractors;

◦ training records, such as for data entry or telephone interviewing staff;

◦ monitoring logs, with dates and times telephone interviewers were monitored, and the

results of those monitoring sessions;

◦ telephone interview scripts, including introductory scripts and responses to frequently

asked questions;

◦ documentation of quality control checks performed on questionnaire mailouts and

receipt; and

◦ verification records, for either data entry or scanning processes, showing the level of

quality control for keyed questionnaires.

• Interview the vendor’s key OAS CAHPS Survey project staff, including the Project

Director, Sampling Manager, Data Manager, and Computer Programmer.

November 2018 XIII. Oversight Activities


The OAS CAHPS Survey Coordination Team may make either scheduled or unscheduled visits

to the vendor’s site. Scheduled visits will be planned far enough in advance to ensure that all

appropriate vendor staff are able to participate in the site visit review process. For unscheduled

visits, the Coordination Team will give the vendor a 3-day window during which the team may

conduct the onsite review.

Generally, the site visit team will consist of two to three individuals, although the size of the

team may vary and may include representatives from CMS. All discussions, observations, and

materials reviewed during the site visit will remain confidential. Thus, although the OAS

CAHPS Survey Coordination Team appreciates that certain systems or processes may be

proprietary to a vendor, full cooperation with the site visit team is expected so that the team may

adequately assess vendor compliance with all OAS CAHPS Survey protocols and guidelines.

After each site visit, the OAS CAHPS Survey Coordination Team will prepare and submit to

CMS a Site Visit Report, which will summarize the findings from each site visit, including any

staffing, systems, and/or data issues. The Site Visit Report will also describe corrective actions

that the vendor will be required to take to correct any deficiencies or problems observed. The

Coordination Team will provide the vendor with the Site Visit Report after it has been reviewed

with CMS. The Coordination Team may request clarification, additional documentation, or

changes to any aspect of the implementation process, if needed. The vendor will then be given a

specified period of time in which to provide the additional information or submit documentation

showing that it has implemented the requested process or system change. The Coordination

Team will follow up with the vendor by teleconference or with additional site visits as needed.

Corrective Action Plans

If a vendor fails to demonstrate adherence to the OAS CAHPS Survey protocols and guidelines,

as evidenced by ongoing problems with its submitted data or as observed in its implementation

process during a site visit, CMS may ask the OAS CAHPS Survey Coordination Team to either

increase oversight of the vendor’s activities (or submitted data files) or, if necessary, put the

vendor on a corrective action plan.

If the vendor is put on a corrective action plan, the OAS CAHPS Survey Coordination Team will

work out a schedule with CMS by which the vendor must comply with the tasks set forth in the

corrective action plan. These will include interim monitoring dates, where the Coordination

Team and the vendor will meet via teleconference to discuss the status of the plan and what

changes the vendor has made or is in the process of making. The nature of the requested changes

that the vendor is asked to implement will dictate the kind of “deliverables” the vendor will be

expected to provide and the dates by which the deliverable must be provided.

Survey vendors that fail to comply with the oversight activities described above or whose

implementation of the OAS CAHPS Survey is found to be unsatisfactory after the opportunity is



given to correct deficiencies may be subject to having their “approved” status rescinded. Further,

any HOPD or ASC survey responses collected by the vendor may be withheld from public

reporting. The affected facilities will be notified by the OAS CAHPS Survey Coordination Team

of their vendor’s failure to comply with oversight activities or unsatisfactory implementation so

that the facilities will have the opportunity to contract with another approved vendor.


XIV. PUBLIC REPORTING

Overview

This chapter describes the public reporting activities associated with the Outpatient and

Ambulatory Surgery CAHPS (OAS CAHPS) Survey. All publicly reported data are available on

the Centers for Medicare & Medicaid Services (CMS) website. Results from the OAS CAHPS

Survey are published quarterly and include each hospital outpatient department’s (HOPD’s) and

ambulatory surgery center’s (ASC’s) most recent four quarters of data.

The chapter begins with a list of the measures that are reported and explains how the results are

adjusted and reported. The chapter concludes with a discussion of Facility Preview Reports and a

table showing the quarters included in each public reporting period.

OAS CAHPS Survey Measures

OAS CAHPS Survey results are reported for three composites and two global items:

Composite Measures

• Facilities and Staff (Q3, Q4, Q5, Q6, Q7, and Q8)

• Communication About Your Procedure (Q1, Q2, Q9, Q10/Q11, and Q10/Q12)

• Preparing for Discharge and Recovery (Q13, Q14, Q15/Q16, Q17/Q18, Q19/Q20, and

Q21/Q22)*

Global Items

• Patients’ Rating of the Facility (Q23)

• Patients Recommending the Facility (Q24)

* Not currently reported on CMS websites. Only reported on Facility Preview Reports on OAS CAHPS website.

CMS is conducting a quality review of this composite.

Each of the three composite measures consists of five or more questions from the survey that are

about related topics. The results from the questions that comprise a composite are reported as one

score. Composite scores are created by first determining the proportion of answers to each

response option for all questions in the composite. The final composite score averages the

proportion of those responding to each answer choice in all questions in the composite. Only

questions that are answered by survey respondents are included in the calculation of composite

scores.

XIV. Public Reporting November 2018


Some of the questions in the Communications About Your Procedure composite score

(Q10/Q11) and the Preparations for Discharge and Recovery composite score (Q15/Q16,

Q17/Q18, Q19/Q20, and Q21/Q22) are combined for analysis and scoring, but they are not all

reported in the scores themselves.

For the Preparations for Discharge and Recovery composite score, the initial question in each

pair (Q15, Q17, Q19, and Q21) asks if the patient was told that he or she might have

pain/nausea/vomiting/bleeding/infection. The second question in each pair (Q16, Q18, Q20, and

Q22) asks if the patient experienced each of these outcomes. Only the initial questions in each

pair (Q15, Q17, Q19, and Q21) are the responses that will be reported in the composite score, but

even those may be suppressed if the responses to the second question in each pair (Q16, Q18,

Q20, and Q22) are negative. Top box scores (“Yes, definitely”) to the initial questions will

always be included in the composite despite the response to the second questions.

For example, if the response to Q17 (was the

patient told what to do if (s)he had nausea or

vomiting) was “Yes, definitely” this top box

score would be included regardless of the

response to Q18 (did the patient have nausea or

vomiting as a result of the procedure). If the

response to Q17 was “Yes, somewhat” or

“No,” Q17 would only be reported in the

composite score if the response to Q18 was

“Yes” (nausea or vomiting was experienced). If

the response to Q18 was “No” or missing, Q17

would be excluded from the composite score

(and the denominator would be reduced by 1

question) if the response to Q17 was anything

other than “Yes, definitely.” The intention of

this scoring is to ensure that the composites

reflect whether information was provided to the

patient only if the information was needed

based on the patient’s situation (type of

surgery). Some surgeries and procedures may

not require the same type of recovery

information. These questions are designed to report only what is meaningful for each situation.

In some cases, the composite score will exclude some of the component questions (17, 19, and

21) if they were determined not to be appropriate.

Reporting OAS CAHPS Top-, Middle-, and

Bottom-Box Scores on data.medicare.gov

OAS CAHPS results are reported as “top-box,”

“bottom-box,” and “middle-box” scores.

The top-box is the most positive response to

survey items, for example “Yes, definitely” for

most of the survey items. For the Overall Facility

Rating item, the top-box score is “9” or “10.” For

the Recommend Facility item, “Definitely yes” is

the top-box score.

The “middle-box” captures intermediate

responses, for example “Yes, somewhat” for most

of the survey items. For the Overall Facility

Rating item, the middle-box score is “7” or “8.”

For the Recommend facility item, “Probably yes”

is the middle-box score.

The bottom-box is the least positive response

category, for example “No” for most of the survey

items. For the Overall Facility Rating item, the

bottom-box score is “0” to “6.” For the

Recommend Facility item, “Definitely no” and

‘Probably No” is the bottom-box score.

November 2018 XIV. Public Reporting


Adjustment and Reporting of Results

In 2015, the OAS CAHPS Survey Coordination Team conducted a mode experiment to test the

effects of using three data collection modes: mail only, telephone only, and mixed mode (mail

with telephone follow-up of nonrespondents). The overall response rate for all three modes was

39%. By mode, the response rates were 37% for the mail-only mode, 34% for telephone-only

mode, and 50% for mixed mode (mail with telephone follow-up).

The results of the OAS CAHPS Survey mode experiment showed no significant differences in

results based on survey mode. There were, however, differences in responses attributable to

patient-mix characteristics. The following six patient characteristics were found to be significant

predictors: surgery type, overall health, overall mental health, age, education, and how well the

patient speaks English. Therefore, patient-mix adjustments are made on OAS CAHPS Survey

results that are publicly reported using the six patient characteristics identified during the mode

experiment, but no adjustments are needed for mode differences. The patient-mix adjustment

coefficients are updated quarterly.

Because some patients’ assessment of the care they received from HOPDs and ASCs may be

influenced by patient characteristics that are beyond the facilities’ control, CMS used the data

from the mode experiment to determine whether and to what extent characteristics of patients

participating in the OAS CAHPS Survey statistically affect survey results. Statistical models

were developed to adjust or control for these patient characteristics. These statistical adjustments

are applied before survey results are publicly reported. Also, some patients may not respond to

the survey, and this may impact the accuracy and comparability of results. Therefore, the data

from the mode experiment were analyzed to detect potential nonresponse bias. The results of

these analyses determined applicable statistical adjustments that are made on each quarter of the

OAS CAHPS Survey data.

OAS CAHPS Survey results are reported for a rolling four quarters of data that are updated

quarterly by replacing the oldest quarter of data with data from the most recent quarter. During

voluntary participation, users can access OAS CAHPS Survey results at the facility, state, and

national levels in three locations:

• on data.medicare.gov (by clicking on “Hospital Compare data” box [under “Explore &

download data” header] and then searching the term “OAS CAHPS”);

• through Hospital Compare (direct link to OAS CAHPS data:

https://www.medicare.gov/hospitalcompare/OASCAHPS-measures.html); and

• via downloadable databases on data.medicare.gov.

https://www.medicare.gov/hospitalcompare/OASCAHPS-measures.html



Table 14.1 shows a crosswalk of the composite measures and global ratings mapped to the text

that is displayed on Hospital Compare and data.medicare.gov.



Table 14.1 Crosswalk of Composite Measures and Global Ratings

SCORE

MEASURES

COMPOSITE SCORE GLOBAL RATING

Facilities and Staff

Questions 3–8

Communication about your procedure

Questions 1–2, 9–12

Preparing for discharge and recovery

Questions 13–22

Patients’ rating of the facility

Question 23

Patients recommending the facility

Question 24

Patients who reported that staff… Patients who

gave the facility…

Patients who reported…

Top Box Definitely gave care in a professional way and the facility was clean

Definitely communicated about what to expect during and after the procedure

Definitely gave them information about what to do if they had pain, nausea or vomiting, bleeding or possible signs of infection as a result of the procedure or anesthesia

a rating of 9 or 10 on a scale from 0 (lowest) to 10 (highest)

YES they would definitely recommend the facility to family or friends

Middle Box

Somewhat gave care in a professional way or the facility was somewhat clean

Somewhat communicated about what to expect during and after the procedure

Somewhat gave them information about what to do if they had pain, nausea or vomiting, bleeding or possible signs of infection as a result of the procedure or anesthesia

a rating of 7 or 8 on a scale from 0 (lowest) to 10 (highest)

PROBABLY YES they would recommend the facility to family or friends

Bottom Box

Did not give care in a professional way or the facility was not clean

Did not communicate about what to expect during and after the procedure

Did not give them information about what to do if they had pain, nausea or vomiting, bleeding or possible signs of infection as a result of the procedure or anesthesia

a rating of 0 to 6 on a scale from 0 (lowest) to 10 (highest)

NO they would not recommend the facility to family or friends

Star Ratings

Currently, OAS CAHPS star ratings are under development. Future plans involve reporting star

ratings on Hospital Compare for HOPDs and ASCs: a star rating for each of the publicly reported

OAS CAHPS composite measures, one for the Overall Rating of Care measure, one for

Willingness to Recommend measure, and one Survey Summary Star, which is a simple average



of all star ratings. OAS CAHPS star ratings will be based on the same patient survey results

publicly reported on Hospital Compare. More information on how the star ratings are calculated

will be available in the future.

Facility Preview Reports

Prior to publishing the results on the CMS website, the OAS CAHPS Survey Coordination Team

makes available a preview report on the OAS CAHPS website so that each HOPD and ASC can

review the results that will be publicly reported. Each quarterly public reporting period includes

survey results from data collected for the prior 12 months, as the oldest quarter’s data are

dropped and the newest quarter’s data are added. During voluntary participation, OAS CAHPS

Survey data will be refreshed on Hospital Compare and data.medicare.gov according to the

schedule provided in Table 14.2.

Public Reporting Periods

Table 14.2 shows the quarters included in each public reporting period.



Table 14.2 Data Submission Deadlines Linked to the Public Reporting Period

Vendors Data Submission

Deadline to (1)

Includes Sample

Months in…. Public Reporting

Period (#) Public Reporting Period

Covers

Date posted on

data.medicare.gov (2) (3)

July 13, 2016 Qtr. 1, 2016 October 2016 (1) Qtr. 1, 2016 Not posted

Oct. 12, 2016 Qtr. 2, 2016 January 2017 (2) Qtr. 1, 2016–Qtr. 2, 2016 Not posted

Jan. 11, 2017 Qtr. 3, 2016 April 2017 (3) Qtr. 1, 2016–Qtr. 3, 2016 Not posted

April 12, 2017 Qtr. 4, 2016 July 2017 (4) Qtr. 1, 2016–Qtr. 4, 2016 Not posted

July 12, 2017 Qtr. 1, 2017 October 2017 (5) Qtr. 2, 2016–Qtr. 1, 2017 Not posted

Oct. 11, 2017 Qtr. 2, 2017 January 2018 (6) Qtr. 3, 2016–Qtr. 2, 2017 Not posted

Jan. 10, 2018 Qtr. 3, 2017 April 2018 (7) Qtr. 4, 2016–Qtr. 3, 2017 April 2018

April 11, 2018 Qtr. 4, 2017 July 2018 (8) Qtr. 1, 2017–Qtr. 4, 2017 July 2018

July 11, 2018 Qtr. 1, 2018 October 2018 (11) Qtr. 2, 2017–Qtr. 1, 2018 Oct. 2018

Oct. 10, 2018 Qtr. 2, 2018 January 2019 (12) Qtr. 3, 2017–Qtr. 2, 2018 Jan. 2019



July 10, 2019 Qtr. 1, 2019 October 2019 (15) Qtr. 2, 2018–Qtr. 1, 2019 Oct. 2019

Oct. 9, 2019 Qtr. 2, 2019 January 2020 (16) Qtr. 3, 2018–Qtr. 2, 2019 Jan. 2020



NOTES: (1) Data submissions will be second Wednesday of month. (2) Data are publicly released for a facility

when that facility has four consecutive quarters of data. (3) During voluntary participation, OAS CAHPS data are

publicly reported on data.medicare.gov.





XV. EXCEPTIONS REQUEST PROCESS AND DISCREPANCY

NOTIFICATION REPORT

Overview

This chapter describes the process to be used to request an exception to the Outpatient and

Ambulatory Surgery CAHPS (OAS CAHPS) Survey protocols, including guidelines for

submitting an Exceptions Request Form. This chapter also covers the process for alerting the

OAS CAHPS Survey Coordination Team of an unplanned discrepancy in the collected or

submitted survey data. Vendors are expected to submit a Discrepancy Notification Report

whenever there has been an inadvertent or temporary deviation from the standard OAS CAHPS

Survey protocols. The vendor is expected to notify the Coordination Team within 24 hours after

the discovery of the discrepancy.

Exceptions Request Process

The Exceptions Request Form (see Appendix O) is designed to allow the survey vendor to

request a planned deviation from the standard OAS CAHPS Survey protocols. Vendors are asked

to submit an Exceptions Request Form for any exceptions to the OAS CAHPS Survey protocol.

The Coordination Team will consult with the Centers for Medicare & Medicaid Services (CMS)

to make a determination after reviewing each request whether to approve the exception. The

OAS CAHPS Survey Coordination Team has identified five allowable exceptions on the OAS

CAHPS Survey at this time:

1. the use of disproportionate stratified random sampling (DSRS) (see Chapter IV),

2. more frequent than monthly sampling (see Chapter IV),

3. an alternative method of determining eligibility for patient records missing

procedural codes (CPT-425

and G-Codes) (see Chapter IV),

4. request to exclude CPT-4 codes that fall within the range of Codes for Surgery from

being eligible for the OAS CAHPS Survey (Chapter IV), and

5. displaying the HOPD or ASC’s name and/or logo on the outgoing envelope (see

Chapters V and VII).


XV. Exceptions Request Process and Discrepancy Notification Report November 2018


Vendors must complete and submit an Exceptions Request Form to obtain approval to

implement these exceptions.

The Exceptions Request Form is designed to allow the survey vendor to request the same

exception for multiple hospital outpatient departments (HOPDs) or ambulatory surgery centers

(ASCs) for which it is responsible for collecting data. The Exceptions Request Form can be

accessed and submitted online (https://oascahps.org/ ).

DSRS Exceptions Request Form Requirements

Vendors must include the following information in the Exceptions Request Form for each CMS

Certification Number (CCN) for which they are requesting to implement the DSRS sampling

method. It is acceptable for vendors to use estimated monthly figures or the last sample month’s

figures when providing this information for each applicable CCN:

1. CCN and facility name

2. The names of each strata

3. The expected number of eligible patients or procedures in each strata (for a sample

month)

4. The number of patients or procedures to be sampled in each strata (for a sample month)

5. Additional data validation checks to ensure that the minimum number of 10 eligible

patients per stratum is sampled

Below is an example describing how the above information should be provided in an Exceptions

Request Form requesting to implement DSRS for one CCN with two strata:

1. CCN and facility name: 123456, OAS Example Hospital

2. The names of each strata: OAS Example Hospital South, OAS Example Hospital North

3. Expected # of eligible patients or procedures: OAS Example Hospital South = 330, OAS

Example Hospital North = 415

4. Number of patients or procedures would like to sample: OAS Example Hospital South =

255, OAS Example Hospital North = 310

5. Additional validation checks: Reviewed previous annual patient records to ensure that the

number of eligible patients per strata would never be fewer than 10 and were fairly

consistent within strata across months. Will monitor the number of eligible cases monthly

to ensure that there is sufficient sample so that DSRS remains a viable sampling strategy.


November 2018 XV. Exceptions Request Process and Discrepancy Notification Report


An Excel template (“DSRS Template”) is available under the Exceptions Request Form link on

the website that vendors are encouraged to use to submit the information required for a DSRS

request. When using this Excel template, vendors should note the following:

• If vendors choose to submit an Excel file, they will be required to use this DSRS

Template.

• The template allows for information for multiple CCNs to be provided but they must be

entered in separate Excel sheets (tabs).

• Note that vendors must submit a new template for each new request for DSRS.

• If updates are needed [for additional CCNs following the same protocol], vendors may

update and resubmit an existing online Exceptions Request Form and DSRS Template.

However, a new online Exceptions Request Form must be submitted if the protocol will

differ.

• Also, note that you are still required to complete the online Exceptions Request Form for

all DSRS requests, but you must submit the Excel template by sending an e-mail to

[email protected].

If a vendor’s Exceptions Request Form for DSRS is approved, please be reminded that the

vendor must use the DSRS XML data file layout to submit data for the facility. The vendor

should review the DSRS XML Header Record to ensure that it has all the information that is

required.

Continuous Sampling Exceptions Request Form Requirements

When submitting the first Exceptions Request Form requesting to implement continuous

sampling, the survey vendor must include the list of all CCNs that will have the sample drawn

continuously (i.e., more frequently than monthly). Vendors must indicate if the Exceptions

Request covers future clients as well by adding “all future CCNs” to the Exceptions Request

Form. With this added statement, vendors do not have to update this Exceptions Request Form if

additional, future clients would like to implement continuous sampling. To receive approval for

future clients, the submitted Exceptions Request will require additional information to ensure

that the sampling process will be successfully implemented regardless of the sample size for each

future client facility.

Each of the following eligibility criteria and sample selection protocols must be

comprehensively explained in the Exceptions Request Form when requesting the implementation

of continuous sampling for current and future clients:




In terms of patient and surgery or procedure eligibility:

• In general, what size facilities (as measured by patient volume) are requesting to use

continuous sampling, and how does the facility size relate to the sampling frequency

(e.g., small facilities with low volume [100 or fewer eligible patients per month] can be

sampled every 2 weeks, large facilities with high patient volume [more than 100 eligible

patients per month] can be sampled daily).

• Explain the frequency by which the eligibility will be assessed and confirmed (daily,

every few days, weekly or other periodicity). See the Chapter IV for the eligibility

criteria. The OAS CAHPS Survey is not appropriate for people who did not have an OAS

CAHPS-eligible procedure or surgery, and such individuals should be removed from the

sample frame before selection.

• Explain how the de-duplication and check for patients who were sampled in the previous

5 months will be performed for the planned sampling periodicity (daily, every few days,

weekly, or other periodicity).

In terms of sampling:

• What sampling methods will be used? As stated in Chapter IV, if there are two or more

components within the CCN, a proportional method (Stratified Systematic Sampling,

Proportionate Stratified Random Sampling [PSRS], or DSRS if approved) must be used.

• When frames are assembled frequently, will there be enough cases on the frame (which

includes the frames of individual strata) to perform sampling? As a reminder, for PSRS

and DSRS there must be 10 eligible patients on the frame from which the sample is

selected.

• What sampling rate will be used? If there are multiple components, be specific for each

component within the CCN. What will be done if the frame size is small (100 or fewer

eligible patients per month) and cannot support the sampling rate? (Sampling rates may

differ by CCN, if so, please provide these rates in the examples requested below.)

Provide an example of implementation of sampling procedures for one small and one large

CCN:

Please include in your Exceptions Request Form an example of how you would implement

continuous sampling for a large CCN and a small CCN, if available. Choose one of the CCNs

(that has more than 100 eligible patients per month) as an example. If there are any CCNs that

have 100 or fewer eligible patients, provide another example. Below are examples of how this

information should be displayed in the Exceptions Request Form.



Example 1 – Large size CCN (more than 100 eligible patients per month):

• Facility Name: Hospital North

• CCN: 654321

• Number of Eligible Patients in a sample month: 1,652

• Number of Eligible Patients in a sample bimonthly period: 820

• Number of Eligible Patients in a sample week: 398

• Number of Eligible Patients in a sample day: 56

• Proposed frequency: We propose sampling patients on a weekly basis.

Example 2 – Small size CCN (100 or fewer eligible patients per month):

• Facility Name: Hospital South

• CCN: 123456

• Number of Eligible Patients in a sample month: 100

• Number of Eligible Patients in a sample bimonthly period: 58

• Number of Eligible Patients in a sample week: 30

• Number of Eligible Patients in a sample day: 6

• Proposed frequency: We propose sampling patients on a weekly basis.

Displaying HOPD/ASC’s Name and/or Logo on Outgoing Envelopes

To display an HOPD’s or ASC’s name and/or logo on an outgoing mailing envelope, vendors

must obtain the facility’s permission to display the name and/or logo and assurances that the

facility does not consider displaying the name and/or logo to be a HIPAA risk. It is up to each

vendor to determine what kind of documentation or assurances it needs from its clients for its

own internal recordkeeping to feel comfortable submitting the Exceptions Request Form. The

documentation pertaining to such a request will not be reviewed during site visits.

The Exceptions Request Form submitted to the Coordination Team should include a statement

that the vendor has discussed or will discuss the potential for HIPAA risks with its current and

future client(s) and has or will obtain approval from the client(s) to display the facility name



and/or logo on the envelope or through the envelope window. Vendors only need to submit one

Exceptions Request Form to cover all their current and future clients.

Review Process

The OAS CAHPS Survey Coordination Team will review the vendor’s exceptions request,

evaluating the methodological strengths and weaknesses of the proposed approach. The

Coordination Team will let the survey vendor know whether the exceptions request has been

approved or denied. If denied, the vendor will have 5 business days to appeal the decision. To

submit an appeal, the vendor needs to check “Appeal of Exception Denial” in Box 1b on the

Exceptions Request Form and update the form to provide further information about the exception

being requested. The Coordination Team will review the appeal and return a final decision to the

survey vendor within 10 business days.

Discrepancy Notification Report

The Discrepancy Notification Report (DNR) (see Appendix P) is designed to allow the survey

vendor to notify the OAS CAHPS Survey Coordination Team of an unplanned deviation from

the OAS CAHPS Survey protocols that will require some form of corrective action on the part of

the survey vendor. Examples of instances when a DNR is required include the following:

• the vendor or facility inadvertently omitted from the sample frame patients who were

eligible for the survey;

• the vendor is unable to initiate the survey by the 21st day after the sample month ended

and needs to initiate it from the 22nd through the 26th day after the sample month ended;

• a variable was incorrectly coded and submitted on the XML file;

• there has been a natural disaster or event that has interrupted data collection in such a

way as to adversely affect survey outcomes;

• the HOPD or ASC was unable to provide the vendor with a file for the sample

month; the

reason the HOPD or ASC was unable to provide the monthly patient information file

must be specified in the Discrepancy Notification Report; and

• the facility is unable to provide the vendor with procedural codes (CPT-426

and G-codes)

for patient records. The vendor must include the number of cases that were fielded with

or without an approved alternative method to determine eligibility, the reason the




procedural codes were missing, and a description of the method used to determine each

of the case’s “Surgical Category” for the XML file and for how many cases.

The DNR form can be accessed and submitted online via the OAS CAHPS Survey website

(https://oascahps.org/ ) once the vendor’s OAS CAHPS Survey Administrator has logged in.

The vendor is expected to notify the OAS CAHPS Survey Coordination Team within 24 hours

after the discovery of the discrepancy. The vendor must also notify all affected HOPDs and

ASCs that a DNR has been submitted to the Coordination Team on their behalf. The report must

clearly describe the discrepancy and the action proposed by the vendor to correct the

discrepancy, along with a proposed timeline to correct the discrepancy. At a minimum, the

following information must be included on the report form:

• the HOPD’s or ASC’s CCN;

• affected survey quarter (selected from a drop-down list of options);

• discrepancy reason (selected from a drop-down list of options, including No Sample

Provided, Patients Omitted from Sample Frame, Late Start, No Survey Administered,

Survey Interrupted, Variable Incorrectly Coded, and Some Other Reason);

• number of affected patients;

• dates in which data collection took place (if the selected discrepancy reason is Late Start);

• a detailed description of the discrepancy and whether the deviation from OAS CAHPS

Survey protocol was caused by the vendor or facility;

• remediation plan for the affected month and the timeline for the remediation activity;

• corrective actions to be taken to avoid the situation in the future; and

• any other information that will help the OAS CAHPS Survey Coordination Team

understand the discrepancy.

The information required on the DNR form will vary depending on the reason selected for the

Discrepancy Reason field. Table 15.1 below provides a brief description of when it is

appropriate for an OAS CAHPS Survey vendor to select each of the listed reasons. Other

situations may occur that are not included in the table below. For guidance on which discrepancy

reason is most applicable, please contact the OAS CAHPS Survey Coordination Team.




Table 15.1 Example Scenarios of Various Discrepancy Reasons

Discrepancy Reason When to Select Discrepancy Reason

No Sample Provided The HOPD or ASC was unable to provide the vendor with a monthly patient file.

Patients Omitted from the Sample Frame

The survey vendor, HOPD, ASC, or software vendor inadvertently omitted from the sample frame patients who were eligible for the survey.

Late Start The vendor is unable to initiate the survey by the 21st day after the sample month ended and needs to initiate it from the 22nd through the 26th day after the sample month ended. Note that a DNR is not required if a late start e-mail request was submitted because the e-mail request serves as the needed documentation.

No Survey Administered The vendor received the monthly patient file from the HOPD or ASC, but did not initiate data collection for the sample. Note that a DNR is not required if a late start e-mail request was submitted and denied because the e-mail request serves as the needed documentation.

Survey Interrupted Data collection for a sample month was initiated but was interrupted. This reason applies to situations when data collection activities resume after the interruption and when data collection does not resume. For example, a natural disaster or event interrupted data collection in such a way as to adversely affect survey outcomes.

Variable Incorrectly Coded An incorrect final disposition code was applied on a submitted XML file, or a variable was incorrectly coded on a submitted XML file. If response data were incorrectly coded after the case is finalized either before or after the XML file has been submitted to the OAS CAHPS Data Center, this reason should be selected.

Some Other Reason A reason that does not fall into one of the other reasons. For example, this could include an HOPD or ASC that is closed or no longer operating under a CCN, the submission of an XML file under the wrong CCN.

Vendors are required to submit a DNR if an HOPD or ASC client does not submit a monthly

patient information file for a sample month. However, survey vendors do not need to continue

submitting these reports for facilities that are not submitting monthly patient information files

once the facility has failed to submit a monthly patient information file for 3 consecutive

sample months. It is the responsibility of the OAS CAHPS Survey vendor to track the number

of months the HOPD or ASC has failed to submit a monthly patient information file and to

submit a DNR for the first 3 months that this occurs.

Vendors are reminded that no DNR is needed if a facility has notified the vendor via submission

of a zero eligible file or an e-mail that it has no eligible patients in a given sample month. If an

HOPD or ASC submits a file to its vendor with no eligible patients, the vendor must submit an

XML file for that facility for that sample month indicating that there were no eligible patients.



Discrepancy Report Review Process

The OAS CAHPS Survey Coordination Team will review the vendor’s DNR and evaluate the

impact of the discrepancy on the publicly reported data. Depending on the type of discrepancy, a

footnote may be added to the publicly reported data. The Coordination Team will let the survey

vendor know whether additional information is required to document or correct the discrepancy.

Centers for Medicare & Medicaid Services Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual

APPENDIX A:

VENDOR APPLICATION FORM

Appendix A: Vendor Application Form November 2018



Centers for Medicare & Medicaid Services A-1 Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual


A-2 Centers for Medicare & Medicaid Services Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual

November 2018 Appendix A: Vendor Application Form
























APPENDIX B:

ENGLISH:

MAIL SURVEY COVER LETTERS, MAIL QUESTIONNAIRES,

INSTRUCTIONS FOR SCANNABLE MAIL QUESTIONNAIRE, TELEPHONE INTERVIEW SCRIPT


Instructions for Scannable Mail Questionnaire, Telephone Interview Script November 2018



Centers for Medicare & Medicaid Services B-1 Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual

SAMPLE COVER LETTER FOR FIRST QUESTIONNAIRE MAILING

Outpatient and Ambulatory Surgery CAHPS Survey

To be Printed on Ambulatory Surgery Center or Hospital Outpatient Department or Vendor

Letterhead

«FirstName» «LastName»

«Address1» «Address2»

«City_Name», «State_Code» «Zip_Zip4»

Dear «FirstName» «LastName»:

[FACILITY] would like to learn more about the quality of health care that patients receive in our

facility. [VENDOR], an independent research company, is helping us conduct this survey. Our

records show that you had a surgery or procedure at [FACILITY]. The results of this survey will

be used to help us understand more about patient experiences in our facility.

The enclosed survey asks for your experiences with the outpatient surgery or procedure you had

on [DATE OF SURGERY]. We hope that you will take a few minutes to complete and return the

questionnaire to [VENDOR] in the enclosed, postage-paid envelope.

When answering the questions, please consider your visit to [FACILITY] on [DATE OF

SURGERY]. Do not answer questions based on any other surgeries or procedures you might

have had at either this facility or another.

All information you provide will be confidential and is protected by the Privacy Act. Your

answers to the survey will be grouped with answers from all other survey participants; your

name and identifying information will not be linked to your answers when the data are analyzed.

The overall survey results for [FACILITY NAME] and other facilities will be publicly reported

on the Internet at https://www.medicare.gov/. These results will help people make more

informed decisions when choosing an outpatient or ambulatory surgery facility. Your

participation is voluntary and will not affect any health care benefits you currently receive or will

receive in the future.

