PRC EasyView Training HCAHPS Application By Denise Rabalais, Director Service Measurement & Improvement
PRCEasyView Web Address: https://www.prceasyview.com/vanderbilt Go to: My Studies HCAHPS C Master *CAHPS Application* Denise Rabalais 6-6066 Meredith Speight 6-6014 Denise Mitten 6-6067 2
HCAHPS Survey* * Scale = % Always, Usually, Sometimes, Never unless otherwise noted Communication with 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? Responsiveness of Hospital Staff 4. During this hospital stay, after you pressed the call button, how often did you get help as soon as you wanted it? 5. During this hospital stay, did you need help from nurses or other hospital staff in getting to the bathroom or in using a bedpan? 6. How often did you get help in getting to the bathroom or in using a bedpan as soon as you wanted? Communication with Doctors 7. During this hospital stay, how often did doctors treat you with courtesy and respect? 8. During this hospital stay, how often did doctors listen carefully to you? 9. During this hospital stay, how often did doctors explain things in a way you could understand? Cleanliness of Hospital Environment 10. During this hospital stay, how often were your room and bathroom kept clean? Quietness of Hospital Environment 11. During this hospital stay, how often was the area around your room quiet at night? Pain Management 12. During this hospital stay, did you need medicine for pain? (Yes/No) 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? Communication about Medicines 15. During this hospital stay, were you given any medicine that you had not taken before? (Yes/No) 16. Before giving you any new medicine, how often did hospital staff tell you what the medicine was for? 17. Before giving you any new medicine, how often did hospital staff describe possible side effects in a way you could understand? Discharge Information 18. After you left the hospital, did you go directly to your own home, to someone else s home, or to another health facility? 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) 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) Overall Hospital Rating 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? (0-10) Willingness to Recommend 22. Would you recommend this hospital to your friends and family? (Definitely Yes, Probably Yes, Probably No, Definitely No) 3
Element 0 10 20 30 40 50 60 70 80 90 95 100 Nurses Communicate Always 45 69 72 74 75 77 78 79 81 84 86 100 Doctors Communication Always 43 74 76 78 79 80 82 83 85 87 90 100 Staff Responsiveness - Always 16 54 57 60 62 64 66 68 72 77 81 99 Pain Management - Always 7 63 66 67 68 69 71 72 73 76 79 100 Medicine Communication - Always 17 54 56 58 59 61 62 64 66 69 73 100 Cleanliness - Always 27 62 65 68 70 71 73 75 78 82 85 97 Quiet - Always 28 46 50 53 55 58 61 64 67 72 77 100 Discharge Info - Yes 47 77 79 81 82 83 84 85 87 88 90 100 Overall - 9 and 10 2 57 61 64 66 68 70 72 75 79 83 100 Recommend - Definitely Yes 23 57 62 65 68 70 73 75 78 82 86 100 4
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HCAHPS Application in PRCEasyView Introductory Screen HCAHPS Trending Graphs Includes the most recent VUH data available (through current interviews) as well as historical trends for all domains as well as the individual survey questions. One of the selections will provide the VBP threshold level so the hospital can determine if they are equal to, above or below that level. HCAHPS Reports VUH results based on the current data in Hospital Compare. Reports show the % Always, Usually, Sometimes, or Never as well as the percentage above or below the State or National Average Compare Hospitals Includes all data from Hospital Compare for comparisons of VUH to all other facilities locally or across the US. Includes either state or national averages comparisons and percentile scores. HCAHPS Scorecard - Includes the data from Hospital Compare for comparisons of hospitals by domain within the same market as well as historical trending for a specified hospital. HCAHPS VBP Calculator The application includes VUMC current scores for both clinical and patient experience in the VBP performance period, compared to the baseline period, and how VUMC should focus efforts to improve the overall score. The VBP calculator also provides recommendations on areas of focus to improve the achievement, improvement and consistency scores that are part of the VBP calculation. 6
HCAHPS Trending Graphs Main Screen CCN Number identifier for a multiple hospital system to pull out the individual facility results. State, Nat l or VBP Threshold Compares our results to the state or national averages for the time period publicly reported. State and National averages may change from period to period. Results on Hospital Compare usually reported in 4 quarter increments and reported 9 months behind. Trend By Can be selected for any individual period and/or same period as is reported on Hospital Compare. Interviews to Show The default is to show the results that are reported by CMS. For the more recent interviews, they have not been publicly reported and the results may change somewhat by the time they are publicly reported. It is our best guess as to the results with case mix and mode adjustments applied. Reporting Composite Domain and individual questions, same as under Hospital, but allows you to change the questions after other filters have been set (such as trend by). 7
HCAHPS Domain Categories HCAHPS Domain Categories the domains from the HCAHPS survey that are reported on Hospital Compare. The individual questions that contribute to the domain scores are reported separately in this application, but are not reported on the Hospital Compare website or in the Hospital Compare application. 8
