Understand the current status of OAS CAHPS related to

Size: px

Start display at page:

Download "Understand the current status of OAS CAHPS related to"

Erica Bailey
6 years ago
Views:

August 25, 2017 Kathy Wilson, RN, MHA, LHRM Vice President, Quality AmSurg Objectives Understand the current status of OAS CAHPS related to the ASC Quality Reporting Program Describe the potential

1 August 25, 2017 Kathy Wilson, RN, MHA, LHRM Vice President, Quality AmSurg Objectives Understand the current status of OAS CAHPS related to the ASC Quality Reporting Program Describe the potential benefits of voluntary implementation Understand the role of the survey vendor in implementation Understand the role of the billing vendor in complying with requirements for data transfer Gain awareness of steps in implementation process 2 1

2 What is CAHPS? Consumer Assessment of Healthcare Providers and Systems Funded and overseen by the Agency for Healthcare Research and Quality (AHRQ) develop and maintain the surveys Family of surveys used to collect data from patients regarding their experiences during care CMS has already implemented in hospitals, home health agencies, hemodialysis facilities, group practices and hospice providers 3 What Is OAS CAHPS? Outpatient and Ambulatory Surgery Consumer Assessment of Healthcare Providers and Systems Has been in development since 2012 Total of 37 Questions (including Demographics). Experience questions are related to: preparation for surgery, check in and pre op processes, cleanliness and privacy, facility staff, including Anesthesia discharge preparation for recovery at home patient reported health outcomes (pain, nausea, bleeding and infection) Can add up to 15 supplemental questions 4 2

3 OAS CAHPS Development Development began Field test with 36 facilities Mode experiment to test effect of the various methodologies Final Rule published in November 5 Proposed Rule 7/13/17 Includes proposed changes to ASC Quality Reporting Program Open for comment until September 11 Final Rule in November Removal of 3 measures and addition of 3 measures AND Proposal to delay mandatory implementation of OAS CAHPS (delay linkage to payment), but continue voluntary implementation through 2018 Evaluate national survey data 251 ASC s reporting data to CMS Evaluate response rates of survey measures Evaluate cost burden Possibly decrease the number of questions Looking at web survey 6 3

4 Information from ASC Quality Collaboration Meeting 7/18/17 Patient input during the survey development process and cognitive testing: topics important to patients and way questions are asked Public Reporting: 3 Composite and 2 Global Translations available: English, Spanish, traditional and simplified Chinese, and Korean (can request additional languages) 23 Approved vendors Currently analyzing data 2,164 registered facilities 30% response rate 7 Why Are We Doing This? OAS CAHPS will be part of the CMS Quality Reporting Program for ASC s Will have comparative data with other ASC s and HOPD s Public posting format still to be determined, but most likely by domain Early adoption option allows time to identify improvement opportunities and course correct Data can be used to enhance patient experience 8 4

5 CMS Quality Measure Original ASC 15 a e: Five survey based measures derived from OAS CAHPS 3 Composite Measures Groups of Survey questions (domains) related to Facilities and Staff Communication about Procedure Preparation for Discharge and Recovery 2 Global Measures Using any number from 1 10, where 0 is the worst facility possible and 10 is the best facility possible, what number would you use to rate this facility? Would you recommend this facility to your friends and family? 9 Facilities and Staff Question How Question is Worded Options for Response 3 Did the check in process run smoothly? 4 Was the facility clean? 5 Were the clerks and receptionists as helpful as you thought they should be? 6 Did the clerks and receptionists treat you with courtesy and respect? Yes, definitely Yes, somewhat No 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? 10 5

6 Communication Question How Question is Worded Options for Response 1 Before your procedure, did your doctor or anyone from the facility give you all the information you needed about your procedure? 2 Before your procedure, did your doctor or anyone from the facility give you easy to understand instructions about getting ready for your procedure? 9 Did the doctors and nurses explain your procedure in a way that was easy to understand? 10 Were you given anesthesia? If no, skip 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? Yes, definitely Yes, somewhat No 11 Preparation for Discharge and Recovery If after leaving the facility, the patient reported having pain, nausea/vomiting, bleeding, or possible signs of infection as a result of the procedure or anesthesia, had the ASC staff given the patient information about what to do about it? Question How Question is Worded Options for Response 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? 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 and 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 or NO Yes, definitely Yes, somewhat No 12 6