If you have any questions about the survey, please call NAME toll-free at 1-800-XXX-XXXX. If

you need help in reading the questions or marking responses, a friend or family member can

assist you. Thank you in advance for your participation. Si desea recibir la versión de la encuesta

en español, por favor llame al 1-800-XXX-XXXX.

Sincerely,

NAME

Title

Enclosures [PRINT UNIQUE SAMPLE ID NUMBER HERE]

https://www.medicare.gov/



B-2 Centers for Medicare & Medicaid Services Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual

SAMPLE COVER LETTER FOR SECOND QUESTIONNAIRE MAILING TO MAIL

SURVEY NONRESPONDENTS



Letterhead




Dear «FirstName» «LastName»:

Recently, we sent you a letter asking for your help on a survey to provide [FACILITY] with

information about the quality of health care provided to patients who receive an outpatient

surgery or procedure in our facility. As of today, we have not yet received your completed

questionnaire. If you have already completed and returned the questionnaire, please accept

our thanks. If you have not completed it, please take a few minutes to do so now. Then

return the questionnaire in the enclosed, postage-paid envelope.

When answering the questions, please consider your visit to [FACILITY] on [DATE OF

SURGERY]. Do not answer questions based on any other surgeries or procedures you might

have had at either our facility or another.

The results of this survey will be used to help us understand more about patient experiences in

our facility. All information you provide will be confidential and is protected by the Privacy Act.

Your answers to the survey will be grouped with answers from all other survey participants; your

name and identifying information will not be linked to your answers when the data are analyzed.

Your participation is voluntary and will not affect any health care benefits you currently receive

or will receive in the future.

If you have any questions about the survey, please call NAME toll-free at 1-800-XXX-XXXX. If

you need help in reading the questions or marking responses, a friend or family member can

assist you. Thank you in advance for your participation. Si desea recibir la versión de la encuesta

en español, por favor llame al 1-800-XXX-XXXX.

Sincerely,

NAME

Title

Enclosures [PRINT UNIQUE SAMPLE ID NUMBER HERE]

Consumer Assessment of Healthcare Providers and Systems

Outpatient and Ambulatory Surgery Survey

(OAS CAHPS®)

A PATIENT EXPERIENCE OF CARE SURVEY ABOUT OUTPATIENT AND AMBULATORY SURGERIES

AND PROCEDURES

ACCORDING TO THE PAPERWORK REDUCTION ACT OF 1995, NO PERSONS ARE REQUIRED TO RESPOND TO A

COLLECTION OF INFORMATION UNLESS IT DISPLAYS A VALID OMB CONTROL NUMBER. THE VALID OMB CONTROL

NUMBER FOR THIS INFORMATION COLLECTION IS 0938-1240. THE TIME REQUIRED TO COMPLETE THIS

INFORMATION COLLECTION IS ESTIMATED TO AVERAGE 8 MINUTES PER RESPONSE, INCLUDING THE TIME TO

REVIEW INSTRUCTIONS, SEARCH EXISTING DATA RESOURCES, GATHER THE DATA NEEDED, AND COMPLETE AND

REVIEW THE INFORMATION COLLECTION. IF YOU HAVE COMMENTS CONCERNING THE ACCURACY OF THE TIME

ESTIMATE(S) OR SUGGESTIONS FOR IMPROVING THIS FORM, PLEASE WRITE TO: CMS, 7500 SECURITY

BOULEVARD, ATTN: PRA REPORTS CLEARANCE OFFICER, MAIL STOP C4-26-05, BALTIMORE, MARYLAND

21244-1850.




SURVEY INSTRUCTIONS

Answer all the questions by checking the box to the left of your answer.

You are sometimes told to skip over some questions in this survey. When this happens you will see an arrow with a note that tells you what question to answer next, like this:

Yes

No If No, go to #1 This survey asks about your experience at the facility named in the cover letter. For this survey, we use the term “procedure” for diagnostic, surgical or other procedures. We refer to “facility” as the place where you had your procedure.

Please answer these questions only for the procedure(s) you had on the date included in the cover letter. Do not include any other procedures in your answers.

I. BEFORE YOUR PROCEDURE

The first few questions are about getting ready for your procedure. Include any information you received before and on the day of your procedure.

1. Before your procedure, did your doctor or anyone from the facility give you all the information you needed about your procedure?

1 Yes, definitely 2 Yes, somewhat 3 No

2. Before your procedure, did your doctor or anyone from the facility give you easy to understand instructions about getting ready for your procedure?


II. ABOUT THE FACILITY AND STAFF

The next questions ask about the day of your procedure.

3. Did the check-in process run smoothly?


4. Was the facility clean?


5. Were the clerks and receptionists at the facility as helpful as you thought they should be?


6. Did the clerks and receptionists at the facility treat you with courtesy and respect?



November 2018 Instructions for Scannable Mail Questionnaire, Telephone Interview Script


7. Did the doctors and nurses treat you with courtesy and respect?


8. Did the doctors and nurses make sure you were as comfortable as possible?


III. COMMUNICATIONS ABOUT YOUR

PROCEDURE

As a reminder, please include any information you received before and on the day of the procedure.

9. Did the doctors and nurses explain your procedure in a way that was easy to understand?


10. Anesthesia is something that would make you feel sleepy or go to sleep during your procedure. Were you given anesthesia?

1 Yes 2 No If No, go to #13

11. Did your doctor or anyone from the facility explain the process of giving anesthesia in a way that was easy to understand?


12. Did your doctor or anyone from the facility explain the possible side effects of the anesthesia in a way that was easy to understand?


13. Discharge instructions include things like symptoms you should watch for after your procedure, instructions about medicines, and home care. Before you left the facility, did you get written discharge instructions?

1 Yes 2 No

IV. YOUR RECOVERY

14. Did your doctor or anyone from the facility prepare you for what to expect during your recovery?





15. Some ways to control pain include prescription medicine, over-the-counter pain relievers or ice packs. Did your doctor or anyone from the facility give you information about what to do if you had pain as a result of your procedure?


16. At any time after leaving the facility, did you have pain as a result of your procedure?

1 Yes 2 No

17. Before you left the facility, did your doctor or anyone from the facility give you information about what to do if you had nausea or vomiting?


18. At any time after leaving the facility, did you have nausea or vomiting as a result of either your procedure or the anesthesia?

1 Yes 2 No

19. Before you left the facility, did your doctor or anyone from the facility give you information about what to do if you had bleeding as a result of your procedure?


20. At any time after leaving the facility, did you have bleeding as a result of your procedure?

1 Yes 2 No

21. Possible signs of infection include fever, swelling, heat, drainage or redness. Before you left the facility, did your doctor or anyone from the facility give you information about what to do if you had possible signs of infection?


22. At any time after leaving the facility, did you have any signs of infection?

1 Yes 2 No




V. YOUR OVERALL EXPERIENCE

23. Using any number from 0 to 10, where 0 is the worst facility possible and 10 is the best facility possible, what number would you use to rate this facility?

0 Worst facility possible

1

2

3

4

5

6

7

8

9

10 Best facility possible

24. Would you recommend this facility to your friends and family?

1 Definitely no 2 Probably no 3 Probably yes 4 Definitely yes

VI. ABOUT YOU

25. In general, how would you rate your overall health?

1 Excellent 2 Very good 3 Good 4 Fair 5 Poor

26. In general, how would you rate your overall mental or emotional health?

1 Excellent 2 Very good 3 Good 4 Fair 5 Poor

27. What is your age?

1 18 to 24 2 25 to 34 3 35 to 44 4 45 to 54 5 55 to 64 6 65 to 74 7 75 to 79 8 80 to 84 9 85 or older

28. Are you male or female?

1 Male 2 Female

29. What is the highest grade or level of school that you have completed?

1 8th grade or less 2 Some high school, but did not

graduate 3 High school graduate or GED 4 Some college or 2-year degree 5 4-year college graduate 6 More than 4-year college

degree




30. Are you of Hispanic, Latino, or Spanish origin?

1 Yes, Hispanic, Latino, or Spanish

2 No, not Hispanic, Latino, or Spanish If No, go to #32

31. Which group best describes you?

1 Mexican, Mexican American, Chicano

2 Puerto Rican 3 Cuban 4 Another Hispanic, Latino, or

Spanish origin

32. What is your race? You may select one or more categories.

1 White 2 Black or African American 3 American Indian or Alaska

Native 4 Asian Indian 5 Chinese 6 Filipino 7 Japanese 8 Korean 9 Vietnamese 10 Other Asian 11 Native Hawaiian 12 Guamanian or Chamorro 13 Samoan 14 Other Pacific Islander

33. How well do you speak English?

1 Very well 2 Well 3 Not well 4 Not at all

34. Do you speak a language other than English at home?

1 Yes 2 No If No, go to #36

35. What is that language?

1 Spanish 2 Other Language

(PLEASE SPECIFY): ________________________ (Please print.)

36. Did someone help you complete this survey?

1 Yes 2 No If No, go to END.

37. How did that person help you? Check all that apply.

1 Read the questions to me 2 Wrote down the answers I

gave 3 Answered the questions for me 4 Translated the questions into

my language 5 Helped in some other way:

(EXPLAIN): ________________________ (Please print.)

6 No one helped me complete this survey

END




(Alternative Instructions for Scannable Forms)

SURVEY INSTRUCTIONS

• Answer all the questions by completely filling in the circle to the left of your answer.

• You are sometimes told to skip over some questions in this survey. When this happens

you will see an arrow with a note that tells you what question to answer next, like this:

Yes

No If No, go to #1

This survey asks about your experience at the facility named in the cover letter. For this survey,

we use the term “procedure” for diagnostic, surgical or other procedures. We refer to “facility”

as the place where you had your procedure.

Please answer these questions only for the procedure(s) you had on the date included in the

cover letter. Do not include any other procedures in your answers.




TELEPHONE INTERVIEW SCRIPT

FOR THE OUTPATIENT AND AMBULATORY SURGERY CAHPS SURVEY (OAS

CAHPS®)

GO TO INTRO4 IF THIS IS A FOLLOW-UP CALL TO AN INTERVIEW THAT WAS

STARTED IN A PRECEDING CALL. OTHERWISE GO TO INTRO1.

INTRO1 Hello, may I please speak to [SAMPLED MEMBER’S NAME]?

IF ASKED WHO IS CALLING:

This is [INTERVIEWER NAME] calling from [VENDOR] on behalf of

[FACILITY NAME]. I’d like to speak to [SAMPLE MEMBER’S NAME] about

a health care survey.

1. YES [GO TO INTRO2]

2. NO, NOT AVAILABLE RIGHT NOW [SET CALLBACK]

3. NO [REFUSAL] [GO TO Q_REF SCREEN ]

4. MENTALLY/PHYSICALLY INCAPABLE [GO TO Q_INELIGIBLE

SCREEN]

INTRO2 (Hello, this is [INTERVIEWER NAME] calling on behalf of [FACILITY

NAME].) [FACILITY NAME] is participating in a survey about patients’

experiences with outpatient surgeries and procedures. The results will be used to

help [FACILITY NAME] understand patient experiences in their facilities.

Your participation in this survey is completely voluntary and will not affect any

health care or benefits you receive. All information you provide is confidential

and is protected by the Privacy Act. The interview will take about 8 minutes to

complete. This call may be monitored or recorded for quality improvement

purposes.

[ADDRESS ANY QUESTIONS/CONCERNS THEN CONTINUE.]

NOTE: THE LENGTH OF THE INTERVIEW WILL DEPEND ON WHETHER THE

FACILITY ADDS SUPPLEMENTAL QUESTIONS TO THE SURVEY. IF

SUPPLEMENTAL ITEMS ARE ADDED, INCREASE THE STATED

NUMBER OF MINUTES IN INTRO2 ACCORDINGLY.




INTRO3 This survey asks about your experience at [FACILITY NAME]. For this survey,

we use the term “procedure” for diagnostic, surgical or other procedures. We refer

to “facility” as the place where you had your procedure. Please answer these

questions only for the procedure you had on [DATE]. Do not include any other

procedures in your answers.

[ADDRESS ANY QUESTIONS/CONCERNS THEN SELECT RESPONSE OPTION.]

1 BEGIN INTERVIEW [GO TO Q1_INTRO]

2 NO, NOT RIGHT NOW [SET CALLBACK]

3 DID NOT RECEIVE SURGERY/PROCEDURE FROM THIS FACILITY

DURING [MONTH] [GO TO Q_INELIGIBLE SCREEN]

4 NO [REFUSAL] [GO TO Q_REF SCREEN]

INEL ITEMS ARE OPTIONAL AND ASKED ONLY IF NEW TELEPHONE NUMBER

IDENTIFIED.

INEL1 Were you ever a patient at [FACILITY NAME]?

1 YES [GO TO INEL2]

2 NO [GO TO INEL_END]

INEL2 When was this?

NOTE: IF DATE IS WITHIN 2 WEEKS OF SURGERY DATE ON RECORD,

GO TO Q1_INTRO. IF NOT, GO TO INEL_END.

INEL_END Thank you for your time. It looks like we made a mistake. Have a good

(day/evening).

INTRO4 USED ONLY IF CALLING SAMPLE PATIENT BACK TO COMPLETE A

SURVEY THAT WAS STARTED IN A PREVIOUS CALL. NOTE THAT THE

PATIENT MUST HAVE ANSWERED AT LEAST ONE QUESTION IN THE

SURVEY IN A PRECEDING CALL.

Hello, may I please speak to [SAMPLE MEMBER’S NAME]?


This is [INTERVIEWER NAME] calling from [VENDOR] on behalf of




[FACILITY NAME]. I’d like to speak to [SAMPLE MEMBER’S NAME] about

a health care survey.

1 YES, SAMPLE PATIENT IS AVAILABLE AND ON PHONE NOW [GO

TO INTRO5]

2 NO, NOT AVAILABLE RIGHT NOW [SET CALLBACK]


4 MENTALLY/PHYSICALLY INCAPABLE [GO TO Q_INELIGIBLE

SCREEN]

INTRO5 Hello, this is [INTERVIEWER NAME] calling from [VENDOR]. I am calling to

continue the survey that we started in a previous call, regarding your experience at

[FACILITY NAME]. I’d like to continue with that survey now.

1 CONTINUE WITH INTERVIEW AT FIRST UNANSWERED QUESTION



Q1_INTRO The first few questions are about getting ready for your procedure. Include any

information you received before and on the day of your procedure.

Q1. Before your procedure, did your doctor or anyone from the facility give you all

the information you needed about your procedure? Would you say…

1 Yes, definitely,

2 Yes, somewhat, or

3 No?

M MISSING/DK

Q2. Before your procedure, did your doctor or anyone from the facility give you easy

to understand instructions about getting ready for your procedure? Would you

say…

1 Yes, definitely,

2 Yes, somewhat, or

3 No?

M MISSING/DK

Q3_INTRO The next questions ask about the day of your procedure.




Q3. Did the check-in process run smoothly? Would you say…

1 Yes, definitely,

2 Yes, somewhat, or

3 No?

M MISSING/DK

Q4. Was the facility clean? Would you say…

1 Yes, definitely,

2 Yes, somewhat, or

3 No?

M MISSING/DK

Q5. Were the clerks and receptionists at the facility as helpful as you thought they

should be? Would you say…

1 Yes, definitely,

2 Yes, somewhat, or

3 No?

M MISSING/DK

Q6. Did the clerks and receptionists at the facility treat you with courtesy and respect?

Would you say…

1 Yes, definitely,

2 Yes, somewhat, or

3 No?

M MISSING/DK

Q7. Did the doctors and nurses treat you with courtesy and respect? Would you say…

1 Yes, definitely,

2 Yes, somewhat, or

3 No?

M MISSING/DK




Q8. Did the doctors and nurses make sure you were as comfortable as possible?

Would you say…

1 Yes, definitely,

2 Yes, somewhat, or

3 No?

M MISSING/DK

Q9_INTRO As a reminder, please include any information you received before and on the day

of the procedure.

Q9. Did the doctors and nurses explain your procedure in a way that was easy to

understand? Would you say…

1 Yes, definitely,

2 Yes, somewhat, or

3 No?

M MISSING/DK

Q10. Anesthesia is something that would make you feel sleepy or go to sleep during

your procedure. Were you given anesthesia?

1 YES

2 NO [GO TO Q13]

M MISSING/DK [GO TO Q13]

Q11. Did your doctor or anyone from the facility explain the process of giving

anesthesia in a way that was easy to understand? Would you say…

1 Yes, definitely,

2 Yes, somewhat, or

3 No?

M MISSING/DK




Q12. Did your doctor or anyone from the facility explain the possible side effects of the

anesthesia in a way that was easy to understand? Would you say…

1 Yes, definitely,

2 Yes, somewhat, or

3 No?

M MISSING/DK

Q13. Discharge instructions include things like symptoms you should watch for after

your procedure, instructions about medicines, and home care. Before you left the

facility, did you receive written discharge instructions?

1 YES

2 NO

M MISSING/DK

Q14. Did your doctor or anyone from the facility prepare you for what to expect during

your recovery? Would you say…

1 Yes, definitely,

2 Yes, somewhat, or

3 No?

M MISSING/DK

Q15. Some ways to control pain include prescription medicine, over-the-counter pain

relievers or ice packs. Did your doctor or anyone from the facility give you

information about what to do if you had pain as a result of your procedure?

Would you say…

1 Yes, definitely,

2 Yes, somewhat, or

3 No?

M MISSING/DK

Q16. At any time after leaving the facility, did you have pain as a result of your

procedure?

1 YES

2 NO

M MISSING/DK




Q17. Before you left the facility, did your doctor or anyone from the facility give you

information about what to do if you had nausea or vomiting? Would you say…

1 Yes, definitely,

2 Yes, somewhat, or

3 No?

M MISSING/DK

Q18. At any time after leaving the facility, did you have nausea or vomiting as a result

of either your procedure or the anesthesia?

1 YES

2 NO

M MISSING/DK

Q19. Before you left the facility, did your doctor or anyone from the facility give you

information about what to do if you had bleeding as a result of your procedure?

Would you say…

1 Yes, definitely,

2 Yes, somewhat, or

3 No?

M MISSING/DK

Q20. At any time after leaving the facility, did you have bleeding as a result of your

procedure?

1 YES

2 NO

M MISSING/DK

Q21. Possible signs of infection include fever, swelling, heat, drainage or redness.

Before you left the facility, did your doctor or anyone from the facility give you

information about what to do if you had possible signs of infection? Would you

say…

1 Yes, definitely,

2 Yes, somewhat, or

3 No?

M MISSING/DK




Q22. At any time after leaving the facility, did you have any signs of infection?

1 YES

2 NO

M MISSING/DK

Q23_INTRO The next two questions ask about your overall experience.

Q23. Using any number from 0 to 10, where 0 is the worst facility possible and 10 is

the best facility possible, what number would you use to rate this facility?

0 WORST FACILITY POSSIBLE

1

2

3

4

5

6

7

8

9

10 BEST FACILITY POSSIBLE

M MISSING/DK

Q24. Would you recommend this facility to your friends and family? Would you say…

1 Definitely no,

2 Probably no,

3 Probably yes, or

4 Definitely yes?

M MISSING/DK

Q25. In general, how would you rate your overall health? Would you say …

1 Excellent,

2 Very good,

3 Good,

4 Fair, or

5 Poor?

M MISSING/DK




Q26. In general, how would you rate your overall mental or emotional health? Would

you say …

1 Excellent,

2 Very good,

3 Good,

4 Fair, or

5 Poor?

M MISSING/DK

Q27. What is your age?

1 18 TO 24

2 25 TO 34

3 35 TO 44

4 45 TO 54

5 55 TO 64

6 65 TO 74

7 75 TO 79

8 80 TO 84

9 85 OR OLDER

M MISSING/DK

Q28. Are you male or female?

1 MALE

2 FEMALE

M MISSING/DK

Q29. What is the highest grade or level of school that you have completed? Would you

say…

1 8th grade or less,

2 Some high school, but did not graduate,

3 High school graduate or GED,

4 Some college or 2-year degree,

5 4-year college graduate, or

6 More than 4-year college degree?

M MISSING/DK




Q30. Are you of Hispanic, Latino, or Spanish origin?

1 YES

2 NO [GO TO Q32]


Q31. Which group best describes you…

1 Mexican, Mexican American, Chicano,

2 Puerto Rican,

3 Cuban, or

4 Another Hispanic, Latino, or Spanish origin?

M MISSING/DK

Q32. What is your race? You may select one or more categories. Are you…

1 White,

2 Black or African American,

3 American Indian or Alaska Native,

4 Asian, or

5 Native Hawaiian or Pacific Islander?

6 NONE OF THE ABOVE

M MISSING/DK

PROGRAMMER INSTRUCTIONS: IF WHITE ONLY, BLACK/AFRICAN AMERICAN

ONLY, OR AMERICAN INDIAN/ALASKA NATIVE ONLY, OR ANY COMBINATION OF

THESE THREE OPTIONS, NONE OF THE ABOVE OR MISSING/DK, GO TO Q33.

IF ASIAN ONLY, GO TO Q32A. IF WHITE, BLACK/AFRICAN AMERICAN, AND/OR

AMERICAN INDIAN/ALASKA NATIVE AND ASIAN ARE CHOSEN, GO TO Q32A. IF

NATIVE HAWAIIAN/PACIFIC ISLANDER IS ALSO CHOSEN, SEE INSTRUCTION

AFTER Q32A.

IF NATIVE HAWAIIAN/PACIFIC ISLANDER ONLY, GO TO Q32B. IF WHITE,

BLACK/AFRICAN AMERICAN, AND/OR AMERICAN INDIAN/ALASKA NATIVE AND

NATIVE HAWAIIAN/PACIFIC ISLANDER ARE CHOSEN, GO TO Q32B.




Q32a. Which groups best describe you? You may select one or more categories. Are

you…

1 Asian Indian,

2 Chinese,

3 Filipino,

4 Japanese,

5 Korean,

6 Vietnamese, or

7 Other Asian?

8 NONE OF THE ABOVE

M MISSING/DK

IF NATIVE HAWAIIAN/PACIFIC ISLANDER WAS ALSO CHOSEN IN Q32, GO TO Q32B.

ELSE, GO TO Q33.

Q32b. Which groups best describe you? You may select one or more categories. Are

you…

1 Native Hawaiian,

2 Guamanian or Chamorro,

3 Samoan, or

4 Other Pacific Islander?

5 NONE OF THE ABOVE

M MISSING/DK

Q33. How well do you speak English? Would you say…

1 Very well,

2 Well,

3 Not well, or

4 Not at all?

M MISSING/DK

Q34. Do you speak a language other than English at home? Would you say…

1 Yes, I speak a language other than English, or

2 No, I speak English at home? [GO TO Q_END]

M MISSING/DK [GO TO Q_END]




Q35. What is that language?

1 SPANISH [GO TO Q_END]

2 OTHER LANGUAGE [GO TO Q35a]


Q35a. What is that language? [ENTER RESPONSE BELOW. ALLOW UP TO 50

CHARACTERS]

M MISSING/DK

Q_END These are all the questions I have for you. Thank you for your time. Have a good

(day/evening).

INELIGIBLE SCREEN:

Q_INELIG Thank you for your time. Have a good (day/evening).

REFUSAL SCREEN:

Q_REF Thank you for your time. Have a good (day/evening).






APPENDIX C:

SPANISH: MAIL SURVEY COVER LETTERS,

MAIL QUESTIONNAIRES,

INSTRUCTIONS FOR SCANNABLE MAIL QUESTIONNAIRE, TELEPHONE INTERVIEW SCRIPT





Centers for Medicare & Medicaid Services C-1 Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual




Letterhead




Estimado(a) «FirstName» «LastName»:

[FACILITY NAME] participará en una encuesta nacional para saber más sobre la calidad de la

atención médica que reciben los pacientes. [VENDOR], una organización independiente que

realiza estudios, está ayudando a realizar esta encuesta. Nuestros registros muestran que usted se

hizo un procedimiento o cirugía en [FACILITY NAME]. Los resultados se usarán para ayudar a

comprender las experiencias de los pacientes de nuestro centro.

La encuesta que adjuntamos hace preguntas sobre sus experiencias con el procedimiento o la

cirugía que recibió el [Date of Procedure]. Esperamos que tome unos cuantos minutos para

completar y devolver el cuestionario a [VENDOR], en el sobre adjunto con franqueo postal

pagado.

Al contestar las preguntas, tenga en cuenta su visita a [FACILITY NAME] el [Date of

Procedure]. No responda las preguntas acerca de otras cirugías o procedimientos que haya tenido

en este centro de cirugía o en otro lugar.

Toda la información que proporcione será confidencial y estará protegida por la Ley de

Privacidad. Sus respuestas a la encuesta se agruparán con las de otros participantes del estudio.

Su nombre y su información de identidad no se asociarán a sus respuestas cuando se analicen los

datos. Los resultados generales de la encuesta de [FACILITY NAME] y de otras instalaciones se

reportará públicamente en internet en https://www.medicare.gov/. Estos resultados ayudarán a

las personas a tomar decisiones más informadas cuando eligen un centro para cirugía externa o

ambulatoria. Su participación es voluntaria y no afectará a ningún beneficio de atención médica

que usted reciba ahora o en el futuro.

Si tiene alguna pregunta sobre la encuesta, puede llamar al personal de la encuesta a la línea

gratuita 1-800-XXX-XXXX. Si necesita ayuda para leer las preguntas o marcar respuestas, una

amistad o miembro de la familia puede ayudarle. Le agradecemos de antemano por su

participación.




C-2 Centers for Medicare & Medicaid Services Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual

Atentamente,

NAME

Title

Documento adjunto [PRINT UNIQUE SAMPLE ID NUMBER HERE]








Letterhead




Estimado(a) «FirstName» «LastName»:

Hace poco, le enviamos una carta pidiéndole su ayuda en una encuesta para dar información a

[FACILITY] sobre la calidad de la atención médica que reciben los pacientes de cirugía para

pacientes externos o ambulatorios. Al día de hoy, no hemos recibido el cuestionario con sus

respuestas. Si usted ya completó el cuestionario y lo regresó, se lo agradecemos. Si no lo ha

completado, por favor dedique unos minutos para hacerlo ahora. Luego envíe el

cuestionario en el sobre adjunto con franqueo postal pagado.

Al contestar las preguntas, por favor tenga en cuenta su visita a [FACILITY] el [DATE OF

SURGERY]. No responda las preguntas acerca de otras cirugías o procedimientos que haya

tenido en este centro de cirugía o en otro lugar.

Los resultados de la encuesta se usarán para ayudar a comprender las experiencias de los

pacientes del centro. Toda la información que proporcione será confidencial y estará protegida

por la Ley de Privacidad. Sus respuestas a la encuesta se agruparán con las de otros participantes

del estudio. Su nombre y su información de identidad no se asociarán a sus respuestas cuando se

analicen los datos. Su participación es voluntaria y no afectará a ningún beneficio de atención

médica que usted reciba ahora o en el futuro.

Si tiene alguna pregunta sobre la encuesta, puede llamar al personal de la encuesta a la línea

gratuita 1-800-XXX-XXXX. Si necesita ayuda para leer las preguntas o marcar respuestas, una

amistad o miembro de la familia puede ayudarle. Le agradecemos de antemano por su

participación.

Atentamente,

NAME

Title

Documento adjunto [PRINT UNIQUE SAMPLE ID NUMBER HERE]

Encuesta CAHPS sobre la cirugía externa o ambulatoria

(OAS CAHPS®)

UNA ENCUESTA DE PACIENTES SOBRE LA EXPERIENCIA CON LA ATENCIÓN DE CIRUGÍAS Y

PROCEDIMIENTOS AMBULATORIOS

DE ACUERDO A LA LEY DE REDUCCIÓN DE TRABAJO ADMINISTRATIVO DE 1995 (PAPERWORK REDUCTION ACT

OF 1995), NINGUNA PERSONA TIENE LA OBLIGACIÓN DE RESPONDER A UN CUESTIONARIO QUE SOLICITE

INFORMACIÓN, A MENOS QUE LLEVE UN NÚMERO DE CONTROL DE OMB (OFICINA DE ADMINISTRACIÓN Y

PRESUPUESTO) VÁLIDO. EL NÚMERO DE CONTROL OMB VÁLIDO PARA ESTE CUESTIONARIO ES 0938-1240. SE

ESTIMA QUE EL TIEMPO PROMEDIO NECESARIO PARA COMPLETAR ESTE CUESTIONARIO ES DE 8 MINUTOS POR

RESPUESTA, INCLUYENDO EL TIEMPO PARA REVISAR LAS INSTRUCCIONES, BUSCAR EN LAS FUENTES DE DATOS

EXISTENTES, RECOPILAR LOS DATOS NECESARIOS, COMPLETAR Y REVISAR LA INFORMACIÓN RECOPILADA. SI

TIENE ALGÚN COMENTARIO SOBRE LA EXACTITUD DEL TIEMPO ESTIMADO O SUGERENCIAS PARA MEJORAR ESTE

FORMULARIO, POR FAVOR ESCRIBA A: CMS, 7500 SECURITY BOULEVARD, ATTN: PRA REPORTS CLEARANCE

OFFICER, MAIL STOP C4-26-05, BALTIMORE, MARYLAND 21244-1850.




INSTRUCCIONES PARA LA ENCUESTA

Conteste todas las preguntas marcando el cuadrito que aparece a la izquierda de su respuesta.

A veces se le pide que salte algunas preguntas en esta encuesta. Cuando esto ocurra, verá una flecha con una nota que le indicará cuál es la siguiente pregunta a la que tiene que ir, de esta manera:

Sí

No Si contestó “No”,

pase a la pregunta 1 Esta encuesta pregunta acerca de sus experiencias en el centro ambulatorio que se menciona en la carta de presentación. Para esta encuesta, usamos el término “procedimiento” para procedimientos de diagnóstico, cirugías u otros procedimientos. Nos referimos al “centro ambulatorio” como el lugar en donde se realizó su procedimiento.

Por favor, responda las preguntas solo para el/los procedimiento(s) que tuvo en la fecha que se incluye en la carta de presentación. No incluya ningún otro procedimiento en sus respuestas.

I. ANTES DEL PROCEDIMIENTO

Las primeras preguntas son acerca de la preparación para su procedimiento. Incluya cualquier información que haya recibido antes o en el día del procedimiento.

1. Antes del procedimiento, ¿le dio un doctor o alguien del centro ambulatorio toda la información que necesitaba acerca de su procedimiento?

1 Sí, definitivamente 2 Sí, algo 3 No

2. Antes del procedimiento, ¿le dio un doctor o alguien del centro ambulatorio instrucciones fáciles de entender sobre lo que necesitaba para prepararse para su procedimiento?


II. ACERCA DEL CENTRO

AMBULATORIO Y EL PERSONAL

Las siguientes preguntas se refieren al día de su procedimiento.

3. ¿Fue fácil el proceso de registro?


4. ¿Estaba limpio el centro ambulatorio?





5. ¿Le ayudó el personal administrativo y de recepción del centro ambulatorio tanto como usted pensaba que debían hacerlo?


6. ¿Le trató el personal administrativo y de recepción del centro ambulatorio con cortesía y respeto?


7. ¿Le trataron los doctores y enfermeras con cortesía y respeto?


8. ¿Se aseguraron los doctores y enfermeras que usted estuviera tan cómodo como fuera posible?


III. COMUNICACIÓN SOBRE SU

PROCEDIMIENTO

Le recordamos que por favor incluya cualquier información que haya recibido ya sea antes o en el día del procedimiento.

9. ¿Le explicaron los doctores y enfermeras el procedimiento de tal manera que fue fácil de entender?


10. La anestesia es algo que le haría sentir sueño o dormir durante el procedimiento. ¿Le dieron anestesia?

1 Sí 2 No Si contestó “No”,

pase a la pregunta 13

11. ¿Le explicó el doctor o alguien del centro ambulatorio el proceso de dar anestesia de tal manera que fue fácil de entender?


12. ¿Le explicó el doctor o alguien del centro ambulatorio los posibles efectos secundarios de la anestesia de tal manera que fuera fácil de entender?





