Outpatient and Ambulatory Surgery CAHPS ® Survey Protocols and Guidelines Manual Version 3.0 November 2018
Outpatient and Ambulatory Surgery CAHPS
® Survey
Protocols and Guidelines Manual
Version 3.0
November 2018
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Centers for Medicare & Medicaid Services i Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual
COMMUNICATIONS AND TECHNICAL SUPPORT FOR THE OUTPATIENT AND
AMBULATORY SURGERY CAHPS SURVEY
Hospital outpatient departments, ambulatory surgery centers, and survey vendors may use
the following resources to obtain information or technical support with any aspect of the
Outpatient and Ambulatory Surgery CAHPS Survey.
For general information, important news, updates, and all materials to support implementation of
the Outpatient and Ambulatory Surgery CAHPS Survey:
https://oascahps.org/
For technical assistance, contact the Outpatient and Ambulatory Surgery CAHPS Survey
Coordination Team as noted below.
By e-mail: [email protected]
By telephone: (866) 590-7468
Hospital outpatient departments, ambulatory surgery centers and Outpatient and Ambulatory
Surgery CAHPS (OAS CAHPS) Survey vendors must provide the facility’s name and CMS
Certification Number (CCN) when contacting the OAS CAHPS Survey Coordination Team by
e-mail or telephone for technical assistance.
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LIST OF ABBREVIATIONS AND ACRONYMS
OUTPATIENT AND AMBULATORY SURGERY CAHPS SURVEY PROTOCOLS AND
GUIDELINES MANUAL
Abbreviation/ Acronym Term/Phrase
AAPOR American Association for Public Opinion Research
AHRQ Agency for Healthcare Research and Quality
ASC Ambulatory surgery center
CAH Critical access hospital
CAHPS Consumer Assessment of Healthcare Providers and Systems
CATI Computer-assisted telephone interview
CCN CMS Certification Number (formerly known as the Medicare Provider
Number)
CMS Centers for Medicare & Medicaid Services
CPT Current Procedural Terminology1
DHHS Department of Health and Human Services
DSRS Disproportionate stratified random sampling
FAQ Frequently Asked Questions (a list of frequently asked questions and
suggested responses)
HCPCS Healthcare Common Procedure Coding System
HIPAA Health Insurance Portability and Accountability Act
HOPD Hospital outpatient department
IRB Institutional Review Board
MRN Medical Record Number
NCOA National Change of Address
NQF National Quality Forum
OAS CAHPS Outpatient and Ambulatory Surgery CAHPS Survey
OMB Office of Management and Budget
OPPS Outpatient Prospective Payment System
PHI Private health information
PII Personally identifiable information
PSRS Proportionate stratified random sampling
1 CPT only copyright 2019 American Medical Association. All rights reserved.
iv Centers for Medicare & Medicaid Services Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual
Abbreviation/ Acronym Term/Phrase
QAP Quality Assurance Plan
RAT-STATS Regional Advanced Techniques Staff Statistics Program
SAS Statistical Analysis System
SID Sample identification (number)
SRS Simple random sampling
SSS Stratified systematic sampling
XML Extensible Markup Language
Centers for Medicare & Medicaid Services v Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual
OUTPATIENT AND AMBULATORY SURGERY CAHPS SURVEY PROTOCOLS AND GUIDELINES MANUAL
TABLE OF CONTENTS
Communications and Technical Support for the Outpatient and Ambulatory
Surgery CAHPS Survey i
List of Abbreviations and Acronyms Outpatient and Ambulatory Surgery
CAHPS Survey Protocols and Guidelines Manual iii
I. Overview of the Contents of the Protocols and Guidelines Manual 1 Overview 1
Section-by-Section Contents of the Outpatient and Ambulatory Surgery CAHPS
Survey Protocols and Guidelines Manual 1
II. Introduction and Background 5 Overview of CAHPS Survey 5
Development of the OAS CAHPS Survey 7 Office of Management and Budget and Public Comment Process 7 OAS CAHPS Survey Instrument 7
OAS CAHPS Survey Data Collection and Public Reporting 8 Sources of Information About the OAS CAHPS Survey 9
III. Survey Participation Requirements 13
Overview 13 Roles and Responsibilities 13 Responsibilities of Both HOPDs/ASCs and Survey Vendors 20
Vendor Business Requirements 23
IV. Sampling Procedures 31
Overview 31 Step 1: Obtain a Monthly Patient Information File From Each Client HOPD or ASC
Under the Same CCN 34 Step 2: Examine the Monthly Patient Information File for Completeness and
Possible Duplication 44
Step 3: Identify Eligible Patients and Construct a Sampling Frame 45 Step 4: Determine the Sampling Method Most Appropriate for the OAS CAHPS
Survey for This CCN 47 Step 5: Determine the Ideal Sample Size, Calculate the Sampling Rate, and Select
the Sample 49 Step 6: Verify or Update Contact Information for Sampled Patients 59 Step 7: Assign Unique Sample Identification Numbers 60
Step 8: Finalize the Monthly Sample File and Initiate Data Collection Activities 60 Sampling Issues and Errors 61
OUTPATIENT AND AMBULATORY SURGERY CAHPS SURVEY PROTOCOLS AND GUIDELINES MANUAL
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vi Centers for Medicare & Medicaid Services Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual
V. Mail-Only Administration Procedures 67 Overview 67 Data Collection Schedule 67 Questionnaires, Letters, and Envelopes 68 Mailing Requirements and Recommendations 73
Data Receipt, Data Entry, and Optical Scanning Requirements 75 Staff Training 77 Quality Control Guidelines for Mail-Only Survey 78
VI. Telephone-Only Administration Procedures 81
Overview 81
Data Collection Schedule 81
Telephone Interview Development Process 82 Telephone Interviewing Requirements 84
Telephone Interviewer Training 88 Telephone Data Processing Procedures 89 Telephone-Only Quality Control Guidelines 90
VII. Mail with Telephone Follow-Up (Mixed-Mode) Survey Administration
Procedures 93
Overview 93 Data Collection Schedule 93
Questionnaires, Letters, and Envelopes 94 Data Receipt, Data Entry, and Optical Scanning Requirements 100
Staff Training 102 Telephone Interview Development Process 103 Telephone Interviewing Requirements and Recommendations 105
Interviewer Training 109
Telephone Data Processing Procedures 110 Mixed-Mode Quality Control Guidelines 111
VIII. Confidentiality and Data Security 115 Overview 115 Safeguarding Patient Data 115
Confidentiality Agreements 119 Physical and Electronic Data Security 119 Communicating With Sample Members About Confidentiality and Security 120
IX. Data Processing and Coding 123 Overview 123 Sample Identification Numbers 123 Data Processing Decision Rules and Coding Guidelines – Mail Surveys 124
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Data Processing Decision Rules and Coding Guidelines – Telephone Surveys 128 Survey Disposition Codes 129 Definition of a Completed Survey or Survey Completion Criteria 129
Handling Blank Questionnaires 134 Handling Proxy Cases 134 Quality Control Measures 135 Computing the Response Rate 138
X. The OAS CAHPS Survey Website 141
Overview 141
The OAS CAHPS Website 141 System and Security Requirements for the OAS CAHPS Website 159
XI. File Preparation and Data Submission 165 Overview 165
Quarterly Data Submission Deadlines 165 Data File Preparation 165 Step 1: Format and Clean Survey Data Following the XML File Specifications 166
XML Data File Specifications 166 Step 2: Data File Submission 173
Step 3: Review and Follow Up on Data Upload Reports 175 Potential Situations When Vendors Will Not Submit Data 175
Data Submission Quality Control 177
XII. Website Reports 181
Overview 181 Reports for Survey Vendors 181 Reports for HOPDs and ASCs 184
XIII. Oversight Activities 187
Overview 187 Quality Assurance Plan 187 Data Review 188 Communication Between Survey Vendors and the OAS CAHPS Survey
Coordination Team 189
Site Visits to Survey Vendors 189 Corrective Action Plans 191
XIV. Public Reporting 193 Overview 193
OAS CAHPS Survey Measures 193 Adjustment and Reporting of Results 195 Star Ratings 197
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Facility Preview Reports 198 Public Reporting Periods 198
XV. Exceptions Request Process and Discrepancy Notification Report 201
Overview 201 Exceptions Request Process 201
Displaying HOPD/ASC’s Name and/or Logo on Outgoing Envelopes 205 Review Process 206 Discrepancy Notification Report 206 Discrepancy Report Review Process 209
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Appendix A: Vendor Application Form
Appendix B: English: Mail Survey Cover Letters, Mail Questionnaires,
Instructions for Scannable Mail Questionnaire, Telephone
Interview Script
Appendix C: Spanish: Mail Survey Cover Letters, Mail Questionnaires,
Instructions for Scannable Mail Questionnaire, Telephone
Interview Script
Appendix D: Chinese: Mail Survey Cover Letters, Mail Questionnaires,
Instructions for Scannable Mail Questionnaire
Appendix E: Korean: Mail Survey Cover Letters, Mail Questionnaire, and
Instructions for Scannable Mail Questionnaire
Appendix F: Consent to Share Identifying Information Question
Appendix G: OMB Paperwork Reduction Act Language
Appendix H: Frequently Asked Questions for Telephone Interviewers
(English)
Appendix I: Frequently Asked Questions for Telephone Interviews
(Spanish)
Appendix J: General Guidelines for Telephone Interviewers
Appendix K: XML Data File Layout for Standard Header Record
Appendix L: XML Data File Layout for Disproportionate Stratified
Random Sampling (DSRS) Header Record
Appendix M: XML Data File Layout for Zero Sampled File
Appendix N: Model Quality Assurance Plan (QAP) Outline
Appendix O: Exceptions Request Form
Appendix P: Discrepancy Notification Report
Appendix Q: Excluded Procedural Codes
Appendix R: Example Patient File Layout
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Exhibits
Exhibit 9.1 Steps for Determining Whether a Questionnaire Meets Completeness
Criteria 130
Exhibit 9.2 How to Determine a Proxy Case 135
Exhibit 9.3 How Response Rates Are Calculated 139
Exhibit 10.1 OAS CAHPS Website Diagram 142
Exhibit 10.2 OAS CAHPS Home Page (Public Website) 143
Exhibit 10.3 Announcements Page on the OAS CAHPS Website 145
Exhibit 10.4 Recent Announcements Section on the OAS CAHPS Website Home Page 146
Exhibit 10.5 Facility Administrator Registration Form 148
Exhibit 10.6 Facility CCN Registration Form 149
Exhibit 10.7 Manage Users Console 151
Exhibit 10.8 User Details Form 151
Exhibit 10.9 Pending Access Requests from Facility Dashboard 152
Exhibit 10.10 Vendor Registration Form 156
Exhibit 10.11 Facility Dashboard Page 158
Exhibit 10.12 Vendor Dashboard Page 159
Exhibit 11.1 Link to Data Submission Tool 174
Exhibit 11.2 Uploading Multiple Files 175
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Tables
Table 4.1 Information Needed From HOPDs/ASCs for Patient Served During Sample
Month 36
Table 4.2 Response Rates Obtained by Mode Anticipated for OAS CAHPS 49
Table 5.1 Mail-Only Administration Schedule and Protocol 67
Table 6.1 Telephone-Only Administration Schedule and Protocol 81
Table 7.1 Tasks and Schedule of Activities for Mail with Telephone Follow-Up 93
Table 9.1 OAS CAHPS Survey Disposition Codes 130
Table 14.1 Crosswalk of Composite Measures and Global Ratings 197
Table 14.2 Data Submission Deadlines Linked to the Public Reporting Period 199
Table 15.1 Example Scenarios of Various Discrepancy Reasons 208
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Centers for Medicare & Medicaid Services 1 Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual
I. OVERVIEW OF THE CONTENTS OF THE PROTOCOLS AND GUIDELINES MANUAL
Overview
The Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual has
been developed by the Centers for Medicare & Medicaid Services (CMS) to provide guidance
and standard protocols for conducting the Outpatient and Ambulatory Surgery Consumer
Assessment of Healthcare Providers and Systems (CAHPS®) Survey, hereafter referred to as the
“OAS CAHPS Survey.” The OAS CAHPS Survey measures the experiences of patients who
receive outpatient or ambulatory services from hospital outpatient departments (HOPDs) and
ambulatory surgery centers (ASCs). This section provides survey vendors, HOPDs, and ASCs
with a top-level view of the contents of this manual. Each section is briefly described below,
along with an explanation of the contents of the appendices.
Section-by-Section Contents of the Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual
II. Introduction and Background
The Introduction and Background chapter provides information about the purpose of the OAS
CAHPS Survey and history of the OAS CAHPS Survey initiative, including a discussion of the
instrument development and pilot test activities. It also includes information about the public
reporting timeline and sources for more information about the OAS CAHPS Survey.
III. OAS CAHPS Survey Participation Requirements
This chapter describes the roles and responsibilities of CMS, the OAS CAHPS Survey
Coordination Team, HOPDs and ASCs, and approved survey vendors. It also includes
information on the vendor rules of participation and business requirements for becoming an
approved survey vendor. Information about how to communicate with and obtain technical
assistance from the Coordination Team is also provided in the OAS CAHPS Survey Participation
Requirements chapter.
IV. Sampling Procedures
This chapter describes the sampling process for the OAS CAHPS Survey. It includes
requirements for developing the sample frame of eligible patients from HOPDs and ASCs and
the method to be followed in selecting the sample of patients.
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2 Centers for Medicare & Medicaid Services Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual
V. Mail-Only Administration Procedures
The Mail-Only Administration Procedures chapter contains the protocols and guidelines for
administering the OAS CAHPS Survey as a mail-only survey. The data collection schedule,
production and mailing requirements, data receipt and processing requirements, and quality
control guidelines associated with conducting a mail-only mode survey are covered in detail.
VI. Telephone-Only Administration Procedures
Procedures and guidelines for administering the OAS CAHPS Survey as a telephone-only survey
are provided in the Telephone-Only Administration Procedures chapter. The data collection
schedule, electronic data collection and tracking system, telephone interviewing requirements,
and quality control guidelines associated with conducting a telephone-only mode survey are
covered in detail.
VII. Mixed-Mode Administration Procedures
The Mixed-Mode Administration Procedures chapter contains the protocols and guidelines for
administering the OAS CAHPS Survey as a mixed-mode survey—that is, mail survey with
telephone follow-up of nonrespondents. The data collection schedule, production and mailing
requirements, electronic data collection and tracking system, telephone interviewing
requirements, data receipt and processing requirements, and quality control for conducting a
mixed-mode survey are covered in detail.
VIII. Confidentiality and Data Security
The requirements and guidelines for protecting the identity of sample members, confidentiality
of respondent data, ensuring data security, instructions for handling confidential data, and the
importance of confidentiality agreements are covered in this chapter. The importance of
establishing and maintaining physical and electronic data security, and explaining these measures
to sample members, is also covered.
IX. Data Processing and Coding
Data processing procedures, including the assignment of a unique sample identification number
to each sampled case, decision rules for assigning survey disposition codes, quality control
measures, and the definition of a completed survey are described in the Data Processing and
Coding chapter.
X. OAS CAHPS Survey Website
The OAS CAHPS Survey Website chapter provides detailed information about the OAS CAHPS
Survey website and the data submission process, including screenshots of the data submission
tool and instructions for data submission.
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XI. File Preparation and Submission
The File Preparation and Submission chapter provides an overview of the purpose and functions
of the OAS CAHPS Survey website and a summary description of how to prepare and submit
data files following OAS CAHPS Survey data file preparation and submission guidelines. More
detailed information about the OAS CAHPS Survey website and the data submission process,
including screenshots of the data submission tool and instructions for data submission, is
included in the OAS CAHPS Survey Website User and Data Submission Manual, Version 2.0.
XII. OAS CAHPS Survey Website Reports
The OAS CAHPS Survey Website Reports chapter provides an overview of the reports available
to vendors and HOPDs and ASCs through the OAS CAHPS Survey website. The reports are
briefly described, with an emphasis on the intended audience for each report and how the reports
should be used.
XIII. Oversight Activities
The Oversight Activities chapter provides information about the quality assurance activities that
the OAS CAHPS Survey Coordination Team and CMS take to ensure the successful
administration of the OAS CAHPS Survey by survey vendors. The chapter begins with a
discussion of the vendor Quality Assurance Plan and reviews the various activities that the
Coordination Team conducts to ensure compliance with OAS CAHPS Survey protocols and
guidelines.
XIV. Public Reporting
The Public Reporting chapter presents an overview of the public reporting of OAS CAHPS
Survey results, including the composite measures and global items that are publicly reported,
patient-mix adjustments, preview reports, and public reporting periods.
XV. Exceptions Request Process and Discrepancy Notification Report
The Exceptions Request Process and Discrepancy Notification Report chapter describes the
process used to request an exception to the OAS CAHPS Survey protocols, including guidelines
for submitting an Exceptions Request Form. This section also covers the process for alerting the
OAS CAHPS Survey Coordination Team of an unplanned discrepancy in data collection
procedures.
Appendices
The appendices contain copies of the Vendor Application, questionnaires, cover letters and
telephone interview script (in English and other languages), the optional Consent to Share
Identifying Information Question, Office of Management and Budget (OMB) approval
statement, frequently asked questions for telephone interviewers, general guidelines for
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4 Centers for Medicare & Medicaid Services Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual
telephone interviewers, XML data file layout for standard Header Record, XML data file layout
for disproportionate stratified random sampling, XML data file layout for zero sampled patient
file, Quality Assurance Plan instructions, Exception Request Form, Discrepancy Notification
Report, list of procedural codes excluded from the OAS CAHPS Survey, and example patient
file layout.
The Outpatient and Ambulatory Surgery CAHPS Survey Protocols and
Guidelines Manual
An electronic file of the Outpatient and Ambulatory Surgery CAHPS Survey Protocols and
Guidelines Manual and its appendices are available on the project website at
https://oascahps.org/ . Organizations can request a hardcopy manual by sending an e-mail to the
Coordination Team at [email protected].
Centers for Medicare & Medicaid Services 5 Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual
II. INTRODUCTION AND BACKGROUND
Overview of CAHPS Survey
The Centers for Medicare & Medicaid Services (CMS) has partnered with the Agency for
Healthcare Research and Quality (AHRQ), another agency within the United States Department
of Health and Human Services, to develop surveys measuring patient perspectives of care.
Beginning in 1995 as part of the Consumer Assessment of Healthcare Providers and Systems
(CAHPS) initiative, AHRQ and its CAHPS grantees began to develop surveys focusing on
patient experiences with their healthcare. Since 1995, the initiative has expanded to cover a range
of surveys of health care services at multiple levels of the delivery system, including patients
receiving care from both ambulatory and institutional settings. The intent of the CAHPS
initiative is to provide a standardized survey instrument and data collection methodology for
measuring patients’ perspectives on patient care. CAHPS is meant to complement the data that
providers collect to support improvements in internal customer services and quality-related
activities.
The Outpatient and Ambulatory Surgery CAHPS (OAS CAHPS) Quality
Initiative
In November 2002, the Quality Initiative was launched to ensure quality health care for all
Americans through accountability and public disclosure. The initiative aims to (a) empower
consumers with quality of care information to help them make more informed decisions about
their health care, and (b) stimulate and support providers and clinicians to improve the quality of
health care.2 The Quality Initiative was launched nationally in November 2002 for nursing
homes (the Nursing Home Quality Initiative) and expanded in 2003 to the nation’s home health
care facilities (the Home Health Quality Initiative) and hospitals (the Hospital Quality Initiative).
This Quality Initiative is continuing for hospital outpatient departments (HOPDs) and
ambulatory surgery centers (ASCs) through the national implementation of OAS CAHPS.3
2 Centers for Medicare & Medicaid Services. http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-
Instruments/QualityInitiativesGenInfo/index.html. Also http://www.cms.gov/Research-Statistics-Data-and-
Systems/Research/CAHPS/index.html 3 http://cms.hhs.gov/Research-Statistics-Data-and-Systems/Research/CAHPS/OAS-CAHPS.html
II. Introduction and Background November 2018
6 Centers for Medicare & Medicaid Services Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual
Definition of HOPD and ASC
An HOPD is an outpatient surgery department or specialized department of a hospital that
performs outpatient surgeries and procedures. A hospital is eligible to participate in the OAS
CAHPS Survey if it has an HOPD or any department that meets all of the following criteria:
• performs procedures that are within the OAS CAHPS–eligible range of CPT-44 Codes for
Surgery (i.e., CPT codes between 10021 and 69990) or one of the following G-codes:
G0104, G0105, G0121, or G0260;
• is Medicare-certified and has a CMS Certification Number (CCN);
• bills under the Outpatient Payment Prospective System (OPPS) using CMS-1450 claim
form for provider-based offices (not CMS-1500 claim form used for the Physician Fee
Schedule), with the exclusion of emergency department procedures; and
• has an agreement with CMS and meets the general conditions and requirements in
accordance with 42 CFR 419 subpart B.
Critical access hospitals (CAHs) are also eligible for OAS CAHPS even though CAHs do not
bill under OPPS; however, participation for CAHs is voluntary.
An ASC is a freestanding medical facility that performs outpatient surgeries and procedures.
CMS specifically defines eligible ASCs as distinct entities that operate exclusively for the
purpose of furnishing outpatient services to patients. An ASC is eligible to participate in the
OAS CAHPS Survey if it meets all of the following criteria:
• performs procedures that are within the OAS CAHPS–eligible range of CPT-45 Codes for
Surgery (i.e., CPT codes between 10021 and 69990) or one of the following G-codes:
G0104, G0105, G0121, or G0260;
• is Medicare-certified and has a CCN;
• bills under ASC Payment System; and
• has an agreement with CMS and meets the general conditions and requirements in
accordance with 42 CFR 416 subpart B.
4 Current Procedural Terminology (CPT) is a registered trademark of the American Medical Association. CPT only
copyright 2019 American Medical Association. All rights reserved. 5 CPT only copyright 2019 American Medical Association. All rights reserved.
November 2018 II. Introduction and Background
Centers for Medicare & Medicaid Services 7 Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual
Some ASCs have more than one location, typically in a geographic region.
Development of the OAS CAHPS Survey
The OAS CAHPS Survey seeks to provide information about patients’ perception of the care
they receive from Medicare-certified HOPDs and ASCs. The OAS CAHPS development began
in 2012. The survey development process followed the principles and guidelines outlined by
AHRQ and its CAHPS® Consortium in developing a patient experience of care survey.
Development included reviewing surveys submitted as a result of a public call for measures,
reviewing existing literature, conducting focus groups with patients who had recent outpatient
surgery, conducting cognitive interviews with patients to test their understanding and ability to
answer the questions, obtaining stakeholder input on the draft survey and other issues that may
affect implementation, and conducting a field test. The goal of the survey development contract
was to identify and include dimensions of care that patients and other consumers want or need to
inform their choice of an outpatient surgery department/center.
A field test was conducted in the summer of 2014 with 36 facilities (18 HOPDs and 18 ASCs) to
test the reliability and validity of the survey items and implementation procedures. Based on the
field test findings, the survey instrument was revised and finalized.
After the survey instrument was finalized, a mode experiment was conducted in 2015. The
objective of the mode experiment was to test the effect on survey responses using three data
collection modes: mail only, telephone only, and mixed mode (mail with telephone follow-up of
nonrespondents). CMS also used data from the mode experiment to determine whether and to
what extent characteristics of patients participating statistically influence OAS CAHPS Survey
results. Statistical models were developed to adjust or control for these patient characteristics
before the survey results were reported to participating facilities. Data from the mode experiment
were also analyzed to detect potential nonresponse bias; the results of these analyses determined
whether applicable nonresponse statistical adjustments must be made on the OAS CAHPS
Survey data.
Office of Management and Budget and Public Comment Process
CMS received approval of the OAS CAHPS Survey from the United States Office of
Management and Budget with control number 0938-1240.
OAS CAHPS Survey Instrument
The OAS CAHPS Survey instrument contains 37 items that cover topics such as access to care,
communications, and experience of the facility and interactions with facility staff. There are two
global items: one asks the patient to rate the care provided by the HOPD or ASC, and the second
asks the patient about his or her willingness to recommend the HOPD or ASC to family and
friends. The survey also contains items that ask for self-reported health status and basic
II. Introduction and Background November 2018
8 Centers for Medicare & Medicaid Services Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual
demographic information (race/ethnicity, education attainment level, language spoken in the
home, etc.).
The OAS CAHPS Survey is currently available in English, Spanish, Chinese, and Korean. A
version is provided for both mail and telephone survey administration modes on the OAS
CAHPS Survey website. HOPDs and ASCs and their survey vendors will not be permitted to
translate the OAS CAHPS Survey into any other languages. CMS will provide additional
translations over time based on the language needs of patients. Please check the OAS CAHPS
Survey website, https://oascahps.org/ , for announcements about additional translations.
OAS CAHPS Survey Data Collection and Public Reporting
Starting in January 2016, Medicare-certified HOPDs and ASCs were invited to submit data on a
voluntary basis for national implementation of the OAS CAHPS Survey. Interested facilities
contract with survey vendors to conduct the survey on their behalf. Survey vendors interested in
administering the OAS CAHPS Survey must meet a set of minimum business requirements,
complete and submit an application, attend OAS CAHPS Survey training sessions, complete and
pass a Training Certification, and participate in all update trainings sponsored by CMS. Survey
vendors cannot collect and submit data to CMS until they receive approval to conduct the survey.
Following each quarter of survey data collection, vendors submit the survey data they collected
using the data submission tool function on the OAS CAHPS Survey website
(https://oascahps.org/ ). The data submitted are reviewed, cleaned, scored, and adjusted by the
OAS CAHPS Survey Coordination Team. Survey results are compiled for each HOPD and ASC.
Public reporting includes four rolling quarters of data; the publicly available results during
voluntary participation are published on Hospital Compare and data.medicare.gov. Before the
data are publicly reported a “preview” report containing the individual results is made available
to each facility for review through the OAS CAHPS Survey website.
The Proposed Rule for the Hospital Outpatient Prospective Payment and Ambulatory Surgical
Center Payment Systems and Quality Reporting Programs was published in the Federal Register
on July 30, 2018 (Federal Register/Vol. 83, No. 147/Tuesday, July 30, 2018/ Pages 33558–
33724). It indicates that the implementation of the OAS CAHPS Survey will remain voluntary
until further action in future rulemaking. Therefore, voluntary implementation of the OAS
CAHPS Survey will continue in 2019. Confirmation of plans will be published in the CY 2019
Final Rule in November 2018.
After the voluntary reporting period concludes, Medicare-certified hospitals and ASCs that
treated 60 or more survey-eligible patients in the year preceding the data collection period are
eligible to participate in the OAS CAHPS Survey. Medicare-certified hospitals and ASCs that
treat fewer than 60 survey-eligible patients during the same 12-month eligibility period have the
option to submit a request for exemption from participating in the OAS CAHPS Survey. The
November 2018 II. Introduction and Background
Centers for Medicare & Medicaid Services 9 Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual
Participation Exemption Request form will be available on the OAS CAHPS website in the
future for these exemption requests.
As per the CY 2017 Final Rule (Federal Register/Vol. 81, No. 219/Monday, November 14,
2016/Page 79810), an ASC that qualifies for the exemption from the ASCQR Program because
it had fewer than 240 Medicare claims (Medicare primary and secondary payer) in the year prior
to the data collection year for the applicable payment determination would also qualify for the
exemption from the OAS CAHPS Survey for the same time period. In accordance with the CY
2017 Final Rule, these ASCs are not required to submit a participation exemption request form
for the OAS CAHPS Survey for the same time period.
Sources of Information About the OAS CAHPS Survey
More information about the OAS CAHPS Survey and ambulatory and outpatient surgical care is
available at the two websites described below.
The OAS CAHPS Survey Website (https://oascahps.org/ )
The OAS CAHPS Survey Coordination Team maintains a website, which is available at
https://oascahps.org/ and hereafter in this chapter referred to as the OAS CAHPS website or
simply as the “website.” This website provides general information about the OAS CAHPS
Survey, contains the protocols and materials needed for survey implementation, and is one of the
main vehicles for communicating information about the survey to HOPDs, ASCs, and survey
vendors. The website has both public and secure pages.
The public access pages contain the following:
• general information about the OAS CAHPS Survey;
• announcements about updates or changes in the survey protocols or materials and
participation requirements;
• requirements for becoming an OAS CAHPS Survey vendor;
• data collection materials, protocols, and guidelines for administration of the OAS
CAHPS Survey;
• a list of approved OAS CAHPS Survey vendors;
• quality assurance plan requirements;
• training information and materials;
• data submission deadlines, resources, and requirements;
II. Introduction and Background November 2018
10 Centers for Medicare & Medicaid Services Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual
• instructional documents about OAS CAHPS participation and the OAS CAHPS website
for hospitals and ASCs; and
• information about how to obtain technical assistance.
The Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual is
updated annually to reflect changes to participation requirements and changes in survey
protocols, materials, and procedures. However, CMS and the OAS CAHPS Survey Coordination
Team use the OAS CAHPS website to disseminate important interim updates and news about the
OAS CAHPS Survey, including information related to participation requirements, updates and
changes to survey protocols or survey materials, information about upcoming events (e.g., data
submission deadlines, vendor training sessions), and public reporting. Announcements posted on
the OAS CAHPS Survey website may clarify or supersede existing protocols.
Therefore, it is critically important that survey vendors, HOPDs, and ASCs check the OAS
CAHPS Survey website frequently for updates. To view announcements, go to the website at
https://oascahps.org/ and click on “Recent Announcements” at the bottom of the home page or
the “Announcement” link under “General Information.” The announcements are listed in
chronological order with the most recent announcement listed first.
The secure or restricted-access sections of the OAS CAHPS Survey website are accessible only
to OAS CAHPS Survey vendors and HOPDs and ASCs that have registered to access the links
on the private sections of the website. The links provided within this section of the website will
enable HOPDs and ASCs to:
• grant access to additional users within the HOPD or ASC;
• authorize a survey vendor to submit OAS CAHPS Survey data on their behalf, switch
vendors, or view the facility’s authorization history;
• view data submission reports for data submitted by their respective survey vendors; and
• “preview” their OAS CAHPS Survey results before the results are publicly reported.
Additional secured links on the OAS CAHPS Survey website are accessible to survey vendors
that have been given access credentials. These private secured links allow survey vendors to:
• view the current list of HOPDs and ASCs that have authorized the vendor to submit data
on their behalf;
• access the Exceptions Request Form and the DSRS Excel template file, and Discrepancy
Notification Report to report deviations from the standardized survey protocols;
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Centers for Medicare & Medicaid Services 11 Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual
• access the Quality Assurance Plan submission tool; and
• access the OAS CAHPS Survey data submission tool and reports containing information
about submitted data.
More detailed information about the OAS CAHPS Survey website is included in Chapter X of
this manual.
The Medicare Website (http://www.medicare.gov )
This website is maintained by CMS and contains information on the services Medicare provides.
The Medicare website provides information to the public on various quality measures. Viewers
can obtain comparative information about HOPDs and ASCs by state, ZIP code, and county.
OAS CAHPS Survey results are based on survey response data from the four quarters for which
OAS CAHPS Survey data are available and are “refreshed” each calendar year quarter.
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Centers for Medicare & Medicaid Services 13 Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual
III. SURVEY PARTICIPATION REQUIREMENTS
Overview
This chapter describes participation requirements for the Outpatient and Ambulatory Surgery
CAHPS Survey (OAS CAHPS), including the roles and responsibilities of the Centers for
Medicare & Medicaid Services (CMS) and its OAS CAHPS Survey Coordination Team, hospital
outpatient departments (HOPDs) and ambulatory surgery centers (ASCs), and survey vendors
that administer the OAS CAHPS Survey for HOPDs and ASCs. This chapter also discusses the
rules of participation and outlines the business requirements that survey vendors must meet to be
approved to administer the OAS CAHPS Survey. Information about obtaining technical
assistance from the Coordination Team is also provided in this chapter.
Roles and Responsibilities
CMS is responsible for ensuring that the OAS CAHPS Survey is administered using
standardized survey protocols and data collection and processing methods. CMS works very
closely with its OAS CAHPS Survey Coordination Team to provide training, technical
assistance, and oversight to approved survey vendors. Technical assistance is also provided to
HOPDs and ASCs because they are responsible for contracting with an approved survey vendor
to conduct the OAS CAHPS Survey on their behalf and for providing a patient information file
to their survey vendor each month. Survey vendors are responsible for conducting the OAS
CAHPS Survey on behalf of their client HOPDs and ASCs following the standard protocols and
guidelines described in this manual.
The roles and responsibilities of each of these participating organizations are described below.
CMS and the OAS CAHPS Survey Coordination Team Responsibilities
CMS and the OAS CAHPS Survey Coordination Team are responsible for the following
activities on the OAS CAHPS Survey:
• disseminate information about OAS CAHPS Survey administration;
• train survey vendors on OAS CAHPS Survey protocols and requirements;
• monitor data integrity of OAS CAHPS Survey administration to ensure the quality and
comparability of the data;
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14 Centers for Medicare & Medicaid Services Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual
• provide technical assistance to HOPDs and ASCs and approved OAS CAHPS Survey
vendors via a toll-free telephone number, e-mails, and the OAS CAHPS website at
https://oascahps.org/ ;
• conduct oversight and quality assurance of survey vendors;
• receive and conduct final processing of OAS CAHPS Survey data submitted by all
approved survey vendors;
• calculate and adjust OAS CAHPS Survey data for mode and patient-mix effects prior to
publicly reporting survey results; and
• generate preview reports containing OAS CAHPS Survey results for participating
HOPDs and ASCs to review prior to public reporting.
Hospital Outpatient Departments’ and Ambulatory Surgery Centers’
Responsibilities
Participating HOPDs or ASCs must:
• Contract with an approved OAS CAHPS Survey vendor to conduct their survey on a
monthly basis.
• Authorize the contracted survey vendor to collect and submit OAS CAHPS Survey data
to the OAS CAHPS Data Center on the facility’s behalf.
• Work with their approved vendor to determine a date each month by which the vendor
will need the monthly patient information file allowing adequate time for vendor
sampling and fielding the survey by the 21st day following the sample month.
• By the agreed-upon date, compile and deliver to the survey vendor a complete and
accurate list of patients (i.e., the monthly patient information file) and information that
will enable the vendor to sample patients and administer the survey.
• Use a secure method to transmit monthly patient information files to the survey vendor,
ensuring that data are encrypted prior to sending to the vendor.
• Work with their approved vendor to determine a date each month or quarter by which the
vendor will submit data to the OAS CAHPS Data Center.
• Review the online Data Submission Report to ensure that their survey vendor has
submitted data to the OAS CAHPS Data Center on time and without data problems
(allow ample time for this prior to the quarterly data submission deadlines because data
cannot be corrected after the deadline has passed).
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Centers for Medicare & Medicaid Services 15 Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual
• Review OAS CAHPS Survey results prior to public reporting.
• Avoid influencing patients in any way about how to answer the OAS CAHPS Survey.
For example, HOPDs and ASCs may not hand out any information to patients about how
to answer the survey. (Please refer to the section below titled Communications With
Patients About the OAS CAHPS Survey.)
When participation in the OAS CAHPS Survey is linked to HOPDs’ and ASCs’ payment
determination, it will be the responsibility of Medicare-certified HOPDs and ASCs to participate
every month in the OAS CAHPS Survey to obtain the full payment reimbursement from CMS. If
an HOPD or ASC served fewer than 60 survey eligible patients during the year preceding the
data collection period, the facility can request an exemption. To request an exemption, an HOPD
or ASC must submit a Participation Exemption Request (PER) form for that payment
determination period. This PER form will be available on the OAS CAHPS website in the future.
HOPDs and ASCs will need to submit a PER for every year for which they qualify and wish to
seek an exemption from participation. HOPDs and ASCs are encouraged to monitor the OAS
CAHPS website for announcements regarding the availability of the OAS CAHPS Survey PER
form.
As per the CY 2017 Final Rule (Federal Register/Vol. 81, No. 219/Monday, November 14,
2016/Page 79810), an ASC that qualifies for the exemption from the ASCQR Program because
it had fewer than 240 Medicare claims (Medicare primary and secondary payer) in the year prior
to the data collection year for the applicable payment determination would also qualify for the
exemption from the OAS CAHPS Survey for the same time period. In accordance with the CY
2017 Final Rule, these ASCs are not required to submit a PER form for the OAS CAHPS Survey
for the same time period.
Each payment determination period has an associated reference count period and participation
period that corresponds to a calendar year (January to December). The reference count period
(which HOPDs and ASCs should use to determine eligibility for the payment determination
period) is the year preceding the data collection period. More information on participation
requirements for the payment determination will be available on the OAS CAHPS website at a
later date.
If an HOPD or ASC is eligible to participate, it must follow the participation requirements listed
directly under this section’s header. In addition, the HOPD or ASC must understand the payment
determination periods, including key date ranges and deadline dates. Information about payment
determination periods and other participation requirements will be provided in the Final Rule
published for the Hospital Outpatient Prospective Payment and Ambulatory Surgical Center
Payment Systems and Quality Reporting Programs for each calendar year.
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16 Centers for Medicare & Medicaid Services Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual
Communications With Patients About the OAS CAHPS Survey
It is important to avoid influencing patient responses to the OAS CAHPS Survey. Any
information or communication about the survey from HOPDs and ASCs may introduce bias to
the survey. It is acceptable for HOPDs and ASCs to inform patients that they may be asked to
respond to a patient experience survey. This information can be provided in writing or verbally
with discharge instructions or with paperwork provided to the patient in advance of the surgery
or procedure. Information to patients about the survey can include the following messaging:
• The HOPD or ASC is participating in the survey to learn more about the quality of health
care that patients receive.
• Patients may be selected to participate in a survey about their experience at the HOPD or
ASC.
• Indicate the mode of the survey that the patient should anticipate receiving (telephone or
mail).
It is not acceptable for HOPDs or ASCs to do any of the following:
• Provide a copy of the OAS CAHPS Survey questionnaire or cover letters to the patients.
• Ask any OAS CAHPS or similar questions of patients prior to administration of the
survey or after discharge.
• Include words or phrases verbatim from the OAS CAHPS Survey in marketing or
promotional materials.
• Attempt to influence their patients’ answers to the OAS CAHPS Survey questions.
• Tell the patients the facility hopes or expects their patients will give them the best or
highest rating or to respond in a certain way to the survey questions.
• Imply that the HOPD or ASC or its staff will be rewarded for positive feedback from
patients.
• Offer incentives of any kind to the patients for participating (or not) in the survey.
• Help the patient answer the survey questions, even if the patient asks for the provider’s
help.
• Ask patients why they gave a certain response or rating to any of the OAS CAHPS
Survey questions.
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Centers for Medicare & Medicaid Services 17 Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual
• Include any messages or materials promoting the HOPD or ASC or the services it
provides in survey materials, including mail survey cover letters, questionnaires, and
telephone interview scripts.
HOPDs and ASCs should never ask their patients if they would like to be included in the survey.
All patients selected to participate in the OAS CAHPS Survey must be able to decide on their
own whether they wish to participate and will be provided an opportunity to do so as part of the
survey process.
Survey Vendor Responsibilities
The list below provides a synopsis of the responsibilities of survey vendors on the OAS CAHPS
Survey.
• Complete the Vendor Application, which is available on the OAS CAHPS Survey
website approximately 6 weeks prior to the annual Introduction to the OAS CAHPS
Survey Webinar Training.
• Participate in and successfully complete the two-part Introduction to the OAS CAHPS
Survey Webinar Training and in all Update Training sessions.
• The survey vendor’s designated OAS CAHPS Project Director must also complete and
pass a Training Certification after participating in the two-part Introduction to the OAS
CAHPS Survey Webinar Training.
• Ensure that all survey vendor staff who work on the OAS CAHPS Survey are trained and
follow the standard OAS CAHPS Survey protocols and guidelines.
• Report any deviations from the protocols and guidelines to the OAS CAHPS Survey
Coordination Team within 24 hours after the discrepancy has been discovered, either
through a Discrepancy Notification Report (see Chapter XV) or other e-mail or telephone
contact with the Coordination Team.
• Follow the participation requirements listed in the “Survey Vendor Requirements” tab of
the Vendor Application and also repeated in the following chapters in this manual.
• Work with appropriate HOPD or ASC staff to create monthly patient information files,
including data elements needed and file format specifications (see Appendix R, Example
Patient File Layout) and decide on a date each month by which the HOPD or ASC must
provide each monthly patient information file.
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• Receive and perform checks on the monthly patient information files provided by HOPDs
and ASCs to ensure that they include the entire eligible population and all required data
elements.
• Sample patients, following the sampling protocols described in this manual (see
Chapter IV).
• Administer the OAS CAHPS Survey in accordance with the protocols specified in
Chapters V–VII of this manual and oversee the quality of work performed by staff and
any subcontractors, if applicable.
• Verify that each client HOPD or ASC has authorized the vendor to submit data on the
facility’s behalf.
• Prepare and submit data files to the OAS CAHPS Data Center following the guidelines
specified in Chapters IX and X of this manual and in the OAS CAHPS Survey Website
User and Data Submission Manual, Version 2.0.
• Review all data submission reports for client HOPDs and ASCs to ensure that data have
been successfully uploaded and received.
Survey Vendor Participation Requirements
Survey organizations interested in becoming an approved survey vendor for the OAS CAHPS
Survey must agree to the following requirements of participation.
• Participate in both the Introduction to the OAS CAHPS Survey Training Sessions and in
any subsequent Update Trainings. The vendor’s staff member designated as the OAS
CAHPS Project Director must attend these trainings; we strongly advise that the vendor’s
sampling and data managers also attend. All training sessions will be conducted via
Webinar and require that the survey vendor register in advance. The survey vendor’s
designated OAS CAHPS Project Director must complete and pass a post-training
certification exercise, also referred to as a Training Certification Form, after attending
the Introduction to the OAS CAHPS Survey Training. The Introduction to the OAS
CAHPS Survey Training will be provided in two 4-hour sessions. Each Update Training
session, when offered, will usually consist of one 2- to 3-hour session.
• Review the Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines
Manual and follow the protocols and procedures described in this manual during survey
administration. This manual is the main resource for survey vendors to use in
implementing all stages of the OAS CAHPS Survey—from sampling and data collection
to file development and submission. It is expected that vendors will refer to this manual
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Centers for Medicare & Medicaid Services 19 Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual
frequently and adhere to all protocols contained within it. Protocol and policy updates
will be posted on the OAS CAHPS Survey website.
• Check the OAS CAHPS website frequently to review announcements and protocol
updates, and review and respond as appropriate to e-mails from the OAS CAHPS Survey
Coordination Team (e-mails will be from [email protected]).
• Communicate in a timely manner (within 24 hours when possible) with the OAS CAHPS
Survey Coordination Team any instances when the survey is not following the protocols
and guidelines in this manual. As explained in Chapter XV, there are two forms that are
used in this regard: the Exception Request (regarding a planned deviation) and the
Discrepancy Notification Report (regarding an unplanned deviation). For situations when
these two forms are not appropriate, contact the Coordination Team.
• Develop and submit a Quality Assurance Plan (QAP), following guidelines described in
Chapter XIII of this manual and the QAP instructions provided in the Model QAP
Outline (Appendix N). Survey vendors must complete and submit a QAP within 6 weeks
after the vendor’s first quarterly OAS CAHPS Survey data submission. The QAP must be
updated annually or as needed whenever changes are made to key personnel, survey
modes being administered, or protocols. The QAP must include the following elements:
◦ organizational background and staff experience;
◦ initial communications with HOPDs and ASCs;
◦ work plan for each approved mode of data collection;
◦ sampling protocols and quality assurance procedures;
◦ survey administration protocols and quality assurance procedures;
◦ data security, confidentiality, and privacy protocols; and
◦ copies of the survey instrument (questionnaire or computer-assisted telephone
interview [CATI] script) and cover letters.
• Participate and cooperate in all oversight activities conducted by the OAS CAHPS
Survey Coordination Team, including but not limited to conference calls and site visits,
as deemed necessary. Additionally, the Coordination Team may request teleconference
calls with vendors to review sampling protocols, file submissions, or any other aspect of
the data collection process. Documentation and requirements that vendors are expected to
follow in light of these oversight activities are described in the Vendor Application
(Appendix A) and in Chapter XIII of this manual. All vendors must also correct any
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20 Centers for Medicare & Medicaid Services Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual
issues identified by the Coordination Team, whether they are identified at a site visit, in
the QAP document, or during the course of data collection.
• As noted on the Vendor Application, all survey vendors seeking approval to conduct the
OAS CAHPS Survey must review and agree to the participation requirements listed in
the “Survey Vendor Requirements” tab of the Vendor Application and described in the
bullets above. Vendors that fail to adhere to or comply with the participation
requirements risk losing their status as an approved OAS CAHPS Survey vendor.
• If interim approval is denied to a vendor applicant, the survey vendor will be notified by
the OAS CAHPS Survey Coordination Team and provided documentation regarding the
requirements that have not been met. The vendor applicant has the option to formally
appeal the application denial by submitting an online Appeals form and providing
sufficient documentation that addresses the unmet requirements within 10 business days
of the denial notification.
Responsibilities of Both HOPDs/ASCs and Survey Vendors
Administering the OAS CAHPS Survey in Conjunction With Other Surveys
Some HOPDs and ASCs may wish to conduct other patient surveys to support internal quality
improvement activities. A “survey,” for purposes of this project, is defined as a formal, patient
experience or satisfaction survey. A formal survey, regardless of the data collection mode
employed, is one in which the primary goal is to ask standardized questions of a sample of the
patient population. Contacting patients to assess their care at any time or calling a patient to
check on services received are both considered to be routine patient contacts, not surveys.
HOPDs and ASCs that are administering other outpatient surveys must follow the guidelines
below.
With regard to sampling and ensuring that patients are not overburdened by multiple surveys:
• For each sample month, the survey vendor must select the OAS CAHPS Survey sample
prior to selecting the samples for any other HOPD or ASC survey.
• The HOPDs and ASCs cannot select the sample for the other facility survey. The vendor
must select the sample because the sample selection for OAS CAHPS cannot be
disclosed to the facility.
• If another CMS- or other federally sponsored effort is also conducting a survey of
patients in the HOPD or ASC that month, the facility must contact the OAS CAHPS
Survey Coordination Team to make arrangements for both surveys.
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Centers for Medicare & Medicaid Services 21 Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual
With regard to questionnaire content of other outpatient surveys:
• In other surveys that an HOPD or ASC conducts, the facility can include any of the OAS
CAHPS questions or similar questions.
• They can also include questions that ask for more in-depth information about OAS
CAHPS issues.
It is permissible for HOPDs or ASCs that are participating in the American College of Surgeons’
National Surgical Quality Improvement Program (NSQIP) to administer the OAS CAHPS
Survey in conjunction with the NSQIP post-operative survey to patients such that each survey
can be administered independently. In other words, the OAS CAHPS Survey vendor can sample
OAS CAHPS patients as they normally would and the NSQIP follow-ups can be administered as
required.
Adding Supplemental Questions to the OAS CAHPS Questionnaire
The OAS CAHPS Survey mail questionnaire contains 37 questions, and the OAS CAHPS
Survey telephone script 35 questions. The survey can be administered as a standalone survey or
can be combined with supplemental questions as explained in this section. Questions 1 to 24 are
considered the “core” OAS CAHPS Survey questions and must be placed at the beginning of the
questionnaire. Questions 25 to 37 (or 35 in the telephone script) are the “About You” OAS
CAHPS Survey questions and must be administered as a unit.
Survey vendors and their client HOPDs and ASCs may elect to add up to 15 questions per
respondent to the OAS CAHPS Survey. These could be questions they develop themselves or
use from an existing survey.
• All supplemental questions must be placed after the “core” OAS CAHPS Survey
questions (Q1-Q24). Supplemental questions may be placed either before or after the
OAS CAHPS Survey “About You” questions. (Refer to the Questionnaire in
Appendix B.)
• We strongly recommend avoiding sensitive questions or lengthy additions, because these
will likely reduce expected response.
• Supplemental questions cannot ask patients why they gave a certain response or rating to
any of the OAS CAHPS Survey questions.
• Supplemental questions do not need to be approved by or reported to CMS. However,
survey vendors should review the appropriateness of supplemental questions added to the
OAS CAHPS Survey and share any concerns they have directly with the HOPD or ASC,
or the OAS CAHPS Survey Coordination Team.
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22 Centers for Medicare & Medicaid Services Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual
• Survey vendors must not include responses to the supplemental questions on the data
files that will be submitted to the OAS CAHPS Data Center.
• Supplemental questions cannot repeat any of the survey items in the OAS CAHPS
Survey, even if the response scale is different.
• Supplemental questions cannot be used with the intention of marketing or promoting
services provided by the HOPD, ASC, or any other organization. An example of a
question for marketing or promotion is “Can you provide the names and contact
information of any friends or family members who are interested in learning about the
services we provide?”
• Supplemental questions cannot ask sample patients to identify other individuals who may
need outpatient surgical services because of privacy and confidentiality issues they raise
if personally identifiable information (PII) was shared with the HOPD or ASC without
that person’s knowledge and permission.
• The Consent to Share Identifying Information question (Appendix F), if vendors elect to
include it, is considered one of the 15 allowable supplemental questions. The Consent to
Share Identifying Information question asks sample members if they will permit the
survey vendor to link their name and identifying information (responses to the About
You questions) to their survey responses. If the sample member answers “No” or the
response is “Missing” to the Consent to Share Identifying Information question, the
vendor cannot link the sample member’s name to their survey responses. However, the
vendor is permitted to share responses to the sample member’s About You questions in
aggregate form and only if a minimum of 11 responses were provided for each response
option (see Chapter VIII for more information on providing response data to HOPDs and
ASCs). If an HOPD or ASC would like these identifying data, their survey vendor must
include the Consent to Share Identifying Information question. This question is typically
placed at the end of the questionnaire, as the last question. The Consent to Share
Identifying Information question is currently available in English, Spanish, Chinese, and
Korean. Additional languages may be added in the future.
• Vendors and their client facilities cannot ask supplemental questions that would reveal
the patient’s identity without the Consent to Share Identifying Information question
affirmatively answered.
Depending on the placement of the supplemental questions in the OAS CAHPS Survey, it is
acceptable to replace the skip instruction currently provided in Q36 of the OAS CAHPS mail
survey, “Go to END,” with the skip instruction, “Go to Q38,” if the vendor adds the Consent to
Share Identifying Information question or any supplemental questions to the mail survey starting
with Q38. If adding supplemental questions to the end of the OAS CAHPS telephone script, it is
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Centers for Medicare & Medicaid Services 23 Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual
also permissible to revise the programmable skip logic in Q35, “GO TO Q_END,” to instead
skip to Q36.
If a survey vendor, HOPD, or ASC wishes to add more than 15 supplemental questions per
sampled patient, the vendor should submit an Exceptions Request Form (ERF) (see
Chapter XV). The ERF should include the questions, the reason for including more than 15
supplemental questions, and an estimate of the additional time required for sample members to
respond to them.
Vendor Business Requirements
An organization that owns, operates, or provides staffing for an HOPD or ASC is not permitted
to administer its own OAS CAHPS Survey or administer the survey on behalf of any other
HOPDs and ASCs. If any vendor personnel are affiliated with a healthcare provider (hospital,
ambulatory surgery center [ASC], management company, etc.), the vendor cannot be contracted
to conduct OAS CAHPS for that provider as long as the vendor personnel maintain the
affiliation. CMS believes an independent third party (survey vendor) will be better able to solicit
unbiased responses to the OAS CAHPS Survey; therefore, CMS requires that HOPDs and ASCs
contract with an independent, approved OAS CAHPS Survey vendor to administer the OAS
CAHPS Survey on their behalf.
The following types of survey organizations will not be eligible to administer the OAS CAHPS
Survey:
• organizations or divisions within organizations that own or operate an HOPD or ASC, or
provide outpatient or ambulatory surgical services, even if the division is run as a
separate entity to the HOPD or ASC;
• organizations that provide telehealth, monitoring of outpatient or ambulatory surgery
patients, or teleprompting services for HOPDs and ASCs; and
• organizations that provide staffing to HOPDs and ASCs for providing care to outpatient
or ambulatory surgery patients.
Survey vendors seeking approval as an OAS CAHPS Survey vendor must have proven
experience in conducting mail-only, telephone-only, and/or mixed-mode surveys, depending on
which mode(s) they are seeking approval for. They also must have the capability and capacity to
collect and process all survey-related data for the survey administration mode they intend to use
on the OAS CAHPS Survey following standardized procedures and guidelines. The business
requirements that survey vendors must meet are described in the following sections.
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24 Centers for Medicare & Medicaid Services Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual
Relevant Business Experience
The following section describes the business experience a vendor must possess. Vendors should
submit the online Vendor Application (Appendix A) only if they meet these requirements.
Vendors will also need to document details of this experience in their QAP. The OAS CAHPS
Survey Coordination Team will—through its review of Vendor Applications, through its review
of QAPs, and through site visits—confirm that vendors meet these requirements. These
requirements are the following.
A vendor must have relevant business experience, including a minimum of 3 years in business, a
minimum of 2 years conducting surveys with individuals, and a minimum of 2 years conducting
surveys in the selected data collection mode. A “survey of individuals” is defined as the
collection of data from individuals selected by statistical sampling methods and the data
collected are used for statistical purposes. An applicant organization must:
• Have conducted surveys of individuals responding about their own experiences.
• Be able to demonstrate that a statistical sampling process (e.g., simple random sampling,
proportionate stratified random sampling, or disproportionate stratified random sampling)
was used in the previously conducted survey(s). This means that the organization has to
have conducted surveys where a sample of individuals was selected.
• Be able to demonstrate that it has conducted surveys of individuals as an organization for
at least 2 years. If someone within the applicant organization has relevant experience
obtained while in the employment of a different organization, that experience will not
count toward the 2-year minimum of survey experience.
• Currently possess all required facilities and systems to implement the OAS CAHPS
Survey. CMS and its OAS CAHPS Survey Coordination Team reserve the right to
request photographs of the applicant organization’s telephone call center for
organizations applying for the telephone-only and mixed modes, scanning and data
processing systems if applying for the mail-only or mixed modes, and other relevant
equipment and facilities.
The following are examples of data collection activities that do not satisfy the requirement of
experience conducting surveys of individuals, as defined for the OAS CAHPS Survey, and will
not be considered as part of the experience that OAS CAHPS requires:
• polling questions administered to trainees or participants of training sessions or
educational courses, seminars, or workshops;
• focus groups, cognitive interviews, or any other qualitative data collection activities;
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Centers for Medicare & Medicaid Services 25 Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual
• surveys of fewer than 600 individuals;
• surveys conducted that did not involve using statistical sampling methods;
• Internet or Web-based surveys; and
• interactive Voice Recognition surveys.
Survey Capabilities and Capacity
The following section describes the capabilities and capacity that vendors must possess to be
approved for OAS CAHPS. There are specific requirements pursuant to Personnel, Facilities and
Systems, Security Policies, mail administration, telephone administration, mixed-mode
administration, data processing, and file submission. The OAS CAHPS Survey Coordination
Team will—through its review of Vendor Applications and follow-up correspondence, through
its review of QAPs, and through site visits—confirm that vendors meet these requirements.
These requirements are the following.
Personnel
Vendors must designate a Project Director with relevant survey experience, designate a
Sampling Manager with sample frame development and sample selection experience, and
designate a programmer capable of processing data and preparing data files for electronic
submission.
Facilities and Systems
Vendors must currently:
• have a secure commercial work environment;
• meet all local commercial code requirements; and
• have physical facilities, electronic equipment, and software to receive sample files from
participating facilities and upload OAS CAHPS data to the OAS CAHPS Data Center.
Vendors must conduct all of their OAS CAHPS business operations within the United States.
This requirement applies to all staff and subcontractors. Home-based or virtual interviewers or
mail survey staff may not be used to administer the OAS CAHPS Survey nor may they conduct
any survey administration process.
Security Policies
Vendor and all subcontractors must have and implement systems and security policies that
protect the security of PII as defined by the Health Insurance Portability and Accountability Act.
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26 Centers for Medicare & Medicaid Services Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual
This includes sample data and survey data. Vendors will be required to submit policies.
Submissions must describe in sufficient detail policies and procedures for:
• authorizing and de-authorizing individuals to access PII and survey data (including
background checks, training, signed agreements);
• preventing unauthorized individuals from accessing PII and survey data in physical
format (including key card/locked access, locked file cabinets);
• preventing unauthorized individuals from accessing data in electronic format (including
password protections, firewalls, data encryption software, personnel access limitation
procedures, and virus and spyware protection);
• safeguarding PII and survey data in physical format against loss or destruction (including
fire and building safety codes);
• safeguarding PII and survey data in electronic format against loss or destruction (e.g.,
offsite daily backups);
• establishing a disaster recovery plan for survey data in the event of a disaster; and
• destroying PII and survey data when specified.
Further information on security policies is presented in Chapter VIII.
Mail-Only Survey Administration
Vendors that are using mail-only survey administration must demonstrate prior experience and
have commercial facilities, equipment, and software to enable them to:
• assign a random, unique, de-identified identification number to each sampled patient;
• obtain and verify addresses of sampled patients;
• print according to OAS CAHPS formatting guidelines professional-quality survey
questionnaires (containing single-coded questions, code-all-that-apply questions) and
materials;
• merge and print sample patient name and address, the name of the outpatient facility, and
the date of procedure or surgery on personalized mail survey cover letters and print
unique sample identification on the survey questionnaire;
• track fielded surveys throughout the protocol, avoiding respondent burden and losing
respondents;
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Centers for Medicare & Medicaid Services 27 Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual
• receive and process (key entry or scanning) completed questionnaires;
• track and identify nonrespondents for follow-up mailing;
• provide a toll-free customer support line and respond to calls within 48 hours; and
• assign final status codes in accordance with OAS CAHPS coding requirements to reflect
the results of the attempt(s) to obtain a completed interview with each sampled patient
(see Chapter IX).
Telephone-Only Survey Administration
Vendors that are using telephone-only survey administration must demonstrate prior experience
and have commercial facilities, equipment, and software to enable them to:
• assign a random, unique, de-identified identification number to each sampled patient;
• obtain and verify telephone numbers of sampled patients;
• develop computer programs for electronically administering the survey (for CATI);
• collect data using CATI, which allows seamless administration of single-coded questions,
code-all-that-apply questions;
• track fielded surveys throughout the protocol, avoiding respondent burden and losing
respondents;
• schedule callbacks to nonrespondents at varying times of the day and week;
• provide a toll-free customer support line and respond to calls within 48 hours;
• assign final status codes in accordance with OAS CAHPS coding guidelines to reflect the
results of attempt(s) to obtain a completed interview with each sampled patient; and
• conduct monitoring of interviewers.
Mixed-Mode Survey Administration
Vendors that apply for administering the OAS CAHPS Survey as a mixed-mode survey (mail
with telephone follow-up of nonrespondents) must demonstrate prior experience and have
commercial facilities, equipment, and software to enable them to adhere to all mail-only and
telephone-only survey administration requirements described above. In addition, they must have
an electronic tracking system that can track cases from the mail survey through telephone follow-
up activities.
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Data Processing and File Submission
Vendors must demonstrate prior experience and have facilities, equipment, and software to
enable them to:
• Scan or key responses to single coded questions and code-all-that-apply questions from
completed surveys.
• Develop data files and edit and clean data according to standard protocols.
• Follow all data cleaning and data submission rules, including verifying that data files are
de-identified and contain no duplicate patient records.
• Export data from the electronic data collection system to an XML template, confirm that
the data were exported correctly, and that the XML files are formatted correctly and
contain the correct data headers and data records.
• Submit data electronically in the specified format (XML) via the OAS CAHPS secured
website.
◦ Vendors must work with the OAS CAHPS Survey Coordination Team to quickly
resolve data problems and data submission problems. As stated above with regard to
the Discrepancy Notification Report, vendors must inform the Coordination Team
promptly (within 24 hours after the discrepancy has been identified, when possible)
of any deviation from the protocol. Vendors are encouraged to submit their test data
files early so as to reveal any potential problems, and afford time to address them
prior to submission.
Adherence to Quality Assurance Guidelines
Vendors must have prior experience, facilities, equipment, and software to enable them to:
• Incorporate well-documented quality control procedures (as applicable) for:
◦ in-house training of staff involved in survey operations;
◦ printing, mailing, and recording of receipt of survey questionnaires;
◦ telephone administration of survey;
◦ coding and editing of survey data and survey-related materials;
◦ scanning or keying in survey data;
◦ preparation of final person-level data files for submission; and
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Centers for Medicare & Medicaid Services 29 Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual
◦ all other functions and processes that affect the administration of the OAS CAHPS
Survey.
• Participate in any conference calls and site visits requested by the Coordination Team as
part of overall quality monitoring activities. Site visits will be conducted with all
approved vendors.
• Provide documentation as requested for site visits and conference calls, including but not
limited to staff training records, telephone interviewer monitoring records, and file
construction documentation.
Participation in Training and Quality Assurance Activities
Survey vendors must participate in all required training and quality assurance activities necessary
to ensure the successful implementation of the OAS CAHPS Survey. This includes the following
requirements:
• Review and follow all procedures described in the OAS CAHPS Survey Protocols and
Guidelines Manual that are applicable to the selected survey data collection mode.
• Attend all CMS Introduction and Update training sessions. (Failure to complete all
required vendor training will result in withdrawal of approved vendor status.)
• Participate in any conference calls and site visits requested by the OAS CAHPS Survey
Coordination Team as part of overall quality monitoring activities. Site visits will be
conducted with all approved vendors. Vendors must provide documentation as requested
for site visits and conference calls, including but not limited to staff training records,
telephone interviewer monitoring records, sample frame development documentation,
and file construction documentation.
Subcontractor Requirements
Any survey vendor using a subcontractor in any capacity on the OAS CAHPS Survey is required
to complete the relevant sections of the Vendor Application (Appendix A) about each of its
subcontractors. Information requested on the Vendor Application about subcontractor capabilities
is similar to that requested for vendors. Details must be provided about the capabilities and
capacity of the subcontractor to handle mail, telephone, and mixed-mode survey activities (as
appropriate). Further, specific information must also be provided about the subcontractor’s
quality assurance practices, data security policies, and facilities and systems.
If a vendor applicant’s subcontractor will conduct substantive work to support the
implementation of the OAS CAHPS Survey, that subcontractor is strongly encouraged to attend
relevant portions of the Introduction to OAS CAHPS Webinar Training Session and all OAS
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30 Centers for Medicare & Medicaid Services Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual
CAHPS Update Training Sessions. For purposes of this survey, “substantive work” is defined as
follows:
• ANY statistical function, including sample selection,
• telephone survey data collection (i.e., if an approved vendor is subcontracting telephone
data collection activities),
• mail or questionnaire receipt and processing, and
• construction or submission of XML data files.
If an applicant vendor will be using a subcontractor to conduct any substantive work as defined
above, the subcontractor organization will be subject to the same or similar requirements as the
applicant vendor.
Additional Requirements
CMS and its OAS CAHPS Survey Coordination Team reserve the right to request additional
information from applicant organizations to help determine whether approval status should be
granted. Information requested may include the following:
• Taxpayer Identification Number;
• website address;
• detailed description of surveys conducted that demonstrate statistical sampling and data
collection capabilities;
• photographs of applicant organization’s facilities and systems;
• resumes of key staff, demonstrating experience with data collection, sampling, and
computer programming; and
• additional descriptions of processes, including treatment of confidential data, control or
tracking systems, quality assurance practices, and XML file construction.
Centers for Medicare & Medicaid Services 31 Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual
IV. SAMPLING PROCEDURES
Overview
This chapter describes the procedures survey vendors should use for sample selection. The
process includes requesting a file of patients for the hospital outpatient departments or
ambulatory surgery centers (HOPDs or ASCs), identifying patients and procedures eligible for
the survey, constructing a sampling frame, and selecting a patient sample each month. The
sampling procedures described in this chapter were developed to ensure standardized
administration of the OAS CAHPS Survey by all survey vendors and to ensure comparability of
the data and survey results that are publicly reported.
Before explaining patient sampling steps, it is
necessary to explain facility eligibility and
how the OAS CAHPS Survey is constructed
for analysis and reporting. See the text box for
a review of the definition of a facility that is
eligible for OAS CAHPS. When this chapter
refers to “facilities” or “HOPDs or ASCs” it
is referring to HOPDs and ASCs that meet
this definition.
The unit of analysis in OAS CAHPS is the
CCN, not the individual HOPD or ASC.
Implications of this fact are as follows:
• For HOPDs: Every HOPD that reports
under the hospital’s CCN needs to
participate in OAS CAHPS for the sample to be valid. Vendors should work with their
client hospitals to determine all HOPDs and other departments or units that perform
outpatient surgeries and procedures and include all of them in OAS CAHPS.
• For ASCs: Every location or unit within the ASC that is under their CCN needs to
participate in OAS CAHPS for the sample to be valid. Vendors should work with their
client ASCs to determine all locations or units that report under the same CCN and
include all of them in OAS CAHPS.
Definition of OAS CAHPS-eligible facilities
(For further detail see Chapter II)
HOPD: A unit of a hospital that performs
outpatient surgeries and procedures, is Medicare-
certified, has a CMS Certification Number (CCN),
bills CMS under the Outpatient Prospective
Payment System (OPPS); and meets the general
conditions and requirements in accordance with 42
CFR 419 subpart B.
ASC: A freestanding medical facility that performs
outpatient surgeries and procedures, is Medicare-
certified, has a CCN, bills under the ASC Payment
System, and meets the general conditions and
requirements in accordance with 42 CFR 416
subpart B.
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32 Centers for Medicare & Medicaid Services Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual
Determining Eligibility of Surgeries and Procedures
For OAS CAHPS, the primary criterion for determining
eligible surgeries and procedures is the Current
Procedural Terminology (CPT-4)6 codes. HOPDs and
ASCs use CPT-4 codes for billing purposes. CPT codes
are composed of three categories: Category I (services,
procedures, and surgeries), Category II (performance
measurement), and Category III (emerging technology).
Category I codes are divided into the following
subcategories:
• Codes for anesthesia: 00100–01999; 99100–99150
• Codes for surgery: 10021–69990
• Codes for radiology: 70010–79999
• Codes for pathology and laboratory: 80047–89398
• Codes for medicine: 90281–99099; 99151–99199; 99500–99607
• Codes for evaluation and management: 99201–99499
OAS CAHPS-eligible surgeries and procedures fall within the Category I CPT-4 range Codes for
Surgery (i.e., CPT codes between 10021 and 69990) or one of the following Category II G-
codes: G0104, G0105, G0121, or G0260. All other CPT codes are considered ineligible for OAS
CAHPS. For more information about other patient eligibility requirements, see the section titled
Patient Eligibility Requirements—12 Criteria). Detailed explanations of each data element that
HOPDs and ASCs will provide to their vendor are covered in the section titled Definition and
Explanation of Some of the Data Elements Required From HOPDs and ASCs and Appendix R
(Example Patient File Layout).
6 CPT is a registered trademark of the AMA.
Use of CPT-4 Codes for OAS CAHPS
CPT-4 codes are a standardized set of 5-
digit codes developed by the American
Medical Association (AMA).
Participating facilities have appropriate
licensure agreements with the AMA to
use CPT codes. CMS-approved vendors
for OAS CAHPS will use the CPT-4
codes to determine eligibility of patient
records provided by the facilities.
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Centers for Medicare & Medicaid Services 33 Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual
Patient Eligibility Requirements—12 Criteria
1. Patients who had at least one outpatient surgery/procedure during the sample month
(including outpatient surgeries and procedures when the patient had an overnight stay for
observation but was not transferred or admitted to the hospital);
2. Patients who were at least 18 years of age when they received their outpatient surgery or
procedure;
3. Patients regardless of insurance or method of payment;
4. Patients whose outpatient surgery or procedure was given in an HOPD or ASC as defined
by the project;
5. Patient’s surgery or procedure meets project eligibility definitions, which are as follows:
5a. A procedure is OAS CAHPS-eligible if it has a G-Code7 of G0104, G0105, G0121,
or G0260, or
5b. A surgery, diagnostic procedure, or other type of procedure is OAS CAHPS-eligible
if it has a CPT-48 code in the 10021–69990 range, was performed in an outpatient
surgery department or ambulatory surgery center, and if it has no accompanying
modifier of 73 or 74 (discontinued procedure)9
5c. Note that a facility may assign more than one code to a surgery or procedure. The
presence of one eligible G-code or CPT code is all that is needed to make it OAS
CAHPS-eligible.
6. Patients who have a domestic U.S. mailing address;
7. Patients who are not deceased;
8. Patients who do not reside in a nursing home;
7 G-Codes (HCPCS Level II) are alphanumeric medical procedure codes for temporary procedures and professional
services. HCPCS Level II codes are maintained by CMS. 8 CPT only copyright 2019 American Medical Association. All rights reserved.
9 Modifiers 73 and 74 (discontinued procedure) indicate that a procedure or surgery did not take place. CPT-4 codes
with Modifier 73 or 74 should be excluded.
Licensure Issues Associated With the Use of CPT-4 Codes
CMS has entered into an agreement with the American Medical Association (AMA), to use CPT data
in print and on the web. Fee schedules, relative value units, conversion factors, or related components
are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The
AMA does not directly or indirectly practice medicine or dispense medical services. The AMA
assumes no liability for the data contained or not contained herein. Applicable FARS/DFARS apply to
government use.
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34 Centers for Medicare & Medicaid Services Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual
9. Patients who were not discharged to hospice care following their surgery;
10. Patients who are not identified as prisoners;
11. Patients who did not request that the HOPDs or ASCs protect their identity (that is, not
release their name and contact information to anyone other than facility personnel),
hereafter referred to in this manual as “no publicity” patients; and
12. Some states have regulations and laws governing the release of patient information for
patients with specific illnesses or conditions, and for other special patient populations,
including patients with HIV/AIDS. It is the HOPD’s or ASC’s responsibility to identify
any applicable state laws and regulations and exclude state-regulated patients from the
survey as required by law or regulation.
The remaining sections in this chapter on sampling are organized chronologically corresponding
to the sampling steps listed below.
• Step 1: Obtain a monthly patient information file from each client HOPD or ASC under
the same CCN.
• Step 2: Examine the monthly patient information file for completeness and work with the
HOPD or ASC to obtain missing data elements. Process and check the file for duplicate
patient records.
• Step 3: Identify eligible patients and surgeries/procedures and construct a sampling
frame.
• Step 4: Determine the sampling method most appropriate for the OAS CAHPS Survey for
this CCN.
• Step 5: Determine the ideal sample size, calculate the sampling rate, and select the
sample.
• Step 6: Verify or update contact information for sampled patients.
• Step 7: Assign a unique sample identification number to each selected sampled patient.
• Step 8: Finalize the monthly sample file and initiate data collection activities.
Step 1: Obtain a Monthly Patient Information File From Each Client HOPD or ASC Under the Same CCN
Schedule for Receiving the Monthly Patient Information File
HOPDs or ASCs administering the OAS CAHPS Survey must submit a monthly patient
information file to their contracted OAS CAHPS Survey vendor each time they conduct the
November 2018 IV. Sampling Procedures
Centers for Medicare & Medicaid Services 35 Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual
survey. Appendix R is an example of a patient file layout that includes the data variables that
vendors need from participating facilities to sample and field the OAS CAHPS Survey.
Survey vendors select samples each month from the frame of patients who meet survey eligibility
criteria. Survey vendors also initiate the survey on a monthly basis. It is critical that client
HOPDs and ASCs provide monthly patient information in a timely manner, leaving vendors
enough time to conduct sampling and quality control checks before the monthly survey is
initiated. For each monthly set of sampled patients, the survey must be initiated within 21 days
after the sample month ends. CMS recognizes that on rare occasions an HOPD or ASC may have
a situation that may prevent it from providing the monthly patient information in time for the
vendor to initiate the survey within 21 days after the sample month ends. Therefore, the vendor
can initiate the survey within 26 days after the sample month ends. These exceptions are
described in Chapters V, VI, and VII pursuant to each mode of data collection.
Construction of Monthly Patient Information Files
When the HOPD or ASC construct the file, it must include the following:
• all patients whose outpatient surgery or procedure was given in an HOPD or ASC as
defined by the project (eligibility criterion #4);
• all patients who had at least one outpatient surgery or procedure during the sample month
(including outpatient surgeries and procedures when the patient had an overnight stay for
observation but was not transferred or admitted to the hospital) (eligibility criterion #1).