7 Discharge and Recovery (cont.) Question How Question is Worded Options for Response 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? 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? 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 is you had possible signs of infection? Yes, definitely Yes, somewhat No 13 Scoring and Reporting Top Box Most positive response Yes, definitely for most questions For Overall Facility Rating, top box is 9 or 10 For Recommend Facility, Yes, Definitely is Top Box Middle Box Intermediate responses Yes, somewhat for most questions For Overall Facility Rating, middle box is 7 or 8 For Recommend Facility, middle box is Probably Yes Bottom Box Least positive response No for most questions For Overall Facility Rating, bottom box is 0 6 For Recommend Facility, bottom box is Definitely No and Probably No 14 7

Timeline Voluntary implementation 2016 2018 Mandatory implementation TBD First public data reporting One year later Payment impact Two years later 15 Payment Impact Part of the ASC Quality Reporting

8 Timeline Voluntary implementation Mandatory implementation TBD First public data reporting One year later Payment impact Two years later 15 Payment Impact Part of the ASC Quality Reporting Program Reimbursement impact currently tied with participation, not results (Pay for Reporting) Anticipate future Pay for Performance Non participation penalty: 2% reduction in Medicare payment update 16 8

Voluntary Early Adoption Do not have to report to CMS prior to mandatory implementation, but early reporting is an option As surgical volume shifts to outpatient setting, ability to

opportunities prior to public reporting Time to educate center staff and physicians about the survey and how they impact results 17 Regulatory Initiatives Driving Change Hospital CAHPS drove

9 Voluntary Early Adoption Do not have to report to CMS prior to mandatory implementation, but early reporting is an option As surgical volume shifts to outpatient setting, ability to differentiate center on publicly available quality and patient experience measures differentiates a center from other outpatient competitors Opportunity to identify performance improvement opportunities prior to public reporting Time to educate center staff and physicians about the survey and how they impact results 17 Regulatory Initiatives Driving Change Hospital CAHPS drove improvement and shifted distribution of percentile ranking Percentile Rank if 75% of patients rated hospital 9 or 10 Source: Press Ganey 18 9

10 Results during Voluntary Implementation Overall satisfaction generally lower on OAS CAHPS than previous survey Domains above 90% on Top Box: Communication except Anesthesia side effects Facility and Personnel Domain below 90% on Top Box: Discharge Recovery instructions, info on subsequent outcomes (pain, nausea/vomiting, bleeding, infection) 19 Sample Report Top Box Scores 4/1/17 6/30/17 QUESTION Freestanding ASC Benchmark Overall Patient Experience % Recommend the Facility 87.2% COMMUNICATION DOMAIN 91.6% Information about procedure 93.1% Preparation instructions 95.0% Procedure info easy to understand 93.9% Anesthesia info easy to understand 93.3% Anesthesia side effects understand 82.7% 20 10

Sample Report Top Box Scores 4/1/17 6/30/17 QUESTION FACILITY, PERSONAL TREATMENT DOMAIN Freestanding ASC Benchmark 97.3% Check in smooth 95.7% Facility clean 98.3% Clerks, receptionists helpful 96.