HCAHPS Reports First Screen Select time period(s) you want to view. Hold the CTRL button to select multiple periods. Check the Show Full PDF option to view the comparison charts. You can change the Main Title, Sub Title or time Periods Title. Click on Customize to edit each line. 9
HCAHPS Reports Preview Screen Select View Report and report will display. Title: HCAHPS Analysis Vanderbilt University Medical Center 10
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Compare Hospitals Filter Options Check the box next to the State(s) you want to filter by. Check the box next to the Cities, then Hospitals you want to filter by. 17
Compare Hospitals Hospital Data Select Add Hospitals. The data for each hospital chosen will populate at the bottom of the page. Report displays the % Always or top score percentages for each hospital selected by domain. Number in ( ) is the national percentile or state percentile score. The percentile scores are the national or state percentile scores in the HCAHPS database. Red Score is below the state or national average Green Score is at or above the state or national average Export Will export to Adobe or Excel. Adobe is preferable. The report also includes percentile graphs for each hospital selected (see attachment). Report Title: Compare Hospitals 18
Compare Hospitals Questions, Comparisons and Timeframe Questions Choose to omit domains. The default is for reporting on all HCAHPS domains Comparisons Select to report using State or National comparisons Timeframe Choose different timeframes. The default is the most recent on Hospital Compare You can select the Export To option to view the full report in an Excel or PDF format. 19
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HCAHPS Scorecard Filter Options HCAHPS Scorecard Select a State(s) to view for cities and hospitals. A ranking of all hospitals in that state(s) will be listed. The Graph Data menu at the top of the screen allows you to view data for each dimension. 24
You may also choose historical periods for one hospital. Click on the hospital s data bar, then Trending. Click on Back to Standard Graph to return to the previous graph with all of the hospitals listed. 25
Select All VBP Dimensions and the scores for all domains reported on Hospital Compare will view, as in the chart below. Select PowerPoint to export the chart to a PowerPoint slide. 26
HCAHPS VBP CALCULATOR FIRST SCREEN Click on performance period you wish to see. 27
HCAHPS VBP CALCULATOR HCAHPS Measures Summary of HCAHPS and Clinic scores 28
HCAHPS VBP CALCULATOR Clinical Measures 29
HCAHPS VBP CALCULATOR Outcome Measures 30
HCAHPS VBP CALCULATOR Efficiency Measures 31
HCAHPS VBP CALCULATOR What If s Reset Scores to original scores Move the sliding bars to signify an increase or decrease in the score for each dimension. The scores will change across the row as well as the Overall Scores below. 32
HCAHPS VBP CALCULATOR HCAHPS Score Details & Priorities HCAHPS Scoring Details shows individual data for each dimension including points earned. You can Export to PDF or PowerPoint. 33
HCAHPS VBP CALCULATOR HCAHPS Score Details & Priorities, Cont d 34
COMPLIANCE TRACKER Compliance Tracker is an application to be used with both the HCAHPS and Adult inpatient survey project results. This application allows the combining of the questions from the HCAHPS survey into the overall domain scores. To log into Compliance Tracker and pull data by unit: Select the Adult Inpatient project from the drop down Study Menu Select the HCAHPS Compliance Tracker Select GO 35
COMPLIANCE TRACKER First Page To select data at the unit level in Adult Inpatient, select Process Improvement. Select VBP/Public Reporting when you want to look at HCAHPS results at the hospital level. 36
COMPLIANCE TRACKER Process Improvement This is the view you will see when first accessing the unit specific portion of Compliance Tracker. The most recent period is visible. You will need to select the time period you need and the units you need. Please remember that the HCAHPS results do not include enough results by unit to be meaningful unless you select a large grouping of data. 37
COMPLIANCE TRACKER Set Time Period, Units and Questions Select Chart Options to choose the dimensions, areas and time periods to filter by. The latest VBP period is selected by default. Select the Apply button to set the changes made. When looking at adult inpatient results, you do NOT want to apply the mode and patient mix adjustments to the scores. Do not check the box applying these adjustments. These are only for HCAHPS scores. Select Chart Options again to close the menu. 38
COMPLIANCE TRACKER Report Example This is an example of a report from the adult inpatient study indicating the combined scores for the questions included within each domain. The application also color codes to indicate whether the score is at a high level or below the adjustment point level (in red). The Number of Surveys (n size) at the bottom are large enough to draw conclusions from the scores. If you see very small n sizes, you are probably looking at HCAHPS data instead of adult inpatient data. 39
COMPLIANCE TRACKER Exporting Data Data from Compliance Tracker can be exported in many formats. You can choose to Export to PDF, Excel or PowerPoint. 40
Reference Material 41