If multiple survey-eligible surgeries or procedures were performed during the sample
month for a patient, all of these surgeries or procedures should be included in the sample
file;
• all patients regardless of insurance or method of payment (eligibility criterion #3);
and must exclude the following:
• patients who cannot be surveyed because of state regulations (eligibility criterion #12);
• no-publicity patients10
(eligibility criterion #11);
• prisoners if known (eligibility criterion #10);
10 Facilities or software vendors cannot exclude patients who indicated that they do not participate in surveys. These
patients must be included in the monthly patient information file. If selected, they have the right to refuse to
participate.
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36 Centers for Medicare & Medicaid Services Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual
• nursing home residents if known (eligibility criterion #8);
• patients discharged to hospice if known (eligibility criterion #9); and
• deceased patients if known (eligibility criterion #7).
The HOPD or ASC and its vendor should reach a mutually acceptable arrangement as to whether
the facility, or the vendor, should be responsible for excluding patients who fail eligibility
criteria 2 [age], 5 [surgical code], and 6 [domestic address].
It is the survey vendor’s responsibility to ensure that
• the facility understands which patients to include and exclude from the files, and
• the facility provides the vendor with sufficient information to identify and exclude
patients who do not meet eligibility requirements.
Monthly HOPD and ASC files must contain information at both the patient and the facility level,
as described below.
Information Needed From HOPDs and ASCs for Each Patient in the Monthly
Patient Information File
HOPDs and ASCs are required to provide all of the information shown in Table 4.1 for each
patient in the monthly patient information file. The information the HOPD or ASC provides will
be used by the survey vendor to survey sampled patients and will be used by the OAS CAHPS
Survey Coordination Team for data analysis. Appendix R is an example of a patient file layout
and can be used by survey vendors as an example template of patient data needed from a client
HOPD or ASC to sample and field the OAS CAHPS Survey.
Table 4.1 Information Needed From HOPDs/ASCs for Patient Served During Sample Month
Data Element Required Reason Needed
Patient’s full name (First Name, Middle Initial, and Last Name as separate fields)
Survey administration
Gender Survey administration and analysis
Patient’s date of birth (MMDDYYYY) Survey eligibility
Mailing address (Patient Mailing Address 1, Patient Mailing Address 2, Address City, Address State, and Address Zip Code as separate data fields)
Survey administration
Patient’s telephone number including area code Survey administration
Indication whether telephone number is a cell phone Telephone survey administration (ensuring compliance with FCC Regulations)
Medical Record Number (Patient’s HOPD or ASC medical record number)
Deduplication of patients before sampling
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Centers for Medicare & Medicaid Services 37 Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual
(continued) Table 4.1 (continued)
Information Needed From HOPDs/ASCs for Patient Served During Sample Month
Data Element Required Reason Needed
Procedure code(s) (CPT11
or G-code) Survey eligibility
Date of procedure (MMDDYYYY) Survey administration
Name of location where surgery occurred Survey administration (to use facility name that will be familiar to the sampled patient)
Information Needed From Each HOPD or ASC at the Facility Level
HOPDs and ASCs are required to submit several facility-level data elements along with their
monthly patient information file. These elements are the CCN, the name associated with the
CCN, the Sample Month, Sample Year, and Number of Patients Served. Further explanation of
these required numbers is found in Chapter XI and in Appendix K (XML File Layout for
Standard Header Record).
Removing Non-eligible Patients From Monthly Files
Some HOPDs and ASCs may want to provide their contracted vendor with a monthly patient
information file that contains information only about patients who meet the survey eligibility
criteria. If the facility is making the exclusions, it is the vendor’s responsibility to make sure that
the facility understands and correctly applies the patient eligibility criteria. And, the survey
vendor must still examine the file for completeness and to make sure that all patients on the file
meet all of the eligibility criteria.
Other facilities may opt to provide a file containing information about all patients served during
the sample month so that the vendor can make the exclusions. If the survey vendor is making the
exclusions, it is the survey vendor’s responsibility to stress to its client facilities that all patients
must be represented in the file they submit. The facility must provide the vendor with sufficient
information for the vendor to identify and exclude patients who do not meet eligibility
requirements. And, even if the survey vendor is making the exclusions, the facility must exclude
state-regulated and no publicity patients.
11 CPT only copyright 2019 American Medical Association. All rights reserved.
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38 Centers for Medicare & Medicaid Services Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual
Definition and Explanation of Some of the Data Elements Required From
HOPDs and ASCs
This section provides more explanation on some of the variables on the monthly patient
information file.
• Patient’s date of birth. Patients must be 18 years of age on the day of their outpatient
surgery or procedure to be eligible for participation in the OAS CAHPS Survey.
• Vendors should ensure that their client HOPDs and ASCs include each patient’s mailing
address, even if a telephone survey is planned for that HOPD or ASC. For facilities
planning telephone surveys, the mailing address for each patient is needed so that the
vendor can obtain or verify the sample patient’s telephone number. The facilities provide
the initial contact information; however, survey vendors are strongly encouraged to use
address verification or telephone number look-up services to obtain updated contact
information.
• Patient telephone phone number is needed for mixed-mode and telephone-only surveys. It
is strongly recommended for mail-only modes because the telephone can be used to
validate or update the patient’s address information.
• Indication of cell phone is needed for mixed-mode and phone-only surveys. FCC
regulations prohibit auto-dialing of cell phone numbers. Therefore, cell phone numbers
need to be identified in advance to allow the vendor to treat cell phone numbers in a way
that complies with FCC regulations. Vendors are advised to familiarize themselves with
all applicable state and federal laws. If the facility is unable to identify which telephone
numbers are cell phone numbers, it is the vendor’s responsibility to use an external
source to obtain an up-to-date list of cell phone numbers and landline numbers that have
been ported to cell phone. The external source must be compared to the phone numbers of
the sampled patients to identify any phone numbers that are cell phones.
• The patient’s medical record number is the unique identifier that the HOPD or ASC
assigns to the patient that allows the HOPD or ASC to track and document the care
provided to the patient. This number, along with other data elements, will allow the
vendor to keep track of whether each patient has been recently sampled.
• CPT-4 codes12
relevant to OAS CAHPS are divided into the following categories:
12 CPT only copyright 2019 American Medical Association. All rights reserved.
November 2018 IV. Sampling Procedures
Centers for Medicare & Medicaid Services 39 Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual
◦ 10021–10022 general
◦ 10030–19499 integumentary system
◦ 20000–29999 musculoskeletal system
◦ 30000–32999 respiratory system
◦ 33010–37799 cardiovascular system
◦ 38100–38999 hemic and lymphatic systems
◦ 39000–39599 mediastinum and diaphragm
◦ 40490–49999 digestive system
◦ 50010–53899 urinary system
◦ 54000–55899 male genital system
◦ 55920–55980 reproductive system and intersex
◦ 56405–58999 female genital system
◦ 59000–59899 maternity care and delivery
◦ 60000–60699 endocrine system
◦ 61000–64999 nervous system
◦ 65091–68899 eye and ocular adnexa
◦ 69000–69979 auditory system
◦ 69990 microsurgery
• G-Codes or HCPCS Level II codes are alphanumeric medical procedure codes for
temporary procedures and professional services. HCPCS Level II codes are maintained
by CMS. At this time, only four G-codes are OAS CAHPS-eligible: G0104, G0105,
G0121, and G0260.
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40 Centers for Medicare & Medicaid Services Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual
• Vendors should work closely with facilities to ensure that only eligible surgeries and
procedures are included in the sample. Some HOPDs and ASCs perform additional
procedures that would be inappropriate for the OAS CAHPS Survey because of the
limited involvement of the doctors and nurses or the fact that the CPT code13
represents
preadmission testing, postsurgery follow-up testing, physical therapy, respiratory therapy,
laboratory, or radiology testing only. For the majority of these types of ineligible
procedures, the CPT code provides the exclusion criteria. As noted previously in this
chapter, codes for anesthesia, radiology, pathology, laboratory, medicine, and evaluation
and management would not fall within the range of eligible CPT codes for surgery
(10021–69990).
• However, some outpatient procedures that fall within the Codes for Surgery range could
be considered ineligible for OAS CAHPS based on a number of criteria, including
whether the procedure was significant enough for the survey questions to be relevant.
• See Appendix Q, Excluded Procedural Codes, for a list of CPT codes that have been
approved for exclusion by CMS. Some examples of ineligible CPT codes represent
procedures, such as the application of a compression system, collection of blood for
testing, application of casts, and bladder catheterization.
Additional CPT codes within the eligible range may also be excluded; however, the vendor
must submit an Exceptions Request Form (ERF) to document the codes to be excluded.
Name of location where surgery occurred. Some HOPDs or ASCs are part of larger, multisite
institutions. The monthly patient information file should state the name of the location where
each patient received his or her surgery. This name is included on the cover letter so that the
patient recognizes the name of this location. It may not be the official name of the facility. If
there is only one location for all patients, then this value will be identical for all patients.
Although location where surgery occurred is part of the monthly patient information file, OAS
CAHPS does not report survey results for individual locations or units within the CCN. OAS
CAHPS reports only at the CCN level.
Protocol for Missing Procedural Codes (CPT-4 Codes14 and G-Codes)
Occasionally, procedural codes (CPT-4 and G-codes) may be missing for some patient records
included in the monthly patient data file that the survey vendor receives from an HOPD/ASC.
13 CPT only copyright 2019 American Medical Association. All rights reserved.
14 CPT only copyright 2019 American Medical Association. All rights reserved.
November 2018 IV. Sampling Procedures
Centers for Medicare & Medicaid Services 41 Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual
Guidance on how to handle this missing data is based on the percentage of procedural codes that
are determined to be missing.
• If vendors determine that the percentage of patient records with missing procedural codes
is 3% or less, they are permitted to assume that the records with missing procedural codes
are eligible and continue with sampling and data collection. During file preparation, these
records should be coded into surgical category 5 (Missing).
• If vendors determine that the percentage of patient records with missing procedural codes
is higher than 3%, they are required to follow up with their client facilities to obtain the
missing procedural codes by the vendor’s deadline, which will allow them to initiate data
collection within the acceptable window of time.
If the facility cannot provide procedural codes for all of the patient records by the vendor’s
sampling deadline, vendors should work with the HOPD/ASC to determine whether the
procedural codes can be provided at a later date. After making this determination, the vendor
should follow the guidance below.
Guidelines for when missing procedural codes >3% can be provided at a later date
• If the updated monthly patient data file is received by the 26th day of the month
following the sample month, the vendor should follow the guidance provided in either
option a or b below.
a. If the vendor has been approved to conduct continuous sampling for the affected
facility, the vendor may conduct an additional round of sampling on the updated
records. If data collection for the newly sampled cases is initiated between 22 and 26
days after the end of the sample month, the vendor is required to submit a
Discrepancy Notification Report (DNR). Additional information about DNRs can be
found in Chapter XV.
b. If the vendor is conducting monthly sampling for the affected facility, the vendor
should wait until all patient records are updated to conduct sampling activities. If data
collection is initiated between 22 and 26 days after the end of the sample month, the
vendor is required to submit a DNR.
• If the updated monthly patient data file is received after the 26th day of the month
following the sample month, the vendor must first obtain CMS approval to initiate data
collection by submitting a Late Start Request e-mail to the OAS CAHPS Survey
Coordination Team, copying the HOPD or ASC client. The e-mail request should explain
the reason for the delay, state when the vendor will initiate the survey (if approved),
specify the affected sample month, and request CMS’ approval, regardless of the
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42 Centers for Medicare & Medicaid Services Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual
sampling method or frequency (continuous, monthly, etc.). If the request is approved, the
vendor should proceed with data collection activities. Note that monthly sampling cannot
be done on a partial file so if updates are expected for some cases, the vendor must wait
to select the sample.
Guidelines for when missing procedural codes >3% cannot be provided at a later date
• If the facility cannot provide an update to records with missing procedural codes, the
vendor should do the following:
a. Work with the facility to identify an alternative method of determining eligibility for
these cases and submit the proposed alternative method in an ERF. If the proposed
alternative method is approved, then initiate sampling and data collection.
b. Work with the facility to identify a way to code the “Surgical Category” variable,
which must be included in the XML file.
• If the facility cannot provide an update to records with missing procedural codes, and the
facility is unable to determine an alternate method of determining eligibility, the vendor
should do the following:
a. Verify with the facility that they confirm that the patient records with missing
procedural codes are eligible. If they meet all of the other eligibility criteria, include
them in the sample frame. Follow the protocols described under the “Guidelines for
when missing procedural codes >3% can be provided at a later date” header to initiate
data collection.
b. Work with the affected facility to determine how the cases should be coded for the
“Surgical Category” variable, which must be included in the XML file. For example,
if the facility can determine that the cases with missing procedural codes were pulled
from the Orthopedics department, then assign the cases to “surgical category 2
(orthopedic).” If the facility cannot identify a department or another method that
would determine how the cases should be classified, assign the cases to “surgical
category 5 (Missing).”
Once sampling is complete, submit a DNR reporting that sampled cases with missing procedural
codes were fielded for a given sample month. Be sure to include the number of affected cases
and the reason that the procedural codes are missing. Also include a description of the method
used to determine each of the case’s “Surgical Category” for the XML file and for how many
cases.
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If the facility cannot confirm that the patient records with missing procedural codes are eligible,
the vendor should not select the sample from facilities with missing procedural codes above
10%. In this case, submit a DNR documenting that the vendor could not conduct sampling for a
given sample month, the number of affected cases, the percentage of cases with missing
procedural codes, and the reason that the procedural codes are missing.
Sampling More Frequently Than Monthly
Some HOPDs and ASCs may prefer to deliver patient records to their survey vendors more
frequently than monthly (e.g., weekly, biweekly) per their convenience. This is acceptable,
provided that sampling is done using a monthly patient information file.
However, if the survey vendor wishes to perform sampling on a continuous basis it must
complete and submit an ERF that explains its reasons and proposed procedures. It may receive
approval from CMS for more frequent sampling. Information about the ERF and process is
provided in Chapter XV of this manual.
Protocol for No Eligible Patients Served in the Sample Month
If the HOPD or ASC did not perform any outpatient surgeries or procedures or did not serve any
patients who met survey eligibility criteria during the sample month, the facility must still submit
a monthly patient information file or an e-mail notification to its survey vendor stating that no
survey-eligible patients were served during that sample month.
Vendors are still required to submit data to the OAS CAHPS Data Center for a month when there
are no eligible cases. The vendor submits a Zero Eligible File in this situation. The vendor must
indicate on the file that there were zero eligible cases in data element for “Eligible Patients” and
enter all other information required in the Header Record Section of the XML file (refer to
Chapter XI in this manual for more information about data file preparation and submission). If
the vendor does not submit a zero-eligible file in this case, CMS and the OAS CAHPS Survey
Coordination Team will view the HOPD or ASC as having “missed” a sample month. HOPDs or
ASCs for which an OAS CAHPS Survey data file is not submitted for a month in the reporting
period may be considered as being noncompliant with OAS CAHPS Survey participation
requirements.
Protocol for Administering Other Surveys in Conjunction With the OAS
CAHPS Survey
Some HOPDs and ASCs may wish to administer other surveys of their patients. The following
guidelines should be used if the HOPD or ASC is planning to administer other surveys in
addition to the OAS CAHPS Survey.
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44 Centers for Medicare & Medicaid Services Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual
If an HOPD or ASC will be fielding another survey of its patients, it must provide a file of all
OAS CAHPS-eligible patients to its survey vendor for the OAS CAHPS Survey first, prior to
selecting patients for any other survey. Patients who were not randomly selected into the OAS
CAHPS Survey sample for the sample month may be included in a sample for a separate survey
that the vendor conducts on the HOPD’s or ASC’s behalf that month. This secondary survey
sample must be selected after the OAS CAHPS Survey sample has been drawn. The vendor
cannot provide the list of sampled patients for OAS CAHPS to the HOPD or ASC because this
would be a violation of the patient’s confidentiality. Because of the coordination required
between surveys, both surveys must be administered by the same vendor.
Facilities that are conducting patient surveys in parallel with OAS CAHPS are reminded that they
are allowed to add up to 15 supplemental questions of their own to the OAS CAHPS
questionnaire. Subsuming the questions from their other survey into OAS CAHPS and
discontinuing the other survey may be more efficient than administering both surveys
simultaneously.
It is permissible for HOPDs or ASCs that are participating in the American College of Surgeons’
National Surgical Quality Improvement Program (NSQIP) to administer the OAS CAHPS
Survey in conjunction with the NSQIP post-operative survey to patients such that each survey
can be administered independently. In other words, the OAS CAHPS Survey vendor can sample
OAS CAHPS patients as they normally would and the NSQIP follow-ups can be administered as
required.
Approved OAS CAHPS Survey vendors are expected to work closely with their client HOPDs
and ASCs to identify patients who are eligible for inclusion in other surveys the facilities
conduct. It is very important to avoid burdening patients with both OAS CAHPS and other
surveys. If the other survey is federally sponsored, vendors should contact the OAS CAHPS
Survey Coordination Team to make arrangements for both surveys.
Step 2: Examine the Monthly Patient Information File for Completeness and Possible Duplication
Survey vendors should examine each monthly patient information file provided by their client
facilities to ensure that information they need for determining survey eligibility for all records in
the file has been provided. This includes CPT15
or G-code(s) classifying the surgery, patient date
of birth, and date of surgery or procedure. If patient information needed for sample selection is
missing, the vendor should work with the HOPD or ASC to obtain all missing data before
15 CPT only copyright 2019 American Medical Association. All rights reserved.
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selecting the sample. Additional guidance on handling missing procedural codes is provided
earlier in this chapter.
Survey vendors should check the monthly patient information file to ensure that it does not
include duplicate information—that is, to ensure that a patient does not appear more than once on
the file. If duplicate information is included, the vendor should review the patient information
provided to determine whether multiple survey-eligible surgeries or procedures were performed
for a patient. Unique surgery or procedure entries for each patient should be retained to conduct
Step 3 below. For all other duplicated patient information, make a copy of the monthly patient
information file and remove the duplicate information on the new file. Note that vendors are
required to retain the original monthly patient information files submitted by their client HOPDs
and ASCs, and any new copies made, for possible audits by CMS and the OAS CAHPS Survey
Coordination Team.
When checking the monthly patient information files to identify “duplicate” patients or patients
who may have been listed on the file more than once, vendors should use the patient’s Medical
Record Number (MRN) and at least one other patient data element to check for duplicate cases.
Data elements that will be useful for identifying duplicates include the surgery code(s), patient’s
name, date of birth, telephone number, etc. Using the MRN in conjunction with other patient data
elements will help ensure that patients identified as duplicate patients on the file are indeed
“duplicate” records.
If a patient had more than one surgery or procedure in the sample month, it is to be expected that
he or she will have more than one record in the monthly patient information file. Vendors should
remove the patient’s record associated with a surgery code that is not OAS CAHPS-eligible. If
the patient received procedures on different dates in the month and the procedures on all dates are
OAS CAHPS-eligible, the vendor should remove the records for the earlier procedures and keep
only the latest (most recent) procedure on the sample frame.
The vendor should have a different staff member conduct a QC check on these two processes
(completeness check, removal of duplicates) before proceeding to Step 3.
Step 3: Identify Eligible Patients and Construct a Sampling Frame
After the completeness check and the duplicate patient removal, the survey vendor should verify
the eligibility of the patients. As stated above, HOPDs and ASCs may elect to remove ineligible
patients and surgeries before supplying the monthly patient information file, or may elect to have
their vendor do it on their behalf. Either way, the vendor should do the following:
1. Compute patient age at the time of surgery by use of the date of birth and surgery date.
Verify that the patient was 18 years of age or older at the time of his or her surgery.
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2. Verify that at least one surgery or procedure for each patient is OAS CAHPS-eligible
according to its CPT code(s)16
or G-code(s), the procedures was billed through OPPS, and
that the procedure was not performed in an emergency department.
Note: If a patient record has both eligible and ineligible procedural codes associated with
it, that patient could be eligible for the OAS CAHPS Survey if at least one CPT code or
G-code is eligible.
3. If a patient record has more than one procedural code, determine the primary code.
4. If there are patients with more than one OAS CAHPS-eligible procedure, retain the most
recent patient record (based on the visit date) only.
5. Verify that patients have a U.S. domestic address.
6. Verify that the date of the surgery or procedure is within the sample month.
These six checks align with the Patient Eligibility Requirements listed in Step 1. Patients who fail
any of these verifications are not OAS CAHPS-eligible and should be removed from the sample
frame.
After the completeness and duplication review in Step 2 and the removal of ineligible patients in
Step 3, there is another step that must be performed before creating a definitive sample frame for
the month. That step is to remove all patients who were sampled for OAS CAHPS in the
previous 5 months.
To reduce respondent burden, outpatient surgical patients can only be sampled for OAS CAHPS
once in a 6-month period. Therefore, the survey vendor must also exclude from the sample frame
patients who were included in the OAS CAHPS Survey sample during the 5 months preceding
the sample month. Vendors must compare all eligible patients on the new month’s file to all
patients selected for the survey in the past 5 months and identify any repeats. Such
repeating patients are ineligible and must be removed from the sample frame. This determination
must be made before sampling from the sample frame begins.
For purposes of audit and quality assurance, survey vendors must keep the original monthly
patient information files submitted by all HOPDs and ASCs and the sampling frame created for
each sample month for 18 months. Vendors must record and retain documentation showing the
reasons patients were excluded from the sample frame for each sample month and the quality
16 CPT only copyright 2019 American Medical Association. All rights reserved.
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control checks completed during the sampling process. This documentation will be subject to
review by the OAS CAHPS Survey Coordination Team during site visits.
Step 4: Determine the Sampling Method Most Appropriate for the OAS CAHPS Survey for This CCN
As a reminder, OAS CAHPS
participation within the CCN must be
comprehensive. As stated in Step 1, all
components within the CCN that are OAS
CAHPS-eligible are to be included in
OAS CAHPS. When this chapter
mentions the term “components” it refers
to the definition in the text box.
The components present in the CCN, the volume of eligible patients in each, and analytic goals
of the client CCN dictate which sampling method is most appropriate. There are four acceptable
sampling methods for OAS CAHPS:
• Simple random sampling method;
• Stratified systematic sampling method;
• Proportionate stratified random sampling method; and
• Disproportionate stratified random sampling method.
Simple Random Sampling (SRS) Method
Appropriate use: When there is a single component within the CCN.
Example: Northshore Ambulatory Surgery Center sees about 400 patients per month. It does not
share the CCN with any other surgery centers and has only one location.
Stratified Systematic Sampling (SSS) Method
Appropriate use: There are two or more components (strata) within the CCN and patients from
all components need to be included in the OAS CAHPS sample proportionally to their volume in
the CCN to make a valid sample. However, the strata are small or the facility does not wish to
track results at the strata level.
Example: ABC Surgery Center comprises three locations (strata). They all bill under the same
CCN. Location A served 100 eligible patients in the sample month, Location B, 140, and
Location C, 80 eligible patients in the sample month, for a total of 320 eligible patients.
Definition of “Component” Used in This Chapter
Components of an HOPD: Any departments,
locations, or other divisions that meet the definition of
an OAS CAHPS-eligible HOPD and that bill under the
hospital’s CCN.
Components of an ASC: Any departments, locations,
or centers that are within or associated with the eligible
ASC and that bill under the ASC’s CCN.
For sampling purposes, components are considered
sampling strata.
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48 Centers for Medicare & Medicaid Services Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual
Proportionate Stratified Random Sampling (PSRS) Method
Appropriate use: There are two or more components (strata) within the CCN and patients from
all components need to be included in the OAS CAHPS sample proportionally to their volume in
the CCN to make a valid sample. Additionally:
• the HOPD or ASC would like to keep track of samples and results for each stratum, or
• the HOPD or ASC would like to designate other aggregates of operating units for tracking
while using the same sampling rate for each.
Example: Any-City Best Care Surgical Center comprises three locations (strata) but they all bill
under the same CCN. These patients were located in Facility A, which serves 200
patients/month, Facility B, which serves 150 patients/month, and Facility C, which serves 180
patients/month. Facility A has been in operation for 10 years, but Facilities B and C were opened
in the last 2 years. Any-City Best Surgical Center wants the survey estimates from each location
to have statistical precision and would like to track them separately over time.
Additional requirements and limitations: A minimum of 10 eligible patients must be in each
stratum for PSRS sampling to be used. The statistical precision of survey results at the stratum
level will not be very good unless the stratum sample size is about the size of the overall sample
requirements (25 completed surveys per month).
Disproportionate Stratified Random Sampling (DSRS) Method
Appropriate use: There are two or more components (strata) within the CCN and the CCN
wishes to achieve statistically precise survey estimates for the component facilities.
Example: Memorial Hospital includes three eligible outpatient departments (strata): Same Day
Surgery (120/month), Outpatient (100/month), and Endoscopy (40/month). Memorial wants each
department’s survey estimate to have statistical precision.
Additional requirements and limitations: A minimum of 10 eligible patients must be in each
stratum for DSRS sampling to be used. The goal of the DSRS is to obtain sufficient statistical
power to detect differences at the stratum level. Vendors wishing to use DSRS must submit an
Exceptions Request Form to the OAS CAHPS Survey Coordination Team and receive approval
from CMS prior to using this method.
Deciding Which Method to Use
The facility, in conjunction with the vendor, should determine which of the four OAS CAHPS-
approved sampling methods described above is most appropriate for their CCN and meets the
analytic needs of the facility. Unless DSRS has been approved for use, if there are two or more
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components with the CCN either SSS or PSRS must be used. SRS may not be used if there are
two or more components.
The same sampling method must be used for all sample months in the quarter. Vendors may
switch to a different sampling method only at the beginning of a new quarter.
Step 5: Determine the Ideal Sample Size, Calculate the Sampling Rate, and Select the Sample
Determine the Ideal Sample Size
The target for the statistical precision of OAS CAHPS Survey results that will be publicly
reported is based on a reliability criterion. The reliability target for the OAS CAHPS Survey
ratings and most of the composites is 0.8 or higher. For reasons of statistical precision, a target
minimum of 300 completed OAS CAHPS Surveys has been set for each HOPD or ASC over
each 12-month reporting period. This is an average of 25 completed surveys per month.
The mode of survey administration will be an important factor in determining sample size and
response rates. Table 4.2 shows response rates by mode that are anticipated for OAS CAHPS and
the sample sizes needed based on these rates.
Table 4.2 Response Rates Obtained by Mode Anticipated for OAS CAHPS
Mode Expected Response Rate Sample Size for 25 Responses/Month
Mail only 28% 90
Phone only 24% 105
Mixed 38% 66
The sample size estimates above were derived using the following formula:
Sample size = (number of responses needed) (response rate) = 25 (response rate)
where the value used for the number of responses needed is 25. These sample size estimates have
been rounded up to the nearest integer. Each vendor should work with its client HOPD or ASC
and use experience on other surveys with similar populations to determine the appropriate data
collection mode and expected response rate to use as a guide for calculating monthly sample
sizes.
Calculate the Sampling Rate
Survey vendors must calculate a sampling rate and use that rate to ensure that an even
distribution of patients is sampled over a 12-month period. To calculate the sampling rate,
vendors will need to have a good estimate of the size of the sample frame. The typical frame size
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will depend on the number of patients served by the HOPD or ASC and the percentage of these
patients and surgeries and procedures that are OAS CAHPS-eligible.
Vendors should expect that there will be variability in the number of patients the HOPD or ASC
serves and the number eligible for the survey because these characteristics vary over time. In
some cases there could be seasonality to surgeries, depending on the mix of patients served by
different HOPDs or ASCs. The number of patients to be selected each month to yield a minimum
of 300 annual completed surveys will vary from month to month depending on the number of
eligible patients submitted to the vendor and the sampling rate that is applied.
The sampling rate must be approximately the same for each month in a quarter. The rate may be
increased in subsequent months to achieve the target of 300 annual completed surveys, but
should not be decreased simply to avoid exceeding 300 completed surveys.
The survey vendor should estimate a sampling rate by working with its client HOPDs and ASCs
to understand the number of patients served and how many of them will typically be eligible, as
described below.
Using Prior Months From the HOPD or ASC in the Calculation of the
Sampling Rate
The vendor should work with the HOPD or ASC prior to the first sample month that the HOPD
or ASC begins its participation in the OAS CAHPS Survey to estimate the sample frame size.
This sample frame size should be estimated from the number of patients served monthly and the
percentage of those patients, and surgeries and procedures that are OAS CAHPS-eligible. The
HOPD or ASC should supply to the vendor monthly patient information files with all the
required data elements (see Table 4.1) for each of the preceding 3 to 6 months. The more months
the facility provides, the better the vendor will be able to estimate sample frame size and its
variability. A single month can be nonrepresentative of an HOPD’s or ASC’s patient size or
surgeries and procedures performed, so consider a range of months to guard against estimating
sampling rates that will yield a sampling frame that is either too large or too small.
In looking at the sample frame information for the 3 to 6 months that precede the first sample
month of participation, the vendor should apply the same sample frame construction criteria for
each month that it would apply for the first sample month. Note that in the first month’s sample
file, the rule that a patient cannot be sampled more than once in the 6-month period will not be a
constraint. In the second month of the 3- to 6-month test period, all patients sampled in the first
month will be excluded from the frame. Only patients not sampled the previous sample months
can be included on the sample frame for the second (and subsequent) month(s).
Once the vendor has a good understanding of the average monthly frame size, it should calculate
the sampling rate using the formula
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Sampling rate = (Required sample size) (frame size)
The required sample size, as explained above, is
Required sample size = (number of responses needed) (response rate)
Adjustments to the sampling rate may be needed over time to reach the annual target of 300
completes over each of the rolling four quarter periods. However, sampling rate should not
fluctuate wildly between months. All patients sampled in a sample month must be surveyed. The
target of 300 completed surveys is not a quota after which surveying or processing can stop.
The Purpose of Using a Sampling Rate
Using a sampling rate, instead of a fixed number of patients each month (i.e., target sample size),
helps smooth out the influence of patient characteristics over time. This ensures that patients’
perspective of the care at various points in time is proportionately captured. There is variability
in HOPD and ASC activities over time including the patients served, surgeries performed,
facility staff, and general operations.
Example: Center City Surgical Center is a new participating facility. It provides information
about its historical patient counts to its vendor. The vendor determines Center City Surgical
Center has about 100 eligible patients each month. Based on past experience on the OAS
CAHPS Survey or other work the vendor expects a 30% response rate from these patients. Using
the sample size formula above for this facility, the ideal sample size for a month is:
Required sample size = (number of responses needed) (response rate)
83 patients = (25 completes) (30% response rate)
For a typical month of 100 eligible patients, the vendor would select 83 patients.
In reality, Center City Surgical Center will not have exactly 100 eligible patients each month.
Therefore, the vendor will not select 83 patients each month. Months where there are fewer
eligible patients will yield fewer sampled patients. If the January monthly patient information file
has only 90 eligible patients, the vendor will apply the 83% sampling rate to 90 patients and
sample 75 patients. For a month when the facility has more eligible patients, the sample will be
larger.
Sampling Rates That Yield Above and Below the Minimum Number of
Patients
The targeted number of completed surveys for OAS CAHPS is 300 over a 12-month period.
Some HOPDs and ASCs may want to survey more of their patients. Reasons for doing so include
having more patients represented in the survey results or achieving a reliability target for a
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component within the CCN, a type of patient, or a surgical procedure. There is no upper limit to
the number of patients who may be surveyed for OAS CAHPS. However, the vendor should still
use a sampling rate and select a sample (rather than surveying all eligible patients each month) so
that the sample is evenly distributed across a 12-month period. As a reminder, samples that are
selected disproportionately―that is, with a different sampling rate for different strata―require
approval from the OAS CAHPS Survey Coordination Team via an ERF. As stated previously,
the survey vendor should determine a sampling rate and select the sample so that there is an even
distribution of patients over a 12-month period.
For small facilities with low patient volumes, the number of survey-eligible patients served may
be less than the number required by the sampling rate. In this case, it is acceptable to sample, and
then survey, all survey-eligible patients served during that sample month. For small facilities that
sample all eligible patients (i.e., conducting a census), the survey measures the true value of the
patient population. The survey measures the true value because all patients were selected for the
survey. Large facilities target 300 completed surveys to achieve sufficient statistical precision to
reflect their population of patients. Thus, the ratings for large facilities and the ratings for small
facilities both achieve the statistical precision for the OAS CAHPS Survey results based on the
reliability criterion targeted.
Generation of Random Numbers Needed for Sample Selection
All four methods of sampling approved for OAS CAHPS described in Step 4 require the use of
random numbers. Survey vendors should use a random number generator that is generally
accepted as having satisfied criteria of randomness. The random numbers should be generated
from the uniform distribution―each number having an equal probability of selection. Most
random number generators are pseudo-random number generators that repeat numbers after some
specified period. An acceptable random number generator will repeat only after many billions of
numbers are produced. An important feature of the random number generator is the “seed”
number used to start the cycle. The seed number must be known and retained as part of the
documentation vendors keep so that the sampling process can be reproduced for OAS CAHPS
Survey Coordination Team site visits. The selection of the seed number should be such that it
cannot be manipulated.
Survey vendors should use a reputable statistical program like SAS v9 either to select a sample
from a frame using its procedures for survey sample selection or to generate random numbers
that can be applied as described above. An appropriate seed often used is the clock time as
measured by the computer. This seed varies each fraction of a second but the value used is
documented by the program and is part of the output that can be retained.
Another reliable program, which runs under Windows, is RAT-STATS, developed by the
Department of Health and Human Service Inspector General’s Office. Survey vendors can
download this program at no cost from https://oig.hhs.gov/compliance/rat-stats/index.asp.
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In addition to the RAT-STATS program, survey vendors may download a detailed user’s guide
and comprehensive manual describing how this program operates. There are many sampling
tools in the program. One module can simply produce a sample size, n, random integers between
1 and the frame size, using the computer clock to generate the seed, which is retained and
reported.
Both SAS and RAT-STATS are examples of readily available, high-quality, rigorously tested
tools for selecting samples randomly. Commonly available spreadsheet programs also have
random number generators; however, they do not use these random number generators when
selecting monthly samples for the OAS CAHPS Survey because they do not generate a report of
the seed used. Note, however, that a spreadsheet is an acceptable way to present and manipulate
the sample frame.
It is also especially critical to document how the random start number was generated and how the
sample frame was sorted for survey oversight purposes. During oversight telephone calls or site
visits, the OAS CAHPS Survey Coordination Team will check each vendor’s sampling
procedures and documentation, including documentation of all quality control checks conducted
by vendor staff.
The following are two acceptable ways to choose a random sample of patients from the sample
frame for the OAS CAHPS Survey.
Method 1—Generate N Random Numbers
Sort the sample frame of N eligible patients by any replicable method.
• Generate the N random numbers.
• Assign the random numbers in the order generated to each element in the frame.
• Re-sort the elements as ordered by the random numbers.
• Select the first n, the sample size required for the mode used.
In this way, the initial sort of the data does not affect the result, although a standard sort order
should always be used so that it does not appear that a frame has been altered. This method
requires generating as many random numbers as there are patients on the frame.
Method 2—Generate n Random Numbers
If the random number generator is able to produce integers from a range of values, given that N
is the size of the sample frame of eligible patients, we can use the following steps to select our
sample.
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• Generate n distinct random integers whose values range from 1 to N, where n is the
sample size required for the mode used.
• Select the element of the frame that corresponds to the random number generated. For
example, if the random number 10 is generated then select the 10th element on the frame
for the sample.
• Continue selection of elements according to the random numbers generated until all n
distinct elements have been selected.
For Method 2, the initial sort of the data does affect the result, and the vendor should clearly
document any sorting or file manipulation that occurred prior to random number generation.
Either Method 1 or Method 2 may be used for SRS, PSRS, or DSRS.
Method of Simple Random Sampling
Appropriate Use: SRS can be used when there is a single component within the CCN. For
example, if there is only one eligible HOPD in the hospital’s CCN or only one location in the
ASC’s CCN, SRS can be used.
Example: Northshore Ambulatory Surgery Center sees about 400 patients per month. It does not
share the CCN with any other surgery centers. From looking over the past 3–6 months it is
revealed that on average 350 patients per month are OAS CAHPS-eligible. Northshore is
required to obtain 25 completed surveys per month (300 completed surveys / 12 months = 25
completed surveys per month). Because the surgery center will be doing mixed-mode data
collection to which a 38% response rate is expected, it will need to sample 65.8 patients per
month (25 completes / .38 response rate = 65.8 selected patients), which is rounded up to 66.
Northshore’s sampling rate is 65.8/350, or 18.8%.
Use either Method 1 or Method 2 for selecting the patients from the sample frame.
If Method 1 is used, sort the month’s eligible patient list by the random number and select the
first 66 patients. If Method 2 is used, generate 66 random numbers between 1 and 350. Select the
elements from the frame that correspond to the random numbers generated.
Method of Stratified Systematic Sampling
Appropriate Use: Vendors may use SSS when a CCN comprises two or more strata and patients
from all strata need to be included in the OAS CAHPS sample proportionally to their volume in
the CCN to make a valid sample. SSS is appropriate when the strata are small or the facility does
not wish to track results at the strata level.
There are two variations to implement the SSS sampling method:
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• Variation 1 (SSS1): The same sampling rate is applied to each stratum; it is equivalent to
PSRS. In SSS1, a same skip pattern (for example, picking one and skipping 4) is applied
in each stratum; in PSRS, first calculate the number of patients selected from each
stratum proportionally to eligible patient volumes, then select patients independently
within each stratum. Both methods may yield exactly the same number of patients
selected but may be slightly different because of rounding.
• Variation 2 (SSS2): Different sampling rates are applied to different strata; it is
equivalent to DSRS. Similar to SSS1, both methods may yield exactly the same number
of patients selected but may be slightly different because of rounding.
Example: ABC Surgery Center comprises three locations but they all bill under the same CCN.
Location A served 100 eligible patients in the sample month. Location B served 140 eligible
patients in the sample month. Location C served 80 eligible patients in the sample month. There
are 320 eligible patients in this sample month. Assume the vendor expects a 40% response rate.
The vendor will want to sample 63 patients each month to ensure about 25 completed surveys
each month to total approximately 300 completed surveys in a 12-month period.
63 patients * 40% response rate = 25 completed surveys
25 completed surveys *12 months = 300 completes in a year
The vendor needs to sample 63 patients in total from ABC Regional Medical Center, but the
locations A, B, and C should be representative (proportionate) in this total. The vendor should
calculate the proportion of patients from each location, as shown in Column B. The vendor
should then allocate the 63 patients proportionally to each location, as shown in Column C.
A.
Patient Count
B. Proportion of Patients on
Frame (Column A/320)
C. Number of Patients to be
Sampled (63 x Column B/100)
(numbers rounded up)
Location A 100 31.25 19.69 (round to 20)
Location B 140 43.75 27.56 (round to 28)
Location C 80 25.00 15.75 (round to 16)
Total 320 100.00 64.00
Although the vendor’s goal was to get 63 patients, it is important to round up to the next highest
integer. In this example, the sum in column C shows the total sample size ends up being 64
patients. Rounding down could result in not achieving the target of 300 completed interviews.
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Once the vendor knows how many patients to sample from each location, it will apply the
systematic sampling process to the sample frame for each location. First, the vendor will need to
select a starting observation. To do this the vendor should use a random number generator to
apply random numbers to all frame members. Then the vendor should find the lowest random
number, and the corresponding frame member will be the first sample member and be the starting
point of the systemic sample. Next, the vendor needs to calculate the size of the interval. For
Location A, the frame has 100 patients and 20 need to be sampled. The interval will be 100 / 20
= 5. The vendor will take Sample Member #1 based on the random number generation. Say
Patient #19 had the lowest random number and was the first patient selected. Using the interval
of 5, the vendor will go down the list and select Patient #24, then Patient #29, Patient #34, and so
on until 20 patients are selected. If the starting number is toward the bottom of the list (e.g.,
Patient #90), the vendor would go to the top of the list and continue down again, considering the
list to be circular.
Vendors should not allow a patient to be selected multiple times. No sorting should occur. After
selecting the 20 patients from Location A, the vendor should repeat this process on the list of
eligible patients from Location B and on the list of eligible patients from Location C. The interval
will always be 5.
Method of Proportionate Stratified Random Sampling
Appropriate use: There are two or more components (strata) within the CCN and patients from
all components need to be included in the OAS CAHPS sample proportionally to their volume in
the CCN to be a valid sample. Additionally,
• the HOPD or ASC would like to keep track of samples and results for each stratum, or
• the HOPD or ASC would like to designate other aggregates of operating units for tracking
while using the same sampling rate for each.
In PSRS, the same sampling rate must be applied to each stratum included in the sample. The
strata created must be large enough to support the same sampling rate in each stratum.
Example: Any-City Best Care Surgical Center comprises three locations (strata) but they all bill
under the same CCN. The surgical center serves 530 patients per month, across Facility A, which
serves 200 patients/month, Facility B, which serves 150 patients/month, and Facility C, which
serves 180 patients/month. Facility A has been in operation for 10 years, but Facilities B and C
were opened in the last 2 years. Any-City Best Surgical Center wants the survey estimates from
each location to have statistical precision and would like to track them separately over time.
These facilities each serve as a stratum for sampling. The vendor for this ASC selected a
sampling rate of approximately 45%, based on its prior experience with this client facility.
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The sampling rate for the CCN as a whole is 45%, to get 239 sampled patients in the sample
month. Then the vendor will apply that same sampling rate to each stratum, as demonstrated
below:
• Location A: 200 eligible patients * 45% sampling rate = 90 patients sampled
• Location B: 150 eligible patients * 45% sampling rate = 68 patients sampled
• Location C: 180 eligible patients * 45% sampling rate = 81 patients sampled
The vendor would round any fractions of a patient up to the next largest whole number. For
example, a sample of 67.5 patients should become 68 sampled patients. The vendor should use
Method 1 or 2 to select the sample of 90 patients in Location A, 68 patients in Location B, and 81
patients in Location C.
This vendor uses mixed-mode administration and expects a response of rate of 40% (see
Table 4.2). If the vendor achieves a response rate of 40% the number of completed surveys will
be as follows:
• Location A: 62 patients sampled * 40% Response Rate = 36 completed surveys
• Location B: 68 patients sampled * 40% Response Rate = 28 completed surveys
• Location C: 81 patients sampled * 40% Response Rate = 33 completed surveys
The total number of completed surveys from this CCN in the sample month is 97, which greatly
exceeds the number of responses needed to get 300 completed interviews. Additionally, each
stratum (location) has 25 or more completed surveys and is on target to achieve 300 completed
surveys in the 12-month period. There will be adequate statistical precision to track estimates for
each location.
Even if a facility does not have a large number of eligible patients in each stratum, it may still
use PSRS. It may not achieve enough completed surveys in a stratum to have good statistical
precision, but may still proceed so long as each stratum has a minimum of 10 sampled patients
each month.
Method of Disproportionate Stratified Random Sampling
Appropriate use: DSRS is another appropriate sampling option if a hospital, for example, with
multiple HOPDs wishes to achieve statistically precise numbers for each HOPD. To achieve as
good a level of precision for the separate units (in this example, the HOPDs) as required for the
CCN as a whole, each unit would have to have the same number of completed surveys as the
CCN as a whole. In this case, the sampling rate may be different for each stratum. To allow the
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separate strata to be recombined to represent the HOPD or ASC as a whole the sampling rate for
each stratum must be reported in the data submitted to the OAS CAHPS Survey Coordination
Team. This will permit appropriate weighting of the respondents in computing results. Different
sampling rates in strata with particularly high or low ratings could otherwise distort the ratings.
If an HOPD or ASC chooses to use DSRS, its survey vendor must do the following:
• Complete and submit an ERF;
• Use the same name for each stratum in each month in the quarter;
• Make sure that each stratum has a minimum of 10 patients eligible to be included in the
survey during the sample month; and
• Provide to the OAS CAHPS Data Center additional information about each stratum,
including the following:
◦ The name of the stratum;
◦ The total number of patients sampled in each stratum during the sample month;
◦ The total number of patients on the file submitted by the HOPD or ASC for that
stratum;
◦ The number of patients in the stratum who were eligible for the survey during the
sample month; and
◦ The total number of patients sampled during each sample month.
Example: Memorial Hospital includes three eligible outpatient departments (strata): Same Day
Surgery (120/month), Outpatient (100/month), and Endoscopy (40/month). Memorial wants
statistically precise survey estimates for each department. Assume that the target for each stratum
is the same as for the CCN as a whole, that 25 is the target number of responses, and that the
expected response rate is 40%. Therefore, to get the same precision for each stratum the sample
size would be 62 for each of the three strata in this example. Because of the differing patient
volumes for these departments, the vendor’s sampling rate to achieve a sample size of 62 varies,
as shown below:
• Same Day Surgery: 120 eligible patients * 51% sampling rate = 62 sampled patients of
whom 40% respond to get 25 completed interviews.
• Outpatient: 100 eligible patients * 62% sampling rate = 62 sampled patients of whom
40% respond to get 25 completed interviews.
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• Endoscopy: 40 eligible patients * 100% sampling rate = 40 sampled patients of whom
40% respond to get 16 completed interviews.
Note that the survey vendor will report the number of patients eligible for the survey and the
number sampled to the OAS CAHPS Data Center for use in computing weights for the HOPD or
ASC when the data are combined (this information is provided in the vendor’s data submission,
see Appendix L, XML File Layout for DSRS Header Record. Patients in Location A had a
lower probability of selection than those in Locations B and C, and that will be accounted for
when the data from sample members in the strata are combined. Survey vendors should keep in
mind that a minimum of 10 eligible patients must be in each stratum for DSRS sampling to be
used.
The goal of the DSRS process is to obtain about 300 completed interviews for each stratum (e.g.,
location) in the 12-month period. This will provide sufficient statistical power to detect
differences at the stratum level. In this example, Location C will have lower statistical power
because the number of completes (only 16 are expected) will probably not reach 300 in the 12-
month period because of the lower number of eligible patients.
Step 6: Verify or Update Contact Information for Sampled Patients
We strongly recommend that survey vendors send patient mailing addresses of sampled patients
through an outside address service, such as the National Change of Address or a similar provider,
to confirm or update patient contact information. In addition, vendors conducting either a
telephone-only or mixed-mode data collection are urged to send the most updated mailing
addresses through a telephone number provider service to attempt to obtain an updated telephone
number. Performing these quality control activities prior to the start of data collection will result
in fewer surveys returned as undeliverable and fewer unproductive telephone call attempts.
Vendors are also reminded that in Step 2 they were to request contact information for all patients.
If an HOPD or ASC does not provide an address or telephone number for a patient on the
monthly patient information file and this omission was not rectified in Step 2, the vendor should
recontact the HOPD or ASC for the missing information for all patients contained on the
HOPD’s or ASC’s original data file. Asking for the information for all patients is important
because the vendor may not reveal to the facility which patients were selected for OAS CAHPS.
The vendor should also attempt to find an address and phone number for the sampled patients
who lack it. In most cases an HOPD or ASC will have the patient’s telephone number that was
obtained for the purpose of calling them to follow up on their recovery.
Vendors should also note that even if an address or telephone number cannot be obtained for a
patient, the patient is still eligible for inclusion on the sample frame (and in the survey if
sampled) if he or she meets all other survey eligibility criteria. That is, patients with missing
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mailing addresses are considered eligible for the survey and can be sampled. If a patient sampled
for a mail-only survey lacks an address the patient should be assigned the survey disposition
code of 330—Bad Address/Undeliverable Mail or No Address. If a patient sampled for a
telephone-only survey lacks a telephone number the patient should be assigned the survey
disposition code of 340—Wrong, Disconnected, or No Telephone Number. If a patient sampled
for a mixed-mode survey has a telephone phone number or an address, the vendor should
proceed with the survey; if the patient has neither, survey disposition code of 340—Wrong,
Disconnected, or No Telephone Number should be assigned.
Step 7: Assign Unique Sample Identification Numbers
Survey vendors are responsible for assigning a unique alphanumeric sample identification (SID)
number to every sample member selected into each monthly sample. Detailed procedures for
assigning unique SID numbers are described in Chapter IX.
Vendors will track the status of a sampled patient/case throughout the data collection process
using the SID. Note that this number is different from the medical record number that HOPDs
and ASCs will provide to the survey vendor with other information needed to construct the
sample frame. The SID number cannot contain any combination of letters, numbers, or any
information that could link it with a particular sampled patient. For example, no part of the
patient’s name, address, date of birth, telephone number, Social Security number, visit dates, or
Medical Record Number can be used or included in the SID number under any circumstances.
The SID number also cannot include any information that would identify the HOPD or ASC that
served the patient (i.e., HOPD’s or ASC’s name, address, CCN). Each month, vendors must use
a new set of unique SID numbers for the new set of patients sampled that month. Vendors must
not reuse the same SID numbers—that is, once the SID number is assigned, it should never be
assigned again to any sampled patient, either in the current quarter or in subsequent quarters.
Step 8: Finalize the Monthly Sample File and Initiate Data Collection Activities
As soon as the sampling activities described above have been completed, data collection for the
sample month should begin. Survey vendors must initiate the survey for each monthly sample
within 3 weeks (21 days) after the end of the sample month. Exceptions to this start date are
noted earlier in this chapter. All data collection for each monthly sample must be completed
within 6 weeks (42 days) after data collection begins. For mail-only and mixed-mode surveys,
data collection for a monthly sample must end 6 weeks after the first questionnaire is mailed. For
telephone-only surveys, data collection must end 6 weeks following the first telephone attempt.
As noted earlier in this chapter, HOPDs and ASCs must provide the patient information file for
each sample month in time for the survey vendor to initiate the survey within 21 days after the
sample month closes. The HOPD or ASC can choose to submit the data needed on two separate
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files. The first file must contain all patient information that the vendor will need to determine the
patients’ eligibility for the survey and for fielding the survey. The second file may contain
information needed at the facility level for analysis, and it must be submitted to the vendor in
time for the vendor’s data submission to the OAS CAHPS Data Center.
Requirement That the First File Contain All Patient Information
The survey vendor needs to receive all patient and patient procedure information in the first file
and follow the process (described in Step 1) to remove known ineligible patients and procedures
from the frame so they are not sampled. Survey vendors should not initiate the OAS CAHPS
Survey to all patients and determine at a later date which patients had a procedure that was OAS
CAHPS-eligible. Consultations, preadmission tests, or follow-up tests are examples of ineligible
procedures. In general, vendors should use CPT17
codes and G-codes as described in Step 1 to
determine if the surgery is OAS CAHPS-eligible but other methods may suffice. An example of
another method that could suffice is if a facility performed a limited set of procedures and all
were eligible. Please consult the OAS CAHPS Survey Coordination Team for guidance about the
method you would like to use in lieu of CPT coding to determine procedure eligibility.
If procedure ineligibility is revealed during data collection, a sampled patient can be given a
status code of ineligible. Nevertheless, survey vendors must have a process that excludes known
ineligible patients and procedures before the survey is initiated with them.
Preventing patient confusion is one reason for this policy. The OAS CAHPS Survey directs
sample patients to think about the procedure that they had on a particular date. Experience shows
that patients whose reference date was for a secondary visit (e.g., preadmission test) and not a
procedure, or patients whose procedure was not OAS CAHPS-eligible, were confused by the
questionnaire topics.
The second main reason for this policy is that it ensures that the OAS CAHPS data reflect patient
experience with a surgery or procedure itself. If a patient is sampled for an ineligible procedure
his or her questionnaire data will fail to reflect the desired measures. Furthermore, patients may
only be sampled once every 6 months. If they are sampled for a visit that is later found out to be
ineligible, it is no longer possible to sample the eligible procedure visit.
Sampling Issues and Errors
Based on national implementation of other CAHPS Surveys and the OAS CAHPS Survey, CMS
and the OAS CAHPS Survey Coordination Team have observed some common misconceptions
17 CPT only copyright 2019 American Medical Association. All rights reserved.
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and problems with the sampling process. The following is a list of some of these common
misconceptions, paired with the proper implementation method that survey vendors should use to
avoid these issues during the sampling process.
Patient Eligibility Criteria
1. Misconception: Patients with missing or incomplete mailing addresses or telephone numbers
are considered ineligible for the OAS CAHPS Survey.
Correct Implementation: Patients whose address is not a U.S. domestic address are
ineligible, but if they have an address that is missing or incomplete, or if their telephone
number is missing or incomplete, they are eligible to be included in the OAS CAHPS Survey
if they meet all other survey eligibility criteria. Vendors should attempt to obtain complete
contact information. We also recommend that survey vendors use address or telephone-
lookup services to confirm or obtain sample patients’ mailing address or telephone number. If
an address cannot be obtained the case should be finalized as a noncomplete of 330—Bad
Address/Undeliverable Mail or No Address, not as ineligible.
2. Misconception: If the HOPD or ASC did not serve any patients who met survey eligibility
criteria, it does not need to submit a sample file to its OAS CAHPS Survey vendor for that
sample month or notify the vendor in any way.
Correct Implementation: HOPDs and ASCs participating in the OAS CAHPS Survey
should submit a monthly patient information file to their survey vendors for each sample
month or send an e-mail notification if no survey eligible patients were served in a particular
sample month. The survey vendor must, in turn, submit an OAS CAHPS data file to the OAS
CAHPS Data Center for each sample month. Otherwise the HOPD or ASC will be considered
to have “missed” a month of survey participation.
3. Misconception: There is a variable called “number of eligible patients” that is part of
vendors’ data submission to the OAS CAHPS Data Center. To determine the value for that
variable, vendors should remove patient records that were later identified as deceased or
reported that they did not receive care from the HOPD or ASC.
Correct Implementation: The “number of eligible patients” variable on the XML file must
reflect the number of presumed eligible patients who were included on the monthly patient
information file. Patients who were later identified as ineligible for the survey during the data
collection period should be noted by their final survey disposition code and should not be
removed from the “number of eligible patients” count.
4. Misconception: Patient age can be calculated based on their age as of the beginning of the
sample month.
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Correct Implementation: Patient’s age must be calculated based on their age on the date of
surgery.
5. Misconception: If a patient record has multiple procedural codes that are both eligible and
ineligible for the OAS CAHPS Survey, the patient is ineligible for the survey.
Correct Implementation: If a patient record has both eligible and ineligible procedural
codes associated with it, it could be eligible for the OAS CAHPS Survey if at least one
procedural code is eligible and the record meets all other eligibility criteria. In other words,
the presence of an ineligible procedural code in a series of codes for a patient record does not
make that patient record ineligible for OAS CAHPS.
Sampling Procedures and Documentation Requirements
1. Misconception: It is acceptable for a survey vendor to use only the patient’s medical record
number (MRN) to identify patients who may have been listed more than once on a monthly
patient information file or to identify patients who have been sampled in the last 5 months.
Correct Implementation: Survey vendors are urged to use more than one variable to
identify patients for whom duplicate information is provided on the monthly patient
information file and to identify patients who have been sampled in the last 5 months. Using
the MRN together with another variable, including surgical code, date of procedure, patient
name, date of birth, telephone number, or address will ensure that the correct patient is
identified. Vendors may choose to perform the de-duplication process in multiple steps.
However, the MRN should never be applied as the sole variable in any of the steps; that is, it
should always be combined with another patient variable.
2. Misconception: SID number can be assigned more than once.
Correct Implementation: Once the SID number is assigned, it must never be used again. If a
patient is sampled more than once, a new SID number must be assigned to that patient each
time he or she is sampled. During the sampling process, all vendors should check the sample
file to make sure the same SID number is not assigned to two different patients and that the
SID has not been assigned in a preceding sample month.
3. Misconception: A survey vendor can conduct a census survey of all eligible patients during
the first sample month that an HOPD or ASC administers the OAS CAHPS Survey;
therefore, the survey vendor does not have to conduct the survey for the next 5 months.
Correct Implementation: As described in this chapter, survey vendors must select and
survey a sample of patients each sample month, including for very small HOPDs and ASCs.
Using a sampling rate and selecting a sample of patients each sample month will ensure that
an even distribution of patients is surveyed across a 12-month period.
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4. Misconception: The sampling rate should be adjusted each month.
Correct Implementation: Survey vendors should adjust the sampling rate at the beginning
of a quarter unless the number of patients served is dramatically different (either lower or
higher) than for the preceding months in the quarter. The sampling rate should remain
constant during a quarter. If there is a huge difference in the number of patients served in a
month within a quarter, the survey vendor should follow up with the HOPD or ASC to make
sure that the information on the file is correct and determine the reason for the difference.
5. Misconception: The seed number (or random numbers generated) do not need to be saved.
Correct Implementation: Documentation of the seed number and the random number
generation and application process is a critical component of the OAS CAHPS sampling
protocols, as samples must be replicable for OAS CAHPS site visit team review.
6. Misconception: It is not necessary to retain documentation of ineligible sample members.
Correct Implementation: Vendors should retain a separate file or list of each patient
deemed ineligible and the reason the patient did not meet the eligibility criteria. This
information allows someone other than the person who selected the sample to conduct quality
control of the sample, checking to make sure the right patients were excluded. This
information is also subject to review during site visits.
Processing Patient Administrative Data
1. Misconception: If an HOPD or ASC changes or switches vendors, the current OAS CAHPS
Survey vendor must provide a file containing patient information about all patients sampled
in the preceding sample months so the new vendor can exclude those patients from the
sample frame.
Correct Implementation: OAS CAHPS Survey vendors are not required to provide the new
vendor with a file containing information about patients sampled in the last 5 months.
Sampling Quality Control Procedures
1. Misconception: Survey vendors that have automated the receipt and processing of monthly
patient information files and the sample selection process do not need to implement any
quality control procedures, because the programs and algorithms used for these processes
were fully tested after they were developed.
Correct Implementation: All survey vendors must have in place and implement quality
control procedures on the entire sampling process, including receipt and processing of the
monthly patient information files and sample selection for each sample month for each
HOPD or ASC client. This includes vendors that use automated systems/procedures for
sampling. One way to identify problems with the receipt or processing of a monthly patient
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information file is to look at the history of the numbers of patients served and who met
survey eligibility requirements in preceding sample months.
If the numbers of patients served or eligible on the monthly patient information file is very
different from the numbers provided on files submitted in preceding months, this may be a
good indication that there may be a problem with the monthly patient information file
received. If there is an extreme variation in the number of patients served/eligible from one
month to the next, vendors are encouraged to contact the HOPD or ASC to determine the
reason for the extreme difference in numbers.
2. Misconception: Survey vendors may use the same staff who conduct the sampling process to
conduct quality control checks of the sample.
Correct Implementation: The quality control of each sample file should be performed by
someone other than the person who performed each task associated with the sample selection
process. Vendors are also encouraged to apply appropriate quality control checks on and test
all of the computer programs and systems the vendor uses to receive and process monthly
files.
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Centers for Medicare & Medicaid Services 67 Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual
V. MAIL-ONLY ADMINISTRATION PROCEDURES
Overview
This chapter describes the requirements and guidelines for implementing the mail-only mode of
survey administration for the Outpatient and Ambulatory Surgery CAHPS (OAS CAHPS)
Survey. The chapter begins with a discussion of the mail survey protocol and schedule, followed
by a discussion of the requirements for producing all mailing materials, including questionnaires,
cover letters, and envelopes. Guidelines on how the questionnaire packages should be mailed and
data processing guidelines, including optical scanning and data entry, are provided in this
chapter. This chapter also provides suggestions for incorporating quality control activities into
the mail-only mode of survey administration. In this manual, patients included in the sample are
usually referred to as “sample members” or “patients.” However, in discussions of survey
processing and systems they may be referred to as “cases.”
Data Collection Schedule
Data collection for each sample member must be initiated no later than 3 weeks (21 days) after
the close of the sample month. The timing of a mail-only administration process is shown in
Table 5.1.
Questionnaires returned after the 6-week data collection period has ended should be considered
nonresponses and coded as such. Data collection must be closed for a sampled patient by six
weeks (42 calendar days) following the initiation of the survey.
Table 5.1 Mail-Only Administration Schedule and Protocol
Activity Timing
Mail initial questionnaire with cover letter to sample members
No later than 3 weeks (21 days) after the close of the sample month
Mail second questionnaire with cover letter to all sample members who do not respond to first questionnaire mailing
Approximately 3 weeks (21 days) after the first questionnaire is mailed
Complete data collection Six weeks (42 days) after the first questionnaire is mailed
Submit data files to the OAS CAHPS Data Center via the OAS CAHPS Survey website
The second Wednesday of January, April, July, and October
If the 21st day of the month falls on a weekend or holiday, vendors should make every attempt to
begin the survey on the business day prior to that weekend or holiday. However, it is acceptable
to mail the questionnaire on the first business day following the weekend or holiday if necessary.
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If for some reason the survey cannot be initiated within 21 days after the sample month ends, the
vendor can initiate the survey within 26 days after the sample month ends. Vendors that initiate
the survey between 22 and 26 days after the sample month ends must complete and submit a
Discrepancy Notification Report (Chapter XV) to the OAS CAHPS Survey Coordination Team.
If the survey cannot be initiated within 26 days after the close of the sample month, CMS may
allow it to be initiated more than 26 days after the sample month ended. However, survey
vendors must first request permission and obtain approval from CMS to do so via an e-mail to
the OAS CAHPS Survey Coordination Team, copying their hospital outpatient department
(HOPD) or ambulatory surgery center (ASC) client. The e-mailed request should include the
HOPD or ASC’s name and CCN, explain the reason for the delay, state when the vendor will (if
approved) initiate the survey, specify the affected sample month, and request CMS’ approval.
As noted in Table 5.1, data collection must be closed 42 calendar days after the first
questionnaire is mailed. Note as well that the deadline for data submission is constant. This
deadline will not shift later if the vendor starts data collection late.
Questionnaires, Letters, and Envelopes
Currently, the mail survey version of the instrument is available in English, Spanish, Chinese,
and Korean. All versions of the survey materials are available on the OAS CAHPS Survey
website at https://oascahps.org/ .
Copies of the mail survey instrument and sample mail survey cover letters in English, Spanish,
Chinese, and Korean are also included in the appendices to this manual:
• sample mail survey cover letters, questionnaire and questionnaire in scannable format in
English, Appendix B;
• sample mail survey cover letters, questionnaire and questionnaire in scannable format in
Spanish, Appendix C;
• sample mail survey cover letters, questionnaire and questionnaire in scannable format in
Chinese, Appendix D;
• sample mail survey cover letters, questionnaire and questionnaire in scannable format in
Korean, Appendix E;
• Office of Management and Budget (OMB) Disclosure Notice in English, Spanish,
Chinese, and Korean in Appendix G.
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Outpatient and Ambulatory Surgery CAHPS Survey Questionnaire
The OAS CAHPS Survey questionnaire contains 37 questions. It is available in Appendix B, C,
D and E and available on the OAS CAHPS Survey website at https://oascahps.org/ . Additional
information about content of the OAS CAHPS Survey instrument is provided in Chapter III and
in the table below.
Questionnaire Printing Requirements and Recommendations
The following are formatting and content requirements and recommendations for the OAS
CAHPS Survey Questionnaire. Survey vendors cannot deviate from questionnaire requirements.
Requirement Recommendation
Questions Every questionnaire must begin with the
“core” OAS CAHPS Survey questions
(Questions 1 to 24).
n/a
No changes in wording are allowed to either
the OAS CAHPS Survey questions or to the
response options.
n/a
If HOPDs and ASCs elect to add their own
questions they must follow the guidelines in
Chapter III. In terms of placement of
supplemental questions in the questionnaire,
they must be placed after the “core” OAS
CAHPS questions. They may either be
placed before or after the unit of “About
You” questions. It is acceptable to replace
the skip instruction currently provided in
Q36 of the OAS CAHPS mail survey, “Go to
END,” with the skip instruction, “Go to
Q38,” if the vendor adds the Consent to
Share Identifying Information question or
any supplemental questions to the mail
survey starting with Q38.
n/a
Formatting Questions and associated responses options
may not be split across pages. n/a
Vendors must be consistent throughout the
questionnaire in formatting response options
either vertically or horizontally. If a vendor
elects to list the response options vertically,
this must be done for every question in the
questionnaire. Vendors may not format some
response options vertically and some
horizontally.
n/a
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Requirement Recommendation
No matrix formatting of the questions is
allowed. Matrix formatting means formatting
a set of questions as a table, with responses
listed across the top of a page and individual
questions listed in a column on the left.
n/a
Font size should be no smaller than size 10. We strongly recommend that
size 12 or larger be used.
n/a
Use a two-column format, so
there are two columns of
questions per page.
Vendors should use best survey practices
when formatting the questionnaire, such as
maximizing the use of white space and using
simple fonts like Arial.
If data entry keying is being
used as the data entry
method, small coding
numbers next to the response
options may be used.
ID number A unique, randomly generated sample
identification (SID) number must be
assigned and appear on at least the first page
of the survey, for tracking purposes.
Additional identifiers are permitted.
However, the sample member’s name or
other identifying information must not be
printed anywhere on the survey.
n/a
Translation Only CMS-approved translations of the OAS
CAHPS Survey are permitted. If facilities
choose to add their own supplemental
questions, vendors will be responsible for
translating these questions.
n/a
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Requirement Recommendation
Logo and other
information
about the
HOPD or ASC
The HOPD or ASC name or logo should
appear on the survey or the cover letter but
cannot appear on the envelopes (for privacy),
unless vendors receive prior approval from
CMS via the submission of an Exceptions
Request Form indicating that they have the
facility’s approval to display the name or
logo on the outgoing envelope and the
facility believes there are no HIPAA risks.
Note that survey vendors cannot include any
promotional messages or materials on the
OAS CAHPS cover letter, questionnaire, or
outgoing or incoming mailing envelopes.
This includes indications that either the
facility or the survey vendor has been
approved by the Better Business Bureau.
n/a
The vendor’s name and mailing address
must be printed at the bottom of the last page
of the OAS CAHPS Survey questionnaire, in
case the respondent does not use the
enclosed business reply envelope.
n/a
OMB Number The OMB number shown in Appendix G
must be printed on the questionnaire cover.
If there is no cover, then the OMB number
must be printed on the first page of the
questionnaire.
n/a
Cover Letters (First and Second Questionnaire Mailings) Requirements and
Recommendations
Examples of cover letters in English, Spanish, Chinese, and Korean are provided in the
appendices with the survey instruments (see Appendices B–D). Vendors may choose to develop
their own cover letters as well, provided that the following requirements are met:
Requirement Recommendation
Personalization Cover letters must be personalized with the
name and address of the sample member. n/a
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Requirement Recommendation
Cover letters must contain the date of the
surgery or procedure and the name of the
location where the surgery was received. (The
monthly patient information file must contain
the date of surgery, facility name, and location
name because the name recognized by the
patient may differ from the facility’s official
name.)
n/a
ID Number A unique, randomly generated SID number
must be assigned and appear on the cover letter,
for tracking purposes. Additional identifiers are
permitted.
Separate from
questionnaire
Cover letters must be separate from the
questionnaire, so that no personally identifiable
information is returned with the questionnaire
when the respondent sends it back to the
vendor.
n/a
Content of
letters
The OMB disclosure notice (see Appendix G)
must be printed either on the questionnaire or
in the cover letters.
n/a
Vendors may not offer sample members the
opportunity to complete the survey over the
telephone if the vendor is implementing the
mail-only mode.
n/a
Must contain language describing the purpose
of the survey. n/a
Must contain a statement that participation is
voluntary and will not affect any benefits the
sample member receives or expects to receive.
n/a
Must contain language indicating that responses
from all survey participants will be grouped
together and these grouped data may be shared
with the HOPD or ASC, for purposes of quality
improvement.
n/a
Must contain language stating that if the
respondent needs help in reading the questions
or marking responses, a friend or family
member can assist them.
n/a
Must contain a toll-free customer support
telephone number that will be staffed by the
survey vendor.
n/a
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Requirement Recommendation
Must include a statement that all information
the sampled patient provides will be
confidential and is protected by the Privacy
Act. This sentence is included in all of the
sample cover letters in Appendices B (English),
C (Spanish), D (Chinese), and E (Korean).
n/a
Printing The HOPD or ASC name (or logo) must appear
on the letters or the survey, but cannot appear
on the envelopes (for privacy). Note that survey
vendors cannot include any promotional
messages or materials on the OAS CAHPS
cover letter, questionnaire, or outgoing or
incoming mailing envelopes. This includes
indications that either the facility or the survey
vendor has been approved by the Better
Business Bureau.
n/a
Signature on
the letters
A signature is required. We recommend that the
signature of an
appropriate official from
the HOPD or ASC be
printed on each cover
letter If this is not
possible, the signature
from an appropriate
official at the survey
vendor is acceptable.
Requests for
Survey in
Other
Language
n/a
Survey vendors offering
an English, Spanish,
Chinese, and Korean
version of the
questionnaire may add
language to the English
cover letter indicating that
a version of the
questionnaire is available
in those languages.
Mailing Requirements and Recommendations
Requirements and recommendations are described below. Vendors are expected to follow these
requirements to maximize response rates and ensure consistency in how the mail-only mode of
administration is implemented.
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Requirement Recommendation
Questionnaire
contents
Each questionnaire mailing must contain a
personalized cover letter, questionnaire, and
postage-paid business reply envelope.
n/a
Envelopes Vendors are responsible for supplying both the
outgoing envelopes for the questionnaire
mailings and business-reply envelopes that
sample members will use to return their
completed surveys (i.e., they cannot be supplied
by the HOPD or ASC).
n/a
Mailing
n/a
We recommend that
mailings be sent with
first-class postage or
indicia, to ensure timely
delivery and maximize
response rates.
Addresses Patients must have a U.S. domestic address to be
eligible to participate in the OAS CAHPS
Survey.
n/a
If the sample member’s address is missing or
incomplete, the vendor must follow up with the
HOPD or ASC to obtain the address. If an
address cannot be found, or the address that is
found is too incomplete for mailing, the vendor
should treat the patient as eligible (i.e., the case
should remain in the sample) and assign the
applicable final disposition code to the case:
330 – Bad Address/Undeliverable Mail, or No
Address (see Chapter IX).
To reduce the number of
missing addresses, we
recommend that vendors
verify mailing addresses
obtained from the
facilities using
commercial address
update services, such as
the National Change of
Address or the U.S.
Postal Service Zip+4
software.
n/a
We recommend that
vendors attempt to
identify a new or updated
address using
commercial address
vendors or the Internet
for any mail returned as
undeliverable in time to
include the sample
member in the second
mailing.
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Requirement Recommendation
Schedule Mailings must follow the schedule specified for
the mail-only mode of administration—the first
questionnaire package must be mailed no later
than 3 weeks after the close of the sample
month; the second questionnaire to sample
members who do not respond to the first
questionnaire mailing must be mailed
approximately 3 weeks after the first
questionnaire mailing.
n/a
Data collection must end 6 weeks after the first
questionnaire has been mailed. n/a
Incentives The use of incentives is not permitted. This
includes monetary and nonmonetary incentives. n/a
Data Receipt, Data Entry, and Optical Scanning Requirements
The following guidelines are provided for receiving and tracking returned questionnaires and
entering the data using either data entry or optical scanning.
Requirement
Receipting The date the questionnaire was received from each sample member must be
entered into the data record created for each case on the data file.
Completed questionnaires should be logged into the tracking system in a
timely manner to ensure that sample members who respond to the first
mailing are excluded from the second questionnaire mailing.
Mailings that are returned in the mail as undeliverable must also be logged
into the tracking system. Although not required, we recommend that vendors
attempt to identify a new or updated address using commercial address
vendors or the Internet for any mail returned as undeliverable in time to
include the sample member in the second mailing.
If two questionnaires are received from the same sample member, vendors
should keep and use the questionnaire that has the more complete data,
regardless of which questionnaire is received first. If the two questionnaires
received contain the same amount of data (are equally complete), the vendor
should retain and use the first one received.
A final OAS CAHPS Survey disposition code (see Table 9.1 in Chapter IX)
must be assigned to each case.
Reviewing
received
questionnaires
for problems
Questionnaires should be visually reviewed prior to scanning or data entry
for notes and comments. Vendors should have more than one person who
can code or review comments and attach notes for proper disposition code
assignment.
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Requirement
If a completed mail survey questionnaire is returned and the vendor realizes
that it was completed by proxy (i.e., response option “3 – Answered the
questions for me” is selected for Q37 alone or in combination with other
response options for that question, or there is a note written on the
questionnaire that a family member completed the questionnaire because the
patient had died, had moved to a nursing home, had been incarcerated)
vendors should not key or scan a questionnaire for that sample member. This
is because proxy respondents are not permitted on OAS CAHPS. Vendors
should instead assign the applicable final disposition code to the case based
on the information provided in the handwritten note, or disposition code 320
(Refusal) if no note is included and Q37’s response option “3” is selected.
