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A hospital self-administering the HCAHPS survey must meet the Self-administering Hospital Minimum Survey Requirements, and an independent survey vendor or a hospital administering the HCAHPS survey for multiple sites must meet the Survey Vendor Minimum Survey Requirements.

Note: If a survey vendor is non-compliant with program requirements for a contracted hospital, that hospital’s data may not be publicly reported, which could affect that hospital’s Annual Payment Update for the fiscal year.

The minimum survey requirements are as follows: 1. Relevant Survey Experience

Demonstrated experience in fielding mail, and/or telephone, and/or IVR surveys.

Criteria Self-administering Hospital Survey Vendor

Survey Experience ¾ Conducted patient-specific surveys

¾ Mail and/or telephone and/or IVR survey experience

¾ Conducted person-specific surveys

¾ Mail and/or telephone and/or IVR survey experience Number of Years in

Business

¾ Minimum two years ¾ Minimum three years Number of Years

Conducting Surveys

¾ Minimum one year in selected mode of administration

¾ Minimum two years in selected mode of administration

2. Organizational/Survey Capacity

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

Criteria Self–administering Hospital Survey Vendor

Personnel

Note: Volunteers are not permitted to be involved in any aspect of the HCAHPS survey administration process.

¾ Designated HCAHPS Project Manager

¾ Designated HCAHPS personnel, including Project Manager ¾ Survey experience

System Resources ¾ Physical plant resources available to handle the volume of surveys being administered

¾ A systematic process to: • Track fielded survey

throughout the protocol, avoiding respondent burden and losing respondents

• Assign random, unique de-identified patient identification number (Patient ID) to track each sampled patient

¾ Physical plant resources available to handle the volume of surveys being administered, including computer and technical equipment

¾ Electronic or alternative survey management system to:

• Track fielded survey throughout the protocol, avoiding respondent burden and losing respondents • Assign random, unique de-

identified patient identification number (Patient ID) to track each sampled patient

Sample Frame Creation ¾ Generate sample frame data file that contains all

discharged patients who meet the eligible population criteria ¾ Draw sample of discharges,

who meet the eligible population criteria, to be surveyed

¾ Generate the sample frame data file that contains all discharged patients who meet the eligible population criteria

¾ Draw sample of discharges, who meet the eligible population criteria, to be surveyed

Mail Administration ¾ Obtain and update addresses ¾ Produce and print survey

instruments and materials; a sample of all mailing materials must be submitted for review

¾ Mail out of survey materials ¾ Process survey data (key-

entry or scanning)

¾ Track non-respondents for follow-up mailing

¾ Obtain and update addresses ¾ Produce and print survey

instruments and materials; a sample of all mailing materials must be submitted for review ¾ Mail out of survey materials ¾ Process survey data (key-entry

or scanning)

¾ Track non-respondents for follow-up mailing

Telephone Administration

¾ Obtain and update telephone numbers

¾ Collect telephone interview data for the survey; a sample of the telephone script must be submitted for review ¾ Identify non-respondents for

follow-up telephone call

¾ Obtain and update telephone numbers

¾ Collect telephone interview data for the survey, using electronic or alternative interviewing system; a sample of the telephone script must be submitted for review

¾ Identify non-respondents for follow-up telephone call Mixed Mode

Administration

¾ See above referenced Mail Administration requirements ¾ See above referenced

Telephone Administration requirements

¾ See above referenced Mail Administration requirements ¾ See above referenced Telephone

Administration requirements

Active Interactive Voice Response (IVR)

Administration

¾ Obtain and update telephone numbers

¾ Collect touch-tone key pad responses to pre-recorded questions; a sample of the IVR script must be submitted for review

¾ Identify non-respondents for follow-up telephone call ¾ Ability to conduct telephone

interview if respondent opts out of IVR

¾ Obtain and update telephone numbers

¾ Collect touch-tone key pad responses to pre-recorded questions; a sample of the IVR script must be submitted for review

¾ Identify non-respondents for follow-up telephone call ¾ Use electronic telephone or

alternative interviewing system to collect telephone interview if respondent opts out of IVR Data Submission

Note: Hospitals/Survey vendors are responsible for data submission and must not subcontract this process.

¾ Registered user of My QualityNet

¾ Access and submit data electronically via My QualityNet

¾ Registered user of My QualityNet

¾ Obtain My QualityNet survey vendor authorization from contracted hospitals ¾ Access and submit data

electronically via My QualityNet

Technical

Assistance/Customer Support

¾ Provide customer support line ¾ Provide toll-free customer support line

3. Quality Control Procedures

Personnel training and quality control mechanisms employed to collect valid, reliable survey data and achieve, on average, a 40 percent response rate.

Criteria Self-administering Hospital Survey Vendor

Demonstrated Quality Control Procedures

¾ In-house training for staff and subcontractors involved in survey operations

¾ Printing, mailing and recording receipt of survey information, or

¾ Telephone administration of survey, or

¾ IVR administration of survey ¾ Coding and editing or keying

in survey data

¾ Preparing final patient-level data files for submission ¾ All other functions and

processes that affect the administration of the HCAHPS survey

¾ In-house training for staff and subcontractors involved in survey operations

¾ Printing, mailing and recording receipt of survey information, or

¾ Telephone administration of survey, or

¾ IVR administration of survey ¾ Coding and editing or keying

in survey data

¾ Preparing final person-level data files for submission ¾ All other functions and

processes that affect the administration of the HCAHPS survey

Overview

Hospitals/Survey vendors have access to a number of sources of information regarding HCAHPS. These sources are listed below.