13. Las instrucciones al ser dado de alta incluyen observar los síntomas después de su procedimiento, instrucciones sobre los medicamentos y cuidado en el hogar. Antes de salir del centro ambulatorio, ¿recibió instrucciones por escrito al darle de alta?

1 Sí 2 No

IV. SU RECUPERACIÓN

14. ¿Le preparó el doctor o alguien del personal del centro ambulatorio sobre qué esperar durante su recuperación?


15. Algunas maneras para controlar el dolor incluyen medicamentos recetados, medicamentos para el dolor de venta libre o bolsas de hielo. ¿Su doctor o alguien del centro ambulatorio le dio información sobre qué hacer si tenía dolor como resultado de su procedimiento?


16. En algún momento después de salir del centro ambulatorio, ¿tuvo dolor debido al procedimiento?

1 Sí 2 No

17. Antes de salir del centro ambulatorio, ¿su doctor o alguien del personal del centro ambulatorio le dio información sobre qué hacer si tenía náusea o vómitos?


18. En algún momento después de salir del centro ambulatorio, ¿tuvo náusea o vómitos como resultado del procedimiento o la anestesia?

1 Sí 2 No

19. Antes de salir del centro ambulatorio, ¿su doctor o alguien del personal del centro ambulatorio le dio información sobre qué hacer si sangraba como resultado del procedimiento?


20. En algún momento después de salir del centro ambulatorio, ¿tuvo sangrado como resultado del procedimiento?

1 Sí 2 No




21. Posibles señales de infección incluyen fiebre, hinchazón, calor, secreción o enrojecimiento. Antes de salir del centro ambulatorio, ¿su doctor o alguien del personal del centro ambulatorio le dio información sobre qué hacer si tuviera señales de infección?


22. En algún momento después de salir del centro ambulatorio, ¿tuvo señales de infección?

1 Sí 2 No

V. SU EXPERIENCIA GENERAL

23. Usando un número del 0 al 10, en donde 0 es el peor centro ambulatorio posible y 10 es el mejor centro ambulatorio posible, ¿qué número usaría para calificar éste centro ambulatorio?

0 Peor centro ambulatorio

posible

1

2

3

4

5

6

7

8

9

10 Mejor centro ambulatorio

posible

24. ¿Recomendaría este centro ambulatorio a sus amistades y familia?

1 Definitivamente no 2 Probablemente no 3 Probablemente sí 4 Definitivamente sí

VI. ACERCA DE USTED

25. En general, ¿cómo calificaría su salud general?

1 Excelente 2 Muy buena 3 Buena 4 Regular 5 Mala

26. En general, ¿cómo calificaría su salud mental o emocional?

1 Excelente 2 Muy buena 3 Buena 4 Regular 5 Mala

27. ¿Qué edad tiene usted?

1 18 a 24 años 2 25 a 34 años 3 35 a 44 años 4 45 a 54 años 5 55 a 64 años 6 65 a 74 años 7 75 a 79 años 8 80 a 84 años 9 85 años o más




28. ¿Es usted hombre o mujer?

1 Hombre 2 Mujer

29. ¿Cuál es el nivel o año escolar más avanzado que usted ha completado?

1 8 años de escuela o menos 2 9–12 años de escuela, pero

sin graduarse 3 Graduado de la escuela

secundaria, Diploma de escuela secundaria, preparatoria o su equivalente (o GED)

4 Algunos cursos universitarios o un título universitario de un programa de 2 años

5 Título universitario de 4 años 6 Título universitario de más de

4 años

30. ¿Es usted de origen hispano, latino o español?

1 Sí, soy de origen hispano, latino o español

2 No, no soy de origen hispano, latino o español Si contestó “No”, pase a la pregunta 32

31. ¿Cuál grupo lo(a) describe mejor?

1 Mexicano, mexicano americano, chicano

2 Puertorriqueño 3 Cubano 4 Otro origen hispano, latino o

español

32. ¿Cuál es su raza? Puede seleccionar una o más categorías.

1 Blanca 2 Negra o afro americana 3 Indígena americana o nativa

de Alaska 4 India asiática 5 China 6 Filipina 7 Japonesa 8 Coreana 9 Vietnamita 10 Otra raza asiática 11 Nativa de Hawai 12 Procedente de Guam o

Chamorro 13 Samoana 14 Otra raza de las islas del

Pacífico

33. ¿Qué tan bien habla usted inglés?

1 Muy bien 2 Bien 3 No bien 4 Nada

34. ¿Habla usted algún otro idioma que no sea inglés en casa?

1 Sí 2 No Si contestó “No”, pase

a la pregunta 36

35. ¿Qué idioma habla en su casa?

1 Español 2 Otro idioma

(FAVOR DE ESPECIFICAR): _______________________ (Favor de usar letra tipo imprenta.)




36. ¿Le ayudó alguien a completar esta encuesta?

1 Sí 2 No Si contestó No, vaya

al FINAL.

37. ¿De qué manera le ayudó esa persona? Marque todas las respuestas que correspondan.

1 Me leyó las preguntas 2 Anotó las respuestas que le di 3 Contestó las preguntas por mi 4 Me tradujo las preguntas a mi

idioma 5 Me ayudó de alguna otra

manera: (EXPLIQUE): _______________________ (Favor de usar letra tipo imprenta.)

6 Nadie me ayudó a completar esta encuesta

FINAL





INSTRUCCIONES PARA LA ENCUESTA

• Responda todas las preguntas llenando por completo el círculo a la izquierda de su

respuesta.

• A veces se le indica que debe saltarse algunas preguntas de esta encuesta. Cuando ocurra,

verá una flecha con una nota que le indica qué pregunta es la siguiente, de esta manera:

Sí

No Si contestó “No”, pase a la pregunta 1

Esta encuesta pregunta acerca de sus experiencias en el centro ambulatorio que se menciona en

la carta de presentación. Para esta encuesta, usamos el término “procedimiento” para

procedimientos de diagnóstico, cirugías u otros procedimientos. Nos referimos al “centro

ambulatorio” como el lugar en donde se realizó su procedimiento.

Por favor, responda las preguntas solo para el/los procedimiento(s) que tuvo en la fecha

que se incluye en la carta de presentación. No incluya ningún otro procedimiento en sus

respuestas.




TELEPHONE INTERVIEW SCRIPT

FOR THE OUTPATIENT AND AMBULATORY SURGERY CAHPS SURVEY (OAS

CAHPS®)

GO TO INTRO4 IF THIS IS A FOLLOW-UP CALL TO AN INTERVIEW THAT WAS

STARTED IN A PRECEDING CALL. OTHERWISE GO TO INTRO1.

INTRO1 [Buenos días/Buenas tardes/Buenas noches], ¿puedo hablar con [SAMPLE

MEMBER’S NAME]?


Mi nombre es [INTERVIEWER NAME] y estoy llamando de [VENDOR] en

nombre de [FACILITY NAME]. Me gustaría hablar con [SAMPLE MEMBER’S

NAME] sobre una encuesta sobre la atención médica.

1 YES [GO TO INTRO2]




SCREEN]

INTRO2 [Buenos días/Buenas tardes/Buenas noches], mi nombre es [INTERVIEWER

NAME] y estoy llamando de parte de [FACILITY NAME]. [FACILITY NAME]

está participando en una encuesta sobre las experiencias de los pacientes que han

tenido una cirugía o un procedimiento ambulatorio. Los resultados se usarán para

ayudar a [FACILITY NAME] a comprender las experiencias de los pacientes en

su centro ambulatorio.

Su participación en esta encuesta es completamente voluntaria y no afectará a

ningún beneficio de atención médica que usted recibe. Toda la información que

proporcione es confidencial y está protegida por la Ley de Privacidad. La

entrevista se puede completar como en 8 minutos. Esta llamada puede ser

escuchada o grabada con propósitos de mejorar la calidad.

[ADDRESS ANY QUESTIONS/CONCERNS THEN CONTINUE.]

NOTE: THE LENGTH OF THE INTERVIEW WILL DEPEND ON WHETHER THE

FACILITY ADDS SUPPLEMENTAL QUESTIONS TO THE SURVEY. IF




SUPPLEMENTAL ITEMS ARE ADDED, INCREASE THE STATED

NUMBER OF MINUTES IN INTRO2 ACCORDINGLY.

INTRO3 La encuesta hace preguntas sobre sus experiencias con [FACILITY NAME]. Para

esta encuesta, usamos el término “procedimiento” para procedimientos de

diagnóstico, cirugías u otros procedimientos. Nos referimos al “centro

ambulatorio” como el lugar en donde se realizó su procedimiento. Por favor,

responda a estas preguntas solo para el procedimiento que se realizó el [DATE]. No

incluya ningún otro procedimiento en sus respuestas.

[ADDRESS ANY QUESTIONS/CONCERNS THEN SELECT RESPONSE OPTION.]

1 BEGIN INTERVIEW [GO TO Q1_INTRO]


3 DID NOT RECEIVE SURGERY/PROCEDURE FROM THIS FACILITY

DURING [MONTH] [GO TO Q_INELIGIBLE SCREEN]


INEL ITEMS ARE OPTIONAL AND ASKED ONLY IF NEW TELEPHONE NUMBER

IDENTIFIED.

INEL1 ¿Alguna vez fue usted un paciente en [FACILITY NAME]?

3 YES [GO TO INEL2]

4 NO [GO TO INEL_END]

INEL2 ¿Cuándo fue esto?

NOTE: IF DATE IS WITHIN 2 WEEKS OF SURGERY DATE ON RECORD,

GO TO Q1_INTRO. IF NOT, GO TO INEL_END.

INEL_END Gracias por su tiempo. Parece ser que nos equivocamos. Tenga usted (un buen

día/ una buena tarde).

INTRO4 USED ONLY IF CALLING SAMPLE PATIENT BACK TO COMPLETE A

SURVEY THAT WAS BEGUN IN A PREVIOUS CALL. NOTE THAT THE

PATIENT MUST HAVE ANSWERED AT LEAST ONE QUESTION IN THE

SURVEY IN A PRECEDING CALL.




Buenos días/Buenas tardes/Buenas noches. ¿Podría hablar con [SAMPLE

MEMBER’S NAME]?


Mi nombre es [INTERVIEWER NAME] y estoy llamando de [VENDOR] en

nombre de [FACILITY NAME]. Me gustaría hablar con [SAMPLE MEMBER’S

NAME] acerca de un estudio sobre la atención médica.

1 YES, SAMPLE PATIENT IS AVAILABLE AND ON PHONE NOW [GO

TO INTRO5]




SCREEN]

INTRO5 Buenos días/Buenas tardes/Buenas noches. Mi nombre es [INTERVIEWER

NAME] y estoy llamando de [VENDOR]. Estoy llamando para continuar la

encuesta que comenzamos en una llamada anterior, sobre sus experiencias con

[FACILITY NAME]. Me gustaría continuar con esa encuesta en este momento.

1 CONTINUE WITH INTERVIEW AT FIRST UNANSWERED QUESTION



Q1_INTRO Las primeras preguntas son acerca de la preparación para su procedimiento.

Incluya cualquier información que haya recibido antes o en el día del

procedimiento.

Q1. Antes del procedimiento, ¿le dio un doctor o alguien del centro ambulatorio toda

la información que necesitaba acerca de su procedimiento? ¿Diría usted que…

1 Sí, definitivamente,

2 Sí, algo o

3 No?

M MISSING/DK




Q2. Antes del procedimiento, ¿le dio un doctor o alguien del centro ambulatorio

instrucciones fáciles de entender sobre lo que necesitaba para prepararse para su

procedimiento? ¿Diría que…


2 Sí, algo o

3 No?

M MISSING/DK

Q3 INTRO Las siguientes preguntas se refieren al día de su procedimiento.

Q3. ¿Fue fácil el proceso de registro? ¿Diría que…


2 Sí, algo o

3 No?

M MISSING/DK

Q4. ¿Estaba limpio el centro ambulatorio? ¿Diría que…


2 Sí, algo o

3 No?

M MISSING/DK

Q5. ¿Le ayudó el personal administrativo y de recepción del centro ambulatorio tanto

como usted pensaba que debían hacerlo? ¿Diría que…


2 Sí, algo o

3 No?

M MISSING/DK

Q6. ¿Le trató el personal administrativo y de recepción del centro ambulatorio con

cortesía y respeto? ¿Diría que…


2 Sí, algo o

3 No?

M MISSING/DK




Q7. ¿Le trataron los doctores y enfermeras con cortesía y respeto? ¿Diría que…


2 Sí, algo o

3 No?

M MISSING/DK

Q8. ¿Se aseguraron los doctores y enfermeras que usted estuviese tan cómodo como

fuera posible? ¿Diría que…


2 Sí, algo o

3 No?

M MISSING/DK

Q9_INTRO Le recordamos que por favor incluya cualquier información que haya recibido ya

sea antes o en el día del procedimiento.

Q9. ¿Le explicaron los doctores y enfermeras el procedimiento de tal manera que fue

fácil de entender? ¿Diría usted que…


2 Sí, algo o

3 No?

M MISSING/DK

Q10. La anestesia es algo que le haría sentir sueño o dormir durante el procedimiento.

¿Le dieron anestesia?

1 SÍ

2 NO [GO TO Q13]


Q11. ¿Le explicó el doctor o alguien del centro ambulatorio el proceso de dar anestesia

de tal manera que fue fácil de entender? ¿Diría usted que…


2 Sí, algo o

3 No?

M MISSING/DK




Q12. ¿Le explicó el doctor o alguien del centro ambulatorio los posibles efectos

secundarios de la anestesia de tal manera que fuera fácil de entender? ¿Diría usted

que…


2 Sí, algo o

3 No?

M MISSING/DK

Q13. Las instrucciones al ser dado de alta incluyen observar los síntomas después de su

procedimiento, instrucciones sobre los medicamentos y cuidado en el hogar.

Antes de salir del centro ambulatorio, ¿recibió instrucciones por escrito al darle de

alta?

1 SÍ

2 NO

M MISSING/DK

Q14. ¿Le preparó el doctor o alguien del personal del centro ambulatorio sobre qué

esperar durante su recuperación? ¿Diría que…


2 Sí, algo o

3 No?

M MISSING/DK

Q15. Algunas maneras para controlar el dolor incluyen medicamentos recetados,

medicamentos para el dolor de venta libre o bolsas de hielo. ¿Su doctor o alguien

del centro ambulatorio le dio información sobre qué hacer si tenía dolor como

resultado de su procedimiento? ¿Diría que…


2 Sí, algo o

3 No?

M MISSING/DK




Q16. En algún momento después de salir del centro ambulatorio, ¿tuvo dolor debido al

procedimiento?

1 SÍ

2 NO

M MISSING/DK

Q17. Antes de salir del centro ambulatorio, ¿su doctor o alguien del personal del centro

ambulatorio le dio información sobre qué hacer si tenía náusea o vómitos? ¿Diría

que…


2 Sí, algo o

3 No?

M MISSING/DK

Q18. En algún momento después de salir del centro ambulatorio, ¿tuvo náusea o

vómitos como resultado del procedimiento o la anestesia?

1 SÍ

2 NO

M MISSING/DK

Q19. Antes de salir del centro ambulatorio, ¿su doctor o alguien del personal del centro

ambulatorio le dio información sobre qué hacer si sangraba como resultado del

procedimiento? ¿Diría que…


2 Sí, algo o

3 No?

M MISSING/DK

Q20. En algún momento después de salir del centro ambulatorio, ¿tuvo sangrado como

resultado del procedimiento?

1 SÍ

2 NO

M MISSING/DK




Q21. Posibles señales de infección incluyen fiebre, hinchazón, calor, secreción o

enrojecimiento. Antes de salir del centro ambulatorio, ¿su doctor o alguien del

personal del centro ambulatorio le dio información sobre qué hacer si tuviera

señales de infección? ¿Diría que…


2 Sí, algo o

3 No?

M MISSING/DK

Q22. En algún momento después de salir del centro ambulatorio, ¿tuvo señales de

infección?

1 SÍ

2 NO

M MISSING/DK

Q23_INTRO Las siguientes preguntas se refieren a su experiencia en general.

Q23. Usando un número del 0 al 10, en donde 0 es el peor centro ambulatorio posible y

10 es el mejor centro ambulatorio posible, ¿qué número usaría para calificar éste

centro ambulatorio?

0 PEOR CENTRO AMBULATORIO POSIBLE

1

2

3

4

5

6

7

8

9

10 MEJOR CENTRO AMBULATORIO POSIBLE

M MISSING/DK




Q24. ¿Recomendaría este centro ambulatorio a sus amistades y familia? ¿Diría usted

que…

1 Definitivamente no,

2 Probablemente no,

3 Probablemente sí o

4 Definitivamente sí?

M MISSING/DK

Q25. En general, ¿cómo calificaría su salud general? ¿Diría que es…

1 Excelente,

2 Muy buena,

3 Buena,

4 Regular o

5 Mala?

M MISSING/DK

Q26. En general, ¿cómo calificaría su salud mental o emocional? ¿Diría que es…

1 Excelente,

2 Muy buena,

3 Buena,

4 Regular o

5 Mala?

M MISSING/DK

Q27. ¿Qué edad tiene usted?

1 18 A 24 AÑOS

2 25 A 34 AÑOS

3 35 A 44 AÑOS

4 45 A 54 AÑOS

5 55 A 64 AÑOS

6 65 A 74 AÑOS

7 75 A 79 AÑOS

8 80 A 84 AÑOS

9 85 AÑOS O MÁS

M MISSING/DK




Q28. ¿Es usted hombre o mujer?

1 HOMBRE

2 MUJER

M MISSING/DK

Q29. ¿Cuál es el nivel o año escolar más avanzado que usted ha completado? ¿Diría

que…

1 8 años de escuela o menos,

2 9–12 años de escuela, pero sin graduarse,

3 Graduado(a) de escuela secundaria, diploma de escuela secundaria,

preparatoria o su equivalente o 'GED',

4 Algunos cursos universidarios o un título universitario de un programa de 2

años,

5 Título universitario de 4 años o

6 Título universitario de más de 4 años?

M MISSING/DK

Q30. ¿Es usted de origen hispano, latino o español?

1 SÍ,

2 NO [GO TO Q32]


Q31. ¿Cuál grupo lo(a) describe mejor? ¿Diría que usted es…

1 Mexicano(a), mexicano(a) americano(a), chicano(a),

2 Puertorriqueño(a),

3 Cubano(a) o

4 De otro origen hispano, latino o español?

M MISSING/DK




Q32. ¿Cuál es su raza? Puede seleccionar una o más categorías. ¿Es usted…

1 Blanco(a),

2 Negro(a) o africano(a) americano(a),

3 Indígeno(a) americano(a) o nativo(a) de Alaska,

4 Asiático(a) o

5 Nativo(a) de Hawai o de otra isla del Pacífico?

6 NONE OF THE ABOVE

M MISSING/DK

PROGRAMMER INSTRUCTIONS: IF WHITE ONLY, BLACK/AFRICAN AMERICAN

ONLY, OR AMERICAN INDIAN/ALASKA NATIVE ONLY, OR ANY COMBINATION OF

THESE THREE OPTIONS, NONE OF THE ABOVE OR MISSING/DK, GO TO Q33.

IF ASIAN ONLY, GO TO Q32A. IF WHITE, BLACK/AFRICAN AMERICAN, AND/OR

AMERICAN INDIAN/ALASKA NATIVE AND ASIAN ARE CHOSEN, GO TO Q32A. IF

NATIVE HAWAIIAN/PACIFIC ISLANDER IS ALSO CHOSEN, SEE INSTRUCTION

AFTER Q32A.

IF NATIVE HAWAIIAN/PACIFIC ISLANDER ONLY, GO TO Q32B. IF WHITE,

BLACK/AFRICAN AMERICAN, AND/OR AMERICAN INDIAN/ALASKA NATIVE AND

NATIVE HAWAIIAN/PACIFIC ISLANDER ARE CHOSEN, GO TO Q32B.

Q32a ¿Cuál de los siguientes grupos lo(a) describe mejor? Puede seleccionar una o más

categorías. ¿Es usted…

1 Indio(a) asiático(a),

2 Chino(a),

3 Filipino(a),

4 Japones(a),

5 Coreano(a),

6 Vietnamita o

7 De otro grupo asiático?

8 NONE OF THE ABOVE

M MISSING/DK

IF NATIVE HAWAIIAN/PACIFIC ISLANDER WAS ALSO CHOSEN IN Q32, GO TO Q32B.

ELSE, GO TO Q33.




Q32b ¿ Cuál de los siguientes grupos lo(a) describe mejor? Puede seleccionar una o más

categorías. ¿Es usted…

1 Nativo(a) de Hawai,

2 Procedente de Guam o Chamorro,

3 Samoano(a) o

4 De otra isla del Pacífico?

5 NONE OF THE ABOVE

M MISSING/DK

Q33. ¿Qué tan bien habla usted inglés? ¿Diría que…

1 Muy bien,

2 Bien,

3 No bien o

4 Nada?

M MISSING/DK

Q34. ¿Habla usted algún otro idioma que no sea inglés en casa? ¿Diría que…

1 Sí, hablo un idioma que no sea inglés, o

2 No.Yo hablo inglés en casa? [GO TO Q_END]


Q35. ¿Qué idioma habla en su casa?

1 ESPAÑOL [GO TO Q_END]

2 OTRO IDIOMA [GO TO Q35a]





Q35a. ¿Qué idioma habla en su casa? [ENTER RESPONSE BELOW]

{ALLOW UP TO 50 CHARACTERS}

M MISSING/DK

Q_END Estas son todas las preguntas que tengo para usted. Muchas gracias por su tiempo.

Le deseo que tenga (un buen día/una buena tarde/una buena noche).

INELIGIBLE SCREEN:

Q_INELIG Muchas gracias por su tiempo. Le deseo que tenga (un buen día/una buena

tarde/una buena noche).

REFUSAL SCREEN:

Q_REF Muchas gracias por su tiempo. Le deseo que tenga (un buen día/una buena

tarde/una buena noche).


APPENDIX D:

CHINESE: MAIL SURVEY COVER LETTERS,

MAIL QUESTIONNAIRES, INSTRUCTIONS FOR SCANNABLE MAIL QUESTIONNAIRE

Appendix D: Chinese: Mail Survey Cover Letters, Mail Questionnaires, Instructions for Scannable Mail Questionnaire November 2018




Chinese (Simplified)




Centers for Medicare & Medicaid Services D-1 Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual




Letterhead




尊敬的 «FirstName» «LastName»:

[FACILITY]想了解病人在我们的医院得到的医疗服务的质量。 [VENDOR]，一家独立的

研究机构，帮助我们做这个问卷调查。我们的记录表明您在 [FACILITY] 做过手术或接

受过治疗。这个调查的结果，将帮助我们更好地理解病人在我们医院的经历。

随附的调查问卷，将询问在[DATE OF SURGERY]您对您的门诊手术或医疗程序的意见。

我们请您花几分钟时间填写此调查问卷，并用随附的邮资已付的信封将其寄回给我们。

当您回答本调查问卷中的问题时，仅考虑您 [DATE OF SURGERY] 在 [FACILITY] 的经历。

不要涉及您在我们医院或其他医院做其他手术或医疗程序的经历。

您在此提供的所有信息均将保密，并受到《隐私法》(Privacy Act) 保护。您对问卷的回答

将与其他调查研究参与者的回答一起汇总；当分析数据时，您的姓名和身份识别信息不会

与您的回答关联在一起。对[FACILITY NAME]和其他医院调查的结果将于2017年在网上

公布，网址是https://www.medicare.gov/ 。这些调查结果将帮助人们在选择门诊手术及非

住院手术的医院时，做出知情的决定。您的参与纯属自愿，不会影响您的任何医疗福利。

如果您对本调查研究有任何疑问，请拨打免费服务电话1-800-XXX-XXXX致电NAME。

如果您在阅读问卷或回答问题方面需要帮助，请让家人或朋友帮助您。感谢您的参与。

祝好！

NAME

Title



D-2 Centers for Medicare & Medicaid Services Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual

附件 [PRINT UNIQUE SAMPLE ID NUMBER HERE]





Letterhead





最近，我们给您寄了一封信，请您帮助完成一项问卷调查，此问卷询问您在[FACILITY]

接受门诊手术或医疗程序时的该医院的服务质量。迄今为止，我们尚未收到您填妥的调查

问卷。如果您已寄回调查问卷，我们不胜感激。如果您尚未填写该调查问卷，请现在就

花几分钟时间填写。然后用随附的邮资已付的信封将其寄回给我们。

当您回答本调查问卷中的问题时，仅考虑您 [DATE OF SURGERY] 在 [FACILITY] 的经

历。不要涉及您在我们医院或其他医院，做其他手术或医疗程序的经历。

您在此提供的所有信息均将保密，并受到《隐私法》(Privacy Act) 保护。您对问卷的回

答将与其他调查研究参与者的回答一起汇总；当分析数据时，您的姓名和身份识别信息不

会与您的回答关联在一起。您的参与纯属自愿，不会影响您的任何医疗福利。

如果您对该调查研究有任何疑问，请拨打免费服务电话 1-800-XXX-XXXX 致电 NAME。

如果您在阅读问卷或回答问题方面需要帮助，请让家人或朋友帮助您。感谢您的参与。

祝好！

NAME

Title


Consumer Assessment of Healthcare Providers and Systems Outpatient and

Ambulatory Surgery Survey (OAS CAHPS

®)


AND PROCEDURES

消费者评估医疗服务机构和系统

门诊手术及非住院手术问卷调查

(OAS CAHPS®)

关于门诊手术及其他非住院手术和医疗程序中病人经历的问卷调查

根据 1995 年减少纸张使用法案，如果问卷上没有有效的 OMB 控制数码，任何人都无须

回答问卷上的任何问题。这项问卷持有有效的 OMB控制数码：0938-1240。完成这份问

卷，估计需要八分钟。这包括阅读问卷的说明，查找现有的资料，收集和整理所需的信

息，以及完成和审阅所提供的信息。如果您对完成这份问卷所估计的时间或对如何改进

这项问卷有任何看法，请写信给: CMS, 7500 Security Boulevard, Attn: PRA Reports

Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.



调查问卷说明

请回答所有的问题。作答时，请在问题左

边的方格内打勾。

有时问卷会要求您跳过一些问题。这种情

况发生时，您会看到箭头并注明下一个该

回答的问题，如：

是

否如回答否，请跳到#1

本问卷调查是关于您在我们这封信所特指

的医院的经历。在本问卷调查中，“医疗

程序”这个词指的是诊断，外科手术及其

他医疗过程。“医疗处所”这个词指的是进

行您的医疗程序的地方。

请针对印在信函上所列的的日子那天您

所经历的所有医疗程序来回答这些问题。

在您回答问题时，请不要考虑或涉及其

他医疗程序。

I.在您的医疗程序之前

最初的几个问题是关于为进行您的医疗程

序所做的准备的。这包括在医疗程序之

前和程序当天，您所收到的任何有关信

息。

1. 在您的医疗程序之前，这个医疗处

所的医生或者其他人是否给您关于

这个程序您所需要的所有信息？

1 是的，十分确定

2 是的，在某种程度上

3 否

2. 在您的医疗程序之前，这个医疗处

所的医生或者其他人是否给您让您

容易理解的关于怎样准备您的医疗

程序的医嘱？



3 否

II.关于这个医疗处所及其医护人员

下面的问题，是有关您医疗程序当天的经

历。

3. 办理看病登记签到手续的过程是否

顺利流畅？



3 否

4. 这个医疗处所很干净吗？



3 否

Appendix D: Chinese: Mail Survey Cover Letters, November 2018 Mail Questionnaires, Instructions for Scannable Mail Questionnaire


5. 这个医疗处所的工作人员和前台接

待人员是否像您想象的那样很有帮

助？



3 否

6. 这个医疗处所的工作人员和前台接

待人员是否常以礼貌和尊重对待您？



3 否

7. 医生和护士是否常以礼貌和尊重对

待您？



3 否

8. 医生和护士是否尽可能让您感到舒

适？



3 否

III.关于您的医疗程序的沟通交流

注意：请包括您在该医疗程序之前和当

天所收到信息。

9. 医生和护士是否用您听得懂的方式

来向您解释医疗程序？



3 否

10. 麻醉会让您在的医疗程序中感到困

倦或入睡。是否给您用了麻醉？

1 是

2 否如回答否，请跳到#13

11. 医生或这个医疗处所的其他人是否

用您听得懂的方式来向您解释麻醉?



3 否

12. 医生或医疗处所的其他人是否用您

用您听得懂的方式来向您解释麻醉

可能产生的副作用?



3 否

13. 出院医嘱包括：医疗程序之后，有

可能出现的需要注意的症状的说明,

服药说明, 在家调养须知等等。在

您离开医疗处所之前，您是否得到

了书面的出院医嘱？

1 是

2 否



IV.您的术后恢复

14. 您的医生或这个医疗处所的其他人

是否向您解释您的恢复过程是怎样

的？



3 否

15. 止痛的方法有处方药、非处方止疼

药、或者冰袋等。您的医生或这个

医疗处所的其他人是否给您医嘱，

告诉您如果您因医疗程序而产生疼

痛的话应该怎么办？



3 否

16. 从这个医疗处所离开后的任何时候，

您是否因为您的医疗程序而感到疼

痛？

1 是 2 否

17. 在您离开这个医疗处所之前，您的

医生或这个医疗处所的其他人是否

给您医嘱，告诉您如果您恶心或是

呕吐该怎么办？



3 否


您是否因为您的医疗程序而感到恶

心或者呕吐？

1 是 2 否

19. 在您离开这个医疗处所之前，您的

医生或这个医疗处所的其他人是否

给您医嘱，告诉您如果您因医疗程

序而出血的话应该怎么办？



3 否

20. 从这个医疗处所离开以后的任何时

候，您是否因为您的医疗程序而出

血？

1 是 2 否

21. 发生感染的可能迹象包括发烧、肿

胀、发热、流脓流液、发红等。在

您离开这个医疗处所之前，您的医

生或这个医疗处所的其他人是否给

您医嘱，告诉您如果出现感染迹象

时应该怎么办？



3 否


您是否有过任何感染的迹象？

1 是 2 否



V. 您的总体经历

23. 请用下列 0 到 10 中任何一个数字评

价。 0 是最差医疗处所，10 是最佳

医疗处所。您认为那一个数字最能

代表您对此医疗处所的评价?

0 最差医疗处所

1

2

3

4

5

6

7

8

9

10 最佳医疗处所

24. 您是否会向您的朋友和家人推荐这

个医疗处所?

1 绝不会

2 也许不会

3 可能会

4 绝对会

VI. 关于您

25. 总体而言，您如何评价您的整体健

康状况?

1 极好

2 很好

3 好

4 一般

5 差

26. 总体而言，您如何评价您的整体精

神或情绪健康状况？

1 极好

2 很好

3 好

4 一般

5 差



27. 您的年龄多大?

1 18 至 24 岁

2 25 至 34 岁

3 35 至 44 岁

4 45 至 54 岁

5 55 至 64 岁

6 65 至 74 岁

7 75 至 79 岁

8 80 至 84 岁

9 85 岁以上

28. 您是男性还是女性?

1 男性

2 女性

29. 您已完成的最高级别或水平的年级

或院校是什么?

1 8 年級或更低

2 读过高中﹐但未毕业

3 高中毕业或有同等学业文凭

（GED）

4 读过一些大学或二年制学位 5 四年制大学毕业 6 四年制大学毕业以上学历

30. 您是西班牙裔、西语族裔、或拉丁

裔吗?

1 是的，是西语族裔，拉丁裔，

西班牙裔 2 否, 不是西语族裔，拉丁裔，

西班牙裔如回答否，请跳到

#32

31. 以下哪个族裔最适合您?

1 墨西哥裔、墨西哥裔美國人、

美國出生的墨西哥裔人 2 波多黎各裔 3 古巴人 4 其他西班牙人、西裔、拉丁裔

32. 您属于哪一种族？请选一个或一个

以上的回答。

1 白人 2 黑人或非裔美国人 3 美洲印第安人或阿拉斯加原住

民 4 亚洲人

5 华人

6 菲律宾人

7 日本人

8 韩国人

9 越南人

10 其他亚裔

11 夏威夷原住民

12 关岛或查莫罗人

13 萨摩亚人

14 其他太平洋岛国人



33. 您英文说得怎么样?

