Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) MBQIP Educational Session One Phase Two, January 2013

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1 Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) MBQIP Educational Session One Phase Two, January 2013

2 Overview HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) Survey First national, standardized, publicly reported survey of patients perspectives of hospital care 27-item survey instrument and data collection methodology Since 2008, has allowed valid comparisons to be made across hospitals locally, regionally and nationally

3 Development and Endorsement 2002 CMS partnered with Agency for Healthcare Research and Quality (AHRQ) to develop and test the HCAHPS survey May 2005, the survey was endorsed by the National Quality Forum (NQF) October 2006, CMS implemented the survey and first public reporting of results occurred March 2008 Since July 2007, hospitals subject to Inpatient Prospective Payment System (IPPS) must collect and submit data to receive full APU

4 Participation Hospitals must be in compliance with the requirements in the Quality Assurance Guidelines v.7.0. Hospitals/survey vendors must submit a Participation Form to the HCAHPS Project Team for approval prior to the administration of the survey.

5 Hospitals Self-Administering HCAHPS Complete the Participation Form for Hospitals Self-Administering Survey and become approved Sample patients according to the sampling protocols contained in the Guidelines V7.0 Administer the HCAHPS survey and oversee the quality of work of staff and subcontractors

6 Hospitals Self-Administering HCAHPS Submit data files to My QualityNet Review HCAHPS Data Submission Reports and HCAHPS Warehouse Feedback Reports and confirm successful upload of the hospital s data files to My QualityNet Review the HCAHPS Review and Correction Report Preview HCAHPS results prior to public reporting

7 Hospital Education Requirments Attend HCAHPS Training Hospitals or Survey vendors must attend the Introduction to HCAHPS Training and subsequent HCAHPS Update Trainings sponsored by CMS. Minimum, the hospital s/survey vendor s Project Manager must participate in the HCAHPS training sessions.

8 Hospital Survey Rules Participation in HCAHPS Dry Run (Voluntary) A short dry run highly recommended Dry runs are planned for the last month of each quarter Opportunity to gain first-hand experience collecting and transmitting data without public reporting collect data and submit the data to My QualityNet

9 Hospital Survey Rules Review and Follow the Quality Assurance Guidelines V7.0 and Policy Updates Manual used to ensure standardization of the survey data collection process and to ensure the comparability of reported data Hospitals must follow all policy updates, including HCAHPS Bulletins, posted on the HCAHPS Web site at Attest to the Accuracy of the Organization s Data Collection Process Hospital must review and attest to the accuracy of the organization s data collection process

10 Hospital Survey Rules Develop Hospital HCAHPS Quality Assurance Plan Must develop a QAP for survey administration and update the QAP as part of their participation status QAP Outline document (see Appendix N) provides guidelines and updated to reflect changes in key personnel, resources and processes QAP must include the following Organizational background and structure for the project Role of subcontractor Work plan for survey administration

11 Hospital Survey Rules Survey and data management system Quality controls Confidentiality, privacy and security procedures in accordance with the Health Insurance Portability and Accountability Act (HIPAA) Annual reporting of results from quality control activities Update HCAHPS survey materials

12 HCAHPS Survey What? Content Asks recently discharged patients about aspects of their hospital experience Core of survey contains 18 items that ask how often they experienced a critical aspect of hospital care 4 items to direct patients to relevant questions 3 items to adjust for mix of patients across hospitals 2 items that support Congressionallymandated reports

13 HCAHPS Survey Who? Random sample of adult inpatients between 48 hours and six weeks after discharge Eligible cases medical, surgical and maternity care Not restricted to Medicare beneficiaries

14 Survey Modes 4 Modes Mail Telephone Mail with phone follow-up Active interactive voice recognition (IVR)

15 HCAHPS Survey How? Must survey patients throughout each month of the year Completed surveys over four calendar quarters Available in English, Spanish, Chinese, Russian and Vietnamese versions Manual located at