Program Requirements Overview This chapter describes the Program Requirements, which include the purpose of the CAHPS Hospital Survey (HCAHPS), use of HCAHPS with other hospital inpatient surveys, communicating with patients about the HCAHPS survey, roles and responsibilities for participating organizations, the Rules of Participation, and Minimum Survey Requirements to administer HCAHPS. The HCAHPS Rules of Participation listed below apply to hospitals self-administering the HCAHPS survey, hospitals administering the HCAHPS survey for multiple sites, and survey vendors. In addition, there are two different sets of Minimum Survey Requirements: one for self-administering hospitals, and one for survey vendors. A hospital self-administering the HCAHPS survey (without using a survey vendor) must meet the Self-administering Hospital Minimum Survey Requirements. Survey vendors and hospitals administering the HCAHPS survey for multiple sites must meet the Survey Vendor Minimum Survey Requirements. Purpose of the HCAHPS Survey The HCAHPS survey and its administration protocols are designed to produce standardized information about patients perspectives of care that allows objective and meaningful comparisons of hospitals on topics that are important to consumers. Public reporting of HCAHPS results creates incentives for hospitals to improve quality of care while enhancing accountability in healthcare by increasing transparency. In order to fulfill these goals, it is essential that, to the fullest extent possible: 1. Patients respond to the HCAHPS survey, and 2. Patients responses are informed only by the care they receive during the hospital stay CMS carefully developed the HCAHPS survey and its administration protocols to achieve the following outcomes. To increase the likelihood that patients will respond to the survey, HCAHPS should be the first survey patients receive about their experience of hospital care (for more information see Use of HCAHPS with Other Hospital Inpatient Surveys below) To ensure that responses to the HCAHPS survey are based on the patient s own experience of care, proxies are never permitted to respond to the survey To ensure that the patient s responses are unbiased and reflect only his or her experience of care, hospitals and survey vendors (and anyone acting on their behalf) must not attempt to influence how the patient responds to HCAHPS survey items (for more information see Communicating with Patients about the HCAHPS Survey below) Use of HCAHPS with Other Hospital Inpatient Surveys In this section, CMS provides guidelines to employ when asking patients questions regarding their hospital stay. CMS intent is to minimize the burden on patients and to prevent introducing bias to HCAHPS survey responses. In general, activities and encounters that are intended to provide or assess clinical care or promote patient/family well-being are permissible. 42
HCAHPS Fact Sheet (CAHPS Hospital Survey) May 2012 Overview The HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) Survey is the first national, standardized, publicly reported survey of patients' perspectives of hospital care. HCAHPS (pronounced H-caps ), also known as the CAHPS Hospital Survey*, is a 27-item survey instrument and data collection methodology for measuring patients perceptions of their hospital experience. While many hospitals have collected information on patient satisfaction for their own internal use, until HCAHPS there were no common metrics and no national standards for collecting and publicly reporting information about patient experience of care. Since 2008, HCAHPS has allowed valid comparisons to be made across hospitals locally, regionally and nationally. Three broad goals have shaped HCAHPS. First, the standardized survey and implementation protocol produce data that allow objective and meaningful comparisons of hospitals on topics that are important to consumers. Second, public reporting of HCAHPS results creates new incentives for hospitals to improve quality of care. Third, public reporting enhances accountability in health care by increasing transparency of the quality of hospital care provided in return for the public investment. With these goals in mind, the Centers for Medicare & Medicaid Services (CMS) and the HCAHPS Project Team have taken substantial steps to assure that the survey is credible, useful, and practical. HCAHPS Development, Testing and Endorsement Beginning in 2002, CMS partnered with the Agency for Healthcare Research and Quality (AHRQ), another agency in the federal Department of Health and Human Services, to develop and test the HCAHPS Survey. AHRQ carried out a rigorous and multi-faceted scientific process, including a public call for measures; literature review; cognitive interviews; consumer focus groups; stakeholder input; a three-state pilot test; extensive psychometric analyses; consumer testing; and numerous small-scale field tests. In addition, CMS provided three separate opportunities for the public to comment on HCAHPS, and responded to well over one thousand comments. In May 2005, the HCAHPS Survey was endorsed by the National Quality Forum, a national organization that represents the consensus of many healthcare providers, consumer groups, professional associations, purchasers, federal agencies, and research and quality organizations. In December 2005, the federal Office of Management and Budget gave its final approval for the national implementation of HCAHPS for public reporting purposes. CMS implemented the HCAHPS Survey in October 2006, and the first public reporting of HCAHPS results occurred in March 2008. The survey, its methodology and the results it produces are in the public domain. Enactment of the Deficit Reduction Act of 2005 created an additional incentive for acute care hospitals to participate in HCAHPS. Since July 2007, hospitals subject to the Inpatient Prospective Payment System (IPPS) annual payment update provisions ("subsection (d) hospitals") must collect and 43
