Protocols and Guidelines Manual, Version 2.0 has been Posted and Other Resourceful Documents have been Updated
folder_openSurvey Materialscalendar_todayPosted November 14, 2017

Version 2.0 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 CATI script in English and Spanish, Consent to Share Identifying Information Question for mail and telephone in English and Spanish, cover letter for the initial questionnaire mailing in Spanish and Korean, cover letter for the second questionnaire mailing in Korean, Standard XML File Layout, and DSRS XML File Layout. The following is a summary of the main differences between Version 1.3 and Version 2.0.

• Chapter I: Added a reference to the OAS CAHPS Survey Website and Data Submission Manual, Version 1.0 (which will soon be available on the OAS CAHPS website); and added a reference to the newly added appendix (Appendix R, Example Patient File Layout).

• Chapter II: Refined the definitions of a survey-eligible hospital outpatient department (HOPD) and ambulatory surgery center (ASC); added Korean to the list of approved OAS CAHPS Survey languages; added text indicating there is a proposed delay to the implementation of the OAS CAHPS Survey beginning with the CY 2020 payment determination (2018 data collection) until further action in the rulemaking; and added text explaining that an ASC that qualifies for the exemption from the ASCQR also qualifies for an exemption from the OAS CAHPS Survey.

• Chapter III: Added information explaining that vendors and their client facilities cannot ask supplemental questions that reveal the patient’s identity without the Consent to Share Identifying Information question affirmatively answered; added information about an online Appeals form that vendors can submit if their vendor application is denied; under Vendor Business Requirements, clarified that if any vendor personnel are affiliated with a healthcare provider (hospital, ambulatory surgery center, management company, etc.) the vendor cannot be approved to conduct the OAS CAHPS Survey as long as the vendor personnel maintain the affiliation; and included additional text explaining that if an ASC qualifies for the exemption from the ASCQR they also qualify for an exemption from the OAS CAHPS Survey.

• Chapter IV: Clarified the purpose of using a sampling rate; included an example of how to calculate the sampling rate for a facility; added text to the Patient Eligibility Requirements to clarify eligibility for overnight stays for observation; added text explaining two variations of the Stratified Systematic Sampling method (SSS); removed superfluous reference to office setting in the definition of eligible HOPDs; added text to clarify that if a patient record has both eligible and ineligible procedural codes, the patient is still eligible if they have at least one eligible CPT or G code; refined the definition of eligible HOPDs and ASCs; and added a footnote explaining that facilities or software vendors cannot exclude patients who indicated that they do not participate in surveys.

• Chapter V: Added Korean as an approved translation for mail survey administration; added the requirement that the cover letter must include a statement that all information the sampled patient provides will be confidential and is protected by the Privacy Act; and added text explaining that the HOPD’s or ASC’s company name and logo must not be displayed on the outgoing mail envelope or through the window of an outgoing envelope.

• Chapter VI: Added text to code 230 (Ineligible: Language Barrier) to clarify that the language barrier code only applies to the sample member and should not be assigned until a determination is made that the sample member cannot speak any of the language(s) being administered for the client facility; added text to explain that if the vendor called the incorrect phone number for a patient and obtains a new telephone number, the number of telephone contacts for that patient will start at 1 (out of 5) using the new phone number; included additional text explaining that if a sample member hangs up (without any comment) before or during the introductory script, the case should be called again but if the sample member hangs up after the introductory script (without any comment) the interviewer should code the case as a refusal; and removed Delaware and Michigan from the list of states that require two-party or all-party consent when phone calls are monitored or audiotaped.