Proxies are also not permitted for deceased respondents. If a sample member
is found to be deceased, the case should be closed using code 210 –
Deceased.
If a sample member were to die or become ineligible after completing the
questionnaire (vendors might learn of this through a comment written by a
family member on the questionnaire) that questionnaire is still an eligible
complete survey. Vendors should scan the questionnaire and assign the
applicable final disposition code indicating the completed survey.
Duplicate
questionnaires
The key entry process should not permit keying of duplicate questionnaires.
The scanning program should not permit scanning of duplicate
questionnaires.
Out-of-range
or invalid
responses
The key entry program should not permit out-of-range or invalid responses.
The scanning program should not permit out-of-range or invalid responses
Interpreting
blanks and
ambiguous
survey
responses
The following apply for both keying and optical scanning (additional
information about handling blank and ambiguous responses can be found in
Chapter IX):
If a response mark falls between two answer choices but is clearly closer to
one answer choice than to another, select the response that is closest to the
marked response.
If two responses are checked for the same question, select the one that
appears darkest. If it is not possible to make a determination, leave the
response blank and code as “missing” rather than guessing.
If a mark is between two answer choices but is not clearly closer to one
answer choice, code as “missing.”
If a response is missing, leave the response blank and code as “missing.”
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Requirement
Open-ended
responses
The decision on whether to key or scan the responses to open-ended survey
items, specifically, the “Other language” (response option 2) in Q35 and the
“Helped in some other way” (response option 5) in Q37, is up to each
individual HOPD or ASC. Vendors will not be required to key or scan and
include responses to open-ended survey items on the data files submitted to
the OAS CAHPS Data Center.
CMS, however, encourages survey vendors to review the open-ended entries
so they can provide feedback to the OAS CAHPS Survey Coordination
Team about adding additional preprinted response options to these survey
items if needed.
If the vendor includes the Consent to Share Identifying Information question
in the mail survey questionnaire, the vendor is not required to key or scan the
response to that question. However, we do recommend vendors review the
responses to this question for the vendor’s own documentation.
Answers to the Consent to Share Identifying Information question will not
be included on the data files submitted to the OAS CAHPS Data Center.
Staff Training
All staff involved in the mail survey implementation, including support staff, must be thoroughly
trained on the survey specifications and protocols. A copy of relevant chapters of this manual
should be made available to all staff as needed. In particular, staff involved in questionnaire
assembly and mailout, data receipt, and data entry must be trained on:
• use of relevant equipment (case management systems for entering questionnaire receipts,
scanning equipment, data entry programs);
• OAS CAHPS Survey protocol specific to their role (for example, contents of
questionnaire package, how to document or enter returned questionnaires into the
tracking system);
• decision rules and coding guidelines for returned questionnaires (see Chapter IX); and
• proper handling of hardcopy and electronic data, including data storage requirements (see
Chapter VIII).
Staff involved in providing customer support via the toll-free telephone number should also be
trained on the accurate responses to commonly asked questions, how to respond to questions
when customer support does not know the answer, and the rights of survey respondents. If the
OAS CAHPS Survey is being offered in a language other than English, customer support staff
should also be able to handle questions via the toll-free telephone number in that language.
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Telephone interviewer training requirements are described in more detail in Chapter VI of this
manual. Please refer to that chapter for more information on training customer support staff.
Quality Control Guidelines for Mail-Only Survey
The following steps are required or recommended as a means of incorporating quality control
into the mail-only survey administration procedures. Quality control checks should be conducted
by a different staff person than the one who completed the task. Some of these are mentioned
earlier in the chapter.
Required for Mail Protocol
• Check a minimum of 10% of all printed materials to ensure the quality of the printing—
that is, make sure there is no smearing, misaligned pages, duplicate pages, or stray marks
on pages.
• Check a minimum of 10% of all outgoing questionnaire packages to ensure that all
package contents are included and the same unique SID number appears on both the
cover letter and the questionnaire.
• For vendors that are scanning: a sample of questionnaires (minimum of 10 percent)
should be compared with the original hardcopy survey. This serves as a quality control
measure that the scanning program is capturing the hard copy correctly. Any
discrepancies between the scan and the hard copy should be reconciled by a supervisor.
Additionally, the survey responses captured in the database for a sample of
questionnaires (minimum of 10 percent) should be systematically compared to scanned
image for that case. This can be done either by visually examining the scanned image and
the data to reveal inconsistencies or by rescanning and noting whether the data from the
original match the data from the rescan. This serves as a quality control measure that the
scanning program is translating the response marks in the scanned image to the data file
consistently and correctly. Any discrepancies should be reconciled by a supervisor.
• For vendors that are keying: all questionnaires should be 100% rekeyed for quality
control purposes. That is, for every questionnaire, a different keyer should rekey the
questionnaire and the data entry files from the two keyers should be systematically
compared to ensure that all entries are accurate. If any discrepancies are observed, a
supervisor should resolve the discrepancy and ensure that the correct value is stored in
the data.
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Recommended for Mail Protocol
• “Seed” each mailing. That is, include the name and address of designated vendor staff in
each mailing file to assess the completeness of the questionnaire package and timeliness
of package delivery.
• Before submitting XML data to the OAS CAHPS Data Center, we highly recommend
vendors review a sample of cases comparing responses recorded on the hardcopy
questionnaire to responses scanned to the response codes that appear in the XML files.
This quality control step will ensure that the responses included in the XML files
accurately reflect the patients’ responses to the survey questions.
• Vendors are urged to develop a way to measure error rates for their data receipt staff (in
terms of recognizing marginal notes and passing these on to someone for review), for
data entry or scanning operators, and for coders. Vendors should then work with their
staff to minimize error rates. The OAS CAHPS Survey Coordination Team will request
information about data receipt and processing error rates during site visits to survey
vendors.
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Centers for Medicare & Medicaid Services 81 Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual
VI. TELEPHONE-ONLY ADMINISTRATION PROCEDURES
Overview
This chapter describes the requirements and guidelines for implementing the telephone-only
mode of survey administration for the Outpatient and Ambulatory Surgery CAHPS (OAS
CAHPS) Survey. The chapter begins with a discussion of the telephone-only data collection
schedule, followed by a discussion of the requirements for producing all telephone interviewing
materials and systems. It includes guidelines on how the telephone interview should be
developed and administered, including general interviewing guidelines and frequently asked
questions that interviewers may encounter. This chapter also provides suggestions for data
processing procedures and incorporating quality control activities into the telephone-only mode
of survey administration.
Note that in most cases in this and subsequent chapters of this manual, patients included in the
sample are referred to as “sample members” or “sample patients”; in discussions of survey
processing and systems they may be referred to as “cases.”
Data Collection Schedule
If the OAS CAHPS Survey is being administered as a telephone-only survey, data collection
must be initiated no later than 3 weeks (21 days) after the close of the sample month.
Table 6.1 shows the prescribed order of activities and timing for telephone-only OAS CAHPS
Survey administration.
Table 6.1 Telephone-Only Administration Schedule and Protocol
Activity Timing
Begin telephone contact with sample members No later than 3 weeks (21 days) after the close of the sample month
Complete telephone data collection Six weeks (42 days) after initial telephone contact begins
Submit data files to OAS CAHPS Data Center via the OAS CAHPS Survey website
The second Wednesday of January, April, July, and October
If the 21st day of the month falls on a weekend or holiday, vendors should make every attempt to
begin the survey on the business day prior to that weekend or holiday. However, it is acceptable
to begin telephone calls on the first business day following the weekend or holiday if necessary.
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OAS CAHPS Survey vendors must make a concerted effort to initiate the survey for each sample
month within 21 days after the sample month ends. This means that phone contacting should
begin by the 21st day after the end of the sample month.
If for some reason the survey cannot be initiated within 21 days after the sample month ends, the
vendor can initiate the survey within 26 days after the sample month ends. Vendors that initiate
the survey between 22 and 26 days after the sample month ends must complete and submit a
Discrepancy Notification Report (Chapter XV) to the OAS CAHPS Survey Coordination Team.
CMS may allow the survey to be initiated more than 26 days after the sample month ended.
However, survey vendors must first request permission and approval from CMS to do so via an
e-mail to the OAS CAHPS Survey Coordination Team, copying its hospital outpatient
department (HOPD) or ambulatory surgery center (ASC) client. The e-mailed request should
include the HOPD or ASC’s name and CCN, explain the reason for the delay, state when the
vendor will (if approved) initiate the survey, specify the affected sample month, and request
CMS’ approval.
As noted in Table 6.1, data collection must be closed 42 calendar days after the telephone survey
begins. Note as well that the deadline for data submission is constant. This deadline will not shift
later if the vendor starts data collection late.
Telephone Interview Development Process
The following paragraphs describe the requirements for producing all materials and systems
needed for the telephone-only survey. The telephone interview script in English and Spanish is
available on the OAS CAHPS Survey website at https://oascahps.org/ .
A list of questions that are frequently asked by sample members and suggested answers to those
questions are included in Appendix H (English) and Appendix I (Spanish). Some general
guidelines for telephone interviewer training and monitoring are provided in Appendix J.
Specific requirements and guidelines associated with the telephone survey administration are
discussed below.
Telephone Interviewing Systems
An electronic telephone interviewing system means that the interviewer reads from and enters
responses into a computer program. Using an electronic system encourages standardized
interviewing and monitoring of interviewers. Survey vendors administering the OAS CAHPS
Survey in telephone-only survey mode must use an electronic system. Paper-and-pencil
administration is not permitted for telephone surveys. To ensure that sample members are
called at different times of the day and across multiple days of the week, vendors must also have
a survey management system. Ideally, the electronic system will be linked to the survey
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management system so that cases can be tracked, appointments set and called back at appropriate
times, and pending and final case status easily accessed for any case.
Predictive or automatic dialers are permitted, as long as they are compliant with Federal Trade
Commission and Federal Communications Commission regulations, and as long as respondents
can easily interact with a live interviewer. For more information about Federal Trade
Commission and Federal Communications Commission regulations, please visit
https://www.ftc.gov/ and https://www.fcc.gov/.
Telephone Interview Script
Survey vendors are provided with standardized telephone scripts in Appendix B (English) and
Appendix C (Spanish). These scripts include the introductory screens in addition to the survey
questions.
Note that the OAS CAHPS telephone interview script contains only 35 questions and the mail
survey contains 37 questions. The mail survey questionnaire contains questions that ask if
anyone helped the sample member to complete the survey (Questions 36 and 37). These two
questions are not applicable if the survey is administered by telephone. Additional information
about content of the OAS CAHPS Survey instrument is provided in Chapter III.
The following are content and programming requirements and recommendations for the OAS
CAHPS Survey questionnaire. Survey vendors cannot deviate from questionnaire requirements.
• Every questionnaire must begin with the “core” OAS CAHPS questions (Questions 1 to
24). They must be administered in the order in which they appear.
• No changes in wording are allowed for either the OAS CAHPS Survey questions or to
the response options.
• HOPDs and ASCs may add their own questions, following the guidelines in Chapter III.
In terms of placement of supplemental questions in the questionnaire, note that they must
be placed after the “core” OAS CAHPS questions. They may either be placed before or
after the unit of “About You” questions. If adding the Consent to Share Identifying
Information or supplemental questions to the end of the OAS CAHPS telephone script, it
is permissible to revise the programmable skip logic in Q35, “GO TO Q_END,” to
instead skip to Q36.
• Only CMS-approved translations of the OAS CAHPS Survey are permitted, although if
facilities choose to add their own supplemental questions, vendors will be responsible for
translating these questions.
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Telephone Interviewing Requirements
Telephone interviewing requirements and recommendations for the OAS CAHPS Survey
interview are described below. Vendors are expected to follow these requirements to maximize
response rates and to ensure consistency in how the telephone-only mode of administration is
implemented. Vendors are also advised to keep an eye on response rates, to assess whether calls
are being scheduled optimally across the data collection period. A low response rate may be
indicative of calls being spaced too closely together, rather than spread across a number of
weeks.
Telephone Contact
• Vendors must attempt to contact every patient in the sample. Vendors are required to
make five telephone contact attempts for each sampled case, unless the sample member
refuses or the vendor learns that the sample member is ineligible to participate in the
survey.
• A telephone contact attempt is defined as one of the following:
◦ the telephone rings six times with no answer or an answering machine is reached;
◦ the interviewer reaches a household member and is told that the sample member is
not available to take the call;
◦ the interviewer reaches the sample member and is asked to schedule a call-back at a
later date; or
◦ the interviewer gets a busy signal on each of three consecutive phone call attempts,
spaced at least 20 minutes apart.
• Vendors may make more than one phone call in one 7-day period but cannot make all
five attempts in one 7-day period. Scheduling calls to take place over a longer period of
time could reach patients who may be unavailable the first week of the data collection
period.
• Contact with a sample member may be continued after five attempts if the fifth attempt
results in a scheduled appointment with the sample member, as long as the appointment
is within the data collection period.
• Phone calls must be made at different times of the day (i.e., morning, afternoon, and
evening) and different days of the week throughout the data collection period.
• Interviewers may not leave voicemail messages on answering machines or leave
messages with household members.
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• Interviewers may tell household members that they are calling about “a study on health
care.”
• Vendors must maintain a phone call log that keeps track of the date and time phone calls
were made for each sample member.
• If the vendor finds out that a sample member is ineligible for the OAS CAHPS Survey,
the vendor must immediately stop further contact attempts with that sample member.
• Telephone survey data collection for each monthly sample must begin no later than 3
weeks from the close of the sample month and must be completed within 6 weeks from
the initial telephone attempt.
• The use of incentives—monetary or nonmonetary—is not permitted.
• Proxy respondents are not permitted on OAS CAHPS. If a sample member is incapable
of responding to the telephone interview because of mental or physical impairments such
as difficulty hearing, the interviewer must end the interview and apply code 240 –
Mentally or Physically Incapacitated. If a sample member is capable of responding but
just needs some help to do so, a friend or family member may help, but cannot respond
on his or her behalf.
• Proxies are also not permitted for deceased respondents. If a sample member is found to
be deceased, the case should be closed using code 210 – Deceased.
• If a respondent begins the interview but cannot complete it during the call for a reason
other than a refusal, the vendor should follow up with the respondent to complete the
entire interview. The interviewer should follow up even if the respondent answered
enough questions in the interview for the case to pass the completeness criteria. It is
especially important to complete the questions in the “About You” section of the
questionnaire, because data from some of those questions will be used in patient-mix
adjustment.
• The vendor must be able to offer the interview in any of the approved languages for
which an HOPD or ASC has contracted, even if the language is different from the
language that the HOPD or ASC believes the sample member will require. That is, the
vendor must be able to easily switch to accommodate a respondent’s language
preference. For example, if the initial contact is in English but the respondent prefers to
conduct the interview in Spanish, the vendor must be able to switch to Spanish.
• Sample members are still eligible even if they have missing, incomplete, or foreign phone
numbers. The vendor should contact the HOPD or ASC to obtain the telephone number
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and the address of the patient. If the HOPD or ASC cannot provide the telephone number,
the vendor should attempt to obtain a telephone number for the patient from other sources
(directory assistance, Internet directories, etc.). If the vendor still cannot obtain a
telephone number, the vendor should code the case as code 340 – Wrong, Disconnected,
No Telephone Number.
• If the telephone interviewer dials the sample patient’s telephone number, learns the
telephone number is incorrect, and obtains a new telephone number for the sampled
patient, the number of call attempts for that case should start over with the newly
obtained telephone number.
• Once the interviewer has confirmed that the sample member is on the phone, if the
sample member hangs up (without any comment) before or during the introductory
script, the case should be called again on a different day of the week and at a different
time of day. If the sample member hangs up (without any comment) after the
introductory script, the interviewer should code the case as a refusal. As a reminder, final
disposition code 320 – Refusal can only be assigned if sample members (not a
gatekeeper or other individual) indicate they do not wish to participate in the survey.
• If a respondent decides after answering some of the questions in the telephone interview
that he or she does not wish to participate in the survey any longer, the vendor should
code the case as a Refusal. The vendor should not use the partial data that were obtained
before the interview ended. This protocol applies even if the respondent answered enough
questions in the interview for the case to pass the completeness criteria. Note that this
situation is different from the respondent saying that he or she does not wish to continue
an interview. If the respondent breaks off the interview but does not state that he or she
does not wish to participate in the survey, the data may be used as long as the interview
meets the completeness criteria. In this case, the vendor may code the case as a 120 –
Completed Telephone Interview if the case passes the completeness criteria; otherwise, it
should be coded as a 310 – Breakoff.
Contacting Difficult-to-Reach Sample Members
• Although not required, we strongly recommend that survey vendors verify telephone
numbers obtained from HOPDs and ASCs, using a commercial address or telephone
database service or directory assistance.
• We recommend that vendors attempt to identify a new or updated telephone number for
any sample member whose telephone number is no longer in service when called and for
any sample members who have moved so that the sample members can be contacted prior
to the end of the data collection period.
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• If the sample member’s telephone number is incorrect, the interviewer may ask the
person who answers the phone for the sample member’s phone number.
• If the sample member is temporarily ill, on vacation, or unavailable during initial contact,
the interviewer should attempt to recontact the sample member before the data collection
period ends. If the sample member cannot be reached before the data collection period
ends, code the case as 350 – No Response After Maximum Attempts.
• If the sample member does not speak any of the OAS CAHPS Survey language(s) that
the vendor is administering for that facility, the interviewer should thank the sample
member for his or her time, end the interview, and code the case as 230 – Ineligible:
Language Barrier. Note that the language barrier disposition code only applies to the
sample member and should not be assigned until a determination is made that the sample
member cannot speak the language(s) being administered.
• If a sample member is physically or mentally incapable of responding by telephone, the
case should be finalized and coded as 240 – Mentally or Physically Incapacitated.
• For sample members who are living in institutions (assisted living, group homes, etc.),
OAS CAHPS Survey vendors should contact the HOPD or ASC to obtain a direct-dial
telephone number. If the HOPD or ASC cannot provide a direct-dial telephone number
for the patient, try to obtain the sample member’s telephone number using other sources,
such as a telephone number lookup service, directory assistance, or Internet telephone
survey directories. If vendors cannot obtain a telephone number for the patient, they
should assign a disposition code of 340 – Wrong, Disconnected, or No Telephone
Number to the case. As a reminder, sample members living in nursing homes or prisons
are ineligible.
Distressed Respondent Procedures
It is critically important that survey vendors develop a “distressed respondent protocol,” to be
incorporated into all interviewer and help desk training. For survey research organizations, best
interviewing practices recommend having a distressed respondent protocol in place for handling
distressed respondents, which balances the respondent’s right to confidentiality and privacy and
providing assistance, if the situation indicates that the respondent’s health and safety are in
jeopardy.
Therefore, each approved OAS CAHPS Survey vendor is expected to have procedures in place
for handling distressed respondent situations and to follow those procedures. CMS and the OAS
CAHPS Survey Coordination Team cannot provide guidelines on how to evaluate or handle
distressed respondents. However, survey vendors are urged to consult with their organization’s
Committee for the Protection of Human Subjects Institutional Review Board for guidance. In
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addition, professional associations for researchers, such as the American Association of Public
Opinion Researchers (AAPOR), may be able to provide guidance regarding this issue. The
following is an excerpt from AAPOR’s website that lists resources for the protection of human
subjects. More information about protection of human subjects is available at AAPOR’s website
at http://www.aapor.org .18
• The Belmont Report (guidelines and recommendations that gave rise to current federal
regulations)
• Federal Regulations Regarding Protection of Human Research Subjects (45 CFR 46)
(also known as the Common Rule)
• Federal Office for Human Research Protections
• National Institutes of Health Human Participant Investigator Training (although the site
appears to be for cancer researchers, it is the site for the general investigator training used
by many institutions)
• University of Minnesota Web-Based Instruction on Informed Consent
Telephone Interviewer Training
Vendors must provide training to all telephone interviewing and customer support staff prior to
starting telephone survey data collection activities. Telephone interviewer and customer support
staff training must include the following:
• teaching interviewers how to establish rapport with the respondent;
• teaching interviewers the content and purpose of the interview so that they can effectively
communicate this information to the sampled patients;
• teaching interviewers to administer the interview in a standardized format, which
includes reading the questions as they are worded, not providing the respondent with
additional information that is not scripted, maintaining a professional manner, and
adhering to all quality control standards;
• teaching interviewers how to use effective neutral probing techniques;
18 The American Association of Public Opinion Researchers website at
http://www.aapor.org/Additional_IRB_Resources.htmt , July 2010.
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• teaching interviewers to use the frequently asked questions document so that they can
answer questions in a standardized format; and
• teaching multilingual customer support staff how to handle questions in English and the
other language(s) in which the survey is being offered.
Survey vendors should also provide telephone survey supervisors with an understanding of
effective quality control procedures to monitor and supervise interviewers.
Vendors must conduct an interviewer certification process of some kind—oral, written, or
both—for each interviewer and customer service staff member prior to permitting that person to
make or take calls on the OAS CAHPS Survey. The certification should be designed to assess
the interviewer’s level of knowledge and comfort with the OAS CAHPS Survey instrument and
ability to respond to sample members’ questions about the survey. Documentation of training
and certification of all telephone interviewers and customer support staff and outcomes will be
subject to review during oversight visits by the OAS CAHPS Survey Coordination Team.
Telephone Data Processing Procedures
The following guidelines are provided for ensuring that the telephone interview data are properly
processed and managed.
Telephone Data Processing Requirements
• A unique sample identification (SID) number must be assigned to each case and included
in the case management system and on the final data file for each sample member.
• Vendors must capture the date of the interview with each sample member in the survey
management system or in the interview data.
• Vendors must be able to link each telephone interview to their survey management
system, so that appropriate variables, such as the language in which the survey was
conducted, can be pulled into the final data file.
• Vendors must de-identify all telephone interview data when the data are transferred into
the final data file for delivery. Identifiable data include respondent names and contact
information.
• Vendors must assign and include a final OAS CAHPS Survey disposition code to each
sampled case in the final data file (see Chapter IX for a list of these codes). It is up to the
vendor to develop and use a set of pending disposition codes to track actions on a case
before it is finalized appropriately—pending disposition codes are not specified in the
OAS CAHPS Survey protocol.
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Telephone-Only Quality Control Guidelines
The following activities are methods to incorporate quality control into the telephone-only
survey administration procedures. Quality control checks should be conducted by a different
staff person than the one who completed the task.
Required for Telephone Protocol
• OAS CAHPS requires that survey vendors thoroughly test the electronic telephone
interviewing system before beginning the OAS CAHPS Survey. Testing will vary from
system to system, but includes at a minimum comparing each screen to the telephone
script (in Appendices B and C) to verify that the questions and response options are
faithful to the script, checking each question to ensure that the answers input match the
data exported, and checking that a respondent is automatically routed to the next
appropriate question.
• Vendors are required to keep written documentation that all telephone interviewing and
customer support staff have been properly trained prior to interviewing. Copies of
interviewer certification exam scores should be retained as well. Documentation should
be maintained for any retraining required and will be subject to review during oversight
visits. Survey vendors must establish and communicate clear telephone interviewing
quality control guidelines for their staff to follow. These guidelines should be used to
conduct the monitoring and feedback process, and should include clear explanations of
the consequences of not following protocols, including actions such as removal from the
project or termination of employment.
• Vendors are required to silently monitor a minimum of 10% of all telephone interviews to
ensure that correct administration procedures are being followed.
• There are federal and state laws and regulations relating to the monitoring and/or
recording of telephone calls. In certain states, consent must be obtained from every party
or conversation if it involves more than two people (“two-party consent”). When calling
sample members who reside in these states, survey vendors should not begin either
monitoring or recording the telephone calls until after the interviewer has read the
following statement: “This call may be monitored or recorded for quality improvement
purposes.”19
19 The following states currently require two-party or all-party consent when telephone calls are monitored or
audiotaped: California, Connecticut, Florida, Illinois, Maryland, Massachusetts, Montana, New Hampshire,
Pennsylvania, and Washington.
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• All OAS CAHPS Survey vendors are responsible for identifying and adhering to federal
and state laws and regulations in the states in which they will be administering the OAS
CAHPS Survey.
• No revisions or corrections should be made to the OAS CAHPS Survey response data
once a telephone interview has been completed. Corrections can only be made while the
respondent is still on the phone to confirm responses. If survey response errors are
identified through QC measures after the interview, prompt retraining of the interviewer
is required to correct an issue for future interviews.
Recommended for Telephone Protocol
• Vendors are urged to conduct regular Quality Circle meetings with telephone
interviewing and customer support staff to obtain feedback on issues related to telephone
survey administration or handling inbound calls.
• Supervisory staff monitoring telephone interviewers should use the electronic system to
observe the interviewer conducting the interview while simultaneously listening to the
audio of the call.
• Monitoring staff or supervisors should provide performance feedback to interviewers as
soon as possible after the monitoring session has been completed.
• Interviewers should be given the opportunity to correct deficiencies in their
administration through additional practice or retraining; however, interviewers who
receive consistently poor monitoring scores should be removed from the project.
• Vendors should conduct periodic reviews of their XML data files by comparing at least
50 completed telephone interview responses directly from their computer-assisted
telephone interviewing system to the values output in the XML data file. Doing this
monthly review will ensure that the responses are being accurately captured and output to
the XML data file.
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Centers for Medicare & Medicaid Services 93 Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual
VII. MAIL WITH TELEPHONE FOLLOW-UP (MIXED-MODE) SURVEY ADMINISTRATION PROCEDURES
Overview
This chapter describes the requirements and guidelines for implementing a mixed-mode survey
administration for the Outpatient and Ambulatory Surgery CAHPS (OAS CAHPS) Survey. For
the OAS CAHPS Survey, “mixed mode” is defined as a mail survey followed by a telephone
follow-up of nonrespondents.
This chapter begins with a discussion of the data collection schedule that should be followed
when a mixed-mode design is used. The mail survey protocols are described next, followed by a
discussion of the protocols for implementing the telephone follow-up of nonrespondents. The
chapter ends with quality control guidelines that should be implemented throughout the mixed-
mode data collection process and describes data storage requirements.
Note that in most cases in this and subsequent chapters of this manual, patients included in the
sample are referred to as “sample members” or “patients”; in discussions of survey processing
and systems they may be referred to as “cases.”
Data Collection Schedule
Survey vendors using mail with telephone follow-up of nonrespondents must initiate the mail
survey for each monthly sample no later than 3 weeks (21 days) after the close of the sample
month. Table 7.1 shows the basic tasks and timing of activities when conducting the OAS
CAHPS Survey using mixed-mode survey administration.
Table 7.1 Tasks and Schedule of Activities for Mail with Telephone Follow-Up
Activity Timing
Mail questionnaire with cover letter to sample members
No later than 3 weeks (21 days) after the close of the sample month
Initiate telephone follow-up contacts for all mail survey nonrespondents
Approximately 3 weeks (21 days) after the questionnaire is mailed
Complete data collection Six weeks (42 days) after the questionnaire is mailed
Submit data files to the OAS CAHPS Data Center via the OAS CAHPS Survey website
The second Wednesday of January, April, July, and October
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If the 21st day of the month falls on a weekend or holiday, vendors should make every attempt to
begin the survey on the business day prior to that weekend or holiday. However, it is acceptable
to mail the questionnaire on the first business day following the weekend or holiday if necessary.
If for some reason the survey cannot be initiated within 21 days after the sample month ends, the
vendor can initiate the survey within 26 days after the sample month ends. Vendors must
complete and submit a Discrepancy Notification Report (Chapter XV) to the OAS CAHPS
Survey Coordination Team if the survey is initiated between 22 and 26 days after the sample
month ends.
If the survey cannot be initiated within 26 days after the sample month ends, CMS may allow it
to be initiated more than 26 days after the sample month ended. However, survey vendors must
first request permission and approval from CMS to do so via an e-mail to the OAS CAHPS
Survey Coordination Team, copying its hospital outpatient department (HOPD) or ambulatory
surgery center (ASC) client. The e-mailed request should include the HOPD or ASC’s name and
CCN, explain the reason for the delay, state when the vendor will (if approved) initiate the mail
and telephone survey, specify the affected sample month, and request CMS’ approval.
As noted in Table 7.1, data collection must be closed 42 calendar days after the questionnaire is
mailed. Note as well that the deadline for data submission is constant. This deadline will not shift
later if the vendor starts data collection late.
As explained in Chapter IX, all cases that are not finalized as a result of the mail survey
component of the mixed-mode survey must be assigned for telephone follow-up, including both
cases that are returned blank and undeliverable mail. This means that unless the case was a
complete, refusal, or the patient was determined to be ineligible for the survey during the mail
survey data collection phase of the survey, survey vendors should follow up with the patient by
telephone.
All telephone contact should be initiated and completed within the specified 3-week period noted
above in Table 7.1. Questionnaires may be received through the mail after the case has been
referred for telephone follow-up. If these questionnaires arrived before the 6-week data
collection period ended, they should be processed and telephone efforts with this case should be
stopped. If these questionnaires arrived after the 6-week data collection period ended, they
should be considered nonresponses and coded as such.
Questionnaires, Letters, and Envelopes
Vendors administering the OAS CAHPS Survey using mixed-mode must be able to offer the
mail and telephone versions of the instrument in each language in which the survey is being
administered. Vendors may not offer a mail questionnaire in one of the non-English languages
and conduct the telephone follow-up only in English, for example. For this reason, the mixed-
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mode design cannot be used in conjunction with the Chinese or Korean versions of the mail
questionnaire, because there is no corresponding OAS CAHPS–approved telephone interview in
Chinese or Korean. All versions of these survey materials in the approved languages are
available on the OAS CAHPS Survey website at https://oascahps.org/ .
Copies of the mail survey instrument and sample mail survey cover letters in English and
Spanish are also included in the appendices to this manual:
• sample mail survey cover letters, questionnaire, and questionnaire in scannable format in
English, Appendix B;
• sample mail survey cover letters, questionnaire, and questionnaire in scannable format in
Spanish, Appendix C;
• Office of Management and Budget (OMB) Disclosure Notice in all languages in
Appendix G.
Outpatient and Ambulatory Surgery CAHPS Survey Questionnaires
The OAS CAHPS Survey Questionnaire used in the mail mode contains 37 questions. It is
available on the OAS CAHPS Survey website at https://oascahps.org/ . Additional information
about content of the OAS CAHPS Survey instrument is provided in Chapter III and in the table
below.
Questionnaire Printing Requirements and Recommendations
The following are formatting and content requirements and recommendations for the OAS
CAHPS Survey Questionnaire. Survey vendors cannot deviate from questionnaire requirements.
Requirement Recommendation
Questions Every questionnaire must begin with the “core”
OAS CAHPS Survey questions (Questions 1 to 24). n/a
No changes in wording are allowed to either the
OAS CAHPS Survey questions or to the response
options.
n/a
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Requirement Recommendation
If HOPDs and ASCs elect to add their own
questions they must follow the guidelines in
Chapter III. In terms of placement of supplemental
questions in the questionnaire, they must be placed
after the “core” OAS CAHPS questions. They may
either be placed before or after the unit of “About
You” questions. It is acceptable to replace the skip
instruction currently provided in Q36 of the OAS
CAHPS mail survey, “Go to end,” with the skip
instruction, “Go to Q38,” if the vendor adds the
Consent to Share Identifying Information question
or any supplemental questions to the mail survey
starting with Q38.
n/a
Formatting Questions and associated responses options may
not be split across pages. n/a
Vendors must be consistent throughout the
questionnaire in formatting response options either
vertically or horizontally. If a vendor elects to list
the response options vertically, this must be done
for every question in the questionnaire. Vendors
may not format some response options vertically
and some horizontally.
n/a
No matrix formatting of the questions is allowed.
Matrix formatting means formatting a set of
questions as a table, with responses listed across
the top of a page and individual questions listed in
a column on the left.
n/a
Font size should be no smaller than size 10. We strongly
recommend that size
12 or larger be used.
Vendors should use best survey practices when
formatting the questionnaire, such as maximizing
the use of white space and using simple fonts like
Arial.
If data entry keying is
being used as the data
entry method, small
coding numbers next
to the response
options may be used.
ID number A unique, randomly generated sample
identification (SID) number must be assigned and
appear on at least the first page of the survey, for
tracking purposes. Additional identifiers are
permitted. However, the sample member’s name
or other identifying information must not be
printed anywhere on the survey.
n/a
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Requirement Recommendation
Translation Only CMS-approved translations of the OAS
CAHPS Survey are permitted – English and
Spanish only. If facilities choose to add their own
supplemental questions, vendors will be
responsible for translating these questions.
n/a
Logo and other
information
about the
HOPD or ASC
The HOPD or ASC name or logo should appear on
the survey or the cover letter but cannot appear on
the envelopes (for privacy), unless vendors receive
prior approval from CMS via the submission of an
Exceptions Request Form indicating that they have
the facility’s approval to display the name or logo
on the outgoing envelope and the facility believes
there are no HIPAA risks. Note that survey vendors
cannot include any promotional messages or
materials on the OAS CAHPS cover letter,
questionnaire, or outgoing or incoming mailing
envelopes. This includes indications that either the
facility or the survey vendor has been approved by
the Better Business Bureau.
n/a
The vendor’s name and mailing address must be
printed at the bottom of the last page of the OAS
CAHPS Survey questionnaire, in case the
respondent does not use the enclosed business reply
envelope.
n/a
OMB Number The OMB number shown in Appendix G must be
printed on the questionnaire cover. If there is no
cover, then the OMB number must be printed on
the first page of the questionnaire.
n/a
Cover Letter Requirements and Recommendations
Examples of cover letters in English and Spanish are provided in the appendices with the survey
instruments (see Appendices B and C). Vendors may choose to develop their own cover letters as
well, provided that the following requirements are met:
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Requirement Recommendation
Personalization Cover letters must be personalized with the
name and address of the sample member. n/a
Cover letters must contain the date of the
surgery or procedure and the name of the
location where the surgery was received. (The
monthly patient information file must contain
the date of surgery, facility name, and
location name because the name recognized
by the patient may differ from the facility’s
official name.)
n/a
ID Number A unique, randomly generated SID number
must be assigned and appear on the cover
letter, for tracking purposes. Additional
identifiers are permitted.
Separate from
questionnaire
Cover letters must be separate from the
questionnaire, so that no personally
identifiable information (PII) is returned with
the questionnaire when the respondent sends
it back to the vendor.
n/a
Content of
letters
The OMB disclosure notice (see Appendix G)
must be printed either on the questionnaire or
in the cover letters.
n/a
Vendors may not offer sample members the
opportunity to complete the survey over the
telephone. Telephone interviews may only be
conducted as part of the nonresponse follow-
up.
n/a
Must contain language describing the purpose
of the survey. n/a
Must contain a statement that participation is
voluntary and will not affect any benefits the
sample member receives or expects to
receive.
n/a
Must contain language indicating that
responses from all the survey participants will
be grouped together and these grouped data
may be shared with the HOPD or ASC, for
purposes of quality improvement.
n/a
Must contain language stating that if the
respondent needs help in reading the
questions or marking responses, a friend or
family member can assist them.
n/a
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Requirement Recommendation
Must contain a toll-free customer support
telephone number that will be staffed by the
survey vendor.
n/a
Must include a statement that all information
the sampled patient provides will be
confidential and is protected by the Privacy
Act. This sentence is included in all of the
sample cover letters in Appendices B
(English) and C (Spanish).
n/a
Printing The HOPD or ASC name (or logo) must
appear on the letters or the survey, but cannot
appear on the envelopes (for privacy). Note
that survey vendors cannot include any
promotional messages or materials on the
OAS CAHPS cover letter, questionnaire, or
outgoing or incoming mailing envelopes. This
includes indications that either the facility or
the survey vendor has been approved by the
Better Business Bureau.
n/a
Signature on
the letters
A signature is required. We recommend that the
signature of an appropriate
official from the HOPD or
ASC be printed on each
cover letter If this is not
possible, the signature from
an appropriate official at the
survey vendor is acceptable.
Requests for
survey in other
languages
n/a
Survey vendors offering the
OAS CAHPS questionnaire
in Spanish may add
language to the English
cover letter indicating that a
version of the questionnaire
is available in Spanish.
Mailing
Requirements and recommendations are described below. Vendors are expected to follow these
requirements to maximize response rates and ensure consistency in how the mail survey portion
of the mixed-mode administration is implemented.
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100 Centers for Medicare & Medicaid Services Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual
Requirement Recommendation
Questionnaire
contents
Each questionnaire mailing must contain a
personalized cover letter, questionnaire, and
postage-paid business reply envelope.
n/a
Envelopes Vendors are responsible for supplying both the
outgoing envelopes for the questionnaire mailings
and business-reply envelopes that sample members
will use to return their completed surveys (i.e., they
cannot be supplied by the HOPD or ASC).
n/a
Addresses Patients must have a U.S. domestic address to be
eligible to participate in the OAS CAHPS Survey. n/a
If the sample member’s address is missing or
incomplete, the vendor must follow up with the
HOPD or ASC to obtain the address. If an address
cannot be found, or the address that is found is too
incomplete for mailing, the vendor should treat the
patient as eligible (i.e., the case should remain in the
sample) and attempt to contact via telephone as part
of the telephone follow-up survey.
To reduce the
number of missing
addresses, we
recommend that
vendors verify
mailing addresses
obtained from the
facilities using
commercial address
update services, such
as the National
Change of Address or
the U.S. Postal
Service Zip+4
software.
Schedule Mailings must follow the schedule specified for the
mixed-mode administration—the questionnaire
package must be mailed no later than 3 weeks after
the close of the sample month; the phone calls for
telephone follow-up must begin approximately 3
weeks after the questionnaire mailing.
n/a
Data collection must end 6 weeks after the
questionnaire has been mailed. n/a
Incentives The use of incentives is not permitted. This includes
monetary and nonmonetary incentives. n/a
Data Receipt, Data Entry, and Optical Scanning Requirements
The following guidelines are provided for receiving and tracking returned questionnaires and
entering the data using either data entry or optical scanning.
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Requirement
Receipting The date the questionnaire was received from each sample member must be
entered into the data record created for each case on the data file.
Mailings that are returned in the mail as undeliverable must also be logged
into the tracking system. They should then be followed up by telephone.
A final OAS CAHPS Survey disposition code (see Table 9.1 in Chapter IX)
must be assigned to each case.
If a completed questionnaire is received from the sample member after
telephone follow-up begins and a telephone interview with that sample
member has already been completed, retain the questionnaire or interview
with the more complete data. If both surveys are equally complete, the
vendor should use the first one received or completed.
Reviewing
received
questionnaires
for problems
Questionnaires should be visually reviewed prior to scanning or data entry
for notes and comments. Vendors should have more than one person who
can code or review comments and attach notes for proper disposition code
assignment.
If a completed mail survey questionnaire is returned and the vendor realizes
that it was completed by proxy (i.e., response option “3 – Answered the
questions for me” is selected for Q37 alone or in combination with other
response options for that question, or there is a note written on the
questionnaire that a family member completed the questionnaire because the
patient had died, had moved to a nursing home, had been incarcerated)
vendors should not key or scan a questionnaire for that sample member.
They should instead assign the applicable final disposition code to the case
based on the information provided in the handwritten note, or disposition
code 320 (Refusal) if no note is included and Q37’s response option “3” is
selected.
If a sample member were to die or become ineligible after completing the
questionnaire (vendors might learn of this through a comment written by a
family member on the questionnaire) that questionnaire is still an eligible
completed survey. Vendors should scan the questionnaire and assign the
applicable final disposition code indicating the completed survey.
Out-of-range
or invalid
responses
The key entry program should not permit out-of-range or invalid responses.
The scanning program should not permit out-of-range or invalid responses.
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102 Centers for Medicare & Medicaid Services Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual
Requirement
Interpreting
blanks and
ambiguous
survey
responses
The following apply for both keying and optical scanning (additional
information about handling blank and ambiguous responses can be found in
Chapter IX):
If a response mark falls between two answer choices but is clearly closer to
one answer choice than to another, select the response that is closest to the
marked response.
If two responses are checked for the same question, select the one that
appears darkest. If it is not possible to make a determination, leave the
response blank and code as “missing” rather than guessing.
If a mark is between two answer choices but is not clearly closer to one
answer choice, code as “missing.”
If a response is missing, leave the response blank and code as “missing.”
Open-ended
responses
The decision on whether to key or scan the responses to open-ended survey
items, specifically, the “Other language” (response option 2) in Q35 and the
“Helped in some other way” (response option 5) in Q37, is up to each
individual HOPD or ASC. Vendors will not be required to key or scan and
include responses to open-ended survey items on the data files submitted to
the OAS CAHPS Data Center.
CMS, however, encourages survey vendors to review the open-ended entries
so they can provide feedback to the OAS CAHPS Survey Coordination
Team about adding additional preprinted response options to these survey
items if needed.
If the vendor includes the Consent to Share Identifying Information question
in the mail survey questionnaire, the vendor is not required to key or scan the
response to that question. However, we do recommend vendors review the
responses to this question for the vendor’s own documentation.
Responses to the Consent to Share Identifying Information question will not
be included on the data files submitted to the OAS CAHPS Data Center.
Staff Training
All staff involved in the mail survey implementation, including support staff, must be thoroughly
trained on the survey specifications and protocols. A copy of relevant chapters of this manual
should be made available to all staff as needed.
In particular, staff involved in questionnaire assembly and mailout, data receipt, and data entry
must be trained on:
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• use of relevant equipment (case management systems for entering questionnaire receipts,
scanning equipment, data entry programs);
• the OAS CAHPS Survey protocol specific to their role (for example, contents of
questionnaire package, how to document or enter returned questionnaires into the
tracking system);
• decision rules and coding guidelines for returned questionnaires (see Chapter IX); and
• proper handling of hardcopy and electronic data, including data storage requirements (see
Chapter VIII).
Staff involved in providing customer support via the toll-free telephone number should also be
trained on the accurate responses to common respondent questions, how to respond to questions
when customer support does not know the answer, and the rights of survey respondents. If the
OAS CAHPS Survey is being offered in Spanish, customer support staff should also be able to
handle questions via the toll-free telephone number in Spanish. Telephone interviewer training
requirements are described in more detail in Chapter VI of this manual. Please refer to that
chapter for more information on training customer support staff.
Telephone Interview Development Process
The following paragraphs describe the requirements for producing all materials and systems
needed for the telephone survey. The telephone interview script in English and Spanish are
available on the OAS CAHPS Survey website at https://oascahps.org/ .
Copies of the telephone interview script can also be found in Appendix B (in English) and
Appendix C (in Spanish). A list of frequently asked interview questions is included in
Appendix H (English) and Appendix I (Spanish). Some general guidelines for telephone
interviewer training and monitoring are provided in Appendix J.
Specific requirements and guidelines associated with the telephone interview administration are
discussed below.
Telephone Interviewing Systems
In electronic interviewing systems, the interviewer reads from and enters responses into a
computer program. Using an electronic interviewing system or some other type of electronic data
collection system encourages standardized interviewing and monitoring of interviewers. The
OAS CAHPS Survey mixed-mode administration requires vendors use an electronic
interviewing system to administer the follow-up telephone OAS CAHPS Survey. Paper-and-
pencil administration of the OAS CAHPS Survey is not permitted. To ensure that sample
members are called at different times of the day and across multiple days of the week, vendors
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must also have a survey management system. Ideally, the electronic interviewing system will be
linked to the survey management system so that cases can be tracked, appointments set and
called back at appropriate times, and pending and final case status easily accessed for any case.
Predictive or automatic dialers are permitted, as long as they are compliant with Federal Trade
Commission and Federal Communications Commission regulations, and as long as respondents
can easily interact with a live interviewer. For more information about Federal Trade
Commission and Federal Communications Commission regulations please visit
https://www.ftc.gov/ and https://www.fcc.gov/.
Telephone Interview Script
Survey vendors are provided with standardized telephone scripts in Appendix B, English, and
Appendix C, Spanish. These scripts include the introductory screens, in addition to the survey
questions.
Note the OAS CAHPS telephone interview script contains only 35 questions and the mail survey
contains 37 questions, because the mail survey questionnaire contains questions that ask if
anyone helped the sample member to complete the survey (Questions 36 and 37). These two
questions are not applicable if the survey is administered by telephone. Additional information
about the content of the OAS CAHPS Survey instrument is provided in Chapter III.
The following are content and programming requirements and recommendations for the OAS
CAHPS Survey questionnaire. Survey vendors cannot deviate from questionnaire requirements.
• Every questionnaire must begin with the “core” OAS CAHPS questions (Questions 1 to
24). They must be administered in the order in which they appear.
• No changes in wording are allowed for either the OAS CAHPS Survey questions or to
the response options.
• HOPDs and ASCs may add their own questions, following the guidelines in Chapter III.
In terms of placement of supplemental questions in the questionnaire, note that they must
be placed after the “core” OAS CAHPS questions. They may either be placed before or
after the unit of “About You” questions. If adding the Consent to Share Identifying
Information or supplemental questions to the end of the OAS CAHPS telephone script, it
is permissible to revise the programmable skip logic in Q35, “go to Q_end,” to instead
skip to Q36.
• Only CMS-approved translations of the OAS CAHPS Survey are permitted, although if
facilities choose to add their own supplemental questions, vendors will be responsible for
translating these questions.
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Telephone Interviewing Requirements and Recommendations
Telephone interviewing requirements and recommendations for the OAS CAHPS Survey
interview are described below. Vendors are expected to follow these requirements to maximize
response rates and ensure consistency in how the telephone follow-up is implemented in the
mixed-mode administration.
Telephone Contact
• Vendors must attempt to contact every sample member included in the sample. Vendors
are required to make five contact attempts for each nonrespondent to the mail survey,
unless the sample member refuses or the vendor learns that the sample member is
ineligible for the survey.
• A telephone contact attempt is defined as one of the following:
◦ the telephone rings six times with no answer;
◦ the interviewer reaches a household member and is told that the sample member is
not available to take the call;
◦ the interviewer reaches the sample member and is asked to schedule a call-back at a
later date; or
◦ the interviewer gets a busy signal on each of three consecutive phone call attempts,
spaced at least 20 minutes apart.
• Vendors may make more than one phone call in one 7-day period but cannot make all
five attempts in one 7-day period. Scheduling calls to take place over a longer period of
time may reach patients who may be unavailable the first week of the data collection
period.
• Contact with a sample member may be continued after five attempts if the fifth attempt
results in a scheduled appointment with the sample member, as long as the appointment
is within the data collection period.
• Phone calls must be made at different times of the day (i.e., morning, afternoon, and
evening) and different days of the week throughout the data collection period.
• Interviewers may not leave voicemail messages on answering machines or leave
messages with household members.
• Vendors must maintain a phone call log that keeps track of the date and time phone calls
were made for each sample member.
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• If the vendor finds out that a sample member is ineligible for the OAS CAHPS Survey,
the vendor must immediately stop further contact attempts with that sample member.
• Telephone interviewing must follow the schedule specified for the mixed-mode
administration, with the first phone contact initiated approximately 3 weeks after the
questionnaire is mailed and all phone contacts ending 3 weeks after phone contact begins.
• The use of incentives is not permitted. This includes monetary and nonmonetary
incentives.
• Proxy respondents are not permitted on OAS CAHPS for any reason. If response option
“3 – Answered questions for me” is selected for Question 37 alone or in combination
with another response option for that question on a returned mail survey and no
handwritten note is provided, do not key or scan the questionnaire for that sample
member. This type of case should be coded a 320 (Refusal). A proxy mail survey can also
be determined through a note written on the questionnaire that a family member
completed the questionnaire because the patient had died, had moved to a nursing home,
or had been incarcerated. Again, vendors should not key or scan a questionnaire. They
should assign the applicable final disposition code to the case based on the information
provided in the handwritten note.
If a sample member is incapable of responding to the telephone interview because of
mental or physical impairments such as difficulty hearing, the interviewer should end the
interview and apply code 240 – Mentally or Physically Incapacitated. If a sample member
is capable of responding but needs some help to do so, a friend or family member may
help, but cannot respond on his or her behalf.
• Proxies are also not permitted for deceased respondents. If a sample member is found to
be deceased, the case should be closed using code 210 – Deceased.
• If a respondent begins the interview but cannot complete it during the call for a reason
other than a refusal, the vendor should follow up with the respondent to complete the
entire interview. This follow-up should be done even if the respondent answered enough
questions in the interview for the case to pass the completeness criteria. It is especially
important to complete the questions in the “About You” section of the questionnaire,
because data from some of those questions will be used in patient-mix adjustment.
• The vendor must be able to offer the interview in any of the approved languages (English
or Spanish) for which an HOPD or ASC has contracted, even if the language is different
from the language that the HOPD or ASC believes the sample member will require. That
is, the vendor must be able to easily switch to accommodate a respondent’s language
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preference. For example, if the initial contact is in English but the respondent prefers to
conduct the interview in Spanish, the vendor must be able to switch to Spanish.
• Sample members are still eligible even if they have missing, incomplete, or foreign phone
numbers. The vendor should contact the HOPD or ASC to obtain the telephone
number(s) they have on record for the sample member. If the HOPD or ASC cannot
provide this number, the vendor should attempt to obtain a telephone number for the
patient from other sources (directory assistance, Internet directories, etc.). If the vendor
still cannot obtain a telephone number, the vendor should code the case as code 340 —
Wrong, Disconnected, or No Telephone Number.
• If the telephone interviewer dials the sample patient’s telephone number, learns the
telephone number is incorrect, and obtains a new telephone number for the sampled
patient, the number of call attempts for that case should start over with the newly
obtained telephone number.
• Once the interviewer has confirmed the sample member is on the phone, if the sample
member hangs up (without any comment) before or during the introductory script, the
case should be called again on a different day of the week and at a different time of day.
If the sample member hangs up (without any comment) after the introductory script, the
interviewer should code the case as a refusal. As a reminder, final disposition code 320 –
Refusal can only be assigned if sample members (not a gatekeeper or other
individual) indicate they do not wish to participate in the survey.
• If a respondent decides after answering some of the questions in the telephone interview
that he or she does not wish to participate in the survey any longer, the vendor should
code the case as a Refusal. The interviewer should not use the partial data that were
obtained before the interview ended. This protocol applies even if the respondent
answered enough questions in the interview for the case to pass the completeness criteria.
Note that this is different from the respondent saying that he or she does not wish to
continue an interview. If the respondent breaks off the interview but does not state that he
or she does not wish to participate in the survey, the data may be used as long as the
interview meets the completeness criteria. In this case, the vendor may code the case as a
120 – Completed Telephone Interview if the case passes the completeness criteria;
otherwise, it should be coded as a 310 – Breakoff.
Contacting Difficult-to-Reach Sample Members
• Although not required, we strongly recommend that survey vendors verify telephone
numbers obtained from the HOPD or ASC, using a commercial address or telephone
database service or directory assistance.
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• We recommend that vendors attempt to identify a new or updated telephone number for
any sample member whose telephone number is no longer in service when called and for
patients who have moved so that the sample members can be contacted prior to the end of
the data collection period.
• If the sample member’s telephone number is incorrect, the interviewer may ask the
person who answers the phone for the sample member’s phone number.
• If the sample member is temporarily ill, on vacation, or unavailable during initial contact,
the interviewer should attempt to recontact the sample member before the data collection
period ends. If the sample member cannot be reached before the data collection period
ends, code the case as 350 – No Response After Maximum Attempts.
• If the sample member does not speak any of the OAS CAHPS Survey language(s) that
the vendor is administering for that facility, the interviewer should thank the sample
member for his or her time, end the interview, and code the case as 230 – Ineligible:
Language Barrier. Note that the language barrier disposition code only applies to the
sample member and should not be assigned until a determination is made that the sample
member cannot speak the language(s) being administered.
• If a sample member is physically or mentally incapable of responding by telephone, the
case should be coded as a 240 – Mentally or Physically Incapacitated.
• For sample members who are living in institutions (group homes, assisted living,
residential care facilities, etc.), OAS CAHPS Survey vendors should contact the HOPD
or ASC to obtain a direct-dial telephone number for the patients who live in those
facilities. If the HOPD or ASC cannot provide a direct-dial telephone number for the
patient, try to obtain the sample member’s telephone number using other sources, such as
a telephone number lookup service, directory assistance, or Internet telephone survey
directories. If vendors cannot obtain a telephone number for the patient, they should
assign a disposition code of 340 – Wrong, Disconnected, or No Number to the case. As a
reminder, sample members living in nursing homes or prisons are ineligible.
Distressed Respondent Procedures
It is critically important that survey vendors develop a “distressed respondent protocol,” to be
incorporated into all interviewer and help desk training. For survey research organizations, best
interviewing practices recommend having a distressed respondent protocol in place for handling
distressed respondents, which balances the respondent’s right to confidentiality and privacy and
providing assistance, if the situation indicates that the respondent’s health and safety are in
jeopardy.
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Therefore, each approved OAS CAHPS Survey vendor is expected to have procedures in place
for handling distressed respondent situations and to follow those procedures. CMS and the OAS
CAHPS Survey Coordination Team cannot provide guidelines on how to evaluate or handle
distressed respondents. However, survey vendors are urged to consult with their organization’s
Committee for the Protection of Human Subjects Institutional Review Board for guidance. In
addition, professional associations for researchers, such as the American Association of Public
Opinion Researchers (AAPOR), may be able to provide guidance regarding this issue. The
following is an excerpt from AAPOR’s website that lists resources for the protection of human
subjects. More information about protection of human subjects is available at AAPOR’s website
at http://www.aapor.org .20
• The Belmont Report (guidelines and recommendations that gave rise to current federal
regulations)
• Federal Regulations Regarding Protection of Human Research Subjects (45 CFR 46)
(also known as the Common Rule)
• Federal Office for Human Research Protections
• National Institutes of Health Human Participant Investigator Training (although the site
appears to be for cancer researchers, it is the site for the general investigator training used
by many institutions)
• University of Minnesota Web-Based Instruction on Informed Consent
Interviewer Training
Vendors must provide training to all telephone interviewing and customer support staff prior to
starting telephone survey data collection activities. The telephone interview training must include
the following:
• teaching interviewers how to establish rapport with the respondent;
• teaching interviewers the content and purpose of the interview so that they can effectively
communicate this information to the sample members;
• teaching interviewers to administer the interview in a standardized format (reading the
questions as they are worded, not providing the respondent with additional information
20 The American Association of Public Opinion Researchers website at
http://www.aapor.org/Additional_IRB_Resources.html , July 2010.
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that is not scripted, maintaining a professional manner, and adhering to all quality control
standards);
• teaching interviewers how to use effective neutral probing techniques;
• teaching interviewers to use the frequently asked questions document so that they can
answer questions in a standardized format; and
• teaching multilingual customer support staff how to handle questions in English and
Spanish if offered.
Survey vendors should also provide telephone survey supervisors with an understanding of
effective quality control procedures to monitor and supervise interviewers.
Vendors must conduct an interviewer certification process of some kind—either oral, written, or
both—for each interviewer and customer service staff member prior to permitting that person to
make or take calls on the OAS CAHPS Survey. The certification should be designed to assess
the interviewer’s level of knowledge and comfort with the OAS CAHPS Survey instrument and
ability to respond to sample members’ questions about the survey. Documentation of training
and certification of all telephone interviewers and customer support staff and outcomes will be
subject to review during oversight visits by the OAS CAHPS Survey Coordination Team.
Telephone Data Processing Procedures
The following guidelines are provided for ensuring that the telephone interview data are properly
processed and managed.
Telephone Data Processing Requirements
• A unique SID number must be assigned to each sampled case and included in the case
management system and on the final data file for each sample member.
• Vendors must capture the date the interview was conducted with each sample member in
the survey management system or in the interview data.
• Vendors must be able to link each telephone interview to their survey management
system, so that appropriate variables, such as the language in which the survey was
conducted, can be pulled into the final data file.
• Vendors must de-identify all telephone interview data when the data are transferred into
the final data file for delivery. Identifiable data include respondent name and contact
information.
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• Vendors must include and assign a final OAS CAHPS Survey disposition code to each
sampled case in the final data file (see Chapter IX for a list of these codes). It is up to the
vendor to develop and use a set of pending disposition codes to track actions on a case
before it is finalized appropriately—pending disposition codes are not specified in the
OAS CAHPS Survey protocol.
Mixed-Mode Quality Control Guidelines
The following steps are required or recommended as a means of incorporating quality control
into the mixed-mode survey administration procedures. Quality control checks should be
conducted by a different staff person than the one who completed the task.
Required for Mail Protocol
• Check a minimum of 10% of all printed materials to ensure the quality of the printing—
that is, make sure that there is no smearing, misaligned pages, duplicate pages, or stray
marks on pages.
• Check a minimum of 10% of all outgoing questionnaire packages to ensure that all
package contents are included and that the same unique SID number appears on both the
cover letter and the questionnaire.
• For vendors that are scanning: a sample of questionnaires (minimum of 10 percent)
should be compared with the original hardcopy survey. This serves as a quality control
measure that the scanning program is capturing the hard copy correctly. Any
discrepancies between the scan and the hard copy should be reconciled by a supervisor.
Additionally, the survey responses captured in the database for a sample of
questionnaires (minimum of 10 percent) should be systematically compared to scanned
image for that case. This can be done either by visually examining the scanned image and
the data to reveal inconsistencies, or by rescanning and noting whether the data from the
original match the data from the rescan. This serves as a quality control measure that the
scanning program is translating the response marks in the scanned image to the data file
consistently and correctly. Any discrepancies should be reconciled by a supervisor.
• For vendors that are keying: all questionnaires should be 100% rekeyed for quality
control purposes. That is, for every questionnaire, a different keyer should rekey the
questionnaire and the data entry files from the two keyers should be systematically
compared to ensure that all entries are accurate. If any discrepancies are observed, a
supervisor should resolve the discrepancy and ensure that the correct value is stored in
the data.
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Recommended for Mail Protocol
• “Seed” each mailing. That is, include the name and address of designated vendor staff in
each mailing file to assess the completeness of the questionnaire package and timeliness
of package delivery.
• Before submitting XML data to the OAS CAHPS Data Center, we highly recommend
vendors review a sample of cases comparing responses recorded on the hardcopy
questionnaire to responses scanned to the response codes that appear in the XML files.
This quality control step will ensure that the responses included in the XML files
accurately reflect the patients’ responses to the survey questions.
• Vendors are urged to develop a way to measure error rates for their data receipt staff (in
terms of recognizing marginal notes and passing these on to someone for review), for
data entry or scanning operators, and for coders. Vendors should then work with their
staff to minimize error rates. The OAS CAHPS Survey Coordination Team will request
information about data receipt and processing error rates during site visits.
Required for Telephone Protocol
The following activities are methods to incorporate quality control into the survey administration
procedures for the telephone follow-up portion of the mixed-mode survey administration.
Quality control of telephone interviewers and customer support staff should include the
following activities:
• OAS CAHPS requires that survey vendors thoroughly test the electronic telephone
interviewing system before beginning the OAS CAHPS Survey. Testing will vary from
system to system, but includes at a minimum comparing each screen to the telephone
script (in Appendices B and C) to verify that the questions and response options are
faithful to the script; checking each question to ensure that the answers input match the
data exported, and checking that a respondent is automatically routed to the next
appropriate question.
• Vendors are required to keep written documentation that all telephone interviewing and
customer support staff have been properly trained prior to interviewing. Copies of
interviewer certification exam scores should be retained as well. Documentation should
be maintained for any retraining required and will be subject to review during site visits.
• Survey vendors must establish and communicate clear telephone interviewing quality
control guidelines for their staff to follow. These guidelines should be used to conduct the
monitoring and feedback process and should include clear explanations of the
consequences of not following protocols, including actions such as removal from the
project or termination of employment.
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• Vendors are required to silently monitor a minimum of 10% of all telephone interviews to
ensure that correct administration procedures are being followed.
• There are federal and state laws and regulations relating to the monitoring and/or
recording of telephone calls. In certain states, consent must be obtained from every party
or conversation if it involves more than two people (“two-party consent”). When calling
sample members who reside in these states, survey vendors should not begin either
monitoring or recording the telephone calls until after the interviewer has read the
following statement: “This call may be monitored or recorded for quality improvement
purposes.”21
• All OAS CAHPS Survey vendors are responsible for identifying and adhering to federal
and state laws and regulations in the states in which it will be administering the OAS
CAHPS Survey.
• No revisions or corrections should be made to the OAS CAHPS Survey response data
once a telephone interview has been completed. Corrections can only be made while the
respondent is still on the phone to confirm responses. If survey response errors are
identified through QC measures after the interview, prompt retraining of the interviewer
is required to correct an issue for future interviews.
Recommended for Telephone Protocol
• Vendors are urged to conduct regular Quality Circle meetings with telephone
interviewing and customer support staff to obtain feedback on issues relating to telephone
survey administration or handling inbound calls.
• Supervisory staff monitoring telephone interviewers should use the electronic system to
observe the interviewer conducting the interview while listening to the audio of the call at
the same time.
• Monitoring staff or supervisors should provide performance feedback to interviewers as
soon as possible after the monitoring session has been completed.
• Interviewers should be given the opportunity to correct deficiencies in their
administration through additional practice or retraining; however, interviewers who
receive consistently poor monitoring scores should be removed from the project.
21 The following states currently require two-party or all-party consent when telephone calls are monitored or
audiotaped: California, Connecticut, Florida, Illinois, Maryland, Massachusetts, Montana, New Hampshire,
Pennsylvania, and Washington.
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• Vendors should conduct periodic reviews of their XML data files by comparing at least
50 completed telephone interview responses directly from their CATI system to the
values output in the XML data file. Doing this monthly review will ensure that the
responses are being accurately captured and output to the XML data file.
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VIII. CONFIDENTIALITY AND DATA SECURITY
Overview
This chapter describes the requirements and guidelines for (1) protecting the identity of sample
members included in the survey sample, (2) ensuring confidentiality of respondent data, and
(3) ensuring data security. The chapter begins with a discussion of how confidential data should
be handled and the importance of confidentiality agreements. The last section provides
information about the importance of establishing and maintaining physical and electronic data
security.
Safeguarding Patient Data
The Health Insurance Portability and Accountability Act of 1996 (HIPAA) is legislation intended
to protect private medical information and to improve the efficiency of the health care system.
This law went into effect April 14, 2003.
The type of information protected under HIPAA is called “protected health information,” or PHI.
PHI is defined as personally identifiable information that relates to a person’s past, present, or
future health or medical treatment. If the health information is completely de-identified, it is no
longer PHI and can be released. HIPAA also applies to electronic records, whether they are
being stored or transmitted. All vendors approved to implement Outpatient and Ambulatory
Surgery CAHPS (OAS CAHPS) Survey must adhere to HIPAA requirements. That is, vendors
must safeguard any and all data collected from hospital outpatient departments (HOPDs) and
ambulatory surgery centers (ASCs) and sample members as required by HIPAA.
Vendors must adhere to the following requirements when conducting OAS CAHPS. Each of
these is discussed in more detail in the paragraphs that follow.
• Confidential data must be kept secure as described in this chapter.
• Access to confidential data must be limited to authorized staff members.
• Vendors must develop procedures for identifying and handling breaches of confidential
data.
• No data that can identify a sample member can be included on OAS CAHPS data files
submitted to the OAS CAHPS Data Center. That is, all file submissions must contain de-
identified data.
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State Regulations and Laws Protecting Patients With Specific
Conditions/Illnesses
As indicated in Chapter IV, some states have additional regulations and laws governing the
release of patient information for patients with specific illnesses or conditions, and for other
special patient populations, including patients with HIV. It is the HOPD’s or ASC’s
responsibility to identify any applicable state laws and regulations and exclude patients from the
survey as required by the law or regulation.
Confidential Data Must Be Kept Secure
Any identifying information associated with a patient should be considered private and must be
protected. When monthly patient information is received from an HOPD or ASC, it will contain
private information, such as the name and address or telephone number of the patient, and other
information such as outpatient surgeries or procedures performed and the date on which the
surgeries or procedures were performed. HOPDs and ASCs must provide the monthly patient
information files in a manner that adheres to HIPAA guidelines and regulations, at a minimum
encrypting the patient information files prior to sending them to their vendor. Vendors should
stress this important security measure to their client facilities.
From the moment the vendor receives the monthly patient information file, the data must be
handled in a way to ensure that the patient information is kept confidential and that only
authorized personnel have access to it. Examples of ways to keep confidential data secure
include storing the data electronically in password-protected locations and limiting the number of
staff with access to the password. For confidential information that is obtained on hard copy,
data should be kept in a locked room or file cabinet, with access restricted to authorized staff.
Confidential data should not, under any circumstances, be removed from the survey vendor’s
place of business, either in electronic or hardcopy form, even by survey vendor staff.
Confidential data should not be stored on laptop computers unless those laptops have data
encryption software to protect the information should the laptop be lost or stolen. (Additional
guidance on electronic data backup storage and a disaster recovery plan is provided later in this
chapter.)
Limit Access to Confidential Data
Survey vendors should consider carefully who needs access to confidential OAS CAHPS data
and then ensure that only those staff have access. For example, the Sampling Manager will need
access to the facility sample frame to select the sample. However, information on the frame does
not need to be included in every data file—although names and addresses need to be provided in
the file used to create cover letters, other PHI does not have to be on that file.
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Any staff who will be working with data about outpatient surgery patients should sign a
confidentiality agreement specific to OAS CAHPS implementation (see the paragraph on
Confidentiality Agreements for more information).
Develop Procedures for Identifying and Handling Breaches of Confidential
Data
Survey vendors are required to develop protocols for identifying when there has been a breach of
security with OAS CAHPS data, including when an unauthorized individual has gained access to
confidential information and when an authorized individual has distributed confidential data in
an unauthorized manner. The vendor’s plans must include a system to notify the vendor’s OAS
CAHPS Project Director in a timely manner of a security breach, a means to detect the level of
risk represented by the breach in security, and a means to take corrective action against the
individual who created the breach and any persons affected by the breach, including sample
members. The OAS CAHPS Survey Coordination Team should also be notified as soon as
possible following the breach.
Provide Only De-Identified Data Files to the OAS CAHPS Data Center
Although vendors will have access to patients’ confidential information, none of the data files
submitted to the OAS CAHPS Data Center may contain any confidential information (i.e., any
information that would identify a sample member). All files submitted to the Data Center must
contain de-identified data only. Therefore, only the unique patient sample identification (SID)
number that the survey vendor assigns to each sample member should be included on the file for
each data record. (There will be a data record for each patient sampled.)
Providing OAS CAHPS Response Data to HOPDs and ASCs
When providing response data to their clients, survey vendors must provide data that are de-
identified. Survey vendors must be aware of the following requirements and exceptions.
“About You” Questions (Questions 25–35)
Vendors can provide de-identified response data for an “About You” question (Questions 25-35)
only if there are a minimum of 11 responses in each response category for that question. For
example, if there are 11 or more responses in each age category of Q27 (“What is your age?”), it
is acceptable to provide response results for Q27. However, if there are 10 or fewer responses in
any or all of the age categories, it is not acceptable to provide response data for Q27.
There are two questions in the About You section (Questions 36 and 37) that do not require this
restriction. Questions 36 and 37 are proxy questions that collect information about who helped
the patient complete the mail survey and how they helped. Response data for these two survey
items can be reported to client HOPDs and ASCs regardless of how many responses for each
response option there are.
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Alternative Method for Providing De-Identified Response Data
An acceptable alternative method for vendors to report the “About You” response data to client
HOPDs and ASCs is to combine two or more contiguous response options so that the combined
responses meet the reporting requirement of 11 or more. Below is an illustrative example of how
vendors can implement this alternative method with an “About You” survey question (Q27).
HOPD has 50 completed surveys in a month. The distribution of response categories for Q27 is
as follows:
Response
Category
Number of
Responses
18-24 2
25-34 9
35-44 8
45-54 2
55-64 1
65-74 4
75-79 3
80-84 10
85 + 11
In this example, the data for Q27 cannot be shared with the facility because at least one of the
response categories has fewer than 11 responses.
However, using this alternative method, the vendor could combine response categories to meet
the reporting requirement of 11 or more responses per category:
Response
Category
Number of
Responses
18-34 11
35-64 11
65-84 17
85 + 11
Providing Identified Data
Survey vendors can provide responses linked to a sample member’s name and other identifying
information only if the sample member gives his or her consent on the “Consent to Share
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Identifying Information” question (Appendix F). This includes providing this sample member’s
responses to any “About You” questions that do not meet the threshold of 11 that is required for
reporting response data overall.
In the absence of this explicit consent, only de-identified response data can be provided. In this
case, patient-level data cannot be shared with anyone outside of the vendor’s organization,
including, but not limited to, parent organizations (overseeing multiple CCNs) and individual
client facilities.
Confidentiality Agreements
Survey vendors are required to obtain a signed affidavit of confidentiality from all staff,
including subcontractors, who work on the OAS CAHPS implementation. This includes
individuals who will be working as telephone interviewers or staffing the customer support line
and individuals working in data receipt or data entry positions. Copies of the signed agreements
should be retained by the OAS CAHPS Project Director as documentation of compliance with
this requirement. Vendors will be asked to provide this documentation during site visits.
Physical and Electronic Data Security
Vendors must take appropriate actions to safeguard both the hardcopy and electronic data
obtained during the course of implementing OAS CAHPS, including data obtained from HOPDs
and ASCs and data provided by survey respondents.
The following are measures vendors should take to ensure physical and electronic data security:
• Paper copies of questionnaires or sample frame information must be stored in a secure
location, such as a locked file cabinet or within a locked room. At no time should paper
copies be removed from the vendor’s premises, even temporarily.
• At no time should electronic data be removed from the survey vendor’s or
subcontractor’s premises, even temporarily, unless this is done for purpose of backup
storage. If done for this purpose, the data must be encrypted during transmission and
while in storage in a secure commercial work environment. Vendors must have a disaster
recovery plan for the OAS CAHPS Survey data should any natural (floods, hurricanes,
tornadoes, etc.) or man-made (break-in, act of a terrorist, etc.) disasters occur.
• Electronic data must be protected. Electronic security measures may include firewalls,
restricted-access levels, or password-protected access.
• Access to confidential data must be limited to authorized staff members.
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• Data stored electronically must be backed up nightly or more frequently to minimize data
loss.
• Electronic images of paper questionnaires or keyed data, including computer-assisted
telephone interview or alternative electronic system data, should be retained for 3 years in
a secure location at the vendor’s facility.
• Paper copies of questionnaires must be stored in a secure location at the vendor’s facility,
such as a locked room or file cabinet, for 3 years. Paper copies of questionnaires do not
need to be kept if electronic images of the questionnaires are being kept instead.
• Destroy all paper and electronic copies of questionnaires and surveys that contain
personally identifiable information once the proper time has elapsed.
• Protocols for secure file transmission must be established. E-mailing of PHI via unsecure
e-mail is prohibited.
• Confidential data should not be stored on laptop computers unless those laptops have data
encryption software to protect the information should the laptop be lost or stolen.
• Vendors must develop procedures for identifying if breaches of confidential data have
occurred, informing the OAS CAHPS Survey Coordination Team, and implementing a
corrective action plan.
• No data that can identify a patient or a sample of patients can be included on OAS
CAHPS Survey data files submitted to the OAS CAHPS Data Center. That is, all file
submissions must contain de-identified data.
Communicating With Sample Members About Confidentiality and Security
Sample members may wish to understand how the OAS CAHPS Survey keeps information about
them confidential and secure. It is important that survey vendors on OAS CAHPS clearly and
succinctly communicate this information to sample members, when asked. The following are
guidelines of what to convey:
• the purposes of the survey and how the survey results will be used, specifically that all
patients’ survey responses will be reported at the aggregate level and no response will be
linked to an individual patient respondent;
• participation in the study will not affect the care they receive or health care benefits they
currently receive or expect to receive in the future;
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• participation in the OAS CAHPS Survey is voluntary;
• they can skip or refuse to answer any question they do not want to answer;
• all information they provide is protected by the Federal Privacy Act of 1974 and HIPAA
(most patients are familiar with HIPAA);
• all OAS CAHPS project staff have signed affidavits of confidentiality and are prohibited
by law from using survey information for anything other than this research study; and
• no facility personnel will see an individual patient’s answers unless the patient explicitly
gives consent to share his or her answers.
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IX. DATA PROCESSING AND CODING
Overview
This chapter describes the requirements and guidelines for creating and assigning a unique
sample identification (SID) number to each sample member, decision rules related to processing
returned mail survey questionnaires, assignment of survey disposition codes, and quality control
measures. In addition, procedures and steps for determining whether a returned survey meets the
definition of a completed survey and information about how survey response rates are calculated
are provided in this chapter.