1 非常好

2 还好

3 不好

4 不会

34. 除了英文，您在家是否还说其他语

言？

1 是

2 否如回答否，请跳到#36

35. 在家还说什么其他语言?

1 西班牙语 2 其他语言

(请说明):

_______________________

（请工整地填写）

36. 是否有人帮助您填写本调查问卷？

1 是

2 否如果否, 跳到“问卷完”

37. 那人是如何帮助您的？勾选所有适

用项。

1 为我读问题 2 写下我给出的答案

3 替我回答问题

4 将问题译成我的语言

5 以其他方式帮助:

(解释一下):

_______________________

(请用正楷填写) 6 没人帮助我填写本调查问卷

问卷完




(可供扫描的表格填写说明)

调查问卷说明

• 请用完全涂黑答案左侧的圆圈的方式，来回答所有问题。

• 有时会让您跳过某些问题。当出现这种情况时，您会看到一个箭头和一个说明，告

诉您下一步回答什么问题，像这样

是

否如回答否，请跳到问题#1

本问卷调查是关于您在我们这封信所特指的医院的经历。在本问卷调查中，“医疗程序”这

个词指的是诊断，外科手术及其他医疗过程。“医疗处所”这个词指的是进行您的医疗程序

的地方。

请针对印在信函上所列的的日子那天您所经历的所有医疗程序来回答这些问题。在您回

答问题时，请不要考虑或涉及其他医疗程序。






Chinese (Traditional)








Letterhead





[FACILITY]想瞭解病人在我們的醫院得到的醫療服務的質量。 [VENDOR]，一家獨立的

研究機構，幫助我們做這個問卷調查。我們的記錄表明您在 [FACILITY] 做過手術或接

受過治療。這個調查的結果，將幫助我們更好地理解病人在我們醫院的經歷。

隨附的調查問卷，將詢問在[DATE OF SURGERY]您對您的門診手術或醫療程序的意見。

我們請您花幾分鐘時間填寫此調查問卷，並用隨附的郵資已付的信封將其寄回給我們。

當您回答本調查問卷中的問題時，僅考慮您 [DATE OF SURGERY] 在 [FACILITY] 的經歷。

不要涉及您在我們醫院或其他醫院做其他手術或醫療程序的經歷。

您在此提供的所有資訊均將保密，並受到《隱私法》(Privacy Act) 保護。您對問卷的回答

將與其他調查研究參與者的回答一起匯總；當分析資料時，您的姓名和身份識別資訊不會

與您的回答關聯在一起。對[FACILITY NAME]和其他醫院調查的結果將於2017年在網上

公佈，網址是https://www.medicare.gov/ 。這些調查結果將幫助人們在選擇門診手術及非

住院手術的醫院時，做出知情的決定。您的參與純屬自願，不會影響您的任何醫療福利。

如果您對本調查研究有任何疑問，請撥打免費服務電話1-800-XXX-XXXX致電NAME。

如果您在閱讀問卷或回答問題方面需要幫助，請讓家人或朋友幫助您。感謝您的參與。

祝好！

NAME

Title









Letterhead





最近，我們給您寄了一封信，請您幫助完成一項問卷調查，此問卷詢問您在[FACILITY]

接受門診手術或醫療程序時的該醫院的服務質量。迄今為止，我們尚未收到您填妥的調查

問卷。如果您已寄回調查問卷，我們不勝感激。如果您尚未填寫該調查問卷，請現在就

花幾分鐘時間填寫。然後用隨附的郵資已付的信封將其寄回給我們。

當您回答本調查問卷中的問題時，僅考慮您 [DATE OF SURGERY] 在 [FACILITY] 的經歷。

不要涉及您在我們醫院或其他醫院，做其他手術或醫療程序的經歷。

您在此提供的所有資訊均將保密，並受到《隱私法》(Privacy Act) 保護。您對問卷的回

答將與其他調查研究參與者的回答一起匯總；當分析資料時，您的姓名和身份識別資訊不

會與您的回答關聯在一起。您的參與純屬自願，不會影響您的任何醫療福利。

如果您對該調查研究有任何疑問，請撥打免費服務電話1-800-XXX-XXXX致電NAME。

如果您在閱讀問卷或回答問題方面需要幫助，請讓家人或朋友幫助您。感謝您的參與。

祝好！

NAME

Title


Consumer Assessment of Healthcare Providers and Systems Outpatient and

Ambulatory Surgery Survey (OAS CAHPS

®)


AND PROCEDURES

消費者评估醫療服务機構和系統

門診手術及非住院手術問卷調查

(OAS CAHPS®)

關於門诊、門診手术及其他非住院手術和醫療程序中病人經歷的問卷調查

根據 1995年減少紙張使用法案，如果問卷上沒有有效的 OMB控制數碼，任何人都無須回

答問卷上的任何問題。這項問卷持有有效的 OMB控制數碼：0938-1240。完成這份問卷，

估計需要八分鐘。這包括閱讀問卷的說明，查找現有的資料，收集和整理所需的資訊，以

及完成和審閱所提供的資訊。如果您對完成這份問卷所估計的時間或對如何改進這項問卷

有任何看法，請寫信給: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer,

Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.



调查问卷说明

請回答所有的問題。作答時，請在問題左

邊的方格內打勾。

有時問卷會要求您跳過一些問題。這種情

況發生時，您會看到箭頭並注明下一個該

回答的問題，如：

是

否如回答否，請跳到#1

本問卷調查是關於您在我們這封信所特指

的醫院的經歷。在本問卷調查中，“醫療

程序”這個詞指的是診斷，外科手術及其

他醫療過程。“醫療處所”這個詞指的是進

行您的醫療程序的地方。

請針對印在信函上所列的的日子那天您

所經歷的所有醫療程序來回答這些問題。

在您回答問題時，請不要考慮或涉及其

他醫療程序。

I.在您的醫療程序之前

最初的几个问题是关于为進行您的醫療程

序所做的准备的。这包括在医疗程序之前

和程序当天，您所收到的任何有關信息。

1. 在您的醫療程序之前，這個醫療處

所的醫生或者其他人是否給您關於

這個程式您所需要的所有資訊？

1 是的，十分確定

2 是的，在某種程度上

3 否

2. 在您的醫療程序之前，這個醫療處

所的醫生或者其他人是否給您讓您

容易理解的關於怎樣準備您的醫療

程序的醫囑？



3 否

II.关于这個醫療处所及其醫護人員

下面的问题，是有关您医疗程序當天的經

歷。

3. 辦理看病登記簽到手續的過程是否

順利流暢？



3 否

4. 這個醫療處所很乾淨嗎？



3 否

5. 這個醫療處所的工作人員和前臺接

待人員是否像您想像的那樣很有幫

助？



3 否



6. 這個醫療處所的工作人員和前臺接

待人員是否常以禮貌和尊重對待您？



3 否

7. 醫生和護士是否常以禮貌和尊重對

待您?



3 否

8. 醫生和護士是否盡可能讓您感到舒

適？



3 否

III.關於您的醫療程序的溝通交流

注意：請包括您在該醫療程序之前和當

天所收到資訊。

9. 醫生和護士是否用您聽得懂的方式

來向您解釋醫療程序?



3 否

10. 麻醉會讓您在的醫療程序中感到困

倦或入睡。是否給您用了麻醉？

1 是

2 否如回答否，請跳到#13

11. 醫生或這個醫療處所的其他人是否

用您聽得懂的方式來向您解釋麻醉?



3 否

12. 醫生或醫療處所的其他人是否用您

聽得懂的方式來向您解釋麻醉可能

產生的副作用?



3 否

13. 出院醫囑包括：醫療程序之後，有

可能出現的需要注意的症狀的說明,

服藥說明, 在家調養須知等等。在

您離開醫療處所之前，您是否得到

了書面的出院醫囑？

1 是

2 否



IV.您的術後恢復

14. 您的醫生或這個醫療處所的其他人

是否向您解釋您的恢復過程是怎樣

的？



3 否

15. 止痛的方法有處方藥、非處方止疼

藥、或者冰袋等。您的醫生或這個

醫療處所的其他人是否給您醫囑，

告訴您如果您因醫療程序而產生疼

痛的話應該怎麼辦？



3 否

16. 從這個醫療處所離開後的任何時候，

您是否因為您的醫療程序而感到疼

痛？

1 是

2 否

17. 在您離開這個醫療處所之前，您的

醫生或這個醫療處所的其他人是否

給您醫囑，告訴您如果您噁心或是

嘔吐該怎麼辦？



3 否


您是否因為您的醫療程序而感到噁

心或者嘔吐？

1 是

2 否

19. 在您離開這個醫療處所之前，您的

醫生或這個醫療處所的其他人是否

給您醫囑，告訴您如果您因醫療程

序而出血的話應該怎麼辦？



3 否


您是否因為您的醫療程序而出血？

1 是

2 否

21. 發生感染的可能跡象包括發燒、腫

脹、發熱、流膿流液、發紅等。在

您離開這個醫療處所之前，您的醫

生或這個醫療處所的其他人是否給

您醫囑，告訴您如果出現感染跡象

時應該怎麼辦？



3 否


您是否有過任何感染的跡象？

1 是

2 否



V. 您的總體經歷

23. 請用下列 0 到 10 中任何一個數字評

價。 0 是最差醫療處所，10 是最佳

醫療處所。您認為那一個數字最能

代表您對此醫療處所的評價?

0 最差醫療處所

1

2

3

4

5

6

7

8

9

10 最佳醫療處所

24. 您是否會向您的朋友和家人推薦這

個醫療處所?

1 絕不會

2 也許不會

3 可能會 4 絕對會

VI. 關於您

25. 總體而言，您如何評價您的整體健

康狀況?

1 極好

2 很好

3 好

4 一般

5 差

26. 總體而言，您如何評價您的整體精

神或情緒健康狀況？

1 極好

2 很好

3 好

4 一般

5 差

27. 您的年齡多大?

1 18 至 24 歲

2 25 至 34 歲

3 35 至 44 歲

4 45 至 54 歲

5 55 至 64 歲

6 65 至 74 歲

7 75 至 79 歲

8 80 至 84 歲

9 85 歲以上

28. 您是男性還是女性?

1 男性

2 女性



29. 您已完成的最高級別或水準的年級

或院校是什麼?

1 8 年級或更低

2 讀過高中﹐但未畢業

3 高中畢業或有同等學業文憑

（GED）

4 讀過一些大學或二年制學位

5 四年制大學畢業

6 四年制大學畢業以上學歷

30. 您是西班牙裔、西語族裔、或拉丁

裔嗎?

1 是的，是西語族裔，拉丁裔，

西班牙裔 2 否, 不是西語族裔，拉丁裔，

西班牙裔如回答否，請跳到#32

31. 以下哪個族裔最適合您?

1 墨西哥裔、墨西哥裔美國人、

美國出生的墨西哥裔人 2 波多黎各裔 3 古巴人 4 其他西班牙人、西裔、拉丁裔

32. 您屬於哪一種族？請選一個或一個

以上的回答。

1 白人 2 黑人或非裔美國人 3 美洲印第安人或阿拉斯加原住

民 4 亞洲人 5 華人 6 菲律賓人

7 日本人

8 韓國人

9 越南人

10 其他亞裔

11 夏威夷原住民

12 關島或查莫羅人

13 薩摩亞人

14 其他太平洋島國人

33. 您英文說得怎麼樣?

1 非常好

2 還好

3 不好

4 不會

34. 除了英文，您在家是否還說其他語

言？

1 是 2 否如回答否，請跳到#36



35. 在家還說什麼語言?

1 西班牙語 2 其他語言

(請說明):

_______________________

（請工整地填寫）

36. 是否有人幫助您填寫本調查問卷？

1 是

2 否如果否, 跳到“問卷完”

37. 那人是如何幫助您的？勾選所有適

用項。

1 為我讀問題 2 寫下我給出的答案 3 替我回答問題

4 將問題譯成我的語言

5 以其他方式説明:

(解釋一下):

_______________________

(請用正楷填寫) 6 沒人幫助我填寫本調查問卷

問卷完



(可供掃描的表格填寫說明)

调查问卷说明

• 請用完全塗黑答案左側的圓圈的方式，來回答所有問題。

• 有時會讓您跳過某些問題。當出現這種情況時，您會看到一個箭頭和一個說明，告

訴您下一步回答什麼問題，像這樣

是

否如回答否，請跳到問題#1

本問卷調查是關於您在我們這封信所特指的醫院的經歷。在本問卷調查中，“醫療程序”這

個詞指的是診斷，外科手術及其他醫療過程。“醫療處所”這個詞指的是進行您的醫療程序

的地方。

請針對印在信函上所列的的日子那天您所經歷的所有醫療程序來回答這些問題。在您回

答問題時，請不要考慮或涉及其他醫療程序。





APPENDIX E:

KOREAN: MAIL SURVEY COVER LETTERS, MAIL QUESTIONNAIRE, AND INSTRUCTIONS FOR SCANNABLE MAIL QUESTIONNAIRE

Appendix E: Korean: Mail Survey Cover Letters, Mail Questionnaire, Instructions for Scannable Mail Questionnaire November 2018



Centers for Medicare & Medicaid Services Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual E-1




Letterhead




«LastName»«FirstName» 님께

[FACILITY] (은)는 환자분께서 저희 시설에서 경험한 의료 서비스의 품질을 알아보는

조사를 실시하고 있으며, 독립 연구 기관인 [VENDOR] (이)가 조사 자료의 수집을 돕고

있습니다. 저희 기록에 의하면 귀하는 [FACILITY] 에서 수술 혹은 처치를 받으셨습니다.

이 조사 결과를 통해 저희 시설을 이용하신 환자분의 경험을 더 잘 이해하고자 합니다.

동봉된 설문지에는 귀하가 [DATE OF SURGERY] 에 받으신 외래 수술 혹은 처치에 대한

경험과 관련된 질문들이 포함되어 있습니다. 몇 분 동안만 시간을 내셔서 설문을 작성하신

뒤 동봉되어진 요금 선납된 회신 봉투를 이용, [VENDOR] 에게 설문지를 보내 주시면

감사하겠습니다.

설문을 작성하실 때에는 [DATE OF SURGERY]에 있었던 [FACILITY] 방문만을 오직

염두에 두고 응답해 주십시오. 혹시 귀하가 이 시설에서 다른 날짜, 혹은 다른 시설에서

받으신 수술이나 처치를 경험하셨다면, 그것은 제외하고 위에 제시된 날짜와 시설에

관련해서만 답변 하시기를 부탁드립니다.

귀하가 제공하시는 모든 정보는 비밀로 유지되며 개인 정보 보호법에 의해 보호를

받습니다. 귀하의 설문 응답은 다른 응답자들의 응답과 함께 합쳐집니다. 또, 자료 분석

시에 귀하의 이름이나 신상 정보는 설문 응답과 연결되지 않습니다. [FACILITY NAME]

(와)과 다른 시설에 대한 전반적인 조사 결과는 인터넷 사이트

(https://www.medicare.gov/)를 통해 공표될 예정입니다. 이 결과는 사람들이 외래 혹은

응급 수술 시설을 선택하는데 있어 현명한 결정을 할 수 있도록 도울 것입니다. 귀하의



E-2 Centers for Medicare & Medicaid Services Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual

참여는 자발적이며, 이 참여의 결정은 귀하가 현재 받고 있는 혹은 미래에 받을 의료

서비스 혜택에 전혀 영향을 끼치지 않습니다.

이 조사에 대해 질문이 있으시다면, 무료 번호 1-800-XXX-XXXX 로 NAME 에게 전화

주십시오. 만약 질문을 읽으시거나 응답을 표시하는데 도움이 필요하시면, 친구나 가족의

도움을 받으셔도 됩니다. 귀하의 참여에 깊이 감사드립니다.

감사합니다.

NAME

TITLE

설문지 동봉 [PRINT UNIQUE SAMPLE ID NUMBER HERE]

Appendix E: Korean: Mail Survey Cover Letters, Mail Questionnaire, November 2018 Instructions for Scannable Mail Questionnaire






Letterhead




«LastName»«FirstName» 님께

얼마전 귀하께 [FACILITY]에서 외래 수술이나 처치를 받으신 환자분들을 대상으로 하는

의료 서비스 품질에 대한 설문 조사 참여를 요청하는 편지를 보내드렸습니다. 그렇지만

현재까지 귀하의 설문지를 받아보지 못했습니다. 이미 설문지 작성을 마치셨고, 우편으로

설문지를 송부하셨다면, 귀하의 참여에 깊은 감사를 드립니다. 아직 설문 작성을 마치지

못하셨다면, 몇 분만 시간을 내셔서 설문 작성을 완료해 주시길 부탁드립니다. 작성

후에는 동봉되어진 요금 선납된 회신 봉투를 이용해 설문지를 보내 주시면

감사하겠습니다.

설문을 작성하실 때에는 [DATE OF SURGERY]에 있었던 [FACILITY] 방문만을 오직

염두에 두고 응답해 주십시오. 혹시 귀하가 이 시설에서 다른 날짜, 혹은 다른 시설에서

받으신 수술이나 처치를 경험하셨다면, 그것은 제외하고 위에 제시된 날짜와 시설에

관련해서만 답변 하시기를 부탁드립니다.

이 조사 결과를 통해 저희 시설을 이용하신 환자분의 경험을 더 잘 이해하고자 합니다.

귀하의 설문 응답은 다른 응답자들의 응답과 함께 합쳐집니다. 또, 자료 분석 시에 귀하의

이름이나 신상 정보는 설문 응답과 연결되지 않습니다. 귀하가 제공하시는 모든 정보는

비밀로 유지되며 개인 정보 보호법에 의해 보호를 받습니다. 귀하의 참여는 자발적이며,

이 참여의 결정은 귀하가 현재 받고 있는 혹은 미래에 받을 의료 서비스 혜택에 전혀

영향을 끼치지 않습니다.



이 조사에 대해 질문이 있으시다면, 무료 번호 1-800-XXX-XXXX 로 NAME 에게 전화

주십시오. 만약 질문을 읽으시거나 응답을 표시하는데 도움이 필요하시면, 친구나 가족의

도움을 받으셔도 됩니다. 귀하의 참여에 깊이 감사드립니다.

감사합니다.

NAME

TITLE

설문지 동봉 [PRINT UNIQUE SAMPLE ID NUMBER HERE]

의료 서비스 제공자에 대한 소비자 평가

외래 및 응급 수술 설문 조사

(OAS CAHPS®) 환자의 외래 및 응급 수술과 처치 관련 의료 서비스 경험에 대한 설문 조사

1995 년에 제정된 서류 작업 감소 법안에 따라, 귀하는 유효 승인 번호가 표시되지 않은 어떠한

정보 수집에도 응할 의무가 없습니다. 이 조사에 대한 연방 관리예산국의 유효 승인 번호는

0938-1240 입니다. 조사 완료에는 작성 안내, 자료 탐색과 수집, 답변 작성 및 검토 시간을

포함하여 평균 8 분이 걸릴 것으로 예상됩니다. 이 예상 소요 시간이 정확하지 않다고

생각하시거나 조사를 개선하기 위한 제안이 있으시다면 다음 주소로 보내주시기 바랍니다:

CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05,

Baltimore, Maryland 21244-1850



작성 안내

귀하의 응답 왼쪽에 위치한 네모칸에

체크하셔서 질문에 답해 주십시오.

설문 도중 어떤 질문에 대해서는 건너

뛰라고 할 수도 있습니다. 이 경우,

아래에 제시된 바와 같이 다음에 몇 번

질문에 답해야 할 지 화살표로 안내하고

있습니다.

예

아니요 “아니요”면

1 번으로 가주세요

이 조사는 안내 편지에 적힌 시설에서의

귀하의 경험을 묻습니다. 이 조사에서

“처치”는 진단, 수술 등의 모든 의료 처치

활동을 통틀어 일컫는 용어입니다.

여기에서 “시설”은 귀하가 처치를 받은

장소를 말합니다.

안내 편지에 적힌 날짜에 받으신

처치만을 생각하고 질문에 답해

주십시오. 다른 처치에 대해서는

고려하지 말아 주십시오.

I. 처치 전

첫번째로 드리는 질문들은 처치 준비와

관련한 것들입니다. 처치 전이나

처치일에 귀하가 제공 받은 정보를 모두

포함해 주십시오.

1. 처치 전에 시설에서 일하는 담당

의사나 다른 사람이 귀하가 처치와

관련해 필요한 정보를 모두

제공하였습니까?

1 예, 확실히

2 예, 다소

3 아니요

2. 처치 전에 시설에서 일하는 담당

의사나 다른 사람이 귀하의 처치

준비에 대해 이해하기 쉽게 안내해

주었습니까?

1 예, 확실히

2 예, 다소

3 아니요

II. 시설과 직원

다음은 처치 당일에 관한 질문들입니다.

3. 체크인 과정은 순조로왔습니까?

1 예, 확실히

2 예, 다소

3 아니요

4. 시설은 깨끗했습니까?



1 예, 확실히

2 예, 다소

3 아니요

5. 시설의 접수 담당자와 사무

직원들은 귀하의 기대에 부응하는

도움을 주었습니까?

1 예, 확실히

2 예, 다소

3 아니요

6. 시설의 접수 담당자와 사무

직원들은 귀하를 예의바르고

정중하게 대하였습니까?

1 예, 확실히

2 예, 다소

3 아니요



7. 의사와 간호사들은 귀하를

예의바르고 정중하게 대하였습니까?

1 예, 확실히

2 예, 다소

3 아니요

8. 의사와 간호사들은 귀하가 충분히

편안하게 느낄 수 있도록 하기 위해

노력하였습니까?

1 예, 확실히

2 예, 다소

3 아니요

III. 처치 관련 의사소통

처치 전이나 처치 당일 제공 받은 정보를

염두에 두고 답해 주시길 부탁드립니다.

9. 의사와 간호사들은 귀하의 처치에

대해 이해하기 쉽게 설명을 해

주었습니까?

1 예, 확실히

2 예, 다소

3 아니요

10. 마취는 처치를 받는 동안 잠이 들게

하거나 졸리게 합니다. 귀하는

마취를 받았습니까?

1 예

2 아니요 “아니요”면 13 번으로

가주세요.

11. 의사나 시설의 다른 직원이

귀하에게 마취 절차에 대해

이해하기 쉽게 설명을 해

주었습니까?

1 예, 확실히

2 예, 다소

3 아니요


귀하에게 마취와 관련해 발생

가능한 부작용에 대해 이해하기

쉽게 설명해 주었습니까?

1 예, 확실히

2 예, 다소

3 아니요

13. 퇴원 안내에는 귀하가 처치 후 겪을

수 있는 증상이라든지, 약품 복용법,

자택 요양 안내 등이 포함됩니다.

귀하는 시설을 떠나기 전, 문서로 된

퇴원 안내를 받으셨습니까?

1 예

2 아니요

IV. 회복


귀하에게 회복 기간 중 발생 가능한

일에 대해 안내해 주었습니까?



1 예, 확실히

2 예, 다소

3 아니요



15. 통증을 줄이는 방법으로는 처방전

없이 구매가능한 일반 의약품이나

얼음팩의 이용 등 여러 방법이

있습니다. 의사나 시설의 다른

직원이 귀하에게 처치 관련한

통증을 느꼈을 때 대처 요령을

안내해 주었습니까?

1 예, 확실히

2 예, 다소

3 아니요

16. 시설을 떠난 후 처치로 인한 통증을

느낀 적이 한 번이라도 있었습니까?

1 예

2 아니요

17. 시설을 떠나기 전, 의사나 시설의

다른 직원이 구역질이 나거나

구토를 할 경우 대처 요령을 안내해

주었습니까?

1 예, 확실히

2 예, 다소

3 아니요

18. 시설을 떠난 후 언제라도, 처치 혹은

마취로 인해 구역질이나 구토를 한

적이 있었습니까?

1 예

2 아니요

19. 시설을 떠나기 전, 의사나 시설의

다른 직원이 처치로 인한 출혈이

있을 경우 대처 요령을 안내해

주었습니까?

1 예, 확실히

2 예, 다소

3 아니요

20. 시설을 떠난 후 처치로 인해 출혈한

적이 한 번이라도 있었습니까?

1 예

2 아니요

21. 감염의 징후로는 미열, 부기, 열,

체액의 배출이나 붉어짐 등이

있습니다. 시설을 떠나기 전, 의사나

시설의 다른 직원이 이와 같은 감염

징후가 있을 경우 대처 요령을

안내해 주었습니까?

1 예, 확실히

2 예, 다소

3 아니요

22. 시설을 떠난 후 언제라도, 이러한

감염 징후가 나타난 적이

있었습니까?

1 예

2 아니요



V. 전반적인 경험

23. 0 은 최악의 시설이고 10 은 최고의

시설을 의미한다면 귀하는 이

시설에 대하여 0 에서 10 사이의

숫자 중 몇 점을 주시겠습니까?

0 최악의 시설

1

2

3

4

5

6

7

8

9

10 최고의 시설

24. 이 시설을 귀하의 친구나 가족에게

추천하시겠습니까?

1 절대 안함

2 안할 것 같음

3 할 것 같음

4 확실히 할 것 같음

VI. 본인에 관한 정보

25. 일반적으로 귀하의 전반적인 건강

상태를 어떻게 평가하십니까?

1 더할 나위 없이 좋다

2 아주 좋다

3 좋은 편이다

4 그저 그렇다

5 나쁘다

26. 일반적으로 귀하의 정신 및 정서

건강을 어떻게 평가하십니까?

1 더할 나위 없이 좋다

2 아주 좋다

3 좋은 편이다

4 그저 그렇다

5 나쁘다

27. 귀하의 만 나이는 어떻게 되십니까?

1 18 – 24 세

2 25 – 34 세

3 35 – 44 세

4 45 – 54 세

5 55 – 64 세

6 65 – 74 세

7 75 – 79 세

8 80 – 84 세

9 85 세 이상

28. 귀하의 성별은 어떻게 되십니까?

1 남성

2 여성

29. 귀하의 최종 학력은 어떻게

되십니까?



1 중졸 (8 학년) 이하

2 고교 중퇴

3 고졸 혹은 검정 고시 (GED)

4 대학 중퇴 혹은 2 년제 대학

졸업

5 4 년제 대학 졸업

6 대학원 이상



30. 중남미 혹은 히스패닉 출신입니까?

1 예, 중남미 혹은 히스패닉 출신

2 아니요, 중남미 혹은 히스패닉

출신이 아님 “아니요”면,

32 번으로 가주세요.

31. 귀하를 가장 잘 나타내는 것은 다음

중 무엇입니까?

1 멕시코인, 멕시코계 미국인,

치카노인

2 푸에르토리코인

3 쿠바인

4 기타 중남미 혹은 히스패닉

출신

32. 인종이 어떻게 되시나요? 한개 또는

그 이상을 고르실 수 있습니다.

1 백인

2 흑인 혹은 아프리카계 미국인

3 아메리칸 인디언 혹은 알라스카

원주민

4 인도인

5 중국인

6 필리핀인

7 일본인

8 한국인

9 베트남인

10 기타 아시아인

11 하와이 원주민

12 괌족 혹은 차모로족

13 사모아족

14 기타 태평양 제도인

33. 귀하는 영어로 말을 어느 정도로

잘합니까?

1 매우 잘함

2 잘하는 편임

3 잘 못하는 편임

4 전혀 못함

34. 귀하는 댁에서 영어가 아닌 다른

언어를 사용하십니까?

1 예

2 아니요 “아니요”면 36 번으로

가주세요.

35. 그 언어는 무엇입니까?

1 스페인어



2 기타 언어 (구체적으로 쓸 것):

___________________________

(보기쉽게 정자로 적어주십시오)

36. 다른 사람이 설문 작성을 도와

주었습니까?

1 예

2 아니요 “아니요”면 끝으로

가주세요.

37. 그 사람은 어떤 도움을 주었습니까?

해당하는 것을 모두 고르십시오.

1 질문을 내게 읽어줌

2 내 응답을 받아 적음

3 나를 대신에 질문에 답함

4 내가 사용하는 언어로 번역함

5 기타 다른 방법으로 도와줌:

(설명할 것):

______________________________

(보기쉽게 정자로 적어주십시오)

6 설문 작성을 도운 사람 없음

끝



(스캔용 설문지 작성 안내)

작성 안내

• 귀하의 응답 왼쪽에 위치한 동그라미를 완전히 채워 질문에 답해 주십시오.

• 설문 도중 어떤 질문에 대해서는 건너 뛰라고 할 수도 있습니다. 이런 경우, 아래에

제시된 바와 같이 다음에 몇 번 질문에 답해야 할 지 화살표로 안내하고 있습니다.

예

아니요 “아니요”면 1 번으로 가주세요

이 조사는 안내 편지에 적힌 시설에서의 귀하의 경험을 묻습니다. 이 조사에서 “처치”는

진단, 수술 등의 모든 의료 처치 활동을 통틀어 일컫는 용어입니다. 여기에서 “시설”은

귀하가 처치를 받은 장소를 말합니다.

안내 편지에 적힌 날짜에 받으신 처치만을 생각하고 질문에 답해 주십시오. 다른 처치에

대해서는 고려하지 말아 주십시오.





APPENDIX F:

CONSENT TO SHARE IDENTIFYING INFORMATION QUESTION

Appendix F: Consent to Share Identifying Information Question November 2018



Centers for Medicare & Medicaid Services F-1 Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual

HOPDs or ASCs may request that their survey vendor provide survey responses linked to a

sample member’s name and other identifying information (About You responses). If they wish to

do so, they must ask for and receive consent from the sample member using the Consent to Share

Identifying Information question (below). This question should be placed at the end of the

questionnaire as the last question.

Survey vendors can provide responses linked to a sample member’s name and other identifying

information only if the sample member gives his or her consent on the Consent to Share

Identifying Information question. This includes providing this sample member’s responses to any

About You questions that do not meet the threshold of 11 that is required for reporting

aggregated response data overall.

English Mail Questionnaire Version

The facility where you received your surgery or procedure may want to review your survey

responses so that they can decide how to address any concerns that you have.

Do you give your permission to link your name with your survey responses that will be

shared with the facility where you received your surgery or procedure?

1 Yes, I give my permission to link my name with my survey responses. 2 No, I do not give permission to link my name with my survey responses.

English Telephone Interview Version

The facility where you received your surgery or procedure may want to review your survey

responses so that they can decide how to address any concerns that you have.

Do you give your permission to link your name with your survey responses that will be

shared with the facility where you received your surgery or procedure?

1 YES

2 NO


F-2 Centers for Medicare & Medicaid Services Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual

Spanish Mail Questionnaire Version

Es posible que el centro ambulatorio en donde se realizó su cirugía o procedimiento desee revisar

sus respuestas para encontrar la manera de aclarar sus preocupaciones.

¿Nos da usted permiso de asociar su nombre con las respuestas a la encuesta que se

compartirá con el centro ambulatorio en donde se realizó su cirugía o procedimiento?

1 Sí, doy permiso para asociar mi nombre con mis respuestas a la encuesta. 2 No, no doy permiso para asociar mi nombre con mis respuestas a la encuesta.

Spanish Telephone Interview Version

Es posible que el centro ambulatorio en donde se realizó su cirugía o procedimiento desee revisar

sus respuestas para encontrar la manera de aclarar sus preocupaciones.

¿Nos da usted permiso de asociar su nombre con las respuestas a la encuesta que se

compartirá con el centro ambulatorio en donde se realizó su cirugía o procedimiento?

