Questions and Answers From the Introduction to the ICH CAHPS Survey Webinar Training Session held on February 10-11, 2014

Transcription

1 Questions and Answers From the Introduction to the ICH CAHPS Survey Webinar Training Session held on February 10-11, 2014 ICH CAHPS Participation Requirements 1. Will CMS limit the number of approved survey vendors based on the size of the market? How many vendors does CMS plan on approving? A: No, CMS will not limit the number of survey vendors that will be approved to administer the ICH CAHPS survey. 2. If a hemodialysis facility serves only nursing home patients, is the facility required to administer the ICH CAHPS Survey? A: The ICH CAHPS Survey participation requirements were included in the proposed and final ESRD Prospective Payment System Rules for CY2014, which were published in the Federal Register on July 8, 2013, and December 3, 2013, respectively. ICH facilities that have questions about ICH CAHPS Survey participation requirements should send an to the ICH CAHPS Coordination Team. If an ICH facility asks a survey vendor about ICH CAHPS Survey participation requirements, the vendor should ask the facility to contact the ICH CAHPS Coordination Team. Sampling Procedures 3. Will CMS include the preferred language of the patient on the sample files? A: The preferred language spoken by hemodialysis patients is not available on the CROWNWeb database; therefore, it will not be included on the sample files. 4. Can survey vendors obtain the sample patients preferred language from the patient s ICH facility? Can survey vendors ask their ICH facility clients to provide updated addresses or telephone numbers for sample patients? A: ICH CAHPS Survey vendors cannot give the ICH facility a list of sample patients and ask the facility to provide the preferred language or to provide an updated address or telephone number for sample patients. However, survey vendors can ask the ICH facility to provide a list of all of the hemodialysis patients the facility served during the sampling window that contains those patients preferred language, address, and telephone number. To maintain and protect the identity of patients sampled, it is very important that survey vendors do not provide ICH facilities with any information about patients included in the ICH CAHPS Survey. 5. How is the number of ICH facilities for which a vendor receives sample data determined? A: ICH facilities must select and contract with a CMS-approved ICH CAHPS Survey vendor to collect and submit ICH CAHPS Survey data on its behalf. After contracting with a CMS-approved survey vendor, the ICH facility must complete the online Authorize a Vendor form, which is available on the ICH CAHPS website. Each survey vendor can view its own Vendor Authorization Report, which will be available on the ICH CAHPS website, to determine which of its ICH facility clients has completed the online Authorize a Vendor form. 6. In our experience on the Home Health Care CAHPS (HHCAHPS) Survey, a fair percentage of agencies do not upload patient information by the predetermined deadline. Will CMS follow up with ICH facilities to make sure that they provide patient-level information as required? A: The ICH CAHPS Coordination Team is not obtaining patient-level data needed for sampling directly from ICH facilities. The data source for the ICH CAHPS sampling frame is CROWNWeb. 1