Sample Identification Numbers
A unique numeric or alphanumeric SID number must be assigned to each patient included in
the Outpatient and Ambulatory Surgery CAHPS (OAS CAHPS) Survey sample. Vendors will
use the SID to track efforts to complete the survey with each sample member throughout the data
collection period. When creating and assigning SID numbers to sampled cases, follow the
guidelines listed below.
• The SID number assigned to a sample member cannot contain any combination of letters
or numbers that could link the SID with a particular sample member. For example, no
part of a sample member’s name, address, date of birth, telephone number, Social
Security Number, or dates of outpatient surgeries or procedures can be included in the
unique SID created and assigned to the sample member.
• The SID number also cannot link a sample member with a hospital outpatient department
(HOPD) or ambulatory surgery center (ASC). The vendor should not embed within the
SID any items identifying the source HOPD or ASC, such as its CMS Certification
Number (CCN), its initials, or its location. Vendors with multiple OAS CAHPS clients
wishing to track the source should establish a variable distinct from the SID in which to
identify the source HOPD or ASC of the patient.
• The SID can be a numeric or alphanumeric variable. The SID must have a minimum
length of 6 and a maximum length of 16 characters.
• Vendors must assign new SID numbers to the new set of patients sampled each month.
Vendors must not reuse the same SID number.
• If a patient is sampled more than once in a calendar year or across multiple calendar
years, the vendor must assign a new SID number to that patient each time he or she is
sampled.
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Data Processing Decision Rules and Coding Guidelines – Mail Surveys
Guidelines and procedures for handling ambiguous, missing, or inconsistent survey responses
from returned mail survey questionnaires are provided below. Note that these guidelines should
be followed regardless of whether the vendor is using optical scanning or data keying to enter
data from completed questionnaires.
Decision Rules for Handling Missing or Ambiguous Responses
In mail surveys, some respondents may choose not to answer particular questions, and others
may not clearly mark their answer choices. Use the following rules to handle missing or
ambiguous responses when processing completed questionnaires.
• If a response mark falls between two answer choices but is clearly closer to one answer
choice than to another, select the response that is closest to the marked response.
• If two responses are checked for the same question, select the one that appears darkest. If
it is not possible to make a determination, leave the response blank and code as “missing”
rather than guess.
• If a mark is between two answer choices but is not clearly closer to one answer choice,
code as “missing.”
• Note that the only survey items in the OAS CAHPS Survey where two or more answers
are acceptable are Questions 32 and 37, which ask the sample member to check all
answer choices that are applicable to him or her. For both of these questions, enter
responses for all of the categories that the respondent marked.
• If a response is missing, leave the response blank and code it as “Missing.”
Decision Rules for Coding Survey Responses Marked Outside the
Response Box
Although OAS CAHPS mail questionnaires use response bubbles or boxes, vendors may receive
surveys where a response is marked outside the response box. CMS and the OAS CAHPS
Survey Coordination Team acknowledge that there are some instances where it is acceptable to
consider a response “marked,” even if the response box itself is not marked. However, to
minimize the opportunity for coding interpretation errors among vendors, OAS CAHPS requests
that all responses or response boxes that are not circled, checked, underlined, or in some other
way clearly designated by the respondent (i.e., the respondent writes the exact wording of a
response to the right of the response options) be coded as “Missing.”
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Although some text or marks to the right of the response options may seem to point to a
particular response, many times the respondent’s intent is not clear. This opens the door to
nonstandardized interpretations from vendor to vendor. To provide some visual guidance on
what is expected, we offer three examples below of when it is acceptable to code a response and
two examples of when it is not acceptable to code a response.
When it is Acceptable to Code a Response
Example 1:
In this first example, the respondent has
circled a response. The respondent’s
intention is clear and the vendor should code
the answer to Q3 as “No.”
Example 2:
In this second example, the respondent has
underlined a response. The respondent’s
intention is clear and the vendor should code
the answer to Q6 as “Yes, definitely.”
Example 3:
In this third example, the respondent has
placed a check mark very close to a
response. Again, the respondent’s intention
is clear, and the vendor should code the
answer to Q22 as “Yes.”
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When it is NOT Acceptable to Code a Response
Example 1:
In this example, the respondent has placed a
check mark to the right of the response
boxes. It is not clear which response was
intended. Therefore, the correct procedure
for a question presenting like Q10 is to code
the response as “M,” which stands for
“missing.”
Example 2:
In this example, the respondent has placed a
check mark to the right of the response
boxes. It is not clear which response was
intended. Therefore, the correct procedure
for a question presenting like Q9 is to code
the response as “M.”
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Skip Patterns
Some of the questions included in the OAS CAHPS Survey instrument are “screening”
questions—that is, they are designed to determine whether one or more follow-up questions
about the same topic are applicable to the respondent. The respondent is directed to the next
applicable question by a “skip” instruction printed beside the answer choice that he or she marks.
In mail surveys, some respondents may answer the screening question but leave applicable
follow-up questions blank. In other cases, some respondents will mark an answer to follow-up
questions that are not applicable to them (based on the answer to the screening question). Yet in
other cases, some respondents will answer both the screening and follow-up questions with
responses that contradict each other. Use the following rules for completed OAS CAHPS
questionnaires.
Decision Rules for Coding Screening Questions (Qs. 10, 30, 34, and 36)
• Key or scan the response provided by the respondent.
• If the screener question is left blank, code it as “M” for Missing. If both the screener
question and the follow-up questions are left blank, the screening question should be
coded “M” for Missing and the follow-up questions should be coded “X” for Not
Applicable.
Decision Rules for Coding Follow-Up Questions (Qs. 11, 12, 31, 35, and 37*)
*Please note: Question 37 is included in the mail survey only.
• Key or scan the response provided by the respondent whenever one is given, regardless
of whether the response agrees with the screener question. For example, if the respondent
answers “No” to the screener question and then marks a response to the follow-up
question instead of skipping it, that is acceptable—the response must still be keyed or
scanned.
• If the follow-up question is left blank (correctly) because the respondent correctly
followed the skip instruction in the screener question, assign code “X” for Not Applicable
to the follow-up question.
• If the follow-up question is left blank (incorrectly) because the respondent skipped it (or,
if a telephone interview, he or she responded with Don’t Know or Refuse) rather than
answering it, enter code as “M” for Missing to the follow-up question.
To summarize, when follow-up questions are appropriately skipped, the follow-up question
response should be coded as “Not Applicable,” which is code “X.” When follow-up questions
are incorrectly answered, scan or key the response that the respondent provides. If a screener or
follow-up question should have been answered but was not, code the response as “Missing,”
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which is code “M.” Note that in OAS CAHPS, survey vendors will key or scan the response to
every question that the respondent provides.
Data Processing Decision Rules and Coding Guidelines – Telephone Surveys
Guidelines and procedures for handling skip patterns and decision rules for telephone surveys are
provided below.
Skip Patterns
Some of the questions included in the OAS CAHPS Survey instrument are “screening”
questions—that is, they are designed to determine whether one or more follow-up questions
about the same topic are applicable to the respondent. The vendor’s computer-assisted telephone
interview (CATI) system should be programmed such that follow-up questions are skipped if a
screening question is answered in the negative. Therefore, when follow-up questions are skipped,
no response data should be captured by a telephone interviewer.
Decision Rules for Coding Screening Questions (Qs. 10, 30, 34, and 35)
• Key the response provided by the respondent.
• If the response to the screener question is coded as MISSING/DK, code it as “M” for
Missing. If both the screener question and the follow-up questions are left blank, the
screening question should be coded “M” for Missing and the follow-up questions should
be coded “X” for Not Applicable.
Decision Rules for Coding Follow-Up Questions (Qs. 11, 12, 31, 35, and 35a*)
*Please note: Question 35a is included in the telephone survey only.
• If the respondent answered the screening question such that the follow-up question is
skipped, assign code “X” for Not Applicable to the follow-up question.
• If the follow-up question is read to the respondent and coded MISSING/DK, assign code
“M” for Missing to the follow-up question.
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Survey Disposition Codes
Survey disposition codes, which are also referred to as status codes, are used to track the current
status of a sampled case as it moves through the survey process. For example, a disposition code
is used to designate that the first questionnaire has been mailed, and another disposition code is
used to indicate that the questionnaire has been received. Disposition codes can be interim
(meaning that they are expected to change as the case moves through the rest of the survey
process) or final (meaning that no further action will be taken with that case). Understanding and
appropriately using OAS CAHPS disposition codes is required for successful administration and
completion of OAS CAHPS. This section provides a list and description of the final disposition
codes that are to be used on OAS CAHPS, for mail-only, telephone-only, and mixed-mode
surveys.
Survey vendors should apply pending disposition codes to OAS CAHPS cases for internal
tracking purposes only—that is, to describe the result of the most recent work or action on the
case that did not result in a final disposition. Because survey vendors may have already
developed a set of designated pending disposition codes for tracking the pending status of a case,
survey vendors may use their own set of pending codes on OAS CAHPS.
Definition of a Completed Survey or Survey Completion Criteria
As is seen below in the description of all OAS CAHPS status codes, one of the criteria in
determining the correct code is whether the survey is “complete.” A survey is considered to be
“complete” and should be assigned a survey disposition code of 110 or 120 if at least 50% of the
questions applicable to all sample members (Questions 1–10 and 13–24) are answered.
• Survey items that are part of skip patterns and the items in the “About You” section of
the questionnaire (Questions 11, 12 and 25–37) are not included in this calculation of
percentage complete.
• Responses of “Don’t Know” and “Refuse” should be recoded to “M” for Missing and
should not be counted as responses.
• Responses to any supplemental questions should not be included in this calculation of
percentage complete and should not be reported to the OAS CAHPS Data Center.
• Use the steps in Exhibit 9.1 to determine whether a survey can be considered “complete.”
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Exhibit 9.1 Steps for Determining Whether a Questionnaire Meets Completeness Criteria
Sum the number of questions that have been answered by the respondent that are applicable to all
patients. These include questions 1–10 and 13–24.
R = total number of questions answered
Divide the total number of questions answered by 22, which is the total number of questions applicable to
all patients, and then multiply by 100 to determine the percentage.
Percentage Complete = (R / 22) x 100
If the Percentage Complete is greater than or equal to 50 percent, then assign the applicable survey
completed disposition code (code 110 or 120) to indicate that the case meets the definition of a
completed survey. Otherwise, assign the disposition code for breakoff (code 310) to the case.
The vendor must select and assign the applicable code from the disposition codes shown in
Table 9.1 for each sampled case included on the data file submitted to the OAS CAHPS Data
Center.
Table 9.1 OAS CAHPS Survey Disposition Codes
Code Description
110 Completed Mail Survey
See Definition of a Completed Survey (above)
Assign this code for mail-only cases and for mixed-mode cases if the sample member responded by mail.
Note that respondents may receive assistance completing the mail survey and such respondents should be included in Code 110. If they are capable of understanding and answering the questions someone else can provide assistance. For example, someone could read the questions and record their answers to help a blind respondent.
120 Completed Telephone Interview
See Definition of Completed Survey (above)
Assign this code if the interview was completed for telephone-only cases and for mixed-mode cases if the sample member responded by telephone.
Note that respondents may receive assistance in completing the telephone survey and such respondents should be included in Code 120. For example, someone could translate the CATI interviewer’s questions into sign language and state a deaf respondent’s replies to the CATI interviewer.
210 Ineligible: Deceased
Assign this code if the sample member is reported as deceased during the course of the survey period.
(continued)
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Table 9.1 (continued) OAS CAHPS Survey Disposition Codes
Code Description
220 Ineligible: Does Not Meet Eligible Population Criteria22
Assign this code if it is determined during the data collection period that the sample member does not meet all of the required eligibility criteria for being included in the survey sample. Apply this code if:
• The sample member is under age 18 (note: sampling procedures direct vendors to remove such patients from the sample frame based on their birthdate).
• The sample member does not have a domestic U.S. address (note: sampling procedures direct vendors to remove these patients from the sample frame based on their address).
• The sample member resides in a nursing home or in a prison or jail (note: sampling procedures direct vendors to remove these patients from the sampling frame if this residence information is known).
• The sample member reports that he or she did not receive an outpatient surgery or procedure from the named HOPD or ASC.
• The sample member reports that he or she did not receive surgery or procedure on the sample date.
• It is reported that the sample member was discharged to hospice care following his or her surgery during the sample month.
A full listing of eligibility criteria is provided in Chapter IV of this manual.
230 Ineligible: Language Barrier
Assign this code to sample members who do not speak any of the OAS CAHPS language(s) that the vendor is administering for that facility. Note that this code only applies to the sample member and should not be assigned until a determination is made that the sample member cannot speak the language(s) being administered.
240 Ineligible: Mentally or Physically Incapacitated
Assign this code if it is determined that the sample member is unable to complete the survey because he or she is mentally or physically incapable.
310 Break-Off
This code should be assigned if the sample member completes some responses but does not meet the definition of a completed survey (see above).
320 Refusal
This code should be assigned if the sample member indicates either in writing or verbally that he or she does not wish to participate in the survey.
Mail-Only Mode
This code should also be assigned if the first questionnaire mailing is never returned or is returned blank and the second questionnaire is returned blank during the data collection period.
Telephone-Only Mode or Mixed Mode
This code should be assigned if the sample member (not a gatekeeper or other individual) states that he or she does not wish to participate in the survey.
(continued)
22 See Chapter IV for eligibility rules for OAS CAHPS.
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Table 9.1 (continued) OAS CAHPS Survey Disposition Codes
Code Description
330 Bad Address/Undeliverable Mail, or No Address
This code should be assigned only when using the mail-only mode. It should be assigned if it is determined that the sample member’s address is bad (e.g., the questionnaire is returned by the Post Office as undeliverable with no forwarding address).
340 Wrong, Disconnected, or No Telephone Number
This code should be used in telephone-only or mixed-mode survey administration. In the telephone-only mode, this code should be assigned if it is determined the telephone number is bad (disconnected, no telephone number available, etc.). In the mixed mode, this code should be assigned because the telephone follow-up represents the last attempt to reach the sample member even if it is determined that the mailing address is also bad.
350 No Response After Maximum Attempts
This code should be used in all three approved data collection modes. It should be assigned when the contact information for the sample member is assumed to be viable, but the sample member does not respond to the survey or cannot be reached during the data collection period.
This code should also be assigned to completed surveys received after the data collection period ends. As explained earlier, the data collection period ends 42 calendar days after the initial mailout (for mail-only and mixed mode) or 42 calendar days after the initiation of the telephone survey (for telephone-only mode).
Mail-Only Mode
• This code should be assigned if the sample member’s address is viable but he or she does not respond to either the first or second questionnaire mailing during the data collection period. This code should be assigned if the initial questionnaire is never returned or returned blank and the second questionnaire is never returned.
Telephone-Only Mode
• This code should be assigned if it is determined that the telephone number is viable but the required number of telephone attempts (five) did not result in a completed interview or other final disposition code.
Mixed Mode
• This code should be assigned if it is determined that the address and telephone number are viable but the maximum number of contact attempts (i.e., the questionnaire mailing and five telephone attempts) did not result in a completed survey or another final disposition code.
Differentiating Between Disposition Codes 330 (Bad/No Address), 340
(Bad/No Telephone Number), and 350 (No Response After Maximum
Attempts)
Code 330: Nonresponse: Bad or No Address should be assigned only if there is evidence that
the patient’s address is not viable. This code is for mail-only mode. Evidence that the address is
not viable includes the following:
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• the HOPD or ASC does not provide an address for the sample member and the vendor
has attempted but failed to obtain an address;
• the questionnaire is returned as “undeliverable, no forwarding address”; and
• the questionnaire is returned as “address or addressee unknown” or some other reason the
mail was not delivered.
The vendor is strongly encouraged to use an outside address update service prior to mailing
questionnaires to ensure that the most accurate mailing address is used. Survey vendors are
permitted to ask HOPDs and ASCs to provide updated address information for all patients
treated within the sample month, if needed. The survey vendors cannot, however, give a list of
sample members to the HOPD or ASC to request this information. Similarly, if a questionnaire is
returned as undeliverable, the vendor is strongly encouraged to attempt to locate a new address
prior to the second questionnaire mailing.
Code 340: Nonresponse: Bad or No Telephone Number should be assigned only if there is
evidence that the sample member’s telephone number is not viable. This applies to both
telephone-only and mixed-mode administration. Evidence that the telephone number is not
viable includes the following:
• the HOPD or ASC does not provide a telephone number for the sample member and the
vendor has attempted and failed to obtain a telephone number;
• on calling, the telephone interviewer learns that the telephone number on file is
disconnected, nonworking, or out of order, and no new telephone number is provided;
and
• on calling, the telephone interviewer reaches a person and learns that the telephone
number is the wrong number for the sample member and no new number is provided.
To ensure that the most accurate telephone number is used, the vendor is strongly encouraged to
use an outside telephone number update service prior to initiating telephone contact. Similarly, if
the vendor learns that a telephone number is not viable, the vendor is strongly encouraged to
attempt to locate a new telephone number for the sample member prior to the end of the data
collection period. Survey vendors are permitted to ask HOPDs and ASCs to provide updated
telephone number information for all patients treated within the sample month, if needed. The
survey vendors cannot, however, give a list of sample members to the HOPD or ASC to request
this information.
Code 350: Nonresponse: No Response After Maximum Attempts should be assigned if there is
evidence that the sample member’s address or telephone number is viable but the sample
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member has not responded after all questionnaire mailings or telephone attempts appropriate for
the given mode have been implemented.
Handling Blank Questionnaires
In handling questionnaires that are returned blank, vendors should differentiate between mail
survey questionnaires that are returned blank because the United States Postal Service could not
deliver the mail (referred to as undeliverables) and those returned blank by the sample member
or the sample member’s family or friend. The procedures described below are for surveys that
are returned blank and are not marked as undeliverable.
For the mail-only mode, it is appropriate to send a second questionnaire to the sample member if
the first questionnaire is returned blank, as long as it is mailed before the end of the data
collection period. If the second questionnaire is also returned blank, the vendor should assign a
final survey disposition code 320 – Refusal. If the first survey for the mail-only mode is never
returned and the second survey is returned blank, then that case should also be assigned a final
disposition code of 320 – refusal. If the first survey for the mail-only mode is never returned or
returned blank and the second questionnaire is not returned at all, the vendor should assign the
final survey disposition code 350 – No Response After Maximum Attempts. If any survey for the
a mail-only or mixed mode is returned with only supplemental questions marked (i.e., the OAS
CAHPS Survey Questions 1–37 are left blank), it is considered a “blank survey” as response data
for supplemental questions are not reported to the OAS CAHPS Data Center. Such a case should
be coded a 320 – Refusal.
Note that all cases that are not finalized as a result of the mail survey component of the mixed-
mode survey must be assigned for telephone follow-up. This means that unless the case was a
refusal or the sample member was determined to be ineligible for the survey during the mail
survey data collection phase of the survey, survey vendors should follow up with the sample
member by telephone. This includes cases for which the questionnaire was returned blank and
those for which the questionnaire was undeliverable. An exception to this rule is for “blank
surveys” coded a 320 – Refusal because only the supplemental questions have been marked in
the mail survey. Mail surveys meeting this criterion should not be contacted again (i.e., if in the
mail-only mode, a second questionnaire should not be sent to the sample member, and if in the
mixed mode, survey vendors should not follow up with the sample member by telephone).
Handling Proxy Cases
Proxies are not permitted on the OAS CAHPS Survey. However, it is possible someone other
than the sample member completes and returns the OAS CAHPS mail survey questionnaire.
There are two ways to determine a proxy case: the response to Question 37 is response option
“3 - Answered questions for me” (alone or in combination with other response options for that
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question) or through a note written on or attached to the questionnaire. Exhibit 9.2 shows when a
case is a proxy based on the response provided for Question 37.
Exhibit 9.2 How to Determine a Proxy Case
Value for Q36 Is response option 3 to Question 37
selected? Proxy?
1 Yes Yes
2 Yes Yes
M Yes Yes
1 No No
2 No No
M No No
If a proxy case is identified, the vendor must not key or scan any of the responses provided
because no data can be accepted for a survey completed by a proxy. A proxy case must not be
assigned a disposition code of 110, 120, or 310. Instead, the vendor’s data receipt or data keying
staff should review the returned questionnaire for any information that could inform an
appropriate final disposition code. This must be based on the information provided in the
handwritten note (e.g., an indication that a family member completed the questionnaire because
the sample member died, moved to a nursing home, is mentally incapable of responding, or is
incarcerated). If there is no note indicating why the mail survey was completed by proxy and
Q37’s response option “3” is selected, the vendor should assign the final disposition code 320 –
Refusal to the case.
Quality Control Measures
Vendors are strongly encouraged to implement quality control measures for every aspect of mail
and telephone data processing activities. Required and recommended quality control measures
are described in detail in the mail, telephone, and mixed-mode data collection chapters of this
manual; however, we have repeated key measures here as well. Quality control measures are
listed by topic in the paragraphs that follow. Vendors should conduct additional quality control
measures as warranted, based on their individual processes. All quality control checks should be
conducted by a different person than the one who completed the task.
Quality Control for Mail Survey Data Processing Activities
• Vendors should review at least 10% of the printed questionnaires for each batch of
questionnaires that are printed each sample month to ensure the quality of the printed
questionnaires. The questionnaires should be examined to make sure there are no bleed-
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throughs, which can impact or cause problems when scanning the data from completed
surveys, and to make sure all pages are included in the questionnaire.
• Vendors should check to make sure the number of mail survey packages to be mailed
matches the number of sampled cases.
• Vendors should check a sample of at least 10%of mail survey packages before they are
sealed and mailed. In this check, make sure that the SID number on the questionnaire
matches the SID number on the cover letter.
• For vendors that use scanning software for data capture procedures, select a sample of
questionnaires (minimum of 10 percent), rescan, and compare the scanned images against
the original hardcopy survey as a quality control measure. For vendors that use data
keying as their data capture process, all questionnaires should be 100% rekeyed by a
different keyer to ensure that all entries are accurate. If any discrepancies are observed, a
supervisor should resolve the discrepancy and ensure that the correct value is keyed.
• For coding, vendors should select and review a sample of cases coded by each coder to
make sure coding rules were followed correctly.
• We highly recommend before submitting data to the OAS CAHPS Data Center that
vendors compare the responses coded on the hardcopy questionnaire for a sample of at
least 10% of cases with the responses that were actually scanned or keyed and with the
responses entered on the XML file. This check will ensure that the responses included in
the XML files accurately reflect the sample members’ responses to the survey questions.
• We highly recommend that vendors calculate and review the response rates periodically
for each of their client HOPDs or ASCs. If a sample was selected for an HOPD or ASC
but there is no response or a very low response rate, this could be an indicator that
incoming mail was not processed, scanned data were not exported to the XML data file,
or other problems occurred with the mail survey. In instances where the number of cases
sampled was very small (e.g., 10 or fewer), it is possible that all of the sample members
decided not to return a completed survey. For HOPDs and ASCs with larger sample sizes,
no response from any of the sample members could be indicative of a data collection or
data processing problem.
• Vendors are urged to develop a way to measure error rates of both their data receipt staff
in terms of recognizing marginal notes and passing these on to someone for review and in
terms of data entry or scanning verification. Vendors should then work with their staff to
minimize error rates. The OAS CAHPS Survey Coordination Team will request
information about data receipt and processing error rates during site visits to survey
vendors.
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Centers for Medicare & Medicaid Services 137 Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual
Quality Control for Telephone Survey Data Processing Activities
• Vendors must silently monitor a minimum of 10% of all telephone interviews to ensure
that correct administration and coding procedures are being followed. Supervisory staff
monitoring telephone interviewers should use the electronic system to observe the
interviewer conducting the interview while listening to the audio of the call at the same
time.
• We highly recommend that vendors calculate and review the response rates on a periodic
basis for each of their client HOPDs and ASCs. If a sample was selected for an HOPD or
ASC but there is no response or a very low response rate, this could be an indication of a
data collection or data processing problem. In cases where the number of cases sampled
was very small (e.g., 10 or fewer), it is possible all of the sample members decided not to
participate in the survey. For HOPDs and ASCs with larger sample sizes, it is highly
unlikely that 100% of the sample cases will refuse to participate in the survey.
• Vendors should conduct periodic reviews of their XML data files by comparing at least
50 completed telephone interview responses directly from their CATI system to the
values output in the XML file. Doing this review monthly will ensure that the responses
are being accurately captured and output to the XML file.
• Vendors should generate and review frequencies of cases at the various interim and final
disposition codes for each HOPD and ASC and perhaps by telephone interviewer. For
instance, a high percentage of cases coded as “not available” after maximum attempts
could indicate that call attempts are not scheduled appropriately.
Quality Control on XML Files
• Vendors should use the XML validation tool to conduct an initial quality control of their
XML file formatting. The XML Schema Validation Tool is available on the OAS
CAHPS website through the “Data Submission Resources” link, under the “Data
Submission” menu.
• We highly recommend that vendors conduct some additional quality control measures on
the data included on XML files to ensure that the data from completed mail and
telephone surveys are being captured accurately. This includes running frequencies of
distributions on both the patient administrative data and the patient response data to look
for outliers or anomalies, including missing values.
Examples of frequencies vendors could run include the race variable (are all respondents
coded as Alaska Native, for example?) or the age variable (is there a reasonable
distribution of age categories across sample members, or do the ages lean heavily toward
the very young or very old?). By reviewing frequencies of both the patient administrative
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138 Centers for Medicare & Medicaid Services Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual
data and the patient response data, vendors may be able to identify problems in the data
they receive from HOPDs and ASCs, their own facility data file processing, or their XML
coding operations.
• Vendors should periodically check their data processing programs to confirm that
variables on the XML files are coded properly on the XML file.
• Vendors should conduct a final check of the
disposition code assigned to all sampled
cases before submitting XML files to the
OAS CAHPS Data Center. If the vendor
identifies a case assigned either an
ineligible or noncomplete final disposition
code AND there are data included in the Patient Response Record section of the XML
file, they should check their records to determine why code 110, 120, or 310 was not
assigned to the case. If it is determined that the case is indeed ineligible or was a
noncomplete, remove the survey response data from the XML file.
• Vendors should select a random sample of
cases on the XML file and compare the
variables in the Patient Administrative Data
Record against the patient information that
was provided by the HOPD or ASC on the
original monthly patient information file to
make sure the information was exported to the XML file correctly.
Computing the Response Rate
Survey vendors are not required to compute a response rate for each monthly sample. However,
CMS will compute and report a response rate for each HOPD and ASC when survey results are
publicly reported. For a given public reporting period (i.e., the last four quarters of collected
data), a response rate for each HOPD and ASC will be calculated as described in Exhibit 9.3.
The information below is provided for illustrative purposes only.
The Patient Response Record section of the
XML file contains the responses to the OAS
CAHPS Survey from every patient who
answered the survey during the sample
month.
The Patient Administrative Data Record
section of the XML file contains data about
each patient who was sampled for the sample
month, including both those who responded to
the survey and nonrespondents.
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Centers for Medicare & Medicaid Services 139 Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual
Exhibit 9.3 How Response Rates Are Calculated
Response Rate =
Total number of Completed Surveys is the number of surveys assigned a final survey disposition code of
110 or 120.
Total Number of Surveys Fielded is the total number of patients selected for the survey in the sample
month. This includes all cases with a final survey disposition code of 110 through 350.
Total Number of Ineligible Surveys is the number of sample cases assigned a final survey disposition
code of 210, 220, 230, or 240. No other cases will be removed from the denominator.
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Centers for Medicare & Medicaid Services 141 Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual
X. THE OAS CAHPS SURVEY WEBSITE
Overview
This chapter presents an overview of the Outpatient and Ambulatory Surgery CAHPS Survey
(OAS CAHPS) website and the web portal within the website. This website is the official site for
the OAS CAHPS Survey with public and private sections. The private section is an interactive
site that supports the functionality needed by survey vendors, hospital outpatient departments
(HOPDs) and ambulatory surgery centers (ASCs) participating in the OAS CAHPS Survey. For
example, it contains procedural documents, survey materials, an online tool for data submission
and vendor authorization, and reports for vendors, HOPDs, and ASCs.
The OAS CAHPS Website
The OAS CAHPS Data Center is maintained by RTI International, which is assisting the Centers
for Medicare & Medicaid Services (CMS) with OAS CAHPS. RTI also developed and maintains
the OAS CAHPS website, available at https://oascahps.org/ . This website is the main vehicle
for communicating and updating information about OAS CAHPS to HOPDs, ASCs, and survey
vendors. The website has both public and secure (restricted-access) sections to ensure the
security and privacy of selected interactions. On the public page, a link to a login allows
authorized users (survey vendor, HOPD or ASC staff) access to the restricted private sections of
the website, where they can carry out administrative functions according to their role. Access to
the secure sections will be restricted and controlled through user identification and password.
Specifically, survey vendors will use the website to submit OAS CAHPS data to the OAS
CAHPS Data Center. It will also allow Medicare-certified HOPDs and ASCs to authorize their
contracted survey vendor to submit OAS CAHPS data on their behalf, access their data
submission reports, and review their OAS CAHPS Survey results before the results are publicly
reported. Exhibit 10.1 provides an overview of both the public and private links and information
available on the website. In the diagram, private links are shown in red text and public links are
shown in black text.
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142 Centers for Medicare & Medicaid Services Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual
Exhibit 10.1 OAS CAHPS Website Diagram
Public Links on the OAS CAHPS Website
The public side of the OAS CAHPS website is located at https://oascahps.org/ . This address
defaults to the public Home page, which is shown in Exhibit 10.2. Note that this is a secured
website; therefore, users should be sure to include the “s” in the “http” when accessing the site.
OAS CAHPS Web Portal Diagram
About OAS CAHPS Survey National Implementation and Public Rpt Mode Experiment Vendor Application Process Announcements Contact Us
General Information
Schedule Agenda Registration Training Slides
Training
Vendor Registration Minimum Business Requirements Vendor Application
* Exceptions Request Form
* Discrepancy Notification Form
* Model QA Plan Submit QA Plan
* Survey Vendor Authorization Report
* Manage Users
*
For Vendors
oascahps . org
OAS CAHPS Procedures Manual Questionnaire Sample Letters and Phone Scripts FAQs and OMB Disclosure Notice
Survey and Protocols
Data Submission Deadlines Sample File Download
* Data Submission Resources
Data Submission Tool
* Data Submission Reports
*
Data Submission
Facility User Registration Registered CCNs Report
* Manage Users
* Authorize a Vendor
* View Data Submission History
* Survey Preview Report
*
For Facilities
Vendor Approval Process
* Training Summary
* Vendor Authorization Status
* User Access Summary
* Data Submission Summary
*
Vendor Dashboard
Login
Required Action Items
* Registration Status
* Authorization Status
* User Access Summary
* Info for Dialysis Facilities
* Recent Announcements
* Data Submission Summary
*
Facilities Dashboard
- Publicly Available Pages and Links - Private Pages and Links requiring Login Authentication
*
Legend
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Centers for Medicare & Medicaid Services 143 Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual
Exhibit 10.2 OAS CAHPS Home Page (Public Website)
On the Home page, there is a welcome message that includes brief information about OAS
CAHPS. In that message, there are hyperlinks embedded in the underlined text that lead to other
pages that provide more specific information.
The OAS CAHPS website uses navigation features that include standard dropdown menus and
other navigation tools. A horizontal menu bar is displayed near the top of the Home page. The
bar has different tabs, each with its own dropdown options to allow users to perform various
functions and access more information. The navigation tabs include the following:
• General Information;
• Training;
• For Vendors;
• Survey Materials;
• Data Submission; and
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144 Centers for Medicare & Medicaid Services Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual
• For Facilities.
The public pages on the OAS CAHPS website contain various links and information including
the following:
• Background information about OAS CAHPS, including information about the mode
experiment, national implementation, and public reporting;
• Requirements and a description of the application process for survey vendors interested
in becoming a CMS-approved OAS CAHPS Survey vendor;
• Contact information for the OAS CAHPS Survey Coordination Team (e-mail address and
toll-free telephone number);
• Survey questionnaires and related survey administration materials in English, Spanish,
Chinese, and Korean;
• Survey administration protocols, guidelines for data submission, and information about
the data submission tool (including this manual and the OAS CAHPS Survey Website
User and Data Submission Manual, Version 2.0);
• Vendor Registration Form, to be completed by the survey vendor’s designated Survey
Administrator; the Survey Administrator must complete this form so that he or she can
access and submit a Vendor Application to become a CMS-approved OAS CAHPS
Survey vendor;
• Minimum Business Requirements, a set of requirements survey organizations must meet
to be considered for approval for the OAS CAHPS Survey;
• Facility Administrator Registration Form, to be completed by the HOPD’s or ASC’s
designated OAS CAHPS Survey Administrator to create an account and credentials for
accessing links in the secure section of the website;
• Continuous updates in the Announcements section (shown in Exhibit 10.3), which is
under the “General Information” menu tab. These updates will provide vendors, HOPDs,
and ASCs with any new policies or changes in survey administration protocols and
procedures, announcements about updates to the Protocols and Guidelines Manual, the
Data Submission Manual, reminders of upcoming data submission deadlines, and
information about the annual training sessions;
• A Recent Announcements section also appears on the Home page (shown in Exhibit
10.4);
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Centers for Medicare & Medicaid Services 145 Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual
• A list of Approved Survey Vendors that may administer the OAS CAHPS Survey;
• Helpful documents for HOPDs and ASCs, including information about OAS CAHPS
participation process and guidelines, steps on Getting Started to participate in OAS
CAHPS, instructions on How to Authorize a Vendor on the OAS CAHPS website, and
Frequently Asked Questions (FAQs) for hospitals and ASCs;
• A copy of the most recent Hospital Outpatient Prospective Payment and Ambulatory
Surgical Center Payment Systems and Quality Reporting Programs Proposed or Final
Rule published on the Federal Register that HOPDs, ASCs, and vendors can reference
for OAS CAHPS participation guidelines;
• Information about the patient-mix coefficients and adjustments made for publicly
reported OAS CAHPS Survey Results (updated quarterly when results are refreshed on
data.medicare.gov); and
• Training information and materials for the annual Introduction to the OAS CAHPS
Survey Training and Update Training sessions, including a Training Information page
and Training Registration form.
Exhibit 10.3 Announcements Page on the OAS CAHPS Website
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146 Centers for Medicare & Medicaid Services Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual
Exhibit 10.4 Recent Announcements Section on the OAS CAHPS Website Home Page
How to Obtain Access to the Private Side of the OAS CAHPS Website
All Users (Survey Vendors, HOPDs, and ASCs)
Designate an OAS CAHPS Survey Administrator. Before any participating HOPD, ASC, or
survey vendor can access the restricted portion of the website, the organization first must
designate a staff member to serve as its OAS CAHPS Survey Administrator. The designated
OAS CAHPS Survey Administrator’s roles and responsibilities are listed below.
• Complete the registration process on the OAS CAHPS website:
◦ For HOPDs and ASCs, this is a two-step process:
Step 1: Register as the Survey Administrator establishing login credentials for this
website; and
Step 2: Register the CCN(s) of the HOPD or ASC the Survey Administrator will be
responsible for;
◦ For vendors, register as the Survey Administrator establishing login credentials for
this website;
• Designate another individual within the organization to serve as the backup OAS CAHPS
Survey Administrator;
• Remove access or approve the removal of access for users who are no longer authorized
to access the private side of the website;
• Serve as the main point of contact with the OAS CAHPS Survey Coordination Team; and
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Centers for Medicare & Medicaid Services 147 Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual
• Notify the OAS CAHPS Survey Coordination Team if your role as the OAS CAHPS
Survey Administrator will no longer be valid and identify a successor.
HOPD and ASC Users
Step 1: The individual designated as the HOPD’s or ASC’s OAS CAHPS Survey
Administrator will complete and submit the Facility Administrator Registration Form. This
online form is located on the public side of the website. It is used to establish an account and
obtain credentials for accessing the secured sections of the website. To do this, click on the
“Register for Login Credentials” link under the “For Facilities” navigation tab on the OAS
CAHPS website (as shown in Exhibit 10.5).
The form will collect the OAS CAHPS Survey Administrator’s name, e-mail address, and
telephone number. The Survey Administrator will also be instructed to create a username and
password that will be used to access the secured links and forms on the private side of the
website. Once all information is correct, click the “Submit” button.
The OAS CAHPS Data Center will activate an account immediately after the online registration
form has been submitted. Once the registration form is submitted, users will be routed to a
personalized dashboard, where they can find the other forms required to complete the registration
process. Additional links to important functions and forms, including the Facility CCN
Registration Form and the Authorize a Vendor Form, are also available on the dashboard.
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148 Centers for Medicare & Medicaid Services Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual
Exhibit 10.5 Facility Administrator Registration Form
Step 2: The OAS CAHPS Survey Administrator will complete and submit the Facility CCN
Registration Form. This online form is located on the private side of the website. The OAS
CAHPS Survey Administrator will enter their username and password to log in (see
Exhibit 10.6). The OAS CAHPS Survey Administrator will enter the CCN(s) for which they are
an administrator into the box. Multiple CCNs can be separated by commas. After the CCN(s) are
entered, click the “Lookup Facility Names” button and the system will automatically display the
facility or facilities name(s) in the display window.
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Exhibit 10.6 Facility CCN Registration Form
The person filling out this form will be presented the list of roles and responsibilities of the OAS
CAHPS Survey Administrator. The OAS CAHPS Survey Administrator needs to personally
acknowledge that that he or she is the OAS CAHPS Survey Administrator for the listed
HOPD(s) or ASC(s), and acknowledge that he or she accepts the roles and responsibilities
for the listed HOPD(s) or ASC(s). Once all information is entered correctly, click “Submit.”
Step 3: The OAS CAHPS Survey Administrator will designate a backup OAS CAHPS
Survey Administrator and create an account for him or her. The backup OAS CAHPS
Survey Administrator will have all of the same permissions on the website as the primary OAS
CAHPS Survey Administrator. Having a backup Survey Administrator will ensure continued
access to the system if the primary Survey Administrator is unavailable or terminates
employment with the HOPD(s) or ASC(s). The Survey Administrator or the backup Survey
Administrator must notify the OAS CAHPS Data Center immediately if the primary Survey
Administrator will no longer serve in that role.
After logging onto the OAS CAHPS website, the form to designate a backup survey
administrator (User Details form) is available on the Facility Dashboard, under the menu item
“Manage Users Console.” Through this console (shown in Exhibit 10.7), the Survey
Administrator can add a new user, delete a user, or edit a user. The User Details form (shown in
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150 Centers for Medicare & Medicaid Services Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual
Exhibit 10.8) collects contact information for the user and allows them to be linked with, or
unlinked from, any of the CCNs associated with the primary Survey Administrator.
The primary Survey Administrator can navigate to the User Details form by clicking on the
“Add New User” button on the Manage Users page, and then follow the steps described below to
complete the desired action.
To add a user, complete all fields on the form (username, first name, last name, e-mail,
telephone, role, and the CCN(s) this user will have access to).
The Role field is populated with one option: “Backup Administrator.” This will allow the
added user to have the same level of access on the OAS CAHPS website as the primary
Survey Administrator.
When all required fields are completed, click “Add User.”
This action will cause an e-mail notification to be sent to the added user. The e-mail will
contain the username that was entered on the User Details form and a temporary password.
The added user will be prompted to change his or her password the first time he or she logs
into the website.
If the user being added has existing login credentials, it will be important that the username
and e-mail address entered on the form matches the user’s existing account information. This
will link all CCNs for which the person should have access to the single set of credentials.
A message in a red box will appear on the screen indicating that the e-mail entered already
exists in the system. Before clicking “Confirm Add,” we encourage the Survey Administrator
(completing the form) to confirm directly with the user that the username entered matches the
user’s existing username. If it does match, click “Confirm Add.” If it does not match, correct
the username entered and then click “Confirm Add.”
The next time the requestee logs in, there will be a new table in the User Access section of
their Facility Dashboard showing the Pending Access Requests (see Exhibit 10.9). The user
can click on “Accept” or “Reject” for each request. After the user accepts or rejects the
request, an e-mail notification is sent to the original requestor (Survey Administrator) with an
update.
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Exhibit 10.7 Manage Users Console
Exhibit 10.8 User Details Form
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Exhibit 10.9 Pending Access Requests from Facility Dashboard
To remove a user’s access to the OAS CAHPS website (for all CCNs linked to his or her
account), the primary Survey Administrator will complete the process described here to delete a
user. First, navigate to the Manage Users Console, and then locate the person’s information in
the grid displayed on this page. Next, click on the red “X” ( ) to the left of the person’s
username. A pop-up confirmation message will appear. Click “yes” to confirm deletion.
Another way in which the Survey Administrator can delete a user’s access is by clicking on
the pen and paper icon ( ) in the far-left column of the individual’s row, and then clicking
“Delete” at the bottom of the form. A pop-up confirmation message will appear. Click “yes”
to confirm deletion.
To edit a user’s account, the Survey Administrator will navigate to the Manage Users Console
and then locate the person’s information in the grid displayed on this page. Next, click on the pen
and paper icon ( ) in the far-left column of the individual’s row. This will open a populated
User Details form with the user’s information that was initially entered on this form. All fields,
including the CCN(s) the user has access to, can be edited, except for the username field. Click
“Update” for the updates to be saved in the system.
If the user is granted access to an additional CCN(s), completing this action will cause an e-
mail notification to be sent to the added user requesting him or her to accept or decline access
to each CCN listed on the User Details form.
Step 4: The OAS CAHPS Survey Administrator or backup completes the Vendor
Authorization Form. After an HOPD or ASC has entered into a contract with a survey vendor,
the facility must authorize the survey vendor to submit data on its behalf before the survey
vendor can successfully submit data to the OAS CAHPS Data Center. Facilities should note that
survey vendors must submit their clients’ survey data (at minimum) on a quarterly basis to the
OAS CAHPS Data Center by the following deadlines: the second Wednesday in July, October,
January, and April. For further details, see Table 14.2 in Chapter XIV.
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To authorize a vendor, the facility’s OAS CAHPS Survey Administrator must log in to the
secure website and proceed to the “Vendor Authorization” submenu under the “For Facilities”
tab. The sub menu provides three options for users:
• Start an Authorization;
• Delete an Authorization; and
• Authorization Report.
A brief description and the steps in each of these actions are provided below.
1. Start an Authorization. This is used by an HOPD or ASC user that is just beginning to
participate in OAS CAHPS and by an HOPD or ASC that is switching to another vendor.
The OAS CAHPS Survey Administrator will:
◦ Select an approved vendor from the dropdown list;
◦ Select the “Start Date,” which is the first day of the first calendar year quarter (either
January 1, April 1, July 1, or October 1) for which the vendor is being authorized to
submit OAS CAHPS data. For example, if a vendor is authorized to submit data
starting with the January, February, or March sample month, the Survey
Administrator should choose a Start Date of January 1;
◦ Select the CCN(s) to which the authorization applies; and
◦ Click the “Submit” button. The OAS CAHPS Survey Administrator will receive an e-
mail notification after the Start an Authorization form has been submitted.
To change or switch to a different survey vendor, the HOPD or ASC user will follow the
steps described above and assign a start date for the new survey vendor. The system will
automatically assign an end date for the existing authorization, based on the start date of the
new authorization. This will ensure that there are no gaps in authorization time periods.
The system will allow an HOPD or ASC to change a start date for multiple CCNs. To select
multiple CCNs, the OAS CAHPS Survey Administrator should check the box next to the
name of each CCN for which this vendor is authorized to submit data. The user should click
the “Submit” button to save the entries selected.
HOPDs and ASCs should note the following details regarding switching vendors:
◦ Whenever possible, HOPDs and ASCs should only switch vendors at the beginning
of a quarter. This is because data for every month in a quarterly submission must
come from a single vendor. Survey vendors may not submit data files after the data
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submission deadline passes for a quarter; therefore, it is critically important that
HOPDs and ASCs make sure the Vendor Authorization form is current with a correct
start date for the new vendor, well in advance of the data submission deadline.
◦ The Vendor Authorization form is an authorization for OAS CAHPS Survey vendors
to submit data, not an authorization to conduct the survey. More than one vendor at a
time may collect data (in the chart below, note the overlapping times for Vendors A
and B to conduct the survey). However, only one vendor at a time can submit data.
Vendor A is collecting data for the February and March sample months, which falls
within the first quarter of 2019. Therefore, Vendor A should be authorized for
Quarter 1, 2019 (with a Start Date of 1/1/2019 and an End Date of 3/31/2019).
Vendor B, who is collecting data starting with the April 2019 sample month and
onward, needs to be authorized to submit data before the October 2019 data
submission deadline. Therefore, Vendor B should be authorized starting with Quarter
2, 2019 (with a Start Date of 4/1/2019 and no end date specified).
Sample month Begin data collection
End data collection
Quarterly data submission deadline to
OAS CAHPS Data Center
Authorization start date
(starting day of first calendar
quarter)
Authorization end date
(ending day of final calendar
quarter)
Vendor A Feb–March 3/21/2019 6/2/2019 7/10/2019 1/1/2019 3/31/2019
Vendor B April-and on 5/21/2019 No end date 10/9/2019 4/1/2019 No end date
2. Delete an Authorization. This function will allow an HOPD or ASC user to delete an existing
authorization. The reasons an HOPD or ASC may want to delete an authorization is to revise
its start date or revise it to show a different vendor. The system will allow an HOPD or ASC
user to delete authorizations for multiple CCNs, if needed. To delete one or more existing
authorizations, the OAS CAHPS Survey Administrator should follow these steps:
◦ Check the box next to each CCN for which the vendor authorization should be
deleted.
◦ Click the “Delete Checked Authorizations” button.
◦ A pop-up box will appear confirming that the selected authorization(s) should be
deleted. To proceed with the deletion, click “Confirm.”
To select a different start date or vendor after deleting the existing authorization(s), follow
the steps in Start an Authorization above.
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3. Authorization Report. This function will allow HOPD and ASC users to view the list of
facilities for which a vendor has been authorized, the vendor’s name, and the start date for
each vendor. If, at any point, the HOPD or ASC switched vendors, the Authorization Report
will display the start and end dates for the different vendors.
Survey Vendors Users
Step 1: The individual designated as the survey vendor’s OAS CAHPS Survey
Administrator will complete an online Vendor Registration Form. This form is available
approximately 2 months before the annual OAS CAHPS Survey Vendor Webinar Trainings and
remains available until approximately 6 weeks after the trainings have concluded. During the
time when it is available, the Vendor Registration Form is located on the public side of the
website. To locate this form, click on the “Vendor Registration Form” link under the “For
Vendors” navigation tab on the OAS CAHPS website (as shown in Exhibit 10.10). When
completing the Vendor Registration Form, the vendor’s OAS CAHPS Survey Administrator will
establish an account and create credentials for accessing the secure sections of the website.
The form will collect the vendor’s OAS CAHPS Survey Administrator’s name, e-mail address,
and telephone number. The Survey Administrator will also be instructed to create a username
and password that will be used to access the secured links and forms on the private side of the
website, including the Vendor Application. Once all information is entered and correct, click the
“Submit” button.
Once it is submitted, the Survey Administrator will be routed to a personalized dashboard.
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Exhibit 10.10 Vendor Registration Form
Step 2: Complete the Vendor Application. This form is located on the private side of the OAS
CAHPS Survey website. It is divided into four pages (or tabs). Vendors need to save each page
to proceed to the next. The application will time out after 60 minutes of inactivity. The OAS
CAHPS Survey Administrator can save and return to it as many times as needed. When the
application is complete and accurate, click “Submit” on the last page (or tab) to submit the
application. The Vendor Application appears in Appendix A.
After the application has been submitted, a new window will appear with a personalized copy of
the OAS CAHPS Survey: Vendor Survey Administrator Consent Form. This is a document on
which the person designated as the OAS CAHPS Survey Administrator will acknowledge that he
or she accepts the roles and responsibilities of the Survey Administrator for the listed survey
vendor. The Survey Administrator will print, review, sign, and date this form in the presence of a
Notary Public, and obtain the notary’s signature and seal on the form. Mail the notarized Consent
Form to the OAS CAHPS Survey Coordination Team at the address provided at the top of the
form.
Step 3: Periodically check the Survey Vendor Authorization Report. Survey vendors should
periodically check the Survey Vendor Authorization Report to ensure that each client HOPD or
ASC with which they have contracted has accurately completed the online Authorize a Vendor
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form and that the Start Date the facility entered is correct. The Survey Vendor Authorization
Report is available on the Vendor Dashboard. HOPDs, ASCs, and survey vendors should note
that CMS will not allow OAS CAHPS vendors to submit data files after the data submission
deadline passes for a quarter; therefore, it is critically important that facilities authorize the
vendor and make sure that the Start Date is correct well in advance of a data submission
deadline.
User Dashboards and Access-Restricted Links
The private OAS CAHPS website menu options differ slightly from those on the public website.
In Exhibit 10.1, the items with an asterisk are accessible only on the private pages of the website.
Access to the secure sections will be restricted and controlled through a user identification and
password, created by the survey vendor, HOPD, or ASC Survey Administrator during the
registration process. Once logged into the website, OAS CAHPS Survey Administrators will be
routed to a personalized dashboard.
Each of the “Dashboard” views (Facility Dashboard and Vendor Dashboard) provides the user
with links to key items on the website, depending on the user.
Facility Dashboard
Each time the HOPD’s or ASC’s OAS CAHPS Survey Administrator logs into the website, he or
she will be taken to the Facility Dashboard (see Exhibit 10.11). Survey Administrators should
note that they can register additional HOPDs or ASCs at any time via the dashboard.
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Exhibit 10.11 Facility Dashboard Page
The Facility Dashboard also includes:
• A Facility CCN Registration link that allows the HOPD or ASC to register the facility’s
CMS Certification Number(s) (CCNs);
• An Authorize a Vendor link that allows the selection of a CMS-approved survey vendor
to submit data on behalf of the HOPD or ASC;
• A Manage Users Console link, where the Survey Administrator can add or delete
authorized users for certain functions on the website; and
• Recent announcements posted on the website.
HOPDs and ASCs are responsible for checking the web announcements displayed both on their
dashboard or the OAS CAHPS Home page regularly for updates.
Vendor Dashboard
Each time the survey vendor’s OAS CAHPS Survey Administrator logs into the website with the
login credentials created during the registration process, he or she will be taken to the Vendor
Dashboard (see Exhibit 10.12). From the dashboard, survey vendors can complete and submit
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the Vendor Application and OAS CAHPS Survey: Vendor Survey Administrator Consent Form.
A Vendor Application must be completed to be considered for approval as a CMS-approved
survey vendor. The OAS CAHPS training session(s) in which the user registered to attend is also
displayed on the Vendor Dashboard.
The Vendor Dashboard also includes the following tools or links:
• Manage Users Console, where the Survey Administrator can add or delete authorized
users on the website;
• Training Certification Exam, which will be available for a period of time after the OAS
CAHPS training sessions conclude; and
• Survey Vendor Authorization Report.
Exhibit 10.12 Vendor Dashboard Page
System and Security Requirements for the OAS CAHPS Website
Approved survey vendors will submit or upload OAS CAHPS Survey data to the OAS CAHPS
Data Center through a link on the OAS CAHPS website. The security level for users’ browser
Internet zone must be set to the equivalent of medium or lower, at least during the time that they
are working in the project website.
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Data Security
OAS CAHPS Survey vendors are required to submit only de-identified data files to the OAS
CAHPS website. This means that no personally identifiable patient information can be included
in the data files that are submitted to the OAS CAHPS Data Center. Vendors are required to
assign a unique sample identification (SID) number to each sampled patient. The data submitted
must include an SID number for each patient included in the sample, regardless of whether the
sample member completed the survey. More information about assigning a unique SID to each
sampled patient is included in Chapter IV.
Even though only de-identified data will be submitted to the OAS CAHPS Data Center, every
measure will be taken to protect and secure OAS CAHPS data. Ensuring data security was a
concern and consideration during the design and development of the OAS CAHPS website. Data
are encrypted whenever vendors upload their data files. The OAS CAHPS Survey Coordination
Team has implemented a number of policies and procedures to ensure that all communications
and transfers are secure. Among these measures are the following:
• requiring that each individual provided access to the private links on the website have a
secure login;
• using Secure Sockets Layer (SSL) technology to encrypt files for transmission; and
• carefully monitoring uploads, upload attempts, and website use in general.
When users log into the private links on the website, the system will automatically check and
authenticate their credentials before allowing access. This ensures that only authorized users are
able to log into the system.
In addition to allowing only credentialed users access to the private links on the website, all
electronic data are stored behind a firewall in a password-protected network. All data traffic
between the vendor’s network and the Internet pass through this single connection point. This
process provides the same level of protection and monitoring to all systems connected to the
vendor’s network. The website firewall is programmed to allow or prevent access to the network
by using a set of rules to determine whether attempted network access is in compliance with the
OAS CAHPS Data Center’s network security policy. In addition, the firewall logs all incoming
traffic to help detect and analyze any problems or suspicious activity.
Survey Vendor’s Website Security Responsibilities
All OAS CAHPS Survey vendors must go through an application and certification process to
participate in the survey. In addition, vendors must agree to strict requirements to continue their
participation. By following the security procedures identified for the project, survey vendors will
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protect their client HOPDs’ and ASCs’ data and those of other vendors participating in OAS
CAHPS.
All OAS CAHPS Survey vendors must also abide by all requirements set forth in the Health
Insurance Portability and Accountability Act of 1996 (HIPAA), legislation intended to protect
private health information and to improve the efficiency of the health care system. The type of
patient information that is protected under HIPAA is called “protected health information” or
PHI. PHI is defined as personally identifiable information (PII) that relates to a person’s past,
present, or future health or medical treatment. If the health information is completely de-
identified, it is no longer considered PHI and can be released. HIPAA applies to all electronic
and hardcopy records whether they are being stored or transmitted.
OAS CAHPS Survey vendors must safeguard all data collected from patients as required by
HIPAA. However, survey vendors will not submit any confidential information to the OAS
CAHPS Data Center as all of data file submissions will contain only de-identified data. Even
with de-identified data files, vendors must still use security measures to keep the data as safe as
possible. This means that when issued credentials to access the private links on the project
website, survey vendors also must follow all safeguards to prevent an unauthorized person from
entering the private side of the website. Therefore, the OAS CAHPS Data Center has password
protected the private side of the website and requires that approved survey vendors, HOPDs and
ASCs use the following guidelines when creating and maintaining their password:
• When an OAS CAHPS Survey vendor’s, HOPD’s, or ASC’s account is approved, the
user will be able to log into the system using the username and password submitted on
the online registration form.
• All users are encouraged to create and use a strong password.
• Each account will be locked out after five successive incorrect password entries. If the
account is locked, the user will need to contact the OAS CAHPS Survey Coordination
Team to have the account unlocked.
• If a password reset is initiated (i.e., the user clicks on “Reset Password” on the Login
screen and follows the instructions to have a password reset link sent via e-mail), the user
will have 24 hours to complete the password reset before it becomes inactive.
• If a user’s password is compromised or lost, contact the OAS CAHPS Survey
Coordination Team immediately to ask that the account be deactivated. The Coordination
Team will then issue new credentials to the user.
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Website Password Generation and Protection
As indicated, data security is of utmost concern to the OAS CAHPS Survey Coordination Team.
When survey vendors, HOPDs, and ASCs generate a password to access the private links on the
project website, they must develop a strong password. A strong password is defined as one that
contains at least nine (9) characters. These nine characters must include the following:
• one upper-case alphabet letter,
• one numeral, and
• one special character (&,%,#,!).
An example of a strong password is Mgh0721$&; it meets the required criteria shown above.
These password rules and guidelines are designed to minimize the chance that automated
password-cracking routines used by unauthorized personnel can gain access to the website. In
addition to the above rules, the following guidelines will help create a strong password:
• Combine two or more related words with punctuation, such as Radio-Cook.
• Use a password that looks like nonsense but allows an easy way to remember it, such as
“Thaawtsom.” for “The hills are alive with the sound of music.” (Note the end
punctuation.)
• Think in terms of vanity license plates, such as “I8myfood.”
The following should be avoided when creating a password; therefore, do not use:
• a single English word;
• a scientific name, biological term, geographic name;
• a person’s name or part of name, even with slight modifications like an added character at
the end or beginning;
• known combinations (e.g., NLRB 1234, attorney1, judge111);
• words found in a dictionary, including names, obscene words, or well-known phrases;
• a password with a repeating series of characters;
• reverse spellings of dictionary words;
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• a name associated with the user in any way (middle name, family names, pet’s name,
sports team name, films, etc.);
• portions of a User ID on the current or other systems; or
• simple keyboard patterns (e.g., “asdfjkl.”).
In addition, a user should never write down his or her password. If the user needs to store
passwords, there are free applications that can be downloaded and used. An application like this
can be very helpful because another password safety rule is to never use the same password
across applications or computers. Finally, do not share or give the password to anyone. OAS
CAHPS Survey vendors, HOPDs, and ASCs are responsible for all access to the private links on
the project website that are made under their credentials.
What To Do If a User Forgets the Password
If a user forgets his or her password, he or she will need to reset his or her password to access the
private side of the OAS CAHPS website. To reset the password, simply click on the “Reset
Password” button on the Login screen on the OAS CAHPS website. The user will need to
provide the registered username and then click “Send Reset Link.” An e-mail with a link to reset
the password will be sent to the user’s registered e-mail address. By clicking on the password
reset link in the e-mail, the user will be taken to a page to create a new password.
For security reasons, a password reset is valid for only 24 hours. Therefore, it is important that
the user attempts to log in and reset his or her password as soon as possible after clicking on the
“Send Reset Link” button.
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XI. FILE PREPARATION AND DATA SUBMISSION
Overview
Survey vendors will construct and submit a data file containing three sections: (1) a Header
Record, (2) a Patient Administrative Record for every sampled case, and (3) a Patient Response
Record for every completed survey in each monthly Outpatient and Ambulatory Surgery CAHPS
(OAS CAHPS) Survey sample. Vendors will submit data files for each of their client hospital
outpatient departments (HOPDs) and ambulatory surgery centers (ASCs) through the OAS
CAHPS website. Data for all three monthly samples in a calendar quarter must be submitted by
the data submission deadline.
Quarterly Data Submission Deadlines
Survey vendors have the option of submitting a data file to the OAS CAHPS Data Center as data
collection and processing activities for each monthly sample are completed or on a quarterly
basis. However, the data file for all months in a specific quarter for each client HOPD or ASC
must be submitted before the submission deadline for that quarter.
OAS CAHPS Data Center will check all data files immediately after they are submitted to ensure
that they pass the initial verification checks. Any files in which problems are detected or that do
not comply with file specification requirements will not be accepted. Survey vendors are
strongly encouraged to submit data files well in advance of a data submission deadline in case
there are problems that must be corrected. Survey vendors are also strongly encouraged to check
the Data Submission History Report or the Data Submission History by Upload Date Report that
are posted on the website (these reports are discussed in the next chapter) to ensure that the files
pass all validation checks and are accepted.
Data File Preparation
OAS CAHPS Survey vendors will submit XML data files for each HOPD or ASC that has
authorized the vendor to collect and submit data on its behalf. OAS CAHPS data files must
contain a record for each sampled patient at the HOPD or ASC for each sample month. Survey
vendors will submit data at least once each quarter by uploading individual .xml files or a zipped
file containing multiple XML files on the OAS CAHPS website. During the data file upload
process, the survey vendor’s data are encrypted until they are received by the OAS CAHPS Data
Center and checked for errors. This means that the data will remain secure from the beginning of
the upload process onward.
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The data file submission steps that survey vendors will follow to submit OAS CAHPS data files
are shown below.
1. Format and prepare survey data following the XML file specifications.
2. Submit data file(s) via the OAS CAHPS website.
3. Review and follow up on Data Upload Reports.
Each of these steps is described in the following sections.
Step 1: Format and Clean Survey Data Following the XML File Specifications
Each XML file should contain data for one sample month collected for all HOPD or ASC
locations that operate under a CMS Certification Number (CCN). The standard OAS CAHPS
XML file structure is included in Appendix K. If disproportionate stratified random sampling
(DSRS) is used, survey vendors must use the XML file specifications for DSRS, which are
provided in Appendix L. Both XML file structure templates are also available for download
under “Survey Materials” on the OAS CAHPS website. The specifications in that document
contain details about the data to be submitted such as data type, field sizes, and order. Survey
vendors should format each OAS CAHPS data file to match those specifications. The XML
templates were developed based on data elements needed for analysis and on the OAS CAHPS
questionnaire.
The XML file format will allow data for all patients sampled during a given sample month to be
submitted in one file.
XML Data File Specifications
OAS CAHPS Survey vendors must submit data using the XML format only. Survey vendors that
need assistance with the XML format should contact the OAS CAHPS Survey Coordination
Team for technical assistance at 1-866-590-7468 or by sending an e-mail to [email protected].
Each OAS CAHPS XML file will consist of three sections: a Header Record, a Patient
Administrative Data Record, and the Patient Response Record. Each of these sections is
described below. There should be only one Header Record for each XML file. Each sampled
patient should have an administrative data record, whether they completed the survey or not. A
survey response record must be included for every sampled patient who completed the survey
questionnaire (via mail (with code 110) or telephone (with code 120)) and who partially
completed the survey questionnaire (with code 310).
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Header Record
The Header Record contains the following data elements:
• Header Type. This is the type of Header Record (standard, DSRS, or zero sampled).
• Provider Name. This is the HOPD’s or ASC’s Provider Name.
• Provider Number. This is the HOPD’s or ASC’s CCN.
• Sample Year. This is the calendar year in which the survey is conducted.
• Sample Month. This is the calendar year month for which the sample was selected.
• Mode of Survey Administration. The survey mode—mail-only, telephone-only, or
mixed mode—must be the same for all sample members in each sample month in the
calendar quarter for all of the HOPD or ASC locations under the same CCN. HOPDs,
ASCs, and their survey vendors cannot change survey administration modes until a new
quarter begins. Also note that the survey mode indicated in the Header Record must be
one of the modes that the survey vendor is approved to use. If the mode is not one of the
modes for which the vendor is approved, the OAS CAHPS Data Center will not accept
the data file when the vendor attempts to submit it.
• Type of Sampling. This is the sampling method that was used to select the sample—
these include census, simple random sampling (SRS), stratified systematic sampling
(SSS), proportionate stratified random sampling (PSRS), and DSRS. See Chapter IV for
information about each of these methods.
• Number of Patients Served. The total number of patients served is used to estimate the
sampling rate and for quality control checks. CCNs that contain multiple locations should
note that this value should reflect the total number of patients served across all eligible
locations. If eligible hospitals or ASCs served no patients during the sample month, enter
zero for this variable on the data file. See the following additional criteria for determining
the number of patients served:
◦ Determining Number of Patients Served in Hospitals: This count should be taken
from the hospital outpatient department or other specialized departments that perform
outpatient procedures and surgeries. These departments (1) must perform procedures
that are within the OAS CAHPS-eligible range of CPT-423
Codes for Surgery (i.e.,
23 CPT only copyright 2019 American Medical Association. All rights reserved.
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CPT codes between 10021- 69990) or one of the following G-codes: G0104, G0105,
G0121 or G0260; (2) must be Medicare-certified and have a CMS Certification
Number (CCN); (3) must bill under the Outpatient Payment Prospective System
(OPPS) using CMS-1450 claim form for provider-based offices (not CMS-1500 claim
form used for the Physician Fee Schedule), with the exclusion of emergency
department procedures; and (4) have an agreement with CMS and meets the general
conditions and requirements in accordance with 42 CFR 419 subpart B.
To calculate the total number of patients served, hospitals should begin by including all
patient records that were billed through OPPS using CMS-1450 claim form but then only
count each patient one time. If a procedure took place in an eligible department, but the
patient was admitted as an inpatient rather than being discharged to home, then the
patient record would not be counted. If a patient has two procedures in a month, only one
patient record should be counted. Patient records come from an eligible department and
only include procedures that fall within the CPT-4 Codes for Surgery range or the G-
codes listed above. This count would also include patient records that could later be
determined to be ineligible, for example, because the patient is deceased or was
discharged to hospice.
◦ Determining Number of Patients Served in ASCs: To calculate the total number of
patients served, ASCs should include all patients who had at least one outpatient
surgery or procedure during the sample month that falls within the CPT-4 Codes for
Surgery range of 10021-69990 or the following G-codes: G0104, G0105, G0121, or
G0260. An ASC must (1) be Medicare-certified and have a CCN; (2) bill under ASC
Payment System; and (3) have an agreement with CMS and meets the general
conditions and requirements in accordance with 42 CFR 416 subpart B. If a patient
has two procedures in a month, only one patient record should be counted. This count
would also include patient records that could later be determined to be ineligible, for
example, because the patient is deceased or was discharged to hospice.
• Number of Patients on the File Submitted by the HOPD(s) or ASC(s). As discussed
in Chapter IV, the HOPD or ASC must provide the survey vendor with a list of all
patients who received at least one outpatient procedure at the HOPD or ASC during the
sample month, with the exception of patients who are deceased, are not 18 years old or
older, were discharged after their procedure to hospice, currently reside in a nursing
home, are prisoners, cannot be surveyed because of state regulations, or requested that the
facility not release their name to anyone outside that facility. The vendor should count the
number of patients that the facility supplies and indicate that number on the data file for
the sample month. This value should reflect patients across all eligible HOPD or ASC
locations under the same CCN. Note that if the HOPD or ASC did not serve any
patients during the sample month, the vendor must still submit a data file for that
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sample month using the zero sampled XML data file template (in Appendix M). This
data file template is available for download under “Survey Materials” on the OAS
CAHPS website. The HOPD or ASC must, therefore, still submit a file to its vendor
showing that there were zero eligible patients. If the HOPD or ASC did not serve any
patients during the sample month, enter zero for this data element on the data file.
• Number of Eligible Patients. This is the number of patients in the file submitted by the
HOPD or ASC that meet survey eligibility criteria in the sample month. This value
should reflect patients across all eligible HOPD or ASC locations under the same CCN.
This value can be zero only if none of the patients on the file provided by the HOPD or
ASC for the sample month was eligible for the survey.
• Number of Patients Sampled. This is the number of patients selected for the survey
during the sample month. This value can be zero only if all of the patients included on the
file that the HOPD or ASC provided for the sample month were ineligible for the survey.
If a value of zero is entered for this variable, the value for the Number of Eligible Patients
variable must also be zero.
If DSRS is used, the survey vendor must use the XML file specifications intended for DSRS,
which are included in Appendix L and available for download under “Survey Materials” on the
OAS CAHPS website. The DSRS XML has these extra data elements in the Header Record,
including:
• DSRS Stratum Name (note that there must be at least two strata identified for DSRS
sampling).
• DSRS Number of Patients on file submitted to vendor, which is the number of patients
included on the file that all of the HOPD or ASC locations that share a CCN provided for
this stratum.
• DSRS Number of Patients eligible in stratum, which is the number of patients who
meet survey eligibility criteria within each stratum.
• DSRS Number of Patients sampled in stratum, which is the number of patients
sampled within the stratum.
Please remember that approved OAS CAHPS vendors must complete and submit an Exceptions
Request Form to the Coordination Team prior to conducting DSRS sampling (see Chapter XV
for more information about the Exceptions Request Form). If a vendor submits a data file with a
DSRS Header Record and does not have prior approval for using DSRS, the data file will be
rejected. More information about DSRS and requirements for DSRS sample selection and file
construction is provided in Chapter IV.
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Patient Administrative Data Record
The second section of the XML file contains data about each patient who was sampled for the
sample month, including both those who responded to the survey and nonrespondents. Any
patients who were deemed ineligible during the sampling process should not be included in the
XML file. For example, the vendor determines a patient is under 18 when creating the sampling
frame for the May sample month. In this case, that patient record would be flagged as ineligible
for the OAS CAHPS Survey, not included in the sample frame, and not included in the May
XML file to the OAS CAHPS Data Center.
In this section of the data file, some of the information provided in the Header Record is
repeated, including the HOPD’s or ASC’s CCN, the Sample Year, and Sample Month. All other
information included in this section of the file is about the patients included in the sample. There
must be a Patient Administrative Data Record for every patient sampled in the sample month.
Only de-identified data will be submitted to the OAS CAHPS Data Center; however, the unique
sample identification (SID) number that the survey vendor assigned to the sample member must
be included on the file. Files submitted with missing or duplicate SID numbers will be rejected.
Most of the information required in the Patient Administrative Data Record is provided by, or
derived from, information the HOPD or ASC submits to the vendor on the monthly patient
information file. The Patient Administrative Data Record will include the following data
elements for each sampled patient. See Appendix K for instructions and coding specifications for
each element.
• Provider Number. This is the HOPD’s or ASC’s CCN.
• Sample Month. This is the calendar year month for which the sample was selected.
• Sample Year. This is the calendar year in which the survey is conducted.
• Sample ID Number. This is the unique de-identified SID number the survey vendor
assigns to the sampled patient record. Additional information about the guidelines
surrounding a SID can be found in Chapter IX.
• Surgical Category. The survey vendor will classify each patient’s surgery one of the
four surgical categories according to the CPT24
or G-code. The four surgical categories
are gastrointestinal, orthopedic, ophthalmologic, or other. The categories are defined as
follows:
24 CPT only copyright 2019 American Medical Association. All rights reserved.
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◦ Surgical category 1 (Gastrointestinal) 40000–49999 or G0105, G0121, or G0104
◦ Surgical category 2 (Orthopedic) 20000–29999 or G0260
◦ Surgical category 3 (Ophthalmologic) 65000–68899
◦ Surgical category 4 (Other) 10021–19999, 30000–39999, 50000–64999, and 68900–
69990
OAS CAHPS Survey vendors may receive patient records from their client HOPDs or
ASCs with multiple, survey-eligible CPT codes from different surgical categories. When
this happens, vendors should use the primary code if the facility can identify the primary
code. If not, then the vendor should use the first CPT code that is OAS CAHPS Survey-
eligible to identify the surgical category.
Below are two examples of CPT codes, their corresponding surgical categories, and how
to handle categorizing the record in the XML data file:
◦ 40701 (Gastrointestinal), 69436 (Other) Record as Surgical Category #1.
◦ 69631 (Other), 20926 (Orthopedic) Record as Surgical Category #4.
There may be instances when an HOPD or ASC cannot provide procedural codes (CPT
Codes and G-Codes) for all of the patient records included in the monthly patient file by
the vendor’s sampling deadline. When this happens and an alternative method for
determining eligibility for these cases is identified and approved by CMS (via an
Exceptions Request Form), the vendor should work with the facility to identify how the
cases should be coded for the “Surgical Category” variable. See Chapter IV for
additional information on the protocols for handling missing procedural codes. If the
facility is unable to determine an alternate method of determining eligibility, the vendor
should work with the facility to determine which “Surgical Category” is appropriate. For
example, if the facility can determine that the cases with missing procedural codes were
pulled from the Orthopedics department, then assign the cases to “Surgical category 2
(Orthopedic).” In this example, if the facility cannot identify a department or another
method that would determine how the cases should be classified, assign the cases to
“Surgical category 5 (Missing).”
• Patient Age. The vendor will calculate the sample member’s age based on the date of
birth provided by the HOPD or ASC. If a sampled patient has an unknown date of birth
(because it was not provided by the facility but meets the other eligibility criteria and is
considered eligible), the vendor is unable to calculate the patient’s age and should apply
code “M” (Unknown/Missing) for this variable.
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• Gender. This is the patient’s gender as indicated on the facility’s monthly patient
information file. If a sampled patient’s gender is unknown, the vendor should apply code
“M” (Unknown/Missing) for this variable.
• Survey Mode. The Survey Mode included in the Patient Administrative Data Record is
the data collection mode the patient used to complete the survey, either mail (code “1”) or
telephone (code “2”). The Survey Mode variable must only be coded a “1” for mail if one
of the following two criteria are met: the mail questionnaire was returned and is a
completed survey (code 110), or it is considered a breakoff (code 310). The Survey Mode
variable must only be coded a “2” for telephone if one of the following two criteria are
met: the vendor spoke to the sampled patient by phone and the interview resulted in a
completed interview (code 120), or a breakoff (code 310). Because a value is required for
this variable, there may be instances when the code for Not Applicable (“X”) is needed
(i.e., all scenarios where the survey does not result in a complete (code 110 or 120) or a
breakoff (code 310)). For example, if the mail questionnaire is never returned, is received
blank, or if the sample member is never reached by phone, or the telephone interview is
never initiated, the Survey Mode variable should be coded “X” (Not Applicable).
• Lag Time. The survey vendor will also compute and provide the Lag Time, which
reflects the number of days that elapsed between the date of surgery and the date the
survey was initiated for that patient.
• Final Survey Status. This is the 3-digit disposition code, or status code, assigned by the
survey vendor to indicate the final status of the sampled patient record. A list of OAS
CAHPS Survey final disposition codes and code descriptions can be found in Table 9.1.
