Protocols and Guidelines Manual, Version 1.3 has been Posted and Other Resourceful Documents have been Updated
folder_openSurvey Materialscalendar_todayPosted November 11, 2016

Version 1.3 of the Protocols and Guidelines Manual has been released on the OAS CAHPS Website as well as revised versions of the standalone documents available on the Survey Materials page, including the Mail Questionnaire in English, CATI script in English and Spanish, Consent to Share Identifying Information Question for mail and telephone in English, Spanish Simplified Chinese and Traditional Chinese, Standard Header Record XML File Layout, and DSRS Header Record XML File Layout. The Model QAP Outline document (under the For Vendors tab) has also been revised. The following is a summary of the main differences between Version 1.2 and Version 1.3.

• Additional clarification about the Current Procedural Terminology (CPT) codes has been included in Chapter IV along with citations throughout the manual. Because the Protocols and Guidelines Manual discusses CPT codes and lists specific CPT codes (as examples), a pop-up agreement will appear each time a user opens the Manual through the OAS CAHPS website.

• List of Abbreviation and Acronyms: Added HCPCS (Healthcare Common Procedure Coding System).

• Chapter II: Refined definitions of a hospital outpatient department (HOPD) and an ambulatory surgery center (ASC); added information about voluntary reporting and facility eligibility or exemption from the OAS CAHPS Survey Proposed Rule published on July 14, 2016; when the Final Rule will be published (on November 14, 2016); and updated references to links and information available on the OAS CAHPS website.

• Chapter III: Added information about survey participation from the Proposed Rule; clarified the acceptable and unacceptable communications with patients about the OAS CAHPS Survey; specified when the online Vendor Application form will be available on the OAS CAHPS website; revised guidance on sampling and administering the OAS CAHPS Survey in conjunction with other surveys; clarified that vendors and/or facilities can add up to 15 supplemental questions per respondent to the OAS CAHPS Survey; and clarified that it is acceptable to modify the skip instructions in the mail survey and telephone script for Q36 (“Go to END” or “GO TO Q_END,” respectively) with “Go to Q38” depending on placement of Consent to Share Identifying Information question or supplemental question(s).

• Chapter IV: Revised definition of an OAS CAHPS-eligible HOPD and ASC; added guidance on determining eligibility of surgeries and procedures; added guidance on how the vendor and HOPD and ASC are to handle instances when multiple survey-eligible surgeries and/or procedures were performed during the sample month for a patient; updated list of data elements each HOPD or ASC needs to provide their survey vendor; clarified ineligible of CPT codes; added protocol for handling a patient file with missing procedural codes (CPT or G codes); added guidance on determining a sampling rate for small HOPDs and ASCs; and corrected language in misconception #3.

• Chapter V: Corrected range of days when a Discrepancy Notification Report (DNR) would be required for initiating the survey (between 22 and 26 days after the sample month ends); revised late start e-mail request requirements; clarified that it is acceptable to modify the skip instructions in the mail survey for Q36 (“Go to END”) with “Go to Q38” depending on placement of Consent to Share Identifying Information question or supplemental question(s); expanded guidance on identifying and handling proxy cases; and added new Quality Control requirement about not revising response data once the survey has been processed.

• Chapter VI: Corrected range of days when a Discrepancy Notification Report (DNR) would be required for initiating the survey (between 22 and 26 days after the sample month ends); revised late start e-mail request requirements; clarified that it is acceptable to modify the skip instructions in telephone script for Q36 (“GO TO Q_END”) with “Go to Q38” depending on placement of Consent to Share Identifying Information question or supplemental question(s); clarified that vendors are required to make 5 telephone contact attempts for each sampled case; and added new Quality Control requirement about not revising response data once the telephone interview has been completed or finalized.

• Chapter VII: Revised late start e-mail request requirements; clarified that it is acceptable to modify the skip instructions in the mail survey and telephone script for Q36 (“Go to END” or “GO TO Q_END,” respectively) with “Go to Q38” depending on placement of Consent to Share Identifying Information question or supplemental question(s); added receipting requirement about processing two surveys completed by the same respondent; expanded guidance on identifying and handling proxy cases; added new Quality Control requirement about not revising response data once the mail survey or telephone interview has been completed or finalized; and clarified that vendors are required to make 5 telephone contact attempts for each sampled case.

• Chapter VIII: Clarified that vendors should not share patient-level data with anyone outside of their organization; and that the only allowable circumstance for removing electronic data from vendor’s or subcontractor’s premises is for backup storage.

• Chapter IX: Clarified decision rules for coding screening and follow-up questions in both the mail and telephone surveys; expanded definition of a completed survey to clarify that responses to supplemental questions should not be included in completeness calculations; summarized guidance for handling blank surveys in Table 9.1 for code 320 (Refusal); clarified descriptions under Mail-Only Mode and Telephone-Only Mode in Table 9.1 for code 350 (No Response After Maximum Attempts); expanded guidance on handling blank questionnaires to include returned surveys with primarily or only responses to supplemental questions; and added protocols for identifying and handling proxy cases, including a new table (Table 9.2 – How to Determine a Proxy Case).