2 7. What happens if a sample is not provided for one or more of a survey vendor s facility clients? A: The survey vendor should first check its Vendor Authorization Report to make sure that the facility has completed the online Authorize a Vendor Form. If the facility has authorized the vendor, the sample file that the vendor downloads will contain a sample for every facility (CCN) that has authorized the vendor to collect and submit data on its behalf. Some facilities, especially very small facilities, might not have any survey-eligible patients during a survey period. If that is the case, the sample file will show the ICH facility s CCN and name, and will indicate that 0 (zero) patients were sampled for that facility during the survey period. Survey Administration for Mail-Only, Phone-Only, and Mixed-Mode Surveys 8. Are there any limitations on the placement of supplemental questions on the survey? A: The specifications that apply to the placement of the ICH CAHPS supplemental questions and any facility-specific questions are described on Pages 35 and 36 of the ICH CAHPS Survey Administration and Specifications Manual, Version Should survey vendors send mail surveys in all five languages to all sample patients? A: ICH CAHPS Survey vendors must offer the survey in English in all data collection modes for which they are approved. Survey vendors can choose which of the other approved languages (Spanish, Simplified Chinese, Traditional Chinese, and Samoan) they will offer. Some ICH facilities, however, have patient populations whose primary language is not English and, to maximize survey response, might choose a survey vendor offering the approved language that most of its patients speak. 10. The specifications posted on the ICH CAHPS website last November indicated that survey vendors should make a maximum of five call attempts to complete the survey with a sample patient by telephone. In today s discussion you mentioned that the maximum number of call attempts is 10. Is that correct? A: Yes, the maximum number of call attempts that survey vendors should make to complete the survey is now 10. This requirement was changed based on the experience from the ICH CAHPS mode experiment. Survey vendors should keep in mind that hemodialysis patients are very ill, and five call attempts might not be sufficient to reach these patients because some may not feel well enough to participate in the survey when first contacted, and some may be hospitalized when first contacted. 11. If a patient asks a survey vendor not to contact him or her anymore, will that request be honored in subsequent survey periods? A: If the patient makes it clear that the survey vendor should never contact him or her again, survey vendors must honor that patient s request. Survey vendors should note, however, that the prenotification letter indicates that sample patients may be sampled again in the future; it is likely that patients who receive hemodialysis care from small ICH facilities will be sampled in a subsequent survey period. Patients included in the sample for two or more survey periods can choose whether they want to participate in the survey during each survey period. Survey vendors should make sure that they differentiate between sample patients who refuse to participate during a specific survey period and those who indicate that the survey vendor should never contact them again. If the sample patient refuses to participate during the current survey period but does not indicate that the vendor should never contact him or her again, the survey vendor should attempt to survey the patient if he or she is included in the sample in subsequent survey periods. 12. Is CMS looking into the possibility of using other data collection modes, such as an Internet or webbased survey, on the ICH CAHPS Survey? 2

3 A: CMS is very interested in whether different patient populations will and can respond to a web-based survey and is currently conducting some research to determine who responds to web-based surveys. CMS, however, does not plan to use a web-survey data collection option on the ICH CAHPS during the first few survey periods, but may consider or web-based surveys for some of its surveys in the future. Some patients, especially those who live in rural areas and some minority populations, do not have access to the Internet, so CMS must be careful to use data collection modes that would not exclude certain types of sample members from the survey. 13. You mentioned that you might make adjustments after the mode experiment is conducted. Will adjustments mean dropping any of the approved data collection modes? A: No, CMS does not plan to drop any of the approved data collection modes. 14. Can you please provide specifics describing the proper disposal of questionnaires per the last bullet on Slide 29 that was shown in Session II of the training session, which noted the following: Questionnaires received after the data collection period ends must be properly disposed of according to ICH CAHPS Survey protocols. A: Completed surveys that the vendor receives after the data collection period ends cannot be used. Survey vendors should make sure that the sample patient did not include any notes or comments on the questionnaire that can identify the sample member, and then shred the questionnaire. Data Processing and Coding 15. Some respondents will not mark a response category for a question that has an open-ended response option, but they will record an answer in the open-ended field. How should survey vendors handle this situation? A: If there is no response marked for any of the preprinted response options in a question that includes an open-ended entry, the vendor should assign the M Code to indicate Missing. It is up to the survey vendor to decide whether to key or scan open-ended entries. 16. Question 60a in the ICH CAHPS Survey questionnaire has Spanish as a preprinted response option, but does not include a preprinted response option for the other approved languages (Chinese and Samoan). If the respondent writes in one of these languages in the open-ended field and the vendor does not key the open-ended entries, CMS will not know what language is spoken in the home. Is there a reason you do not have the other languages shown as preprinted response options? A: The ICH CAHPS Coordination Team is in the process of revising the ICH CAHPS mail survey questionnaire to include preprinted response options in Question 60a for Chinese and Samoan. Note that the ICH CAHPS Survey cannot be administered by telephone survey in Chinese and Samoan. Therefore, the response options in Q60a in the telephone script posted on the ICH CAHPS website will not change. 17. Is there any chance that the ICH CAHPS Survey Questionnaire will change prior to the beginning of the CY2014 survey based on results of the mode experiment? A: As noted in the response to Question 15 above, CMS will add additional response options in Question 60a in the questionnaire. CMS may consider making some other minor changes to the ICH CAHPS Survey questionnaire. Survey vendors should note that the ICH CAHPS Survey will not be finalized until sometime in April The Coordination Team will post an announcement on the ICH CAHPS website and send an to approved survey vendors when the final ICH CAHPS Survey questionnaire has been posted on the website. 3