• Survey Language. The Survey Language included in the Patient Administrative Data
Record is the identified approved language in which the patient completed the survey,
either English (code “1”), Spanish (code “2”), Chinese (code “3”), or Korean (code “4”).
The Survey Language variable must be coded a “1,” “2,” “3,” or “4” if one of the
following two criteria are met: the mail survey or telephone interview resulted in a
completed survey (code 110 or 120, respectively) or a breakoff interview (code 310) in
one of the approved languages. Note: If the survey was administered by telephone, the
Survey Language variable must be coded either a “1” or “2,” since the OAS CAHPS
telephone survey is only available in English and Spanish. Because a value is required for
this variable, there may be instances when the code for Not Applicable (“X”) should be
applied (i.e., all scenarios where the mail survey or telephone interview does not result in
a complete (code 110 or 120, respectively) or a breakoff (code 310)).
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Patient Response Record
The third section of the XML file is the Patient Response Record, which contains the responses
to the OAS CAHPS Survey from every patient who answered the survey during the sample
month. Note that only the OAS CAHPS Survey questions should be submitted. Do not
submit responses to non-OAS CAHPS questions (i.e., supplemental questions) that were
added by the HOPD or ASC. The only records that should be included are those with a final
Survey Status code for a completed survey (Codes 110 and 120) and those with Code 310
(BreakOff). For all patient response records that are included on the file, all response fields must
have a legitimate value, which can include “Missing” or “Not Applicable.”
The decision whether to key the responses to the two open-ended survey items―“Other
language” (response option 2) in Q35 and “Helped in some other way” (response option 5) in
Q37―is up to each individual HOPD or ASC. Vendors should not include responses to open-
ended survey items on the data files submitted to the OAS CAHPS Data Center. CMS, however,
encourages survey vendors to review the open-ended entries so that they can provide feedback to
the OAS CAHPS Survey Coordination Team about adding additional preprinted response
options to these survey items, if needed.
Step 2: Data File Submission
OAS CAHPS vendors should follow the steps outlined below for submitting data via the OAS
CAHPS website. Additional information on the data submission tool and process can be found in
the OAS CAHPS Survey Website and Data Submission Manual, Version 2.0.
1. Login to the OAS CAHPS website; when logged in, the system will display the vendor’s
dashboard.
2. Click the “Submit Data” link under “Data Submission.” The data submission tool page
will display (as shown in Exhibit 11.1).
3. Click the “Select” button to select the file to upload. The Select button permits users to
locate and directly upload a file that has been saved in their own computer system.
Survey vendors can select either a single XML file or a single ZIP file that contains
multiple XML files.
4. After selecting the file to be uploaded, click “Upload XML” to submit the file. The
Validation Results Report based on the file selected will appear. A link to this report will
also be e-mailed to the vendor’s OAS CAHPS Survey Administrator.
5. To upload more than one file at a time, click the “Add” button on the same screen.
Additional file selection rows will be added. Repeat Step 3 above for each file to be
uploaded.
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6. To remove rows that have been added, click the “Remove” button to the right of the row
to be deleted.
Exhibit 11.1 Link to Data Submission Tool
Exhibit 11.2 shows how the screen looks when submitting multiple files.
As the upload begins, the XML file will undergo validation checks. The first check will
determine whether the CCN(s) in the Header Record and the Patient Administrative Data Record
are aligned for the client HOPD’s or ASC’s authorized survey vendor and the facility’s CCN.
The next validation checks will determine the quality and completeness of the data.
If the file fails any of the validation checks, the survey vendor will receive an error message
within seconds after a file error is detected noting that the file upload failed, giving details on
why the file failed to upload. For example, the message may indicate that there is no
authorization from the HOPD or ASC for the survey vendor to submit data on its behalf or that
the number of patient records listed in the Header Record does not match the number of sample
members for which data are provided in the Patient Administrative Data Record section of the
file.
If a file does not pass the upload validations, none of the data on the file are accepted or stored
by the OAS CAHPS Data Center. Survey vendors must review data submission reports
(discussed in Chapter XII and the OAS CAHPS Survey Website and Data Submission Manual,
Version 2.0) and correct any data errors on the XML file and resubmit the file. CMS will not
accept data files that are submitted after the quarterly data submission deadline. We strongly
encourage survey vendors to submit their data files well in advance of the data submission
deadline for a survey period. Survey vendors can resubmit a data file for an HOPD or ASC client
as many times as needed prior to the data submission deadline However, if a data file for a
sample month is submitted more than once, the most recent submission overwrites the data file
previously submitted for that facility for that month , even if those files “passed” all checks.
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Therefore, the final file submission must contain data for all patients who were sampled in
that sample month for all HOPD or ASC locations under a specific CCN.
Exhibit 11.2 Uploading Multiple Files
Step 3: Review and Follow Up on Data Upload Reports
There are three data submission reports that are available to survey vendors via the OAS CAHPS
website. These reports inform survey vendors about the outcome of each of the vendor’s data file
upload attempts, and they also provide the vendor with a history of upload efforts. The three
reports are listed below:
• Validation Results Report;
• Data Submission History Report; and
• Data Submission History by Upload Date Report.
Each of these reports is described in detail in Chapter XII.
Potential Situations When Vendors Will Not Submit Data
If there is an active survey vendor authorization in place (explained in Chapter X, Step 4), the
OAS CAHPS Data Center will expect the survey vendor to submit data for the contract HOPD
or ASC for every quarter. If the survey vendor fails to submit, the HOPD or ASC may be
considered noncompliant for that quarter.
However, there are situations when a survey vendor will not be able to submit data. The
paragraphs below describe those situations and provide guidance to survey vendors on how to
proceed.
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Survey Not Yet in Effect or Survey Not Administered
Survey vendor authorizations (described in Chapter X) remain in effect until they reach the end
date (if any) of the authorization period. Should an HOPD or ASC authorize a vendor for Quarter
1 beginning in January, yet begin collecting data mid-quarter (for example, March), the elapsed
months between quarter start and survey start (in this example, January and February) will not
have survey data. Starting data collection mid-quarter is permitted on the OAS CAHPS Survey;
however, HOPDs and ASCs should not switch vendors in the middle of a calendar year quarter,
unless it is a situation of new ownership or other extenuating circumstances. Please note the
following guidelines for starting data collection mid-quarter:
1. If the HOPD or ASC is authorizing a vendor for the first time: The HOPD or ASC
should simply complete the online vendor authorization form by selecting the survey
quarter during which the vendor will start submitting survey data on their behalf. The
authorized vendor will begin collecting data the month that it is instructed to do so by its
client, and within the survey quarter it has been authorized. The vendor will not need to
submit a Discrepancy Notification Report (DNR) for any month(s) it was not authorized
to collect data. For example, if an HOPD or ASC begins participation with the March
sample month, the authorized survey vendor will collect and submit data for that sample
month. The vendor does not need to submit a DNR for January or February (in this
example). This only applies to the quarter for which the vendor was first authorized; after
it is authorized, the vendor will need to submit a DNR for any unplanned deviations
moving forward (i.e., a DNR is required if a CCN is already participating but misses
administering the survey for any month). Additional information on when a DNR should
be submitted can be found in Chapter XV.
2. If the HOPD or ASC is switching vendors mid-quarter: Manual vendor authorization
changes are required when an HOPD or ASC switches vendors mid-quarter. This ensures
that only one vendor is authorized for a CCN and there are no gaps in participation. The
affected facility must contact the OAS CAHPS Survey Coordination Team via e-mail to
formally request a manual vendor authorization change. The facility should include its
name, CCN, reason for the mid-quarter switch, the previous vendor’s name, end date for
its authorization, new vendor’s name, and start date for its authorization. Please note that
HOPDs and ASCs are encouraged to wait until the end of a quarter before switching to a
new vendor.
Closed CCN or Closed Location Within a CCN
If an HOPD or ASC closes or is no longer active while its OAS CAHPS vendor is still contracted
to conduct and provide survey data on its behalf, the vendor authorization that that HOPD or
ASC submitted will remain in effect for the entire authorization period. It remains in effect until
either the facility’s OAS CAHPS Survey Administrator modifies the end date of the vendor
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authorization, or, alternatively, until the OAS CAHPS Survey Coordination Team marks the
CCN as inactive. Inactive HOPDs or ASCs are viewable on the Survey Vendor Authorization
Report and are designated with an asterisk (*) symbol.
If the CCN remains active but one of the HOPD or ASC locations or entities within it closes, the
remaining active location(s) should continue participating in OAS CAHPS.
Data Submission Quality Control
The following issues and guidelines are provided to assist vendors in making sure that XML files
are prepared properly and that quality control measures are conducted on each file before the
vendor attempts to submit the file to the OAS CAHPS Data Center. Implementing adequate
quality control on XML files, and submitting each file well in advance of the data submission
deadline, will help ensure that each HOPD’s or ASC’s monthly data files are accepted and that
high-quality data are submitted. Quality control checks should be conducted by a different staff
person than the one who completed the task.
Verify that the vendor is authorized to submit data. Vendors should check the Survey Vendor
Authorization Report regularly to make sure that each of their clients has authorized them to
submit data on their behalf and that the Start Date entered is correct.
Help ensure proper file format by using the validation tools on the OAS CAHPS website.
The following can be downloaded from the OAS CAHPS website:
• Templates for the XML files;
• XML schemas;
• Schema validation tool; and
• Data submission tips.
Vendors should apply the validation schema posted on the OAS CAHPS website on each data
file. This validation tool contains some of the same validation checks that are applied when the
data file is submitted to the OAS CAHPS Data Center. Using the validation schema to identify
file problems and correcting any problems detected will reduce the number of attempts to submit
the data file.
Perform additional quality control checks. In addition to using the validation schema, survey
vendors are encouraged to make additional quality control checks on the data files before they
attempt to submit the files to the OAS CAHPS Data Center. Some suggested quality checks are
listed below.
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a. Check the sample month entered on the XML file to verify that the sample month is
correct. The OAS CAHPS Data Center will not accept a data file for a sample month in a
previous data submission quarter, but it will accept files for months in the current and
upcoming data submission quarters. Similarly, make sure that the sample month on the
file correctly indicates the month in which the sample patients received their outpatient
surgery or procedure.
b. Select a sample of patients for whom data are entered on the XML file and compare the
data on the XML file for those patients with the data for that patient on the original (raw)
data source. For example, compare the variables entered in the Patient Administrative
Data Record section of the XML with the information that the HOPD or ASC provided
for the sample patient in the original monthly patient information file. Similarly, compare
the entries in the Patient Survey Response Record section of the XML with the hardcopy
questionnaire or scanned image of the patient’s completed survey or, if the survey was
completed by phone, with the original CATI or telephone survey data file. Implementing
this quality control check on a sample of the data records will ensure that data are
correctly exported from the data source onto the XML file.
c. After the XML file is prepared, generate data distributions (frequencies of responses and
variables) on selected variables and inspect the output for data anomalies. A visual
inspection of data frequencies is a quick way to identify data problems. For example, if
the race variable for all patients entered on the XML file is American Indian, this could
be an indication that the race variable is incorrect. Similarly, response option “2” is coded
for the overall rating of care variable for all patients on the file, this is likely an indication
that there is a problem with the file.
d. Check that a valid response code has been entered for all variables in the XML file. Note
if data are missing for a variable, either the Missing code (“M”) or the code for Not
Applicable (“X”) must be entered for the variable.
e. Confirm that there have not been any assigned duplicate SID numbers in the XML files
across months in the data submission period or across prior data submission periods. The
SID number can only be assigned to one patient and cannot be reused.
f. Confirm that the only patient response records included in the third section of the XML
file are those with a final Survey Status code for a completed survey (codes 110 and 120)
and those with code 310 – Breakoff.
g. Verify that all final disposition codes are correct. Vendors must make sure that no
response data are submitted for non-interview cases that are coded as deceased,
ineligible, refusals, etc.
h. Vendors should change the disposition code for a completed survey that does not pass the
OAS CAHPS completeness criteria to 310 – Breakoff. Also, make sure that code 340 –
Wrong, Disconnected, or No Telephone Number is being appropriately assigned to
telephone-only or mixed-mode cases and only in situations when the vendor could not
obtain a “working” telephone number for the sample patient. Similarly, make sure that
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code 330 – Bad Address/Undeliverable Mail, or No Address is being appropriately
assigned to mail-only cases when it is determined that the sample member’s address is
bad and no new address is obtained.
i. Conduct quality checks of mail survey coders’ work by having a different person recheck
a sample of each coder’s cases to make sure that they are following and applying correct
coding guidelines.
j. Check the file to make sure that all patient data the HOPD or ASC provided for a patient
on the monthly patient information file exported correctly to the XML file.
k. Check the XML file name to make sure that it conforms to OAS CAHPS recommended
file naming conventions, which are to include the sample month, year, and CCN or
facility name in the filename.
l. Confirm that an XML file has been accepted for each sample month for each client
HOPD or ASC.
Survey vendors should check the XML data files for internal logic and consistency prior to
submitting them to the OAS CAHPS Data Center. Some examples of items to check are provided
below:
a. The number of eligible patients included in the variable on the Header Record should
always be equal to or smaller than the number of patients the facility served during the
sample month. It should never be more than the number of patients served.
b. The number of patients eligible must be equal to or larger than the number of patients
sampled.
c. The number of patients sampled must be equal to or less than the number of patients
served.
d. The total number of patients for which the vendor has included administrative
information in the patient administrative section of the XML file must equal the number
of patients sampled.
Survey vendors are reminded that if none of the patients for whom information is provided on
the monthly patient information file is eligible for OAS CAHPS, the vendor must still prepare
and submit an XML file for that sample month (see Appendix M). The vendor must indicate on
the file that there were zero eligible cases in the number eligible variable and enter all other
information required in the Header Record section of the XML file. Note that OAS CAHPS
vendors are not required to submit a DNR for situations where there are zero eligible cases;
however, they are required to submit a DNR if the HOPD or ASC did not submit a file at all (see
Potential Situations When Vendors Will Not Submit Data, above).
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XII. WEBSITE REPORTS
Overview
The Outpatient and Ambulatory Surgery CAHPS (OAS CAHPS) Data Center will generate and
provide a number of online reports (via the OAS CAHPS website) to indicate the status of data
submissions and the quality of the data submitted. These reports are described in the following
sections.
Reports for Survey Vendors
Survey vendors will be able to access a number of reports via the website, once logged in. The
most important of these are tied to the data submission and file review process—the Validation
Results Report, Data Submission History Report and Data Submission History by Upload Date
Report. Another important report is the Survey Vendor Authorization Report, which allows the
survey vendor to view all hospital outpatient departments (HOPDs) and ambulatory surgery
centers (ASCs) that have authorized the vendor to collect and submit data on their behalf. Each
of these reports is discussed separately below.
The Data Submission Reports
A data submission report (Validation Results Report) is immediately generated and available to
survey vendors after they upload data via the Data Submission Tool. Once the vendor submits
data, the system will check for the correct file layout, missing data, duplicate sample
identification (SID) numbers, invalid responses, etc. After a successful file upload, the OAS
CAHPS Data Center conducts a more thorough review of the data, which is done within an hour
of the file submission. This second validation check is also referred to as the “secondary
validation.” The Data Submission History Report is updated after the secondary validation
checks have been made. The Data Submission History by Upload Date Report is also available
for vendors to search for a data submission report by the actual upload date.
The first check of the submitted data file is to make sure that the XML template has been used
and is properly formatted. If the survey vendor has an incorrectly formatted template, the data
upload process will stop immediately and display an error message (in the Validation Results
Report) that describes the problem detected. After the system verifies that a properly formatted
template has been used, it will begin a series of data checks. It will look for any fields in the
Header Record with missing data. If any data are missing, the file will be rejected, and the
Validation Results Report will inform the vendor what data fields are missing. The system will
also check for any duplicate SID numbers to make sure a vendor has not used an SID more than
once for a given HOPD or ASC in a given quarter. If a vendor has used a duplicate SID, the file
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will be rejected and the Validation Results Report will inform the vendor where the error is so it
can be corrected. Finally, the report will check that the vendor is authorized to upload data for
the CMS Certification Number (CCN).
If the data file successfully passes the initial checks, the Validation Results Report will display a
message saying that the upload was successful. This screen will also provide the vendor with a
count of records received by CCN. The message will also indicate that the file will be sent
through a more formal data processing step within an hour.
Files that have successfully passed the upload validation process are then subjected to a
secondary validation process. The system will check for missing data fields required for patient
eligibility determination. Each Patient Response Record included on the file will be checked to
ensure that all entries are within the acceptable range. In addition, a completeness algorithm will
be run to verify that all patient response records included on the file meet survey completeness
criteria (although this step will be used to ensure that the appropriate cases are included as
“complete” and will not be a reason for rejecting a file).
The results of the secondary validation are updated on the Data Submission History Report for
each file that was uploaded. This report provides sufficient detail, by CCN, of data file errors that
caused data files to be rejected so that the vendor can fix those errors and resubmit the file(s). To
view the XML validation results (and detail about the file errors found), select “Detailed” for the
Report Type field. After the validation checks, the system will generate and send an e-mail to the
vendor after the secondary validation process has been completed indicating that the data
processing step has been completed. Survey vendors can access data submission reports at any
time from the website by going to the “Data Submission” menu and selecting the “Data
Submission Reports” link. Survey vendors can select to view a history of all reports or history by
upload date.
Files that successfully pass both stages of validation will be accepted and processed for public
reporting. If any problems are detected in the data file, this information will be displayed on the
Data Submission History Report (when “Detailed” is selected for Report Type) and the Data
Submission History by Upload Date Report, and the vendor will be expected to correct the errors
and resubmit the file.
As explained in Chapter XI, each XML file contains a single CCN for a single month. However,
vendors can upload a zip file containing XML files for several CCNs and several months. Files
will be accepted or rejected based on CCN.
Because of the two-part nature of the OAS CAHPS Data Center’s data processing steps, vendors
are strongly advised to submit files far enough in advance of the quarterly submission deadline to
allow for both the initial upload file check and the secondary validation checks, if they have to
resubmit a file. The Data Center will not accept files after 8:00 PM EST on the data submission
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deadline date for each quarter. The quarterly data submission deadlines can be found through the
“Data Submission Deadlines” link under the “Data Submission” menu tab on the website.
Below is an example Data Submission History Report.
Below is an example of what a vendor would see upon selecting a particular file upload date in
the Data Submission History by Upload Date Report.
Survey Vendor Authorization Report
The Survey Vendor Authorization Report allows survey vendors to view a list of HOPDs and
ASCs that have authorized the vendor to collect and submit data on their behalf. Any files a
vendor submits for an HOPD or ASC that has not formally authorized the vendor to submit data
on its behalf will be rejected during data submission. It is the vendor’s responsibility to ensure
that any HOPD or ASC with which it is contracted to conduct the OAS CAHPS Survey completes
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the authorization process. The OAS CAHPS Data Center will reject data files if the form is out
of date. Below is an example Survey Vendor Authorization Report.
If a facility closes or is no longer active while its survey vendor is still contracted to conduct and
provide survey data on its behalf, any vendor authorizations will remain in effect for the entire
authorization period. The authorized vendor must submit the data that were collected for the
closed HOPD or ASC to the OAS CAHPS Data Center.
Reports for HOPDs and ASCs
HOPDs and ASCs will be able to access three reports after logging in to the OAS CAHPS
Survey website. The first report HOPD and ASC users can access is a Registered Facilities
Report—this report displays a list of the facilities (by CCN) that the user has access to. The
second report, the Data Submission Summary Report, is intended to provide a means for the
facility to monitor its vendor’s data submission activities and should be reviewed on a monthly
or quarterly basis, depending on the agreement that the facility has worked out with the vendor in
terms of frequency of data submission. The third report available to HOPDs and ASCs is the
Facility Preview Report―this report is a preview of the OAS CAHPS Survey results that are
compiled for each facility on a quarterly basis prior to being publicly reported. These reports are
discussed in more detail below.
Registered Facilities Report
The Registered Facilities Report is available to HOPDs and ASCs from the “Registered CCNs
Report” link in the “For Facilities” menu and via a link on the Facility Dashboard on the OAS
CAHPS Survey website. This report lists all of the facilities (by CCN) affiliated with the user’s
account, regardless of whether the user or someone else from the facility registered the CCN on
the OAS CAHPS website. This report also includes the facility’s name and the date in which it
was registered on the OAS CAHPS website.
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Data Submission History Report
The Data Submission History Report is available to HOPDs and ASCs from the “Data
Submission Reports” link in the “For Facilities” menu on the OAS CAHPS Survey website.
HOPDs and ASCs that have contracted with a survey vendor will be able to log into the website
and view, print, and download a report that includes information on the number of submissions
and the submission status of their authorized vendor’s monthly or quarterly file submissions.
HOPDs and ASCs are strongly advised to review these reports on a regular basis.
The Data Submission Summary Report displays all of the dates on which the OAS CAHPS Data
Center accepted the data files the vendor submitted for the HOPD or ASC. Only files that passed
both the initial edit checks implemented during file upload and those that passed the secondary
set of edit checks will be listed on this report. The purpose of this report is to allow an HOPD or
ASC to monitor whether its vendor is successfully submitting data files by the required quarterly
data submission deadlines. The Data Submission Summary Report also includes a hyperlink
embedded in the date of each submission that takes the user to the data validation checks that
were performed on the uploaded files for that date. This report will give users the ability to view
a list of successful data file transmissions.
To protect the confidentiality of each HOPD or ASC and the vendor it has selected, only the
facility and its authorized vendor will be able to view the submission history relating to that
facility’s data.
Facility Preview Report
The OAS CAHPS Survey Facility Preview Report provides HOPDs and ASCs with a preview of
their own survey results that will be publicly reported on the CMS website. The preview report is
made available approximately 2 to 3 weeks before the OAS CAHPS Survey results are publicly
reported. HOPDs and ASCs are able to access their Preview Report(s) via the OAS CAHPS
website. To access the reports, HOPDs and ASCs must log into the OAS CAHPS website and
then select the “Preview Reports” link under the “For Facilities” menu. HOPDs and ASCs
participating in the OAS CAHPS Survey can only access their own reports. The Preview Report
is not be available to the OAS CAHPS Survey vendor or to anyone other than the HOPD or
ASC.
“Understanding the Preview Reports” document is available on the OAS CAHPS website, under
the “For Facilities” menu tab. It provides a brief explanation of the information included in the
Facility Preview Report.
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XIII. OVERSIGHT ACTIVITIES
Overview
This chapter describes oversight activities that will be conducted by the Outpatient and
Ambulatory Surgery CAHPS (OAS CAHPS) Survey Coordination Team to ensure that the
survey is being administered according to required OAS CAHPS Survey protocols.
Requirements for vendor Quality Assurance Plans (QAPs), data review activities to be conducted
by the Coordination Team, communication between the Coordination Team and the vendors, and
site visit procedures are described in the following sections.
Quality Assurance Plan
All vendors seeking approval to conduct the OAS CAHPS Survey must submit a QAP, a
document that describes how the vendor will implement, comply with, and provide oversight of
all sampling, survey, and data processing activities associated with the OAS CAHPS Survey.
The first QAP must be submitted within 6 weeks after the vendor’s first quarterly data
submission deadline. It must be updated and submitted annually thereafter and at any time that
changes occur in staff or vendor capabilities or systems.
A Model QAP Outline is included in Appendix N to assist vendors in the development of their
own QAP. The vendor’s QAP should include the following sections:
• Organization Background and Staff Experience
• Initial Communications with Hospital Outpatient Departments (HOPDs) and Ambulatory
Surgery Centers (ASCs)
• Work Plan for Each Approved Mode of Data Collection
• Sampling Plan
• Survey Implementation Plan
• Data Security, Confidentiality, Privacy Plan
• Exceptions Request Process and Discrepancy Notification Reporting
• Questionnaire and Materials Attachments (in each language offered to clients)
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Within each section, the vendor must specify all key staff responsible for implementing or
overseeing the activity or activities, procedures, and methods being used, and quality assurance
activities that will be implemented. Changes to key staff must be reported to the OAS CAHPS
Survey Coordination Team. There should be sufficient detail provided for all of these
components so that the Centers for Medicare & Medicaid Services (CMS) can evaluate whether
the vendor is complying with all approved protocols. If CMS and the Coordination Team do not
feel that the vendor’s QAP has sufficient detail to make this determination, the vendor will be
asked to make additions or edits to its QAP and resubmit it. Vendors will also be required to
submit a copy of sample cover letters, and the mail questionnaire (for mail and mixed-mode
surveys), or the screenshots from their electronic telephone interview (for telephone surveys) as
part of their QAP, depending on the mode(s) the vendor is approved to administer. Note that the
submission of a completed QAP is one of the components of the vendor approval process.
When preparing the QAP, vendors should review and refer to the Model QAP Outline available
on the OAS CAHPS website to ensure that they provide all information requested, including
detailed information about systems, protocols, and processes. Vendors should also organize the
information in their QAPs to conform to the sections included in the Model QAP Outline and
make sure that the QAP is paginated for ease of reference and review by CMS and the
Coordination Team.
Data Review
The OAS CAHPS Survey Coordination Team will conduct ongoing reviews of the data
submitted by each survey vendor. As discussed in Chapter XI of this manual, data files are
reviewed immediately upon submission for proper formatting, completeness, accuracy of record
count, and out-of-range and missing values. In addition, the Coordination Team will run a series
of edits on the data to check for such issues as outlier response rate patterns or unusual data
elements.
The OAS CAHPS Survey Coordination Team will attempt to resolve data issues with the vendor
through the use of conference calls or e-mail exchanges. If the Coordination Team believes that
there are any significant issues with a vendor’s data, or if repeated discussions and contact with a
vendor fail to result in cleaner data submissions, a more thorough review of the vendor’s data
processing and survey implementation activities may be initiated. At that time, the Coordination
Team may request copies of documentation associated with whatever the data issue is—for
example, if out-of-range values are found repeatedly, the Coordination Team may request copies
of documents showing the training program used to train data entry keying staff, training records,
and documentation that recommended quality assurance practices associated with keying data
were followed. Vendors are expected to comply with all such requests for documentation.
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Communication Between Survey Vendors and the OAS CAHPS Survey Coordination Team
The OAS CAHPS Survey Coordination Team welcomes communication from vendors related to
any part of the OAS CAHPS Survey implementation process. Vendors may communicate with
the Coordination Team via telephone or e-mail. The Coordination Team is also available to
participate in teleconference calls as needed to ensure vendors’ successful implementation of the
OAS CAHPS Survey. As noted in a preceding section of this manual, the vendor must provide
the facility name and CMS Certification Number (CCN) in all communications with the
Coordination Team.
The OAS CAHPS Survey Coordination Team expects that, in addition to communication with
vendors about technical assistance issues, it will also schedule conference calls with selected
vendors to review vendor procedures and ensure adherence to the OAS CAHPS Survey protocols
and guidelines. The Coordination Team will make periodic calls to vendors to assess the status of
sampling, data collection, and file processing issues in general. These calls will be scheduled in
advance so that appropriate members of the vendor’s project team can participate.
Site Visits to Survey Vendors
The OAS CAHPS Survey Coordination Team conducts site visits to all approved vendors. The
purpose of the site visits is to allow the Coordination Team to observe the entire OAS CAHPS
Survey implementation process, from the sampling stage through file preparation and
submission.
The OAS CAHPS Survey Coordination Team expects, at a minimum, to accomplish the
following on each site visit:
• Discuss the vendor’s initial communications with the HOPDs and ASCs, review the
process the survey vendor followed to determine the eligibility of their clients, and how
the vendor:
◦ worked with the hospital management to determine whether a particular hospital has
one or more eligible HOPDs or departments that meet the eligibility criteria for
inclusion in the OAS CAHPS Survey. Vendors will be asked to report what types of
questions hospitals have, and what information or specific website links the vendor
provides the hospitals to address their questions; and
◦ worked with the ASC management to understand the CCN(s) of their facilities,
including different sites. Vendors will be asked to report what types of questions
ASCs have and what information or specific website links the vendor provides the
ASCs to address their questions.
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• “Walk through” the systems and processes used from the point of obtaining a sample
frame from an HOPD or ASC to preparation of a final data file, including but not limited
to a review of:
◦ software and/or programs used to select and store the sample; how patient contact
information (name and address) and sample identification (SID) number are printed
on letters accompanying questionnaire mailings or provided to a call center for
telephone survey data collection; questionnaire production, mailout, and receipt
facilities and processes; telephone survey operation facilities and processes, including
listening to interviews;
◦ all data processing activities, including how final status codes are assigned;
◦ file preparation and submission activities and file storage facilities;
◦ quality control on all aspects of the survey, including data entry and capture,
sampling, and file construction; and
◦ data security (including discussion of firewalls, passwords, data backup systems) and
adequacy of sample file, data file, and questionnaire storage facilities.
• Review documentation associated with any of the above steps, as applicable. The
documentation to be reviewed includes, but is not limited to:
◦ signed confidentiality forms for all applicable staff, including subcontractors;
◦ training records, such as for data entry or telephone interviewing staff;
◦ monitoring logs, with dates and times telephone interviewers were monitored, and the
results of those monitoring sessions;
◦ telephone interview scripts, including introductory scripts and responses to frequently
asked questions;
◦ documentation of quality control checks performed on questionnaire mailouts and
receipt; and
◦ verification records, for either data entry or scanning processes, showing the level of
quality control for keyed questionnaires.
• Interview the vendor’s key OAS CAHPS Survey project staff, including the Project
Director, Sampling Manager, Data Manager, and Computer Programmer.
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The OAS CAHPS Survey Coordination Team may make either scheduled or unscheduled visits
to the vendor’s site. Scheduled visits will be planned far enough in advance to ensure that all
appropriate vendor staff are able to participate in the site visit review process. For unscheduled
visits, the Coordination Team will give the vendor a 3-day window during which the team may
conduct the onsite review.
Generally, the site visit team will consist of two to three individuals, although the size of the
team may vary and may include representatives from CMS. All discussions, observations, and
materials reviewed during the site visit will remain confidential. Thus, although the OAS
CAHPS Survey Coordination Team appreciates that certain systems or processes may be
proprietary to a vendor, full cooperation with the site visit team is expected so that the team may
adequately assess vendor compliance with all OAS CAHPS Survey protocols and guidelines.
After each site visit, the OAS CAHPS Survey Coordination Team will prepare and submit to
CMS a Site Visit Report, which will summarize the findings from each site visit, including any
staffing, systems, and/or data issues. The Site Visit Report will also describe corrective actions
that the vendor will be required to take to correct any deficiencies or problems observed. The
Coordination Team will provide the vendor with the Site Visit Report after it has been reviewed
with CMS. The Coordination Team may request clarification, additional documentation, or
changes to any aspect of the implementation process, if needed. The vendor will then be given a
specified period of time in which to provide the additional information or submit documentation
showing that it has implemented the requested process or system change. The Coordination
Team will follow up with the vendor by teleconference or with additional site visits as needed.
Corrective Action Plans
If a vendor fails to demonstrate adherence to the OAS CAHPS Survey protocols and guidelines,
as evidenced by ongoing problems with its submitted data or as observed in its implementation
process during a site visit, CMS may ask the OAS CAHPS Survey Coordination Team to either
increase oversight of the vendor’s activities (or submitted data files) or, if necessary, put the
vendor on a corrective action plan.
If the vendor is put on a corrective action plan, the OAS CAHPS Survey Coordination Team will
work out a schedule with CMS by which the vendor must comply with the tasks set forth in the
corrective action plan. These will include interim monitoring dates, where the Coordination
Team and the vendor will meet via teleconference to discuss the status of the plan and what
changes the vendor has made or is in the process of making. The nature of the requested changes
that the vendor is asked to implement will dictate the kind of “deliverables” the vendor will be
expected to provide and the dates by which the deliverable must be provided.
Survey vendors that fail to comply with the oversight activities described above or whose
implementation of the OAS CAHPS Survey is found to be unsatisfactory after the opportunity is
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given to correct deficiencies may be subject to having their “approved” status rescinded. Further,
any HOPD or ASC survey responses collected by the vendor may be withheld from public
reporting. The affected facilities will be notified by the OAS CAHPS Survey Coordination Team
of their vendor’s failure to comply with oversight activities or unsatisfactory implementation so
that the facilities will have the opportunity to contract with another approved vendor.
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XIV. PUBLIC REPORTING
Overview
This chapter describes the public reporting activities associated with the Outpatient and
Ambulatory Surgery CAHPS (OAS CAHPS) Survey. All publicly reported data are available on
the Centers for Medicare & Medicaid Services (CMS) website. Results from the OAS CAHPS
Survey are published quarterly and include each hospital outpatient department’s (HOPD’s) and
ambulatory surgery center’s (ASC’s) most recent four quarters of data.
The chapter begins with a list of the measures that are reported and explains how the results are
adjusted and reported. The chapter concludes with a discussion of Facility Preview Reports and a
table showing the quarters included in each public reporting period.
OAS CAHPS Survey Measures
OAS CAHPS Survey results are reported for three composites and two global items:
Composite Measures
• Facilities and Staff (Q3, Q4, Q5, Q6, Q7, and Q8)
• Communication About Your Procedure (Q1, Q2, Q9, Q10/Q11, and Q10/Q12)
• Preparing for Discharge and Recovery (Q13, Q14, Q15/Q16, Q17/Q18, Q19/Q20, and
Q21/Q22)*
Global Items
• Patients’ Rating of the Facility (Q23)
• Patients Recommending the Facility (Q24)
* Not currently reported on CMS websites. Only reported on Facility Preview Reports on OAS CAHPS website.
CMS is conducting a quality review of this composite.
Each of the three composite measures consists of five or more questions from the survey that are
about related topics. The results from the questions that comprise a composite are reported as one
score. Composite scores are created by first determining the proportion of answers to each
response option for all questions in the composite. The final composite score averages the
proportion of those responding to each answer choice in all questions in the composite. Only
questions that are answered by survey respondents are included in the calculation of composite
scores.
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Some of the questions in the Communications About Your Procedure composite score
(Q10/Q11) and the Preparations for Discharge and Recovery composite score (Q15/Q16,
Q17/Q18, Q19/Q20, and Q21/Q22) are combined for analysis and scoring, but they are not all
reported in the scores themselves.
For the Preparations for Discharge and Recovery composite score, the initial question in each
pair (Q15, Q17, Q19, and Q21) asks if the patient was told that he or she might have
pain/nausea/vomiting/bleeding/infection. The second question in each pair (Q16, Q18, Q20, and
Q22) asks if the patient experienced each of these outcomes. Only the initial questions in each
pair (Q15, Q17, Q19, and Q21) are the responses that will be reported in the composite score, but
even those may be suppressed if the responses to the second question in each pair (Q16, Q18,
Q20, and Q22) are negative. Top box scores (“Yes, definitely”) to the initial questions will
always be included in the composite despite the response to the second questions.
For example, if the response to Q17 (was the
patient told what to do if (s)he had nausea or
vomiting) was “Yes, definitely” this top box
score would be included regardless of the
response to Q18 (did the patient have nausea or
vomiting as a result of the procedure). If the
response to Q17 was “Yes, somewhat” or
“No,” Q17 would only be reported in the
composite score if the response to Q18 was
“Yes” (nausea or vomiting was experienced). If
the response to Q18 was “No” or missing, Q17
would be excluded from the composite score
(and the denominator would be reduced by 1
question) if the response to Q17 was anything
other than “Yes, definitely.” The intention of
this scoring is to ensure that the composites
reflect whether information was provided to the
patient only if the information was needed
based on the patient’s situation (type of
surgery). Some surgeries and procedures may
not require the same type of recovery
information. These questions are designed to report only what is meaningful for each situation.
In some cases, the composite score will exclude some of the component questions (17, 19, and
21) if they were determined not to be appropriate.
Reporting OAS CAHPS Top-, Middle-, and
Bottom-Box Scores on data.medicare.gov
OAS CAHPS results are reported as “top-box,”
“bottom-box,” and “middle-box” scores.
The top-box is the most positive response to
survey items, for example “Yes, definitely” for
most of the survey items. For the Overall Facility
Rating item, the top-box score is “9” or “10.” For
the Recommend Facility item, “Definitely yes” is
the top-box score.
The “middle-box” captures intermediate
responses, for example “Yes, somewhat” for most
of the survey items. For the Overall Facility
Rating item, the middle-box score is “7” or “8.”
For the Recommend facility item, “Probably yes”
is the middle-box score.
The bottom-box is the least positive response
category, for example “No” for most of the survey
items. For the Overall Facility Rating item, the
bottom-box score is “0” to “6.” For the
Recommend Facility item, “Definitely no” and
‘Probably No” is the bottom-box score.
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Adjustment and Reporting of Results
In 2015, the OAS CAHPS Survey Coordination Team conducted a mode experiment to test the
effects of using three data collection modes: mail only, telephone only, and mixed mode (mail
with telephone follow-up of nonrespondents). The overall response rate for all three modes was
39%. By mode, the response rates were 37% for the mail-only mode, 34% for telephone-only
mode, and 50% for mixed mode (mail with telephone follow-up).
The results of the OAS CAHPS Survey mode experiment showed no significant differences in
results based on survey mode. There were, however, differences in responses attributable to
patient-mix characteristics. The following six patient characteristics were found to be significant
predictors: surgery type, overall health, overall mental health, age, education, and how well the
patient speaks English. Therefore, patient-mix adjustments are made on OAS CAHPS Survey
results that are publicly reported using the six patient characteristics identified during the mode
experiment, but no adjustments are needed for mode differences. The patient-mix adjustment
coefficients are updated quarterly.
Because some patients’ assessment of the care they received from HOPDs and ASCs may be
influenced by patient characteristics that are beyond the facilities’ control, CMS used the data
from the mode experiment to determine whether and to what extent characteristics of patients
participating in the OAS CAHPS Survey statistically affect survey results. Statistical models
were developed to adjust or control for these patient characteristics. These statistical adjustments
are applied before survey results are publicly reported. Also, some patients may not respond to
the survey, and this may impact the accuracy and comparability of results. Therefore, the data
from the mode experiment were analyzed to detect potential nonresponse bias. The results of
these analyses determined applicable statistical adjustments that are made on each quarter of the
OAS CAHPS Survey data.
OAS CAHPS Survey results are reported for a rolling four quarters of data that are updated
quarterly by replacing the oldest quarter of data with data from the most recent quarter. During
voluntary participation, users can access OAS CAHPS Survey results at the facility, state, and
national levels in three locations:
• on data.medicare.gov (by clicking on “Hospital Compare data” box [under “Explore &
download data” header] and then searching the term “OAS CAHPS”);
• through Hospital Compare (direct link to OAS CAHPS data:
https://www.medicare.gov/hospitalcompare/OASCAHPS-measures.html); and
• via downloadable databases on data.medicare.gov.
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Table 14.1 shows a crosswalk of the composite measures and global ratings mapped to the text
that is displayed on Hospital Compare and data.medicare.gov.
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Table 14.1 Crosswalk of Composite Measures and Global Ratings
SCORE
MEASURES
COMPOSITE SCORE GLOBAL RATING
Facilities and Staff
Questions 3–8
Communication about your procedure
Questions 1–2, 9–12
Preparing for discharge and recovery
Questions 13–22
Patients’ rating of the facility
Question 23
Patients recommending the facility
Question 24
Patients who reported that staff… Patients who
gave the facility…
Patients who reported…
Top Box Definitely gave care in a professional way and the facility was clean
Definitely communicated about what to expect during and after the procedure
Definitely gave them information about what to do if they had pain, nausea or vomiting, bleeding or possible signs of infection as a result of the procedure or anesthesia
a rating of 9 or 10 on a scale from 0 (lowest) to 10 (highest)
YES they would definitely recommend the facility to family or friends
Middle Box
Somewhat gave care in a professional way or the facility was somewhat clean
Somewhat communicated about what to expect during and after the procedure
Somewhat gave them information about what to do if they had pain, nausea or vomiting, bleeding or possible signs of infection as a result of the procedure or anesthesia
a rating of 7 or 8 on a scale from 0 (lowest) to 10 (highest)
PROBABLY YES they would recommend the facility to family or friends
Bottom Box
Did not give care in a professional way or the facility was not clean
Did not communicate about what to expect during and after the procedure
Did not give them information about what to do if they had pain, nausea or vomiting, bleeding or possible signs of infection as a result of the procedure or anesthesia
a rating of 0 to 6 on a scale from 0 (lowest) to 10 (highest)
NO they would not recommend the facility to family or friends
Star Ratings
Currently, OAS CAHPS star ratings are under development. Future plans involve reporting star
ratings on Hospital Compare for HOPDs and ASCs: a star rating for each of the publicly reported
OAS CAHPS composite measures, one for the Overall Rating of Care measure, one for
Willingness to Recommend measure, and one Survey Summary Star, which is a simple average
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of all star ratings. OAS CAHPS star ratings will be based on the same patient survey results
publicly reported on Hospital Compare. More information on how the star ratings are calculated
will be available in the future.
Facility Preview Reports
Prior to publishing the results on the CMS website, the OAS CAHPS Survey Coordination Team
makes available a preview report on the OAS CAHPS website so that each HOPD and ASC can
review the results that will be publicly reported. Each quarterly public reporting period includes
survey results from data collected for the prior 12 months, as the oldest quarter’s data are
dropped and the newest quarter’s data are added. During voluntary participation, OAS CAHPS
Survey data will be refreshed on Hospital Compare and data.medicare.gov according to the
schedule provided in Table 14.2.
Public Reporting Periods
Table 14.2 shows the quarters included in each public reporting period.
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Table 14.2 Data Submission Deadlines Linked to the Public Reporting Period
Vendors Data Submission
Deadline to (1)
Includes Sample
Months in…. Public Reporting
Period (#) Public Reporting Period
Covers
Date posted on
data.medicare.gov (2) (3)
July 13, 2016 Qtr. 1, 2016 October 2016 (1) Qtr. 1, 2016 Not posted
Oct. 12, 2016 Qtr. 2, 2016 January 2017 (2) Qtr. 1, 2016–Qtr. 2, 2016 Not posted
Jan. 11, 2017 Qtr. 3, 2016 April 2017 (3) Qtr. 1, 2016–Qtr. 3, 2016 Not posted
April 12, 2017 Qtr. 4, 2016 July 2017 (4) Qtr. 1, 2016–Qtr. 4, 2016 Not posted
July 12, 2017 Qtr. 1, 2017 October 2017 (5) Qtr. 2, 2016–Qtr. 1, 2017 Not posted
Oct. 11, 2017 Qtr. 2, 2017 January 2018 (6) Qtr. 3, 2016–Qtr. 2, 2017 Not posted
Jan. 10, 2018 Qtr. 3, 2017 April 2018 (7) Qtr. 4, 2016–Qtr. 3, 2017 April 2018
April 11, 2018 Qtr. 4, 2017 July 2018 (8) Qtr. 1, 2017–Qtr. 4, 2017 July 2018
July 11, 2018 Qtr. 1, 2018 October 2018 (11) Qtr. 2, 2017–Qtr. 1, 2018 Oct. 2018
Oct. 10, 2018 Qtr. 2, 2018 January 2019 (12) Qtr. 3, 2017–Qtr. 2, 2018 Jan. 2019
Jan. 9, 2019 Qtr. 3, 2018 April 2019 (13) Qtr. 4, 2017–Qtr. 3, 2018 April 2019
April 10, 2019 Qtr. 4, 2018 July 2019 (14) Qtr. 1, 2018–Qtr. 4, 2018 July 2019
July 10, 2019 Qtr. 1, 2019 October 2019 (15) Qtr. 2, 2018–Qtr. 1, 2019 Oct. 2019
Oct. 9, 2019 Qtr. 2, 2019 January 2020 (16) Qtr. 3, 2018–Qtr. 2, 2019 Jan. 2020
Jan. 8, 2020 Qtr. 3, 2019 April 2020 (17) Qtr. 4, 2018–Qtr. 3, 2019 April 2020
April 8, 2020 Qtr. 4, 2019 July 2020 (18) Qtr. 1, 2018–Qtr. 4, 2018 July 2020
NOTES: (1) Data submissions will be second Wednesday of month. (2) Data are publicly released for a facility
when that facility has four consecutive quarters of data. (3) During voluntary participation, OAS CAHPS data are
publicly reported on data.medicare.gov.
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XV. EXCEPTIONS REQUEST PROCESS AND DISCREPANCY
NOTIFICATION REPORT
Overview
This chapter describes the process to be used to request an exception to the Outpatient and
Ambulatory Surgery CAHPS (OAS CAHPS) Survey protocols, including guidelines for
submitting an Exceptions Request Form. This chapter also covers the process for alerting the
OAS CAHPS Survey Coordination Team of an unplanned discrepancy in the collected or
submitted survey data. Vendors are expected to submit a Discrepancy Notification Report
whenever there has been an inadvertent or temporary deviation from the standard OAS CAHPS
Survey protocols. The vendor is expected to notify the Coordination Team within 24 hours after
the discovery of the discrepancy.
Exceptions Request Process
The Exceptions Request Form (see Appendix O) is designed to allow the survey vendor to
request a planned deviation from the standard OAS CAHPS Survey protocols. Vendors are asked
to submit an Exceptions Request Form for any exceptions to the OAS CAHPS Survey protocol.
The Coordination Team will consult with the Centers for Medicare & Medicaid Services (CMS)
to make a determination after reviewing each request whether to approve the exception. The
OAS CAHPS Survey Coordination Team has identified five allowable exceptions on the OAS
CAHPS Survey at this time:
1. the use of disproportionate stratified random sampling (DSRS) (see Chapter IV),
2. more frequent than monthly sampling (see Chapter IV),
3. an alternative method of determining eligibility for patient records missing
procedural codes (CPT-425
and G-Codes) (see Chapter IV),
4. request to exclude CPT-4 codes that fall within the range of Codes for Surgery from
being eligible for the OAS CAHPS Survey (Chapter IV), and
5. displaying the HOPD or ASC’s name and/or logo on the outgoing envelope (see
Chapters V and VII).
25 CPT only copyright 2019 American Medical Association. All rights reserved.
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202 Centers for Medicare & Medicaid Services Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual
Vendors must complete and submit an Exceptions Request Form to obtain approval to
implement these exceptions.
The Exceptions Request Form is designed to allow the survey vendor to request the same
exception for multiple hospital outpatient departments (HOPDs) or ambulatory surgery centers
(ASCs) for which it is responsible for collecting data. The Exceptions Request Form can be
accessed and submitted online (https://oascahps.org/ ).
DSRS Exceptions Request Form Requirements
Vendors must include the following information in the Exceptions Request Form for each CMS
Certification Number (CCN) for which they are requesting to implement the DSRS sampling
method. It is acceptable for vendors to use estimated monthly figures or the last sample month’s
figures when providing this information for each applicable CCN:
1. CCN and facility name
2. The names of each strata
3. The expected number of eligible patients or procedures in each strata (for a sample
month)
4. The number of patients or procedures to be sampled in each strata (for a sample month)
5. Additional data validation checks to ensure that the minimum number of 10 eligible
patients per stratum is sampled
Below is an example describing how the above information should be provided in an Exceptions
Request Form requesting to implement DSRS for one CCN with two strata:
1. CCN and facility name: 123456, OAS Example Hospital
2. The names of each strata: OAS Example Hospital South, OAS Example Hospital North
3. Expected # of eligible patients or procedures: OAS Example Hospital South = 330, OAS
Example Hospital North = 415
4. Number of patients or procedures would like to sample: OAS Example Hospital South =
255, OAS Example Hospital North = 310
5. Additional validation checks: Reviewed previous annual patient records to ensure that the
number of eligible patients per strata would never be fewer than 10 and were fairly
consistent within strata across months. Will monitor the number of eligible cases monthly
to ensure that there is sufficient sample so that DSRS remains a viable sampling strategy.
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Centers for Medicare & Medicaid Services 203 Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual
An Excel template (“DSRS Template”) is available under the Exceptions Request Form link on
the website that vendors are encouraged to use to submit the information required for a DSRS
request. When using this Excel template, vendors should note the following:
• If vendors choose to submit an Excel file, they will be required to use this DSRS
Template.
• The template allows for information for multiple CCNs to be provided but they must be
entered in separate Excel sheets (tabs).
• Note that vendors must submit a new template for each new request for DSRS.
• If updates are needed [for additional CCNs following the same protocol], vendors may
update and resubmit an existing online Exceptions Request Form and DSRS Template.
However, a new online Exceptions Request Form must be submitted if the protocol will
differ.
• Also, note that you are still required to complete the online Exceptions Request Form for
all DSRS requests, but you must submit the Excel template by sending an e-mail to
If a vendor’s Exceptions Request Form for DSRS is approved, please be reminded that the
vendor must use the DSRS XML data file layout to submit data for the facility. The vendor
should review the DSRS XML Header Record to ensure that it has all the information that is
required.
Continuous Sampling Exceptions Request Form Requirements
When submitting the first Exceptions Request Form requesting to implement continuous
sampling, the survey vendor must include the list of all CCNs that will have the sample drawn
continuously (i.e., more frequently than monthly). Vendors must indicate if the Exceptions
Request covers future clients as well by adding “all future CCNs” to the Exceptions Request
Form. With this added statement, vendors do not have to update this Exceptions Request Form if
additional, future clients would like to implement continuous sampling. To receive approval for
future clients, the submitted Exceptions Request will require additional information to ensure
that the sampling process will be successfully implemented regardless of the sample size for each
future client facility.
Each of the following eligibility criteria and sample selection protocols must be
comprehensively explained in the Exceptions Request Form when requesting the implementation
of continuous sampling for current and future clients:
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204 Centers for Medicare & Medicaid Services Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual
In terms of patient and surgery or procedure eligibility:
• In general, what size facilities (as measured by patient volume) are requesting to use
continuous sampling, and how does the facility size relate to the sampling frequency
(e.g., small facilities with low volume [100 or fewer eligible patients per month] can be
sampled every 2 weeks, large facilities with high patient volume [more than 100 eligible
patients per month] can be sampled daily).
• Explain the frequency by which the eligibility will be assessed and confirmed (daily,
every few days, weekly or other periodicity). See the Chapter IV for the eligibility
criteria. The OAS CAHPS Survey is not appropriate for people who did not have an OAS
CAHPS-eligible procedure or surgery, and such individuals should be removed from the
sample frame before selection.
• Explain how the de-duplication and check for patients who were sampled in the previous
5 months will be performed for the planned sampling periodicity (daily, every few days,
weekly, or other periodicity).
In terms of sampling:
• What sampling methods will be used? As stated in Chapter IV, if there are two or more
components within the CCN, a proportional method (Stratified Systematic Sampling,
Proportionate Stratified Random Sampling [PSRS], or DSRS if approved) must be used.
• When frames are assembled frequently, will there be enough cases on the frame (which
includes the frames of individual strata) to perform sampling? As a reminder, for PSRS
and DSRS there must be 10 eligible patients on the frame from which the sample is
selected.
• What sampling rate will be used? If there are multiple components, be specific for each
component within the CCN. What will be done if the frame size is small (100 or fewer
eligible patients per month) and cannot support the sampling rate? (Sampling rates may
differ by CCN, if so, please provide these rates in the examples requested below.)
Provide an example of implementation of sampling procedures for one small and one large
CCN:
Please include in your Exceptions Request Form an example of how you would implement
continuous sampling for a large CCN and a small CCN, if available. Choose one of the CCNs
(that has more than 100 eligible patients per month) as an example. If there are any CCNs that
have 100 or fewer eligible patients, provide another example. Below are examples of how this
information should be displayed in the Exceptions Request Form.
November 2018 XV. Exceptions Request Process and Discrepancy Notification Report
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Example 1 – Large size CCN (more than 100 eligible patients per month):
• Facility Name: Hospital North
• CCN: 654321
• Number of Eligible Patients in a sample month: 1,652
• Number of Eligible Patients in a sample bimonthly period: 820
• Number of Eligible Patients in a sample week: 398
• Number of Eligible Patients in a sample day: 56
• Proposed frequency: We propose sampling patients on a weekly basis.
Example 2 – Small size CCN (100 or fewer eligible patients per month):
• Facility Name: Hospital South
• CCN: 123456
• Number of Eligible Patients in a sample month: 100
• Number of Eligible Patients in a sample bimonthly period: 58
• Number of Eligible Patients in a sample week: 30
• Number of Eligible Patients in a sample day: 6
• Proposed frequency: We propose sampling patients on a weekly basis.
Displaying HOPD/ASC’s Name and/or Logo on Outgoing Envelopes
To display an HOPD’s or ASC’s name and/or logo on an outgoing mailing envelope, vendors
must obtain the facility’s permission to display the name and/or logo and assurances that the
facility does not consider displaying the name and/or logo to be a HIPAA risk. It is up to each
vendor to determine what kind of documentation or assurances it needs from its clients for its
own internal recordkeeping to feel comfortable submitting the Exceptions Request Form. The
documentation pertaining to such a request will not be reviewed during site visits.
The Exceptions Request Form submitted to the Coordination Team should include a statement
that the vendor has discussed or will discuss the potential for HIPAA risks with its current and
future client(s) and has or will obtain approval from the client(s) to display the facility name
XV. Exceptions Request Process and Discrepancy Notification Report November 2018
206 Centers for Medicare & Medicaid Services Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual
and/or logo on the envelope or through the envelope window. Vendors only need to submit one
Exceptions Request Form to cover all their current and future clients.
Review Process
The OAS CAHPS Survey Coordination Team will review the vendor’s exceptions request,
evaluating the methodological strengths and weaknesses of the proposed approach. The
Coordination Team will let the survey vendor know whether the exceptions request has been
approved or denied. If denied, the vendor will have 5 business days to appeal the decision. To
submit an appeal, the vendor needs to check “Appeal of Exception Denial” in Box 1b on the
Exceptions Request Form and update the form to provide further information about the exception
being requested. The Coordination Team will review the appeal and return a final decision to the
survey vendor within 10 business days.
Discrepancy Notification Report
The Discrepancy Notification Report (DNR) (see Appendix P) is designed to allow the survey
vendor to notify the OAS CAHPS Survey Coordination Team of an unplanned deviation from
the OAS CAHPS Survey protocols that will require some form of corrective action on the part of
the survey vendor. Examples of instances when a DNR is required include the following:
• the vendor or facility inadvertently omitted from the sample frame patients who were
eligible for the survey;
• the vendor is unable to initiate the survey by the 21st day after the sample month ended
and needs to initiate it from the 22nd through the 26th day after the sample month ended;
• a variable was incorrectly coded and submitted on the XML file;
• there has been a natural disaster or event that has interrupted data collection in such a
way as to adversely affect survey outcomes;
• the HOPD or ASC was unable to provide the vendor with a file for the sample
month; the
reason the HOPD or ASC was unable to provide the monthly patient information file
must be specified in the Discrepancy Notification Report; and
• the facility is unable to provide the vendor with procedural codes (CPT-426
and G-codes)
for patient records. The vendor must include the number of cases that were fielded with
or without an approved alternative method to determine eligibility, the reason the
26 CPT only copyright 2019 American Medical Association. All rights reserved.
November 2018 XV. Exceptions Request Process and Discrepancy Notification Report
Centers for Medicare & Medicaid Services 207 Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual
procedural codes were missing, and a description of the method used to determine each
of the case’s “Surgical Category” for the XML file and for how many cases.
The DNR form can be accessed and submitted online via the OAS CAHPS Survey website
(https://oascahps.org/ ) once the vendor’s OAS CAHPS Survey Administrator has logged in.
The vendor is expected to notify the OAS CAHPS Survey Coordination Team within 24 hours
after the discovery of the discrepancy. The vendor must also notify all affected HOPDs and
ASCs that a DNR has been submitted to the Coordination Team on their behalf. The report must
clearly describe the discrepancy and the action proposed by the vendor to correct the
discrepancy, along with a proposed timeline to correct the discrepancy. At a minimum, the
following information must be included on the report form:
• the HOPD’s or ASC’s CCN;
• affected survey quarter (selected from a drop-down list of options);
• discrepancy reason (selected from a drop-down list of options, including No Sample
Provided, Patients Omitted from Sample Frame, Late Start, No Survey Administered,
Survey Interrupted, Variable Incorrectly Coded, and Some Other Reason);
• number of affected patients;
• dates in which data collection took place (if the selected discrepancy reason is Late Start);
• a detailed description of the discrepancy and whether the deviation from OAS CAHPS
Survey protocol was caused by the vendor or facility;
• remediation plan for the affected month and the timeline for the remediation activity;
• corrective actions to be taken to avoid the situation in the future; and
• any other information that will help the OAS CAHPS Survey Coordination Team
understand the discrepancy.
The information required on the DNR form will vary depending on the reason selected for the
Discrepancy Reason field. Table 15.1 below provides a brief description of when it is
appropriate for an OAS CAHPS Survey vendor to select each of the listed reasons. Other
situations may occur that are not included in the table below. For guidance on which discrepancy
reason is most applicable, please contact the OAS CAHPS Survey Coordination Team.
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208 Centers for Medicare & Medicaid Services Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual
Table 15.1 Example Scenarios of Various Discrepancy Reasons
Discrepancy Reason When to Select Discrepancy Reason
No Sample Provided The HOPD or ASC was unable to provide the vendor with a monthly patient file.
Patients Omitted from the Sample Frame
The survey vendor, HOPD, ASC, or software vendor inadvertently omitted from the sample frame patients who were eligible for the survey.
Late Start The vendor is unable to initiate the survey by the 21st day after the sample month ended and needs to initiate it from the 22nd through the 26th day after the sample month ended. Note that a DNR is not required if a late start e-mail request was submitted because the e-mail request serves as the needed documentation.
No Survey Administered The vendor received the monthly patient file from the HOPD or ASC, but did not initiate data collection for the sample. Note that a DNR is not required if a late start e-mail request was submitted and denied because the e-mail request serves as the needed documentation.
Survey Interrupted Data collection for a sample month was initiated but was interrupted. This reason applies to situations when data collection activities resume after the interruption and when data collection does not resume. For example, a natural disaster or event interrupted data collection in such a way as to adversely affect survey outcomes.
Variable Incorrectly Coded An incorrect final disposition code was applied on a submitted XML file, or a variable was incorrectly coded on a submitted XML file. If response data were incorrectly coded after the case is finalized either before or after the XML file has been submitted to the OAS CAHPS Data Center, this reason should be selected.
Some Other Reason A reason that does not fall into one of the other reasons. For example, this could include an HOPD or ASC that is closed or no longer operating under a CCN, the submission of an XML file under the wrong CCN.
Vendors are required to submit a DNR if an HOPD or ASC client does not submit a monthly
patient information file for a sample month. However, survey vendors do not need to continue
submitting these reports for facilities that are not submitting monthly patient information files
once the facility has failed to submit a monthly patient information file for 3 consecutive
sample months. It is the responsibility of the OAS CAHPS Survey vendor to track the number
of months the HOPD or ASC has failed to submit a monthly patient information file and to
submit a DNR for the first 3 months that this occurs.
Vendors are reminded that no DNR is needed if a facility has notified the vendor via submission
of a zero eligible file or an e-mail that it has no eligible patients in a given sample month. If an
HOPD or ASC submits a file to its vendor with no eligible patients, the vendor must submit an
XML file for that facility for that sample month indicating that there were no eligible patients.
November 2018 XV. Exceptions Request Process and Discrepancy Notification Report
Centers for Medicare & Medicaid Services 209 Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual
Discrepancy Report Review Process
The OAS CAHPS Survey Coordination Team will review the vendor’s DNR and evaluate the
impact of the discrepancy on the publicly reported data. Depending on the type of discrepancy, a
footnote may be added to the publicly reported data. The Coordination Team will let the survey
vendor know whether additional information is required to document or correct the discrepancy.
Centers for Medicare & Medicaid Services Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual
APPENDIX A:
VENDOR APPLICATION FORM
Appendix A: Vendor Application Form November 2018
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APPENDIX B:
ENGLISH:
MAIL SURVEY COVER LETTERS, MAIL QUESTIONNAIRES,
INSTRUCTIONS FOR SCANNABLE MAIL QUESTIONNAIRE, TELEPHONE INTERVIEW SCRIPT
Appendix B: English: Mail Survey Cover Letters, Mail Questionnaires,
Instructions for Scannable Mail Questionnaire, Telephone Interview Script November 2018
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Centers for Medicare & Medicaid Services B-1 Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual
SAMPLE COVER LETTER FOR FIRST QUESTIONNAIRE MAILING
Outpatient and Ambulatory Surgery CAHPS Survey
To be Printed on Ambulatory Surgery Center or Hospital Outpatient Department or Vendor
Letterhead
«FirstName» «LastName»
«Address1» «Address2»
«City_Name», «State_Code» «Zip_Zip4»
Dear «FirstName» «LastName»:
[FACILITY] would like to learn more about the quality of health care that patients receive in our
facility. [VENDOR], an independent research company, is helping us conduct this survey. Our
records show that you had a surgery or procedure at [FACILITY]. The results of this survey will
be used to help us understand more about patient experiences in our facility.
The enclosed survey asks for your experiences with the outpatient surgery or procedure you had
on [DATE OF SURGERY]. We hope that you will take a few minutes to complete and return the
questionnaire to [VENDOR] in the enclosed, postage-paid envelope.
When answering the questions, please consider your visit to [FACILITY] on [DATE OF
SURGERY]. Do not answer questions based on any other surgeries or procedures you might
have had at either this facility or another.
All information you provide will be confidential and is protected by the Privacy Act. Your
answers to the survey will be grouped with answers from all other survey participants; your
name and identifying information will not be linked to your answers when the data are analyzed.
The overall survey results for [FACILITY NAME] and other facilities will be publicly reported
on the Internet at https://www.medicare.gov/. These results will help people make more
informed decisions when choosing an outpatient or ambulatory surgery facility. Your
participation is voluntary and will not affect any health care benefits you currently receive or will
receive in the future.
If you have any questions about the survey, please call NAME toll-free at 1-800-XXX-XXXX. If
you need help in reading the questions or marking responses, a friend or family member can
assist you. Thank you in advance for your participation. Si desea recibir la versión de la encuesta
en español, por favor llame al 1-800-XXX-XXXX.
Sincerely,
NAME
Title
Enclosures [PRINT UNIQUE SAMPLE ID NUMBER HERE]
Appendix B: English: Mail Survey Cover Letters, Mail Questionnaires,
Instructions for Scannable Mail Questionnaire, Telephone Interview Script November 2018
B-2 Centers for Medicare & Medicaid Services Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual
SAMPLE COVER LETTER FOR SECOND QUESTIONNAIRE MAILING TO MAIL
SURVEY NONRESPONDENTS
Outpatient and Ambulatory Surgery CAHPS Survey
To be Printed on Ambulatory Surgery Center or Hospital Outpatient Department or Vendor
Letterhead
«FirstName» «LastName»
«Address1» «Address2»
«City_Name», «State_Code» «Zip_Zip4»
Dear «FirstName» «LastName»:
Recently, we sent you a letter asking for your help on a survey to provide [FACILITY] with
information about the quality of health care provided to patients who receive an outpatient
surgery or procedure in our facility. As of today, we have not yet received your completed
questionnaire. If you have already completed and returned the questionnaire, please accept
our thanks. If you have not completed it, please take a few minutes to do so now. Then
return the questionnaire in the enclosed, postage-paid envelope.
When answering the questions, please consider your visit to [FACILITY] on [DATE OF
SURGERY]. Do not answer questions based on any other surgeries or procedures you might
have had at either our facility or another.
The results of this survey will be used to help us understand more about patient experiences in
our facility. All information you provide will be confidential and is protected by the Privacy Act.
Your answers to the survey will be grouped with answers from all other survey participants; your
name and identifying information will not be linked to your answers when the data are analyzed.
Your participation is voluntary and will not affect any health care benefits you currently receive
or will receive in the future.
If you have any questions about the survey, please call NAME toll-free at 1-800-XXX-XXXX. If
you need help in reading the questions or marking responses, a friend or family member can
assist you. Thank you in advance for your participation. Si desea recibir la versión de la encuesta
en español, por favor llame al 1-800-XXX-XXXX.
Sincerely,
NAME
Title
Enclosures [PRINT UNIQUE SAMPLE ID NUMBER HERE]
Consumer Assessment of Healthcare Providers and Systems
Outpatient and Ambulatory Surgery Survey
(OAS CAHPS®)
A PATIENT EXPERIENCE OF CARE SURVEY ABOUT OUTPATIENT AND AMBULATORY SURGERIES
AND PROCEDURES
ACCORDING TO THE PAPERWORK REDUCTION ACT OF 1995, NO PERSONS ARE REQUIRED TO RESPOND TO A
COLLECTION OF INFORMATION UNLESS IT DISPLAYS A VALID OMB CONTROL NUMBER. THE VALID OMB CONTROL
NUMBER FOR THIS INFORMATION COLLECTION IS 0938-1240. THE TIME REQUIRED TO COMPLETE THIS
INFORMATION COLLECTION IS ESTIMATED TO AVERAGE 8 MINUTES PER RESPONSE, INCLUDING THE TIME TO
REVIEW INSTRUCTIONS, SEARCH EXISTING DATA RESOURCES, GATHER THE DATA NEEDED, AND COMPLETE AND
REVIEW THE INFORMATION COLLECTION. IF YOU HAVE COMMENTS CONCERNING THE ACCURACY OF THE TIME
ESTIMATE(S) OR SUGGESTIONS FOR IMPROVING THIS FORM, PLEASE WRITE TO: CMS, 7500 SECURITY
BOULEVARD, ATTN: PRA REPORTS CLEARANCE OFFICER, MAIL STOP C4-26-05, BALTIMORE, MARYLAND
21244-1850.
Appendix B: English: Mail Survey Cover Letters, Mail Questionnaires,
Instructions for Scannable Mail Questionnaire, Telephone Interview Script November 2018
B-4 Centers for Medicare & Medicaid Services Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual
SURVEY INSTRUCTIONS
Answer all the questions by checking the box to the left of your answer.
You are sometimes told 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, like this:
Yes
No If No, go to #1 This survey asks about your experience at the facility named in the cover letter. For this survey, we use the term “procedure” for diagnostic, surgical or other procedures. We refer to “facility” as the place where you had your procedure.
Please answer these questions only for the procedure(s) you had on the date included in the cover letter. Do not include any other procedures in your answers.
I. BEFORE YOUR PROCEDURE
The first few questions are about getting ready for your procedure. Include any information you received before and on the day of your procedure.
1. Before your procedure, did your doctor or anyone from the facility give you all the information you needed about your procedure?
1 Yes, definitely 2 Yes, somewhat 3 No
2. Before your procedure, did your doctor or anyone from the facility give you easy to understand instructions about getting ready for your procedure?
1 Yes, definitely 2 Yes, somewhat 3 No
II. ABOUT THE FACILITY AND STAFF
The next questions ask about the day of your procedure.
3. Did the check-in process run smoothly?
1 Yes, definitely 2 Yes, somewhat 3 No
4. Was the facility clean?
1 Yes, definitely 2 Yes, somewhat 3 No
5. Were the clerks and receptionists at the facility as helpful as you thought they should be?
1 Yes, definitely 2 Yes, somewhat 3 No
6. Did the clerks and receptionists at the facility treat you with courtesy and respect?
1 Yes, definitely 2 Yes, somewhat 3 No
Appendix B: English: Mail Survey Cover Letters, Mail Questionnaires,
November 2018 Instructions for Scannable Mail Questionnaire, Telephone Interview Script
Centers for Medicare & Medicaid Services B-5 Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual
7. Did the doctors and nurses treat you with courtesy and respect?
1 Yes, definitely 2 Yes, somewhat 3 No
8. Did the doctors and nurses make sure you were as comfortable as possible?
1 Yes, definitely 2 Yes, somewhat 3 No
III. COMMUNICATIONS ABOUT YOUR
PROCEDURE
As a reminder, please include any information you received before and on the day of the procedure.
9. Did the doctors and nurses explain your procedure in a way that was easy to understand?
1 Yes, definitely 2 Yes, somewhat 3 No
10. Anesthesia is something that would make you feel sleepy or go to sleep during your procedure. Were you given anesthesia?
1 Yes 2 No If No, go 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?
1 Yes, definitely 2 Yes, somewhat 3 No
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?
1 Yes, definitely 2 Yes, somewhat 3 No
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?
1 Yes 2 No
IV. YOUR RECOVERY
14. Did your doctor or anyone from the facility prepare you for what to expect during your recovery?
1 Yes, definitely 2 Yes, somewhat 3 No
Appendix B: English: Mail Survey Cover Letters, Mail Questionnaires,
Instructions for Scannable Mail Questionnaire, Telephone Interview Script November 2018
B-6 Centers for Medicare & Medicaid Services Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual
15. Some ways to control pain include prescription medicine, over-the-counter pain relievers or 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?
1 Yes, definitely 2 Yes, somewhat 3 No
16. At any time after leaving the facility, did you have pain as a result of your procedure?
1 Yes 2 No
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?
1 Yes, definitely 2 Yes, somewhat 3 No
18. At any time after leaving the facility, did you have nausea or vomiting as a result of either your procedure or the anesthesia?
1 Yes 2 No
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?
1 Yes, definitely 2 Yes, somewhat 3 No
20. At any time after leaving the facility, did you have bleeding as a result of your procedure?
1 Yes 2 No
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 if you had possible signs of infection?
1 Yes, definitely 2 Yes, somewhat 3 No
22. At any time after leaving the facility, did you have any signs of infection?
1 Yes 2 No
Appendix B: English: Mail Survey Cover Letters, Mail Questionnaires,
November 2018 Instructions for Scannable Mail Questionnaire, Telephone Interview Script
Centers for Medicare & Medicaid Services B-7 Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual
V. YOUR OVERALL EXPERIENCE
23. Using any number from 0 to 10, where 0 is the worst facility possible and 10 is the best facility possible, what number would you use to rate this facility?
0 Worst facility possible
1
2
3
4
5
6
7
8
9
10 Best facility possible
24. Would you recommend this facility to your friends and family?
1 Definitely no 2 Probably no 3 Probably yes 4 Definitely yes
VI. ABOUT YOU
25. In general, how would you rate your overall health?
1 Excellent 2 Very good 3 Good 4 Fair 5 Poor
26. In general, how would you rate your overall mental or emotional health?
1 Excellent 2 Very good 3 Good 4 Fair 5 Poor
27. What is your age?
1 18 to 24 2 25 to 34 3 35 to 44 4 45 to 54 5 55 to 64 6 65 to 74 7 75 to 79 8 80 to 84 9 85 or older
28. Are you male or female?
1 Male 2 Female
29. What is the highest grade or level of school that you have completed?
1 8th grade or less 2 Some high school, but did not
graduate 3 High school graduate or GED 4 Some college or 2-year degree 5 4-year college graduate 6 More than 4-year college
degree
Appendix B: English: Mail Survey Cover Letters, Mail Questionnaires,
Instructions for Scannable Mail Questionnaire, Telephone Interview Script November 2018
B-8 Centers for Medicare & Medicaid Services Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual
30. Are you of Hispanic, Latino, or Spanish origin?
1 Yes, Hispanic, Latino, or Spanish
2 No, not Hispanic, Latino, or Spanish If No, go to #32
31. Which group best describes you?
1 Mexican, Mexican American, Chicano
2 Puerto Rican 3 Cuban 4 Another Hispanic, Latino, or
Spanish origin
32. What is your race? You may select one or more categories.
1 White 2 Black or African American 3 American Indian or Alaska
Native 4 Asian Indian 5 Chinese 6 Filipino 7 Japanese 8 Korean 9 Vietnamese 10 Other Asian 11 Native Hawaiian 12 Guamanian or Chamorro 13 Samoan 14 Other Pacific Islander
33. How well do you speak English?
1 Very well 2 Well 3 Not well 4 Not at all
34. Do you speak a language other than English at home?
1 Yes 2 No If No, go to #36
35. What is that language?
1 Spanish 2 Other Language
(PLEASE SPECIFY): ________________________ (Please print.)
36. Did someone help you complete this survey?
1 Yes 2 No If No, go to END.
37. How did that person help you? Check all that apply.
1 Read the questions to me 2 Wrote down the answers I
gave 3 Answered the questions for me 4 Translated the questions into
my language 5 Helped in some other way:
(EXPLAIN): ________________________ (Please print.)
6 No one helped me complete this survey
END
Appendix B: English: Mail Survey Cover Letters, Mail Questionnaires,
November 2018 Instructions for Scannable Mail Questionnaire, Telephone Interview Script
Centers for Medicare & Medicaid Services B-9 Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual
(Alternative Instructions for Scannable Forms)
SURVEY INSTRUCTIONS
• Answer all the questions by completely filling in the circle to the left of your answer.