submit HCAHPS data in order to receive their full annual payment update. IPPS hospitals that fail to publicly report the required quality measures, which include the HCAHPS Survey, may receive an annual payment update that is reduced by 2.0 percentage points. Non-IPPS hospitals, such as Critical Access Hospitals, may voluntarily participate in HCAHPS. The incentive for IPPS hospitals to improve patient experience of care was further strengthened by the Patient Protection and Affordable Care Act of 2010 (P.L. 111-148), which specifically included HCAHPS performance in the calculation of the value-based incentive payment in the Hospital Value-Based Purchasing program, beginning with discharges in October 2012; see below for more information about HCAHPS in Hospital VBP. HCAHPS Content and Survey Administration The HCAHPS Survey asks recently discharged patients about aspects of their hospital experience that they are uniquely suited to address. The core of the survey contains 18 items that ask how often or whether patients experienced a critical aspect of hospital care, rather than whether they were satisfied with the care. The survey also includes four items to direct patients to relevant questions, three items to adjust for the mix of patients across hospitals, and two items that support Congressionally-mandated reports. HCAHPS is administered to a random sample of adult inpatients between 48 hours and six weeks after discharge. Patients admitted in the medical, surgical and maternity care service lines are eligible for the survey; the survey is not restricted to Medicare beneficiaries. Hospitals may use an approved survey vendor, or collect their own HCAHPS data (if approved by CMS to do so). To accommodate hospitals, HCAHPS can be implemented in four different survey modes: mail, telephone, mail with telephone follow-up, or active interactive voice recognition (IVR), each of which requires multiple attempts to contact patients. Hospitals may use the HCAHPS Survey alone, or include additional questions after the core HCAHPS items. Hospitals must survey patients throughout each month of the year, and IPPS hospitals must achieve at least 300 completed surveys over four calendar quarters. HCAHPS is available in official English, Spanish, Chinese, Russian and Vietnamese versions. The survey itself and the protocols for sampling, data collection, coding and file submission can be found in the current HCAHPS Quality Assurance Guidelines manual, available on the official HCAHPS On- Line Web site, www.hcahpsonline.org. HCAHPS Measures Ten HCAHPS measures (six summary measures, two individual items and two global items) are publicly reported on the Hospital Compare Web site (www.hospitalcompare.hhs.gov) for each participating hospital. Each of the six summary measures, or composites, is constructed from two or three survey questions. Combining related questions into composites allows consumers to quickly review patient experience of care data and increases the statistical reliability of these measures. The six composites summarize how well nurses and doctors communicate with patients, how responsive hospital staff are to patients needs, how well hospital staff help patients manage pain, how well the staff communicates with patients about medicines, and whether key 44
information is provided at discharge. The two individual items address the cleanliness and quietness of patients rooms, while the two global items report patients overall rating of the hospital, and whether they would recommend the hospital to family and friends. Survey response rate and the number of completed surveys, in broad ranges, are also publicly reported. To ensure that publicly reported HCAHPS scores allow fair and accurate comparisons across hospitals, it is necessary to adjust for factors that are not directly related to hospital performance but which affect how patients answer HCAHPS Survey items. CMS and the HCAHPS Project Team apply adjustments that are intended to eliminate any advantage or disadvantage in scores that might result from the survey mode employed or from characteristics of patients that are beyond a hospital s control. In addition, the HCAHPS Project Team undertakes a series of quality oversight activities, including inspection of survey administration procedures, statistical analyses of submitted data, and site visits of HCAHPS survey vendors, to assure that the HCAHPS Survey is being administered according to protocols. HCAHPS and Public Reporting on Hospital Compare Publicly reported HCAHPS results are based on four consecutive quarters of patient surveys. CMS publishes HCAHPS results on the Hospital Compare Web site (www.hospitalcompare.hhs.gov) four times a year, rolling the oldest quarter of patient surveys off and the newest quarter on each time. A downloadable version of HCAHPS results is also available on this Web site. The first public reporting of HCAHPS results in March 2008 included 2,521 hospitals and 1.1 million completed surveys; the Spring 2012 public reporting entailed 3,851 hospitals and 2.8 million completed surveys. Summary analyses of HCAHPS scores are available on the HCAHPS On-Line Web site, www.hcahpsonline.org. This Web site houses tables that summarize current state and national HCAHPS results (and an archive of past results), top-box and bottom-box (which represent the most and least positive survey responses) percentiles for each HCAHPS measure, inter-correlations of the measures, charts that compare HCAHPS results by key hospital characteristics, and a bibliography