1 SÍ

2 NO

November 2018 Appendix F: Consent to Share Identifying Information Question

Centers for Medicare & Medicaid Services F-3 Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual

Chinese (Simplified) Mail Questionnaire Version

为您做手术或进行医疗程序的机构可能希望了解您的回答，以便他们了解和解除您的顾虑。

您是否同意将您的姓名与您对此调查问卷的回答联系起来，并与此机构分享此信息？

1 是，我同意将我的姓名与我对此调查问卷的回答联系起来。 2 否，我不同意将我的姓名与我对此调查问卷的回答联系起来。

Chinese (Traditional) Mail Questionnaire Version

為您做手術或進行醫療程序的機構可能希望瞭解您的回答，以便他們了解和解除您的顧慮。

您是否同意將您的姓名與您對此調查問卷的回答聯繫起來，并與此機構分享此資訊？

1 是，我同意將我的姓名與我對此調查問卷的回答聯繫起來。 2 否，我不同意將我的姓名與我對此調查問卷的回答聯繫起來。


F-4 Centers for Medicare & Medicaid Services Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual

Korean Mail Questionnaire Version

귀하가 수술이나 처치를 받으신 시설은 귀하의 염려나 불만 사항에 적절히 대처하기

위해 귀하의 설문 조사 응답을 검토하고 싶어할 수도 있습니다.

귀하는 귀하가 수술이나 처치를 받은 시설과 귀하의 이름으로 작성된 설문 응답을

공유하는 것을 허가하십니까?

1 예, 제 이름과 설문 응답을 공유하는 것을 허가합니다.

2 아니요, 제 이름과 설문 응답을 공유하는 것을 허가하지 않습니다.


APPENDIX G:

OMB PAPERWORK REDUCTION ACT LANGUAGE

Appendix G: OMB Paperwork Reduction Act Language November 2018



Centers for Medicare & Medicaid Services G-1 Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual


The Office of Management and Budget (OMB) Paperwork Reduction Act language below must

be included in the Outpatient and Ambulatory Surgery CAHPS Survey mailings. It can be

included in the cover letter or on the front or back of the questionnaire. It does not need to be

included in both the cover letter and the questionnaire.

ENGLISH

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a

collection of information unless it displays a valid OMB control number. The valid OMB control

number for this information collection is 0938-1240. The time required to complete this

information collection is estimated to average 8 minutes per response, including the time to

review instructions, search existing data resources, gather the data needed, and complete and

review the information collection. If you have comments concerning the accuracy of the time

estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security

Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland

21244-1850.


G-2 Centers for Medicare & Medicaid Services Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual






SPANISH

De acuerdo a la Ley de Reducción de Trabajo Administrativo de 1995 (Paperwork Reduction

Act of 1995), ninguna persona tiene la obligación de responder a un cuestionario que solicite

información, a menos que lleve un número de control de OMB (Oficina de Administración y

Presupuesto) válido. El número de control OMB válido para este cuestionario es 0938-1240. Se

estima que el tiempo promedio necesario para completar este cuestionario es de 8 minutos por

respuesta, incluyendo el tiempo para revisar las instrucciones, buscar en las fuentes de datos

existentes, recopilar los datos necesarios, completar y revisar la información recopilada. Si tiene

algún comentario sobre la exactitud del tiempo estimado o sugerencias para mejorar este

formulario, por favor escriba a: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance

Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

November 2018 Appendix G: OMB Paperwork Reduction Act Language







CHINESE (SIMPLIFIED)

根据 1995 年减少纸张使用法案，如果问卷上没有有效的 OMB 控制数码，任何人都无须

回答问卷上的任何问题。这项问卷持有有效的 OMB控制数码：0938-1240。完成这份问

卷，估计需要八分钟。这包括阅读问卷的说明，查找现有的资料，收集和整理所需的信

息，以及完成和审阅所提供的信息。如果您对完成这份问卷所估计的时间或对如何改进这

项问卷有任何看法，请写信给: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance









CHINESE (TRADITIONAL)

根據 1995年減少紙張使用法案，如果問卷上沒有有效的 OMB 控制數碼，任何人都無須

回答問卷上的任何問題。這項問卷持有有效的 OMB 控制數碼：0938-1240。完成這份問

卷，估計需要八分鐘。這包括閱讀問卷的說明，查找現有的資料，收集和整理所需的資

訊，以及完成和審閱所提供的資訊。如果您對完成這份問卷所估計的時間或對如何改進這

項問卷有任何看法，請寫信給:CMS,7500 Security Boulevard, Attn: PRA Reports Clearance


November 2018 Appendix G: OMB Paperwork Reduction Act Language







KOREAN

1995 년에 제정된 문서 감축 법안에 따라, 귀하는 유효 승인 번호가 표시되지 않은

어떠한 정보 수집에도 응할 의무가 없습니다. 이 조사에 대한 연방 관리예산국의 유효

승인 번호는 0938-1240 입니다. 조사 완료에는 작성 안내, 기존 자료 탐색과 수집, 답변

작성 및 검토 시간을 포함하여 평균 8 분이 걸릴 것으로 예상됩니다. 이 예상 소요 시간이

정확하지 않다고 생각하시거나 조사 개선을 위한 제안이 있으시다면 다음 주소로 편지를

보내주시기 바랍니다: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance






APPENDIX H:

FREQUENTLY ASKED QUESTIONS FOR TELEPHONE INTERVIEWERS

(ENGLISH)

Appendix H: Frequently Asked Questions for Telephone Interviewers (English) November 2018



Centers for Medicare & Medicaid Services H-1 Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual

FREQUENTLY ASKED QUESTIONS

OAS CAHPS®

What is the purpose of this survey?

The purpose of this survey is to learn about your experiences with the care you received for your

recent outpatient surgery or procedure. The survey results will help other patients make more

informed choices when choosing an outpatient surgery facility and help facilities in the study to

improve the quality of care provided to their patients.

I’ve already completed a mail survey. Do I need to complete this survey again?

Thank you for completing the survey and mailing it back in. However, we have not yet received

the survey and so we are following up to gather your feedback by phone. If you have some time

right now we could go through the questions. Or I can call you back in a few days if we still have

not received the survey by mail.

I lost the mail survey. Would you please mail me another one?

We are nearing the end of the survey data collection period and are not allowed to send out any

additional surveys. Because the feedback you provide will help improve the quality of the

outpatient surgery care you and others like you receive, we are asking that you please complete

the survey with us over the phone. If now is okay, let’s get started!

I already completed/received a survey about this.

Sometimes hospitals and surgeons conduct surveys of their recent patients, and you may have

received one of those surveys. The survey we are asking you to do is about your experience at

the outpatient facility where your surgery or procedure was performed. The results will be used

to help people make more informed decisions when choosing an outpatient surgery facility. The

facilities will also use survey results to help improve the quality of care they give to their

patients.

How are the results from the study going to be used?

Results from this survey will be used to help people make more informed decisions when

choosing an outpatient surgery facility. The facilities will also use survey results to help improve

the quality of care they give to their patients.

Do I have to take part in this survey?

Your participation in this survey is voluntary. All information that you give in this survey will be

held in confidence and is protected by the Privacy Act. Please know that none of your individual

answers will be shared with [FACILITY NAME], nor will they know whether or not you

participated.


H-2 Centers for Medicare & Medicaid Services Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual

It is also important that you know that your decision to participate in this survey and your

answers to the questions will not affect any health care benefits you receive now or expect to

receive in the future.

You can also skip or refuse to answer any question you don’t feel comfortable with. But, we

hope you will participate because the feedback you provide will help improve the quality of the

care you, and others like you, receive.

I did not have surgery. This survey does not apply to me.

This survey is applicable to you if you had a medical or diagnostic procedure at [FACILITY

NAME] in [MONTH, YEAR]. Examples of these types of procedures include colonoscopy,

endoscopy, biopsy and injection for pain management. [NOTE: IF NEEDED, EXPLAIN TO

RESPONDENT HOW THEY WERE SELECTED: You were randomly selected to participate in

this survey because our records show that you had a procedure at (FACILITY NAME).]

I can’t remember any specific procedure/I didn’t have surgery on that date.

For privacy reasons, we do not have access to the procedures you had at this facility during

[MONTH]. Please try to answer the questions as best as you can for the procedure you remember

the most in [MONTH].

My surgery was not outpatient/ambulatory because I stayed overnight at the hospital/facility. This survey does not apply to me.

This survey is for people who had outpatient surgeries, including those who went home on the

same day and those who stayed overnight for observation. As long as you went home after

observation and you were not discharged to a hospital as an inpatient, then this survey is for you.

What do I have to do/What kinds of questions are there?

I would like to ask you some questions about your experiences with your recent outpatient

surgery or procedure at [FACILITY NAME]. For example, the questions will ask for your

experience with the check-in process, the facility itself, the communication you had with the

facility’s staff, the information you received on your procedure, and your overall experience.

This survey takes on average about 8 minutes to complete, and I will move through the questions

as quickly as possible.

Is it okay for RESPONDENT’S wife, husband, child, legal guardian, etc. to answer these questions?

Because you were chosen at random to participate in this important study, and because you were

the one who received care for an outpatient surgery or procedure, no other person can take your

place. But, you may skip or refuse to answer any question you’re uncomfortable with.

November 2018 Appendix H: Frequently Asked Questions for Telephone Interviewers (English)


How do I know this is confidential?

Your individual answers will only be seen by research staff, who have signed statements of

confidentiality. All personal identifying information, such as names and addresses, will be

removed from data records before they are analyzed. And, everyone’s answers will be combined

to produce a summary report.

Why do you want to know all this personal stuff about me (RACE, AGE, GENERAL HEALTH, etc.) if this is a survey about my outpatient surgery care experiences?

I understand your concern with the questions about your general health and background. We

have found that people’s experiences may differ based on their current health status and other

characteristics. This is a very important survey. If a question bothers you, just tell me you’d

rather not answer it, and I’ll move on to the next question.

I’m on the Do Not Call list. Why are you calling me?

The Do Not Call list stops sales and telemarketing calls. We are conducting survey research on

behalf of [FACILITY NAME]. We are not calling to sell or market a product or service.

I’m not going to answer a lot of questions over the phone!

Your cooperation is very important to us. The information that you provide in this survey will

help others make more informed choices about an outpatient surgery center and will help the

facility you visited to improve the care they give. Please know that you can skip or refuse to

answer any question you don’t feel comfortable with, and that all of your answers will be kept

completely confidential since they are protected by the Federal Privacy Act of 1974. Let me start

and you can see what the questions are like…[READ FIRST QUESTION]

How did you get my name? How was I chosen for the survey?

Your name was randomly selected from a list of patients at [FACILITY NAME] who received an

outpatient surgery or procedure in [MONTH].

I did not like my outpatient surgery center!

I understand. Your opinions are very important and will help your outpatient surgery center

understand how to improve its care. Let’s start now. [NOTE: DO NOT ARGUE BACK. MAKE

SHORT, NEUTRAL COMMENTS TO LET THEM KNOW THAT YOU ARE LISTENING

AND IMMEDIATELY ASK THE FIRST QUESTION.]

How long will this take?

This survey takes on average about 8 minutes to complete. I’ll move through the questions as

quickly as possible.


H-4 Centers for Medicare & Medicaid Services Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual

Probe options for when respondent answers “Yes” instead of “Yes, Definitely” or “Yes, Somewhat.”

• “Would you say, ‘Yes, Definitely’ or ‘Yes, Somewhat?’”

• “Thank you for your response. For this question, I have three categories. Category 1 is

‘Yes, Definitely;’ Category 2 is ‘Yes, Somewhat;’ and Category 3 is ‘No.’ You said

‘Yes.’ Would that be Category 1 – ‘Yes, Definitely’ – or Category 2 – ‘Yes,

Somewhat?’”

• “Some of the questions have simple yes/no responses. Many of the questions have three

response choices. One, ‘Yes, Definitely.’ Two, ‘Yes, Somewhat.’ And, three, ‘No.’ I

cannot enter a simple ‘Yes’ response. I can enter ‘Yes, Definitely’ or ‘Yes, Somewhat.’

You said, ‘Yes’ to [REPEAT QUESTION ONLY], would that be ‘Yes, Definitely’ or

‘Yes, Somewhat?’”

Where can I see the results from the study?

The results from this survey will be publicly reported on a CMS website. You can access the

results by visiting https://www.medicare.gov/hospitalcompare/OASCAHPS-measures.html.

https://www.medicare.gov/hospitalcompare/OASCAHPS-measures.html.

November 2018 Appendix H: Frequently Asked Questions for Telephone Interviewers (English)




APPENDIX I:

FREQUENTLY ASKED QUESTIONS FOR TELEPHONE INTERVIEWS

(SPANISH)

Preguntas más frecuentes para entrevistas por teléfono

Appendix I: Frequently Asked Questions for Telephone Interviews (Spanish) November 2018



Centers for Medicare & Medicaid Services I-1 Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual

PREGUNTAS MÁS FRECUENTES

OAS CAHPS®

¿Cuál es el propósito de esta encuesta?

El objetivo de la encuesta es aprender sobre sus experiencias con los servicios que recibió

durante su más reciente cirugía externa o procedimiento ambulatorio. Los resultados de la

encuesta ayudarán a otros pacientes a tomar decisiones más informadas al seleccionar un centro

de cirugía ambulatoria así como para ayudar a los centros que participan en el estudio a mejorar

la calidad de la atención que proporcionan a sus pacientes.

Ya completé una encuesta por correo. ¿Tengo que completar esta encuesta otra vez?

Muchas gracias por completar la encuesta y enviarla por correo. Sin embargo, aún no hemos

recibido la encuesta, y estamos dándole seguimiento para obtener sus comentarios por teléfono.

Si tiene tiempo en este momento puedo hacerle las preguntas. O le puedo volver a llamar en unos

días si aún no hemos recibido la encuesta por correo.

Perdí la encuesta que se envía por correo. ¿Me puede enviar otra por correo?

Estamos cerca del final del periodo de recolección de datos y no nos permiten enviar ninguna

encuesta adicional. Como las opiniones que usted proporcione nos ayudarán a mejorar la calidad

de la atención de pacientes de cirugía externa o ambulatoria que usted y otras personas reciben,

le estamos pidiendo que por favor complete la encuesta con nosotros por teléfono. Si este es un

buen momento, ¡comencemos!

Ya completé/recibí una encuesta como esa.

A veces los hospitales y los cirujanos llevan a cabo encuestas de sus pacientes recientes y usted

pudiera haber recibido una de esas encuestas. La encuesta que le estamos pidiendo que haga es

sobre su experiencia en la instalación de cirugía externa en donde le realizaron la cirugía o

procedimiento. Los resultados se utilizarán para ayudar a las personas a tomar decisiones más

informadas cuando eligen un centro para cirugía externa o ambulatoria. Los centros también van

a utilizar la encuesta para ayudar a mejorar la calidad de los servicios que dan a sus pacientes.

¿Cómo se utilizarán los resultados del estudio?

Los resultados de esta encuesta se usarán para ayudar a las personas a tomar decisiones más

informadas cuando eligen un centro para cirugía externa o ambulatoria. Los centros también van

a utilizar la encuesta para ayudar a mejorar la calidad de los servicios que dan a sus pacientes.


I-2 Centers for Medicare & Medicaid Services Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual

¿Tengo que participar en esta encuesta?

Su participación en esta encuesta es voluntaria. Toda la información que usted proporcione en

esta encuesta se mantendrá confidencial y está protegida por la Ley de privacidad. Deseamos que

sepa que ninguna de sus respuestas individuales se compartirán con [FACILITY NAME], ni

sabrán si usted participó o no.

También es importante que sepa que su decisión de participar en esta encuesta y sus respuestas a

las preguntas no afectarán a ningún beneficio de atención médica que usted reciba ahora o que

espere recibir en el futuro.

También se puede saltar o rehusar contestar cualquier pregunta que le moleste. Sin embargo,

esperamos que participe porque los comentarios que usted nos dé nos ayudarán a mejorar la

calidad de los servicios que recibe usted y otras personas como usted.

No tuve una cirugía. Esta encuesta no me corresponde.

Esta encuesta sí le corresponde si le realizaron un procedimiento médico o de diagnóstico en

[FACILITY NAME] en [MES, AÑO]. Ejemplos de este tipo de procedimientos incluyen:

colonoscopía, endoscopía, biopsia e inyección para control del dolor. [NOTE: IF NEEDED,

EXPLAIN TO RESPONDENT HOW THEY WERE SELECTED: Usted fue seleccionado al

azar para participar en esta encuesta porque nuestros registros indican que le realizaron un

procedimiento en (FACILITY NAME).]

No recuerdo ningún procedimiento/No tuve una cirugía en esa fecha.

Por razones de privacidad, no tenemos acceso a los procedimientos que le realizaron a usted en

ese centro durante [MES]. Por favor trate de responder a las preguntas lo mejor que pueda para el

procedimiento que mejor recuerde en [MES].

Mi cirugía no fue como paciente externo/ambulatorio porque me tuve que quedar una noche en el hospital/centro. Esta encuesta no me aplica.

Esta encuesta es para personas que tuvieron cirugía como pacientes externos, incluyendo a las

personas que se fueron a casa el mismo día y los que se quedaron una noche para observación.

Siempre y cuando se fuera a su casa después del periodo de observación y no le dieron de alta a

un hospital como paciente interno, entonces esto es para usted.

¿Qué tengo que hacer/Qué tipos de preguntas son?

Me gustaría hacerle algunas preguntas sobre sus experiencias con su reciente cirugía externa o

procedimiento ambulatorio en [FACILITY NAME]. Por ejemplo, las preguntas le pedirán sus

experiencias con el proceso de registro, el centro de cirugía en sí, la comunicación que tuvo con

el personal del centro de cirugía, la información que recibió sobre su procedimiento y su

November 2018 Appendix I: Frequently Asked Questions for Telephone Interviews (Spanish)

Centers for Medicare & Medicaid Services I-3 Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual

experiencia en general. En promedio, esta encuesta se puede completar en unos 10 minutos y voy

a avanzar con las preguntas tan rápido como sea posible.

¿Es posible que (la esposa, el esposo, el hijo, el tutor legal, etc.) responda a estas preguntas?

Como usted fue seleccionado(a) al azar para participar en este importante estudio y como usted

fue la persona que recibió la atención médica para la cirugía externa o procedimiento

ambulatorio, ninguna otra persona puede tomar su lugar. Pero se puede saltar o rehusar contestar

cualquier pregunta que le moleste.

¿Cómo sé que esto es confidencial?

Las respuestas que usted dé solo serán vistas por el personal del estudio, quienes han firmado

declaraciones de confidencialidad. Toda la información de identidad, como los nombres y las

direcciones, serán separados de los registros de datos antes de ser analizados. Y, las respuestas de

todas las personas se combinarán para generar un reporte de resumen.

¿Por qué desea saber todos esos datos personales acerca de mi (SALUD, RAZA, EDAD, etc.) si esta encuesta es acerca de mis experiencias sobre la atención médica durante mi cirugía externa o ambulatoria?

Entiendo su preocupación sobre las preguntas sobre su salud en general y antecedentes. Hemos

encontrado que las experiencias de las personas pueden variar de acuerdo al estado salud y otras

características. Esta es una encuesta muy importante. Si le molesta alguna pregunta, solo dígame

que no desea responderla y avanzaré a la siguiente pregunta.

Estoy en la lista de no llamar. ¿Por qué me están llamando?

La lista de No llamar previene las llamadas de ventas y telemercadeo. Estamos llevando a cabo

el estudio de encuesta a nombre de [FACILITY NAME]. No le estamos llamando para vender o

promover un producto o servicio.

¡No voy a responder a tantas preguntas por teléfono!

Su cooperación es muy importante para nosotros. La información que usted proporcione en esta

encuesta ayudará a otras personas a tomar decisiones más informadas sobre un centro de cirugía

externo o ambulatorio y ayudará al centro de cirugía, a mejorar sus servicios. Por favor tenga en

cuenta que se puede saltar o negar a contestar cualquier pregunta que le moleste y que sus

respuestas se mantendrán completamente confidenciales porque están protegidas por la ley

federal de privacidad de 1974. Empecemos y usted podrá ver cómo son las preguntas…[READ

FIRST QUESTION]


I-4 Centers for Medicare & Medicaid Services Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual

¿Cómo obtuvo mi nombre? ¿Cómo me seleccionaron para la encuesta?

Su nombre se seleccionado al azar de una lista de pacientes en [FACILITY NAME] que tuvieron

una cirugía externa o procedimiento ambulatorio durante el mes de [MES].

¡No me agradó el centro de cirugía externa/ambulatoria!

Le entiendo. Sus opiniones son muy importantes y ayudarán a su centro de cirugía

externa/ambulatoria a entender como mejorar sus servicios. Comencemos. [NOTE: DO NOT

ARGUE BACK. MAKE SHORT, NEUTRAL COMMENTS TO LET THEM KNOW THAT

YOU ARE LISTENING AND IMMEDIATELY ASK THE FIRST QUESTION.]

¿Cuánto tiempo va a tomar?

En promedio esta encuesta se puede completar como en 8 minutos. Trataré de hacer las

preguntas tan rápido como me sea posible.

Probe options for when respondent answers “Sí” instead of “Sí, definitivamente” or “Sí, algo.”

“¿Diría usted que, ‘Sí, definitivamente’ o ‘Sí, algo?’”

“Gracias por su respuesta. Para esta pregunta, tengo tres categorias. Categoría 1 es ‘Sí,

definitivamente;’ Categoría 2 es ‘Sí, algo;’ y Categoría 3 es ‘No.’ Usted dijo ‘Sí.’ Eso

sería la Categoría 1 – ‘Sí, definitivamente’ – o la Categoría 2 – ‘Sí, algo?’”

“Las respuestas para algunas preguntas son simplemente sí/no. Muchas de las preguntas

tienes tres opciones de respuesta. Una, ‘Sí, definitivamente.’ Dos, ‘Sí, algo.’ Y, tres,

‘No.’ No puede ingresar solo ‘sí’ como la respuesta. Solo puedo ingresar ‘Sí,

definitivamente’ o ‘Sí, algo.’ Usted dijo, ‘Sí’ a [REPEAT QUESTION ONLY], eso sería

‘Sí, definitivamente’ o ‘Sí, algo?’”

¿En dónde puedo ver los resultados del estudio?

Los resultados de esta encuesta se publicarán en un reporte en el sitio web de los Centros de

Servicios de Medicare y Medicaid (CMS, por sus siglas en inglés). Usted puede accesar los

resultados visitando https://www.medicare.gov/hospitalcompare/OASCAHPS-measures.html.

https://www.medicare.gov/hospitalcompare/OASCAHPS-measures.html.


APPENDIX J:

GENERAL GUIDELINES FOR TELEPHONE INTERVIEWERS

Appendix J: General Guidelines for Telephone Interviewers November 2018



Centers for Medicare & Medicaid Services J-1 Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual

OUTPATIENT AND AMBULATORY SURGERY CAHPS SURVEY

GENERAL GUIDELINES FOR TELEPHONE INTERVIEWING

Overview

The Outpatient and Ambulatory Surgery (OAS) CAHPS Survey is administered as an electronic

system telephone interview. As a telephone interviewer on the OAS CAHPS, you will use the

system to conduct each interview. The questions you ask are programmed into a computer. The

phone number is provided by the computer for you to make the call. You will read the questions

from the computer screen and enter the answer to each question into the computer. Based on the

answer you enter, the computer will automatically take you to a screen with the next applicable

question.

You play an extremely important role in the overall success of this study. You are the link to the

hundreds of respondents who will provide valuable information to the project team. You are the

person who develops rapport with the respondents, assures them that their participation is

important, and obtains their full cooperation and informed consent.

As a professional interviewer, your job is to help each respondent feel at ease and comfortable

with the interview. Key to accomplishing this goal is to be fully informed about the survey, the

interview, and the data collection procedures.

General Interviewing Techniques

The process of asking questions, probing, and entering responses correctly is crucial to obtaining

high-quality data for the OAS CAHPS Survey. General techniques and procedures you should

follow when conducting the OAS CAHPS Survey interviews are provided below.

Administering Survey Questions

• Ask the questions exactly as they are presented. Do not change the wording or condense

any question when reading it to the respondent.

• Emphasize all words or phrases that appear in bold, are underlined, or appear in italics.

• Ask every question specified, even when a respondent has seemingly provided the

answer as part of the response to a preceding question. The answer received in the

context of one question may not be the same answer that will be received when the other

question is asked. If it becomes cumbersome to the respondent, remind him or her gently

that you must ask all questions of all respondents.

• If the answer to a question indicates that the respondent did not understand the intent of

the question, or if the respondent requests that any part of the question be clarified, even

if it is only one word, repeat the question.


J-2 Centers for Medicare & Medicaid Services Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual

• Read the questions slowly, at a pace that allows them to be readily understood.

Remember that the respondent has not heard these questions before and will not have had

the exposure that you have had to the questionnaire.

• Transition statements are designed to inform the respondent of the nature of an upcoming

question or a series of questions, to define a word, or to describe what is being asked for

in the question. Read transition statements just as they are presented. Don’t create

“transition statements” of your own, because these may unintentionally introduce bias

into the interview.

• Give the respondent plenty of time to recall past events.

• Do not suggest answers to the respondent. Your job as an interviewer is to read the

questions exactly as they are printed, make sure the respondent understands the question,

and then enter the responses. Do not help the respondent answer the questions.

• Ask questions in the exact order in which they are presented.

• Do not read words that appear in ALL CAPITAL LETTERS to the respondent. This

includes both questions and response categories.

• Read all questions including those that may appear to be sensitive to the respondent in the

same manner with no hesitation or change in inflection.

• Thoroughly familiarize yourself with the Frequently Asked Questions list before you

conduct interviews so that you are knowledgeable about the OAS CAHPS Survey.

• At the end of the interview, tell the sample member that the survey is completed and

thank him or her for taking part in the survey.

Introducing the Survey

The introduction is of the utmost importance to successfully completing a telephone interview.

Most people hang up in the first few minutes of the interview, so if you can convince the

respondent to remain on the line long enough to hear the purpose of the study and begin asking

the questions, the chances that your respondent will complete the interview increase

dramatically.

• When reading the introduction, sound confident and pronounce the words as clearly as

you can.

• Respondents are typically not expecting survey research calls, so they may need your

help to clarify the nature of the call.

November 2018 Appendix J: General Guidelines for Telephone Interviewers


• Practice the introduction until you can present it in such a manner that your presentation

sounds confident, sincere, and natural.

• Deliver the introduction at a conversational pace. Rushing through the introduction gives

an impression of lack of confidence and may also cause the listener to misunderstand.

• Try not to pause too long before asking the first question in the survey following the

introduction. A pause tends to indicate that you are waiting for approval to continue.

Avoiding Refusals

The first and most critical step in avoiding refusals is your effort to establish rapport with

reluctant sample members, therefore minimizing the incidence of refusals. Remember, you will

not be able to call back and convert a refusal―your initial contact with the sample member is the

only chance you will have to create a successful interview. The following are some tips to follow

to avoid refusals.

• Make sure you are mentally prepared when you start each call, and have a positive

attitude.

• Treat respondents the way you would like to be treated.

• Always use an effective/positive/friendly tone and maintain a professional outlook.

• Pay careful attention to what the respondent says during the interview.

• Listen to the respondent completely rather than assuming you know what he or she is

objecting to.

• Listen before evaluating and entering a response code.

• Be accommodating to the respondents’ needs.

• Always remain in control of the interaction.

• Understand the reason for reluctance/refusal at the start of the call, or figure it out as

quickly as possible.

• Listen as an ally, not an adversary, and do not debate or argue with the respondent.

• Be prepared to address one (or more) reason(s) for reluctance/refusal.

• Focus your comments to sample members on why they specifically are important to the

study.



• Paraphrase what you hear and repeat this back to the respondent.

• Remember that you are a professional representative of your survey organization and the

health care facility whose patients you are contacting.

General Interviewing Guidance

The following sections provide guidance on the use of neutral feedback, probes, avoiding bias,

and entering responses accurately. By following these rules, interviewers will help ensure that

the OAS CAHPS Survey interviews are conducted in a standardized manner.

Providing Neutral Positive Feedback

The use of neutral feedback can help build rapport with sample members. Periodically

acknowledging the respondent during the interview can help gain and retain cooperation during

the interview.

Acceptable neutral acknowledgment words:

• Thank you

• All right

• Okay

• I understand

• Let me repeat the question

Probing

At times, it will be necessary for you to probe to obtain a more complete or more specific answer

from a respondent. To elicit an acceptable response, you will often need to use an appropriate

neutral or nondirective probe. The important thing to remember is not to suggest answers or lead

the respondent. Some general rules for probing follow:

• Repeat the question if the respondent misunderstood or misinterpreted the question. After

hearing the question the second time, the respondent will probably understand what

information is expected.

• Use a silent probe, which is pausing or hesitating to indicate to the respondent that you

need additional or better information. This is a good probe to use after you have

determined the respondent’s response pattern.

• Use neutral questions or statements to encourage a respondent to elaborate on an

inadequate response. Examples of neutral probes include the following: “What do you



mean?” “How do you mean?” “Tell me what you have in mind.” “Tell me more

about….”

• Use clarification probes when the response is unclear, ambiguous, or contradictory. Be

careful not to appear to challenge the respondent when clarifying a statement and always

use a neutral probe. Examples of clarification probes are “Can you give me an example?”

or “Could you be more specific?”

• Encourage the respondent to give his or her best guess if a respondent gives a “don’t

know” response. Let the respondent know that this is not a test and there are no right or

wrong answers. We are interested in the respondent’s opinions and assessment of the care

that he or she has received at their ambulatory surgery center or hospital outpatient

department.

• If the respondent asks you to answer the question for him or her, let the respondent know

that you cannot. Instead, ask the respondent if she or he requires clarification on the

content or meaning of the question.

Avoiding Bias

One common pitfall of interviewing is unknowingly introducing bias into an interview. Bias

occurs when an interviewer says or does something that affects the answers respondents give in

an interview. An interview that has significant bias will not provide accurate data for the research

being conducted; such an interview may have to be thrown out.

As a professional interviewer, remaining neutral at all times ensures that bias is not introduced

into the interview. There are many things you can do or avoid to help ensure that no bias is

introduced. You should

• read all statements and questions exactly as they are written,

• use neutral probes that do not suggest answers,

• not provide your own personal opinions or answers in an effort to “help” respondents,

and

• not use nonverbal language, such as a cough, pause or a yawn to influence the interview.

Taking these steps to monitor your own spoken and unspoken language will go a long way to

guarantee that the interviews you conduct are completed correctly and efficiently.



Entering Responses

The majority of the questions you will ask have precoded responses. To enter a response for

these types of questions, you will simply select the appropriate response option and enter the

number corresponding to that response.

The conventions presented below must be followed at all times to ensure that the responses you

enter accurately reflect the respondents’ answers and to ensure that questionnaire data are all

collected in the same systematic manner.

• You must listen to what the respondent says and enter the appropriate answer if the

response satisfies the objective of the question. If the answer does not appear to satisfy

the objective, repeat the question.

• In entering answers to open-ended questions or “Other (specify)” categories, enter the

response verbatim, exactly as it was given by the respondent.

• Enter the response immediately after it is given.

• If a respondent gives a range in response to a question, probe as appropriate for a more

specific answer. For example, if a respondent says, “Oh, 2 or 3 times” and you can enter

only one number, ask for clarification: “Would that be closer to 2 or to 3?”

Rules for Successful Telephone Interviewing

Remember, the key to successful interviewing is being prepared for every contact that you make.

Have a complete set of the appropriate materials at your work station, organized in such a

manner that you do not have to stop and search for required documents. Some general rules that

you should follow every time you place a call are provided below.

1. Be prepared before you place a call. Be prepared to talk to the sample member. You should

be able to explain the purpose of your call to the sample member or his or her family and

friends. Do not rely on your memory alone to answer questions. Make sure you review and

understand the Frequently Asked Questions (FAQs).

2. Act professionally. Convey to sample members that you are a professional who specializes in

asking questions and conducting interviews. As a professional interviewer, you have specific

tasks to accomplish for this survey.

3. Make the most of your contact. Even though you may not be able to obtain an interview on

this call, it is important to make the most of the contact to aid in future attempts. For

example, if you are trying to contact the sample member and he or she is not available, gain

as much information as you can to help reach the sample member the next time he or she is

called. Important questions to ask:



◦ When is the sample member usually home?

◦ What is the best time to reach the sample member?

◦ Can you schedule an “appointment” to reach the sample member at a later time?