16 HCAHPS Survey How? Two versions available Standard Survey 27 questions implemented 2006 Core questions 1-22 About you questions Expanded Survey 32 questions July 1, 2012 Core questions 1-25 About you questions 26-32

17 Components of Standard Survey The standardized 27-item survey instrument is composed of the following measures: Six Composite Measures Communication with Nurses (three items) Communication with Doctors (three items) Responsiveness of Hospital Staff (two items) Pain Management (two items) Communication About Medicines (two items) Discharge Information (two items)

18 Components of Standard Survey (cont.) Two Individual Items Cleanliness of Hospital Environment Quietness of Hospital Environment Two Global Items Recommend the Hospital Overall Hospital Rating

19 HCAHPS Survey Questions Survey Instructions Answer all the questions by checking the box Sometimes instructions 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

20 Survey Questions Your Care From Nurses 3 Questions using this scale Never Sometimes Usually Always

21 Questions Your Care From Nurses 1. During this hospital stay, how often did nurses treat you with courtesy and respect? 2. During this hospital stay, how often did nurses listen carefully to you? 3. During this hospital stay, how often did nurses explain things in a way you could understand?

22 Survey Questions Your Care From Nurses 4. During this hospital stay, after you pressed the call button, how often did you get help as soon as you wanted it? Never Sometimes Usually Always I never pressed the call button

23 Survey Questions Your Care From Doctors 3 questions using this scale Never Sometimes Usually Always

24 Survey Questions Your Care From Doctors 5. During this hospital stay, how often did doctors treat you with courtesy and respect? 6. During this hospital stay, how often did doctors listen carefully to you? 7. During this hospital stay, how often did doctors explain things in a way you could understand?

25 Survey Questions The Hospital Environment 2 questions using this scale Never Sometimes Usually Always

26 Survey Questions The Hospital Environment 8. During this hospital stay, how often were your room and bathroom kept clean? 9. During this hospital stay, how often was the area around your room quiet at night?

27 Survey Questions Your Experiences in this Hospital 10.During this hospital stay, did you need help from nurses or other hospital staff in getting to the bathroom or in using a bedpan? Yes No If No, Go to question How often did you get help in getting to the bathroom or in using a bedpan as soon as you wanted? Never Sometimes Usually Always

28 Survey Questions Your Experiences in this Hospital 12.During this hospital stay, did you need medicine for pain? Yes No If No, Go to Question 15

29 Survey Questions Your Experiences in this Hospital 13. During this hospital stay, how often was your pain well controlled? 14. During this hospital stay, how often did the hospital staff do everything they could to help you with your pain? Never Sometimes Usually Always

30 Survey Questions Your Experiences in this Hospital 15.During this hospital stay, were you given any medicine that you had not taken before? Yes No If No, Go to Question Before giving you any new medicine, how often did hospital staff tell you what the medicine was for? Never Sometimes Usually Always 17. Before giving you any new medicine, how often did hospital staff describe possible side effects in a way you could understand?

31 Survey Questions When You Left the Hospital 18.After you left the hospital, did you go directly to your own home, to someone else s home, or to another health facility? Own home Someone else s home Another health facility If Another, Go to Question 21

32 Survey Questions When You Left the Hospital 19.During this hospital stay, did doctors, nurses or other hospital staff talk with you about whether you would have the help you needed when you left the hospital? Yes No

33 Survey Questions When You Left the Hospital 20.During this hospital stay, did you get information in writing about what symptoms or health problems to look out for after you left the hospital? Yes No

34 Survey Questions Overall Rating of Hospital 21. Using any number from 0 to 10, where 0 is the worst hospital possible and 10 is the best hospital possible, what number would you use to rate this hospital during your stay? 0 Worst hospital possible 10 Best hospital possible

35 Survey Questions Overall Rating of Hospital 22.Would you recommend this hospital to your friends and family? Definitely no Probably no Probably yes Definitely yes