• Chapter VII: Added Korean as an approved translation for mail survey administration; added the requirement that the cover letter must include a statement that all information the sampled patient provides will be confidential and is protected by the Privacy Act; added text explaining that the HOPD’s or ASC’s company name and logo must not be displayed on the outgoing mail envelope or through the window of an outgoing envelope; added text to code 230 (Ineligible: Language Barrier) to clarify that the language barrier code only applies to the sample member and should not be assigned until a determination is made that the sample member cannot speak any of the language(s) being administered for the client facility; and included additional text explaining that if a sample member hangs up (without any comment) before or during the introductory script, the case should be called again, but if the sample member hangs up after the introductory script (without any comment) the interviewer should code the case as a refusal.

• Chapter VIII: Added an alternative method for reporting “About You” response data to client facilities where the vendor can combine two or more contiguous response options so that the combined responses meet the reporting requirement of 11 or more, including examples; and withdrew the suppression of data for Q36 and Q37 in the “About You” questions when reporting data to client facilities.

• Chapter IX: Added text to code 230 (Ineligible: Language Barrier) to clarify that the language barrier 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 for the client facility; included additional text to clarify that if the screener question and the follow-up questionnaire left blank, the screening question should be coded as “Missing (Code M)” and the follow-up questions should be coded “Not Applicable (Code X)”; and streamlined information provided under Decision Rules for Coding Survey Responses Marked Outside the Response Box.

• Chapter X: Included instructions for adding a user if that person has an existing account; included a reference to the Data Submission Manual, which facilities and vendors should use if they have questions about the registration or vendor authorization processes; streamlined and clarified the steps for facility users’ registration and authorization processes; included an explanation about the password reset expiration (after 24 hours of the submitted password reset request); updated with new screenshots of the OAS CAHPS Survey website to reflect the revised layout of the website; and added references to new resource documents available on the OAS CAHPS website (such as the Frequently Asked Questions [FAQs] for hospitals and ASCs and the OAS CAHPS Survey Website and Data Submission Manual, Version 1.0).

• Chapter XI: Clarified text to explain that patients who were deemed ineligible during the sampling process should not be included in the XML file; added text explaining that the total number of patients served is used to estimate the sampling rate and for quality control checks; added clarification about coding the Patient Age data variable; added clarification about coding the Patient Gender data variable; and streamlined the required data elements and accompanying descriptions for the Header Records and Patient Administrative Data Record sections.

• Chapter XII: Added information about the Registered Facilities

• Chapter XIV: Under the Measures That Are Reported header, updated composite measure “Communications About Your Procedure” to clarify that question 10 is a gate question that impacts question 12 as well as question 11.

• Chapter XV: Added text to clarify that when submitting an Exceptions Request Form for continuous sampling, the vendor must include the list of all CCNs that will have the sample drawn continuously and can add text indicating that the request applies to “all future CCNs” if they choose so that they do not have to update the request form when future clients wish to implement continuous sampling.

• Appendix B: NOTE – Most of the revisions listed here had already been incorporated into the standalone English survey materials on the OAS CAHPS website and documented in previous announcements. Added a sentence in the sample cover letter for the second questionnaire mailing stating that patient’s name and identifying information will not be linked to their answers when then the data are analyzed; included additional information clarifying that the length of the survey stated in INTRO2 of the CATI script can vary depending whether supplemental questions are used; added optional survey items (INEL1, INEL2, and INEL_END) in the CATI script that vendors can use when a new telephone number for a sampled patient has been identified from a source other than the facility; and added skip instructions for the “MISSING/DK” response options for Q10, Q30, Q34, and Q35 in the CATI script.