• Chapter X: Updated Exhibits 10.1, 10.2, 10.3, 10.4, 10.5, 10.7, 10.9, 10.10, and 11; added a new exhibit (Exhibit 10.8 – User Details Form); updated list of public web pages and links to reflect what is currently available on the OAS CAHPS website; updated the names of various links, menus, forms, documents, etc. available on the website; added instructions on how to add, edit, and delete a new user on the website; clarified instructions and example provided under the three actions described for vendor authorizations; added when the Vendor Registration Form is generally available on the website; updated what is available on the Vendor Dashboard to include the OAS CAHPS Survey training sessions vendor’s Survey Administrator is registered to attend and a link to the Training Certification Exam; and clarified what to do if a user forgets the password.

• Chapter XI: Added that survey response data should be included in the XML file for cases coded a complete (110 or 120) and breakoff (310); clarified how each facility type (hospitals and ASCs) should determine the Number of Patients Served; clarified how vendors are to determine the Surgical Category when multiple survey-eligible CPT codes are provided; added guidance on handling missing procedural codes, the use of an alternative method for determining eligibility and the Surgical Category; added how Survey Mode and Survey Language should be coded in the Patient Administrative Record; updated the names of the various reports to reflect what is currently available on the OAS CAHPS website; clarified how to handle starting the survey mid-quarter and switching vendors mid-quarter; updated guidelines on notifying the OAS CAHPS Survey Coordination Team if an HOPD or ASC is no longer active or closes while the vendor is still under contract; and added a new Quality Control check to confirm only patient response data are included for cases coded a 110, 120, or 310.

• Chapter XII: Updated the names and descriptions of the functions for the various reports to reflect what is currently available, including the Validation Results Report (immediately available after upload), Data Submission History Report (updated after the second file validation check is complete), and the Data Submission History by Upload Date Report (vendors can use to search by upload date); and updated screenshot for the Survey Vendor Authorization Report.

• Chapter XIII: Updated name of Appendix N mentioned throughout this chapter; updated the list of sections a vendor’s QAP should include to match the Model QAP document; removed requirement that approved survey vendors must  have clients within 2 years or must reapply for approval; and revised list of site visit expectations to include a discussion about the vendor’s initial communications with HOPDs and ASCs, and a “walk through” and documentation review of quality control activities on all aspects of OAS CAHPS and data security.

• Chapter XIV: Added information about the three composite measures and how they are analyzed and scored, including an example; added information about top-, middle-, and bottom-box reporting; added results of the mode experiment; and corrected two dates in Table 14.2 – second row under Vendors Data Submission Deadline to “Oct. 12, 2016” and third row under Public Reporting Period (#) to “April 2017 (3).”

• Chapter XV: Updated the list of four allowable exceptions on OAS CAHPS to include an alternative method for determining eligibility for patient records missing procedural codes and to request exclusion of CPT-4 codes that fall within the range of Codes for Surgery, and removed survey not yet in effect; added DSRS and continuous sampling Exceptions Request Form requirements; updated list of when a Discrepancy Notification Report (DNR) is required to include when the facility is unable to provide the vendor with procedural codes for patient records; updated list of information needed in the DNR to match the fields on the online DNR form; and added a new table (Table 15.1 – Example Scenarios of Various Discrepancy Reasons).

• Appendix B: NOTE – Most of the revisions listed here have already been incorporated into the standalone English survey materials on the OAS CAHPS website. Added CAHPS trademark symbol on mail questionnaire cover page and first page of the telephone script; bolded the example skip instructions under Survey Instructions on page 1 of the mail questionnaire; underlined “facility named in the cover letter” on page 1 of the mail questionnaire and in the Alternative Instructions for Scannable Forms; removed “/a” from “Latino/a” in Q30 of the mail questionnaire; removed “/a” from the “Chicano/a” and the “Latino/a” in Q31 of the mail questionnaire; added new breakoff script and programming logic (for resuming a telephone survey that was started in a preceding call) at the top of the telephone script and INTRO4 and INTRO5; revised the order of the “IF ASKED WHO IS CALLING…” script to appear above the 4 response options; revised programming logic for response options in INTRO1; added commas, “, or” and “?” to the end of the response options for Q1-Q9, Q11-Q12, Q14-Q15, Q17, Q19, Q21, Q24, Q31, Q32a, Q32b, and Q33-Q34; revised Q30 to read: “Are you of Hispanic, Latino, or Spanish origin;” and revised response options for Q35 to read in ALL CAPS.