11 Sample Report Top Box Scores 4/1/17 6/30/17 QUESTION FACILITY, PERSONAL TREATMENT DOMAIN Freestanding ASC Benchmark 97.3% Check in smooth 95.7% Facility clean 98.3% Clerks, receptionists helpful 96.2% Clerks, receptionists courteous 97.6% Staff courtesy, respect 98.5% You were comfortable 97.5% DISCHARGE DOMAIN 79.20% Written discharge instructions 97.7% Recovery instructions 88.2% Subsequent pain information 88.6% Nausea information 68.7% Subsequent bleeding information 80.7% Response to infection information NA 21 Survey Administration Mandatory Methodology Standardized administration protocols Proposed minimum of 300 completed surveys within 12 month period If unable to meet 300, ASC will need to survey all patients Must use CMS approved vendor List of approved vendors on OAS CAHPS website 22 11

12 Approved Methodologies Mail only Two waves no later than 3 weeks after close of sample month, and then approximately 3 weeks later to nonrespondents Telephone only Start no later than 3 weeks after close of sample month Complete within 6 weeks No more than 5 attempts Mixed Mode mail survey with telephone follow up Start no later than 3 weeks after close of sample month Complete within 6 weeks 23 Sampling CMS proposes the following sample sizes to achieve 300 completed surveys in 12 month period (25 per month) Mode Mail (2 mailings) Completed Surveys per Month Estimated Response Rate Minimum Sample Calculation 25 32% 78 25/.32=78 Telephone 25 32% 78 25/.32=78 Mixed Mode Mail with Telephone Follow up 25 40% 63 25/.40=

13 Public Reporting Schedule OAS CAHPS survey data reported after 4 quarters of participation Publicly reported data will be refreshed quarterly Preview reports will be posted on CMS website prior to public posting Survey results will be from prior 12 months, and last quarter will drop off 25 Patient Eligibility Patients must meet the following Eligibility Requirements to be included in the survey: Had at least one outpatient surgery/procedure in the sample period which meet the procedure code requirements Is at least 18 years old at the time of surgery/procedure Has a U.S. domestic mailing address Has any type of insurance or payment (not limited to Medicare) 26 13

14 Patient Ineligibility Admitted as an inpatient following the surgery/procedure Deceased Discharged to hospice Prisoner Nursing home resident No publicity patient request that the ASC not release their name and contact information to anyone other than facility personnel Patients with specific illnesses or conditions for which state has regulations governing release of information 27 ASC Exemptions Exemption from requirement if treating fewer than 60 survey eligible patients Patient count for exemptions made at the CCN level Exemption form to be made available on OAS CAHPS website Exemption form must be submitted each year the facility wishes to be granted an exemption 28 14

Patient Communication about the Survey ASC s are permitted to communicate to patient: Written or verbal information prior to or after the procedure informing patient that they may be selected to

15 Patient Communication about the Survey ASC s are permitted to communicate to patient: Written or verbal information prior to or after the procedure informing patient that they may be selected to participate in a survey about their experience What the anticipated mode is 29 Prohibited Communication ASC s are prohibited from: Providing a copy of the survey or cover letter Sending information in advance, alerting patients about survey Including words or phrases from the survey in marketing materials Telling patients that the ASC hopes they will give them a high rating Offering any type of incentive or assistance Ask patient why a certain response Including messages or materials promoting the ASC or the services it provides in the survey materials, i.e. cover letter 30 15

16 Data Collection Monthly data collection File specifications provided by survey vendor core set of specifications for CMS Files uploaded to survey vendor on monthly basis must meet file specifications Must work with billing vendor to build report that meets the file specifications allow 3 5 weeks for approval Survey vendor then follows CMS defined process to pull patient names randomly from the file to administer survey 31 ASC Data Collection ASC Obtains File Specifications from Survey Vendor File Specifications provided to Billing Vendor Billing Vendor builds report per File Specifications Test File Uploaded to Survey Vendor Test File Approved ASC Uploads File per established schedule 32 16

Survey Vendor Must be approved by CMS Vendors complete initial and ongoing training Must follow standard OAS CAHPS Survey protocols and guidelines Must comply with security and confidentiality