4. Don’t be too quick to code a sample member as incapable. Some sample members may be

hard of hearing or appear not to fully understand you when you call. Rather than immediately

coding these cases as “Incapable,” please attempt to set a call-back for a different time of day

and different day of the week. It is possible that reaching the sample member at a different

time may result in your being able to conduct the interview with him or her. It is also

possible that a friend or family member can assist the sample member with the interview.

You cannot allow them to proxy for the sample member, but you can allow them to provide

general help.





APPENDIX K:

XML DATA FILE LAYOUT FOR STANDARD HEADER RECORD

Appendix K: XML Data File Layout for Standard Header Record November 2018



Cen

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STANDARD XML DATA FILE LAYOUT

OUTPATIENT AND AMBULATORY CAHPS SURVEY

STANDARD HEADER RECORD

The following section defines the format of the Header Record.

NOTE: Each element must have a closing tag that is the same as the opening tag but with a forward slash. Data element names do not contain

any spaces, underscores, or capital letters.

XML Element Description Valid Values Data Type Field

Size

Data

Element

Required

Type of Header Record

headertype

This header element should only occur once

per file.

Example: headertype 1 /headertype

Type of Header Record 1 = Standard Header

Record

Numeric 1 Yes

Provider Name

<providername


per file.

Example: providername

SampleHOPDASCName / providername

This is the HOPD’s or ASC’s

Provider Name

— Alphanumeric 100 Yes

Provider Number

providernum

This header element will occur again as an

administrative data element in the patient level

data record.

Example: providernum 123456 /

providernum


CMS Certification Number

(CCN, formerly known as the

Medicare Provider ID Number)

No Dashes or spaces

Valid 6- or 10-digit CMS

Certification Number

(CCN)

Alphanumeric 10 Yes

Ap

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Data

File

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Size

Data

Element

Required

Sample Month

samplemonth This header element will occur again as an


data record.

Example: samplemonth 12 /

samplemonth

Survey vendors will select a

sample of patients who meet

survey eligibility criteria for each

calendar month. The Sample

Month is the month for which the

sample was selected.

MM

(1 – 12 = January –

December)

Numeric 2 Yes

Sample Year

sampleyear This header element will occur again as an


data record.

Example: sampleyear 2016 /

sampleyear

This is the calendar year in which

the survey is conducted.

YYYY

(2016 or greater)

Numeric 4 Yes

Survey Mode

surveymode



data record.

Example: surveymode 1 / surveymode

The survey mode, either mail

only, phone only, or mixed mode,

must be the same for all sample

members in each sample month in

the calendar quarter for all of the

HOPD or ASC locations under

the same CCN.

1 = Mail only

2 = Telephone only

3 = Mixed mode

Numeric 1 Yes

Type of Sampling

sampletype


per file.

Example: sampletype 1 /sampletype

Type of sampling used. Note:

Sample Type must be the same

for all three months in each

quarter.

1 = Census

2 = Simple random

sampling

3 = Stratified systematic

sampling

4 = Proportionate

Stratified Random

sampling

Numeric 1 Yes

No

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Data

File

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Size

Data

Element

Required

Patients Served

patientsserved


per file.

Example: patientsserved 600 /

patientsserved

This is the total number of

patients who had at least one

outpatient surgery or procedure

during the sample month at the

HOPD or ASC, regardless of

whether the patient or surgery was

OAS CAHPS eligible.

1 – 999999

M = Unknown/Missing

Alphanumeric 6 Yes

Patients on file(s) submitted to Vendor

patientsfile


per file.

Example: patientsfile 595 /patientsfile

Number of patients included on

the file that the vendor received

for this HOPD or ASC.

1 – 999999 Numeric 6 Yes

Eligible Patients

eligiblepatients


per file.

Example: eligiblepatients 500 /

eligiblepatients

This is the number of patients in

the file submitted by the HOPD or

ASC that meet survey eligibility

criteria in the sample month.


Sampled Patients

sampledpatients


per file.

Example: sampledpatients 450 /

sampledpatients

This is the number of patients

selected for the survey during the

sample month.


Ap

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K: X

ML

Data

File

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PATIENT ADMINISTRATIVE DATA RECORD

The following section defines the format of the patient level data record.




Size

Data

Element

Required

Provider Number

providernum

This administrative element also occurs in the

previous Header Record.


providernum





No Dashes or spaces



(CCN)

Alphanumeric 10 Yes

Sample Month

samplemonth This administrative element also occurs in the



samplemonth

OAS CAHPS Survey sampling

month

MM

(1 – 12 = January –

December)

Numeric 2 Yes

Sample Year

sampleyear This administrative element also occurs in the



sampleyear

Year of sample month YYYY

(2016 or greater)

Numeric 4 Yes

No

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Size

Data

Element

Required

Sample ID No.

sampleid This administrative element should only occur

once per patient.

Example: sampleid 1234567 /sampleid

Survey vendors will assign a

unique de-identified sample

identification number (SID) to

each patient. The SID number

will be used to track the survey

status of the patient throughout

the survey administration process

and to designate sample patients

on the data file submitted to the

Data Center.

Maximum of 16

characters

Alphanumeric 16 Yes

Ap

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K: X

ML

Data

File

Layo

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No

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Size

Data

Element

Required

Surgical Category

surgicalcat This administrative element should only occur

once per patient.

Example: surgicalcat 1 /surgicalcat

This is the category for the

surgery, and must be one of the

following options:

Gastrointestinal (GI), Orthopedic,

Ophthalmologic, Other, Missing.

If CPT27

code(s) in range 40000–

49999 or G-code(s) G0105,

G0121, or G0104, assign surgical

category 1.

If CPT code(s) in range 20000–

29999 or G-code is G0260, assign

surgical category 2.


68899, assign surgical category 3.


19999, 30000–39999, 50000–

64999, or 68900–69990 or if G-

code(s) not in the range for

surgical categories 1, 2, or 3,

assign surgical category 4.

If surgical category cannot be

determined, assign category 5.

1 = Gastrointestinal (GI)

2 = Orthopedic

3 = Ophthalmologic

4 = Other

5 = Missing

Numeric 1 Yes


No

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Data

File

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Size

Data

Element

Required

Age

patientage

This administrative element should only occur

once per patient.

Example: patientage 7 /patientage

Category for patient’s age as of

date of surgery/procedure.

(Patients must be 18 or older at

the date of surgery/procedure to

be eligible for the survey.)

18–24 .......................... 1

25–29 .......................... 2

30–34 .......................... 3

35–39 .......................... 4

40–44 .......................... 5

45–49 .......................... 6

50–54 .......................... 7

55–59 .......................... 8

60–64 .......................... 9

65–69 ........................ 10

70–74 ........................ 11

75–79 ........................ 12

80–84 ........................ 13

85–89 ........................ 14

90 or older................. 15

Unknown/Missing .... M

NOT APPLICABLE .. X

Alphanumeric 2 Yes

Gender

patientgender This administrative element should only occur

once per patient.

Example: patientgender 1 /

patientgender

Patient’s gender 1 = Male

2 = Female

M = Unknown/Missing

X = NOT APPLICABLE

Alphanumeric 1 Yes

Survey Mode

surveymode


once per patient.

Example: surveymode 1 /surveymode

This is the mode of data

collection the patient used to

complete the survey. Apply code

“X” (Not Applicable) to all

sampled cases where the survey

does not result in a Complete

(code 110 or 120) or a Breakoff

(code 310).

1 = Mail only

2 = Telephone only

X = NOT APPLICABLE

Alphanumeric 1 Yes

Ap

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K: X

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Size

Data

Element

Required

Lag Time

<lagtime>


once per patient.

Example: lagtime 51 /lagtime

The number of calendar days

between the date of eligible

surgery/procedure and the date

when this patient’s survey was

initiated.

0–90

X = NOT APPLICABLE

Alphanumeric 2 Yes

Final Survey Status

finalstatus


once per patient.

Example: finalstatus 110 /finalstatus

Final disposition of survey 110 = Completed Mail

Survey

120 = Completed Phone

Survey

210 = Ineligible:

Deceased

220 = Ineligible: Does

not Meet Eligibility

criteria

230 = Ineligible:

Language Barrier

240 = Ineligible:

Mentally or

Physically

Incapacitated

310 = Breakoff

320 = Refusal

330 = Bad Address/

Undeliverable Mail

340 = Wrong/Disc/No

Telephone Number

350 = No response after

Maximum attempts

Numeric 3 Yes

No

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Size

Data

Element

Required

Survey Language

language This administrative data element should only

occur once per patient.

Example: language 1 /language

Identify language in which survey

was completed

1 = English

2 = Spanish

3 = Chinese

4 = Korean

X = NOT APPLICABLE

Alphanumeric 1 Yes

Ap

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PATIENT RESPONSE RECORD

The following section defines the format of the Patient Response Record.




Size

Data

Element

Required

Q1 Informed

informed

This patient response data element should only


Example: informed 1 /informed

Before your procedure, did your

doctor or anyone from the facility

give you all the information you

needed about your procedure?

Yes, definitely............. 1

Yes, somewhat ............ 2

No ............................... 3

MISSING/DK ........... M

Alphanumeric 1 Yes

Q2 Instructions

instructions



Example: instructions 1 /instructions


doctor or anyone from the facility

give you easy to understand

instructions about getting ready

for your procedure?


Yes, somewhat ............ 2

No ............................... 3


Alphanumeric 1 Yes

Q3 Check In

checkin This patient response data element should only


Example: checkin 1 /checkin

Did the check-in process run

smoothly?


Yes, somewhat ............ 2

No ............................... 3


Alphanumeric 1 Yes

Q4 Clean

clean



Example: clean 1 /clean

Was the facility clean? Yes, definitely............. 1

Yes, somewhat ............ 2

No ............................... 3


Alphanumeric 1 Yes

Q5 Clerk Helpful

clerkhelpful This patient response data element should only


Example: clerkhelpful 1 /clerkhelpful

Were the clerks and receptionists

at the facility as helpful as you

thought they should be?


Yes, somewhat ............ 2

No ............................... 3


Alphanumeric 1 Yes

No

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Data

Element

Required

Q6 Clerk Respect

clerkrespect



Example: clerkrespect 1 /clerkrespect

Did the clerks and receptionists at

the facility treat you with courtesy

and respect?


Yes, somewhat ............ 2

No ............................... 3


Alphanumeric 1 Yes

Q7 Dr. Respect

drrespect



Example: drrespect 1 /drrespect

Did the doctors and nurses treat

you with courtesy and respect?


Yes, somewhat ............ 2

No ............................... 3


Alphanumeric 1 Yes

Q8 Dr. Comfort

drcomfort



Example: drcomfort 1 /drcomfort

Did the doctors and nurses make

sure you were as comfortable as

possible?


Yes, somewhat ............ 2

No ............................... 3


Alphanumeric 1 Yes

Q9 Dr. Explain

drexplain



Example: drexplain 1 /drexplain

Did the doctors and nurses

explain your procedure in a way

that was easy to understand?


Yes, somewhat ............ 2

No ............................... 3


Alphanumeric 1 Yes

Q10 Anesthesia

anesthesia



Example: anesthesia 1 /anesthesia

Anesthesia is something that

would make you feel sleepy or go

to sleep during your procedure.

Were you given anesthesia?

Yes .............................. 1

No ............................... 2


Alphanumeric 1 Yes

Ap

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dix

K: X

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Size

Data

Element

Required

Q11 Anesthesia Explain

anesthesiaexplain



Example: anesthesiaexplain 2 /

anesthesiaexplain

Did your doctor or anyone from

the facility explain the process of

giving anesthesia in a way that

was easy to understand?


Yes, somewhat ............ 2

No ............................... 3


NOT APPLICABLE .. X

Alphanumeric 1 Yes

Q12 Anesthesia Side

anesthesiaside



Example: anesthesiaside 1 /

anesthesiaside


the facility explain the possible

side effects of the anesthesia in a

way that was easy to understand?


Yes, somewhat ............ 2

No ............................... 3


NOT APPLICABLE .. X

Alphanumeric 1 Yes

Q13 Discharge Instructions

dischargeinstructions This patient response data element should only


Example: dischargeinstructions 1 /

dischargeinstructions

Discharge instructions include

things like symptoms you should

watch for after your procedure,

instructions about medicines, and

home care. Before you left the

facility, did you get written

discharge instructions?

Yes .............................. 1

No ............................... 2


Alphanumeric 1 Yes

Q14 Recovery

recovery



Example: recovery 1 /recovery


the facility prepare you for what

to expect during your recovery?


Yes, somewhat ............ 2

No ............................... 3


Alphanumeric 1 Yes

No

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Data

Element

Required

Q15 Pain Info

paininfo This patient response data element should only


Example: paininfo 1 /paininfo

Some ways to control pain

include prescription medicine,

over-the-counter pain relievers or

ice packs. Did your doctor or

anyone from the facility give you

information about what to do if

you had pain as a result of your

procedure?


Yes, somewhat ............ 2

No ............................... 3


Alphanumeric 1 Yes

Q16 Pain Result

painresult



Example: painresult 1 /painresult

At any time after leaving the

facility, did you have pain as a

result of your procedure?

Yes .............................. 1

No ............................... 2


Alphanumeric 1 Yes

Q17 Nausea

nausea



Example: nausea 1 /nausea

Before you left the facility, did

your doctor or anyone from the

facility give you information

about what to do if you had

nausea or vomiting?


Yes, somewhat ............ 2

No ............................... 3


Alphanumeric 1 Yes

Q18 Nausea Result

nausearesult



Example: nausearesult 1 /nausearesult


facility, did you have nausea or

vomiting as a result of either your

procedure or the anesthesia?

Yes .............................. 1

No ............................... 2


Alphanumeric 1 Yes

Q19 Bleeding Instruction

bleedinginstruction This patient response data element should only


Example: bleedinginstruction 1 /

bleedinginstruction





bleeding as a result of your

procedure?


Yes, somewhat ............ 2

No ............................... 3


Alphanumeric 1 Yes

Ap

pen

dix

K: X

ML

Data

File

Layo

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Size

Data

Element

Required

Q20 Bleeding Result

bleedingresult



Example: bleedingresult 1

bleedingresult


facility, did you have bleeding as

a result of your procedure?

Yes .............................. 1

No ............................... 2


Alphanumeric 1 Yes

Q21 Infection Info

infectioninfo This patient response data element should only


Example: infectioninfo 1 /infectioninfo

Possible signs of infection include

fever, swelling, heat, drainage or

redness. Before you left the

facility, did your doctor or anyone

from the facility give you

information about what to do if

you had possible signs of

infection?


Yes, somewhat ............ 2

No ............................... 3


Alphanumeric 1 Yes

Q22 Infections Signs

infectionsigns This patient response data element should only


Example: infectionsigns 1 /

infectionsigns


facility, did you have any signs of

infection?

Yes .............................. 1

No ............................... 2


Alphanumeric 1 Yes

No

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Size

Data

Element

Required

Q23 Rate Facility

ratefacility This patient response data element should only


Example: ratefacility 2 /ratefacility

Using any number from 0 to 10,

where 0 is the worst facility

possible and 10 is the best facility

possible, what number would you

use to rate this facility?

Worst facility

possible ....................... 0

.................................... 1

.................................... 2

.................................... 3

.................................... 4

.................................... 5

.................................... 6

.................................... 7

.................................... 8

.................................... 9

Best facility possible . 10


Alphanumeric 2 Yes

Q24 Recommend

recommend This patient response data element should only


Example: recommend 2 /recommend

Would you recommend this

facility to your friends and

family?

Definitely no ............... 1

Probably no ................. 2

Probably yes ............... 3

Definitely yes.............. 4


Alphanumeric 1 Yes

Q25 Rate Overall

rateoverall This patient response data element should only


Example: rateoverall 1 /rateoverall

In general, how would you rate

your overall health?

Excellent ..................... 1

Very good ................... 2

Good ........................... 3

Fair .............................. 4

Poor ............................ 5


Alphanumeric 1 Yes

Q26 Rate Overall Mental

rateoverallmental This patient response data element should only


Example: rateoverallmental 1 /

rateoverallmental


your overall mental or emotional

health?

Excellent ..................... 1

Very good ................... 2

Good ........................... 3

Fair .............................. 4

Poor ............................ 5


Alphanumeric 1 Yes

Ap

pen

dix

K: X

ML

Data

File

Layo

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Size

Data

Element

Required

Q27 Age

age This patient response data element should only


Example: age 1 /age

What is your age? 18 to 24 ....................... 1

25 to 34 ....................... 2

35 to 44 ....................... 3

45 to 54 ....................... 4

55 to 64 ....................... 5

65 to 74 ....................... 6

75 to 79 ....................... 7

80 to 84 ....................... 8

85 or older................... 9


Alphanumeric 1 Yes

Q28 Gender

gender This patient response data element should only


Example: gender 1 /gender

Are you male or female? Male ............................ 1

Female ........................ 2


Alphanumeric 1 Yes

Q29 Education

education This patient response data element should only


Example: education 3 /education

What is the highest grade or level

of school that you have

completed?

8th grade or less .......... 1

Some high school,

but did not graduate .... 2

High school graduate

or GED ....................... 3

Some college or 2-

year degree.................. 4

4-year college

graduate ...................... 5

More than 4-year

college degree ............. 6


Alphanumeric 1 Yes

No

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Size

Data

Element

Required

Q30 Ethnicity

ethnicity This patient response data element should only


Example: ethnicity 2 /ethnicity

Are you of Hispanic, Latino, or

Spanish origin?

Yes .............................. 1

No ............................... 2


Alphanumeric 1 Yes

Q31 Group

group



Example: group 1 /group

Which group best describes you? Mexican, Mexican

American,

Chicano ....................... 1

Puerto Rican ............... 2

Cuban .......................... 3

Another Hispanic,

Latino, or Spanish

origin .......................... 4


NOT APPLICABLE .. X

Alphanumeric 1 Yes

Q32 Race White-mail

racewhite-mail



Example: racewhite-mail 1 /racewhite-

mail

What is your race? You may

select one or more categories.

White .......................... 1


NOT APPLICABLE .. X

Alphanumeric 1 Yes

Q32 Race African American-mail

raceafricanamer-mail This patient response data element should only


Example: raceafricanamer-mail 1

/raceafricanamer-mail



Black or African

American .................... 1


NOT APPLICABLE .. X

Alphanumeric 1 Yes

Ap

pen

dix

K: X

ML

Data

File

Layo

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Se

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Size

Data

Element

Required

Q32 Race American Indian-mail

raceamerindian-mail This patient response data element should only


Example: raceamerindian-mail 1 /

raceamerindian-mail



American Indian or

Alaska Native ............. 1


NOT APPLICABLE .. X

Alphanumeric 1 Yes

Q32 Race Asian Indian-mail

raceasianindian-mail This patient response data element should only


Example: raceasianindian-mail 1 /

raceasianindian-mail



Asian Indian................ 1


NOT APPLICABLE .. X

Alphanumeric 1 Yes

Q32 Race Chinese-mail

racechinese-mail This patient response data element should only


Example: racechinese-mail 1 /

racechinese-mail



Chinese ....................... 1


NOT APPLICABLE .. X

Alphanumeric 1 Yes

Q32 Race Filipino-mail

racefilipino-mail This patient response data element should only


Example: racefilipino-mail 1 /

racefilipino-mail



Filipino ....................... 1


NOT APPLICABLE .. X

Alphanumeric 1 Yes

Q32 Race Japanese-mail

racejapanese-mail This patient response data element should only


Example: racejapanese-mail 1 /

racejapanese-mail



Japanese ...................... 1


NOT APPLICABLE .. X

Alphanumeric 1 Yes

No

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Data

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Size

Data

Element

Required

Q32 Race Korean-mail

racekorean-mail This patient response data element should only


Example: racekorean-mail 1 /

racekorean-mail



Korean ........................ 1


NOT APPLICABLE .. X

Alphanumeric 1 Yes

Q32 Race Vietnamese-mail

racevietnamese-mail This patient response data element should only


Example: racevietnamese-mail 1 /

racevietnamese-mail



Vietnamese ................. 1


NOT APPLICABLE .. X

Alphanumeric 1 Yes

Q32 Race Other Asian-mail

raceotherasian-mail This patient response data element should only


Example: raceotherasian-mail 1 /

raceotherasian-mail



Other Asian ................. 1


NOT APPLICABLE .. X

Alphanumeric 1 Yes

Q32 Race Native Hawaiian-mail

racenativehawaiian-mail This patient response data element should only


Example: racenativehawaiian-mail 1 /

racenativehawaiian-mail



Native Hawaiian ......... 1


NOT APPLICABLE .. X

Alphanumeric 1 Yes

Q32 Race Guamanian Chamorro-mail

raceguamanianchamorro-mail This patient response data element should only


Example: raceguamanianchamorro-mail

1 /raceguamanianchamorro-mail



Guamanian or

Chamorro .................... 1


NOT APPLICABLE .. X

Alphanumeric 1 Yes

Ap

pen

dix

K: X

ML

Data

File

Layo

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r Sta

nd

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eco

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No

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K-2

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Cen

ters

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Se

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tpatie

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urg

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ual


Size

Data

Element

Required

Q32 Race Samoan-mail

racesamoan-mail This patient response data element should only


Example: racesamoan-mail 1 /

racesamoan-mail



Samoan ....................... 1


NOT APPLICABLE .. X

Alphanumeric 1 Yes

Q32 Race Other Pacific Islander-mail

raceotherpacificislander-mail This patient response data element should only


Example: raceotherpacificislander-mail 1

/raceotherpacificislander-mail



Other Pacific

Islander ....................... 1


NOT APPLICABLE .. X

Alphanumeric 1 Yes

Q32 Race White-phone

racewhite-phone This patient response data element should only


Example: racewhite-phone 1 /racewhite-

phone


select one or more categories. Are

you…

White .......................... 1


NOT APPLICABLE .. X

Alphanumeric 1 Yes

Q32 Race African American-phone

raceafricanamer-phone



Example: raceafricanamer-phone 1 /




you…

Black or African

American .................... 1


NOT APPLICABLE .. X

Alphanumeric 1 Yes

Q32 Race American Indian-phone

raceamerindian-phone



Example: raceamerindian-phone 1 /




you…

American Indian or



NOT APPLICABLE .. X

Alphanumeric 1 Yes

No

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Data

File

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Se

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ual


Size

Data

Element

Required

Q32 Race Asian-phone

raceasian-phone



Example: raceasian-phone 1 /raceasian-

phone



you…

Asian ........................... 1


NOT APPLICABLE .. X

Alphanumeric 1 Yes

Q32 Race Native Hawaiian Pacific Islander-

phone

racenativehawaiianpacificislander-phone



Example:

racenativehawaiianpacificislander-phone 1

/racenativehawaiianpacificislander-phone



you…

Native Hawaiian or

Pacific Islander ........... 1


NOT APPLICABLE .. X

Alphanumeric 1 Yes

Q32 Race None of Above-phone

racenoneofabove-phone



Example: racenoneofabove-phone 1 / racenoneofabove-phone



you…

NONE OF ABOVE .... 1


NOT APPLICABLE .. X

Alphanumeric 1 Yes

Q32a Race Asian Indian-phone

raceasianindian-phone



Example: raceasianindian-phone 1 / raceasianindian-phone

Which groups best describe you?

You may select one or more

categories. Are you…

Asian Indian................ 1


NOT APPLICABLE .. X

Alphanumeric 1 Yes

Ap

pen

dix

K: X

ML

Data

File

Layo

ut fo

r Sta

nd

ard

He

ad

er R

eco

rd

No

vem

be

r 20

18

K-2

2

Cen

ters

for M

ed

ica

re &

Med

icaid

Se

rvic

es

Ou

tpatie

nt a

nd

Am

bu

lato

ry S

urg

ery

CA

HP

S S

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co

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lines M

an

ual


Size

Data

Element

Required

Q32a Race Chinese-phone

racechinese-phone



Example: racechinese-phone 1

/racechinese-phone




Chinese ....................... 1


NOT APPLICABLE .. X

Alphanumeric 1 Yes

Q32a Race Filipino-phone

racefilipino-phone



Example: racefilipino-phone 1

/racefilipino-phone




Filipino ....................... 1


NOT APPLICABLE .. X

Alphanumeric 1 Yes

Q32a Race Japanese-phone

racejapanese-phone



Example: racejapanese-phone 1 /

racejapanese-phone




Japanese ...................... 1


NOT APPLICABLE .. X

Alphanumeric 1 Yes

Q32a Race Korean-phone

racekorean-phone



Example: racekorean-phone 1 /

racekorean-phone




Korean ........................ 1


NOT APPLICABLE .. X

Alphanumeric 1 Yes

Q32a Race Vietnamese-phone

racevietnamese-phone



Example: racevietnamese-phone 1 /





Vietnamese ................. 1


NOT APPLICABLE .. X

Alphanumeric 1 Yes

No

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18

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Data

File

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icaid

Se

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-23

O

utp

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nt a

nd

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ery

CA

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Size

Data

Element

Required

Q32a Race Other Asian-phone

raceotherasian-phone



Example: raceotherasian-phone 1 /





Other Asian ................. 1


NOT APPLICABLE .. X

Alphanumeric 1 Yes

Q32a Race None of Above Asian Indian-

phone

racenoneofaboveasianindian-phone



Example: racenoneofaboveasianindian-

phone 1 / racenoneofaboveasianindian-

phone






NOT APPLICABLE .. X

Alphanumeric 1 Yes

Q32b Race Native Hawaiian-phone

racenativehawaiian-phone



Example: racenativehawaiian-phone 1 /







NOT APPLICABLE .. X

Alphanumeric 1 Yes

Q32b Race Guamanian Chamorro-phone

raceguamanianchamorro-phone



Example: raceguamanianchamorro-phone

1 /raceguamanianchamorro-phone




Guamanian or

Chamorro .................... 1


NOT APPLICABLE .. X

Alphanumeric 1 Yes

Ap

pen

dix

K: X

ML

Data

File

Layo

ut fo

r Sta

nd

ard

He

ad

er R

eco

rd

No

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r 20

18

K-2

4

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ters

for M

ed

ica

re &

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icaid

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rvic

es

Ou

tpatie

nt a

nd

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urg

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CA

HP

S S

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ual


Size

Data

Element

Required

Q32b Race Samoan-phone

racesamoan-phone



Example: racesamoan-phone 1 /

racesamoan-phone




Samoan ....................... 1


NOT APPLICABLE .. X

Alphanumeric 1 Yes

Q32b Race Other Pacific Islander-phone

raceotherpacificislander-phone



Example: raceotherpacificislander-phone

1 /raceotherpacificislander-phone




Other Pacific

Islander ....................... 1


NOT APPLICABLE .. X

Alphanumeric 1 Yes

Q32b Race None of Above Pacific-phone

racenoneofabovepacific-phone



Example: racenoneofabovepacific-phone

1 /racenoneofabovepacific-phone






NOT APPLICABLE .. X

Alphanumeric 1 Yes

Q33 Speak English

speakenglish This patient response data element should only


Example: speakenglish 1 /speakenglish

How well do you speak English?

(Would you say…)

Very well .................... 1

Well ............................ 2

Not well ...................... 3

Not at all ..................... 4


Alphanumeric 1 Yes

Q34 Speak Other

speakother This patient response data element should only


Example: speakother 1 /speakother

Do you speak a language other

than English at home?

Yes, speak language

other than English ....... 1

No, speak English at

home ........................... 2


Alphanumeric 1 Yes

No

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Size

Data

Element

Required

Q35 Speak Other Specify

speakotherspecify This patient response data element should only


Example: speakotherspecify 1 /

speakotherspecify

What is that language? Spanish ....................... 1

Other ........................... 2


NOT APPLICABLE .. X

Alphanumeric 1 Yes

Q36 Help-mail

help This patient response data element should only


Example: help 1 /help

Did someone help you complete

this survey?

Yes .............................. 1

No ............................... 2


NOT APPLICABLE .. X

Alphanumeric 1 Yes

Q37 Help Read-mail

helpread This patient response data element should only


Example: helpread 1 /helpread

How did that person help you?

Check all that apply.

Read the questions

to me ........................... 1


NOT APPLICABLE .. X

Alphanumeric 1 Yes

Q37 Help Wrote-mail

helpwrote This patient response data element should only


Example: helpwrote 1 /helpwrote



Wrote down the

answers I gave ............ 1


NOT APPLICABLE .. X

Alphanumeric 1 Yes

Q37 Help Answer-mail

helpanswer This patient response data element should only


Example: helpanswer 1 /helpanswer



Answered the

questions for me ......... 1


NOT APPLICABLE .. X

Alphanumeric 1 Yes

Ap

pen

dix

K: X

ML

Data

File

Layo

ut fo

r Sta

nd

ard

He

ad

er R

eco

rd

No

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r 20

18

K-2

6

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for M

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tpatie

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Size

Data

Element

Required

Q37 Help Translate-mail

helptranslate This patient response data element should only


Example: helptranslate 1 /

helptranslate



Translated the

questions into my

language ...................... 1


NOT APPLICABLE .. X

Alphanumeric 1 Yes

Q37 Help Other-mail

helpother This patient response data element should only


Example: helpother 1 /helpother



Helped in some

other way .................... 1


NOT APPLICABLE .. X

Alphanumeric 1 Yes

Q37 Help None-mail

helpnone This patient response data element should only


Example: helpnone 1 /helpnone



No one helped me

complete this survey ... 1


NOT APPLICABLE .. X

Alphanumeric 1 Yes


APPENDIX L:

XML DATA FILE LAYOUT FOR DISPROPORTIONATE STRATIFIED

RANDOM SAMPLING (DSRS) HEADER RECORD

Appendix L: XML Data File Layout for Disproportionate Stratified Random Sampling (DSRS) Header Record November 2018



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DSRS XML DATA FILE LAYOUT


DSRS HEADER RECORD





Size

Data

Element

Required


headertype>


per file.


Type of Header Record 2 = DSRS Numeric 1 Yes

Provider Name

<providername


per file.


SampleHOPDASCName /providername


Provider Name


Provider Number

providernum



data record.


providernum





No Dashes or spaces



(CCN)

Alphanumeric 10 Yes

Ap

pen

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L: X

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File

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Size

Data

Element

Required

Sample Month



data record.


samplemonth







MM

(1 – 12 = January –

December)

Numeric 2 Yes

Sample Year



data record.


sampleyear



YYYY

(2016 or greater)

Numeric 4 Yes

Survey Mode

surveymode



data record.







HOPD or ASC locations and

strata under the same CCN.

1 = Mail only

2 = Telephone only

3 = Mixed mode

Numeric 1 Yes

Type of Sampling

sampletype


per file.





quarter.

5 = Disproportionate

stratified random

sampling

Numeric 1 Yes

A

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L: X

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File

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Size

Data

Element

Required

DSRS Strata

dsrs-strata

This header element should occur once per

strata.

Example:

dsrs-strata

stratumname samedaysurgery /

stratumname

patientsserved 50 /patientsserved

patientsfile 40 /patientsfile

eligiblepatients 30 /eligiblepatients

sampledpatients 20 /

sampledpatients

/dsrs-strata

The DSRS Strata subsection

should occur once per stratum.

There is a minimum of two

Stratum required.

Each DSRS-Strata element must

contain the following five data

elements:

Stratum Name

# Patients Served

# Patients of File

# Eligible Patients

# Sampled Patients

Please refer to the sample DSRS

XML File available from the OAS

CAHPS website for a full

example of how to use the DSRS

Strata element.

n/a n/a n/a Yes

DSRS Stratum Name

stratumname


strata.

Example: stratumname samedaysurgery

/stratumname

This is the name of the stratum. If DSRS, then at least 2

strata must be defined.

Strata names must be the

same within a quarter.

Categories can be

characters or numbers.

Alphanumeric 45 Yes

Patients Served for the Stratum

patientsserved


strata.


patientsserved




during the sample month in this

stratum, regardless of whether the

patient or surgery was OAS

CAHPS eligible.

1 – 999999

M = Unknown/Missing

Alphanumeric 6 Yes

Ap

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dix

L: X

ML

Data

File

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L-4

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Size

Data

Element

Required

DSRS Patients on file(s) submitted to Vendor

patientsfile


strata.




for this stratum for this sample

month.