• You are sometimes told 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, like this:
Yes
No If No, go to #1
This survey asks about your experience at the facility named in the cover letter. For this survey,
we use the term “procedure” for diagnostic, surgical or other procedures. We refer to “facility”
as the place where you had your procedure.
Please answer these questions only for the procedure(s) you had on the date included in the
cover letter. Do not include any other procedures in your answers.
Appendix B: English: Mail Survey Cover Letters, Mail Questionnaires,
Instructions for Scannable Mail Questionnaire, Telephone Interview Script November 2018
B-10 Centers for Medicare & Medicaid Services Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual
TELEPHONE INTERVIEW SCRIPT
FOR THE OUTPATIENT AND AMBULATORY SURGERY CAHPS SURVEY (OAS
CAHPS®)
GO TO INTRO4 IF THIS IS A FOLLOW-UP CALL TO AN INTERVIEW THAT WAS
STARTED IN A PRECEDING CALL. OTHERWISE GO TO INTRO1.
INTRO1 Hello, may I please speak to [SAMPLED MEMBER’S NAME]?
IF ASKED WHO IS CALLING:
This is [INTERVIEWER NAME] calling from [VENDOR] on behalf of
[FACILITY NAME]. I’d like to speak to [SAMPLE MEMBER’S NAME] about
a health care survey.
1. YES [GO TO INTRO2]
2. NO, NOT AVAILABLE RIGHT NOW [SET CALLBACK]
3. NO [REFUSAL] [GO TO Q_REF SCREEN ]
4. MENTALLY/PHYSICALLY INCAPABLE [GO TO Q_INELIGIBLE
SCREEN]
INTRO2 (Hello, this is [INTERVIEWER NAME] calling on behalf of [FACILITY
NAME].) [FACILITY NAME] is participating in a survey about patients’
experiences with outpatient surgeries and procedures. The results will be used to
help [FACILITY NAME] understand patient experiences in their facilities.
Your participation in this survey is completely voluntary and will not affect any
health care or benefits you receive. All information you provide is confidential
and is protected by the Privacy Act. The interview will take about 8 minutes to
complete. This call may be monitored or recorded for quality improvement
purposes.
[ADDRESS ANY QUESTIONS/CONCERNS THEN CONTINUE.]
NOTE: THE LENGTH OF THE INTERVIEW WILL DEPEND ON WHETHER THE
FACILITY ADDS SUPPLEMENTAL QUESTIONS TO THE SURVEY. IF
SUPPLEMENTAL ITEMS ARE ADDED, INCREASE THE STATED
NUMBER OF MINUTES IN INTRO2 ACCORDINGLY.
Appendix B: English: Mail Survey Cover Letters, Mail Questionnaires,
November 2018 Instructions for Scannable Mail Questionnaire, Telephone Interview Script
Centers for Medicare & Medicaid Services B-11 Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual
INTRO3 This survey asks about your experience at [FACILITY NAME]. For this survey,
we use the term “procedure” for diagnostic, surgical or other procedures. We refer
to “facility” as the place where you had your procedure. Please answer these
questions only for the procedure you had on [DATE]. Do not include any other
procedures in your answers.
[ADDRESS ANY QUESTIONS/CONCERNS THEN SELECT RESPONSE OPTION.]
1 BEGIN INTERVIEW [GO TO Q1_INTRO]
2 NO, NOT RIGHT NOW [SET CALLBACK]
3 DID NOT RECEIVE SURGERY/PROCEDURE FROM THIS FACILITY
DURING [MONTH] [GO TO Q_INELIGIBLE SCREEN]
4 NO [REFUSAL] [GO TO Q_REF SCREEN]
INEL ITEMS ARE OPTIONAL AND ASKED ONLY IF NEW TELEPHONE NUMBER
IDENTIFIED.
INEL1 Were you ever a patient at [FACILITY NAME]?
1 YES [GO TO INEL2]
2 NO [GO TO INEL_END]
INEL2 When was this?
NOTE: IF DATE IS WITHIN 2 WEEKS OF SURGERY DATE ON RECORD,
GO TO Q1_INTRO. IF NOT, GO TO INEL_END.
INEL_END Thank you for your time. It looks like we made a mistake. Have a good
(day/evening).
INTRO4 USED ONLY IF CALLING SAMPLE PATIENT BACK TO COMPLETE A
SURVEY THAT WAS STARTED IN A PREVIOUS CALL. NOTE THAT THE
PATIENT MUST HAVE ANSWERED AT LEAST ONE QUESTION IN THE
SURVEY IN A PRECEDING CALL.
Hello, may I please speak to [SAMPLE MEMBER’S NAME]?
IF ASKED WHO IS CALLING:
This is [INTERVIEWER NAME] calling from [VENDOR] on behalf of
Appendix B: English: Mail Survey Cover Letters, Mail Questionnaires,
Instructions for Scannable Mail Questionnaire, Telephone Interview Script November 2018
B-12 Centers for Medicare & Medicaid Services Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual
[FACILITY NAME]. I’d like to speak to [SAMPLE MEMBER’S NAME] about
a health care survey.
1 YES, SAMPLE PATIENT IS AVAILABLE AND ON PHONE NOW [GO
TO INTRO5]
2 NO, NOT AVAILABLE RIGHT NOW [SET CALLBACK]
3 NO [REFUSAL] [GO TO Q_REF SCREEN]
4 MENTALLY/PHYSICALLY INCAPABLE [GO TO Q_INELIGIBLE
SCREEN]
INTRO5 Hello, this is [INTERVIEWER NAME] calling from [VENDOR]. I am calling to
continue the survey that we started in a previous call, regarding your experience at
[FACILITY NAME]. I’d like to continue with that survey now.
1 CONTINUE WITH INTERVIEW AT FIRST UNANSWERED QUESTION
2 NO, NOT RIGHT NOW [SET CALLBACK]
3 NO [REFUSAL] [GO TO Q_REF SCREEN]
Q1_INTRO The first few questions are about getting ready for your procedure. Include any
information you received before and on the day of your procedure.
Q1. Before your procedure, did your doctor or anyone from the facility give you all
the information you needed about your procedure? Would you say…
1 Yes, definitely,
2 Yes, somewhat, or
3 No?
M MISSING/DK
Q2. Before your procedure, did your doctor or anyone from the facility give you easy
to understand instructions about getting ready for your procedure? Would you
say…
1 Yes, definitely,
2 Yes, somewhat, or
3 No?
M MISSING/DK
Q3_INTRO The next questions ask about the day of your procedure.
Appendix B: English: Mail Survey Cover Letters, Mail Questionnaires,
November 2018 Instructions for Scannable Mail Questionnaire, Telephone Interview Script
Centers for Medicare & Medicaid Services B-13 Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual
Q3. Did the check-in process run smoothly? Would you say…
1 Yes, definitely,
2 Yes, somewhat, or
3 No?
M MISSING/DK
Q4. Was the facility clean? Would you say…
1 Yes, definitely,
2 Yes, somewhat, or
3 No?
M MISSING/DK
Q5. Were the clerks and receptionists at the facility as helpful as you thought they
should be? Would you say…
1 Yes, definitely,
2 Yes, somewhat, or
3 No?
M MISSING/DK
Q6. Did the clerks and receptionists at the facility treat you with courtesy and respect?
Would you say…
1 Yes, definitely,
2 Yes, somewhat, or
3 No?
M MISSING/DK
Q7. Did the doctors and nurses treat you with courtesy and respect? Would you say…
1 Yes, definitely,
2 Yes, somewhat, or
3 No?
M MISSING/DK
Appendix B: English: Mail Survey Cover Letters, Mail Questionnaires,
Instructions for Scannable Mail Questionnaire, Telephone Interview Script November 2018
B-14 Centers for Medicare & Medicaid Services Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual
Q8. Did the doctors and nurses make sure you were as comfortable as possible?
Would you say…
1 Yes, definitely,
2 Yes, somewhat, or
3 No?
M MISSING/DK
Q9_INTRO As a reminder, please include any information you received before and on the day
of the procedure.
Q9. Did the doctors and nurses explain your procedure in a way that was easy to
understand? Would you say…
1 Yes, definitely,
2 Yes, somewhat, or
3 No?
M MISSING/DK
Q10. Anesthesia is something that would make you feel sleepy or go to sleep during
your procedure. Were you given anesthesia?
1 YES
2 NO [GO TO Q13]
M MISSING/DK [GO TO Q13]
Q11. Did your doctor or anyone from the facility explain the process of giving
anesthesia in a way that was easy to understand? Would you say…
1 Yes, definitely,
2 Yes, somewhat, or
3 No?
M MISSING/DK
Appendix B: English: Mail Survey Cover Letters, Mail Questionnaires,
November 2018 Instructions for Scannable Mail Questionnaire, Telephone Interview Script
Centers for Medicare & Medicaid Services B-15 Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual
Q12. Did your doctor or anyone from the facility explain the possible side effects of the
anesthesia in a way that was easy to understand? Would you say…
1 Yes, definitely,
2 Yes, somewhat, or
3 No?
M MISSING/DK
Q13. 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 receive written discharge instructions?
1 YES
2 NO
M MISSING/DK
Q14. Did your doctor or anyone from the facility prepare you for what to expect during
your recovery? Would you say…
1 Yes, definitely,
2 Yes, somewhat, or
3 No?
M MISSING/DK
Q15. Some ways to control pain include prescription medicine, over-the-counter pain
relievers or 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?
Would you say…
1 Yes, definitely,
2 Yes, somewhat, or
3 No?
M MISSING/DK
Q16. At any time after leaving the facility, did you have pain as a result of your
procedure?
1 YES
2 NO
M MISSING/DK
Appendix B: English: Mail Survey Cover Letters, Mail Questionnaires,
Instructions for Scannable Mail Questionnaire, Telephone Interview Script November 2018
B-16 Centers for Medicare & Medicaid Services Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual
Q17. 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? Would you say…
1 Yes, definitely,
2 Yes, somewhat, or
3 No?
M MISSING/DK
Q18. At any time after leaving the facility, did you have nausea or vomiting as a result
of either your procedure or the anesthesia?
1 YES
2 NO
M MISSING/DK
Q19. 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?
Would you say…
1 Yes, definitely,
2 Yes, somewhat, or
3 No?
M MISSING/DK
Q20. At any time after leaving the facility, did you have bleeding as a result of your
procedure?
1 YES
2 NO
M MISSING/DK
Q21. 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 if you had possible signs of infection? Would you
say…
1 Yes, definitely,
2 Yes, somewhat, or
3 No?
M MISSING/DK
Appendix B: English: Mail Survey Cover Letters, Mail Questionnaires,
November 2018 Instructions for Scannable Mail Questionnaire, Telephone Interview Script
Centers for Medicare & Medicaid Services B-17 Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual
Q22. At any time after leaving the facility, did you have any signs of infection?
1 YES
2 NO
M MISSING/DK
Q23_INTRO The next two questions ask about your overall experience.
Q23. Using any number from 0 to 10, where 0 is the worst facility possible and 10 is
the best facility possible, what number would you use to rate this facility?
0 WORST FACILITY POSSIBLE
1
2
3
4
5
6
7
8
9
10 BEST FACILITY POSSIBLE
M MISSING/DK
Q24. Would you recommend this facility to your friends and family? Would you say…
1 Definitely no,
2 Probably no,
3 Probably yes, or
4 Definitely yes?
M MISSING/DK
Q25. In general, how would you rate your overall health? Would you say …
1 Excellent,
2 Very good,
3 Good,
4 Fair, or
5 Poor?
M MISSING/DK
Appendix B: English: Mail Survey Cover Letters, Mail Questionnaires,
Instructions for Scannable Mail Questionnaire, Telephone Interview Script November 2018
B-18 Centers for Medicare & Medicaid Services Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual
Q26. In general, how would you rate your overall mental or emotional health? Would
you say …
1 Excellent,
2 Very good,
3 Good,
4 Fair, or
5 Poor?
M MISSING/DK
Q27. What is your age?
1 18 TO 24
2 25 TO 34
3 35 TO 44
4 45 TO 54
5 55 TO 64
6 65 TO 74
7 75 TO 79
8 80 TO 84
9 85 OR OLDER
M MISSING/DK
Q28. Are you male or female?
1 MALE
2 FEMALE
M MISSING/DK
Q29. What is the highest grade or level of school that you have completed? Would you
say…
1 8th grade or less,
2 Some high school, but did not graduate,
3 High school graduate or GED,
4 Some college or 2-year degree,
5 4-year college graduate, or
6 More than 4-year college degree?
M MISSING/DK
Appendix B: English: Mail Survey Cover Letters, Mail Questionnaires,
November 2018 Instructions for Scannable Mail Questionnaire, Telephone Interview Script
Centers for Medicare & Medicaid Services B-19 Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual
Q30. Are you of Hispanic, Latino, or Spanish origin?
1 YES
2 NO [GO TO Q32]
M MISSING/DK [GO TO Q32]
Q31. Which group best describes you…
1 Mexican, Mexican American, Chicano,
2 Puerto Rican,
3 Cuban, or
4 Another Hispanic, Latino, or Spanish origin?
M MISSING/DK
Q32. What is your race? You may select one or more categories. Are you…
1 White,
2 Black or African American,
3 American Indian or Alaska Native,
4 Asian, or
5 Native Hawaiian or Pacific Islander?
6 NONE OF THE ABOVE
M MISSING/DK
PROGRAMMER INSTRUCTIONS: IF WHITE ONLY, BLACK/AFRICAN AMERICAN
ONLY, OR AMERICAN INDIAN/ALASKA NATIVE ONLY, OR ANY COMBINATION OF
THESE THREE OPTIONS, NONE OF THE ABOVE OR MISSING/DK, GO TO Q33.
IF ASIAN ONLY, GO TO Q32A. IF WHITE, BLACK/AFRICAN AMERICAN, AND/OR
AMERICAN INDIAN/ALASKA NATIVE AND ASIAN ARE CHOSEN, GO TO Q32A. IF
NATIVE HAWAIIAN/PACIFIC ISLANDER IS ALSO CHOSEN, SEE INSTRUCTION
AFTER Q32A.
IF NATIVE HAWAIIAN/PACIFIC ISLANDER ONLY, GO TO Q32B. IF WHITE,
BLACK/AFRICAN AMERICAN, AND/OR AMERICAN INDIAN/ALASKA NATIVE AND
NATIVE HAWAIIAN/PACIFIC ISLANDER ARE CHOSEN, GO TO Q32B.
Appendix B: English: Mail Survey Cover Letters, Mail Questionnaires,
Instructions for Scannable Mail Questionnaire, Telephone Interview Script November 2018
B-20 Centers for Medicare & Medicaid Services Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual
Q32a. Which groups best describe you? You may select one or more categories. Are
you…
1 Asian Indian,
2 Chinese,
3 Filipino,
4 Japanese,
5 Korean,
6 Vietnamese, or
7 Other Asian?
8 NONE OF THE ABOVE
M MISSING/DK
IF NATIVE HAWAIIAN/PACIFIC ISLANDER WAS ALSO CHOSEN IN Q32, GO TO Q32B.
ELSE, GO TO Q33.
Q32b. Which groups best describe you? You may select one or more categories. Are
you…
1 Native Hawaiian,
2 Guamanian or Chamorro,
3 Samoan, or
4 Other Pacific Islander?
5 NONE OF THE ABOVE
M MISSING/DK
Q33. How well do you speak English? Would you say…
1 Very well,
2 Well,
3 Not well, or
4 Not at all?
M MISSING/DK
Q34. Do you speak a language other than English at home? Would you say…
1 Yes, I speak a language other than English, or
2 No, I speak English at home? [GO TO Q_END]
M MISSING/DK [GO TO Q_END]
Appendix B: English: Mail Survey Cover Letters, Mail Questionnaires,
November 2018 Instructions for Scannable Mail Questionnaire, Telephone Interview Script
Centers for Medicare & Medicaid Services B-21 Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual
Q35. What is that language?
1 SPANISH [GO TO Q_END]
2 OTHER LANGUAGE [GO TO Q35a]
M MISSING/DK [GO TO Q_END]
Q35a. What is that language? [ENTER RESPONSE BELOW. ALLOW UP TO 50
CHARACTERS]
M MISSING/DK
Q_END These are all the questions I have for you. Thank you for your time. Have a good
(day/evening).
INELIGIBLE SCREEN:
Q_INELIG Thank you for your time. Have a good (day/evening).
REFUSAL SCREEN:
Q_REF Thank you for your time. Have a good (day/evening).
Appendix B: English: Mail Survey Cover Letters, Mail Questionnaires,
Instructions for Scannable Mail Questionnaire, Telephone Interview Script November 2018
B-22 Centers for Medicare & Medicaid Services Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual
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Centers for Medicare & Medicaid Services Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual
APPENDIX C:
SPANISH: MAIL SURVEY COVER LETTERS,
MAIL QUESTIONNAIRES,
INSTRUCTIONS FOR SCANNABLE MAIL QUESTIONNAIRE, TELEPHONE INTERVIEW SCRIPT
Appendix C: Spanish: Mail Survey Cover Letters, Mail Questionnaires,
Instructions for Scannable Mail Questionnaire, Telephone Interview Script November 2018
Centers for Medicare & Medicaid Services Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual
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Centers for Medicare & Medicaid Services C-1 Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual
SAMPLE COVER LETTER FOR FIRST QUESTIONNAIRE MAILING
Outpatient and Ambulatory Surgery CAHPS Survey
To be Printed on Ambulatory Surgery Center or Hospital Outpatient Department or Vendor
Letterhead
«FirstName» «LastName»
«Address1» «Address2»
«City_Name», «State_Code» «Zip_Zip4»
Estimado(a) «FirstName» «LastName»:
[FACILITY NAME] participará en una encuesta nacional para saber más sobre la calidad de la
atención médica que reciben los pacientes. [VENDOR], una organización independiente que
realiza estudios, está ayudando a realizar esta encuesta. Nuestros registros muestran que usted se
hizo un procedimiento o cirugía en [FACILITY NAME]. Los resultados se usarán para ayudar a
comprender las experiencias de los pacientes de nuestro centro.
La encuesta que adjuntamos hace preguntas sobre sus experiencias con el procedimiento o la
cirugía que recibió el [Date of Procedure]. Esperamos que tome unos cuantos minutos para
completar y devolver el cuestionario a [VENDOR], en el sobre adjunto con franqueo postal
pagado.
Al contestar las preguntas, tenga en cuenta su visita a [FACILITY NAME] el [Date of
Procedure]. No responda las preguntas acerca de otras cirugías o procedimientos que haya tenido
en este centro de cirugía o en otro lugar.
Toda la información que proporcione será confidencial y estará protegida por la Ley de
Privacidad. Sus respuestas a la encuesta se agruparán con las de otros participantes del estudio.
Su nombre y su información de identidad no se asociarán a sus respuestas cuando se analicen los
datos. Los resultados generales de la encuesta de [FACILITY NAME] y de otras instalaciones se
reportará públicamente en internet en https://www.medicare.gov/. Estos resultados ayudarán a
las personas a tomar decisiones más informadas cuando eligen un centro para cirugía externa o
ambulatoria. Su participación es voluntaria y no afectará a ningún beneficio de atención médica
que usted reciba ahora o en el futuro.
Si tiene alguna pregunta sobre la encuesta, puede llamar al personal de la encuesta a la línea
gratuita 1-800-XXX-XXXX. Si necesita ayuda para leer las preguntas o marcar respuestas, una
amistad o miembro de la familia puede ayudarle. Le agradecemos de antemano por su
participación.
Appendix C: Spanish: Mail Survey Cover Letters, Mail Questionnaires,
Instructions for Scannable Mail Questionnaire, Telephone Interview Script November 2018
C-2 Centers for Medicare & Medicaid Services Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual
Atentamente,
NAME
Title
Documento adjunto [PRINT UNIQUE SAMPLE ID NUMBER HERE]
Appendix C: Spanish: Mail Survey Cover Letters, Mail Questionnaires,
November 2018 Instructions for Scannable Mail Questionnaire, Telephone Interview Script
Centers for Medicare & Medicaid Services C-3 Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual
SAMPLE COVER LETTER FOR SECOND QUESTIONNAIRE MAILING TO MAIL
SURVEY NONRESPONDENTS
Outpatient and Ambulatory Surgery CAHPS Survey
To be Printed on Ambulatory Surgery Center or Hospital Outpatient Department or Vendor
Letterhead
«FirstName» «LastName»
«Address1» «Address2»
«City_Name», «State_Code» «Zip_Zip4»
Estimado(a) «FirstName» «LastName»:
Hace poco, le enviamos una carta pidiéndole su ayuda en una encuesta para dar información a
[FACILITY] sobre la calidad de la atención médica que reciben los pacientes de cirugía para
pacientes externos o ambulatorios. Al día de hoy, no hemos recibido el cuestionario con sus
respuestas. Si usted ya completó el cuestionario y lo regresó, se lo agradecemos. Si no lo ha
completado, por favor dedique unos minutos para hacerlo ahora. Luego envíe el
cuestionario en el sobre adjunto con franqueo postal pagado.
Al contestar las preguntas, por favor tenga en cuenta su visita a [FACILITY] el [DATE OF
SURGERY]. No responda las preguntas acerca de otras cirugías o procedimientos que haya
tenido en este centro de cirugía o en otro lugar.
Los resultados de la encuesta se usarán para ayudar a comprender las experiencias de los
pacientes del centro. Toda la información que proporcione será confidencial y estará protegida
por la Ley de Privacidad. Sus respuestas a la encuesta se agruparán con las de otros participantes
del estudio. Su nombre y su información de identidad no se asociarán a sus respuestas cuando se
analicen los datos. Su participación es voluntaria y no afectará a ningún beneficio de atención
médica que usted reciba ahora o en el futuro.
Si tiene alguna pregunta sobre la encuesta, puede llamar al personal de la encuesta a la línea
gratuita 1-800-XXX-XXXX. Si necesita ayuda para leer las preguntas o marcar respuestas, una
amistad o miembro de la familia puede ayudarle. Le agradecemos de antemano por su
participación.
Atentamente,
NAME
Title
Documento adjunto [PRINT UNIQUE SAMPLE ID NUMBER HERE]
Encuesta CAHPS sobre la cirugía externa o ambulatoria
(OAS CAHPS®)
UNA ENCUESTA DE PACIENTES SOBRE LA EXPERIENCIA CON LA ATENCIÓN DE CIRUGÍAS Y
PROCEDIMIENTOS AMBULATORIOS
DE ACUERDO A LA LEY DE REDUCCIÓN DE TRABAJO ADMINISTRATIVO DE 1995 (PAPERWORK REDUCTION ACT
OF 1995), NINGUNA PERSONA TIENE LA OBLIGACIÓN DE RESPONDER A UN CUESTIONARIO QUE SOLICITE
INFORMACIÓN, A MENOS QUE LLEVE UN NÚMERO DE CONTROL DE OMB (OFICINA DE ADMINISTRACIÓN Y
PRESUPUESTO) VÁLIDO. EL NÚMERO DE CONTROL OMB VÁLIDO PARA ESTE CUESTIONARIO ES 0938-1240. SE
ESTIMA QUE EL TIEMPO PROMEDIO NECESARIO PARA COMPLETAR ESTE CUESTIONARIO ES DE 8 MINUTOS POR
RESPUESTA, INCLUYENDO EL TIEMPO PARA REVISAR LAS INSTRUCCIONES, BUSCAR EN LAS FUENTES DE DATOS
EXISTENTES, RECOPILAR LOS DATOS NECESARIOS, COMPLETAR Y REVISAR LA INFORMACIÓN RECOPILADA. SI
TIENE ALGÚN COMENTARIO SOBRE LA EXACTITUD DEL TIEMPO ESTIMADO O SUGERENCIAS PARA MEJORAR ESTE
FORMULARIO, POR FAVOR ESCRIBA A: CMS, 7500 SECURITY BOULEVARD, ATTN: PRA REPORTS CLEARANCE
OFFICER, MAIL STOP C4-26-05, BALTIMORE, MARYLAND 21244-1850.
Appendix C: Spanish: Mail Survey Cover Letters, Mail Questionnaires,
November 2018 Instructions for Scannable Mail Questionnaire, Telephone Interview Script
Centers for Medicare & Medicaid Services C-5 Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual
INSTRUCCIONES PARA LA ENCUESTA
Conteste todas las preguntas marcando el cuadrito que aparece a la izquierda de su respuesta.
A veces se le pide que salte algunas preguntas en esta encuesta. Cuando esto ocurra, verá una flecha con una nota que le indicará cuál es la siguiente pregunta a la que tiene que ir, de esta manera:
Sí
No Si contestó “No”,
pase a la pregunta 1 Esta encuesta pregunta acerca de sus experiencias en el centro ambulatorio que se menciona en la carta de presentación. Para esta encuesta, usamos el término “procedimiento” para procedimientos de diagnóstico, cirugías u otros procedimientos. Nos referimos al “centro ambulatorio” como el lugar en donde se realizó su procedimiento.
Por favor, responda las preguntas solo para el/los procedimiento(s) que tuvo en la fecha que se incluye en la carta de presentación. No incluya ningún otro procedimiento en sus respuestas.
I. ANTES DEL PROCEDIMIENTO
Las primeras preguntas son acerca de la preparación para su procedimiento. Incluya cualquier información que haya recibido antes o en el día del procedimiento.
1. Antes del procedimiento, ¿le dio un doctor o alguien del centro ambulatorio toda la información que necesitaba acerca de su procedimiento?
1 Sí, definitivamente 2 Sí, algo 3 No
2. Antes del procedimiento, ¿le dio un doctor o alguien del centro ambulatorio instrucciones fáciles de entender sobre lo que necesitaba para prepararse para su procedimiento?
1 Sí, definitivamente 2 Sí, algo 3 No
II. ACERCA DEL CENTRO
AMBULATORIO Y EL PERSONAL
Las siguientes preguntas se refieren al día de su procedimiento.
3. ¿Fue fácil el proceso de registro?
1 Sí, definitivamente 2 Sí, algo 3 No
4. ¿Estaba limpio el centro ambulatorio?
1 Sí, definitivamente 2 Sí, algo 3 No
Appendix C: Spanish: Mail Survey Cover Letters, Mail Questionnaires,
Instructions for Scannable Mail Questionnaire, Telephone Interview Script November 2018
C-6 Centers for Medicare & Medicaid Services Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual
5. ¿Le ayudó el personal administrativo y de recepción del centro ambulatorio tanto como usted pensaba que debían hacerlo?
1 Sí, definitivamente 2 Sí, algo 3 No
6. ¿Le trató el personal administrativo y de recepción del centro ambulatorio con cortesía y respeto?
1 Sí, definitivamente 2 Sí, algo 3 No
7. ¿Le trataron los doctores y enfermeras con cortesía y respeto?
1 Sí, definitivamente 2 Sí, algo 3 No
8. ¿Se aseguraron los doctores y enfermeras que usted estuviera tan cómodo como fuera posible?
1 Sí, definitivamente 2 Sí, algo 3 No
III. COMUNICACIÓN SOBRE SU
PROCEDIMIENTO
Le recordamos que por favor incluya cualquier información que haya recibido ya sea antes o en el día del procedimiento.
9. ¿Le explicaron los doctores y enfermeras el procedimiento de tal manera que fue fácil de entender?
1 Sí, definitivamente 2 Sí, algo 3 No
10. La anestesia es algo que le haría sentir sueño o dormir durante el procedimiento. ¿Le dieron anestesia?
1 Sí 2 No Si contestó “No”,
pase a la pregunta 13
11. ¿Le explicó el doctor o alguien del centro ambulatorio el proceso de dar anestesia de tal manera que fue fácil de entender?
1 Sí, definitivamente 2 Sí, algo 3 No
12. ¿Le explicó el doctor o alguien del centro ambulatorio los posibles efectos secundarios de la anestesia de tal manera que fuera fácil de entender?
1 Sí, definitivamente 2 Sí, algo 3 No
Appendix C: Spanish: Mail Survey Cover Letters, Mail Questionnaires,
November 2018 Instructions for Scannable Mail Questionnaire, Telephone Interview Script
Centers for Medicare & Medicaid Services C-7 Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual
13. Las instrucciones al ser dado de alta incluyen observar los síntomas después de su procedimiento, instrucciones sobre los medicamentos y cuidado en el hogar. Antes de salir del centro ambulatorio, ¿recibió instrucciones por escrito al darle de alta?
1 Sí 2 No
IV. SU RECUPERACIÓN
14. ¿Le preparó el doctor o alguien del personal del centro ambulatorio sobre qué esperar durante su recuperación?
1 Sí, definitivamente 2 Sí, algo 3 No
15. Algunas maneras para controlar el dolor incluyen medicamentos recetados, medicamentos para el dolor de venta libre o bolsas de hielo. ¿Su doctor o alguien del centro ambulatorio le dio información sobre qué hacer si tenía dolor como resultado de su procedimiento?
1 Sí, definitivamente 2 Sí, algo 3 No
16. En algún momento después de salir del centro ambulatorio, ¿tuvo dolor debido al procedimiento?
1 Sí 2 No
17. Antes de salir del centro ambulatorio, ¿su doctor o alguien del personal del centro ambulatorio le dio información sobre qué hacer si tenía náusea o vómitos?
1 Sí, definitivamente 2 Sí, algo 3 No
18. En algún momento después de salir del centro ambulatorio, ¿tuvo náusea o vómitos como resultado del procedimiento o la anestesia?
1 Sí 2 No
19. Antes de salir del centro ambulatorio, ¿su doctor o alguien del personal del centro ambulatorio le dio información sobre qué hacer si sangraba como resultado del procedimiento?
1 Sí, definitivamente 2 Sí, algo 3 No
20. En algún momento después de salir del centro ambulatorio, ¿tuvo sangrado como resultado del procedimiento?
1 Sí 2 No
Appendix C: Spanish: Mail Survey Cover Letters, Mail Questionnaires,
Instructions for Scannable Mail Questionnaire, Telephone Interview Script November 2018
C-8 Centers for Medicare & Medicaid Services Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual
21. Posibles señales de infección incluyen fiebre, hinchazón, calor, secreción o enrojecimiento. Antes de salir del centro ambulatorio, ¿su doctor o alguien del personal del centro ambulatorio le dio información sobre qué hacer si tuviera señales de infección?
1 Sí, definitivamente 2 Sí, algo 3 No
22. En algún momento después de salir del centro ambulatorio, ¿tuvo señales de infección?
1 Sí 2 No
V. SU EXPERIENCIA GENERAL
23. Usando un número del 0 al 10, en donde 0 es el peor centro ambulatorio posible y 10 es el mejor centro ambulatorio posible, ¿qué número usaría para calificar éste centro ambulatorio?
0 Peor centro ambulatorio
posible
1
2
3
4
5
6
7
8
9
10 Mejor centro ambulatorio
posible
24. ¿Recomendaría este centro ambulatorio a sus amistades y familia?
1 Definitivamente no 2 Probablemente no 3 Probablemente sí 4 Definitivamente sí
VI. ACERCA DE USTED
25. En general, ¿cómo calificaría su salud general?
1 Excelente 2 Muy buena 3 Buena 4 Regular 5 Mala
26. En general, ¿cómo calificaría su salud mental o emocional?
1 Excelente 2 Muy buena 3 Buena 4 Regular 5 Mala
27. ¿Qué edad tiene usted?
1 18 a 24 años 2 25 a 34 años 3 35 a 44 años 4 45 a 54 años 5 55 a 64 años 6 65 a 74 años 7 75 a 79 años 8 80 a 84 años 9 85 años o más
Appendix C: Spanish: Mail Survey Cover Letters, Mail Questionnaires,
November 2018 Instructions for Scannable Mail Questionnaire, Telephone Interview Script
Centers for Medicare & Medicaid Services C-9 Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual
28. ¿Es usted hombre o mujer?
1 Hombre 2 Mujer
29. ¿Cuál es el nivel o año escolar más avanzado que usted ha completado?
1 8 años de escuela o menos 2 9–12 años de escuela, pero
sin graduarse 3 Graduado de la escuela
secundaria, Diploma de escuela secundaria, preparatoria o su equivalente (o GED)
4 Algunos cursos universitarios o un título universitario de un programa de 2 años
5 Título universitario de 4 años 6 Título universitario de más de
4 años
30. ¿Es usted de origen hispano, latino o español?
1 Sí, soy de origen hispano, latino o español
2 No, no soy de origen hispano, latino o español Si contestó “No”, pase a la pregunta 32
31. ¿Cuál grupo lo(a) describe mejor?
1 Mexicano, mexicano americano, chicano
2 Puertorriqueño 3 Cubano 4 Otro origen hispano, latino o
español
32. ¿Cuál es su raza? Puede seleccionar una o más categorías.
1 Blanca 2 Negra o afro americana 3 Indígena americana o nativa
de Alaska 4 India asiática 5 China 6 Filipina 7 Japonesa 8 Coreana 9 Vietnamita 10 Otra raza asiática 11 Nativa de Hawai 12 Procedente de Guam o
Chamorro 13 Samoana 14 Otra raza de las islas del
Pacífico
33. ¿Qué tan bien habla usted inglés?
1 Muy bien 2 Bien 3 No bien 4 Nada
34. ¿Habla usted algún otro idioma que no sea inglés en casa?
1 Sí 2 No Si contestó “No”, pase
a la pregunta 36
35. ¿Qué idioma habla en su casa?
1 Español 2 Otro idioma
(FAVOR DE ESPECIFICAR): _______________________ (Favor de usar letra tipo imprenta.)
Appendix C: Spanish: Mail Survey Cover Letters, Mail Questionnaires,
Instructions for Scannable Mail Questionnaire, Telephone Interview Script November 2018
C-10 Centers for Medicare & Medicaid Services Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual
36. ¿Le ayudó alguien a completar esta encuesta?
1 Sí 2 No Si contestó No, vaya
al FINAL.
37. ¿De qué manera le ayudó esa persona? Marque todas las respuestas que correspondan.
1 Me leyó las preguntas 2 Anotó las respuestas que le di 3 Contestó las preguntas por mi 4 Me tradujo las preguntas a mi
idioma 5 Me ayudó de alguna otra
manera: (EXPLIQUE): _______________________ (Favor de usar letra tipo imprenta.)
6 Nadie me ayudó a completar esta encuesta
FINAL
Appendix C: Spanish: Mail Survey Cover Letters, Mail Questionnaires,
November 2018 Instructions for Scannable Mail Questionnaire, Telephone Interview Script
Centers for Medicare & Medicaid Services C-11 Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual
(Alternative Instructions for Scannable Forms)
INSTRUCCIONES PARA LA ENCUESTA
• Responda todas las preguntas llenando por completo el círculo a la izquierda de su
respuesta.
• A veces se le indica que debe saltarse algunas preguntas de esta encuesta. Cuando ocurra,
verá una flecha con una nota que le indica qué pregunta es la siguiente, de esta manera:
Sí
No Si contestó “No”, pase a la pregunta 1
Esta encuesta pregunta acerca de sus experiencias en el centro ambulatorio que se menciona en
la carta de presentación. Para esta encuesta, usamos el término “procedimiento” para
procedimientos de diagnóstico, cirugías u otros procedimientos. Nos referimos al “centro
ambulatorio” como el lugar en donde se realizó su procedimiento.
Por favor, responda las preguntas solo para el/los procedimiento(s) que tuvo en la fecha
que se incluye en la carta de presentación. No incluya ningún otro procedimiento en sus
respuestas.
Appendix C: Spanish: Mail Survey Cover Letters, Mail Questionnaires,
Instructions for Scannable Mail Questionnaire, Telephone Interview Script November 2018
C-12 Centers for Medicare & Medicaid Services Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual
TELEPHONE INTERVIEW SCRIPT
FOR THE OUTPATIENT AND AMBULATORY SURGERY CAHPS SURVEY (OAS
CAHPS®)
GO TO INTRO4 IF THIS IS A FOLLOW-UP CALL TO AN INTERVIEW THAT WAS
STARTED IN A PRECEDING CALL. OTHERWISE GO TO INTRO1.
INTRO1 [Buenos días/Buenas tardes/Buenas noches], ¿puedo hablar con [SAMPLE
MEMBER’S NAME]?
IF ASKED WHO IS CALLING:
Mi nombre es [INTERVIEWER NAME] y estoy llamando de [VENDOR] en
nombre de [FACILITY NAME]. Me gustaría hablar con [SAMPLE MEMBER’S
NAME] sobre una encuesta sobre la atención médica.
1 YES [GO TO INTRO2]
2 NO, NOT AVAILABLE RIGHT NOW [SET CALLBACK]
3 NO [REFUSAL] [GO TO Q_REF SCREEN]
4 MENTALLY/PHYSICALLY INCAPABLE [GO TO Q_INELIGIBLE
SCREEN]
INTRO2 [Buenos días/Buenas tardes/Buenas noches], mi nombre es [INTERVIEWER
NAME] y estoy llamando de parte de [FACILITY NAME]. [FACILITY NAME]
está participando en una encuesta sobre las experiencias de los pacientes que han
tenido una cirugía o un procedimiento ambulatorio. Los resultados se usarán para
ayudar a [FACILITY NAME] a comprender las experiencias de los pacientes en
su centro ambulatorio.
Su participación en esta encuesta es completamente voluntaria y no afectará a
ningún beneficio de atención médica que usted recibe. Toda la información que
proporcione es confidencial y está protegida por la Ley de Privacidad. La
entrevista se puede completar como en 8 minutos. Esta llamada puede ser
escuchada o grabada con propósitos de mejorar la calidad.
[ADDRESS ANY QUESTIONS/CONCERNS THEN CONTINUE.]
NOTE: THE LENGTH OF THE INTERVIEW WILL DEPEND ON WHETHER THE
FACILITY ADDS SUPPLEMENTAL QUESTIONS TO THE SURVEY. IF
Appendix C: Spanish: Mail Survey Cover Letters, Mail Questionnaires,
November 2018 Instructions for Scannable Mail Questionnaire, Telephone Interview Script
Centers for Medicare & Medicaid Services C-13 Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual
SUPPLEMENTAL ITEMS ARE ADDED, INCREASE THE STATED
NUMBER OF MINUTES IN INTRO2 ACCORDINGLY.
INTRO3 La encuesta hace preguntas sobre sus experiencias con [FACILITY NAME]. Para
esta encuesta, usamos el término “procedimiento” para procedimientos de
diagnóstico, cirugías u otros procedimientos. Nos referimos al “centro
ambulatorio” como el lugar en donde se realizó su procedimiento. Por favor,
responda a estas preguntas solo para el procedimiento que se realizó el [DATE]. No
incluya ningún otro procedimiento en sus respuestas.
[ADDRESS ANY QUESTIONS/CONCERNS THEN SELECT RESPONSE OPTION.]
1 BEGIN INTERVIEW [GO TO Q1_INTRO]
2 NO, NOT RIGHT NOW [SET CALLBACK]
3 DID NOT RECEIVE SURGERY/PROCEDURE FROM THIS FACILITY
DURING [MONTH] [GO TO Q_INELIGIBLE SCREEN]
4 NO [REFUSAL] [GO TO Q_REF SCREEN]
INEL ITEMS ARE OPTIONAL AND ASKED ONLY IF NEW TELEPHONE NUMBER
IDENTIFIED.
INEL1 ¿Alguna vez fue usted un paciente en [FACILITY NAME]?
3 YES [GO TO INEL2]
4 NO [GO TO INEL_END]
INEL2 ¿Cuándo fue esto?
NOTE: IF DATE IS WITHIN 2 WEEKS OF SURGERY DATE ON RECORD,
GO TO Q1_INTRO. IF NOT, GO TO INEL_END.
INEL_END Gracias por su tiempo. Parece ser que nos equivocamos. Tenga usted (un buen
día/ una buena tarde).
INTRO4 USED ONLY IF CALLING SAMPLE PATIENT BACK TO COMPLETE A
SURVEY THAT WAS BEGUN IN A PREVIOUS CALL. NOTE THAT THE
PATIENT MUST HAVE ANSWERED AT LEAST ONE QUESTION IN THE
SURVEY IN A PRECEDING CALL.
Appendix C: Spanish: Mail Survey Cover Letters, Mail Questionnaires,
Instructions for Scannable Mail Questionnaire, Telephone Interview Script November 2018
C-14 Centers for Medicare & Medicaid Services Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual
Buenos días/Buenas tardes/Buenas noches. ¿Podría hablar con [SAMPLE
MEMBER’S NAME]?
IF ASKED WHO IS CALLING:
Mi nombre es [INTERVIEWER NAME] y estoy llamando de [VENDOR] en
nombre de [FACILITY NAME]. Me gustaría hablar con [SAMPLE MEMBER’S
NAME] acerca de un estudio sobre la atención médica.
1 YES, SAMPLE PATIENT IS AVAILABLE AND ON PHONE NOW [GO
TO INTRO5]
2 NO, NOT AVAILABLE RIGHT NOW [SET CALLBACK]
3 NO [REFUSAL] [GO TO Q_REF SCREEN]
4 MENTALLY/PHYSICALLY INCAPABLE [GO TO Q_INELIGIBLE
SCREEN]
INTRO5 Buenos días/Buenas tardes/Buenas noches. Mi nombre es [INTERVIEWER
NAME] y estoy llamando de [VENDOR]. Estoy llamando para continuar la
encuesta que comenzamos en una llamada anterior, sobre sus experiencias con
[FACILITY NAME]. Me gustaría continuar con esa encuesta en este momento.
1 CONTINUE WITH INTERVIEW AT FIRST UNANSWERED QUESTION
2 NO, NOT RIGHT NOW [SET CALLBACK]
3 NO [REFUSAL] [GO TO Q_REF SCREEN]
Q1_INTRO Las primeras preguntas son acerca de la preparación para su procedimiento.
Incluya cualquier información que haya recibido antes o en el día del
procedimiento.
Q1. Antes del procedimiento, ¿le dio un doctor o alguien del centro ambulatorio toda
la información que necesitaba acerca de su procedimiento? ¿Diría usted que…
1 Sí, definitivamente,
2 Sí, algo o
3 No?
M MISSING/DK
Appendix C: Spanish: Mail Survey Cover Letters, Mail Questionnaires,
November 2018 Instructions for Scannable Mail Questionnaire, Telephone Interview Script
Centers for Medicare & Medicaid Services C-15 Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual
Q2. Antes del procedimiento, ¿le dio un doctor o alguien del centro ambulatorio
instrucciones fáciles de entender sobre lo que necesitaba para prepararse para su
procedimiento? ¿Diría que…
1 Sí, definitivamente,
2 Sí, algo o
3 No?
M MISSING/DK
Q3 INTRO Las siguientes preguntas se refieren al día de su procedimiento.
Q3. ¿Fue fácil el proceso de registro? ¿Diría que…
1 Sí, definitivamente,
2 Sí, algo o
3 No?
M MISSING/DK
Q4. ¿Estaba limpio el centro ambulatorio? ¿Diría que…
1 Sí, definitivamente,
2 Sí, algo o
3 No?
M MISSING/DK
Q5. ¿Le ayudó el personal administrativo y de recepción del centro ambulatorio tanto
como usted pensaba que debían hacerlo? ¿Diría que…
1 Sí, definitivamente,
2 Sí, algo o
3 No?
M MISSING/DK
Q6. ¿Le trató el personal administrativo y de recepción del centro ambulatorio con
cortesía y respeto? ¿Diría que…
1 Sí, definitivamente,
2 Sí, algo o
3 No?
M MISSING/DK
Appendix C: Spanish: Mail Survey Cover Letters, Mail Questionnaires,
Instructions for Scannable Mail Questionnaire, Telephone Interview Script November 2018
C-16 Centers for Medicare & Medicaid Services Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual
Q7. ¿Le trataron los doctores y enfermeras con cortesía y respeto? ¿Diría que…
1 Sí, definitivamente,
2 Sí, algo o
3 No?
M MISSING/DK
Q8. ¿Se aseguraron los doctores y enfermeras que usted estuviese tan cómodo como
fuera posible? ¿Diría que…
1 Sí, definitivamente,
2 Sí, algo o
3 No?
M MISSING/DK
Q9_INTRO Le recordamos que por favor incluya cualquier información que haya recibido ya
sea antes o en el día del procedimiento.
Q9. ¿Le explicaron los doctores y enfermeras el procedimiento de tal manera que fue
fácil de entender? ¿Diría usted que…
1 Sí, definitivamente,
2 Sí, algo o
3 No?
M MISSING/DK
Q10. La anestesia es algo que le haría sentir sueño o dormir durante el procedimiento.
¿Le dieron anestesia?
1 SÍ
2 NO [GO TO Q13]
M MISSING/DK [GO TO Q13]
Q11. ¿Le explicó el doctor o alguien del centro ambulatorio el proceso de dar anestesia
de tal manera que fue fácil de entender? ¿Diría usted que…
1 Sí, definitivamente,
2 Sí, algo o
3 No?
M MISSING/DK
Appendix C: Spanish: Mail Survey Cover Letters, Mail Questionnaires,
November 2018 Instructions for Scannable Mail Questionnaire, Telephone Interview Script
Centers for Medicare & Medicaid Services C-17 Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual
Q12. ¿Le explicó el doctor o alguien del centro ambulatorio los posibles efectos
secundarios de la anestesia de tal manera que fuera fácil de entender? ¿Diría usted
que…
1 Sí, definitivamente,
2 Sí, algo o
3 No?
M MISSING/DK
Q13. Las instrucciones al ser dado de alta incluyen observar los síntomas después de su
procedimiento, instrucciones sobre los medicamentos y cuidado en el hogar.
Antes de salir del centro ambulatorio, ¿recibió instrucciones por escrito al darle de
alta?
1 SÍ
2 NO
M MISSING/DK
Q14. ¿Le preparó el doctor o alguien del personal del centro ambulatorio sobre qué
esperar durante su recuperación? ¿Diría que…
1 Sí, definitivamente,
2 Sí, algo o
3 No?
M MISSING/DK
Q15. Algunas maneras para controlar el dolor incluyen medicamentos recetados,
medicamentos para el dolor de venta libre o bolsas de hielo. ¿Su doctor o alguien
del centro ambulatorio le dio información sobre qué hacer si tenía dolor como
resultado de su procedimiento? ¿Diría que…
1 Sí, definitivamente,
2 Sí, algo o
3 No?
M MISSING/DK
Appendix C: Spanish: Mail Survey Cover Letters, Mail Questionnaires,
Instructions for Scannable Mail Questionnaire, Telephone Interview Script November 2018
C-18 Centers for Medicare & Medicaid Services Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual
Q16. En algún momento después de salir del centro ambulatorio, ¿tuvo dolor debido al
procedimiento?
1 SÍ
2 NO
M MISSING/DK
Q17. Antes de salir del centro ambulatorio, ¿su doctor o alguien del personal del centro
ambulatorio le dio información sobre qué hacer si tenía náusea o vómitos? ¿Diría
que…
1 Sí, definitivamente,
2 Sí, algo o
3 No?
M MISSING/DK
Q18. En algún momento después de salir del centro ambulatorio, ¿tuvo náusea o
vómitos como resultado del procedimiento o la anestesia?
1 SÍ
2 NO
M MISSING/DK
Q19. Antes de salir del centro ambulatorio, ¿su doctor o alguien del personal del centro
ambulatorio le dio información sobre qué hacer si sangraba como resultado del
procedimiento? ¿Diría que…
1 Sí, definitivamente,
2 Sí, algo o
3 No?
M MISSING/DK
Q20. En algún momento después de salir del centro ambulatorio, ¿tuvo sangrado como
resultado del procedimiento?
1 SÍ
2 NO
M MISSING/DK
Appendix C: Spanish: Mail Survey Cover Letters, Mail Questionnaires,
November 2018 Instructions for Scannable Mail Questionnaire, Telephone Interview Script
Centers for Medicare & Medicaid Services C-19 Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual
Q21. Posibles señales de infección incluyen fiebre, hinchazón, calor, secreción o
enrojecimiento. Antes de salir del centro ambulatorio, ¿su doctor o alguien del
personal del centro ambulatorio le dio información sobre qué hacer si tuviera
señales de infección? ¿Diría que…
1 Sí, definitivamente,
2 Sí, algo o
3 No?
M MISSING/DK
Q22. En algún momento después de salir del centro ambulatorio, ¿tuvo señales de
infección?
1 SÍ
2 NO
M MISSING/DK
Q23_INTRO Las siguientes preguntas se refieren a su experiencia en general.
Q23. Usando un número del 0 al 10, en donde 0 es el peor centro ambulatorio posible y
10 es el mejor centro ambulatorio posible, ¿qué número usaría para calificar éste
centro ambulatorio?
0 PEOR CENTRO AMBULATORIO POSIBLE
1
2
3
4
5
6
7
8
9
10 MEJOR CENTRO AMBULATORIO POSIBLE
M MISSING/DK
Appendix C: Spanish: Mail Survey Cover Letters, Mail Questionnaires,
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C-20 Centers for Medicare & Medicaid Services Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual
Q24. ¿Recomendaría este centro ambulatorio a sus amistades y familia? ¿Diría usted
que…
1 Definitivamente no,
2 Probablemente no,
3 Probablemente sí o
4 Definitivamente sí?
M MISSING/DK
Q25. En general, ¿cómo calificaría su salud general? ¿Diría que es…
1 Excelente,
2 Muy buena,
3 Buena,
4 Regular o
5 Mala?
M MISSING/DK
Q26. En general, ¿cómo calificaría su salud mental o emocional? ¿Diría que es…
1 Excelente,
2 Muy buena,
3 Buena,
4 Regular o
5 Mala?
M MISSING/DK
Q27. ¿Qué edad tiene usted?
1 18 A 24 AÑOS
2 25 A 34 AÑOS
3 35 A 44 AÑOS
4 45 A 54 AÑOS
5 55 A 64 AÑOS
6 65 A 74 AÑOS
7 75 A 79 AÑOS
8 80 A 84 AÑOS
9 85 AÑOS O MÁS
M MISSING/DK
Appendix C: Spanish: Mail Survey Cover Letters, Mail Questionnaires,
November 2018 Instructions for Scannable Mail Questionnaire, Telephone Interview Script
Centers for Medicare & Medicaid Services C-21 Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual
Q28. ¿Es usted hombre o mujer?
1 HOMBRE
2 MUJER
M MISSING/DK
Q29. ¿Cuál es el nivel o año escolar más avanzado que usted ha completado? ¿Diría
que…
1 8 años de escuela o menos,
2 9–12 años de escuela, pero sin graduarse,
3 Graduado(a) de escuela secundaria, diploma de escuela secundaria,
preparatoria o su equivalente o 'GED',
4 Algunos cursos universidarios o un título universitario de un programa de 2
años,
5 Título universitario de 4 años o
6 Título universitario de más de 4 años?
M MISSING/DK
Q30. ¿Es usted de origen hispano, latino o español?
1 SÍ,
2 NO [GO TO Q32]
M MISSING/DK [GO TO Q32]
Q31. ¿Cuál grupo lo(a) describe mejor? ¿Diría que usted es…
1 Mexicano(a), mexicano(a) americano(a), chicano(a),
2 Puertorriqueño(a),
3 Cubano(a) o
4 De otro origen hispano, latino o español?
M MISSING/DK
Appendix C: Spanish: Mail Survey Cover Letters, Mail Questionnaires,
Instructions for Scannable Mail Questionnaire, Telephone Interview Script November 2018
C-22 Centers for Medicare & Medicaid Services Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual
Q32. ¿Cuál es su raza? Puede seleccionar una o más categorías. ¿Es usted…
1 Blanco(a),
2 Negro(a) o africano(a) americano(a),
3 Indígeno(a) americano(a) o nativo(a) de Alaska,
4 Asiático(a) o
5 Nativo(a) de Hawai o de otra isla del Pacífico?
6 NONE OF THE ABOVE
M MISSING/DK
PROGRAMMER INSTRUCTIONS: IF WHITE ONLY, BLACK/AFRICAN AMERICAN
ONLY, OR AMERICAN INDIAN/ALASKA NATIVE ONLY, OR ANY COMBINATION OF
THESE THREE OPTIONS, NONE OF THE ABOVE OR MISSING/DK, GO TO Q33.
IF ASIAN ONLY, GO TO Q32A. IF WHITE, BLACK/AFRICAN AMERICAN, AND/OR
AMERICAN INDIAN/ALASKA NATIVE AND ASIAN ARE CHOSEN, GO TO Q32A. IF
NATIVE HAWAIIAN/PACIFIC ISLANDER IS ALSO CHOSEN, SEE INSTRUCTION
AFTER Q32A.
IF NATIVE HAWAIIAN/PACIFIC ISLANDER ONLY, GO TO Q32B. IF WHITE,
BLACK/AFRICAN AMERICAN, AND/OR AMERICAN INDIAN/ALASKA NATIVE AND
NATIVE HAWAIIAN/PACIFIC ISLANDER ARE CHOSEN, GO TO Q32B.
Q32a ¿Cuál de los siguientes grupos lo(a) describe mejor? Puede seleccionar una o más
categorías. ¿Es usted…
1 Indio(a) asiático(a),
2 Chino(a),
3 Filipino(a),
4 Japones(a),
5 Coreano(a),
6 Vietnamita o
7 De otro grupo asiático?
8 NONE OF THE ABOVE
M MISSING/DK
IF NATIVE HAWAIIAN/PACIFIC ISLANDER WAS ALSO CHOSEN IN Q32, GO TO Q32B.
ELSE, GO TO Q33.
Appendix C: Spanish: Mail Survey Cover Letters, Mail Questionnaires,
November 2018 Instructions for Scannable Mail Questionnaire, Telephone Interview Script
Centers for Medicare & Medicaid Services C-23 Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual
Q32b ¿ Cuál de los siguientes grupos lo(a) describe mejor? Puede seleccionar una o más
categorías. ¿Es usted…
1 Nativo(a) de Hawai,
2 Procedente de Guam o Chamorro,
3 Samoano(a) o
4 De otra isla del Pacífico?
5 NONE OF THE ABOVE
M MISSING/DK
Q33. ¿Qué tan bien habla usted inglés? ¿Diría que…
1 Muy bien,
2 Bien,
3 No bien o
4 Nada?
M MISSING/DK
Q34. ¿Habla usted algún otro idioma que no sea inglés en casa? ¿Diría que…
1 Sí, hablo un idioma que no sea inglés, o
2 No.Yo hablo inglés en casa? [GO TO Q_END]
M MISSING/DK [GO TO Q_END]
Q35. ¿Qué idioma habla en su casa?
1 ESPAÑOL [GO TO Q_END]
2 OTRO IDIOMA [GO TO Q35a]
M MISSING/DK [GO TO Q_END]
Appendix C: Spanish: Mail Survey Cover Letters, Mail Questionnaires,
Instructions for Scannable Mail Questionnaire, Telephone Interview Script November 2018
C-24 Centers for Medicare & Medicaid Services Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual
Q35a. ¿Qué idioma habla en su casa? [ENTER RESPONSE BELOW]
{ALLOW UP TO 50 CHARACTERS}
M MISSING/DK
Q_END Estas son todas las preguntas que tengo para usted. Muchas gracias por su tiempo.
Le deseo que tenga (un buen día/una buena tarde/una buena noche).
INELIGIBLE SCREEN:
Q_INELIG Muchas gracias por su tiempo. Le deseo que tenga (un buen día/una buena
tarde/una buena noche).
REFUSAL SCREEN:
Q_REF Muchas gracias por su tiempo. Le deseo que tenga (un buen día/una buena
tarde/una buena noche).
Centers for Medicare & Medicaid Services Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual
APPENDIX D:
CHINESE: MAIL SURVEY COVER LETTERS,
MAIL QUESTIONNAIRES, INSTRUCTIONS FOR SCANNABLE MAIL QUESTIONNAIRE
Appendix D: Chinese: Mail Survey Cover Letters, Mail Questionnaires, Instructions for Scannable Mail Questionnaire November 2018
Centers for Medicare & Medicaid Services Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual
This page intentionally left blank.
Centers for Medicare & Medicaid Services Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual
Chinese (Simplified)
Appendix D: Chinese: Mail Survey Cover Letters, Mail Questionnaires, Instructions for Scannable Mail Questionnaire November 2018
Centers for Medicare & Medicaid Services Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual
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Centers for Medicare & Medicaid Services D-1 Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual
SAMPLE COVER LETTER FOR FIRST QUESTIONNAIRE MAILING
Outpatient and Ambulatory Surgery CAHPS Survey
To be Printed on Ambulatory Surgery Center or Hospital Outpatient Department or Vendor
Letterhead
«FirstName» «LastName»
«Address1» «Address2»
«City_Name», «State_Code» «Zip_Zip4»
尊敬的 «FirstName» «LastName»:
[FACILITY]想了解病人在我们的医院得到的医疗服务的质量。 [VENDOR],一家独立的
研究机构,帮助我们做这个问卷调查。 我们的记录表明您在 [FACILITY] 做过手术或接
受过治疗。 这个调查的结果,将帮助我们更好地理解病人在我们医院的经历。
随附的调查问卷,将询问在[DATE OF SURGERY]您对您的门诊手术或医疗程序的意见。
我们请您花几分钟时间填写此调查问卷,并用随附的邮资已付的信封将其寄回给我们。
当您回答本调查问卷中的问题时,仅考虑您 [DATE OF SURGERY] 在 [FACILITY] 的经历。
不要涉及您在我们医院或其他医院做其他手术或医疗程序的经历。
您在此提供的所有信息均将保密,并受到《隐私法》(Privacy Act) 保护。您对问卷的回答
将与其他调查研究参与者的回答一起汇总;当分析数据时,您的姓名和身份识别信息不会
与您的回答关联在一起。对[FACILITY NAME]和其他医院调查的结果将于2017年在网上
公布,网址是https://www.medicare.gov/ 。这些调查结果将帮助人们在选择门诊手术及非
住院手术的医院时,做出知情的决定。 您的参与纯属自愿,不会影响您的任何医疗福利。
如果您对本调查研究有任何疑问,请拨打免费服务电话1-800-XXX-XXXX致电NAME。
如果您在阅读问卷或回答问题方面需要帮助,请让家人或朋友帮助您。感谢您的参与。
祝好!
NAME
Title
Appendix D: Chinese: Mail Survey Cover Letters, Mail Questionnaires, Instructions for Scannable Mail Questionnaire November 2018
D-2 Centers for Medicare & Medicaid Services Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual
附件 [PRINT UNIQUE SAMPLE ID NUMBER HERE]
SAMPLE COVER LETTER FOR SECOND QUESTIONNAIRE MAILING TO MAIL
SURVEY NONRESPONDENTS
Outpatient and Ambulatory Surgery CAHPS Survey
To be Printed on Ambulatory Surgery Center or Hospital Outpatient Department or Vendor
Letterhead
«FirstName» «LastName»
«Address1» «Address2»
«City_Name», «State_Code» «Zip_Zip4»
尊敬的 «FirstName» «LastName»:
最近,我们给您寄了一封信,请您帮助完成一项问卷调查,此问卷询问您在[FACILITY]
接受门诊手术或医疗程序时的该医院的服务质量。迄今为止,我们尚未收到您填妥的调查
问卷。如果您已寄回调查问卷,我们不胜感激。 如果您尚未填写该调查问卷,请现在就
花几分钟时间填写。然后用随附的邮资已付的信封将其寄回给我们。
当您回答本调查问卷中的问题时,仅考虑您 [DATE OF SURGERY] 在 [FACILITY] 的经
历。不要涉及您在我们医院或其他医院,做其他手术或医疗程序的经历。
您在此提供的所有信息均将保密,并受到《隐私法》(Privacy Act) 保护。 您对问卷的回
答将与其他调查研究参与者的回答一起汇总;当分析数据时,您的姓名和身份识别信息不
会与您的回答关联在一起。您的参与纯属自愿,不会影响您的任何医疗福利。
如果您对该调查研究有任何疑问,请拨打免费服务电话 1-800-XXX-XXXX 致电 NAME。
如果您在阅读问卷或回答问题方面需要帮助,请让家人或朋友帮助您。感谢您的参与。
祝好!
NAME
Title
附件 [PRINT UNIQUE SAMPLE ID NUMBER HERE]
Consumer Assessment of Healthcare Providers and Systems Outpatient and
Ambulatory Surgery Survey (OAS CAHPS
®)
A PATIENT EXPERIENCE OF CARE SURVEY ABOUT OUTPATIENT AND AMBULATORY SURGERIES
AND PROCEDURES
消费者评估医疗服务机构和系统
门诊手术及非住院手术问卷调查
(OAS CAHPS®)
关于门诊手术及其他非住院手术和医疗程序中病人经历的问卷调查
根据 1995 年减少纸张使用法案,如果问卷上没有有效的 OMB 控制数码,任何人都无须
回答问卷上的任何问题。这项问卷持有有效的 OMB控制数码:0938-1240。完成这份问
卷,估计需要八分钟。这包括阅读问卷的说明,查找现有的资料,收集和整理所需的信
息,以及完成和审阅所提供的信息。如果您对完成这份问卷所估计的时间或对如何改进
这项问卷有任何看法,请写信给: CMS, 7500 Security Boulevard, Attn: PRA Reports
Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.
Appendix D: Chinese: Mail Survey Cover Letters, Mail Questionnaires, Instructions for Scannable Mail Questionnaire November 2018
D-4 Centers for Medicare & Medicaid Services Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual
调查问卷说明
请回答所有的问题。作答时,请在问题左
边的方格内打勾。
有时问卷会要求您跳过一些问题。这种情
况发生时,您会看到箭头并注明下一个该
回答的问题,如:
是
否 如回答否,请跳到#1
本问卷调查是关于您在我们这封信所特指
的医院的经历。在本问卷调查中,“医疗
程序”这个词指的是诊断,外科手术及其
他医疗过程。“医疗处所”这个词指的是进
行您的医疗程序的地方。
请针对印在信函上所列的的日子那天您
所经历的所有医疗程序来回答这些问题。
在您回答问题时,请不要考虑或涉及其
他医疗程序。
I.在您的医疗程序之前
最初的几个问题是关于为进行您的医疗程
序所做的准备的。这包括在医疗程序之
前和程序当天,您所收到的任何有关信
息。
1. 在您的医疗程序之前,这个医疗处
所的医生或者其他人是否给您关于
这个程序您所需要的所有信息?
1 是的,十分确定
2 是的,在某种程度上
3 否
2. 在您的医疗程序之前,这个医疗处
所的医生或者其他人是否给您让您
容易理解的关于怎样准备您的医疗
程序的医嘱?
1 是的,十分确定
2 是的,在某种程度上
3 否
II.关于这个医疗处所及其医护人员
下面的问题,是有关您医疗程序当天的经
历。
3. 办理看病登记签到手续的过程是否
顺利流畅?
1 是的,十分确定
2 是的,在某种程度上
3 否
4. 这个医疗处所很干净吗?
1 是的,十分确定
2 是的,在某种程度上
3 否
Appendix D: Chinese: Mail Survey Cover Letters, November 2018 Mail Questionnaires, Instructions for Scannable Mail Questionnaire
Centers for Medicare & Medicaid Services D-5 Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual
5. 这个医疗处所的工作人员和前台接
待人员是否像您想象的那样很有帮
助?
1 是的,十分确定
2 是的,在某种程度上
3 否
6. 这个医疗处所的工作人员和前台接
待人员是否常以礼貌和尊重对待您?
1 是的,十分确定
2 是的,在某种程度上
3 否
7. 医生和护士是否常以礼貌和尊重对
待您?
1 是的,十分确定
2 是的,在某种程度上
3 否
8. 医生和护士是否尽可能让您感到舒
适?
1 是的,十分确定
2 是的,在某种程度上
3 否
III.关于您的医疗程序的沟通交流
注意:请包括您在该医疗程序之前和当
天所收到信息。
9. 医生和护士是否用您听得懂的方式
来向您解释医疗程序?
1 是的,十分确定
2 是的,在某种程度上
3 否
10. 麻醉会让您在的医疗程序中感到困
倦或入睡。是否给您用了麻醉?
1 是
2 否 如回答否,请跳到#13
11. 医生或这个医疗处所的其他人是否
用您听得懂的方式来向您解释麻醉?
1 是的,十分确定
2 是的,在某种程度上
3 否
12. 医生或医疗处所的其他人是否用您
用您听得懂的方式来向您解释麻醉
可能产生的副作用?
1 是的,十分确定
2 是的,在某种程度上
3 否
13. 出院医嘱包括:医疗程序之后,有
可能出现的需要注意的症状的说明,
服药说明, 在家调养须知等等。在
您离开医疗处所之前,您是否得到
了书面的出院医嘱?
1 是
2 否
Appendix D: Chinese: Mail Survey Cover Letters, Mail Questionnaires, Instructions for Scannable Mail Questionnaire November 2018
D-6 Centers for Medicare & Medicaid Services Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual
IV.您的术后恢复
14. 您的医生或这个医疗处所的其他人
是否向您解释您的恢复过程是怎样
的?
1 是的,十分确定
2 是的,在某种程度上
3 否
15. 止痛的方法有处方药、非处方止疼
药、或者冰袋等。您的医生或这个
医疗处所的其他人是否给您医嘱,
告诉您如果您因医疗程序而产生疼
痛的话应该怎么办?
1 是的,十分确定
2 是的,在某种程度上
3 否
16. 从这个医疗处所离开后的任何时候,
您是否因为您的医疗程序而感到疼
痛?
1 是 2 否
17. 在您离开这个医疗处所之前,您的
医生或这个医疗处所的其他人是否
给您医嘱,告诉您如果您恶心或是
呕吐该怎么办?
1 是的,十分确定
2 是的,在某种程度上
3 否
18. 从这个医疗处所离开后的任何时候,
您是否因为您的医疗程序而感到恶
心或者呕吐?
1 是 2 否
19. 在您离开这个医疗处所之前,您的
医生或这个医疗处所的其他人是否
给您医嘱,告诉您如果您因医疗程
序而出血的话应该怎么办?
1 是的,十分确定
2 是的,在某种程度上
3 否
20. 从这个医疗处所离开以后的任何时
候,您是否因为您的医疗程序而出
血?
1 是 2 否
21. 发生感染的可能迹象包括发烧、肿
胀、发热、流脓流液、发红等。在
您离开这个医疗处所之前,您的医
生或这个医疗处所的其他人是否给
您医嘱,告诉您如果出现感染迹象
时应该怎么办?
1 是的,十分确定
2 是的,在某种程度上
3 否
22. 从这个医疗处所离开后的任何时候,
您是否有过任何感染的迹象?
1 是 2 否
Appendix D: Chinese: Mail Survey Cover Letters, November 2018 Mail Questionnaires, Instructions for Scannable Mail Questionnaire
Centers for Medicare & Medicaid Services D-7 Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual
V. 您的总体经历
23. 请用下列 0 到 10 中任何一个数字评
价。 0 是最差医疗处所,10 是最佳
医疗处所。您认为那一个数字最能
代表您对此医疗处所的评价?
0 最差医疗处所
1
2
3
4
5
6
7
8
9
10 最佳医疗处所
24. 您是否会向您的朋友和家人推荐这
个医疗处所?
1 绝不会
2 也许不会
3 可能会
4 绝对会
VI. 关于您
25. 总体而言,您如何评价您的整体健
康状况?
1 极好
2 很好
3 好
4 一般
5 差
26. 总体而言,您如何评价您的整体精
神或情绪健康状况?
1 极好
2 很好
3 好
4 一般
5 差
Appendix D: Chinese: Mail Survey Cover Letters, Mail Questionnaires, Instructions for Scannable Mail Questionnaire November 2018
D-8 Centers for Medicare & Medicaid Services Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual
27. 您的年龄多大?
1 18 至 24 岁
2 25 至 34 岁
3 35 至 44 岁
4 45 至 54 岁
5 55 至 64 岁
6 65 至 74 岁
7 75 至 79 岁
8 80 至 84 岁
9 85 岁以上
28. 您是男性还是女性?
1 男性
2 女性
29. 您已完成的最高级别或水平的年级
或院校是什么?
1 8 年級或更低
2 读过高中﹐但未毕业
3 高中毕业或有同等学业文凭
(GED)
4 读过一些大学或二年制学位 5 四年制大学毕业 6 四年制大学毕业以上学历
30. 您是西班牙裔、西语族裔、或拉丁
裔吗?
1 是的,是西语族裔,拉丁裔,
西班牙裔 2 否, 不是西语族裔,拉丁裔,
西班牙裔 如回答否,请跳到
#32
31. 以下哪个族裔最适合您?
1 墨西哥裔、墨西哥裔美國人、
美國出生的墨西哥裔人 2 波多黎各裔 3 古巴人 4 其他西班牙人、西裔、拉丁裔
32. 您属于哪一种族?请选一个或一个
以上的回答。
1 白人 2 黑人或非裔美国人 3 美洲印第安人或阿拉斯加原住
民 4 亚洲人
5 华人
6 菲律宾人
7 日本人
8 韩国人
9 越南人
10 其他亚裔
11 夏威夷原住民
12 关岛或查莫罗人
13 萨摩亚人
14 其他太平洋岛国人
Appendix D: Chinese: Mail Survey Cover Letters, November 2018 Mail Questionnaires, Instructions for Scannable Mail Questionnaire
Centers for Medicare & Medicaid Services D-9 Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual
33. 您英文说得怎么样?
1 非常好
2 还好
3 不好
4 不会
34. 除了英文,您在家是否还说其他语
言?
1 是
2 否 如回答否,请跳到#36
35. 在家还说什么其他语言?
1 西班牙语 2 其他语言
(请说明):
_______________________
(请工整地填写)
36. 是否有人帮助您填写本调查问卷?
1 是
2 否 如果否, 跳到“问卷完”
37. 那人是如何帮助您的?勾选所有适
用项。
1 为我读问题 2 写下我给出的答案
3 替我回答问题
4 将问题译成我的语言
5 以其他方式帮助:
(解释一下):
_______________________
(请用正楷填写) 6 没人帮助我填写本调查问卷
问卷完
Appendix D: Chinese: Mail Survey Cover Letters, Mail Questionnaires, Instructions for Scannable Mail Questionnaire November 2018
D-10 Centers for Medicare & Medicaid Services Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual
(Alternative Instructions for Scannable Forms)
(可供扫描的表格填写说明)
调查问卷说明
• 请用完全涂黑答案左侧的圆圈的方式,来回答所有问题。
• 有时会让您跳过某些问题。当出现这种情况时,您会看到一个箭头和一个说明,告
诉您下一步回答什么问题,像这样
是
否 如回答否,请跳到问题#1
本问卷调查是关于您在我们这封信所特指的医院的经历。在本问卷调查中,“医疗程序”这
个词指的是诊断,外科手术及其他医疗过程。“医疗处所”这个词指的是进行您的医疗程序
的地方。
请针对印在信函上所列的的日子那天您所经历的所有医疗程序来回答这些问题。在您回
答问题时,请不要考虑或涉及其他医疗程序。
Appendix D: Chinese: Mail Survey Cover Letters, November 2018 Mail Questionnaires, Instructions for Scannable Mail Questionnaire
Centers for Medicare & Medicaid Services D-11 Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual
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Appendix D: Chinese: Mail Survey Cover Letters, Mail Questionnaires, Instructions for Scannable Mail Questionnaire November 2018
D-12 Centers for Medicare & Medicaid Services Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual
Chinese (Traditional)
Centers for Medicare & Medicaid Services D-13 Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual
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Appendix D: Chinese: Mail Survey Cover Letters, Mail Questionnaires, Instructions for Scannable Mail Questionnaire November 2018
D-14 Centers for Medicare & Medicaid Services Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual
SAMPLE COVER LETTER FOR FIRST QUESTIONNAIRE MAILING
Outpatient and Ambulatory Surgery CAHPS Survey
To be Printed on Ambulatory Surgery Center or Hospital Outpatient Department or Vendor
Letterhead
«FirstName» «LastName»
«Address1» «Address2»
«City_Name», «State_Code» «Zip_Zip4»
尊敬的 «FirstName» «LastName»:
[FACILITY]想瞭解病人在我們的醫院得到的醫療服務的質量。 [VENDOR],一家獨立的
研究機構,幫助我們做這個問卷調查。 我們的記錄表明您在 [FACILITY] 做過手術或接
受過治療。 這個調查的結果,將幫助我們更好地理解病人在我們醫院的經歷。
隨附的調查問卷,將詢問在[DATE OF SURGERY]您對您的門診手術或醫療程序的意見。
我們請您花幾分鐘時間填寫此調查問卷,並用隨附的郵資已付的信封將其寄回給我們。
當您回答本調查問卷中的問題時,僅考慮您 [DATE OF SURGERY] 在 [FACILITY] 的經歷。
不要涉及您在我們醫院或其他醫院做其他手術或醫療程序的經歷。
您在此提供的所有資訊均將保密,並受到《隱私法》(Privacy Act) 保護。您對問卷的回答
將與其他調查研究參與者的回答一起匯總;當分析資料時,您的姓名和身份識別資訊不會
與您的回答關聯在一起。對[FACILITY NAME]和其他醫院調查的結果將於2017年在網上
公佈,網址是https://www.medicare.gov/ 。這些調查結果將幫助人們在選擇門診手術及非
住院手術的醫院時,做出知情的決定。 您的參與純屬自願,不會影響您的任何醫療福利。
如果您對本調查研究有任何疑問,請撥打免費服務電話1-800-XXX-XXXX致電NAME。
如果您在閱讀問卷或回答問題方面需要幫助,請讓家人或朋友幫助您。感謝您的參與。
祝好!