of related research publications from the HCAHPS Project Team. HCAHPS On-Line, the official source of information for the HCAHPS program, also includes current news and upcoming events, training materials and survey instruments and implementation protocols. HCAHPS and Hospital Value-Based Purchasing The Hospital Value-Based Purchasing (Hospital VBP) program links a portion of IPPS hospitals' payment from CMS to performance on a set of quality measures. The Hospital VBP Total Performance Score (TPS) for FY 2013 has two components: the Clinical Process of Care Domain, which accounts for 70% of the TPS; and the Patient Experience of Care Domain, 30% of the TPS. The HCAHPS Survey is the basis of the Patient Experience of Care Domain. HCAHPS and Hospital VBP Scoring Eight HCAHPS measures are employed in Hospital VBP (these are termed dimensions in Hospital VBP): the six HCAHPS composites (Communication with Nurses, Communication with Doctors, Staff Responsiveness, Pain Management, Communication about Medicines, and Discharge Information); one new composite that combines the hospital Cleanliness and Quietness survey items; and one Global item (Overall Rating of Hospital). The percentage of a hospital s patients who chose 45
the most positive, or top-box, survey response in these HCAHPS dimensions is used to calculate the Patient Experience of Care Domain score. Hospital VBP utilizes HCAHPS scores from two time periods: a Baseline and a Performance Period. For FY 2013, the Baseline Period covers patients discharged from July 1, 2009 through March 31, 2010, and the Performance Period from July 1, 2011 through March 31, 2012. The Patient Experience of Care Domain score is comprised of two parts: the HCAHPS Base Score (maximum of 80 points) and the HCAHPS Consistency Points score (maximum of 20 points). Each of the eight HCAHPS dimensions contributes to the HCAHPS Base Score through either an Improvement or Achievement score. Improvement is the amount of change in an HCAHPS dimension from the earlier Baseline Period to the later Performance Period. Achievement is the comparison of each dimension in the Performance Period to the national median for that dimension during the Baseline Period. The larger of the Improvement or Achievement score for each dimension is used to calculate a hospital s HCAHPS Base Score. The second part of the Patient Experience of Care Domain is the Consistency Points score, which ranges from 0 to 20 points. Consistency Points are designed to target and further incentivize improvement in a hospital's lowest performing HCAHPS dimension. The Patient Experience of Care Domain Score is the sum of the HCAHPS Base Score (0 80 points) and HCAHPS Consistency Points score (0 20 points), thus ranges from 0 to 100 points, and comprises 30% of the Hospital VBP Total Performance Score. For More Information For more information about Hospital VBP, please visit CMS' dedicated Web site, http:// www.cms.gov/hospital-value-based-purchasing/. A slide set that describes the Hospital VBP program and its scoring in more detail can be found at http://www.cms.gov/hospital-value-based- Purchasing/Downloads/HospVBP_ODF_072711.pdf. In particular, slides 35 to 61 explain in detail the scoring of the Patient Experience of Care Domain (HCAHPS). To learn more about HCAHPS, including background information, policy updates, survey administration procedures, patient-mix and survey mode adjustments, training opportunities, and how to participate in the survey, please visit HCAHPS On-Line, at www.hcahpsonline.org. To Provide Comments or Ask Questions To communicate with CMS staff about HCAHPS: Hospitalcahps@cms.hhs.gov For technical assistance, contact the HCAHPS Project Team: hcahps@azqio.sdps.org or 1-888-884-4007 * CAHPS is a registered trademark of the Agency for Healthcare Research and Quality, a U.S. Government agency. 46
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HCAHPS Bulletin Number 2009-01 Revised The Use of HCAHPS in Conjunction with Other Hospital Inpatient Surveys During the February 2009 HCAHPS Training sessions, several questions were asked about the appropriate protocol for administering the HCAHPS survey in conjunction with other hospital inpatient surveys. In response, after training, the Centers for Medicare & Medicaid Services (CMS) and the HCAHPS Project Team (HPT) issued HCAHPS Bulletin 2009-01 to clarify this matter. Since the Bulletin s release in February, other issues and circumstances have been raised concerning what hospitals, and others acting on their behalf, should do when their regular patient care or other patient survey activities seem to conflict with HCAHPS protocols; see HCAHPS Quality Assurance Guidelines V4.0 (QAG V4.0), especially Communicating with Patients about the HCAHPS Survey, p. 15, for relevant survey protocols. In response, the HCAHPS Project Team has added clarifications to HCAHPS Bulletin Number 2009-01 Revised. Background The HCAHPS survey and its administration protocols are designed to produce standardized information about patients perspective of care that allow objective and meaningful comparisons of hospitals on topics that are important to consumers. Public reporting of HCAHPS results creates incentives for hospitals to improve quality of care while enhancing accountability in healthcare by increasing transparency. In order to fulfill these goals, it is essential that, to the fullest extent possible, 1. Patients respond to the HCAHPS survey, and 2. Patients responses are informed only by the care they received during the hospital stay. CMS carefully developed the HCAHPS survey and its administration protocols to achieve these outcomes. CMS and the HPT would like to reiterate the following key points: To increase the likelihood that patients respond to the survey, HCAHPS should be the first survey patients receive about their experience of hospital care. To ensure that responses to the HCAHPS survey are based on the patient s own experience of care, proxies are never permitted to respond to the survey. In general, activities and encounters that are intended to provide or assess clinical care or promote patient/family well-being are permissible. However, activities and encounters that are primarily intended to influence how patients, or which patients, respond to HCAHPS survey items should be avoided. 48