4 18. Which final disposition code should be assigned to a case in which the sample patient indicates that he or she has received hemodialysis at the sample facility for fewer than 3 months, but then marks an answer for some of the questions in the series Q3-Q44 but not enough for the case to pass the completeness criteria? A: Assign final disposition code 130 (Completed survey: eligibility unknown) to the case. Survey vendors should note that completed survey in this case is a misnomer. 19. On a mail survey, what code do you assign if the screener question is blank and all of the follow-up questions are also blank? A: Assign Code M to each question. 20. You mentioned that the survey vendor must print the sample patient s SID number on the questionnaire cover page. What should you do if the sample patient returns the questionnaire without a cover page, or marks through or defaces the SID number printed on the questionnaire? A: If the SID number is printed only on the cover page and the completed survey is returned without the cover page, the survey vendor has no way of matching the survey to the correct SID. Therefore, the completed survey cannot be used. That is, the survey responses cannot be included on the XML data file. The ICH CAHPS Coordination Team recommends that the survey vendor print the SID number on every page of the questionnaire or on every other page. Survey vendors should also consider printing the SID at the top and bottom of every page in the questionnaire or encrypting the SID number so that it is only readable by a bar code reader. 21. Please confirm that if the sample patient completes the telephone survey and then returns a completed mail survey, the survey vendor should keep data from the completed telephone survey. A: Per the specifications in Chapter IX in the ICH CAHPS Survey Administration and Specifications Manual, if a sample patient completes a telephone interview and then returns a completed mail survey, the survey vendor should use the survey with the most complete data, regardless of which survey was completed first. 22. If the survey is completed but we receive a note later that says the patient is deceased, do we keep the survey data? A: If there was no indication that the survey was completed by someone else (based on the response to Q65), keep the data. 23. There is no final disposition code to indicate that the survey was completed by a proxy respondent. How do we indicate that the survey was completed by a proxy respondent? A: Use of proxy respondents is not allowed on the ICH CAHPS Survey. If the survey was completed by mail, the Data Coordination Team will identify a case in which someone answered the questions for the respondent based on the answer to Q65. Data from those cases will not be included in data analysis. ICH CAHPS Survey Website 24. Can survey vendors sign up to receive automatic notifications whenever new announcements are posted on the ICH CAHPS website and when new information or links are added to the website? A: No, the system will not send automatic notifications when new information is posted on the ICH CAHPS website. The Coordination Team, however, will send the text of most of the announcements posted on the website to approved survey vendors via . The Quick Links box on the website 4

5 home page has a lightning bolt icon and will show the date of the most recent announcement that was posted. Survey vendors are encouraged to check the website on a frequent and routine basis to view announcements and new information posted on the website. 25. Is it possible to assign two back-up administrators on the ICH CAHPS website? A: Yes, there is no limit to the number of back-up administrators that can be assigned on the ICH CAHPS website. In fact, the Coordination Team recommends having two or more staff members designated as the back-up Survey Administrator. Reporting ICH CAHPS Survey Results 26. Will there be any results reported by CMS prior to the first public reporting? A: CMS will provide a Preview Report to ICH facilities so that they can review their own survey results before the results are published on the Dialysis Facility Compare on the Medicare.gov website. 27. Will there be a preview report after data for the 2014 ICH CAHPS Fall Survey are submitted? A: ICH CAHPS Survey results will not be publicly reported until after ICH CAHPS Survey data for two survey periods have been submitted. The first preview report that ICH facilities receive will contain survey results that are based on the first two survey periods (CY2014 Fall Survey and the CY2015 Spring Survey). Survey results from the ICH CAHPS Survey mode experiment will not be publicly reported. 5