DSRS Eligible Patients

eligiblepatients


strata.


eligiblepatients

Number of patients who meet

survey eligibility criteria within

this stratum for this sample

month.


DSRS Sampled Patients

sampledpatients


strata.


sampledpatients

This is the number of sampled

patients for this stratum for this

sample month. This variable will

be used to weight the data.

Note: DSRS requires a minimum

of 10 sampled patients in every

stratum in every month. The

range allows fewer than 10 in

case a month has a lower than

expected number of sampled

patients.


A

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L: X

ML

Data

File

Layo

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No

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Se

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-5

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PATIENT ADMINISTRATIVE DATA RECORD

The following section defines the format of the patient level data record.




Size

Data

Element

Required

Provider Number

providernum

This administrative element also occurs in the



providernum





No Dashes or spaces

Valid 6- or 10- digit CMS


(CCN)

Alphanumeric 10 Yes

Sample Month

samplemonth This administrative element also occurs in the



samplemonth

OAS CAHPS Survey sampling

month

MM

(1 – 12 = January –

December)

Numeric 2 Yes

Sample Year

sampleyear This administrative element also occurs in the



sampleyear

Year of sample month YYYY

(2016 or greater)

Numeric 4 Yes

DSRS Stratum Name

stratumname


once per patient.

Example: stratumname samedaysurgery

/stratumname

This is the name of the stratum for

the patient.

Maximum of 45

characters. Must match

one of the stratum names

from the Header Record.

Alphanumeric 45 Yes

Ap

pen

dix

L: X

ML

Data

File

Layo

ut fo

r Dis

pro

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rtion

ate

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Ran

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No

vem

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L-6

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Size

Data

Element

Required

Sample ID No.

sampleid This administrative element should only occur

once per patient.

Example: sampleid 1234567 /sampleid

Survey vendors will assign a

unique de-identified sample

identification number (SID) to

each patient. The SID number

will be used to track the survey

status of the patient throughout

the survey administration process

and to designate sample patients

on the data file submitted to the

Data Center.

Maximum of 16

characters

Alphanumeric 16 Yes

A

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dix

L: X

ML

Data

File

Layo

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No

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for M

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Se

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L

-7

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tpatie

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Size

Data

Element

Required

Surgical Category

surgicalcat This administrative element should only occur

once per patient.

Example: surgicalcat 1234567 /

surgicalcat

This is the category for the

surgery, and must be one of the

following options:

Gastrointestinal (GI), Orthopedic,

Ophthalmologic, Other, Missing.

If CPT28

code(s) in range 40490–

49999 or G-code(s) G0105,

G0121, or G0104, assign surgical

category 1.


29999 or G-code is G0260, assign

surgical category 2.


68899, assign surgical category 3.


19999, 30000–39999, 50000–

64999, or 68900–69990 or if G-

code(s) not in the range for

surgical categories 1, 2 or 3,

assign surgical category 4.

If surgical category cannot be

determined, assign category 5.

1 = Gastrointestinal (GI)

2 = Orthopedic

3 = Ophthalmologic

4 = Other

5 = Missing

Numeric 1 Yes


Ap

pen

dix

L: X

ML

Data

File

Layo

ut fo

r Dis

pro

po

rtion

ate

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tified

Ran

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No

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L-8

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for M

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ual


Size

Data

Element

Required

Age

patientage


once per patient.

Example: patientage 7 /patientage

Category for patient’s age as of

the date of surgery/procedure.

(Patients must be 18 or older at

the date of surgery/procedure to

be eligible for the survey.)

18–24 .......................... 1

25–29 .......................... 2

30–34 .......................... 3

35–39 .......................... 4

40–44 .......................... 5

45–49 .......................... 6

50–54 .......................... 7

55–59 .......................... 8

60–64 .......................... 9

65–69 ........................ 10

70–74 ........................ 11

75–79 ........................ 12

80–84 ........................ 13

85–89 ........................ 14

90 or older................. 15

Unknown/Missing .... M

NOT APPLICABLE .. X

Alphanumeric 2 Yes

Gender

patientgender This administrative element should only occur

once per patient.

Example: patientgender 1 /

patientgender

Patient’s gender 1 = Male

2 = Female

M = Unknown/Missing

X = NOT APPLICABLE

Alphanumeric 1 Yes

Survey Mode

surveymode


once per patient.


This is the mode of data

collection the patient used to

complete the survey. Apply code

“X” (Not Applicable) to all

sampled cases where the survey

does not result in a Complete

(code 110 or 120) or a Breakoff

(code 310).

1 = Mail only

2 = Telephone only

X = NOT APPLICABLE

Alphanumeric 1 Yes

A

pp

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dix

L: X

ML

Data

File

Layo

ut fo

r Dis

pro

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rtion

ate

No

vem

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18

S

tratifie

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m S

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SR

S) H

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Med

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Se

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L

-9

Ou

tpatie

nt a

nd

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urg

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CA

HP

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an

ual


Size

Data

Element

Required

Lag Time

lagtime


once per patient.

Example: lagtime 51 /lagtime

The number of calendar days

between the date of eligible

surgery/procedure and the date

when this patient’s survey was

initiated.

0–90

X = NOT APPLICABLE

Alphanumeric 2 Yes

Final Survey Status

finalstatus


once per patient.

Example: finalstatus 110 /finalstatus

Final disposition of survey 110 = Completed Mail

Survey

120 = Completed Phone

Survey

210 = Ineligible:

Deceased

220 = Ineligible: Does

not Meet Eligibility

criteria

230 = Ineligible:

Language Barrier

240 = Ineligible:

Mentally or

Physically

Incapacitated

310 = Breakoff

320 = Refusal

330 = Bad Address/

Undeliverable Mail

340 = Wrong/Disc/No

Telephone Number

350 = No response after

Maximum attempts

Numeric 3 Yes

Ap

pen

dix

L: X

ML

Data

File

Layo

ut fo

r Dis

pro

po

rtion

ate

Stra

tified

Ran

do

m S

am

plin

g (D

SR

S) H

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er R

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rd

No

vem

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18

L-1

0

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for M

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Size

Data

Element

Required

Survey Language

language This administrative data element should only


Example: language 1 /language

Identify language in which survey

was completed

1 = English

2 = Spanish

3 = Chinese

4 = Korean

X = NOT APPLICABLE

Alphanumeric 1 Yes

A

pp

en

dix

L: X

ML

Data

File

Layo

ut fo

r Dis

pro

po

rtion

ate

No

vem

be

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S

tratifie

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SR

S) H

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for M

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ica

re &

Med

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Se

rvic

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L

-11

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PATIENT RESPONSE RECORD

The following section defines the format of the Patient Response Record.




Size

Data

Element

Required

Q1 Informed

informed



Example: informed 1 /informed


doctor or anyone from the

facility give you all the

information you needed about

your procedure?


Yes, somewhat ............ 2

No ............................... 3


Alphanumeric 1 Yes

Q2 Instructions

instructions



Example: instructions 1 /instructions


doctor or anyone from the

facility give you easy to

understand instructions about

getting ready for your

procedure?


Yes, somewhat ............ 2

No ............................... 3


Alphanumeric 1 Yes

Q3 Check In

checkin This patient response data element should only


Example: checkin 1 /checkin

Did the check-in process run

smoothly?


Yes, somewhat ............ 2

No ............................... 3


Alphanumeric 1 Yes

Q4 Clean

clean



Example: clean 1 /clean

Was the facility clean? Yes, definitely............. 1

Yes, somewhat ............ 2

No ............................... 3


Alphanumeric 1 Yes

Ap

pen

dix

L: X

ML

Data

File

Layo

ut fo

r Dis

pro

po

rtion

ate

Stra

tified

Ran

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m S

am

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g (D

SR

S) H

ead

er R

eco

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No

vem

be

r 20

18

L-1

2

Cen

ters

for M

ed

ica

re &

Med

icaid

Se

rvic

es

Ou

tpatie

nt a

nd

Am

bu

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urg

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CA

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Data

Element

Required

Q5 Clerk Helpful

clerkhelpful This patient response data element should only


Example: clerkhelpful 1 /clerkhelpful

Were the clerks and receptionists

at the facility as helpful as you

thought they should be?


Yes, somewhat ............ 2

No ............................... 3


Alphanumeric 1 Yes

Q6 Clerk Respect

clerkrespect



Example: clerkrespect 1 /clerkrespect

Did the clerks and receptionists

at the facility treat you with

courtesy and respect?


Yes, somewhat ............ 2

No ............................... 3


Alphanumeric 1 Yes

Q7 Dr. Respect

drrespect



Example: drrespect 1 /drrespect

Did the doctors and nurses treat

you with courtesy and respect?


Yes, somewhat ............ 2

No ............................... 3


Alphanumeric 1 Yes

Q8 Dr. Comfort

drcomfort



Example: drcomfort 1 /drcomfort

Did the doctors and nurses make

sure you were as comfortable as

possible?


Yes, somewhat ............ 2

No ............................... 3


Alphanumeric 1 Yes

Q9 Dr. Explain

drexplain



Example: drexplain 1 /drexplain

Did the doctors and nurses

explain your procedure in a way

that was easy to understand?


Yes, somewhat ............ 2

No ............................... 3


Alphanumeric 1 Yes

Q10 Anesthesia

anesthesia



Example: anesthesia 1 /anesthesia

Anesthesia is something that

would make you feel sleepy or

go to sleep during your

procedure. Were you given

anesthesia?

Yes .............................. 1

No ............................... 2


Alphanumeric 1 Yes

A

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L: X

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Data

File

Layo

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Data

Element

Required

Q11 Anesthesia Explain

anesthesiaexplain



Example: anesthesiaexplain 2 /

anesthesiaexplain


the facility explain the process of

giving anesthesia in a way that

was easy to understand?


Yes, somewhat ............ 2

No ............................... 3


NOT APPLICABLE .. X

Alphanumeric 1 Yes

Q12 Anesthesia Side

anesthesiaside



Example: anesthesiaside 1 /

anesthesiaside


the facility explain the possible

side effects of the anesthesia in a

way that was easy to

understand?


Yes, somewhat ............ 2

No ............................... 3


NOT APPLICABLE .. X

Alphanumeric 1 Yes

Q13 Discharge Instructions

dischargeinstructions This patient response data element should only


Example: dischargeinstructions 1 /

dischargeinstructions

Discharge instructions include

things like symptoms you should

watch for after your procedure,

instructions about medicines,

and home care. Before you left

the facility, did you get written

discharge instructions?

Yes .............................. 1

No ............................... 2


Alphanumeric 1 Yes

Q14 Recovery

recovery



Example: recovery 1 /recovery


the facility prepare you for what

to expect during your recovery?


Yes, somewhat ............ 2

No ............................... 3


Alphanumeric 1 Yes

Ap

pen

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L: X

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Data

File

Layo

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r Dis

pro

po

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ate

Stra

tified

Ran

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No

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for M

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Se

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ual


Size

Data

Element

Required

Q15 Pain Info

paininfo This patient response data element should only


Example: paininfo 1 /paininfo

Some ways to control pain

include prescription medicine,

over-the-counter pain relievers

or ice packs. Did your doctor or

anyone from the facility give

you information about what to

do if you had pain as a result of

your procedure?


Yes, somewhat ............ 2

No ............................... 3


Alphanumeric 1 Yes

Q16 Pain Result

painresult



Example: painresult 1 /painresult


facility, did you have pain as a

result of your procedure?

Yes .............................. 1

No ............................... 2


Alphanumeric 1 Yes

Q17 Nausea

nausea



Example: nausea 1 /nausea





nausea or vomiting?


Yes, somewhat ............ 2

No ............................... 3


Alphanumeric 1 Yes

Q18 Nausea Result

nausearesult



Example: nausearesult 1 /nausearesult


facility, did you have nausea or

vomiting as a result of either

your procedure or the

anesthesia?

Yes .............................. 1

No ............................... 2


Alphanumeric 1 Yes

Q19 Bleeding Instruction

bleedinginstruction This patient response data element should only


Example: bleedinginstruction 1 /

bleedinginstruction





bleeding as a result of your

procedure?


Yes, somewhat ............ 2

No ............................... 3


Alphanumeric 1 Yes

A

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L: X

ML

Data

File

Layo

ut fo

r Dis

pro

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rtion

ate

No

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S

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for M

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icaid

Se

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ual


Size

Data

Element

Required

Q20 Bleeding Result

bleedingresult



Example: bleedingresult 1 bleedingresult


facility, did you have bleeding as

a result of your procedure?

Yes .............................. 1

No ............................... 2


Alphanumeric 1 Yes

Q21 Infection Info

infectioninfo This patient response data element should only


Example: infectioninfo 1 /infectioninfo

Possible signs of infection

include fever, swelling, heat,

drainage or redness. Before you

left the facility, did your doctor

or anyone from the facility give

you information about what to

do if you had possible signs of

infection?


Yes, somewhat ............ 2

No ............................... 3


Alphanumeric 1 Yes

Q22 Infections Signs

infectionsigns This patient response data element should only


Example: infectionsigns 1 /

infectionsigns


facility, did you have any signs

of infection?

Yes .............................. 1

No ............................... 2


Alphanumeric 1 Yes

Ap

pen

dix

L: X

ML

Data

File

Layo

ut fo

r Dis

pro

po

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ate

Stra

tified

Ran

do

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No

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ters

for M

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ica

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icaid

Se

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ual


Size

Data

Element

Required

Q23 Rate Facility

ratefacility This patient response data element should only


Example: ratefacility 2 /ratefacility

Using any number from 0 to 10,

where 0 is the worst facility

possible and 10 is the best

facility possible, what number

would you use to rate this

facility?

Worst facility

possible ....................... 0

.................................... 1

.................................... 2

.................................... 3

.................................... 4

.................................... 5

.................................... 6

.................................... 7

.................................... 8

.................................... 9

Best facility possible . 10


Alphanumeric 2 Yes

Q24 Recommend

recommend This patient response data element should only


Example: recommend 2 /recommend

Would you recommend this

facility to your friends and

family?

Definitely no ............... 1

Probably no ................. 2

Probably yes ............... 3

Definitely yes.............. 4


Alphanumeric 1 Yes

Q25 Rate Overall

rateoverall This patient response data element should only


Example: rateoverall 1 /rateoverall


your overall health?

Excellent ..................... 1

Very good ................... 2

Good ........................... 3

Fair .............................. 4

Poor ............................ 5


Alphanumeric 1 Yes

Q26 Rate Overall Mental

rateoverallmental This patient response data element should only


Example: rateoverallmental 1 /

rateoverallmental


your overall mental or emotional

health?

Excellent ..................... 1

Very good ................... 2

Good ........................... 3

Fair .............................. 4

Poor ............................ 5


Alphanumeric 1 Yes

A

pp

en

dix

L: X

ML

Data

File

Layo

ut fo

r Dis

pro

po

rtion

ate

No

vem

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18

S

tratifie

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for M

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Se

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L

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nd

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Size

Data

Element

Required

Q27 Age

age This patient response data element should only


Example: age 1 /age

What is your age? 18 to 24 ....................... 1

25 to 34 ....................... 2

35 to 44 ....................... 3

45 to 54 ....................... 4

55 to 64 ....................... 5

65 to 74 ....................... 6

75 to 79 ....................... 7

80 to 84 ....................... 8

85 or older................... 9


Alphanumeric 1 Yes

Q28 Gender

gender This patient response data element should only


Example: gender 1 /gender

Are you male or female? Male ............................ 1

Female ........................ 2


Alphanumeric 1 Yes

Q29 Education

education This patient response data element should only


Example: education 3 /education

What is the highest grade or

level of school that you have

completed?

8th grade or less .......... 1

Some high school,

but did not graduate .... 2

High school graduate

or GED ....................... 3

Some college or 2-

year degree.................. 4

4-year college

graduate ...................... 5

More than 4-year

college degree ............. 6


Alphanumeric 1 Yes

Ap

pen

dix

L: X

ML

Data

File

Layo

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r Dis

pro

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ate

Stra

tified

Ran

do

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rd

No

vem

be

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Cen

ters

for M

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ica

re &

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icaid

Se

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ual


Size

Data

Element

Required

Q30 Ethnicity

ethnicity This patient response data element should only


Example: ethnicity 2 /ethnicity

Are you of Hispanic, Latino, or

Spanish origin?

Yes .............................. 1

No ............................... 2


Alphanumeric 1 Yes

Q31 Group

group



Example: group 1 /group

Which group best describes you? Mexican, Mexican

American,

Chicano ....................... 1

Puerto Rican ............... 2

Cuban .......................... 3

Another Hispanic,

Latino, or Spanish

origin .......................... 4


NOT APPLICABLE .. X

Alphanumeric 1 Yes

Q32 Race White-mail

racewhite-mail



Example: racewhite-mail 1 /racewhite-

mail



White .......................... 1


NOT APPLICABLE .. X

Alphanumeric 1 Yes

Q32 Race African American-mail

raceafricanamer-mail This patient response data element should only


Example: raceafricanamer-mail 1 /

raceafricanamer-mail



Black or African

American .................... 1


NOT APPLICABLE .. X

Alphanumeric 1 Yes

A

pp

en

dix

L: X

ML

Data

File

Layo

ut fo

r Dis

pro

po

rtion

ate

No

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be

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Se

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ual


Size

Data

Element

Required

Q32 Race American Indian-mail

raceamerindian-mail This patient response data element should only


Example: raceamerindian-mail 1 /

raceamerindian-mail



American Indian or



NOT APPLICABLE .. X

Alphanumeric 1 Yes

Q32 Race Asian Indian-mail

raceasianindian-mail This patient response data element should only


Example: raceasianindian-mail 1 /

raceasianindian-mail



Asian Indian................ 1


NOT APPLICABLE .. X

Alphanumeric 1 Yes

Q32 Race Chinese-mail

racechinese-mail This patient response data element should only


Example: racechinese-mail 1 /

racechinese-mail



Chinese ....................... 1


NOT APPLICABLE .. X

Alphanumeric 1 Yes

Q32 Race Filipino-mail

racefilipino-mail This patient response data element should only


Example: racefilipino-mail 1 /

racefilipino-mail



Filipino ....................... 1


NOT APPLICABLE .. X

Alphanumeric 1 Yes

Q32 Race Japanese-mail

racejapanese-mail This patient response data element should only


Example: racejapanese-mail 1 /

racejapanese-mail



Japanese ...................... 1


NOT APPLICABLE .. X

Alphanumeric 1 Yes

Ap

pen

dix

L: X

ML

Data

File

Layo

ut fo

r Dis

pro

po

rtion

ate

Stra

tified

Ran

do

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plin

g (D

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rd

No

vem

be

r 20

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L-2

0

Cen

ters

for M

ed

ica

re &

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icaid

Se

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ual


Size

Data

Element

Required

Q32 Race Korean-mail

racekorean-mail This patient response data element should only


Example: racekorean-mail 1 /

racekorean-mail



Korean ........................ 1


NOT APPLICABLE .. X

Alphanumeric 1 Yes

Q32 Race Vietnamese-mail

racevietnamese-mail This patient response data element should only


Example: racevietnamese-mail 1 /

racevietnamese-mail



Vietnamese ................. 1


NOT APPLICABLE .. X

Alphanumeric 1 Yes

Q32 Race Other Asian-mail

raceotherasian-mail This patient response data element should only


Example: raceotherasian-mail 1 /

raceotherasian-mail



Other Asian ................. 1


NOT APPLICABLE .. X

Alphanumeric 1 Yes

Q32 Race Native Hawaiian-mail

racenativehawaiian-mail This patient response data element should only


Example: racenativehawaiian-mail 1 /

racenativehawaiian-mail





NOT APPLICABLE .. X

Alphanumeric 1 Yes

Q32 Race Guamanian Chamorro-mail

raceguamanianchamorro-mail This patient response data element should only


Example: raceguamanianchamorro-mail 1

/raceguamanianchamorro-mail



Guamanian or

Chamorro .................... 1


NOT APPLICABLE .. X

Alphanumeric 1 Yes

A

pp

en

dix

L: X

ML

Data

File

Layo

ut fo

r Dis

pro

po

rtion

ate

No

vem

be

r 20

18

S

tratifie

d R

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do

m S

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S) H

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ters

for M

ed

ica

re &

Med

icaid

Se

rvic

es

L

-21

Ou

tpatie

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ual


Size

Data

Element

Required

Q32 Race Samoan-mail

racesamoan-mail This patient response data element should only


Example: racesamoan-mail 1 /

racesamoan-mail



Samoan ....................... 1


NOT APPLICABLE .. X

Alphanumeric 1 Yes

Q32 Race Other Pacific Islander-mail

raceotherpacificislander-mail This patient response data element should only


Example: raceotherpacificislander-mail 1

/raceotherpacificislander-mail



Other Pacific

Islander ....................... 1


NOT APPLICABLE .. X

Alphanumeric 1 Yes

Q32 Race White-phone

racewhite-phone This patient response data element should only


Example: racewhite-phone 1 /racewhite-

phone



Are you…

White .......................... 1


NOT APPLICABLE .. X

Alphanumeric 1 Yes

Q32 Race African American-phone




Example: raceafricanamer-phone 1 /




Are you…

Black or African

American .................... 1


NOT APPLICABLE .. X

Alphanumeric 1 Yes

Q32 Race American Indian-phone




Example: raceamerindian-phone 1 /




Are you…

American Indian or



NOT APPLICABLE .. X

Alphanumeric 1 Yes

Ap

pen

dix

L: X

ML

Data

File

Layo

ut fo

r Dis

pro

po

rtion

ate

Stra

tified

Ran

do

m S

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plin

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S) H

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rd

No

vem

be

r 20

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L-2

2

Cen

ters

for M

ed

ica

re &

Med

icaid

Se

rvic

es

Ou

tpatie

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nd

Am

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CA

HP

S S

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an

ual


Size

Data

Element

Required

Q32 Race Asian-phone

raceasian-phone



Example: raceasian-phone 1 / raceasian-

phone



Are you…

Asian ........................... 1


NOT APPLICABLE .. X

Alphanumeric 1 Yes

Q32 Race Native Hawaiian Pacific Islander-

phone

racenativehawaiianpacificislander-phone This patient response data element should only


Example:

racenativehawaiianpacificislander-phone 1

/racenativehawaiianpacificislander-phone



Are you…

Native Hawaiian or

Pacific Islander ........... 1


NOT APPLICABLE .. X

Alphanumeric 1 Yes

Q32 Race None of Above-phone

racenoneofabove-phone



Example: racenoneofabove-phone 1 / racenoneofabove-phone



Are you…



NOT APPLICABLE .. X

Alphanumeric 1 Yes

Q32a Race Asian Indian-phone

raceasianindian-phone



Example: raceasianindian-phone 1 / raceasianindian-phone




Asian Indian................ 1


NOT APPLICABLE .. X

Alphanumeric 1 Yes

A

pp

en

dix

L: X

ML

Data

File

Layo

ut fo

r Dis

pro

po

rtion

ate

No

vem

be

r 20

18

S

tratifie

d R

an

do

m S

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S) H

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for M

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ica

re &

Med

icaid

Se

rvic

es

L

-23

Ou

tpatie

nt a

nd

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CA

HP

S S

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an

ual


Size

Data

Element

Required

Q32a Race Chinese-phone

racechinese-phone



Example: racechinese-phone 1 /

racechinese-phone




Chinese ....................... 1


NOT APPLICABLE .. X

Alphanumeric 1 Yes

Q32a Race Filipino-phone

racefilipino-phone



Example: racefilipino-phone 1 /

racefilipino-phone




Filipino ....................... 1


NOT APPLICABLE .. X

Alphanumeric 1 Yes

Q32a Race Japanese-phone

racejapanese-phone



Example: racejapanese-phone 1 /

racejapanese-phone




Japanese ...................... 1


NOT APPLICABLE .. X

Alphanumeric 1 Yes

Q32a Race Korean-phone

racekorean-phone



Example: racekorean-phone 1 /

racekorean-phone




Korean ........................ 1


NOT APPLICABLE .. X

Alphanumeric 1 Yes

Q32a Race Vietnamese-phone




Example: racevietnamese-phone 1 /





Vietnamese ................. 1


NOT APPLICABLE .. X

Alphanumeric 1 Yes

Ap

pen

dix

L: X

ML

Data

File

Layo

ut fo

r Dis

pro

po

rtion

ate

Stra

tified

Ran

do

m S

am

plin

g (D

SR

S) H

ead

er R

eco

rd

No

vem

be

r 20

18

L-2

4

Cen

ters

for M

ed

ica

re &

Med

icaid

Se

rvic

es

Ou

tpatie

nt a

nd

Am

bu

lato

ry S

urg

ery

CA

HP

S S

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ls a

nd

Gu

ide

lines M

an

ual


Size

Data

Element

Required

Q32a Race Other Asian-phone




Example: raceotherasian-phone 1 /





Other Asian ................. 1


NOT APPLICABLE .. X

Alphanumeric 1 Yes

Q32a Race None of Above Asian Indian-phone

racenoneofaboveasianindian-phone



Example: racenoneofaboveasianindian-

phone 1 / racenoneofaboveasianindian-

phone






NOT APPLICABLE .. X

Alphanumeric 1 Yes

Q32b Race Native Hawaiian-phone




Example: racenativehawaiian-phone 1 /







NOT APPLICABLE .. X

Alphanumeric 1 Yes

Q32b Race Guamanian Chamorro-phone

raceguamanianchamorro-phone



Example: raceguamanianchamorro-phone

1 /raceguamanianchamorro-phone




Guamanian or

Chamorro .................... 1


NOT APPLICABLE .. X

Alphanumeric 1 Yes

A

pp

en

dix

L: X

ML

Data

File

Layo

ut fo

r Dis

pro

po

rtion

ate

No

vem

be

r 20

18

S

tratifie

d R

an

do

m S

am

plin

g (D

SR

S) H

ead

er R

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rd

Cen

ters

for M

ed

ica

re &

Med

icaid

Se

rvic

es

L

-25

Ou

tpatie

nt a

nd

Am

bu

lato

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ery

CA

HP

S S

urv

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nd

Gu

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an

ual


Size

Data

Element

Required

Q32b Race Samoan-phone

racesamoan-phone



Example: racesamoan-phone 1 /

racesamoan-phone




Samoan ....................... 1


NOT APPLICABLE .. X

Alphanumeric 1 Yes

Q32b Race Other Pacific Islander-phone

raceotherpacificislander-phone



Example: raceotherpacificislander-phone

1 /raceotherpacificislander-phone




Other Pacific

Islander ....................... 1


NOT APPLICABLE .. X

Alphanumeric 1 Yes

Q32b Race None of Above Pacific-phone

racenoneofabovepacific-phone



Example: racenoneofabovepacific-phone

1 /racenoneofabovepacific-phone






NOT APPLICABLE .. X

Alphanumeric 1 Yes

Q33 Speak English

speakenglish This patient response data element should only


Example: speakenglish 1 /speakenglish

How well do you speak English? Very well .................... 1

Well ............................ 2

Not well ...................... 3

Not at all ..................... 4


Alphanumeric 1 Yes

Q34 Speak Other

speakother This patient response data element should only


Example: speakother 1 /speakother

Do you speak a language other

than English at home?

Yes, speak language

other than English ....... 1

No, speak English at

home ........................... 2


Alphanumeric 1 Yes

Ap

pen

dix

L: X

ML

Data

File

Layo

ut fo

r Dis

pro

po

rtion

ate

Stra

tified

Ran

do

m S

am

plin

g (D

SR

S) H

ead

er R

eco

rd

No

vem

be

r 20

18

L-2

6

Cen

ters

for M

ed

ica

re &

Med

icaid

Se

rvic

es

Ou

tpatie

nt a

nd

Am

bu

lato

ry S

urg

ery

CA

HP

S S

urv

ey P

roto

co

ls a

nd

Gu

ide

lines M

an

ual


Size

Data

Element

Required

Q35 Speak Other Specify

speakotherspecify This patient response data element should only


Example: speakotherspecify 1 /

speakotherspecify

What is that language? Spanish ....................... 1

Other ........................... 2


NOT APPLICABLE .. X

Alphanumeric 1 Yes

Q36 Help-mail

help This patient response data element should only


Example: help 1 /help

Did someone help you complete

this survey?

Yes .............................. 1

No ............................... 2


NOT APPLICABLE .. X

Alphanumeric 1 Yes

Q37 Help Read-mail

helpread This patient response data element should only


Example: helpread 1 /helpread



Read the questions

to me ........................... 1


NOT APPLICABLE .. X

Alphanumeric 1 Yes

Q37 Help Wrote-mail

helpwrote This patient response data element should only


Example: helpwrote 1 /helpwrote



Wrote down the

answers I gave ............ 1


NOT APPLICABLE .. X

Alphanumeric 1 Yes

Q37 Help Answer-mail

helpanswer This patient response data element should only


Example: helpanswer 1 /helpanswer



Answered the

questions for me ......... 1


NOT APPLICABLE .. X

Alphanumeric 1 Yes

A

pp

en

dix

L: X

ML

Data

File

Layo

ut fo

r Dis

pro

po

rtion

ate

No

vem

be

r 20

18

S

tratifie

d R

an

do

m S

am

plin

g (D

SR

S) H

ead

er R

eco

rd

Cen

ters

for M

ed

ica

re &

Med

icaid

Se

rvic

es

L

-27

Ou

tpatie

nt a

nd

Am

bu

lato

ry S

urg

ery

CA

HP

S S

urv

ey P

roto

co

ls a

nd

Gu

ide

lines M

an

ual


Size

Data

Element

Required

Q37 Help Translate-mail

helptranslate This patient response data element should only


Example: helptranslate 1 /

helptranslate



Translated the

questions into my

language ...................... 1


NOT APPLICABLE .. X

Alphanumeric 1 Yes

Q37 Help Other-mail

helpother This patient response data element should only


Example: helpother 1 /helpother



Helped in some

other way .................... 1


NOT APPLICABLE .. X

Alphanumeric 1 Yes

Q37 Help None-mail

helpnone This patient response data element should only


Example: helpnone 1 /helpnone



No one helped me

complete this survey ... 1


NOT APPLICABLE .. X

Alphanumeric 1 Yes

Appendix L: XML Data File Layout for Disproportionate Stratified Random Sampling (DSRS) Header Record November 2018

L-28 Centers for Medicare & Medicaid Services Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual



APPENDIX M:

XML DATA FILE LAYOUT FOR ZERO SAMPLED FILE

Appendix M: XML Data File Layout for Zero Sampled File November 2018



Cen

ters

for M

ed

ica

re &

Med

icaid

Se

rvic

es

M

-1

Ou

tpatie

nt a

nd

Am

bu

lato

ry S

urg

ery

CA

HP

S S

urv

ey P

roto

co

ls a

nd

Gu

ide

lines M

an

ual

ZERO FILE SAMPLED XML DATA FILE LAYOUT


HEADER RECORD





Size

Data

Element

Required


headertype


per file.


Type of Header Record 0 = Zero Sampled Header

Record

Numeric 1 Yes

Provider Name

<providername


per file.


SampleHOPDASCName /providername


Provider Name


Provider Number

providernum


administration data element in the patient level

data record.


providernum





No Dashes or spaces



(CCN)

Alphanumeric 10 Yes

Ap

pen

dix

M: X

ML

Data

File

Layo

ut fo

r Ze

ro S

am

ple

d F

ile

No

vem

be

r 20

18

M-2

C

en

ters

for M

ed

ica

re &

Med

icaid

Se

rvic

es

Ou

tpatie

nt a

nd

Am

bu

lato

ry S

urg

ery

CA

HP

S S

urv

ey P

roto

co

ls a

nd

Gu

ide

lines M

an

ual


Size

Data

Element

Required

Sample Month



data record.


samplemonth







MM

(1 – 12 = January –

December)

Numeric 2 Yes

Sample Year



data record.


sampleyear



YYYY

(2016 or greater)

Numeric 4 Yes

Survey Mode

surveymode



data record.







HOPD or ASC locations under

the same CCN.

1 = Mail only

2 = Telephone only

3 = Mixed mode

Numeric 1 Yes

Type of Sampling

sampletype


per file.





quarter.