NAME
Title
附件 [PRINT UNIQUE SAMPLE ID NUMBER HERE]
Appendix D: Chinese: Mail Survey Cover Letters, November 2018 Mail Questionnaires, Instructions for Scannable Mail Questionnaire
Centers for Medicare & Medicaid Services D-15 Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual
SAMPLE COVER LETTER FOR SECOND QUESTIONNAIRE MAILING TO MAIL
SURVEY NONRESPONDENTS
Outpatient and Ambulatory Surgery CAHPS Survey
To be Printed on Ambulatory Surgery Center or Hospital Outpatient Department or Vendor
Letterhead
«FirstName» «LastName»
«Address1» «Address2»
«City_Name», «State_Code» «Zip_Zip4»
尊敬的 «FirstName» «LastName»:
最近,我們給您寄了一封信,請您幫助完成一項問卷調查,此問卷詢問您在[FACILITY]
接受門診手術或醫療程序時的該醫院的服務質量。迄今為止,我們尚未收到您填妥的調查
問卷。如果您已寄回調查問卷,我們不勝感激。 如果您尚未填寫該調查問卷,請現在就
花幾分鐘時間填寫。然後用隨附的郵資已付的信封將其寄回給我們。
當您回答本調查問卷中的問題時,僅考慮您 [DATE OF SURGERY] 在 [FACILITY] 的經歷。
不要涉及您在我們醫院或其他醫院,做其他手術或醫療程序的經歷。
您在此提供的所有資訊均將保密,並受到《隱私法》(Privacy Act) 保護。 您對問卷的回
答將與其他調查研究參與者的回答一起匯總;當分析資料時,您的姓名和身份識別資訊不
會與您的回答關聯在一起。您的參與純屬自願,不會影響您的任何醫療福利。
如果您對該調查研究有任何疑問,請撥打免費服務電話1-800-XXX-XXXX致電NAME。
如果您在閱讀問卷或回答問題方面需要幫助,請讓家人或朋友幫助您。感謝您的參與。
祝好!
NAME
Title
附件 [PRINT UNIQUE SAMPLE ID NUMBER HERE]
Consumer Assessment of Healthcare Providers and Systems Outpatient and
Ambulatory Surgery Survey (OAS CAHPS
®)
A PATIENT EXPERIENCE OF CARE SURVEY ABOUT OUTPATIENT AND AMBULATORY SURGERIES
AND PROCEDURES
消費者评估醫療服务機構和系統
門診手術及非住院手術問卷調查
(OAS CAHPS®)
關於門诊、門診手术及其他非住院手術和醫療程序中病人經歷的問卷調查
根據 1995年減少紙張使用法案,如果問卷上沒有有效的 OMB控制數碼,任何人都無須回
答問卷上的任何問題。這項問卷持有有效的 OMB控制數碼:0938-1240。完成這份問卷,
估計需要八分鐘。這包括閱讀問卷的說明,查找現有的資料,收集和整理所需的資訊,以
及完成和審閱所提供的資訊。如果您對完成這份問卷所估計的時間或對如何改進這項問卷
有任何看法,請寫信給: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer,
Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.
Appendix D: Chinese: Mail Survey Cover Letters, November 2018 Mail Questionnaires, Instructions for Scannable Mail Questionnaire
Centers for Medicare & Medicaid Services D-17 Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual
调查问卷说明
請回答所有的問題。作答時,請在問題左
邊的方格內打勾。
有時問卷會要求您跳過一些問題。這種情
況發生時,您會看到箭頭並注明下一個該
回答的問題,如:
是
否 如回答否,請跳到#1
本問卷調查是關於您在我們這封信所特指
的醫院的經歷。在本問卷調查中,“醫療
程序”這個詞指的是診斷,外科手術及其
他醫療過程。“醫療處所”這個詞指的是進
行您的醫療程序的地方。
請針對印在信函上所列的的日子那天您
所經歷的所有醫療程序來回答這些問題。
在您回答問題時,請不要考慮或涉及其
他醫療程序。
I.在您的醫療程序之前
最初的几个问题是关于为進行您的醫療程
序所做的准备的。这包括在医疗程序之前
和程序当天,您所收到的任何有關信息。
1. 在您的醫療程序之前,這個醫療處
所的醫生或者其他人是否給您關於
這個程式您所需要的所有資訊?
1 是的,十分確定
2 是的,在某種程度上
3 否
2. 在您的醫療程序之前,這個醫療處
所的醫生或者其他人是否給您讓您
容易理解的關於怎樣準備您的醫療
程序的醫囑?
1 是的,十分確定
2 是的,在某種程度上
3 否
II.关于这個醫療处所及其醫護人員
下面的问题,是有关您医疗程序當天的經
歷。
3. 辦理看病登記簽到手續的過程是否
順利流暢?
1 是的,十分確定
2 是的,在某種程度上
3 否
4. 這個醫療處所很乾淨嗎?
1 是的,十分確定
2 是的,在某種程度上
3 否
5. 這個醫療處所的工作人員和前臺接
待人員是否像您想像的那樣很有幫
助?
1 是的,十分確定
2 是的,在某種程度上
3 否
Appendix D: Chinese: Mail Survey Cover Letters, Mail Questionnaires, Instructions for Scannable Mail Questionnaire November 2018
D-18 Centers for Medicare & Medicaid Services Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual
6. 這個醫療處所的工作人員和前臺接
待人員是否常以禮貌和尊重對待您?
1 是的,十分確定
2 是的,在某種程度上
3 否
7. 醫生和護士是否常以禮貌和尊重對
待您?
1 是的,十分確定
2 是的,在某種程度上
3 否
8. 醫生和護士是否盡可能讓您感到舒
適?
1 是的,十分確定
2 是的,在某種程度上
3 否
III.關於您的醫療程序的溝通交流
注意:請包括您在該醫療程序之前和當
天所收到資訊。
9. 醫生和護士是否用您聽得懂的方式
來向您解釋醫療程序?
1 是的,十分確定
2 是的,在某種程度上
3 否
10. 麻醉會讓您在的醫療程序中感到困
倦或入睡。是否給您用了麻醉?
1 是
2 否 如回答否,請跳到#13
11. 醫生或這個醫療處所的其他人是否
用您聽得懂的方式來向您解釋麻醉?
1 是的,十分確定
2 是的,在某種程度上
3 否
12. 醫生或醫療處所的其他人是否用您
聽得懂的方式來向您解釋麻醉可能
產生的副作用?
1 是的,十分確定
2 是的,在某種程度上
3 否
13. 出院醫囑包括:醫療程序之後,有
可能出現的需要注意的症狀的說明,
服藥說明, 在家調養須知等等。在
您離開醫療處所之前,您是否得到
了書面的出院醫囑?
1 是
2 否
Appendix D: Chinese: Mail Survey Cover Letters, November 2018 Mail Questionnaires, Instructions for Scannable Mail Questionnaire
Centers for Medicare & Medicaid Services D-19 Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual
IV.您的術後恢復
14. 您的醫生或這個醫療處所的其他人
是否向您解釋您的恢復過程是怎樣
的?
1 是的,十分確定
2 是的,在某種程度上
3 否
15. 止痛的方法有處方藥、非處方止疼
藥、或者冰袋等。您的醫生或這個
醫療處所的其他人是否給您醫囑,
告訴您如果您因醫療程序而產生疼
痛的話應該怎麼辦?
1 是的,十分確定
2 是的,在某種程度上
3 否
16. 從這個醫療處所離開後的任何時候,
您是否因為您的醫療程序而感到疼
痛?
1 是
2 否
17. 在您離開這個醫療處所之前,您的
醫生或這個醫療處所的其他人是否
給您醫囑,告訴您如果您噁心或是
嘔吐該怎麼辦?
1 是的,十分確定
2 是的,在某種程度上
3 否
18. 從這個醫療處所離開後的任何時候,
您是否因為您的醫療程序而感到噁
心或者嘔吐?
1 是
2 否
19. 在您離開這個醫療處所之前,您的
醫生或這個醫療處所的其他人是否
給您醫囑,告訴您如果您因醫療程
序而出血的話應該怎麼辦?
1 是的,十分確定
2 是的,在某種程度上
3 否
20. 從這個醫療處所離開後的任何時候,
您是否因為您的醫療程序而出血?
1 是
2 否
21. 發生感染的可能跡象包括發燒、腫
脹、發熱、流膿流液、發紅等。在
您離開這個醫療處所之前,您的醫
生或這個醫療處所的其他人是否給
您醫囑,告訴您如果出現感染跡象
時應該怎麼辦?
1 是的,十分確定
2 是的,在某種程度上
3 否
22. 從這個醫療處所離開後的任何時候,
您是否有過任何感染的跡象?
1 是
2 否
Appendix D: Chinese: Mail Survey Cover Letters, Mail Questionnaires, Instructions for Scannable Mail Questionnaire November 2018
D-20 Centers for Medicare & Medicaid Services Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual
V. 您的總體經歷
23. 請用下列 0 到 10 中任何一個數字評
價。 0 是最差醫療處所,10 是最佳
醫療處所。您認為那一個數字最能
代表您對此醫療處所的評價?
0 最差醫療處所
1
2
3
4
5
6
7
8
9
10 最佳醫療處所
24. 您是否會向您的朋友和家人推薦這
個醫療處所?
1 絕不會
2 也許不會
3 可能會 4 絕對會
VI. 關於您
25. 總體而言,您如何評價您的整體健
康狀況?
1 極好
2 很好
3 好
4 一般
5 差
26. 總體而言,您如何評價您的整體精
神或情緒健康狀況?
1 極好
2 很好
3 好
4 一般
5 差
27. 您的年齡多大?
1 18 至 24 歲
2 25 至 34 歲
3 35 至 44 歲
4 45 至 54 歲
5 55 至 64 歲
6 65 至 74 歲
7 75 至 79 歲
8 80 至 84 歲
9 85 歲以上
28. 您是男性還是女性?
1 男性
2 女性
Appendix D: Chinese: Mail Survey Cover Letters, November 2018 Mail Questionnaires, Instructions for Scannable Mail Questionnaire
Centers for Medicare & Medicaid Services D-21 Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual
29. 您已完成的最高級別或水準的年級
或院校是什麼?
1 8 年級或更低
2 讀過高中﹐但未畢業
3 高中畢業或有同等學業文憑
(GED)
4 讀過一些大學或二年制學位
5 四年制大學畢業
6 四年制大學畢業以上學歷
30. 您是西班牙裔、西語族裔、或拉丁
裔嗎?
1 是的,是西語族裔,拉丁裔,
西班牙裔 2 否, 不是西語族裔,拉丁裔,
西班牙裔 如回答否,請跳到#32
31. 以下哪個族裔最適合您?
1 墨西哥裔、墨西哥裔美國人、
美國出生的墨西哥裔人 2 波多黎各裔 3 古巴人 4 其他西班牙人、西裔、拉丁裔
32. 您屬於哪一種族?請選一個或一個
以上的回答。
1 白人 2 黑人或非裔美國人 3 美洲印第安人或阿拉斯加原住
民 4 亞洲人 5 華人 6 菲律賓人
7 日本人
8 韓國人
9 越南人
10 其他亞裔
11 夏威夷原住民
12 關島或查莫羅人
13 薩摩亞人
14 其他太平洋島國人
33. 您英文說得怎麼樣?
1 非常好
2 還好
3 不好
4 不會
34. 除了英文,您在家是否還說其他語
言?
1 是 2 否 如回答否,請跳到#36
Appendix D: Chinese: Mail Survey Cover Letters, Mail Questionnaires, Instructions for Scannable Mail Questionnaire November 2018
D-22 Centers for Medicare & Medicaid Services Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual
35. 在家還說什麼語言?
1 西班牙語 2 其他語言
(請說明):
_______________________
(請工整地填寫)
36. 是否有人幫助您填寫本調查問卷?
1 是
2 否 如果否, 跳到“問卷完”
37. 那人是如何幫助您的?勾選所有適
用項。
1 為我讀問題 2 寫下我給出的答案 3 替我回答問題
4 將問題譯成我的語言
5 以其他方式説明:
(解釋一下):
_______________________
(請用正楷填寫) 6 沒人幫助我填寫本調查問卷
問卷完
Centers for Medicare & Medicaid Services D-23 Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual
(Alternative Instructions for Scannable Forms)
(可供掃描的表格填寫說明)
调查问卷说明
• 請用完全塗黑答案左側的圓圈的方式,來回答所有問題。
• 有時會讓您跳過某些問題。當出現這種情況時,您會看到一個箭頭和一個說明,告
訴您下一步回答什麼問題,像這樣
是
否 如回答否,請跳到問題#1
本問卷調查是關於您在我們這封信所特指的醫院的經歷。在本問卷調查中,“醫療程序”這
個詞指的是診斷,外科手術及其他醫療過程。“醫療處所”這個詞指的是進行您的醫療程序
的地方。
請針對印在信函上所列的的日子那天您所經歷的所有醫療程序來回答這些問題。在您回
答問題時,請不要考慮或涉及其他醫療程序。
Appendix D: Chinese: Mail Survey Cover Letters, Mail Questionnaires, Instructions for Scannable Mail Questionnaire November 2018
D-24 Centers for Medicare & Medicaid Services Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual
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Centers for Medicare & Medicaid Services Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual
APPENDIX E:
KOREAN: MAIL SURVEY COVER LETTERS, MAIL QUESTIONNAIRE, AND INSTRUCTIONS FOR SCANNABLE MAIL QUESTIONNAIRE
Appendix E: Korean: Mail Survey Cover Letters, Mail Questionnaire, Instructions for Scannable Mail Questionnaire November 2018
Centers for Medicare & Medicaid Services Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual
This page intentionally left blank.
Centers for Medicare & Medicaid Services Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual E-1
SAMPLE COVER LETTER FOR FIRST QUESTIONNAIRE MAILING
Outpatient and Ambulatory Surgery CAHPS Survey
To be Printed on Ambulatory Surgery Center or Hospital Outpatient Department or Vendor
Letterhead
«FirstName» «LastName»
«Address1» «Address2»
«City_Name», «State_Code» «Zip_Zip4»
«LastName»«FirstName» 님께
[FACILITY] (은)는 환자분께서 저희 시설에서 경험한 의료 서비스의 품질을 알아보는
조사를 실시하고 있으며, 독립 연구 기관인 [VENDOR] (이)가 조사 자료의 수집을 돕고
있습니다. 저희 기록에 의하면 귀하는 [FACILITY] 에서 수술 혹은 처치를 받으셨습니다.
이 조사 결과를 통해 저희 시설을 이용하신 환자분의 경험을 더 잘 이해하고자 합니다.
동봉된 설문지에는 귀하가 [DATE OF SURGERY] 에 받으신 외래 수술 혹은 처치에 대한
경험과 관련된 질문들이 포함되어 있습니다. 몇 분 동안만 시간을 내셔서 설문을 작성하신
뒤 동봉되어진 요금 선납된 회신 봉투를 이용, [VENDOR] 에게 설문지를 보내 주시면
감사하겠습니다.
설문을 작성하실 때에는 [DATE OF SURGERY]에 있었던 [FACILITY] 방문만을 오직
염두에 두고 응답해 주십시오. 혹시 귀하가 이 시설에서 다른 날짜, 혹은 다른 시설에서
받으신 수술이나 처치를 경험하셨다면, 그것은 제외하고 위에 제시된 날짜와 시설에
관련해서만 답변 하시기를 부탁드립니다.
귀하가 제공하시는 모든 정보는 비밀로 유지되며 개인 정보 보호법에 의해 보호를
받습니다. 귀하의 설문 응답은 다른 응답자들의 응답과 함께 합쳐집니다. 또, 자료 분석
시에 귀하의 이름이나 신상 정보는 설문 응답과 연결되지 않습니다. [FACILITY NAME]
(와)과 다른 시설에 대한 전반적인 조사 결과는 인터넷 사이트
(https://www.medicare.gov/)를 통해 공표될 예정입니다. 이 결과는 사람들이 외래 혹은
응급 수술 시설을 선택하는데 있어 현명한 결정을 할 수 있도록 도울 것입니다. 귀하의
Appendix E: Korean: Mail Survey Cover Letters, Mail Questionnaire, Instructions for Scannable Mail Questionnaire November 2018
E-2 Centers for Medicare & Medicaid Services Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual
참여는 자발적이며, 이 참여의 결정은 귀하가 현재 받고 있는 혹은 미래에 받을 의료
서비스 혜택에 전혀 영향을 끼치지 않습니다.
이 조사에 대해 질문이 있으시다면, 무료 번호 1-800-XXX-XXXX 로 NAME 에게 전화
주십시오. 만약 질문을 읽으시거나 응답을 표시하는데 도움이 필요하시면, 친구나 가족의
도움을 받으셔도 됩니다. 귀하의 참여에 깊이 감사드립니다.
감사합니다.
NAME
TITLE
설문지 동봉 [PRINT UNIQUE SAMPLE ID NUMBER HERE]
Appendix E: Korean: Mail Survey Cover Letters, Mail Questionnaire, November 2018 Instructions for Scannable Mail Questionnaire
Centers for Medicare & Medicaid Services Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual E-3
SAMPLE COVER LETTER FOR SECOND QUESTIONNAIRE MAILING TO MAIL
SURVEY NONRESPONDENTS
Outpatient and Ambulatory Surgery CAHPS Survey
To be Printed on Ambulatory Surgery Center or Hospital Outpatient Department or Vendor
Letterhead
«FirstName» «LastName»
«Address1» «Address2»
«City_Name», «State_Code» «Zip_Zip4»
«LastName»«FirstName» 님께
얼마전 귀하께 [FACILITY]에서 외래 수술이나 처치를 받으신 환자분들을 대상으로 하는
의료 서비스 품질에 대한 설문 조사 참여를 요청하는 편지를 보내드렸습니다. 그렇지만
현재까지 귀하의 설문지를 받아보지 못했습니다. 이미 설문지 작성을 마치셨고, 우편으로
설문지를 송부하셨다면, 귀하의 참여에 깊은 감사를 드립니다. 아직 설문 작성을 마치지
못하셨다면, 몇 분만 시간을 내셔서 설문 작성을 완료해 주시길 부탁드립니다. 작성
후에는 동봉되어진 요금 선납된 회신 봉투를 이용해 설문지를 보내 주시면
감사하겠습니다.
설문을 작성하실 때에는 [DATE OF SURGERY]에 있었던 [FACILITY] 방문만을 오직
염두에 두고 응답해 주십시오. 혹시 귀하가 이 시설에서 다른 날짜, 혹은 다른 시설에서
받으신 수술이나 처치를 경험하셨다면, 그것은 제외하고 위에 제시된 날짜와 시설에
관련해서만 답변 하시기를 부탁드립니다.
이 조사 결과를 통해 저희 시설을 이용하신 환자분의 경험을 더 잘 이해하고자 합니다.
귀하의 설문 응답은 다른 응답자들의 응답과 함께 합쳐집니다. 또, 자료 분석 시에 귀하의
이름이나 신상 정보는 설문 응답과 연결되지 않습니다. 귀하가 제공하시는 모든 정보는
비밀로 유지되며 개인 정보 보호법에 의해 보호를 받습니다. 귀하의 참여는 자발적이며,
이 참여의 결정은 귀하가 현재 받고 있는 혹은 미래에 받을 의료 서비스 혜택에 전혀
영향을 끼치지 않습니다.
Appendix E: Korean: Mail Survey Cover Letters, Mail Questionnaire, Instructions for Scannable Mail Questionnaire November 2018
E-4 Centers for Medicare & Medicaid Services Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual
이 조사에 대해 질문이 있으시다면, 무료 번호 1-800-XXX-XXXX 로 NAME 에게 전화
주십시오. 만약 질문을 읽으시거나 응답을 표시하는데 도움이 필요하시면, 친구나 가족의
도움을 받으셔도 됩니다. 귀하의 참여에 깊이 감사드립니다.
감사합니다.
NAME
TITLE
설문지 동봉 [PRINT UNIQUE SAMPLE ID NUMBER HERE]
의료 서비스 제공자에 대한 소비자 평가
외래 및 응급 수술 설문 조사
(OAS CAHPS®) 환자의 외래 및 응급 수술과 처치 관련 의료 서비스 경험에 대한 설문 조사
1995 년에 제정된 서류 작업 감소 법안에 따라, 귀하는 유효 승인 번호가 표시되지 않은 어떠한
정보 수집에도 응할 의무가 없습니다. 이 조사에 대한 연방 관리예산국의 유효 승인 번호는
0938-1240 입니다. 조사 완료에는 작성 안내, 자료 탐색과 수집, 답변 작성 및 검토 시간을
포함하여 평균 8 분이 걸릴 것으로 예상됩니다. 이 예상 소요 시간이 정확하지 않다고
생각하시거나 조사를 개선하기 위한 제안이 있으시다면 다음 주소로 보내주시기 바랍니다:
CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05,
Baltimore, Maryland 21244-1850
Appendix E: Korean: Mail Survey Cover Letters, Mail Questionnaire, Instructions for Scannable Mail Questionnaire November 2018
E-6 Centers for Medicare & Medicaid Services Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual
작성 안내
귀하의 응답 왼쪽에 위치한 네모칸에
체크하셔서 질문에 답해 주십시오.
설문 도중 어떤 질문에 대해서는 건너
뛰라고 할 수도 있습니다. 이 경우,
아래에 제시된 바와 같이 다음에 몇 번
질문에 답해야 할 지 화살표로 안내하고
있습니다.
예
아니요 “아니요”면
1 번으로 가주세요
이 조사는 안내 편지에 적힌 시설에서의
귀하의 경험을 묻습니다. 이 조사에서
“처치”는 진단, 수술 등의 모든 의료 처치
활동을 통틀어 일컫는 용어입니다.
여기에서 “시설”은 귀하가 처치를 받은
장소를 말합니다.
안내 편지에 적힌 날짜에 받으신
처치만을 생각하고 질문에 답해
주십시오. 다른 처치에 대해서는
고려하지 말아 주십시오.
I. 처치 전
첫번째로 드리는 질문들은 처치 준비와
관련한 것들입니다. 처치 전이나
처치일에 귀하가 제공 받은 정보를 모두
포함해 주십시오.
1. 처치 전에 시설에서 일하는 담당
의사나 다른 사람이 귀하가 처치와
관련해 필요한 정보를 모두
제공하였습니까?
1 예, 확실히
2 예, 다소
3 아니요
2. 처치 전에 시설에서 일하는 담당
의사나 다른 사람이 귀하의 처치
준비에 대해 이해하기 쉽게 안내해
주었습니까?
1 예, 확실히
2 예, 다소
3 아니요
II. 시설과 직원
다음은 처치 당일에 관한 질문들입니다.
3. 체크인 과정은 순조로왔습니까?
1 예, 확실히
2 예, 다소
3 아니요
4. 시설은 깨끗했습니까?
Appendix E: Korean: Mail Survey Cover Letters, Mail Questionnaire, November 2018 Instructions for Scannable Mail Questionnaire
Centers for Medicare & Medicaid Services Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual E-7
1 예, 확실히
2 예, 다소
3 아니요
5. 시설의 접수 담당자와 사무
직원들은 귀하의 기대에 부응하는
도움을 주었습니까?
1 예, 확실히
2 예, 다소
3 아니요
6. 시설의 접수 담당자와 사무
직원들은 귀하를 예의바르고
정중하게 대하였습니까?
1 예, 확실히
2 예, 다소
3 아니요
Appendix E: Korean: Mail Survey Cover Letters, Mail Questionnaire, Instructions for Scannable Mail Questionnaire November 2018
E-8 Centers for Medicare & Medicaid Services Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual
7. 의사와 간호사들은 귀하를
예의바르고 정중하게 대하였습니까?
1 예, 확실히
2 예, 다소
3 아니요
8. 의사와 간호사들은 귀하가 충분히
편안하게 느낄 수 있도록 하기 위해
노력하였습니까?
1 예, 확실히
2 예, 다소
3 아니요
III. 처치 관련 의사소통
처치 전이나 처치 당일 제공 받은 정보를
염두에 두고 답해 주시길 부탁드립니다.
9. 의사와 간호사들은 귀하의 처치에
대해 이해하기 쉽게 설명을 해
주었습니까?
1 예, 확실히
2 예, 다소
3 아니요
10. 마취는 처치를 받는 동안 잠이 들게
하거나 졸리게 합니다. 귀하는
마취를 받았습니까?
1 예
2 아니요 “아니요”면 13 번으로
가주세요.
11. 의사나 시설의 다른 직원이
귀하에게 마취 절차에 대해
이해하기 쉽게 설명을 해
주었습니까?
1 예, 확실히
2 예, 다소
3 아니요
12. 의사나 시설의 다른 직원이
귀하에게 마취와 관련해 발생
가능한 부작용에 대해 이해하기
쉽게 설명해 주었습니까?
1 예, 확실히
2 예, 다소
3 아니요
13. 퇴원 안내에는 귀하가 처치 후 겪을
수 있는 증상이라든지, 약품 복용법,
자택 요양 안내 등이 포함됩니다.
귀하는 시설을 떠나기 전, 문서로 된
퇴원 안내를 받으셨습니까?
1 예
2 아니요
IV. 회복
14. 의사나 시설의 다른 직원이
귀하에게 회복 기간 중 발생 가능한
일에 대해 안내해 주었습니까?
Appendix E: Korean: Mail Survey Cover Letters, Mail Questionnaire, November 2018 Instructions for Scannable Mail Questionnaire
Centers for Medicare & Medicaid Services Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual E-9
1 예, 확실히
2 예, 다소
3 아니요
Appendix E: Korean: Mail Survey Cover Letters, Mail Questionnaire, Instructions for Scannable Mail Questionnaire November 2018
E-10 Centers for Medicare & Medicaid Services Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual
15. 통증을 줄이는 방법으로는 처방전
없이 구매가능한 일반 의약품이나
얼음팩의 이용 등 여러 방법이
있습니다. 의사나 시설의 다른
직원이 귀하에게 처치 관련한
통증을 느꼈을 때 대처 요령을
안내해 주었습니까?
1 예, 확실히
2 예, 다소
3 아니요
16. 시설을 떠난 후 처치로 인한 통증을
느낀 적이 한 번이라도 있었습니까?
1 예
2 아니요
17. 시설을 떠나기 전, 의사나 시설의
다른 직원이 구역질이 나거나
구토를 할 경우 대처 요령을 안내해
주었습니까?
1 예, 확실히
2 예, 다소
3 아니요
18. 시설을 떠난 후 언제라도, 처치 혹은
마취로 인해 구역질이나 구토를 한
적이 있었습니까?
1 예
2 아니요
19. 시설을 떠나기 전, 의사나 시설의
다른 직원이 처치로 인한 출혈이
있을 경우 대처 요령을 안내해
주었습니까?
1 예, 확실히
2 예, 다소
3 아니요
20. 시설을 떠난 후 처치로 인해 출혈한
적이 한 번이라도 있었습니까?
1 예
2 아니요
21. 감염의 징후로는 미열, 부기, 열,
체액의 배출이나 붉어짐 등이
있습니다. 시설을 떠나기 전, 의사나
시설의 다른 직원이 이와 같은 감염
징후가 있을 경우 대처 요령을
안내해 주었습니까?
1 예, 확실히
2 예, 다소
3 아니요
22. 시설을 떠난 후 언제라도, 이러한
감염 징후가 나타난 적이
있었습니까?
1 예
2 아니요
Appendix E: Korean: Mail Survey Cover Letters, Mail Questionnaire, November 2018 Instructions for Scannable Mail Questionnaire
Centers for Medicare & Medicaid Services Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual E-11
V. 전반적인 경험
23. 0 은 최악의 시설이고 10 은 최고의
시설을 의미한다면 귀하는 이
시설에 대하여 0 에서 10 사이의
숫자 중 몇 점을 주시겠습니까?
0 최악의 시설
1
2
3
4
5
6
7
8
9
10 최고의 시설
24. 이 시설을 귀하의 친구나 가족에게
추천하시겠습니까?
1 절대 안함
2 안할 것 같음
3 할 것 같음
4 확실히 할 것 같음
VI. 본인에 관한 정보
25. 일반적으로 귀하의 전반적인 건강
상태를 어떻게 평가하십니까?
1 더할 나위 없이 좋다
2 아주 좋다
3 좋은 편이다
4 그저 그렇다
5 나쁘다
26. 일반적으로 귀하의 정신 및 정서
건강을 어떻게 평가하십니까?
1 더할 나위 없이 좋다
2 아주 좋다
3 좋은 편이다
4 그저 그렇다
5 나쁘다
27. 귀하의 만 나이는 어떻게 되십니까?
1 18 – 24 세
2 25 – 34 세
3 35 – 44 세
4 45 – 54 세
5 55 – 64 세
6 65 – 74 세
7 75 – 79 세
8 80 – 84 세
9 85 세 이상
28. 귀하의 성별은 어떻게 되십니까?
1 남성
2 여성
29. 귀하의 최종 학력은 어떻게
되십니까?
Appendix E: Korean: Mail Survey Cover Letters, Mail Questionnaire, Instructions for Scannable Mail Questionnaire November 2018
E-12 Centers for Medicare & Medicaid Services Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual
1 중졸 (8 학년) 이하
2 고교 중퇴
3 고졸 혹은 검정 고시 (GED)
4 대학 중퇴 혹은 2 년제 대학
졸업
5 4 년제 대학 졸업
6 대학원 이상
Appendix E: Korean: Mail Survey Cover Letters, Mail Questionnaire, November 2018 Instructions for Scannable Mail Questionnaire
Centers for Medicare & Medicaid Services Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual E-13
30. 중남미 혹은 히스패닉 출신입니까?
1 예, 중남미 혹은 히스패닉 출신
2 아니요, 중남미 혹은 히스패닉
출신이 아님 “아니요”면,
32 번으로 가주세요.
31. 귀하를 가장 잘 나타내는 것은 다음
중 무엇입니까?
1 멕시코인, 멕시코계 미국인,
치카노인
2 푸에르토리코인
3 쿠바인
4 기타 중남미 혹은 히스패닉
출신
32. 인종이 어떻게 되시나요? 한개 또는
그 이상을 고르실 수 있습니다.
1 백인
2 흑인 혹은 아프리카계 미국인
3 아메리칸 인디언 혹은 알라스카
원주민
4 인도인
5 중국인
6 필리핀인
7 일본인
8 한국인
9 베트남인
10 기타 아시아인
11 하와이 원주민
12 괌족 혹은 차모로족
13 사모아족
14 기타 태평양 제도인
33. 귀하는 영어로 말을 어느 정도로
잘합니까?
1 매우 잘함
2 잘하는 편임
3 잘 못하는 편임
4 전혀 못함
34. 귀하는 댁에서 영어가 아닌 다른
언어를 사용하십니까?
1 예
2 아니요 “아니요”면 36 번으로
가주세요.
35. 그 언어는 무엇입니까?
1 스페인어
Appendix E: Korean: Mail Survey Cover Letters, Mail Questionnaire, Instructions for Scannable Mail Questionnaire November 2018
E-14 Centers for Medicare & Medicaid Services Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual
2 기타 언어 (구체적으로 쓸 것):
___________________________
(보기쉽게 정자로 적어주십시오)
36. 다른 사람이 설문 작성을 도와
주었습니까?
1 예
2 아니요 “아니요”면 끝으로
가주세요.
37. 그 사람은 어떤 도움을 주었습니까?
해당하는 것을 모두 고르십시오.
1 질문을 내게 읽어줌
2 내 응답을 받아 적음
3 나를 대신에 질문에 답함
4 내가 사용하는 언어로 번역함
5 기타 다른 방법으로 도와줌:
(설명할 것):
______________________________
(보기쉽게 정자로 적어주십시오)
6 설문 작성을 도운 사람 없음
끝
E-15 Centers for Medicare & Medicaid Services Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual
(Alternative Instructions for Scannable Forms)
(스캔용 설문지 작성 안내)
작성 안내
• 귀하의 응답 왼쪽에 위치한 동그라미를 완전히 채워 질문에 답해 주십시오.
• 설문 도중 어떤 질문에 대해서는 건너 뛰라고 할 수도 있습니다. 이런 경우, 아래에
제시된 바와 같이 다음에 몇 번 질문에 답해야 할 지 화살표로 안내하고 있습니다.
예
아니요 “아니요”면 1 번으로 가주세요
이 조사는 안내 편지에 적힌 시설에서의 귀하의 경험을 묻습니다. 이 조사에서 “처치”는
진단, 수술 등의 모든 의료 처치 활동을 통틀어 일컫는 용어입니다. 여기에서 “시설”은
귀하가 처치를 받은 장소를 말합니다.
안내 편지에 적힌 날짜에 받으신 처치만을 생각하고 질문에 답해 주십시오. 다른 처치에
대해서는 고려하지 말아 주십시오.
Appendix E: Korean: Mail Survey Cover Letters, Mail Questionnaire, Instructions for Scannable Mail Questionnaire November 2018
E-16 Centers for Medicare & Medicaid Services Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual
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Centers for Medicare & Medicaid Services Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual
APPENDIX F:
CONSENT TO SHARE IDENTIFYING INFORMATION QUESTION
Appendix F: Consent to Share Identifying Information Question November 2018
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Centers for Medicare & Medicaid Services F-1 Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual
HOPDs or ASCs may request that their survey vendor provide survey responses linked to a
sample member’s name and other identifying information (About You responses). If they wish to
do so, they must ask for and receive consent from the sample member using the Consent to Share
Identifying Information question (below). This question should be placed at the end of the
questionnaire as the last question.
Survey vendors can provide responses linked to a sample member’s name and other identifying
information only if the sample member gives his or her consent on the Consent to Share
Identifying Information question. This includes providing this sample member’s responses to any
About You questions that do not meet the threshold of 11 that is required for reporting
aggregated response data overall.
English Mail Questionnaire Version
The facility where you received your surgery or procedure may want to review your survey
responses so that they can decide how to address any concerns that you have.
Do you give your permission to link your name with your survey responses that will be
shared with the facility where you received your surgery or procedure?
1 Yes, I give my permission to link my name with my survey responses. 2 No, I do not give permission to link my name with my survey responses.
English Telephone Interview Version
The facility where you received your surgery or procedure may want to review your survey
responses so that they can decide how to address any concerns that you have.
Do you give your permission to link your name with your survey responses that will be
shared with the facility where you received your surgery or procedure?
1 YES
2 NO
Appendix F: Consent to Share Identifying Information Question November 2018
F-2 Centers for Medicare & Medicaid Services Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual
Spanish Mail Questionnaire Version
Es posible que el centro ambulatorio en donde se realizó su cirugía o procedimiento desee revisar
sus respuestas para encontrar la manera de aclarar sus preocupaciones.
¿Nos da usted permiso de asociar su nombre con las respuestas a la encuesta que se
compartirá con el centro ambulatorio en donde se realizó su cirugía o procedimiento?
1 Sí, doy permiso para asociar mi nombre con mis respuestas a la encuesta. 2 No, no doy permiso para asociar mi nombre con mis respuestas a la encuesta.
Spanish Telephone Interview Version
Es posible que el centro ambulatorio en donde se realizó su cirugía o procedimiento desee revisar
sus respuestas para encontrar la manera de aclarar sus preocupaciones.
¿Nos da usted permiso de asociar su nombre con las respuestas a la encuesta que se
compartirá con el centro ambulatorio en donde se realizó su cirugía o procedimiento?
1 SÍ
2 NO
November 2018 Appendix F: Consent to Share Identifying Information Question
Centers for Medicare & Medicaid Services F-3 Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual
Chinese (Simplified) Mail Questionnaire Version
为您做手术或进行医疗程序的机构可能希望了解您的回答,以便他们了解和解除您的顾虑。
您是否同意将您的姓名与您对此调查问卷的回答联系起来,并与此机构分享此信息?
1 是,我同意将我的姓名与我对此调查问卷的回答联系起来。 2 否,我不同意将我的姓名与我对此调查问卷的回答联系起来。
Chinese (Traditional) Mail Questionnaire Version
為您做手術或進行醫療程序的機構可能希望瞭解您的回答,以便他們了解和解除您的顧慮。
您是否同意將您的姓名與您對此調查問卷的回答聯繫起來,并與此機構分享此資訊?
1 是,我同意將我的姓名與我對此調查問卷的回答聯繫起來。 2 否,我不同意將我的姓名與我對此調查問卷的回答聯繫起來。
Appendix F: Consent to Share Identifying Information Question November 2018
F-4 Centers for Medicare & Medicaid Services Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual
Korean Mail Questionnaire Version
귀하가 수술이나 처치를 받으신 시설은 귀하의 염려나 불만 사항에 적절히 대처하기
위해 귀하의 설문 조사 응답을 검토하고 싶어할 수도 있습니다.
귀하는 귀하가 수술이나 처치를 받은 시설과 귀하의 이름으로 작성된 설문 응답을
공유하는 것을 허가하십니까?
1 예, 제 이름과 설문 응답을 공유하는 것을 허가합니다.
2 아니요, 제 이름과 설문 응답을 공유하는 것을 허가하지 않습니다.
Centers for Medicare & Medicaid Services Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual
APPENDIX G:
OMB PAPERWORK REDUCTION ACT LANGUAGE
Appendix G: OMB Paperwork Reduction Act Language November 2018
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OMB PAPERWORK REDUCTION ACT LANGUAGE
The Office of Management and Budget (OMB) Paperwork Reduction Act language below must
be included in the Outpatient and Ambulatory Surgery CAHPS Survey mailings. It can be
included in the cover letter or on the front or back of the questionnaire. It does not need to be
included in both the cover letter and the questionnaire.
ENGLISH
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a
collection of information unless it displays a valid OMB control number. The valid OMB control
number for this information collection is 0938-1240. The time required to complete this
information collection is estimated to average 8 minutes per response, including the time to
review instructions, search existing data resources, gather the data needed, and complete and
review the information collection. If you have comments concerning the accuracy of the time
estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security
Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland
21244-1850.
Appendix G: OMB Paperwork Reduction Act Language November 2018
G-2 Centers for Medicare & Medicaid Services Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual
OMB PAPERWORK REDUCTION ACT LANGUAGE
The Office of Management and Budget (OMB) Paperwork Reduction Act language below must
be included in the Outpatient and Ambulatory Surgery CAHPS Survey mailings. It can be
included in the cover letter or on the front or back of the questionnaire. It does not need to be
included in both the cover letter and the questionnaire.
SPANISH
De acuerdo a la Ley de Reducción de Trabajo Administrativo de 1995 (Paperwork Reduction
Act of 1995), ninguna persona tiene la obligación de responder a un cuestionario que solicite
información, a menos que lleve un número de control de OMB (Oficina de Administración y
Presupuesto) válido. El número de control OMB válido para este cuestionario es 0938-1240. Se
estima que el tiempo promedio necesario para completar este cuestionario es de 8 minutos por
respuesta, incluyendo el tiempo para revisar las instrucciones, buscar en las fuentes de datos
existentes, recopilar los datos necesarios, completar y revisar la información recopilada. Si tiene
algún comentario sobre la exactitud del tiempo estimado o sugerencias para mejorar este
formulario, por favor escriba a: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance
Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.
November 2018 Appendix G: OMB Paperwork Reduction Act Language
Centers for Medicare & Medicaid Services G-3 Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual
OMB PAPERWORK REDUCTION ACT LANGUAGE
The Office of Management and Budget (OMB) Paperwork Reduction Act language below must
be included in the Outpatient and Ambulatory Surgery CAHPS Survey mailings. It can be
included in the cover letter or on the front or back of the questionnaire. It does not need to be
included in both the cover letter and the questionnaire.
CHINESE (SIMPLIFIED)
根据 1995 年减少纸张使用法案,如果问卷上没有有效的 OMB 控制数码,任何人都无须
回答问卷上的任何问题。这项问卷持有有效的 OMB控制数码:0938-1240。完成这份问
卷,估计需要八分钟。这包括阅读问卷的说明,查找现有的资料,收集和整理所需的信
息,以及完成和审阅所提供的信息。如果您对完成这份问卷所估计的时间或对如何改进这
项问卷有任何看法,请写信给: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance
Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.
Appendix G: OMB Paperwork Reduction Act Language November 2018
G-4 Centers for Medicare & Medicaid Services Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual
OMB PAPERWORK REDUCTION ACT LANGUAGE
The Office of Management and Budget (OMB) Paperwork Reduction Act language below must
be included in the Outpatient and Ambulatory Surgery CAHPS Survey mailings. It can be
included in the cover letter or on the front or back of the questionnaire. It does not need to be
included in both the cover letter and the questionnaire.
CHINESE (TRADITIONAL)
根據 1995年減少紙張使用法案,如果問卷上沒有有效的 OMB 控制數碼,任何人都無須
回答問卷上的任何問題。這項問卷持有有效的 OMB 控制數碼:0938-1240。完成這份問
卷,估計需要八分鐘。這包括閱讀問卷的說明,查找現有的資料,收集和整理所需的資
訊,以及完成和審閱所提供的資訊。如果您對完成這份問卷所估計的時間或對如何改進這
項問卷有任何看法,請寫信給:CMS,7500 Security Boulevard, Attn: PRA Reports Clearance
Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.
November 2018 Appendix G: OMB Paperwork Reduction Act Language
Centers for Medicare & Medicaid Services G-5 Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual
OMB PAPERWORK REDUCTION ACT LANGUAGE
The Office of Management and Budget (OMB) Paperwork Reduction Act language below must
be included in the Outpatient and Ambulatory Surgery CAHPS Survey mailings. It can be
included in the cover letter or on the front or back of the questionnaire. It does not need to be
included in both the cover letter and the questionnaire.
KOREAN
1995 년에 제정된 문서 감축 법안에 따라, 귀하는 유효 승인 번호가 표시되지 않은
어떠한 정보 수집에도 응할 의무가 없습니다. 이 조사에 대한 연방 관리예산국의 유효
승인 번호는 0938-1240 입니다. 조사 완료에는 작성 안내, 기존 자료 탐색과 수집, 답변
작성 및 검토 시간을 포함하여 평균 8 분이 걸릴 것으로 예상됩니다. 이 예상 소요 시간이
정확하지 않다고 생각하시거나 조사 개선을 위한 제안이 있으시다면 다음 주소로 편지를
보내주시기 바랍니다: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance
Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.
Appendix G: OMB Paperwork Reduction Act Language November 2018
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Centers for Medicare & Medicaid Services Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual
APPENDIX H:
FREQUENTLY ASKED QUESTIONS FOR TELEPHONE INTERVIEWERS
(ENGLISH)
Appendix H: Frequently Asked Questions for Telephone Interviewers (English) November 2018
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Centers for Medicare & Medicaid Services H-1 Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual
FREQUENTLY ASKED QUESTIONS
OAS CAHPS®
What is the purpose of this survey?
The purpose of this survey is to learn about your experiences with the care you received for your
recent outpatient surgery or procedure. The survey results will help other patients make more
informed choices when choosing an outpatient surgery facility and help facilities in the study to
improve the quality of care provided to their patients.
I’ve already completed a mail survey. Do I need to complete this survey again?
Thank you for completing the survey and mailing it back in. However, we have not yet received
the survey and so we are following up to gather your feedback by phone. If you have some time
right now we could go through the questions. Or I can call you back in a few days if we still have
not received the survey by mail.
I lost the mail survey. Would you please mail me another one?
We are nearing the end of the survey data collection period and are not allowed to send out any
additional surveys. Because the feedback you provide will help improve the quality of the
outpatient surgery care you and others like you receive, we are asking that you please complete
the survey with us over the phone. If now is okay, let’s get started!
I already completed/received a survey about this.
Sometimes hospitals and surgeons conduct surveys of their recent patients, and you may have
received one of those surveys. The survey we are asking you to do is about your experience at
the outpatient facility where your surgery or procedure was performed. The results will be used
to help people make more informed decisions when choosing an outpatient surgery facility. The
facilities will also use survey results to help improve the quality of care they give to their
patients.
How are the results from the study going to be used?
Results from this survey will be used to help people make more informed decisions when
choosing an outpatient surgery facility. The facilities will also use survey results to help improve
the quality of care they give to their patients.
Do I have to take part in this survey?
Your participation in this survey is voluntary. All information that you give in this survey will be
held in confidence and is protected by the Privacy Act. Please know that none of your individual
answers will be shared with [FACILITY NAME], nor will they know whether or not you
participated.
Appendix H: Frequently Asked Questions for Telephone Interviewers (English) November 2018
H-2 Centers for Medicare & Medicaid Services Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual
It is also important that you know that your decision to participate in this survey and your
answers to the questions will not affect any health care benefits you receive now or expect to
receive in the future.
You can also skip or refuse to answer any question you don’t feel comfortable with. But, we
hope you will participate because the feedback you provide will help improve the quality of the
care you, and others like you, receive.
I did not have surgery. This survey does not apply to me.
This survey is applicable to you if you had a medical or diagnostic procedure at [FACILITY
NAME] in [MONTH, YEAR]. Examples of these types of procedures include colonoscopy,
endoscopy, biopsy and injection for pain management. [NOTE: IF NEEDED, EXPLAIN TO
RESPONDENT HOW THEY WERE SELECTED: You were randomly selected to participate in
this survey because our records show that you had a procedure at (FACILITY NAME).]
I can’t remember any specific procedure/I didn’t have surgery on that date.
For privacy reasons, we do not have access to the procedures you had at this facility during
[MONTH]. Please try to answer the questions as best as you can for the procedure you remember
the most in [MONTH].
My surgery was not outpatient/ambulatory because I stayed overnight at the hospital/facility. This survey does not apply to me.
This survey is for people who had outpatient surgeries, including those who went home on the
same day and those who stayed overnight for observation. As long as you went home after
observation and you were not discharged to a hospital as an inpatient, then this survey is for you.
What do I have to do/What kinds of questions are there?
I would like to ask you some questions about your experiences with your recent outpatient
surgery or procedure at [FACILITY NAME]. For example, the questions will ask for your
experience with the check-in process, the facility itself, the communication you had with the
facility’s staff, the information you received on your procedure, and your overall experience.
This survey takes on average about 8 minutes to complete, and I will move through the questions
as quickly as possible.
Is it okay for RESPONDENT’S wife, husband, child, legal guardian, etc. to answer these questions?
Because you were chosen at random to participate in this important study, and because you were
the one who received care for an outpatient surgery or procedure, no other person can take your
place. But, you may skip or refuse to answer any question you’re uncomfortable with.
November 2018 Appendix H: Frequently Asked Questions for Telephone Interviewers (English)
Centers for Medicare & Medicaid Services H-3 Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual
How do I know this is confidential?
Your individual answers will only be seen by research staff, who have signed statements of
confidentiality. All personal identifying information, such as names and addresses, will be
removed from data records before they are analyzed. And, everyone’s answers will be combined
to produce a summary report.
Why do you want to know all this personal stuff about me (RACE, AGE, GENERAL HEALTH, etc.) if this is a survey about my outpatient surgery care experiences?
I understand your concern with the questions about your general health and background. We
have found that people’s experiences may differ based on their current health status and other
characteristics. This is a very important survey. If a question bothers you, just tell me you’d
rather not answer it, and I’ll move on to the next question.
I’m on the Do Not Call list. Why are you calling me?
The Do Not Call list stops sales and telemarketing calls. We are conducting survey research on
behalf of [FACILITY NAME]. We are not calling to sell or market a product or service.
I’m not going to answer a lot of questions over the phone!
Your cooperation is very important to us. The information that you provide in this survey will
help others make more informed choices about an outpatient surgery center and will help the
facility you visited to improve the care they give. Please know that you can skip or refuse to
answer any question you don’t feel comfortable with, and that all of your answers will be kept
completely confidential since they are protected by the Federal Privacy Act of 1974. Let me start
and you can see what the questions are like…[READ FIRST QUESTION]
How did you get my name? How was I chosen for the survey?
Your name was randomly selected from a list of patients at [FACILITY NAME] who received an
outpatient surgery or procedure in [MONTH].
I did not like my outpatient surgery center!
I understand. Your opinions are very important and will help your outpatient surgery center
understand how to improve its care. Let’s start now. [NOTE: DO NOT ARGUE BACK. MAKE
SHORT, NEUTRAL COMMENTS TO LET THEM KNOW THAT YOU ARE LISTENING
AND IMMEDIATELY ASK THE FIRST QUESTION.]
How long will this take?
This survey takes on average about 8 minutes to complete. I’ll move through the questions as
quickly as possible.
Appendix H: Frequently Asked Questions for Telephone Interviewers (English) November 2018
H-4 Centers for Medicare & Medicaid Services Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual
Probe options for when respondent answers “Yes” instead of “Yes, Definitely” or “Yes, Somewhat.”
• “Would you say, ‘Yes, Definitely’ or ‘Yes, Somewhat?’”
• “Thank you for your response. For this question, I have three categories. Category 1 is
‘Yes, Definitely;’ Category 2 is ‘Yes, Somewhat;’ and Category 3 is ‘No.’ You said
‘Yes.’ Would that be Category 1 – ‘Yes, Definitely’ – or Category 2 – ‘Yes,
Somewhat?’”
• “Some of the questions have simple yes/no responses. Many of the questions have three
response choices. One, ‘Yes, Definitely.’ Two, ‘Yes, Somewhat.’ And, three, ‘No.’ I
cannot enter a simple ‘Yes’ response. I can enter ‘Yes, Definitely’ or ‘Yes, Somewhat.’
You said, ‘Yes’ to [REPEAT QUESTION ONLY], would that be ‘Yes, Definitely’ or
‘Yes, Somewhat?’”
Where can I see the results from the study?
The results from this survey will be publicly reported on a CMS website. You can access the
results by visiting https://www.medicare.gov/hospitalcompare/OASCAHPS-measures.html.
November 2018 Appendix H: Frequently Asked Questions for Telephone Interviewers (English)
Centers for Medicare & Medicaid Services H-5 Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual
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Centers for Medicare & Medicaid Services Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual
APPENDIX I:
FREQUENTLY ASKED QUESTIONS FOR TELEPHONE INTERVIEWS
(SPANISH)
Preguntas más frecuentes para entrevistas por teléfono
Appendix I: Frequently Asked Questions for Telephone Interviews (Spanish) November 2018
Centers for Medicare & Medicaid Services Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual
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Centers for Medicare & Medicaid Services I-1 Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual
PREGUNTAS MÁS FRECUENTES
OAS CAHPS®
¿Cuál es el propósito de esta encuesta?
El objetivo de la encuesta es aprender sobre sus experiencias con los servicios que recibió
durante su más reciente cirugía externa o procedimiento ambulatorio. Los resultados de la
encuesta ayudarán a otros pacientes a tomar decisiones más informadas al seleccionar un centro
de cirugía ambulatoria así como para ayudar a los centros que participan en el estudio a mejorar
la calidad de la atención que proporcionan a sus pacientes.
Ya completé una encuesta por correo. ¿Tengo que completar esta encuesta otra vez?
Muchas gracias por completar la encuesta y enviarla por correo. Sin embargo, aún no hemos
recibido la encuesta, y estamos dándole seguimiento para obtener sus comentarios por teléfono.
Si tiene tiempo en este momento puedo hacerle las preguntas. O le puedo volver a llamar en unos
días si aún no hemos recibido la encuesta por correo.
Perdí la encuesta que se envía por correo. ¿Me puede enviar otra por correo?
Estamos cerca del final del periodo de recolección de datos y no nos permiten enviar ninguna
encuesta adicional. Como las opiniones que usted proporcione nos ayudarán a mejorar la calidad
de la atención de pacientes de cirugía externa o ambulatoria que usted y otras personas reciben,
le estamos pidiendo que por favor complete la encuesta con nosotros por teléfono. Si este es un
buen momento, ¡comencemos!
Ya completé/recibí una encuesta como esa.
A veces los hospitales y los cirujanos llevan a cabo encuestas de sus pacientes recientes y usted
pudiera haber recibido una de esas encuestas. La encuesta que le estamos pidiendo que haga es
sobre su experiencia en la instalación de cirugía externa en donde le realizaron la cirugía o
procedimiento. Los resultados se utilizarán para ayudar a las personas a tomar decisiones más
informadas cuando eligen un centro para cirugía externa o ambulatoria. Los centros también van
a utilizar la encuesta para ayudar a mejorar la calidad de los servicios que dan a sus pacientes.
¿Cómo se utilizarán los resultados del estudio?
Los resultados de esta encuesta se usarán para ayudar a las personas a tomar decisiones más
informadas cuando eligen un centro para cirugía externa o ambulatoria. Los centros también van
a utilizar la encuesta para ayudar a mejorar la calidad de los servicios que dan a sus pacientes.
Appendix I: Frequently Asked Questions for Telephone Interviews (Spanish) November 2018
I-2 Centers for Medicare & Medicaid Services Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual
¿Tengo que participar en esta encuesta?
Su participación en esta encuesta es voluntaria. Toda la información que usted proporcione en
esta encuesta se mantendrá confidencial y está protegida por la Ley de privacidad. Deseamos que
sepa que ninguna de sus respuestas individuales se compartirán con [FACILITY NAME], ni
sabrán si usted participó o no.
También es importante que sepa que su decisión de participar en esta encuesta y sus respuestas a
las preguntas no afectarán a ningún beneficio de atención médica que usted reciba ahora o que
espere recibir en el futuro.
También se puede saltar o rehusar contestar cualquier pregunta que le moleste. Sin embargo,
esperamos que participe porque los comentarios que usted nos dé nos ayudarán a mejorar la
calidad de los servicios que recibe usted y otras personas como usted.
No tuve una cirugía. Esta encuesta no me corresponde.
Esta encuesta sí le corresponde si le realizaron un procedimiento médico o de diagnóstico en
[FACILITY NAME] en [MES, AÑO]. Ejemplos de este tipo de procedimientos incluyen:
colonoscopía, endoscopía, biopsia e inyección para control del dolor. [NOTE: IF NEEDED,
EXPLAIN TO RESPONDENT HOW THEY WERE SELECTED: Usted fue seleccionado al
azar para participar en esta encuesta porque nuestros registros indican que le realizaron un
procedimiento en (FACILITY NAME).]
No recuerdo ningún procedimiento/No tuve una cirugía en esa fecha.
Por razones de privacidad, no tenemos acceso a los procedimientos que le realizaron a usted en
ese centro durante [MES]. Por favor trate de responder a las preguntas lo mejor que pueda para el
procedimiento que mejor recuerde en [MES].
Mi cirugía no fue como paciente externo/ambulatorio porque me tuve que quedar una noche en el hospital/centro. Esta encuesta no me aplica.
Esta encuesta es para personas que tuvieron cirugía como pacientes externos, incluyendo a las
personas que se fueron a casa el mismo día y los que se quedaron una noche para observación.
Siempre y cuando se fuera a su casa después del periodo de observación y no le dieron de alta a
un hospital como paciente interno, entonces esto es para usted.
¿Qué tengo que hacer/Qué tipos de preguntas son?
Me gustaría hacerle algunas preguntas sobre sus experiencias con su reciente cirugía externa o
procedimiento ambulatorio en [FACILITY NAME]. Por ejemplo, las preguntas le pedirán sus
experiencias con el proceso de registro, el centro de cirugía en sí, la comunicación que tuvo con
el personal del centro de cirugía, la información que recibió sobre su procedimiento y su
November 2018 Appendix I: Frequently Asked Questions for Telephone Interviews (Spanish)
Centers for Medicare & Medicaid Services I-3 Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual
experiencia en general. En promedio, esta encuesta se puede completar en unos 10 minutos y voy
a avanzar con las preguntas tan rápido como sea posible.
¿Es posible que (la esposa, el esposo, el hijo, el tutor legal, etc.) responda a estas preguntas?
Como usted fue seleccionado(a) al azar para participar en este importante estudio y como usted
fue la persona que recibió la atención médica para la cirugía externa o procedimiento
ambulatorio, ninguna otra persona puede tomar su lugar. Pero se puede saltar o rehusar contestar
cualquier pregunta que le moleste.
¿Cómo sé que esto es confidencial?
Las respuestas que usted dé solo serán vistas por el personal del estudio, quienes han firmado
declaraciones de confidencialidad. Toda la información de identidad, como los nombres y las
direcciones, serán separados de los registros de datos antes de ser analizados. Y, las respuestas de
todas las personas se combinarán para generar un reporte de resumen.
¿Por qué desea saber todos esos datos personales acerca de mi (SALUD, RAZA, EDAD, etc.) si esta encuesta es acerca de mis experiencias sobre la atención médica durante mi cirugía externa o ambulatoria?
Entiendo su preocupación sobre las preguntas sobre su salud en general y antecedentes. Hemos
encontrado que las experiencias de las personas pueden variar de acuerdo al estado salud y otras
características. Esta es una encuesta muy importante. Si le molesta alguna pregunta, solo dígame
que no desea responderla y avanzaré a la siguiente pregunta.
Estoy en la lista de no llamar. ¿Por qué me están llamando?
La lista de No llamar previene las llamadas de ventas y telemercadeo. Estamos llevando a cabo
el estudio de encuesta a nombre de [FACILITY NAME]. No le estamos llamando para vender o
promover un producto o servicio.
¡No voy a responder a tantas preguntas por teléfono!
Su cooperación es muy importante para nosotros. La información que usted proporcione en esta
encuesta ayudará a otras personas a tomar decisiones más informadas sobre un centro de cirugía
externo o ambulatorio y ayudará al centro de cirugía, a mejorar sus servicios. Por favor tenga en
cuenta que se puede saltar o negar a contestar cualquier pregunta que le moleste y que sus
respuestas se mantendrán completamente confidenciales porque están protegidas por la ley
federal de privacidad de 1974. Empecemos y usted podrá ver cómo son las preguntas…[READ
FIRST QUESTION]
Appendix I: Frequently Asked Questions for Telephone Interviews (Spanish) November 2018
I-4 Centers for Medicare & Medicaid Services Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual
¿Cómo obtuvo mi nombre? ¿Cómo me seleccionaron para la encuesta?
Su nombre se seleccionado al azar de una lista de pacientes en [FACILITY NAME] que tuvieron
una cirugía externa o procedimiento ambulatorio durante el mes de [MES].
¡No me agradó el centro de cirugía externa/ambulatoria!
Le entiendo. Sus opiniones son muy importantes y ayudarán a su centro de cirugía
externa/ambulatoria a entender como mejorar sus servicios. Comencemos. [NOTE: DO NOT
ARGUE BACK. MAKE SHORT, NEUTRAL COMMENTS TO LET THEM KNOW THAT
YOU ARE LISTENING AND IMMEDIATELY ASK THE FIRST QUESTION.]
¿Cuánto tiempo va a tomar?
En promedio esta encuesta se puede completar como en 8 minutos. Trataré de hacer las
preguntas tan rápido como me sea posible.
Probe options for when respondent answers “Sí” instead of “Sí, definitivamente” or “Sí, algo.”
“¿Diría usted que, ‘Sí, definitivamente’ o ‘Sí, algo?’”
“Gracias por su respuesta. Para esta pregunta, tengo tres categorias. Categoría 1 es ‘Sí,
definitivamente;’ Categoría 2 es ‘Sí, algo;’ y Categoría 3 es ‘No.’ Usted dijo ‘Sí.’ Eso
sería la Categoría 1 – ‘Sí, definitivamente’ – o la Categoría 2 – ‘Sí, algo?’”
“Las respuestas para algunas preguntas son simplemente sí/no. Muchas de las preguntas
tienes tres opciones de respuesta. Una, ‘Sí, definitivamente.’ Dos, ‘Sí, algo.’ Y, tres,
‘No.’ No puede ingresar solo ‘sí’ como la respuesta. Solo puedo ingresar ‘Sí,
definitivamente’ o ‘Sí, algo.’ Usted dijo, ‘Sí’ a [REPEAT QUESTION ONLY], eso sería
‘Sí, definitivamente’ o ‘Sí, algo?’”
¿En dónde puedo ver los resultados del estudio?
Los resultados de esta encuesta se publicarán en un reporte en el sitio web de los Centros de
Servicios de Medicare y Medicaid (CMS, por sus siglas en inglés). Usted puede accesar los
resultados visitando https://www.medicare.gov/hospitalcompare/OASCAHPS-measures.html.
Centers for Medicare & Medicaid Services Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual
APPENDIX J:
GENERAL GUIDELINES FOR TELEPHONE INTERVIEWERS
Appendix J: General Guidelines for Telephone Interviewers November 2018
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OUTPATIENT AND AMBULATORY SURGERY CAHPS SURVEY
GENERAL GUIDELINES FOR TELEPHONE INTERVIEWING
Overview
The Outpatient and Ambulatory Surgery (OAS) CAHPS Survey is administered as an electronic
system telephone interview. As a telephone interviewer on the OAS CAHPS, you will use the
system to conduct each interview. The questions you ask are programmed into a computer. The
phone number is provided by the computer for you to make the call. You will read the questions
from the computer screen and enter the answer to each question into the computer. Based on the
answer you enter, the computer will automatically take you to a screen with the next applicable
question.
You play an extremely important role in the overall success of this study. You are the link to the
hundreds of respondents who will provide valuable information to the project team. You are the
person who develops rapport with the respondents, assures them that their participation is
important, and obtains their full cooperation and informed consent.
As a professional interviewer, your job is to help each respondent feel at ease and comfortable
with the interview. Key to accomplishing this goal is to be fully informed about the survey, the
interview, and the data collection procedures.
General Interviewing Techniques
The process of asking questions, probing, and entering responses correctly is crucial to obtaining
high-quality data for the OAS CAHPS Survey. General techniques and procedures you should
follow when conducting the OAS CAHPS Survey interviews are provided below.
Administering Survey Questions
• Ask the questions exactly as they are presented. Do not change the wording or condense
any question when reading it to the respondent.
• Emphasize all words or phrases that appear in bold, are underlined, or appear in italics.
• Ask every question specified, even when a respondent has seemingly provided the
answer as part of the response to a preceding question. The answer received in the
context of one question may not be the same answer that will be received when the other
question is asked. If it becomes cumbersome to the respondent, remind him or her gently
that you must ask all questions of all respondents.
• If the answer to a question indicates that the respondent did not understand the intent of
the question, or if the respondent requests that any part of the question be clarified, even
if it is only one word, repeat the question.
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J-2 Centers for Medicare & Medicaid Services Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual
• Read the questions slowly, at a pace that allows them to be readily understood.
Remember that the respondent has not heard these questions before and will not have had
the exposure that you have had to the questionnaire.
• Transition statements are designed to inform the respondent of the nature of an upcoming
question or a series of questions, to define a word, or to describe what is being asked for
in the question. Read transition statements just as they are presented. Don’t create
“transition statements” of your own, because these may unintentionally introduce bias
into the interview.
• Give the respondent plenty of time to recall past events.
• Do not suggest answers to the respondent. Your job as an interviewer is to read the
questions exactly as they are printed, make sure the respondent understands the question,
and then enter the responses. Do not help the respondent answer the questions.
• Ask questions in the exact order in which they are presented.
• Do not read words that appear in ALL CAPITAL LETTERS to the respondent. This
includes both questions and response categories.
• Read all questions including those that may appear to be sensitive to the respondent in the
same manner with no hesitation or change in inflection.
• Thoroughly familiarize yourself with the Frequently Asked Questions list before you
conduct interviews so that you are knowledgeable about the OAS CAHPS Survey.
• At the end of the interview, tell the sample member that the survey is completed and
thank him or her for taking part in the survey.
Introducing the Survey
The introduction is of the utmost importance to successfully completing a telephone interview.
Most people hang up in the first few minutes of the interview, so if you can convince the
respondent to remain on the line long enough to hear the purpose of the study and begin asking
the questions, the chances that your respondent will complete the interview increase
dramatically.
• When reading the introduction, sound confident and pronounce the words as clearly as
you can.
• Respondents are typically not expecting survey research calls, so they may need your
help to clarify the nature of the call.
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• Practice the introduction until you can present it in such a manner that your presentation
sounds confident, sincere, and natural.
• Deliver the introduction at a conversational pace. Rushing through the introduction gives
an impression of lack of confidence and may also cause the listener to misunderstand.
• Try not to pause too long before asking the first question in the survey following the
introduction. A pause tends to indicate that you are waiting for approval to continue.
Avoiding Refusals
The first and most critical step in avoiding refusals is your effort to establish rapport with
reluctant sample members, therefore minimizing the incidence of refusals. Remember, you will
not be able to call back and convert a refusal―your initial contact with the sample member is the
only chance you will have to create a successful interview. The following are some tips to follow
to avoid refusals.
• Make sure you are mentally prepared when you start each call, and have a positive
attitude.
• Treat respondents the way you would like to be treated.
• Always use an effective/positive/friendly tone and maintain a professional outlook.
• Pay careful attention to what the respondent says during the interview.
• Listen to the respondent completely rather than assuming you know what he or she is
objecting to.
• Listen before evaluating and entering a response code.
• Be accommodating to the respondents’ needs.
• Always remain in control of the interaction.
• Understand the reason for reluctance/refusal at the start of the call, or figure it out as
quickly as possible.
• Listen as an ally, not an adversary, and do not debate or argue with the respondent.
• Be prepared to address one (or more) reason(s) for reluctance/refusal.
• Focus your comments to sample members on why they specifically are important to the
study.
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J-4 Centers for Medicare & Medicaid Services Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual
• Paraphrase what you hear and repeat this back to the respondent.
• Remember that you are a professional representative of your survey organization and the
health care facility whose patients you are contacting.
General Interviewing Guidance
The following sections provide guidance on the use of neutral feedback, probes, avoiding bias,
and entering responses accurately. By following these rules, interviewers will help ensure that
the OAS CAHPS Survey interviews are conducted in a standardized manner.
Providing Neutral Positive Feedback
The use of neutral feedback can help build rapport with sample members. Periodically
acknowledging the respondent during the interview can help gain and retain cooperation during
the interview.
Acceptable neutral acknowledgment words:
• Thank you
• All right
• Okay
• I understand
• Let me repeat the question
Probing
At times, it will be necessary for you to probe to obtain a more complete or more specific answer
from a respondent. To elicit an acceptable response, you will often need to use an appropriate
neutral or nondirective probe. The important thing to remember is not to suggest answers or lead
the respondent. Some general rules for probing follow:
• Repeat the question if the respondent misunderstood or misinterpreted the question. After
hearing the question the second time, the respondent will probably understand what
information is expected.
• Use a silent probe, which is pausing or hesitating to indicate to the respondent that you
need additional or better information. This is a good probe to use after you have
determined the respondent’s response pattern.
• Use neutral questions or statements to encourage a respondent to elaborate on an
inadequate response. Examples of neutral probes include the following: “What do you
November 2018 Appendix J: General Guidelines for Telephone Interviewers
Centers for Medicare & Medicaid Services J-5 Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual
mean?” “How do you mean?” “Tell me what you have in mind.” “Tell me more
about….”
• Use clarification probes when the response is unclear, ambiguous, or contradictory. Be
careful not to appear to challenge the respondent when clarifying a statement and always
use a neutral probe. Examples of clarification probes are “Can you give me an example?”
or “Could you be more specific?”
• Encourage the respondent to give his or her best guess if a respondent gives a “don’t
know” response. Let the respondent know that this is not a test and there are no right or
wrong answers. We are interested in the respondent’s opinions and assessment of the care
that he or she has received at their ambulatory surgery center or hospital outpatient
department.
• If the respondent asks you to answer the question for him or her, let the respondent know
that you cannot. Instead, ask the respondent if she or he requires clarification on the
content or meaning of the question.
Avoiding Bias
One common pitfall of interviewing is unknowingly introducing bias into an interview. Bias
occurs when an interviewer says or does something that affects the answers respondents give in
an interview. An interview that has significant bias will not provide accurate data for the research
being conducted; such an interview may have to be thrown out.
As a professional interviewer, remaining neutral at all times ensures that bias is not introduced
into the interview. There are many things you can do or avoid to help ensure that no bias is
introduced. You should
• read all statements and questions exactly as they are written,
• use neutral probes that do not suggest answers,
• not provide your own personal opinions or answers in an effort to “help” respondents,
and
• not use nonverbal language, such as a cough, pause or a yawn to influence the interview.
Taking these steps to monitor your own spoken and unspoken language will go a long way to
guarantee that the interviews you conduct are completed correctly and efficiently.
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J-6 Centers for Medicare & Medicaid Services Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual
Entering Responses
The majority of the questions you will ask have precoded responses. To enter a response for
these types of questions, you will simply select the appropriate response option and enter the
number corresponding to that response.
The conventions presented below must be followed at all times to ensure that the responses you
enter accurately reflect the respondents’ answers and to ensure that questionnaire data are all
collected in the same systematic manner.
• You must listen to what the respondent says and enter the appropriate answer if the
response satisfies the objective of the question. If the answer does not appear to satisfy
the objective, repeat the question.
• In entering answers to open-ended questions or “Other (specify)” categories, enter the
response verbatim, exactly as it was given by the respondent.
• Enter the response immediately after it is given.
• If a respondent gives a range in response to a question, probe as appropriate for a more
specific answer. For example, if a respondent says, “Oh, 2 or 3 times” and you can enter
only one number, ask for clarification: “Would that be closer to 2 or to 3?”
Rules for Successful Telephone Interviewing
Remember, the key to successful interviewing is being prepared for every contact that you make.
Have a complete set of the appropriate materials at your work station, organized in such a
manner that you do not have to stop and search for required documents. Some general rules that
you should follow every time you place a call are provided below.
1. Be prepared before you place a call. Be prepared to talk to the sample member. You should
be able to explain the purpose of your call to the sample member or his or her family and
friends. Do not rely on your memory alone to answer questions. Make sure you review and
understand the Frequently Asked Questions (FAQs).
2. Act professionally. Convey to sample members that you are a professional who specializes in
asking questions and conducting interviews. As a professional interviewer, you have specific
tasks to accomplish for this survey.
3. Make the most of your contact. Even though you may not be able to obtain an interview on
this call, it is important to make the most of the contact to aid in future attempts. For
example, if you are trying to contact the sample member and he or she is not available, gain
as much information as you can to help reach the sample member the next time he or she is
called. Important questions to ask:
November 2018 Appendix J: General Guidelines for Telephone Interviewers
Centers for Medicare & Medicaid Services J-7 Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual
◦ When is the sample member usually home?
◦ What is the best time to reach the sample member?
◦ Can you schedule an “appointment” to reach the sample member at a later time?
4. Don’t be too quick to code a sample member as incapable. Some sample members may be
hard of hearing or appear not to fully understand you when you call. Rather than immediately
coding these cases as “Incapable,” please attempt to set a call-back for a different time of day
and different day of the week. It is possible that reaching the sample member at a different
time may result in your being able to conduct the interview with him or her. It is also
possible that a friend or family member can assist the sample member with the interview.
You cannot allow them to proxy for the sample member, but you can allow them to provide
general help.
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Centers for Medicare & Medicaid Services Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual
APPENDIX K:
XML DATA FILE LAYOUT FOR STANDARD HEADER RECORD
Appendix K: XML Data File Layout for Standard Header Record November 2018
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STANDARD XML DATA FILE LAYOUT
OUTPATIENT AND AMBULATORY CAHPS SURVEY
STANDARD HEADER RECORD
The following section defines the format of the Header Record.
NOTE: Each element must have a closing tag that is the same as the opening tag but with a forward slash. Data element names do not contain
any spaces, underscores, or capital letters.
XML Element Description Valid Values Data Type Field
Size
Data
Element
Required
Type of Header Record
headertype
This header element should only occur once
per file.
Example: headertype 1 /headertype
Type of Header Record 1 = Standard Header
Record
Numeric 1 Yes
Provider Name
<providername
This header element should only occur once
per file.
Example: providername
SampleHOPDASCName / providername
This is the HOPD’s or ASC’s
Provider Name
— Alphanumeric 100 Yes
Provider Number
providernum
This header element will occur again as an
administrative data element in the patient level
data record.