• Appendix C: NOTE – Some of the revisions listed here had already been incorporated into the standalone Spanish survey materials on the OAS CAHPS website and included in previous announcements. Translated “Enclosures” at the bottom of both sample cover letters; added a sentence in the sample cover letter for the second questionnaire mailing stating that patient’s name and identifying information will not be linked to their answers when then the data are analyzed; revised Q9 to include an “y” between “doctores” and “enfermeras” instead of a “u” in both the mail questionnaire and CATI script; added optional survey items (INEL1, INEL2, and INEL_END) in the CATI script which vendors can use when a new telephone number for a sampled patient has been identified from a source other than the facility; updated INTRO1 to include a comma between “[INTERVIEWER NAME] and y estoy;” included additional information clarifying that the length of the survey stated in INTRO2 of the CATI script can vary depending on whether supplemental questions are used; updated INTRO4 to include the text “en nombre de [FACILITY NAME];” changed skip logic for response option 4 for INTRO4 to read, “[GO TO Q_INELIGIBLE SCREEN.]”; removed underlining in Q34; and added skip instructions for the “MISSING/DK” response options for Q10, Q30, Q34, and Q35 in the CATI script.

• Appendix D: NOTE – The second revision listed here had already been incorporated into the standalone Chinese (Traditional and Simplified) survey materials on the OAS CAHPS website. Translated “Enclosures” at the bottom of the cover letters; added a sentence in the sample cover letter for the second questionnaire mailing stating that the patient’s name and identifying information will not be linked to their answers when then the data is analyzed.

• Appendix E: New appendix with Korean survey materials (cover letters and mail questionnaire) to the Manual, Version 2.0; translated “Enclosures” at the bottom of the cover letters; added a sentence in the sample cover letter for the second questionnaire mailing stating that the patient’s name and identifying information will not be linked to their answers when then the data is analyzed.

• Appendix F: Changed the CATI responses in the English and Spanish Consent to Share Identifying Information Question so they appear in ALL CAPS (“YES” and “NO”) so they are not read aloud; and added Korean translation.

• Appendix G: Added Korean translation.

• Appendix H: Added text to the FAQs to clarify that the OAS CAHPS Survey is applicable for patients who had outpatient surgeries and were not discharged to the hospital as an inpatient.

• Appendix I: Reordered appendices I and J; this is now FAQs for Telephone Interviewers (Spanish translation); and added text to the FAQs to clarify that the OAS CAHPS Survey is applicable for patients who had outpatient surgeries and were not discharged to the hospital as an inpatient.

• Appendix J: Reordered appendices I and J; this is now General Guidelines for Telephone Interviewers.

• Appendix K: NOTE – Most of the revisions listed here had already been incorporated into the standalone Standard XML file layout on the OAS CAHPS website and documented in a previous announcement. Incorporated the Surgical Category “Missing” in the category for surgical type; added the value “5” (Missing) to the valid values column; clarified the description for Surgical Category variable to explain when to apply code “4” (Other); expanded on the description for Survey Mode variable in the Patient Administrative Data Record to explain when to apply code “X” (Not Applicable); and added the value “4” (Korean) to the Survey Language variable.

• Appendix L: NOTE – Most of the revisions listed here had already been incorporated into the standalone DSRS XML file layout on the OAS CAHPS website and documented in a previous announcement. Incorporated the Surgical Category “Missing” in the category for surgical type; added the value “5” (Missing) to the valid values column; clarified the description for Surgical Category variable to explain when to apply code “4” (Other); expanded on the description for Survey Mode variable in the Patient Administrative Data Record to explain when to apply code “X” (Not Applicable); and added the value “4” (Korean) to the Survey Language variable.

• Appendix Q: Added 16 procedural codes that are ineligible for the OAS CAHPS Survey.

• Appendix R: New appendix (called Example Patient File Layout) with the OAS CAHPS sample frame specifications.

• Throughout Manual: Added references to the Korean language translation; added references to the new OAS CAHPS Survey Website and Data Submission Manual; added references to the new Appendix R; updated the CPT code citation year to read “CPT only copyright 2016 American Medical Association. All rights reserved;” changed references to the OAS CAHPS website to read either “website” or “web portal;” and changed all references to the “OAS CAHPS Project Manager” to “OAS CAHPS Project Director.”

If you have questions, you can contact the OAS CAHPS Survey Coordination Team via e-mail at oascahps@rti.org or call 1-866-590-7468.