1 = Census

2 = Simple random

sampling

3 = Stratified systematic

sampling

4 = Proportionate

Stratified Random

sampling

5 = DSRS

Numeric 1 Yes

No

vem

be

r 20

18

A

pp

en

dix

M: X

ML

Data

File

Layo

ut fo

r Ze

ro S

am

ple

d F

ile

Cen

ters

for M

ed

ica

re &

Med

icaid

Se

rvic

es

M

-3

Ou

tpatie

nt a

nd

Am

bu

lato

ry S

urg

ery

CA

HP

S S

urv

ey P

roto

co

ls a

nd

Gu

ide

lines M

an

ual


Size

Data

Element

Required

Patients Served

patientsserved


per file.


patientsserved




during the sample month at the

HOPD or ASC, regardless of

whether that patient or

surgery/procedure was OAS

CAHPS-eligible.

0 – 999999

M = Unknown/Missing

Alphanumeric 6 Yes

Patients on file(s) submitted to Vendor

patientsfile


per file.




for this HOPD or ASC.


Eligible Patients

eligiblepatients


per file.


eligiblepatients

This is the number of patients in

the file submitted by the HOPD or

ASC that meet survey eligibility

criteria in the sample month.

0 Numeric 1 Yes

Sampled Patients

sampledpatients


per file.


sampledpatients

This is the number of patients

selected for the survey during the

sample month. This value can be

zero only if all of the patients

included on the file that the

HOPD or ASC provided for the

sample month were ineligible for

the survey.

0 Numeric 1 Yes

Appendix M: XML Data File Layout for Zero Sampled File November 2018

M-4 Centers for Medicare & Medicaid Services Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual



APPENDIX N:

MODEL QUALITY ASSURANCE PLAN (QAP) OUTLINE

Appendix N: Model Quality Assurance Plan (QAP) Outline November 2018



Centers for Medicare & Medicaid Services Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual N-1

INSTRUCTIONS FOR PREPARING A SURVEY VENDOR QUALITY ASSURANCE PLAN

Vendors that have met the minimum requirements and received interim approval, can begin

conducting OAS CAHPS on behalf of client facilities. To become fully approved, vendors must

complete the final step in the approval process: the submission of an acceptable Quality

Assurance Plan (QAP). The QAP must be submitted within 6 weeks of the data submission

deadline date after vendor’s first quarterly submission of OAS CAHPS data. It must be updated

and resubmitted annually on or before April 30 and whenever the survey vendor makes key staff

or protocol changes.

This purpose of this document is to serve as instructions for survey vendors to help them develop

a QAP that describes their specific plans for implementation and compliance with all guidelines

required to implement the OAS CAHPS Survey.

The vendor’s QAP should include the sections listed below. The specific requirements for these

sections are described in the pages that follow.

I. Organization Background and Staff Experience

II. Initial Communications with HOPDs and ASCs

III. Work Plan for Each Approved Mode of Data Collection

IV. Sampling Plan

V. Survey Implementation Plan

VI. Data Security, Confidentiality, and Privacy Plan

VII. Exceptions Request Process and Discrepancy Notification Reporting

VIII. Questionnaire and Materials Attachments

To facilitate review of the QAP, each vendor should use the outline format noted above.

I. ORGANIZATION BACKGROUND AND STAFF EXPERIENCE

In this section of the QAP, each OAS CAHPS Survey vendor must provide the following

information:

• Your organization’s name, address, and telephone number. If your organization has

multiple locations, include the address of both the main location and the address of the


Centers for Medicare & Medicaid Services N-2 Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual

locations at which the primary operations, including sampling, data collection, and data

processing activities, are being conducted.

• Describe the history and affiliation with any other organization (e.g., other company or

university affiliation). Include the scope of business, number of years in business, and

number of years of survey experience.

• Describe your organization’s survey experience conducting person-level surveys using

each approved data collection mode that is allowed for the OAS CAHPS Survey,

specifically, mail-only, CATI-only, and mixed mode (mail with CATI follow-up).

Describe other CAHPS survey experience if applicable. You must discuss each data

collection mode for which you have received approval, regardless of whether you have

any HOPD or ASC clients that are using that mode.

• Provide an organizational chart that shows the names and titles of staff members,

including subcontractors, that are responsible for each of the following tasks:

a. Overall project management, including tracking and supervision of all tasks below.

b. Explaining the nature of the project to hospitals and ASCs, including determining

whether their facility is eligible.

c. Sampling procedures, including creation of the sample frame, selection of the sample,

and assignment of a unique identification number to each sampled patient.

d. Data collection procedures, including overseeing implementation of the data collection

mode for which your organization has been approved.

e. Data receipt and data entry/scanning procedures.

f. File development and submission processes.

The organizational chart should also clearly specify all staff reporting relationships, including

those staff who are responsible for managing subcontractors. It should designate which

individuals have responsibility for quality assurance oversight. A list of individuals with QA

oversight responsibility by task must be included.

• Summarize the background and experience of the individuals who are responsible for the

tasks listed in the organizational chart above, including a description of any

subcontractors serving in these roles. The description of each individual’s experience

should include a discussion of how the person’s qualifications are relevant to the OAS

CAHPS Survey tasks that he or she is expected to perform. Resumes should be available

upon request.

November 2018 Appendix N: Model Quality Assurance Plan (QAP) Outline


Initial Communications with HOPDs and ASCs

• When working with hospitals to explain the study, how do you determine whether a

particular hospital has one or more eligible HOPDs or departments that meet the

eligibility criteria for inclusion in the OAS CAHPS Survey? What questions do hospitals

have and how do you address these questions? What information or specific website links

do you provide the hospitals to help them make this determination?

• When working with ASCs to explain the study, how do you determine eligibility? What

questions do ASCs have and how do you address these questions? What information or

specific website links do you provide the ASCs to help them make this determination?

II. WORK PLAN

• Describe how your organization is implementing the OAS CAHPS Survey for each mode

for which your organization has been approved. This section of your QAP must describe

the entire process that your organization is following, including:

a. how you are obtaining the sample frame and selecting the sample;

b. how you are fielding the survey, receiving and processing the data;

c. the procedures that you are following to prepare and submit final files; and

d. the type of quality control procedures you are following at each stage to ensure data

quality.

• For each step above, you must specify the name of the individual who is responsible for

conducting and providing oversight of each specific activity.

• Include a copy of a schedule or timeline that you are following to ensure that you are able

to conduct all activities within the timeframes specified in the OAS CAHPS Survey

protocols. The timeline must describe when that activity will be completed (for example,

x weeks after sample selection, or y weeks after mailing the first questionnaire). The

timeline must include receipt of files from HOPDs and ASCs, sample selection, each step

of the mailout or telephone implementation, data file cleaning, and data file preparation

and submission.

III. SAMPLING PLAN

• Describe how you are working with your client facilities to ensure that the HOPDs and

ASCs understand patient survey eligibility criteria and the measures you take to ensure

that all patient information needed for sample selection is included on the file that is



submitted and that the monthly patient files are submitted in time for you to select the

sample and initiate the survey within 21 days after the sample month ends.

• Describe how HOPDs or ASCs submit the monthly patient files to your organization and

how you check those files. That is, describe the steps that you take to ensure that the ASC

or HOPD has included all required data on the monthly patient files and the checks you

make to ensure that the same patient information is not included more than once on the

monthly patient information file. Describe how the transmission is done to ensure

security of these Health Insurance Portability and Accountability Act (HIPAA) data.

• Describe how you create the sample frame. This section should describe the process you

are using to develop a sampling frame that complies with the OAS CAHPS Survey

protocol. Specifically, you must explain how you are creating the frame, what patient

survey eligibility criteria you are using, and the types of patients who are being excluded

and how those cases are being identified. Please make sure your QAP addresses each of

the following questions:

a. How do you check monthly patient information files to determine if any required data for

a patients is incomplete?

b. What do you do if information is missing from the monthly patient information files?

c. What are the eligibility and exclusion criteria that you use to determine which patients are

eligible and which patients should be excluded from the sample frame? Refer to

Chapter IV, Sampling Procedures—Patient Eligibility Criteria.

d. How do you know whether your client HOPDs and ASCS have included all patients on

the monthly patient files? Do you obtain and retain documentation from the HOPDs and

ASCs about which patient records were excluded and the reasons those patients were

excluded from the monthly patient information files?

e. How do you know whether all eligible ASCs within the CCN, or all eligible HOPDs

within the CCN, are submitting patient files?

f. Do you check the monthly patient information files to ensure that patients are only listed

once on the file? If so, what information and process do you use to identify and remove

patients who may have been listed on the monthly patient information file more than

once?

g. What process (system or procedures) do you use to identify and remove patients who

have been included in the survey sample in the last 5 months?



h. What process (system, software, or procedure) do you use to assign a unique sample

identification (SID) to each sample patient?

i. OAS CAHPS Survey vendors are expected to calculate and use a sample rate for each

ASC and HOPD client to ensure that an even distribution of patients is sampled over a

12-month period. How do you determine a sample rate for each ASC and HOPD?

j. How is the sample selected? How is the sampling rate at each facility determined? What

software program do you use to generate the seed number and assign random numbers

used for sampling?

k. What documentation about sample frame creation do you retain and for how long? Where

do you document the seed numbers? Note that the replication of sample selection will be

part of the Site Visit process. Vendors should have documentation and systems in place

for this type of audit.

l. If the ASC or HOPD is also conducting other patient experience surveys, what

procedures do you follow to ensure that the sample for OAS CAHPS is selected first, and

is a random selection that is representative of the monthly patient records?

m. Which of the four acceptable sampling methods (SRS, SSS, PSRS, and DSRS) has your

organization implemented on OAS CAHPS?

• Describe the quality control checks that you are performing on the sampling activities,

how frequently are those checks are being performed, and by whom. Indicate what

percentage of the sample frame or sample file is being checked, and describe the

documentation that you maintain to verify that the quality control procedures have taken

place. Note that this documentation may be requested by the OAS CAHPS Survey

Coordination Team at any time.

• If applicable, describe any sampling exceptions that you have requested or for which your

organization has been approved. Explain the exceptions request and the specific

procedures you are or will be following to implement the approved exception.

IV. SURVEY IMPLEMENTATION PLAN

• Describe the system resources that you are using to implement your approved survey

mode(s). This includes a description of the relevant hardware or software. For example,

describe the electronic telephone interviewing systems, mailing equipment, scanning or

data entry equipment, and case management system that you are using.

• Describe training that is being given to all staff working on the OAS CAHPS Survey

project, including telephone interviewers (if applicable), mail survey production staff,



and data receipt/data processing/data entry staffs. If you are using any subcontractors for

any roles, describe how the subcontractor’s staff are being trained. Include a discussion

of quality control procedures that you or your subcontractor are implementing during

training to ensure compliance with OAS CAHPS Survey protocols. Describe the

documentation that is being kept to provide evidence of this quality control.

• Describe the toll-free customer support telephone line that you are offering, including the

actual telephone number, how customer support staff are being trained, and who is

responsible for training and responding to questions related to the OAS CAHPS Survey.

Also include information on the days of the week and times of the day that you are

staffing the customer support line and how you are handling after-hours contacts, and

include text of any recordings that are being used. Include a discussion of quality control

procedures that are being implemented to ensure compliance with OAS CAHPS Survey

protocols and describe documentation that is being kept to provide evidence of this

quality control. (Reference Chapter VI.)

• Describe the production and mailout process for mail surveys, if applicable, including

who is responsible for the process and what quality control checks are being implemented

at each stage (for example, monitoring the quality and content of mail survey packages,

use of seeded mailings, and frequency of checks). Describe all quality control checks that

are being implemented and documented to ensure that the OAS CAHPS Survey protocols

are being followed. (Reference Chapter V.)

• Describe the receipt and data entry or scanning process for mail surveys, if applicable,

including who is responsible for the process and what quality control checks are being

implemented at the questionnaire receipt, data entry, or scanning phase, and how

frequently those checks are being made. Describe all quality control checks that are being

implemented and documented to ensure that the OAS CAHPS Survey protocols are being

followed. (Reference Chapter V.)

• Describe the process for implementing the telephone survey, if applicable, including who

is responsible for training and monitoring interviewer performance, how training and

monitoring are being documented, and what systems and procedures are being used to

ensure that all interviewing is conducted according to the OAS CAHPS Survey protocols

(for example, varying times of day that calls are attempted and tracking the status of call

attempts). If you are using a telephone survey subcontractor, describe oversight activities

you are conducting to ensure that the subcontractor is in compliance with OAS CAHPS

Survey protocols. (Reference Chapter VI.)

• If you are approved for mixed-mode administration, you must address all of the

paragraphs above regarding both mail and telephone processes. In addition, you must



include a discussion of the control system used to monitor case status as the case

transitions from the mail phase of the survey to the telephone follow-up phase. Describe

how you keep track of surveys that are returned while the telephone follow-up phase is in

effect. Describe the processes that you have in place to ensure that sample members who

have returned a completed survey are not called after the completed survey is received.

How do you determine which completed survey to retain (mail or telephone interview

data) if the sample member returns a completed survey and participates in a telephone

interview? (Reference Chapter VII.)

• Describe the processes you are using to create data files and submit them to the OAS

CAHPS Data Center through the OAS CAHPS Survey website. Discuss quality control

checks that are being implemented during file creation, including how these checks are

being documented. (Reference Chapter XI.)

V. DATA SECURITY, CONFIDENTIALITY, AND PRIVACY PLAN

• Describe the measures that you are taking to ensure data security, including a discussion

of the use of passwords, file encryption, backup systems, and any other measures to

ensure the security of OAS CAHPS Survey data. Describe how often passwords are

changed. For both hardcopy questionnaires and electronic data files, describe how and for

how long these materials will be stored and when and how they will be destroyed.

(Reference Chapter VIII.)

• Describe how individuals will be authorized and deauthorized to access personally

identifiable information (PII). Include information about how confidentiality agreements

are being implemented among vendor staff and any subcontractor staff. Describe how

affidavits of confidentiality are being documented, background checks are being

conducted, and confidentiality training procedures are being implemented. Include a copy

of the confidentiality agreement that is being used as an appendix in your QAP. Vendors

must ensure compliance with HIPAA requirements. Describe the measures that are being

taken to protect respondent privacy and ensure compliance with HIPAA requirements.

Describe the required HIPAA training of staff working on OAS CAHPS. If you are using

any subcontractors for any roles, describe how the subcontractor’s staff are being trained

on HIPAA. Include information about how unauthorized individuals are being prevented

from accessing PII and the survey data in physical and electronic format. (Reference

Chapter VIII.)

• If you are approved for telephone surveys, include a screenshot or text indicating the

voluntary nature of the sample member’s participation.

• Provide a general description of the disaster recovery plan for OAS CAHPS Survey data

in the event of a disaster.



VI. EXCEPTIONS REQUEST PROCESS AND DISCREPANCY NOTIFICATION

REPORTING

• Describe any Exceptions Requests that you have or plan to request or document that you

have none but agree to comply with the process outlined in Chapter XV.

• Document your understanding of the Discrepancy Notification Reporting protocol

outlined in Chapter XV and that you agree to comply with the process.

VII. QUESTIONNAIRE AND MATERIALS ATTACHMENTS

• Attach a copy of your formatted mail survey questionnaire if you are approved for mail-

only or mixed-mode administration in each language you offer to clients. Be sure to

include the cover page and back page in each language.

• If you are approved for telephone-only or mixed-mode administration, attach all

screenshots from your telephone interview program—beginning with the introductory

screens and ending with the last question in the interview. If your interview includes the

Consent to Share Identifying Information question, please include a screen shot of this

question as well. Include screenshots of the telephone interview in each language you

offer to clients.

• If you are approved for mail-only or mixed-mode administration, include a copy of your

cover letter(s) in each language you offer to clients.


APPENDIX O:

EXCEPTIONS REQUEST FORM

Appendix O: Exceptions Request Form November 2018



Centers for Medicare & Medicaid Services Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual O-1

OUTPATIENT AND AMBULATORY SURGERY CAHPS SURVEY EXCEPTIONS REQUEST FORM

Use the Exceptions Request Form to report a planned deviation from the standard OAS CAHPS protocols. You may request the same exceptions for multiple Hospital Outpatient Departments (HOPDs) or Ambulatory Surgery Centers (ASCs) with which you contract, if applicable.

To submit this form online, please go to https://oascahps.org/ .

I. Exception Request

Select an exception request classification, and provide the specific reason for your exception request

1a. Date Submitted: <inserted by system>

1b. Exception Request Classification (Select one)

New Exception Request

Update list of applicable HOPDs and ASCs on a previous Exception Request

Update other information on a previous Exception Request

Appeal of denial of a previous Exception Request

1c. Specify Reason for Exception Request:

For example: “We request 5 additional business days to complete the phone attempts for three of our contracted facilities.”

II. Description of Exception Request

2a. Purpose of requested exception (e.g., sampling, data issues).

For example: “The purpose is to allow us to complete the required telephone attempts for three of the facilities for which we collect data. A flu epidemic has spread through our area resulting in many telephone interviewers being unable to work for several days in a row.”

2b. How and when will the exception be implemented?

For example: “Instead of the final calling day being Friday, February 6, 2017, we will continue calling Friday, February 6 through Wednesday, February 11. The extension in the data collection period will allow us to finalize all outstanding phone cases.”

2c. Provide evidence that exception will not affect survey results.

For example: “This procedure will not impact survey results because it only applies to the mail cover letter.” Or “If the extension is granted it will not impact our ability to meet the data submission deadline.”


Appendix O: Exceptions Request Form November 2018

O-2 Centers for Medicare & Medicaid Services Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual

III. Which HOPDs and ASCs are impacted by this Exception Request?

Vendor should revise the Exception Request if additional facilities (CCNs) need to be added after the initial Exception Request was submitted.

If you have multiple CCNs, please enter them as a comma separated list, as shown in the example below. Do not include dashes in the CCN. After entering your CCN(s), click on the "Lookup Facility Names" button.

For example: “111111,222222,333333,44C4444444,55C5555555”

Lookup Facility Names.

To submit this form, visit the Outpatient and Ambulatory Surgery CAHPS Survey website at https://oascahps.org/ . If you have any problems completing the online Exceptions Request Form, please e-mail the OAS CAHPS Survey Coordination Team at [email protected] for assistance.




APPENDIX P:

DISCREPANCY NOTIFICATION REPORT

Appendix P: Discrepancy Notification Report November 2018



Centers for Medicare & Medicaid Services Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual P-1

OUTPATIENT AND AMBULATORY SURGERY CAHPS SURVEY DISCREPANCY NOTIFICATION REPORT

Use the Discrepancy Notification Report (DNR) to notify the OAS CAHPS Survey Coordination Team of any unplanned deviation from the OAS CAHPS protocols that occurred.

To submit this form online, please go to https://oascahps.org/ .

Date Submitted: inserted by system

I. Discrepancy Notification Report

One Discrepancy Notification Report (DNR) is required for each discrepancy reason. If you have multiple CCNs with the same discrepancy reason, please include all CCNs on one DNR. If you have more than one discrepancy reason, you will need to submit a DNR for each discrepancy reason. To complete this form, please complete the following sections:

• Section I—Select the affected Survey Quarter and the reason for the discrepancy from the

drop down boxes.

• Section II—Enter all CCNs that are impacted by the discrepancy reason.

• Section III—Provide a detailed description of the discrepancy being reported for each

CCN and include the number of affected patients. If you do not know the number of

affected patients, please enter UNK. If the number of affected patients is not applicable,

enter NA.

• Section IV—Include a description of the corrective action your organization has taken to

address the discrepancy.

• Section V—Provide any additional information about the discrepancy that you feel the

OAS CAHPS Survey Coordination Team will need.

• Section V—Submit.



Centers for Medicare & Medicaid Services P-2 Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual

II. Affected Facility or Facilities

Please enter the CCN(s) for which you are filing this discrepancy. If you have multiple CCNs, please enter them as a comma separated list, as shown in the example below. Do not include dashes in the CCN. After entering your CCN(s), click on the “Lookup Facility Names” button.

Example: 111111,222222,333333,44C4444444,55C5555555

Lookup Facility Names.

III. Describe Discrepancy

Please complete the items below in detail for each facility listed. Include adequate information so the OAS CAHPS team can fully understand this discrepancy and its root cause.

For example: “We had to mail the surveys after the deadline (21 days after the end of the sample month), because our vendor offices were closed due to inclement weather.” Or “It has come to our attention that an error occurred during data collection and the answers to Q8, Q9, and Q10 were all recorded as “refused” due to a programing error.”

If “Late Start” is selected from the Discrepancy Reason dropdown list, the DNR’s table will appear as

shown below.

If any other discrepancy reason is selected from the Discrepancy Reason dropdown list, the DNR’s table

will appear as shown below.

November 2018 Appendix P: Discrepancy Notification Report


IV Corrective Action

Describe the corrective action(s) that will be taken to address discrepancy. Include the proposed timeline for the corrective action(s).

For example: “We have increased staff hours ensure that all mail surveys are sent no later than 2 days after the deadline.” Or “We have implemented quality control procedures and automated checks to prevent this type of programing error in the future. The CATI system now allows data to be recorded for all items. In future survey periods the CATI instrument will be tested in both the development and live survey environments.”

V. Additional information

Provide additional information that will help the OAS CAHPS Survey Coordination Team understand the discrepancy.

For example: “Due to a blizzard the data collection facility was closed for two days before the mailing deadline for the OAS CAHPS Surveys.” Or “This has been corrected for the current survey quarter. All additional survey data collected will not be impacted by this problem.”

VI. Submit

A Discrepancy Notification form will be submitted for the CCN(s) listed above when you click the "Submit" button below. Please verify that the list is correct. If it is not correct, please edit your CCN(s) above and click the Lookup button again.

To submit this form, visit the Outpatient and Ambulatory Surgery CAHPS Survey website at https://oascahps.org/ . If you have any problems completing the online Discrepancy Notification Form, please e-mail the OAS CAHPS Survey Coordination Team at [email protected] for assistance.







APPENDIX Q:

EXCLUDED PROCEDURAL CODES

Appendix Q: Excluded Procedural Codes November 2018



Centers for Medicare & Medicaid Services Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual Q-1

The CPT codes29

listed below fall within the range for Codes for Surgery but are not considered

to be eligible for OAS CAHPS. They are grouped by category within the Codes for Surgery.

Additional CPT codes within the eligible range may also be excluded; however, the vendor must

submit an Exceptions Request Form (ERF) to document the codes to be excluded.

Category

10030–19499: Integumentary System

11042 Debridement, subcutaneous tissue; first 20sq cm or less

11045 Debridement, subcutaneous tissue; each additional 20 sq cm, or part

thereof

16020, 16025, 16030 Dressings or debridement of partial-thickness burns, initial or

subsequent (small, medium, or large)

Category

20000–29999: Musculoskeletal System

29000 Application of halo type body case

29010 Application of Risser jacket, localizer, body; only

29015 Application of Risser jacket, localizer, body; including head

29020 Application of turnbuckle jacket, body; only

29025 Application of turnbuckle jacket, body; including head

29035 Application of body cast, shoulder to hips;

29040 Application of body cast, shoulder to hips; including head, Minerva

type

29044 Application of body cast, shoulder to hips; including 1 thigh

29046 Application of body cast, shoulder to hips; including both thighs

29049 Application, cast; figure-of-eight

29055 Application, cast; figure-of-eight, shoulder spica

29058 Application, cast; figure-of-eight, plaster Velpeau


http://en.wikipedia.org/wiki/Integumentary_system


Centers for Medicare & Medicaid Services Q-2 Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual

Category


29065 Application, cast; figure-of-eight, shoulder to hand (long arm)

29075 Application, cast; figure-of-eight, elbow to finger (short arm)

29085 Application, cast; figure-of-eight, hand and lower forearm (gauntlet)

29086 Application, cast; figure-of-eight, finger (e.g., contracture)

29105 Application of long arm splint (shoulder to hand)

29125 Application of short arm splint (forearm to hand); static

29126 Application of short arm splint (forearm to hand); dynamic

29130 Application of finger splint; static

29131 Application of finger splint; dynamic

29200 Strapping; thorax

29240 Strapping; shoulder

29260 Strapping; elbow or wrist

29280 Strapping; hand or finger

29305 Application of hip spica cast; 1 leg

29325 Application of hip spica cast; 1 and one-half spica or both legs

29345 Application of long leg cast (thigh to toes)

29355 Application of long leg cast (thigh to toes); walker or ambulatory type

29358 Application of long leg cast brace

29365 Application of cylinder cast (thigh to ankle)

29405 Application of short leg cast (below knee to toes)

29425 Application of short leg cast (below knee to toes); walking or

ambulatory type

29435 Application of patellar tendon bearing (PTB) cast

29440 Adding walker to previously applied cast

29445 Application of rigid total contact leg cast

29450 Application of clubfoot cast with molding or manipulation, long or

short leg

November 2018 Appendix Q: Excluded Procedural Codes


Category


29505 Application of long leg splint

29515 Application of short leg splint

29520 Strapping hip

29530 Strapping knee

29540 Strapping ankle/or foot

29550 Strapping toes

29580 Strapping using unna boot (compression dressing for stasis ulcers and

other venous insufficiencies of the leg)

29581 Application of multilayer compression system; leg (below knee),

including ankle and foot

29582 Application of multilayer compression system; thigh and leg,

including ankle and foot, when performed

29583 Application of multilayer compression system; upper arm and forearm

29584 Application of multilayer compression system; upper arm, forearm,

hand, and fingers

29700 Removal or bivalving; gauntlet, boot or body cast

29705 Removal or bivalving; full arm or full leg cast

29710 Removal or bivalving; shoulder or hip spica, Minerva, or Risser

jacket, etc.

29715 Removal or bivalving; turnbuckle jacket

29720 Repair of spica, body cast or jacket

29730 Windowing of cast

29740 Wedging of cast (except clubfoot casts)

29750 Wedging of clubfoot cast

29799 Unlisted procedure, casting, or strapping

Category

33010–37799: Cardiovascular System

36400 Venipuncture, younger than age 3 years; femoral or jugular vein



Category

33010–37799: Cardiovascular System

36405 Venipuncture, younger than age 3 years; scalp vein

36406 Venipuncture, younger than age 3 years; other vein

36415 Collection of venous blood by venipuncture

36416 Collection of capillary blood specimen

36420 Venipuncture, cutdown; younger than age 1 year

36425 Venipuncture, cutdown; age 1 or over

36430 Transfusion of blood components

36440 Push transfusion, blood, 2 years or younger

36450 Exchange transfusion, blood, newborn

36455 Exchange transfusion, blood, other than newborn

36460 Transfusion, intrauterine, fetal

36468 Single or multiple injections of sclerosing solutions, spider veins

(telangiectasia); limb or trunk

36469 Single or multiple injections of sclerosing solutions, spider veins

(telangiectasia); face

36470 Injection of sclerosing solution, single vein

36471 Injection of sclerosing solution, multiple veins, same leg

36591 Collection of blood specimen from a completely implantable venous

access device

36592 Collection of blood specimen using established central or peripheral

catheter, venous, not otherwise specified

36600 Arterial puncture, withdrawal of blood for diagnosis

36620 Arterial catheterization or cannulation for sampling, monitoring or

transfusion (separate procedure); percutaneous

36625 Arterial catheterization or cannulation for sampling, monitoring or

transfusion (separate procedure); cutdown

36660 Catheterization, umbilical artery, newborn, for diagnosis or therapy

November 2018 Appendix Q: Excluded Procedural Codes


Category

50010–53899: Urinary System

51701 Insertion of non-indwelling bladder catheter

51702 Insertion of temporary indwelling bladder catheter

Category

59000–59899: Maternity Care and Delivery

59020 Fetal contraction stress test

59025 Fetal contraction non-stress test





APPENDIX R:

EXAMPLE PATIENT FILE LAYOUT

Appendix R: Example Patient File Layout November 2018



Centers for Medicare & Medicaid Services Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual R-1

EXAMPLE OF A PATIENT FILE LAYOUT

OAS CAHPS SURVEY

The following table is an example of a patient file layout. Survey vendors may use this layout as

an example template of the patient data needed from a client hospital outpatient department

(HOPD) or ambulatory surgery center (ASC). Information on patient eligibility criteria and

proper construction of the patient information file can be found in Chapter IV.

Data elements in the patient file layout shown below that will not be included on the data

file submitted to the OAS CAHPS Data Center are bolded and italicized.

SAMPLE PATIENT LAYOUT

Data Element

Field

Size Value Labels and Use

Required for

XML

Data Submission

Facility Name 100 Name of HOPD or ASC. Yes

CMS Certification

Number (CCN) 10

Valid 6- or 10-digit CMS Certification Number

(CCN, formerly known as the Medicare Provider

ID Number).

Yes

Sample Month 2 OAS CAHPS Survey sampling month.

MM Yes

Sample Year 4 Year of sample month.

YYYY Yes

No. of Patients Served 6

Total number of patients who had at least one

outpatient surgery or procedure during the sample

month at the HOPD or ASC, regardless of whether

the patient or procedure was OAS CAHPS eligible.

Yes

Patient First Name 30

The name of the patient is needed to generate and

send personalized mail survey materials to sample

members and/or for telephone survey data

collection.

No

(continued)

SAMPLE PATIENT LAYOUT (CONTINUED)

Data Element

Field


Required for

XML

Data Submission

Patient Middle Initial 1




collection.

No

Appendix R: Example Patient File Layout November 2018

R-2 Centers for Medicare & Medicaid Services Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual

Data Element

Field


Required for

XML

Data Submission

Patient Last Name 30




collection.

No

Patient Date of Birth 8

Patient’s birthdate. Used by survey vendor to

determine eligibility and to calculate patient age

prior to submitting data to the OAS CAHPS Data

Center.

MMDDYYYY

No

Gender 1

Patient’s gender.

1 = Male

2 = Female

M = Unknown/Missing

Yes

Language (if available

from patient record) 1

Identify the language the patient speaks. Needed

for survey administration.

1 = English

2 = Spanish

3 = Chinese

4 = Korean

5 = Other

M = Unknown/Missing

No

Patient Mailing Address

1 50

Patient’s street or post office box number.

Address information needed for survey

administration.

No

Patient Mailing Address

2 50 Second line of patient address (if needed). No

Patient Address City 50 Mailing address city. No

Patient Address State 2 Mailing address state. Use 2-character postal

abbreviation. No

(continued)

SAMPLE PATIENT LAYOUT (CONTINUED)

Data Element

Field


Required for

XML

Data Submission

Patient Address Zip

Code 9

9-digit Mailing Address Zip Code.

(5-digit zip code followed by 4-digit extension; no

hyphens, separators or delimiters)

No

November 2018 Appendix R: Example Patient File Layout

Centers for Medicare & Medicaid Services R-3 Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual

Data Element

Field


Required for

XML

Data Submission

Telephone Number

including area code 10

Patient’s primary telephone number. Needed for

survey administration.

Include 3-digit area code and 7-digit number: no

dashes or spaces, separators, or delimiters.

No

Cell Phone Indicator 1

Indication if the telephone number provided is a

cell phone. Needed for telephone survey

administration.

1 = Yes

2 = No

M = Unknown /Missing

No

Medical Record

Number 20 Patient’s Medical Record Number. No

Procedural Codes 5

Eligible CPT-430

codes (within the Codes for

Surgery range – 10021-69990) or G-Code

(G0104, G0105, G0121, and G0260). Used by

vendor to determine Surgical Category. NOTE: if

multiple eligible CPT codes and G-codes, list the

primary code first. Vendors will categorize the

surgery type based on the first code listed if there

are multiples.

No

Date of Procedure 8

Date in which the outpatient surgery or

procedure was performed. Needed for survey

administration.

MMDDYYYY

No

Name of Location

Where

Surgery/Procedure

Occurred

20

If HOPD or ASC has multiple locations, provide

name of the location where patient received

surgery or procedure. This may not be the official

name of the facility. Needed for survey

administration.

No


Documents

Protocols and Guidelines Manual · “OAS CAHPS Survey.” The OAS CAHPS Survey measures the experiences of patients who receive outpatient or ambulatory services from hospital outpatient