The following are specific clarifications to items in HCAHPS Bulletin Number 2009-01: 1. Inpatients should not be given any survey during their hospital stay or at the time of discharge. By survey, we mean a formal, HCAHPS-like, patient experience/satisfaction survey. A formal survey, regardless of the mode employed, is one in which the primary goal is to ask standardized questions of a significant portion of a hospital s patient population. Non-HCAHPS survey questions should avoid using HCAHPS-like response categories (for instance, Always, Usually, Sometimes, Never ). It is permissible for patients to be asked about their hospital experience during their hospital stay or during discharge calls where this is a normal part of clinical rounds, leadership rounds, or patient treatment/care activities. However, such questions should not resemble HCAHPS items or their response categories. The following are examples of the sort of questions that are NOT permissible. Did the nurses always answer your questions? On a scale of 0 to 10, how would you rate your hospital stay? Is there a way we could always have clear communications with you regarding your needs? 2. The HCAHPS survey should be administered prior to any other inpatient survey. As noted above, it is permissible for patients to be asked about their hospital experience during their hospital stay when the focus is on the care of the individual patient. The hospital or its agents must not seek to influence either which patients receive or how patients answer HCAHPS survey items. 3. The HCAHPS survey sample must be drawn prior to administration of any other hospital inpatient survey. Reminder: All discharged hospital inpatients who are eligible for the HCAHPS survey must be included in the HCAHPS sample frame. Patient-initiated or hospital-initiated (including the hospital s agents) contact, comment, response or communication, whether before, during or after the hospital stay, must not influence the likelihood of a patient receiving the HCAHPS survey. 4. Patients who were not randomly selected into the HCAHPS sample become eligible to receive a separate survey at any time after the HCAHPS sample has been drawn. If you would like additional information or clarification regarding this Bulletin or other HCAHPS items, please contact HCAHPS Technical Support via email at hcahps@azqio.sdps.org or via telephone at 1-888-884-4007. For more information on the HCAHPS Survey, please visit the HCAHPS Web site (www.hcahpsonline.org) and review the HCAHPS Quality Assurance Guidelines V4.0 found under the Quality Assurance navigation button on the web site. 49
HCAHPS Bulletin Number 2008-01 October 1, 2008 FROM: HCAHPS Project Team TO: HCAHPS Approved Survey Vendors, Self-administering Hospitals and Multi-site Hospitals RE: Calculation and Submission of Lag Time for the HCAHPS Survey INTRODUCTION The HCAHPS Project Team is instituting a new method of conveying timely information to all approved survey vendors, self-administering hospitals and multi-site hospitals participating in HCAHPS data collection and submission. HCAHPS Bulletins will be issued when the HCAHPS Project Team believes that clarification or correction is called for in key matters pertaining to data collection or submission. HCAHPS Bulletins may also be issued to announce important changes in survey administration, data submission, etc. HCAHPS Bulletins will be sent via email to the contact person of record at each approved survey vendor, self-administering hospital and multi-site hospital. It is the responsibility of this organizational contact to distribute this bulletin as appropriate to their staff, subcontractors or contracted hospitals. In addition, HCAHPS Bulletins will be posted on the HCAHPS website (www.hcahpsonline.org), and archived there as well for reference. Please be sure to notify the HCAHPS Project Team at hcahps@azqio.sdps.org of any changes or update to your contact person of record. It is incumbent upon all approved HCAHPS survey vendors, self-administering hospitals, and multi-site hospitals to promptly read all HCAHPS Bulletins, review their procedures for handling the matters addressed, and where necessary institute changes to comply with HCAHPS protocols. HCAHPS Project Team 2008-01 10/01/2008 Page 1 of 2 50