17 Survey Vendor Must be approved by CMS Vendors complete initial and ongoing training Must follow standard OAS CAHPS Survey protocols and guidelines Must comply with security and confidentiality requirements Must be authorized by ASC to submit data to CMS on center s behalf Must develop and implement a Quality Assurance plan/undergo site visits and other reviews 33 Survey Vendor Selection Approved list of vendors Information/Approved Survey Vendors Cost Choose mode: Mail, Phone, Mixed Supplemental questions Availability of supplemental surveys What is their experience with ASC s? How large is their ASC database? What support resources are available and assigned to a center for implementation and ongoing support? What type of reports will be made available to the center and how are they accessed? 34 17

Supplemental Surveying Some vendors offer supplemental survey administration via email Must collect email address at registration Survey vendor administers CMS survey methodology first/then patients

18 Supplemental Surveying Some vendors offer supplemental survey administration via Must collect address at registration Survey vendor administers CMS survey methodology first/then patients with valid address are sent survey via Supplements number of survey returns 35 Billing Vendor Contact Billing vendor to determine knowledge level of OAS CAHPS Education regarding timelines Establish contact with account manager or other party who will assist in testing file specifications Determine if there are charges for: Initial report set up Monthly data file processing Capability of capturing Exclusions 36 18

19 Data Submission to CMS Center uploads file to survey vendor with patient data Survey vendor performs quality check on file/performs eligibility checks Survey vendor applies random sampling to select patients to be surveyed CMS (OAS CAHPS Survey Coordination Team) scrubs data Survey vendor transmits data to CMS Survey vendor compiles reports and transmits to ASC Data compiled for each ASC by CMS Preview report made available to ASC for 30 days via OAS CAHPS website OAS CAHPS scores are publicly reported on Hospital Compare Starting in January 2019 Patient survey completed Survey vendor collects data 37 Other Steps Required for Mandatory Reporting Designate an OAS CAHPS Survey Administrator for the center and register for log in credentials on OAS CAHPS website Complete CCN Registration (reporting done at CCN level) Authorize survey vendor to submit data on behalf of the center Prepare survey documents with survey vendor, i.e. cover letter with signature 38 19

Lessons Learned/Tips for Success Start early Research survey vendors to ensure good fit Develop budget Ensure exclusions are covered in Registration process Determine who should be on implementation

20 Lessons Learned/Tips for Success Start early Research survey vendors to ensure good fit Develop budget Ensure exclusions are covered in Registration process Determine who should be on implementation team Start with data analysis and improvements after one quarter of data (if before 2018 mandatory date) 39 Discharge Instructions Evaluate/revise discharge instructions for inclusion of information on nausea/vomiting, bleeding, pain and infection Make discharge instructions available to patient while waiting Review information with patient/family in pre op Review information on post op call 40 20

21 Revised Discharge Instructions 41 Anesthesia Communication Text Messaging Campaign 42 21

Staff Education about Survey Share survey with all staff and physicians Have staff take survey as if they were a patient at your center Include front office personnel and receptionists

22 Staff Education about Survey Share survey with all staff and physicians Have staff take survey as if they were a patient at your center Include front office personnel and receptionists they are a focus on the survey Anesthesia staff needs to understand the questions specific to them Share results and involve all affected areas in improvement planning 43 Posting Results 44 22

OAS CAHPS Resources OAS CAHPS News, Training, Survey Info, and the Federal Register Final Rule can be accessed at https://oascahps.

23 OAS CAHPS Resources OAS CAHPS News, Training, Survey Info, and the Federal Register Final Rule can be accessed at For additional OAS CAHPS questions, call toll free number: or oascahps@rti.org OAS CAHPS Survey and Guidelines Manual: Materials OAS CAHPS Register for Log In Credentials: Facilities/Register for Login Credentials Approved Survey Vendors: Information/Approved Survey Vendors 45 Kathy Wilson VP Quality, AmSurg Kathy.Wilson@amsurg.com (615)

FREQUENTLY ASKED QUESTIONS FOR HOSPITALS AND ASCS OAS CAHPS

FREQUENTLY ASKED QUESTIONS FOR HOSPITALS AND ASCS OAS CAHPS How do I know if my hospital or ASC is eligible to participate in the OAS CAHPS Survey? An eligible hospital has an outpatient surgery department