36 Survey Questions About You 23.In general, how would you rate your overall health? Excellent Very good Good Fair Poor

37 Survey Questions About You 24.What is the highest grade or level of school that you have completed? 8 th grade or less Some high school, but did not graduate High school graduate or GED Some college or 2-year degree 4-year college graduate More than 4-year college degree

38 Survey Questions About You 25.Are you of Spanish, Hispanic or Latino origin or descent? No, not Spanish/Hispanic/Latino Yes, Puerto Rican Yes, Mexican, Mexican American, Chicano Yes, Cuban Yes, other Spanish/Hispanic/Latino

39 Survey Questions About You 26.What is your race? Please choose one or more. White Black or African American Asian Native Hawaiian or other Pacific Islander American Indian or Alaska Native

40 Survey Questions About You 27.What language do you mainly speak at home? English Spanish Chinese Russian Vietnamese Some other language (please print):

41 Expanded Version Survey Questions

42 Expanded Version Survey Questions During this hospital stay, staff took my preferences and those of my family or caregiver into account in deciding what my health care needs would be when I left. Strongly agree Disagree Agree Strongly Agree

43 Expanded Version Survey Questions 2 questions with scoring below Strongly agree Disagree Agree Strongly agree

44 Expanded Version Survey Questions When I left the hospital, I had a good understanding of the things I was responsible for in managing my health. When I left the hospital, I clearly understood the purpose for taking each of my medications. Another selection for no medications - I was not given any medication when I left the hospital

45 Expanded Version Survey Questions During this hospital stay, were you admitted to this hospital through the Emergency Room? Yes No

46 Expanded Version Survey Questions In general, how would you rate your overall mental or emotional health? Excellent Very good Good Fair Poor

47 Telephone Script

48 Telephone Script Overview Telephone interview script is provided to assist interviewers while attempting to reach the patient Script explains the purpose of the survey and confirms necessary information about the patient Interviewers must not conduct the survey with a proxy

49 HCAHPS and Public Reporting Four consecutive quarters of patient surveys CMS publishes HCAHPS results on Hospital Compare website four times per year Rolls the oldest quarter of patient surveys off and the newest quarter on each time A downloadable version of results is also available on the web site

50 CMS Scoring

51 Top Box Scoring HCAHPS results are publicly reported on Hospital Compare in groupings Top-box - Always Middle-box middle scores (could be 2 scores) Bottom-box Never

52 About HCAHPS Boxes Top-box - most positive response to survey questions Always for five composites (Communication with Nurses, Communication with Doctors, Responsiveness of Hospital Staff, Pain Management, and Communication about Medicines) two individual items (Cleanliness of Hospital Environment and Quietness of Hospital Environment) Yes for the sixth composite, Discharge Information, 9 or 10 (high) for the Overall Hospital Rating item Would definitely recommend - recommend the hospital item

53 HCAHPS Middle Boxes Intermediate responses Usually five composites (Communication with Nurses, Communication with Doctors, Responsiveness of Hospital Staff, Pain Management, and Communication about Medicines) and two individual items (Cleanliness of Hospital Environment and Quietness of Hospital Environment), 7 or 8 (medium) for the Overall Hospital Rating Would probably recommend for the Recommend the Hospital

54 HCAHPS Bottom Boxes Least positive response category for the measures Sometimes or never five composites (Communication with Nurses, Communication with Doctors, Responsiveness of Hospital Staff, Pain Management, and Communication about Medicines) and two individual items (Cleanliness of Hospital Environment and Quietness of Hospital Environment) No for the sixth composite, DC Information 6 or lower (low) for the Overall Hospital Rating Would not recommend - Recommend Hospital

55 Discharge Composite There is no middle-box response in the Discharge Information composite

HCAHPS Survey SURVEY INSTRUCTIONS

HCAHPS Survey SURVEY INSTRUCTIONS You should only fill out this survey if you were the patient during the hospital stay named in the cover letter. Do not fill out this survey if you were not the patient.