LAG TIME The inaugural HCAHPS Bulletin is issued to clarify the Lag Time variable in the Patient Administrative Data Record of the HCAHPS survey. In the course of oversight of HCAHPS, we have become aware of inconsistencies in the calculation and submission of this required variable. Please note the following clarifications: 1. A Patient Administrative Data Record is required for each patient sampled for the HCAHPS survey, whether or not the patient responded to the survey. Patients that were selected in the sample but then found to be ineligible prior to survey administration must still have a Patient Administrative Data Record Lag Time is a required element of the Patient Administrative Data Record Initial contact with sampled patients must occur between 48 hours and 42 days after discharge Data collection must be closed out no longer than 42 days after the initial contact 2. Lag Time is defined as The number of days between the patient s discharge from hospital and the return of the mail survey, or the final disposition of the telephone or IVR survey. The valid values for Lag Time are 000 to 365 If Lag Time is not applicable, it should be coded 888 3. Surveys that receive a Final Survey Status code of 1 Completed survey or 6 Non-response: Break-off must contain the actual lag time. These surveys should NOT be coded 888 for Lag Time 4. Surveys that receive a Final Survey Status code of 2, 3, 4, 5, 7, 8, 9, 10 or M (that is, any Final Survey Status code OTHER THAN 1 or 6) need not contain the actual lag time. Such surveys MAY use either the actual lag time, or 888 HCAHPS Project Team 2008-01 10/01/2008 Page 2 of 2 51
HCAHPS Publicly Reported Patient Experience Surveying HCAHPS BACKGROUND What does HCAHPS stand for? An acronym that stands for Hospital Consumer Assessment of Healthcare Providers and Systems. This survey measures the patient perception of their experience as an inpatient in an acute care hospital. Who requested that the survey be done? There was a desire to include HCAHPS in the Hospital Quality Alliance reporting initiative. There was a need for a standard survey to allow meaningful comparisons across hospitals. It would provide an incentive for hospitals to improve, and it elevated acceptance of the important of the patient s perspective on the quality of care. What are the goals of implementing HCAHPS? There are three main goals which have shaped HCAHPS. First, the survey is designed to produce data about patients perspectives of care that allow objective and meaningful comparisons of hospitals on topics that are important to consumers. Second, public reporting of the survey results creates new incentives for hospitals to improve quality of care. Third, public reporting serves to enhance public accountability in health care by increasing the transparency of the quality of hospital care provided in return for the public investment. With these goals in mind, the HCAHPS project has taken substantial steps to assure that the survey will be credible, useful, and practical. How is the survey fair when it looks at hospitals all over the country? To ensure that publicly reported HCAHPS scores allow fair and accurate comparisons across hospitals, it is necessary to adjust for factors that are not directly related to hospital performance but do affect how patients answer HCAHPS survey items. CMS performs adjustments that eliminate any advantage or disadvantage in scores that might result from which method was used to survey the patients, or characteristics of patients that are beyond a hospital s control. Why do hospitals participate with HCAHPS? Since July 2007, with the enactment of the Deficit Reduction Act of 2005, there has been an additional incentive for acute care hospitals to participate in HCAHPS. As part of CMS Reporting Hospital Quality Data Annual Payment Update (RHQDAPU) program, hospitals subject to IPPS payment provisions ("subsection (d) hospitals") must collect and submit HCAHPS data in order to receive their full Inpatient Prospective Payment System (IPPS) annual payment update (APU). IPPS hospitals that fail to report the required quality measures, which include the HCAHPS survey, may receive an annual payment update that is reduced by 2.0 percentage points. What does this survey tell me or how does it help me? It allows patients to compare hospitals based on a common set of experience based questions. These questions allow for objective and meaningful comparisons of hospitals on topics that are important to consumers. The survey serves to enhance public accountability in healthcare by increasing transparency of quality of hospital care. 52
ABOUT THE SURVEY How many respondents? How is the survey data collected from the respondents? The goal is for each hospital to get at least 300 completed patient surveys per year. In general, the more patients that respond to a hospital's survey, the more the results shown on this website will reflect the experiences of all the patients who used that hospital. Patients 18 years of age or older discharged from general acute care hospitals after an overnight stay. Patients are randomly selected to participate in the HCAHPS survey. Hospitals are not allowed to choose which patients are selected. HCAHPS survey data must be collected by organizations that are trained by the Federal government in HCAHPS survey data collection procedures. Hospitals can choose to conduct the survey in one of four ways: by mail, by telephone, by mail and telephone, or by active interactive voice recognition (IVR). Regardless of how the survey is conducted, all patients answer the same questions. Patients complete the HCAHPS survey after they leave the hospital. Are all departments/hospitals measured? Psychiatric, children's, rehabilitation and long-term care hospitals currently are not reported on this website, although many have agreed in principle to provide data using standard quality measures. This is due to the fact that the conditions currently measured -- care of adults with a heart attack, heart failure, or pneumonia or having surgery -- are less commonly treated in these settings. How often is the survey conducted? When will it be updated again? CMS first began collecting HCAHPS data for public reporting purposes in October 2006. In March 2008, CMS began to report HCAHPS results, using surveys of