• Appendix C: NOTE – Most of the revisions listed here have already been incorporated into the standalone Spanish survey materials on the OAS CAHPS website. Underlined “centro ambulatorio que se menciona en la carta de presentación” in the Alternative Instructions for Scannable Forms; added CAHPS trademark symbol on the first page of the telephone script; added new breakoff script and programming logic (for resuming a telephone survey that was started in a preceding call) at the top of the telephone script and INTRO4 and INTRO5; revised the order of the “IF ASKED WHO IS CALLING…” script to appear above the 4 response options; revised programming logic for response options in INTRO1; added commas, “, o” and “?” to the end of the response options for Q1-Q9, Q11-Q12, Q14-Q15, Q17, Q19, Q21, Q24-Q26, Q29, Q31-Q34; removed underline from the word “completado” in Q29; revised response option 1 for Q29 to read: “8 años de escuela o menos;” added “¿Diría que…” at the end of Q34; revised response options for Q35 to read in ALL CAPS; and revised text in the parenthesis in Q_END, Q_INELIG, and Q_REF to read: “(un buen día/una buena tarde/una buena noche).”

• Appendix D: NOTE – Most of the revisions listed here have already been incorporated into the standalone Chinese (Traditional and Simplified) survey materials on the OAS CAHPS website. Removed “(FORTHCOMING)” from the appendix cover page; added CAHPS trademark symbol on mail questionnaire cover page; translated header name “Survey Instructions” (on page 1 of the mail questionnaire) into Chinese; bolded the example skip instructions in the survey instructions section on page 1 of the mail questionnaire and in the Alternative Instructions for Scannable Forms; revised the paragraph underneath the example skip logic on page 1 of the mail questionnaire and in the Alternative Instructions for Scannable Forms; bolded the introductory statement above Q9; translated all of the response options in Q27 of the mail questionnaire into Chinese; and removed underlining from last paragraph in the Alternative Instructions for Scannable Forms.

• Appendix F: Clarified what “other identifying information” means (responses to the About You survey questions).

• Appendix I: Added guidelines on providing neutral positive feedback to respondents.

• Appendix K: NOTE – Most of the revisions listed here have already been incorporated into the standalone Standard XML file layout on the OAS CAHPS website. Changed lower limit in the Valid Values column for Patients on file(s) submitted to Vendor, Eligible Patients, and Sampled Patients from 0 to 1; added a fifth valid value (“Missing”) for the Surgical Category data element; updated the Description column for Sampled Patients; removed “/a” from “Latino/a” in the Description column for Q30 Ethnicity; removed “/a” from “Chicano/a” and “Latino/a” in the Valid Values column for Q31 Group; revised XML Element and Valid Values columns for Q32 Race Asian-phone to remove “Indian” (<raceasian-phone>); and added new row for Q32 Race Native Hawaiian Pacific Islander – phone.</raceasian-phone>

• Appendix L: NOTE – Most of the revisions listed here have already been incorporated into the standalone DSRS XML file layout on the OAS CAHPS website. Changed lower limit in the Valid Values column from 0 to 1 and added M = Unknown/Missing and the instruction in Data Type column from Numeric to Alphanumeric for Patients Served for the Stratum; changed lower limit in the Valid Values column from 0 to 1 for DSRS Patients on file(s) submitted to Vendor, DSRS Eligible Patients, and DSRS Sampled Patients; added the Note to the Description column; added a new row for DSRS Stratum Name; added a fifth valid value (“Missing”) for the Surgical Category data element; changed XML Data Element from Q6 Clerk Request to Q6 Clerk Respect; removed “/a” from “Latino/a” in the Description column for Q30 Ethnicity; removed “/a” from “Chicano/a” and “Latino/a” in the Valid Values column for Q31 Group; and revised XML Element and Valid Values columns for Q32 Race Asian-phone to remove “Indian” (<raceasian-phone>).  </raceasian-phone>

• Appendix M: NOTE – The revisions listed here have already been incorporated into the standalone Zero Sampled XML file layout on the OAS CAHPS website. Changed the Valid Values for Type of Header Record from “1 = Standard Header Record” to “0 = Zero Sampled Header Record;” and changed lower limit in the Valid Values column from 1 to 0 for Patients Served.

• Appendix N: Revised appendix header from “Instructions for Preparing a Survey Vendor Quality Assurance Plan (QAP)” to “Model Quality Assurance Plan (QAP);” and revamped the entire appendix so it aligns with the Model QAP document available on the OAS CAHPS website.

• Appendix O: Revised to mirror the current version of the online Exceptions Request Form.
• Appendix P: Revised to mirror the current version of the online Discrepancy Notification Report; and updated screenshots to show the online form’s grid depending on which Discrepancy Reason is selected.
• Appendix Q: New appendix with a list of procedural codes that are ineligible for the OAS CAHPS Survey.