patients discharged from October 2006 through June 2007. Subsequently, HCAHPS results will be published quarterly and will be comprised of the most recent four quarters of data. How many questions are asked in each survey? The HCAHPS survey asks patients 27 questions about their hospital experience, including 18 items about key aspects of the hospital experience (communication with nurses and doctors, the responsiveness of hospital staff, cleanliness and quietness of hospital environment, pain management, communication about medicines, discharge information, overall rating of hospital, and recommendation of hospital). The survey also includes four items to direct patients to relevant questions, three to adjust for the mix of patients across hospitals, and two items that support congressionally-mandated reports. Why these questions? Where did they come from? The tool was created by the Center for Medicare and Medicaid Services (CMS) in cooperation with the Agency for Healthcare research and Quality (AHRQ). Interviews, focus groups, and public response were all used by the AHRQ in developing the tool. Consumer testing and a 3 state pilot test were also used. The survey was then endorsed by the National Quality Forum in May 2005. How long after being discharged from the hospital are patients surveyed? The HCAHPS survey is administered 48 hours to six weeks after discharge to a random sample of adult patients across medical conditions. 53
How often is the survey conducted? When will it be updated again? CMS first began collecting HCAHPS data for public reporting purposes in October 2006. In March 2008, CMS began to report HCAHPS results, using surveys of patients discharged from October 2006 through June 2007. Subsequently, HCAHPS results will be published quarterly and will be comprised of the most recent four quarters of data. Does it matter what insurance the patient has? Will everyone be surveyed regardless of insurance? The Centers for Medicare & Medicaid Services (CMS), along with its collaborators in the Hospital Quality Alliance (HQA) and the nation's hospitals are working together to create and publicly report hospital quality information. This information measures how well hospitals care for their adult patients, regardless of whether the care was paid for by Medicare, Medicaid or a private health insurance plan. Why these scales? This is an experienced based survey tool- measuring the frequency something occurs. My hospital also implements another survey that uses different scales (Excellent to Poor). How do the two scales differ? The majority of the HCAHPS questions have the scales: Always, Usually, Sometimes and Never. The questions on the adult inpatient survey have the scales: Excellent, Very Good, Good, Fair and Poor. The Excellent to Poor scale measures the satisfaction with an aspect of care or service while the Always to Never scale measures the frequency it occurred. There have been studies conducted on the relationship between the two question scales and it was determined that Excellent is a harder level to achieve than Always. So, hospitals that are focusing on being Excellent are also working to improve their Always scores. What is a quality measure? A quality measure is one way to see how well a hospital is caring for its patients. What languages is the survey currently available in? English, Spanish, and Chinese 54
ABOUT THE RESULTS Where can I find my hospital s results? www.hospitalcompare.hhs.gov How do I find my hospital s results? You can find your hospital s results by going to www.hospitalcompare.hhs.gov and clicking on Find and Compare Hospitals To find a particular hospital, click on Find and Compare Hospitals and then Begin Search on the next page (right side of page). You can locate your hospital by name, city, zip code, state, or county. You can then compare up to three hospitals to each other at a time. These results will also display the state and US averages with each set of hospitals. These results are updated each reporting period. Which question is the biggest indicator of patient satisfaction? According to the results, it seems that nursing communication is the biggest indicator of patient satisfaction. According to a 2005 HCAHPS survey report patients gave high ratings in response to questions about hospital care and communication with doctors and nurses. Patients also gave high to moderate responses to questions involving pain management. 55
What should I do if my hospital scores low in areas on the survey? If your hospital scores low in one particular section, rest assured that hospitals participating in HCAHPS are reviewing their low scores and making corrections to their problems. Hospitals care what their patients think and how each patient or patient s family views their hospital. These hospitals are committed to quality care and high standards of customer service. They want patients to return and to recommend them to others. Also, keep in mind that the dates of the results are somewhat in arrears so improvement in the scores may have occurred by the time the HCAHPS results are reported. What is the timeline for HCAHPS reporting and what data will be reported? 1st March 28, 2008 Oct 06-Jun 07 2 nd July 2008 Oct 06-Sept 07 3 rd September 2008 Jan 07-Dec 07 4 th December 2008 Apr 07-Mar 08 5 th March 2009 Jul 07-Jun 08 QUESTIONS AND COMMENTS Where can I learn more about HCAHPS? You can learn more about HCAHPS at www.hcahpsonline.org or at www.cms.hhs.gov /hospitalqualityinits/. Can I ask questions or make comments about HCAHPS? To communicate with CMS staff about HCAHPS, send your questions and comments to Hospitalcahps@cms.hhs.gov. 56