Example: providernum 123456 /
providernum
This is the HOPD’s or ASC’s
CMS Certification Number
(CCN, formerly known as the
Medicare Provider ID Number)
No Dashes or spaces
Valid 6- or 10-digit CMS
Certification Number
(CCN)
Alphanumeric 10 Yes
Ap
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K: X
ML
Data
File
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XML Element Description Valid Values Data Type Field
Size
Data
Element
Required
Sample Month
samplemonth This header element will occur again as an
administrative data element in the patient level
data record.
Example: samplemonth 12 /
samplemonth
Survey vendors will select a
sample of patients who meet
survey eligibility criteria for each
calendar month. The Sample
Month is the month for which the
sample was selected.
MM
(1 – 12 = January –
December)
Numeric 2 Yes
Sample Year
sampleyear This header element will occur again as an
administrative data element in the patient level
data record.
Example: sampleyear 2016 /
sampleyear
This is the calendar year in which
the survey is conducted.
YYYY
(2016 or greater)
Numeric 4 Yes
Survey Mode
surveymode
This header element will occur again as an
administrative data element in the patient level
data record.
Example: surveymode 1 / surveymode
The survey mode, either mail
only, phone only, or mixed mode,
must be the same for all sample
members in each sample month in
the calendar quarter for all of the
HOPD or ASC locations under
the same CCN.
1 = Mail only
2 = Telephone only
3 = Mixed mode
Numeric 1 Yes
Type of Sampling
sampletype
This header element should only occur once
per file.
Example: sampletype 1 /sampletype
Type of sampling used. Note:
Sample Type must be the same
for all three months in each
quarter.
1 = Census
2 = Simple random
sampling
3 = Stratified systematic
sampling
4 = Proportionate
Stratified Random
sampling
Numeric 1 Yes
No
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XML Element Description Valid Values Data Type Field
Size
Data
Element
Required
Patients Served
patientsserved
This header element should only occur once
per file.
Example: patientsserved 600 /
patientsserved
This is the total number of
patients who had at least one
outpatient surgery or procedure
during the sample month at the
HOPD or ASC, regardless of
whether the patient or surgery was
OAS CAHPS eligible.
1 – 999999
M = Unknown/Missing
Alphanumeric 6 Yes
Patients on file(s) submitted to Vendor
patientsfile
This header element should only occur once
per file.
Example: patientsfile 595 /patientsfile
Number of patients included on
the file that the vendor received
for this HOPD or ASC.
1 – 999999 Numeric 6 Yes
Eligible Patients
eligiblepatients
This header element should only occur once
per file.
Example: eligiblepatients 500 /
eligiblepatients
This is the number of patients in
the file submitted by the HOPD or
ASC that meet survey eligibility
criteria in the sample month.
1 – 999999 Numeric 6 Yes
Sampled Patients
sampledpatients
This header element should only occur once
per file.
Example: sampledpatients 450 /
sampledpatients
This is the number of patients
selected for the survey during the
sample month.
1 – 999999 Numeric 6 Yes
Ap
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dix
K: X
ML
Data
File
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PATIENT ADMINISTRATIVE DATA RECORD
The following section defines the format of the patient level data record.
NOTE: Each element must have a closing tag that is the same as the opening tag but with a forward slash. Data element names do not contain
any spaces, underscores, or capital letters.
XML Element Description Valid Values Data Type Field
Size
Data
Element
Required
Provider Number
providernum
This administrative element also occurs in the
previous Header Record.
Example: providernum 123456 /
providernum
This is the HOPD’s or ASC’s
CMS Certification Number
(CCN, formerly known as the
Medicare Provider ID Number)
No Dashes or spaces
Valid 6- or 10-digit CMS
Certification Number
(CCN)
Alphanumeric 10 Yes
Sample Month
samplemonth This administrative element also occurs in the
previous Header Record.
Example: samplemonth 12 /
samplemonth
OAS CAHPS Survey sampling
month
MM
(1 – 12 = January –
December)
Numeric 2 Yes
Sample Year
sampleyear This administrative element also occurs in the
previous Header Record.
Example: sampleyear 2016 /
sampleyear
Year of sample month YYYY
(2016 or greater)
Numeric 4 Yes
No
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XML Element Description Valid Values Data Type Field
Size
Data
Element
Required
Sample ID No.
sampleid This administrative element should only occur
once per patient.
Example: sampleid 1234567 /sampleid
Survey vendors will assign a
unique de-identified sample
identification number (SID) to
each patient. The SID number
will be used to track the survey
status of the patient throughout
the survey administration process
and to designate sample patients
on the data file submitted to the
Data Center.
Maximum of 16
characters
Alphanumeric 16 Yes
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XML Element Description Valid Values Data Type Field
Size
Data
Element
Required
Surgical Category
surgicalcat This administrative element should only occur
once per patient.
Example: surgicalcat 1 /surgicalcat
This is the category for the
surgery, and must be one of the
following options:
Gastrointestinal (GI), Orthopedic,
Ophthalmologic, Other, Missing.
If CPT27
code(s) in range 40000–
49999 or G-code(s) G0105,
G0121, or G0104, assign surgical
category 1.
If CPT code(s) in range 20000–
29999 or G-code is G0260, assign
surgical category 2.
If CPT code(s) in range 65000–
68899, assign surgical category 3.
If CPT code(s) in range 10021–
19999, 30000–39999, 50000–
64999, or 68900–69990 or if G-
code(s) not in the range for
surgical categories 1, 2, or 3,
assign surgical category 4.
If surgical category cannot be
determined, assign category 5.
1 = Gastrointestinal (GI)
2 = Orthopedic
3 = Ophthalmologic
4 = Other
5 = Missing
Numeric 1 Yes
27 CPT only copyright 2019 American Medical Association. All rights reserved.
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XML Element Description Valid Values Data Type Field
Size
Data
Element
Required
Age
patientage
This administrative element should only occur
once per patient.
Example: patientage 7 /patientage
Category for patient’s age as of
date of surgery/procedure.
(Patients must be 18 or older at
the date of surgery/procedure to
be eligible for the survey.)
18–24 .......................... 1
25–29 .......................... 2
30–34 .......................... 3
35–39 .......................... 4
40–44 .......................... 5
45–49 .......................... 6
50–54 .......................... 7
55–59 .......................... 8
60–64 .......................... 9
65–69 ........................ 10
70–74 ........................ 11
75–79 ........................ 12
80–84 ........................ 13
85–89 ........................ 14
90 or older................. 15
Unknown/Missing .... M
NOT APPLICABLE .. X
Alphanumeric 2 Yes
Gender
patientgender This administrative element should only occur
once per patient.
Example: patientgender 1 /
patientgender
Patient’s gender 1 = Male
2 = Female
M = Unknown/Missing
X = NOT APPLICABLE
Alphanumeric 1 Yes
Survey Mode
surveymode
This administrative element should only occur
once per patient.
Example: surveymode 1 /surveymode
This is the mode of data
collection the patient used to
complete the survey. Apply code
“X” (Not Applicable) to all
sampled cases where the survey
does not result in a Complete
(code 110 or 120) or a Breakoff
(code 310).
1 = Mail only
2 = Telephone only
X = NOT APPLICABLE
Alphanumeric 1 Yes
Ap
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XML Element Description Valid Values Data Type Field
Size
Data
Element
Required
Lag Time
<lagtime>
This administrative element should only occur
once per patient.
Example: lagtime 51 /lagtime
The number of calendar days
between the date of eligible
surgery/procedure and the date
when this patient’s survey was
initiated.
0–90
X = NOT APPLICABLE
Alphanumeric 2 Yes
Final Survey Status
finalstatus
This administrative element should only occur
once per patient.
Example: finalstatus 110 /finalstatus
Final disposition of survey 110 = Completed Mail
Survey
120 = Completed Phone
Survey
210 = Ineligible:
Deceased
220 = Ineligible: Does
not Meet Eligibility
criteria
230 = Ineligible:
Language Barrier
240 = Ineligible:
Mentally or
Physically
Incapacitated
310 = Breakoff
320 = Refusal
330 = Bad Address/
Undeliverable Mail
340 = Wrong/Disc/No
Telephone Number
350 = No response after
Maximum attempts
Numeric 3 Yes
No
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XML Element Description Valid Values Data Type Field
Size
Data
Element
Required
Survey Language
language This administrative data element should only
occur once per patient.
Example: language 1 /language
Identify language in which survey
was completed
1 = English
2 = Spanish
3 = Chinese
4 = Korean
X = NOT APPLICABLE
Alphanumeric 1 Yes
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PATIENT RESPONSE RECORD
The following section defines the format of the Patient Response Record.
NOTE: Each element must have a closing tag that is the same as the opening tag but with a forward slash. Data element names do not contain
any spaces, underscores, or capital letters.
XML Element Description Valid Values Data Type Field
Size
Data
Element
Required
Q1 Informed
informed
This patient response data element should only
occur once per patient.
Example: informed 1 /informed
Before your procedure, did your
doctor or anyone from the facility
give you all the information you
needed about your procedure?
Yes, definitely............. 1
Yes, somewhat ............ 2
No ............................... 3
MISSING/DK ........... M
Alphanumeric 1 Yes
Q2 Instructions
instructions
This patient response data element should only
occur once per patient.
Example: instructions 1 /instructions
Before your procedure, did your
doctor or anyone from the facility
give you easy to understand
instructions about getting ready
for your procedure?
Yes, definitely............. 1
Yes, somewhat ............ 2
No ............................... 3
MISSING/DK ........... M
Alphanumeric 1 Yes
Q3 Check In
checkin This patient response data element should only
occur once per patient.
Example: checkin 1 /checkin
Did the check-in process run
smoothly?
Yes, definitely............. 1
Yes, somewhat ............ 2
No ............................... 3
MISSING/DK ........... M
Alphanumeric 1 Yes
Q4 Clean
clean
This patient response data element should only
occur once per patient.
Example: clean 1 /clean
Was the facility clean? Yes, definitely............. 1
Yes, somewhat ............ 2
No ............................... 3
MISSING/DK ........... M
Alphanumeric 1 Yes
Q5 Clerk Helpful
clerkhelpful This patient response data element should only
occur once per patient.
Example: clerkhelpful 1 /clerkhelpful
Were the clerks and receptionists
at the facility as helpful as you
thought they should be?
Yes, definitely............. 1
Yes, somewhat ............ 2
No ............................... 3
MISSING/DK ........... M
Alphanumeric 1 Yes
No
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XML Element Description Valid Values Data Type Field
Size
Data
Element
Required
Q6 Clerk Respect
clerkrespect
This patient response data element should only
occur once per patient.
Example: clerkrespect 1 /clerkrespect
Did the clerks and receptionists at
the facility treat you with courtesy
and respect?
Yes, definitely............. 1
Yes, somewhat ............ 2
No ............................... 3
MISSING/DK ........... M
Alphanumeric 1 Yes
Q7 Dr. Respect
drrespect
This patient response data element should only
occur once per patient.
Example: drrespect 1 /drrespect
Did the doctors and nurses treat
you with courtesy and respect?
Yes, definitely............. 1
Yes, somewhat ............ 2
No ............................... 3
MISSING/DK ........... M
Alphanumeric 1 Yes
Q8 Dr. Comfort
drcomfort
This patient response data element should only
occur once per patient.
Example: drcomfort 1 /drcomfort
Did the doctors and nurses make
sure you were as comfortable as
possible?
Yes, definitely............. 1
Yes, somewhat ............ 2
No ............................... 3
MISSING/DK ........... M
Alphanumeric 1 Yes
Q9 Dr. Explain
drexplain
This patient response data element should only
occur once per patient.
Example: drexplain 1 /drexplain
Did the doctors and nurses
explain your procedure in a way
that was easy to understand?
Yes, definitely............. 1
Yes, somewhat ............ 2
No ............................... 3
MISSING/DK ........... M
Alphanumeric 1 Yes
Q10 Anesthesia
anesthesia
This patient response data element should only
occur once per patient.
Example: anesthesia 1 /anesthesia
Anesthesia is something that
would make you feel sleepy or go
to sleep during your procedure.
Were you given anesthesia?
Yes .............................. 1
No ............................... 2
MISSING/DK ........... M
Alphanumeric 1 Yes
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XML Element Description Valid Values Data Type Field
Size
Data
Element
Required
Q11 Anesthesia Explain
anesthesiaexplain
This patient response data element should only
occur once per patient.
Example: anesthesiaexplain 2 /
anesthesiaexplain
Did your doctor or anyone from
the facility explain the process of
giving anesthesia in a way that
was easy to understand?
Yes, definitely............. 1
Yes, somewhat ............ 2
No ............................... 3
MISSING/DK ........... M
NOT APPLICABLE .. X
Alphanumeric 1 Yes
Q12 Anesthesia Side
anesthesiaside
This patient response data element should only
occur once per patient.
Example: anesthesiaside 1 /
anesthesiaside
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............. 1
Yes, somewhat ............ 2
No ............................... 3
MISSING/DK ........... M
NOT APPLICABLE .. X
Alphanumeric 1 Yes
Q13 Discharge Instructions
dischargeinstructions This patient response data element should only
occur once per patient.
Example: dischargeinstructions 1 /
dischargeinstructions
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?
Yes .............................. 1
No ............................... 2
MISSING/DK ........... M
Alphanumeric 1 Yes
Q14 Recovery
recovery
This patient response data element should only
occur once per patient.
Example: recovery 1 /recovery
Did your doctor or anyone from
the facility prepare you for what
to expect during your recovery?
Yes, definitely............. 1
Yes, somewhat ............ 2
No ............................... 3
MISSING/DK ........... M
Alphanumeric 1 Yes
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XML Element Description Valid Values Data Type Field
Size
Data
Element
Required
Q15 Pain Info
paininfo This patient response data element should only
occur once per patient.
Example: paininfo 1 /paininfo
Some ways to control pain
include prescription medicine,
over-the-counter pain relievers or
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, definitely............. 1
Yes, somewhat ............ 2
No ............................... 3
MISSING/DK ........... M
Alphanumeric 1 Yes
Q16 Pain Result
painresult
This patient response data element should only
occur once per patient.
Example: painresult 1 /painresult
At any time after leaving the
facility, did you have pain as a
result of your procedure?
Yes .............................. 1
No ............................... 2
MISSING/DK ........... M
Alphanumeric 1 Yes
Q17 Nausea
nausea
This patient response data element should only
occur once per patient.
Example: nausea 1 /nausea
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?
Yes, definitely............. 1
Yes, somewhat ............ 2
No ............................... 3
MISSING/DK ........... M
Alphanumeric 1 Yes
Q18 Nausea Result
nausearesult
This patient response data element should only
occur once per patient.
Example: nausearesult 1 /nausearesult
At any time after leaving the
facility, did you have nausea or
vomiting as a result of either your
procedure or the anesthesia?
Yes .............................. 1
No ............................... 2
MISSING/DK ........... M
Alphanumeric 1 Yes
Q19 Bleeding Instruction
bleedinginstruction This patient response data element should only
occur once per patient.
Example: bleedinginstruction 1 /
bleedinginstruction
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?
Yes, definitely............. 1
Yes, somewhat ............ 2
No ............................... 3
MISSING/DK ........... M
Alphanumeric 1 Yes
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XML Element Description Valid Values Data Type Field
Size
Data
Element
Required
Q20 Bleeding Result
bleedingresult
This patient response data element should only
occur once per patient.
Example: bleedingresult 1
bleedingresult
At any time after leaving the
facility, did you have bleeding as
a result of your procedure?
Yes .............................. 1
No ............................... 2
MISSING/DK ........... M
Alphanumeric 1 Yes
Q21 Infection Info
infectioninfo This patient response data element should only
occur once per patient.
Example: infectioninfo 1 /infectioninfo
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 if
you had possible signs of
infection?
Yes, definitely............. 1
Yes, somewhat ............ 2
No ............................... 3
MISSING/DK ........... M
Alphanumeric 1 Yes
Q22 Infections Signs
infectionsigns This patient response data element should only
occur once per patient.
Example: infectionsigns 1 /
infectionsigns
At any time after leaving the
facility, did you have any signs of
infection?
Yes .............................. 1
No ............................... 2
MISSING/DK ........... M
Alphanumeric 1 Yes
No
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XML Element Description Valid Values Data Type Field
Size
Data
Element
Required
Q23 Rate Facility
ratefacility This patient response data element should only
occur once per patient.
Example: ratefacility 2 /ratefacility
Using any number from 0 to 10,
where 0 is the worst facility
possible and 10 is the best facility
possible, what number would you
use to rate this facility?
Worst facility
possible ....................... 0
.................................... 1
.................................... 2
.................................... 3
.................................... 4
.................................... 5
.................................... 6
.................................... 7
.................................... 8
.................................... 9
Best facility possible . 10
MISSING/DK ........... M
Alphanumeric 2 Yes
Q24 Recommend
recommend This patient response data element should only
occur once per patient.
Example: recommend 2 /recommend
Would you recommend this
facility to your friends and
family?
Definitely no ............... 1
Probably no ................. 2
Probably yes ............... 3
Definitely yes.............. 4
MISSING/DK ........... M
Alphanumeric 1 Yes
Q25 Rate Overall
rateoverall This patient response data element should only
occur once per patient.
Example: rateoverall 1 /rateoverall
In general, how would you rate
your overall health?
Excellent ..................... 1
Very good ................... 2
Good ........................... 3
Fair .............................. 4
Poor ............................ 5
MISSING/DK ........... M
Alphanumeric 1 Yes
Q26 Rate Overall Mental
rateoverallmental This patient response data element should only
occur once per patient.
Example: rateoverallmental 1 /
rateoverallmental
In general, how would you rate
your overall mental or emotional
health?
Excellent ..................... 1
Very good ................... 2
Good ........................... 3
Fair .............................. 4
Poor ............................ 5
MISSING/DK ........... M
Alphanumeric 1 Yes
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XML Element Description Valid Values Data Type Field
Size
Data
Element
Required
Q27 Age
age This patient response data element should only
occur once per patient.
Example: age 1 /age
What is your age? 18 to 24 ....................... 1
25 to 34 ....................... 2
35 to 44 ....................... 3
45 to 54 ....................... 4
55 to 64 ....................... 5
65 to 74 ....................... 6
75 to 79 ....................... 7
80 to 84 ....................... 8
85 or older................... 9
MISSING/DK ........... M
Alphanumeric 1 Yes
Q28 Gender
gender This patient response data element should only
occur once per patient.
Example: gender 1 /gender
Are you male or female? Male ............................ 1
Female ........................ 2
MISSING/DK ........... M
Alphanumeric 1 Yes
Q29 Education
education This patient response data element should only
occur once per patient.
Example: education 3 /education
What is the highest grade or level
of school that you have
completed?
8th grade or less .......... 1
Some high school,
but did not graduate .... 2
High school graduate
or GED ....................... 3
Some college or 2-
year degree.................. 4
4-year college
graduate ...................... 5
More than 4-year
college degree ............. 6
MISSING/DK ........... M
Alphanumeric 1 Yes
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Size
Data
Element
Required
Q30 Ethnicity
ethnicity This patient response data element should only
occur once per patient.
Example: ethnicity 2 /ethnicity
Are you of Hispanic, Latino, or
Spanish origin?
Yes .............................. 1
No ............................... 2
MISSING/DK ........... M
Alphanumeric 1 Yes
Q31 Group
group
This patient response data element should only
occur once per patient.
Example: group 1 /group
Which group best describes you? Mexican, Mexican
American,
Chicano ....................... 1
Puerto Rican ............... 2
Cuban .......................... 3
Another Hispanic,
Latino, or Spanish
origin .......................... 4
MISSING/DK ........... M
NOT APPLICABLE .. X
Alphanumeric 1 Yes
Q32 Race White-mail
racewhite-mail
This patient response data element should only
occur once per patient.
Example: racewhite-mail 1 /racewhite-
What is your race? You may
select one or more categories.
White .......................... 1
MISSING/DK ........... M
NOT APPLICABLE .. X
Alphanumeric 1 Yes
Q32 Race African American-mail
raceafricanamer-mail This patient response data element should only
occur once per patient.
Example: raceafricanamer-mail 1
/raceafricanamer-mail
What is your race? You may
select one or more categories.
Black or African
American .................... 1
MISSING/DK ........... M
NOT APPLICABLE .. X
Alphanumeric 1 Yes
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XML Element Description Valid Values Data Type Field
Size
Data
Element
Required
Q32 Race American Indian-mail
raceamerindian-mail This patient response data element should only
occur once per patient.
Example: raceamerindian-mail 1 /
raceamerindian-mail
What is your race? You may
select one or more categories.
American Indian or
Alaska Native ............. 1
MISSING/DK ........... M
NOT APPLICABLE .. X
Alphanumeric 1 Yes
Q32 Race Asian Indian-mail
raceasianindian-mail This patient response data element should only
occur once per patient.
Example: raceasianindian-mail 1 /
raceasianindian-mail
What is your race? You may
select one or more categories.
Asian Indian................ 1
MISSING/DK ........... M
NOT APPLICABLE .. X
Alphanumeric 1 Yes
Q32 Race Chinese-mail
racechinese-mail This patient response data element should only
occur once per patient.
Example: racechinese-mail 1 /
racechinese-mail
What is your race? You may
select one or more categories.
Chinese ....................... 1
MISSING/DK ........... M
NOT APPLICABLE .. X
Alphanumeric 1 Yes
Q32 Race Filipino-mail
racefilipino-mail This patient response data element should only
occur once per patient.
Example: racefilipino-mail 1 /
racefilipino-mail
What is your race? You may
select one or more categories.
Filipino ....................... 1
MISSING/DK ........... M
NOT APPLICABLE .. X
Alphanumeric 1 Yes
Q32 Race Japanese-mail
racejapanese-mail This patient response data element should only
occur once per patient.
Example: racejapanese-mail 1 /
racejapanese-mail
What is your race? You may
select one or more categories.
Japanese ...................... 1
MISSING/DK ........... M
NOT APPLICABLE .. X
Alphanumeric 1 Yes
No
vem
be
r 20
18
A
pp
en
dix
K: X
ML
Data
File
Layo
ut fo
r Sta
nd
ard
He
ad
er R
eco
rd
Cen
ters
for M
ed
ica
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Med
icaid
Se
rvic
es
K
-19
O
utp
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nt a
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Am
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urg
ery
CA
HP
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ey P
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ual
XML Element Description Valid Values Data Type Field
Size
Data
Element
Required
Q32 Race Korean-mail
racekorean-mail This patient response data element should only
occur once per patient.
Example: racekorean-mail 1 /
racekorean-mail
What is your race? You may
select one or more categories.
Korean ........................ 1
MISSING/DK ........... M
NOT APPLICABLE .. X
Alphanumeric 1 Yes
Q32 Race Vietnamese-mail
racevietnamese-mail This patient response data element should only
occur once per patient.
Example: racevietnamese-mail 1 /
racevietnamese-mail
What is your race? You may
select one or more categories.
Vietnamese ................. 1
MISSING/DK ........... M
NOT APPLICABLE .. X
Alphanumeric 1 Yes
Q32 Race Other Asian-mail
raceotherasian-mail This patient response data element should only
occur once per patient.
Example: raceotherasian-mail 1 /
raceotherasian-mail
What is your race? You may
select one or more categories.
Other Asian ................. 1
MISSING/DK ........... M
NOT APPLICABLE .. X
Alphanumeric 1 Yes
Q32 Race Native Hawaiian-mail
racenativehawaiian-mail This patient response data element should only
occur once per patient.
Example: racenativehawaiian-mail 1 /
racenativehawaiian-mail
What is your race? You may
select one or more categories.
Native Hawaiian ......... 1
MISSING/DK ........... M
NOT APPLICABLE .. X
Alphanumeric 1 Yes
Q32 Race Guamanian Chamorro-mail
raceguamanianchamorro-mail This patient response data element should only
occur once per patient.
Example: raceguamanianchamorro-mail
1 /raceguamanianchamorro-mail
What is your race? You may
select one or more categories.
Guamanian or
Chamorro .................... 1
MISSING/DK ........... M
NOT APPLICABLE .. X
Alphanumeric 1 Yes
Ap
pen
dix
K: X
ML
Data
File
Layo
ut fo
r Sta
nd
ard
He
ad
er R
eco
rd
No
vem
be
r 20
18
K-2
0
Cen
ters
for M
ed
ica
re &
Med
icaid
Se
rvic
es
Ou
tpatie
nt a
nd
Am
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urg
ery
CA
HP
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ey P
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nd
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lines M
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XML Element Description Valid Values Data Type Field
Size
Data
Element
Required
Q32 Race Samoan-mail
racesamoan-mail This patient response data element should only
occur once per patient.
Example: racesamoan-mail 1 /
racesamoan-mail
What is your race? You may
select one or more categories.
Samoan ....................... 1
MISSING/DK ........... M
NOT APPLICABLE .. X
Alphanumeric 1 Yes
Q32 Race Other Pacific Islander-mail
raceotherpacificislander-mail This patient response data element should only
occur once per patient.
Example: raceotherpacificislander-mail 1
/raceotherpacificislander-mail
What is your race? You may
select one or more categories.
Other Pacific
Islander ....................... 1
MISSING/DK ........... M
NOT APPLICABLE .. X
Alphanumeric 1 Yes
Q32 Race White-phone
racewhite-phone This patient response data element should only
occur once per patient.
Example: racewhite-phone 1 /racewhite-
phone
What is your race? You may
select one or more categories. Are
you…
White .......................... 1
MISSING/DK ........... M
NOT APPLICABLE .. X
Alphanumeric 1 Yes
Q32 Race African American-phone
raceafricanamer-phone
This patient response data element should only
occur once per patient.
Example: raceafricanamer-phone 1 /
raceafricanamer-phone
What is your race? You may
select one or more categories. Are
you…
Black or African
American .................... 1
MISSING/DK ........... M
NOT APPLICABLE .. X
Alphanumeric 1 Yes
Q32 Race American Indian-phone
raceamerindian-phone
This patient response data element should only
occur once per patient.
Example: raceamerindian-phone 1 /
raceamerindian-phone
What is your race? You may
select one or more categories. Are
you…
American Indian or
Alaska Native ............. 1
MISSING/DK ........... M
NOT APPLICABLE .. X
Alphanumeric 1 Yes
No
vem
be
r 20
18
A
pp
en
dix
K: X
ML
Data
File
Layo
ut fo
r Sta
nd
ard
He
ad
er R
eco
rd
Cen
ters
for M
ed
ica
re &
Med
icaid
Se
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es
K
-21
O
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nt a
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CA
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XML Element Description Valid Values Data Type Field
Size
Data
Element
Required
Q32 Race Asian-phone
raceasian-phone
This patient response data element should only
occur once per patient.
Example: raceasian-phone 1 /raceasian-
phone
What is your race? You may
select one or more categories. Are
you…
Asian ........................... 1
MISSING/DK ........... M
NOT APPLICABLE .. X
Alphanumeric 1 Yes
Q32 Race Native Hawaiian Pacific Islander-
phone
racenativehawaiianpacificislander-phone
This patient response data element should only
occur once per patient.
Example:
racenativehawaiianpacificislander-phone 1
/racenativehawaiianpacificislander-phone
What is your race? You may
select one or more categories. Are
you…
Native Hawaiian or
Pacific Islander ........... 1
MISSING/DK ........... M
NOT APPLICABLE .. X
Alphanumeric 1 Yes
Q32 Race None of Above-phone
racenoneofabove-phone
This patient response data element should only
occur once per patient.
Example: racenoneofabove-phone 1 / racenoneofabove-phone
What is your race? You may
select one or more categories. Are
you…
NONE OF ABOVE .... 1
MISSING/DK ........... M
NOT APPLICABLE .. X
Alphanumeric 1 Yes
Q32a Race Asian Indian-phone
raceasianindian-phone
This patient response data element should only
occur once per patient.
Example: raceasianindian-phone 1 / raceasianindian-phone
Which groups best describe you?
You may select one or more
categories. Are you…
Asian Indian................ 1
MISSING/DK ........... M
NOT APPLICABLE .. X
Alphanumeric 1 Yes
Ap
pen
dix
K: X
ML
Data
File
Layo
ut fo
r Sta
nd
ard
He
ad
er R
eco
rd
No
vem
be
r 20
18
K-2
2
Cen
ters
for M
ed
ica
re &
Med
icaid
Se
rvic
es
Ou
tpatie
nt a
nd
Am
bu
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ry S
urg
ery
CA
HP
S S
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ey P
roto
co
ls a
nd
Gu
ide
lines M
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XML Element Description Valid Values Data Type Field
Size
Data
Element
Required
Q32a Race Chinese-phone
racechinese-phone
This patient response data element should only
occur once per patient.
Example: racechinese-phone 1
/racechinese-phone
Which groups best describe you?
You may select one or more
categories. Are you…
Chinese ....................... 1
MISSING/DK ........... M
NOT APPLICABLE .. X
Alphanumeric 1 Yes
Q32a Race Filipino-phone
racefilipino-phone
This patient response data element should only
occur once per patient.
Example: racefilipino-phone 1
/racefilipino-phone
Which groups best describe you?
You may select one or more
categories. Are you…
Filipino ....................... 1
MISSING/DK ........... M
NOT APPLICABLE .. X
Alphanumeric 1 Yes
Q32a Race Japanese-phone
racejapanese-phone
This patient response data element should only
occur once per patient.
Example: racejapanese-phone 1 /
racejapanese-phone
Which groups best describe you?
You may select one or more
categories. Are you…
Japanese ...................... 1
MISSING/DK ........... M
NOT APPLICABLE .. X
Alphanumeric 1 Yes
Q32a Race Korean-phone
racekorean-phone
This patient response data element should only
occur once per patient.
Example: racekorean-phone 1 /
racekorean-phone
Which groups best describe you?
You may select one or more
categories. Are you…
Korean ........................ 1
MISSING/DK ........... M
NOT APPLICABLE .. X
Alphanumeric 1 Yes
Q32a Race Vietnamese-phone
racevietnamese-phone
This patient response data element should only
occur once per patient.
Example: racevietnamese-phone 1 /
racevietnamese-phone
Which groups best describe you?
You may select one or more
categories. Are you…
Vietnamese ................. 1
MISSING/DK ........... M
NOT APPLICABLE .. X
Alphanumeric 1 Yes
No
vem
be
r 20
18
A
pp
en
dix
K: X
ML
Data
File
Layo
ut fo
r Sta
nd
ard
He
ad
er R
eco
rd
Cen
ters
for M
ed
ica
re &
Med
icaid
Se
rvic
es
K
-23
O
utp
atie
nt a
nd
Am
bu
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ry S
urg
ery
CA
HP
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ey P
roto
co
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nd
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ide
lines M
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ual
XML Element Description Valid Values Data Type Field
Size
Data
Element
Required
Q32a Race Other Asian-phone
raceotherasian-phone
This patient response data element should only
occur once per patient.
Example: raceotherasian-phone 1 /
raceotherasian-phone
Which groups best describe you?
You may select one or more
categories. Are you…
Other Asian ................. 1
MISSING/DK ........... M
NOT APPLICABLE .. X
Alphanumeric 1 Yes
Q32a Race None of Above Asian Indian-
phone
racenoneofaboveasianindian-phone
This patient response data element should only
occur once per patient.
Example: racenoneofaboveasianindian-
phone 1 / racenoneofaboveasianindian-
phone
Which groups best describe you?
You may select one or more
categories. Are you…
NONE OF ABOVE .... 1
MISSING/DK ........... M
NOT APPLICABLE .. X
Alphanumeric 1 Yes
Q32b Race Native Hawaiian-phone
racenativehawaiian-phone
This patient response data element should only
occur once per patient.
Example: racenativehawaiian-phone 1 /
racenativehawaiian-phone
Which groups best describe you?
You may select one or more
categories. Are you…
Native Hawaiian ......... 1
MISSING/DK ........... M
NOT APPLICABLE .. X
Alphanumeric 1 Yes
Q32b Race Guamanian Chamorro-phone
raceguamanianchamorro-phone
This patient response data element should only
occur once per patient.
Example: raceguamanianchamorro-phone
1 /raceguamanianchamorro-phone
Which groups best describe you?
You may select one or more
categories. Are you…
Guamanian or
Chamorro .................... 1
MISSING/DK ........... M
NOT APPLICABLE .. X
Alphanumeric 1 Yes
Ap
pen
dix
K: X
ML
Data
File
Layo
ut fo
r Sta
nd
ard
He
ad
er R
eco
rd
No
vem
be
r 20
18
K-2
4
Cen
ters
for M
ed
ica
re &
Med
icaid
Se
rvic
es
Ou
tpatie
nt a
nd
Am
bu
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ry S
urg
ery
CA
HP
S S
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ey P
roto
co
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nd
Gu
ide
lines M
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ual
XML Element Description Valid Values Data Type Field
Size
Data
Element
Required
Q32b Race Samoan-phone
racesamoan-phone
This patient response data element should only
occur once per patient.
Example: racesamoan-phone 1 /
racesamoan-phone
Which groups best describe you?
You may select one or more
categories. Are you…
Samoan ....................... 1
MISSING/DK ........... M
NOT APPLICABLE .. X
Alphanumeric 1 Yes
Q32b Race Other Pacific Islander-phone
raceotherpacificislander-phone
This patient response data element should only
occur once per patient.
Example: raceotherpacificislander-phone
1 /raceotherpacificislander-phone
Which groups best describe you?
You may select one or more
categories. Are you…
Other Pacific
Islander ....................... 1
MISSING/DK ........... M
NOT APPLICABLE .. X
Alphanumeric 1 Yes
Q32b Race None of Above Pacific-phone
racenoneofabovepacific-phone
This patient response data element should only
occur once per patient.
Example: racenoneofabovepacific-phone
1 /racenoneofabovepacific-phone
Which groups best describe you?
You may select one or more
categories. Are you…
NONE OF ABOVE .... 1
MISSING/DK ........... M
NOT APPLICABLE .. X
Alphanumeric 1 Yes
Q33 Speak English
speakenglish This patient response data element should only
occur once per patient.
Example: speakenglish 1 /speakenglish
How well do you speak English?
(Would you say…)
Very well .................... 1
Well ............................ 2
Not well ...................... 3
Not at all ..................... 4
MISSING/DK ........... M
Alphanumeric 1 Yes
Q34 Speak Other
speakother This patient response data element should only
occur once per patient.
Example: speakother 1 /speakother
Do you speak a language other
than English at home?
Yes, speak language
other than English ....... 1
No, speak English at
home ........................... 2
MISSING/DK ........... M
Alphanumeric 1 Yes
No
vem
be
r 20
18
A
pp
en
dix
K: X
ML
Data
File
Layo
ut fo
r Sta
nd
ard
He
ad
er R
eco
rd
Cen
ters
for M
ed
ica
re &
Med
icaid
Se
rvic
es
K
-25
O
utp
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nt a
nd
Am
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urg
ery
CA
HP
S S
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XML Element Description Valid Values Data Type Field
Size
Data
Element
Required
Q35 Speak Other Specify
speakotherspecify This patient response data element should only
occur once per patient.
Example: speakotherspecify 1 /
speakotherspecify
What is that language? Spanish ....................... 1
Other ........................... 2
MISSING/DK ........... M
NOT APPLICABLE .. X
Alphanumeric 1 Yes
Q36 Help-mail
help This patient response data element should only
occur once per patient.
Example: help 1 /help
Did someone help you complete
this survey?
Yes .............................. 1
No ............................... 2
MISSING/DK ........... M
NOT APPLICABLE .. X
Alphanumeric 1 Yes
Q37 Help Read-mail
helpread This patient response data element should only
occur once per patient.
Example: helpread 1 /helpread
How did that person help you?
Check all that apply.
Read the questions
to me ........................... 1
MISSING/DK ........... M
NOT APPLICABLE .. X
Alphanumeric 1 Yes
Q37 Help Wrote-mail
helpwrote This patient response data element should only
occur once per patient.
Example: helpwrote 1 /helpwrote
How did that person help you?
Check all that apply.
Wrote down the
answers I gave ............ 1
MISSING/DK ........... M
NOT APPLICABLE .. X
Alphanumeric 1 Yes
Q37 Help Answer-mail
helpanswer This patient response data element should only
occur once per patient.
Example: helpanswer 1 /helpanswer
How did that person help you?
Check all that apply.
Answered the
questions for me ......... 1
MISSING/DK ........... M
NOT APPLICABLE .. X
Alphanumeric 1 Yes
Ap
pen
dix
K: X
ML
Data
File
Layo
ut fo
r Sta
nd
ard
He
ad
er R
eco
rd
No
vem
be
r 20
18
K-2
6
Cen
ters
for M
ed
ica
re &
Med
icaid
Se
rvic
es
Ou
tpatie
nt a
nd
Am
bu
lato
ry S
urg
ery
CA
HP
S S
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ey P
roto
co
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nd
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lines M
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ual
XML Element Description Valid Values Data Type Field
Size
Data
Element
Required
Q37 Help Translate-mail
helptranslate This patient response data element should only
occur once per patient.
Example: helptranslate 1 /
helptranslate
How did that person help you?
Check all that apply.
Translated the
questions into my
language ...................... 1
MISSING/DK ........... M
NOT APPLICABLE .. X
Alphanumeric 1 Yes
Q37 Help Other-mail
helpother This patient response data element should only
occur once per patient.
Example: helpother 1 /helpother
How did that person help you?
Check all that apply.
Helped in some
other way .................... 1
MISSING/DK ........... M
NOT APPLICABLE .. X
Alphanumeric 1 Yes
Q37 Help None-mail
helpnone This patient response data element should only
occur once per patient.
Example: helpnone 1 /helpnone
How did that person help you?
Check all that apply.
No one helped me
complete this survey ... 1
MISSING/DK ........... M
NOT APPLICABLE .. X
Alphanumeric 1 Yes
Centers for Medicare & Medicaid Services Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual
APPENDIX L:
XML DATA FILE LAYOUT FOR DISPROPORTIONATE STRATIFIED
RANDOM SAMPLING (DSRS) HEADER RECORD
Appendix L: XML Data File Layout for Disproportionate Stratified Random Sampling (DSRS) Header Record November 2018
Centers for Medicare & Medicaid Services Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual
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DSRS XML DATA FILE LAYOUT
OUTPATIENT AND AMBULATORY CAHPS SURVEY
DSRS HEADER RECORD
The following section defines the format of the Header Record.
NOTE: Each element must have a closing tag that is the same as the opening tag but with a forward slash. Data element names do not contain
any spaces, underscores, or capital letters.
XML Element Description Valid Values Data Type Field
Size
Data
Element
Required
Type of Header Record
headertype>
This header element should only occur once
per file.
Example: headertype 2 /headertype
Type of Header Record 2 = DSRS Numeric 1 Yes
Provider Name
<providername
This header element should only occur once
per file.
Example: providername
SampleHOPDASCName /providername
This is the HOPD’s or ASC’s
Provider Name
— Alphanumeric 100 Yes
Provider Number
providernum
This header element will occur again as an
administrative data element in the patient level
data record.
Example: providernum 123456 /
providernum
This is the HOPD’s or ASC’s
CMS Certification Number
(CCN, formerly known as the
Medicare Provider ID Number)
No Dashes or spaces
Valid 6- or 10-digit CMS
Certification Number
(CCN)
Alphanumeric 10 Yes
Ap
pen
dix
L: X
ML
Data
File
Layo
ut fo
r Dis
pro
po
rtion
ate
Stra
tified
Ran
do
m S
am
plin
g (D
SR
S) H
ead
er R
eco
rd
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XML Element Description Valid Values Data Type Field
Size
Data
Element
Required
Sample Month
samplemonth This header element will occur again as an
administrative data element in the patient level
data record.
Example: samplemonth 12 /
samplemonth
Survey vendors will select a
sample of patients who meet
survey eligibility criteria for each
calendar month. The Sample
Month is the month for which the
sample was selected.
MM
(1 – 12 = January –
December)
Numeric 2 Yes
Sample Year
sampleyear This header element will occur again as an
administrative data element in the patient level
data record.
Example: sampleyear 2016 /
sampleyear
This is the calendar year in which
the survey is conducted.
YYYY
(2016 or greater)
Numeric 4 Yes
Survey Mode
surveymode
This header element will occur again as an
administrative data element in the patient level
data record.
Example: surveymode 1 /surveymode
The survey mode, either mail
only, phone only, or mixed mode,
must be the same for all sample
members in each sample month in
the calendar quarter for all of the
HOPD or ASC locations and
strata under the same CCN.
1 = Mail only
2 = Telephone only
3 = Mixed mode
Numeric 1 Yes
Type of Sampling
sampletype
This header element should only occur once
per file.
Example: sampletype 5 /sampletype
Type of sampling used. Note:
Sample Type must be the same
for all three months in each
quarter.
5 = Disproportionate
stratified random
sampling
Numeric 1 Yes
A
pp
en
dix
L: X
ML
Data
File
Layo
ut fo
r Dis
pro
po
rtion
ate
No
vem
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r 20
18
S
tratifie
d R
an
do
m S
am
plin
g (D
SR
S) H
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er R
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rd
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XML Element Description Valid Values Data Type Field
Size
Data
Element
Required
DSRS Strata
dsrs-strata
This header element should occur once per
strata.
Example:
dsrs-strata
stratumname samedaysurgery /
stratumname
patientsserved 50 /patientsserved
patientsfile 40 /patientsfile
eligiblepatients 30 /eligiblepatients
sampledpatients 20 /
sampledpatients
/dsrs-strata
The DSRS Strata subsection
should occur once per stratum.
There is a minimum of two
Stratum required.
Each DSRS-Strata element must
contain the following five data
elements:
Stratum Name
# Patients Served
# Patients of File
# Eligible Patients
# Sampled Patients
Please refer to the sample DSRS
XML File available from the OAS
CAHPS website for a full
example of how to use the DSRS
Strata element.
n/a n/a n/a Yes
DSRS Stratum Name
stratumname
This header element should occur once per
strata.
Example: stratumname samedaysurgery
/stratumname
This is the name of the stratum. If DSRS, then at least 2
strata must be defined.
Strata names must be the
same within a quarter.
Categories can be
characters or numbers.
Alphanumeric 45 Yes
Patients Served for the Stratum
patientsserved
This header element should occur once per
strata.
Example: patientsserved 600 /
patientsserved
This is the total number of
patients who had at least one
outpatient surgery or procedure
during the sample month in this
stratum, regardless of whether the
patient or surgery was OAS
CAHPS eligible.
1 – 999999
M = Unknown/Missing
Alphanumeric 6 Yes
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XML Element Description Valid Values Data Type Field
Size
Data
Element
Required
DSRS Patients on file(s) submitted to Vendor
patientsfile
This header element should occur once per
strata.
Example: patientsfile 595 /patientsfile
Number of patients included on
the file that the vendor received
for this stratum for this sample
month.
1 – 999999 Numeric 6 Yes
DSRS Eligible Patients
eligiblepatients
This header element should occur once per
strata.
Example: eligiblepatients 500 /
eligiblepatients
Number of patients who meet
survey eligibility criteria within
this stratum for this sample
month.
1 – 999999 Numeric 6 Yes
DSRS Sampled Patients
sampledpatients
This header element should occur once per
strata.
Example: sampledpatients 450 /
sampledpatients
This is the number of sampled
patients for this stratum for this
sample month. This variable will
be used to weight the data.
Note: DSRS requires a minimum
of 10 sampled patients in every
stratum in every month. The
range allows fewer than 10 in
case a month has a lower than
expected number of sampled
patients.
1 – 999999 Numeric 6 Yes
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PATIENT ADMINISTRATIVE DATA RECORD
The following section defines the format of the patient level data record.
NOTE: Each element must have a closing tag that is the same as the opening tag but with a forward slash. Data element names do not contain
any spaces, underscores, or capital letters.
XML Element Description Valid Values Data Type Field
Size
Data
Element
Required
Provider Number
providernum
This administrative element also occurs in the
previous Header Record.
Example: providernum 123456 /
providernum
This is the HOPD’s or ASC’s
CMS Certification Number
(CCN, formerly known as the
Medicare Provider ID Number)
No Dashes or spaces
Valid 6- or 10- digit CMS
Certification Number
(CCN)
Alphanumeric 10 Yes
Sample Month
samplemonth This administrative element also occurs in the
previous Header Record.
Example: samplemonth 12 /
samplemonth
OAS CAHPS Survey sampling
month
MM
(1 – 12 = January –
December)
Numeric 2 Yes
Sample Year
sampleyear This administrative element also occurs in the
previous Header Record.
Example: sampleyear 2016 /
sampleyear
Year of sample month YYYY
(2016 or greater)
Numeric 4 Yes
DSRS Stratum Name
stratumname
This administrative element should only occur
once per patient.
Example: stratumname samedaysurgery
/stratumname
This is the name of the stratum for
the patient.
Maximum of 45
characters. Must match
one of the stratum names
from the Header Record.
Alphanumeric 45 Yes
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XML Element Description Valid Values Data Type Field
Size
Data
Element
Required
Sample ID No.
sampleid This administrative element should only occur
once per patient.
Example: sampleid 1234567 /sampleid
Survey vendors will assign a
unique de-identified sample
identification number (SID) to
each patient. The SID number
will be used to track the survey
status of the patient throughout
the survey administration process
and to designate sample patients
on the data file submitted to the
Data Center.
Maximum of 16
characters
Alphanumeric 16 Yes
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XML Element Description Valid Values Data Type Field
Size
Data
Element
Required
Surgical Category
surgicalcat This administrative element should only occur
once per patient.
Example: surgicalcat 1234567 /
surgicalcat
This is the category for the
surgery, and must be one of the
following options:
Gastrointestinal (GI), Orthopedic,
Ophthalmologic, Other, Missing.
If CPT28
code(s) in range 40490–
49999 or G-code(s) G0105,
G0121, or G0104, assign surgical
category 1.
If CPT code(s) in range 20000–
29999 or G-code is G0260, assign
surgical category 2.
If CPT code(s) in range 65091–
68899, assign surgical category 3.
If CPT code(s) in range 10021–
19999, 30000–39999, 50000–
64999, or 68900–69990 or if G-
code(s) not in the range for
surgical categories 1, 2 or 3,
assign surgical category 4.
If surgical category cannot be
determined, assign category 5.
1 = Gastrointestinal (GI)
2 = Orthopedic
3 = Ophthalmologic
4 = Other
5 = Missing
Numeric 1 Yes
28 CPT only copyright 2019 American Medical Association. All rights reserved.
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XML Element Description Valid Values Data Type Field
Size
Data
Element
Required
Age
patientage
This administrative element should only occur
once per patient.
Example: patientage 7 /patientage
Category for patient’s age as of
the date of surgery/procedure.
(Patients must be 18 or older at
the date of surgery/procedure to
be eligible for the survey.)
18–24 .......................... 1
25–29 .......................... 2
30–34 .......................... 3
35–39 .......................... 4
40–44 .......................... 5
45–49 .......................... 6
50–54 .......................... 7
55–59 .......................... 8
60–64 .......................... 9
65–69 ........................ 10
70–74 ........................ 11
75–79 ........................ 12
80–84 ........................ 13
85–89 ........................ 14
90 or older................. 15
Unknown/Missing .... M
NOT APPLICABLE .. X
Alphanumeric 2 Yes
Gender
patientgender This administrative element should only occur
once per patient.
Example: patientgender 1 /
patientgender
Patient’s gender 1 = Male
2 = Female
M = Unknown/Missing
X = NOT APPLICABLE
Alphanumeric 1 Yes
Survey Mode
surveymode
This administrative element should only occur
once per patient.
Example: surveymode 1 /surveymode
This is the mode of data
collection the patient used to
complete the survey. Apply code
“X” (Not Applicable) to all
sampled cases where the survey
does not result in a Complete
(code 110 or 120) or a Breakoff
(code 310).
1 = Mail only
2 = Telephone only
X = NOT APPLICABLE
Alphanumeric 1 Yes
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XML Element Description Valid Values Data Type Field
Size
Data
Element
Required
Lag Time
lagtime
This administrative element should only occur
once per patient.
Example: lagtime 51 /lagtime
The number of calendar days
between the date of eligible
surgery/procedure and the date
when this patient’s survey was
initiated.
0–90
X = NOT APPLICABLE
Alphanumeric 2 Yes
Final Survey Status
finalstatus
This administrative element should only occur
once per patient.
Example: finalstatus 110 /finalstatus
Final disposition of survey 110 = Completed Mail
Survey
120 = Completed Phone
Survey
210 = Ineligible:
Deceased
220 = Ineligible: Does
not Meet Eligibility
criteria
230 = Ineligible:
Language Barrier
240 = Ineligible:
Mentally or
Physically
Incapacitated
310 = Breakoff
320 = Refusal
330 = Bad Address/
Undeliverable Mail
340 = Wrong/Disc/No
Telephone Number
350 = No response after
Maximum attempts
Numeric 3 Yes
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XML Element Description Valid Values Data Type Field
Size
Data
Element
Required
Survey Language
language This administrative data element should only
occur once per patient.
Example: language 1 /language
Identify language in which survey
was completed
1 = English
2 = Spanish
3 = Chinese
4 = Korean
X = NOT APPLICABLE
Alphanumeric 1 Yes
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PATIENT RESPONSE RECORD
The following section defines the format of the Patient Response Record.
NOTE: Each element must have a closing tag that is the same as the opening tag but with a forward slash. Data element names do not contain
any spaces, underscores, or capital letters.
XML Element Description Valid Values Data Type Field
Size
Data
Element
Required
Q1 Informed
informed
This patient response data element should only
occur once per patient.
Example: informed 1 /informed
Before your procedure, did your
doctor or anyone from the
facility give you all the
information you needed about
your procedure?
Yes, definitely............. 1
Yes, somewhat ............ 2
No ............................... 3
MISSING/DK ........... M
Alphanumeric 1 Yes
Q2 Instructions
instructions
This patient response data element should only
occur once per patient.
Example: instructions 1 /instructions
Before your procedure, did your
doctor or anyone from the
facility give you easy to
understand instructions about
getting ready for your
procedure?
Yes, definitely............. 1
Yes, somewhat ............ 2
No ............................... 3
MISSING/DK ........... M
Alphanumeric 1 Yes
Q3 Check In
checkin This patient response data element should only
occur once per patient.
Example: checkin 1 /checkin
Did the check-in process run
smoothly?
Yes, definitely............. 1
Yes, somewhat ............ 2
No ............................... 3
MISSING/DK ........... M
Alphanumeric 1 Yes
Q4 Clean
clean
This patient response data element should only
occur once per patient.
Example: clean 1 /clean
Was the facility clean? Yes, definitely............. 1
Yes, somewhat ............ 2
No ............................... 3
MISSING/DK ........... M
Alphanumeric 1 Yes
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XML Element Description Valid Values Data Type Field
Size
Data
Element
Required
Q5 Clerk Helpful
clerkhelpful This patient response data element should only
occur once per patient.
Example: clerkhelpful 1 /clerkhelpful
Were the clerks and receptionists
at the facility as helpful as you
thought they should be?
Yes, definitely............. 1
Yes, somewhat ............ 2
No ............................... 3
MISSING/DK ........... M
Alphanumeric 1 Yes
Q6 Clerk Respect
clerkrespect
This patient response data element should only
occur once per patient.
Example: clerkrespect 1 /clerkrespect
Did the clerks and receptionists
at the facility treat you with
courtesy and respect?
Yes, definitely............. 1
Yes, somewhat ............ 2
No ............................... 3
MISSING/DK ........... M
Alphanumeric 1 Yes
Q7 Dr. Respect
drrespect
This patient response data element should only
occur once per patient.
Example: drrespect 1 /drrespect
Did the doctors and nurses treat
you with courtesy and respect?
Yes, definitely............. 1
Yes, somewhat ............ 2
No ............................... 3
MISSING/DK ........... M
Alphanumeric 1 Yes
Q8 Dr. Comfort
drcomfort
This patient response data element should only
occur once per patient.
Example: drcomfort 1 /drcomfort
Did the doctors and nurses make
sure you were as comfortable as
possible?
Yes, definitely............. 1
Yes, somewhat ............ 2
No ............................... 3
MISSING/DK ........... M
Alphanumeric 1 Yes
Q9 Dr. Explain
drexplain
This patient response data element should only
occur once per patient.
Example: drexplain 1 /drexplain
Did the doctors and nurses
explain your procedure in a way
that was easy to understand?
Yes, definitely............. 1
Yes, somewhat ............ 2
No ............................... 3
MISSING/DK ........... M
Alphanumeric 1 Yes
Q10 Anesthesia
anesthesia
This patient response data element should only
occur once per patient.
Example: anesthesia 1 /anesthesia
Anesthesia is something that
would make you feel sleepy or
go to sleep during your
procedure. Were you given
anesthesia?
Yes .............................. 1
No ............................... 2
MISSING/DK ........... M
Alphanumeric 1 Yes
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XML Element Description Valid Values Data Type Field
Size
Data
Element
Required
Q11 Anesthesia Explain
anesthesiaexplain
This patient response data element should only
occur once per patient.
Example: anesthesiaexplain 2 /
anesthesiaexplain
Did your doctor or anyone from
the facility explain the process of
giving anesthesia in a way that
was easy to understand?
Yes, definitely............. 1
Yes, somewhat ............ 2
No ............................... 3
MISSING/DK ........... M
NOT APPLICABLE .. X
Alphanumeric 1 Yes
Q12 Anesthesia Side
anesthesiaside
This patient response data element should only
occur once per patient.
Example: anesthesiaside 1 /
anesthesiaside
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............. 1
Yes, somewhat ............ 2
No ............................... 3
MISSING/DK ........... M
NOT APPLICABLE .. X
Alphanumeric 1 Yes
Q13 Discharge Instructions
dischargeinstructions This patient response data element should only
occur once per patient.
Example: dischargeinstructions 1 /
dischargeinstructions
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?
Yes .............................. 1
No ............................... 2
MISSING/DK ........... M
Alphanumeric 1 Yes
Q14 Recovery
recovery
This patient response data element should only
occur once per patient.
Example: recovery 1 /recovery
Did your doctor or anyone from
the facility prepare you for what
to expect during your recovery?
Yes, definitely............. 1
Yes, somewhat ............ 2
No ............................... 3
MISSING/DK ........... M
Alphanumeric 1 Yes
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XML Element Description Valid Values Data Type Field
Size
Data
Element
Required
Q15 Pain Info
paininfo This patient response data element should only
occur once per patient.
Example: paininfo 1 /paininfo
Some ways to control pain
include prescription medicine,
over-the-counter pain relievers
or 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, definitely............. 1
Yes, somewhat ............ 2
No ............................... 3
MISSING/DK ........... M
Alphanumeric 1 Yes
Q16 Pain Result
painresult
This patient response data element should only
occur once per patient.
Example: painresult 1 /painresult
At any time after leaving the
facility, did you have pain as a
result of your procedure?
Yes .............................. 1
No ............................... 2
MISSING/DK ........... M
Alphanumeric 1 Yes
Q17 Nausea
nausea
This patient response data element should only
occur once per patient.
Example: nausea 1 /nausea
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?
Yes, definitely............. 1
Yes, somewhat ............ 2
No ............................... 3
MISSING/DK ........... M
Alphanumeric 1 Yes
Q18 Nausea Result
nausearesult
This patient response data element should only
occur once per patient.
Example: nausearesult 1 /nausearesult
At any time after leaving the
facility, did you have nausea or
vomiting as a result of either
your procedure or the
anesthesia?
Yes .............................. 1
No ............................... 2
MISSING/DK ........... M
Alphanumeric 1 Yes
Q19 Bleeding Instruction
bleedinginstruction This patient response data element should only
occur once per patient.
Example: bleedinginstruction 1 /
bleedinginstruction
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?
Yes, definitely............. 1
Yes, somewhat ............ 2
No ............................... 3
MISSING/DK ........... M
Alphanumeric 1 Yes
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XML Element Description Valid Values Data Type Field
Size
Data
Element
Required
Q20 Bleeding Result
bleedingresult
This patient response data element should only
occur once per patient.
Example: bleedingresult 1 bleedingresult
At any time after leaving the
facility, did you have bleeding as
a result of your procedure?
Yes .............................. 1
No ............................... 2
MISSING/DK ........... M
Alphanumeric 1 Yes
Q21 Infection Info
infectioninfo This patient response data element should only
occur once per patient.
Example: infectioninfo 1 /infectioninfo
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 if you had possible signs of
infection?
Yes, definitely............. 1
Yes, somewhat ............ 2
No ............................... 3
MISSING/DK ........... M
Alphanumeric 1 Yes
Q22 Infections Signs
infectionsigns This patient response data element should only
occur once per patient.
Example: infectionsigns 1 /
infectionsigns
At any time after leaving the
facility, did you have any signs
of infection?
Yes .............................. 1
No ............................... 2
MISSING/DK ........... M
Alphanumeric 1 Yes
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XML Element Description Valid Values Data Type Field
Size
Data
Element
Required
Q23 Rate Facility
ratefacility This patient response data element should only
occur once per patient.
Example: ratefacility 2 /ratefacility
Using any number from 0 to 10,
where 0 is the worst facility
possible and 10 is the best
facility possible, what number
would you use to rate this
facility?
Worst facility
possible ....................... 0
.................................... 1
.................................... 2
.................................... 3
.................................... 4
.................................... 5
.................................... 6
.................................... 7
.................................... 8
.................................... 9
Best facility possible . 10
MISSING/DK ........... M
Alphanumeric 2 Yes
Q24 Recommend
recommend This patient response data element should only
occur once per patient.
Example: recommend 2 /recommend
Would you recommend this
facility to your friends and
family?
Definitely no ............... 1
Probably no ................. 2
Probably yes ............... 3
Definitely yes.............. 4
MISSING/DK ........... M
Alphanumeric 1 Yes
Q25 Rate Overall
rateoverall This patient response data element should only
occur once per patient.
Example: rateoverall 1 /rateoverall
In general, how would you rate
your overall health?
Excellent ..................... 1
Very good ................... 2
Good ........................... 3
Fair .............................. 4
Poor ............................ 5
MISSING/DK ........... M
Alphanumeric 1 Yes
Q26 Rate Overall Mental
rateoverallmental This patient response data element should only
occur once per patient.
Example: rateoverallmental 1 /
rateoverallmental
In general, how would you rate
your overall mental or emotional
health?
Excellent ..................... 1
Very good ................... 2
Good ........................... 3
Fair .............................. 4
Poor ............................ 5
MISSING/DK ........... M
Alphanumeric 1 Yes
A
pp
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dix
L: X
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Data
File
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XML Element Description Valid Values Data Type Field
Size
Data
Element
Required
Q27 Age
age This patient response data element should only
occur once per patient.
Example: age 1 /age
What is your age? 18 to 24 ....................... 1
25 to 34 ....................... 2
35 to 44 ....................... 3
45 to 54 ....................... 4
55 to 64 ....................... 5
65 to 74 ....................... 6
75 to 79 ....................... 7
80 to 84 ....................... 8
85 or older................... 9
MISSING/DK ........... M
Alphanumeric 1 Yes
Q28 Gender
gender This patient response data element should only
occur once per patient.
Example: gender 1 /gender
Are you male or female? Male ............................ 1
Female ........................ 2
MISSING/DK ........... M
Alphanumeric 1 Yes
Q29 Education
education This patient response data element should only
occur once per patient.
Example: education 3 /education
What is the highest grade or
level of school that you have
completed?
8th grade or less .......... 1
Some high school,
but did not graduate .... 2
High school graduate
or GED ....................... 3
Some college or 2-
year degree.................. 4
4-year college
graduate ...................... 5
More than 4-year
college degree ............. 6
MISSING/DK ........... M
Alphanumeric 1 Yes
Ap
pen
dix
L: X
ML
Data
File
Layo
ut fo
r Dis
pro
po
rtion
ate
Stra
tified
Ran
do
m S
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plin
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S) H
ead
er R
eco
rd
No
vem
be
r 20
18
L-1
8
Cen
ters
for M
ed
ica
re &
Med
icaid
Se
rvic
es
Ou
tpatie
nt a
nd
Am
bu
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urg
ery
CA
HP
S S
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lines M
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XML Element Description Valid Values Data Type Field
Size
Data
Element
Required
Q30 Ethnicity
ethnicity This patient response data element should only
occur once per patient.
Example: ethnicity 2 /ethnicity
Are you of Hispanic, Latino, or
Spanish origin?
Yes .............................. 1
No ............................... 2
MISSING/DK ........... M
Alphanumeric 1 Yes
Q31 Group
group
This patient response data element should only
occur once per patient.
Example: group 1 /group
Which group best describes you? Mexican, Mexican
American,
Chicano ....................... 1
Puerto Rican ............... 2
Cuban .......................... 3
Another Hispanic,
Latino, or Spanish
origin .......................... 4
MISSING/DK ........... M
NOT APPLICABLE .. X
Alphanumeric 1 Yes
Q32 Race White-mail
racewhite-mail
This patient response data element should only
occur once per patient.
Example: racewhite-mail 1 /racewhite-
What is your race? You may
select one or more categories.
White .......................... 1
MISSING/DK ........... M
NOT APPLICABLE .. X
Alphanumeric 1 Yes
Q32 Race African American-mail
raceafricanamer-mail This patient response data element should only
occur once per patient.
Example: raceafricanamer-mail 1 /
raceafricanamer-mail
What is your race? You may
select one or more categories.
Black or African
American .................... 1
MISSING/DK ........... M
NOT APPLICABLE .. X
Alphanumeric 1 Yes
A
pp
en
dix
L: X
ML
Data
File
Layo
ut fo
r Dis
pro
po
rtion
ate
No
vem
be
r 20
18
S
tratifie
d R
an
do
m S
am
plin
g (D
SR
S) H
ead
er R
eco
rd
Cen
ters
for M
ed
ica
re &
Med
icaid
Se
rvic
es
L
-19
Ou
tpatie
nt a
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Am
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urg
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CA
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XML Element Description Valid Values Data Type Field
Size
Data
Element
Required
Q32 Race American Indian-mail
raceamerindian-mail This patient response data element should only
occur once per patient.
Example: raceamerindian-mail 1 /
raceamerindian-mail
What is your race? You may
select one or more categories.
American Indian or
Alaska Native ............. 1
MISSING/DK ........... M
NOT APPLICABLE .. X
Alphanumeric 1 Yes
Q32 Race Asian Indian-mail
raceasianindian-mail This patient response data element should only
occur once per patient.
Example: raceasianindian-mail 1 /
raceasianindian-mail
What is your race? You may
select one or more categories.
Asian Indian................ 1
MISSING/DK ........... M
NOT APPLICABLE .. X
Alphanumeric 1 Yes
Q32 Race Chinese-mail
racechinese-mail This patient response data element should only
occur once per patient.
Example: racechinese-mail 1 /
racechinese-mail
What is your race? You may
select one or more categories.
Chinese ....................... 1
MISSING/DK ........... M
NOT APPLICABLE .. X
Alphanumeric 1 Yes
Q32 Race Filipino-mail
racefilipino-mail This patient response data element should only
occur once per patient.
Example: racefilipino-mail 1 /
racefilipino-mail
What is your race? You may
select one or more categories.
Filipino ....................... 1
MISSING/DK ........... M
NOT APPLICABLE .. X
Alphanumeric 1 Yes
Q32 Race Japanese-mail
racejapanese-mail This patient response data element should only
occur once per patient.
Example: racejapanese-mail 1 /
racejapanese-mail
What is your race? You may
select one or more categories.
Japanese ...................... 1
MISSING/DK ........... M
NOT APPLICABLE .. X
Alphanumeric 1 Yes
Ap
pen
dix
L: X
ML
Data
File
Layo
ut fo
r Dis
pro
po
rtion
ate
Stra
tified
Ran
do
m S
am
plin
g (D
SR
S) H
ead
er R
eco
rd
No
vem
be
r 20
18
L-2
0
Cen
ters
for M
ed
ica
re &
Med
icaid
Se
rvic
es
Ou
tpatie
nt a
nd
Am
bu
lato
ry S
urg
ery
CA
HP
S S
urv
ey P
roto
co
ls a
nd
Gu
ide
lines M
an
ual
XML Element Description Valid Values Data Type Field
Size
Data
Element
Required
Q32 Race Korean-mail
racekorean-mail This patient response data element should only
occur once per patient.
Example: racekorean-mail 1 /
racekorean-mail
What is your race? You may
select one or more categories.
Korean ........................ 1
MISSING/DK ........... M
NOT APPLICABLE .. X
Alphanumeric 1 Yes
Q32 Race Vietnamese-mail
racevietnamese-mail This patient response data element should only
occur once per patient.
Example: racevietnamese-mail 1 /
racevietnamese-mail
What is your race? You may
select one or more categories.
Vietnamese ................. 1
MISSING/DK ........... M
NOT APPLICABLE .. X
Alphanumeric 1 Yes
Q32 Race Other Asian-mail
raceotherasian-mail This patient response data element should only
occur once per patient.
Example: raceotherasian-mail 1 /
raceotherasian-mail
What is your race? You may
select one or more categories.
Other Asian ................. 1
MISSING/DK ........... M
NOT APPLICABLE .. X
Alphanumeric 1 Yes
Q32 Race Native Hawaiian-mail
racenativehawaiian-mail This patient response data element should only
occur once per patient.
Example: racenativehawaiian-mail 1 /
racenativehawaiian-mail
What is your race? You may
select one or more categories.
Native Hawaiian ......... 1
MISSING/DK ........... M
NOT APPLICABLE .. X
Alphanumeric 1 Yes
Q32 Race Guamanian Chamorro-mail
raceguamanianchamorro-mail This patient response data element should only
occur once per patient.
Example: raceguamanianchamorro-mail 1
/raceguamanianchamorro-mail
What is your race? You may
select one or more categories.
Guamanian or
Chamorro .................... 1
MISSING/DK ........... M
NOT APPLICABLE .. X
Alphanumeric 1 Yes
A
pp
en
dix
L: X
ML
Data
File
Layo
ut fo
r Dis
pro
po
rtion
ate
No
vem
be
r 20
18
S
tratifie
d R
an
do
m S
am
plin
g (D
SR
S) H
ead
er R
eco
rd
Cen
ters
for M
ed
ica
re &
Med
icaid
Se
rvic
es
L
-21
Ou
tpatie
nt a
nd
Am
bu
lato
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urg
ery
CA
HP
S S
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ey P
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nd
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ide
lines M
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XML Element Description Valid Values Data Type Field
Size
Data
Element
Required
Q32 Race Samoan-mail
racesamoan-mail This patient response data element should only
occur once per patient.
Example: racesamoan-mail 1 /
racesamoan-mail
What is your race? You may
select one or more categories.
Samoan ....................... 1
MISSING/DK ........... M
NOT APPLICABLE .. X
Alphanumeric 1 Yes
Q32 Race Other Pacific Islander-mail
raceotherpacificislander-mail This patient response data element should only
occur once per patient.
Example: raceotherpacificislander-mail 1
/raceotherpacificislander-mail
What is your race? You may
select one or more categories.
Other Pacific
Islander ....................... 1
MISSING/DK ........... M
NOT APPLICABLE .. X
Alphanumeric 1 Yes
Q32 Race White-phone
racewhite-phone This patient response data element should only
occur once per patient.
Example: racewhite-phone 1 /racewhite-
phone
What is your race? You may
select one or more categories.
Are you…
White .......................... 1
MISSING/DK ........... M
NOT APPLICABLE .. X
Alphanumeric 1 Yes
Q32 Race African American-phone
raceafricanamer-phone
This patient response data element should only
occur once per patient.
Example: raceafricanamer-phone 1 /
raceafricanamer-phone
What is your race? You may
select one or more categories.
Are you…
Black or African
American .................... 1
MISSING/DK ........... M
NOT APPLICABLE .. X
Alphanumeric 1 Yes
Q32 Race American Indian-phone
raceamerindian-phone
This patient response data element should only
occur once per patient.
Example: raceamerindian-phone 1 /
raceamerindian-phone
What is your race? You may
select one or more categories.
Are you…
American Indian or
Alaska Native ............. 1
MISSING/DK ........... M
NOT APPLICABLE .. X
Alphanumeric 1 Yes
Ap
pen
dix
L: X
ML
Data
File
Layo
ut fo
r Dis
pro
po
rtion
ate
Stra
tified
Ran
do
m S
am
plin
g (D
SR
S) H
ead
er R
eco
rd
No
vem
be
r 20
18
L-2
2
Cen
ters
for M
ed
ica
re &
Med
icaid
Se
rvic
es
Ou
tpatie
nt a
nd
Am
bu
lato
ry S
urg
ery
CA
HP
S S
urv
ey P
roto
co
ls a
nd
Gu
ide
lines M
an
ual
XML Element Description Valid Values Data Type Field
Size
Data
Element
Required
Q32 Race Asian-phone
raceasian-phone
This patient response data element should only
occur once per patient.
Example: raceasian-phone 1 / raceasian-
phone
What is your race? You may
select one or more categories.
Are you…
Asian ........................... 1
MISSING/DK ........... M
NOT APPLICABLE .. X
Alphanumeric 1 Yes
Q32 Race Native Hawaiian Pacific Islander-
phone
racenativehawaiianpacificislander-phone This patient response data element should only
occur once per patient.
Example:
racenativehawaiianpacificislander-phone 1
/racenativehawaiianpacificislander-phone
What is your race? You may
select one or more categories.
Are you…
Native Hawaiian or
Pacific Islander ........... 1
MISSING/DK ........... M
NOT APPLICABLE .. X
Alphanumeric 1 Yes
Q32 Race None of Above-phone
racenoneofabove-phone
This patient response data element should only
occur once per patient.
Example: racenoneofabove-phone 1 / racenoneofabove-phone
What is your race? You may
select one or more categories.
Are you…
NONE OF ABOVE .... 1
MISSING/DK ........... M
NOT APPLICABLE .. X
Alphanumeric 1 Yes
Q32a Race Asian Indian-phone
raceasianindian-phone
This patient response data element should only
occur once per patient.
Example: raceasianindian-phone 1 / raceasianindian-phone
Which groups best describe you?
You may select one or more
categories. Are you…
Asian Indian................ 1
MISSING/DK ........... M
NOT APPLICABLE .. X
Alphanumeric 1 Yes
A
pp
en
dix
L: X
ML
Data
File
Layo
ut fo
r Dis
pro
po
rtion
ate
No
vem
be
r 20
18
S
tratifie
d R
an
do
m S
am
plin
g (D
SR
S) H
ead
er R
eco
rd
Cen
ters
for M
ed
ica
re &
Med
icaid
Se
rvic
es
L
-23
Ou
tpatie
nt a
nd
Am
bu
lato
ry S
urg
ery
CA
HP
S S
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ey P
roto
co
ls a
nd
Gu
ide
lines M
an
ual
XML Element Description Valid Values Data Type Field
Size
Data
Element
Required
Q32a Race Chinese-phone
racechinese-phone
This patient response data element should only
occur once per patient.
Example: racechinese-phone 1 /
racechinese-phone
Which groups best describe you?
You may select one or more
categories. Are you…
Chinese ....................... 1
MISSING/DK ........... M
NOT APPLICABLE .. X
Alphanumeric 1 Yes
Q32a Race Filipino-phone
racefilipino-phone
This patient response data element should only
occur once per patient.
Example: racefilipino-phone 1 /
racefilipino-phone
Which groups best describe you?
You may select one or more
categories. Are you…
Filipino ....................... 1
MISSING/DK ........... M
NOT APPLICABLE .. X
Alphanumeric 1 Yes
Q32a Race Japanese-phone
racejapanese-phone
This patient response data element should only
occur once per patient.
Example: racejapanese-phone 1 /
racejapanese-phone
Which groups best describe you?
You may select one or more
categories. Are you…
Japanese ...................... 1
MISSING/DK ........... M
NOT APPLICABLE .. X
Alphanumeric 1 Yes
Q32a Race Korean-phone
racekorean-phone
This patient response data element should only
occur once per patient.
Example: racekorean-phone 1 /
racekorean-phone
Which groups best describe you?
You may select one or more
categories. Are you…
Korean ........................ 1
MISSING/DK ........... M
NOT APPLICABLE .. X
Alphanumeric 1 Yes
Q32a Race Vietnamese-phone
racevietnamese-phone
This patient response data element should only
occur once per patient.
Example: racevietnamese-phone 1 /
racevietnamese-phone
Which groups best describe you?
You may select one or more
categories. Are you…
Vietnamese ................. 1
MISSING/DK ........... M
NOT APPLICABLE .. X
Alphanumeric 1 Yes
Ap
pen
dix
L: X
ML
Data
File
Layo
ut fo
r Dis
pro
po
rtion
ate
Stra
tified
Ran
do
m S
am
plin
g (D
SR
S) H
ead
er R
eco
rd
No
vem
be
r 20
18
L-2
4
Cen
ters
for M
ed
ica
re &
Med
icaid
Se
rvic
es
Ou
tpatie
nt a
nd
Am
bu
lato
ry S
urg
ery
CA
HP
S S
urv
ey P
roto
co
ls a
nd
Gu
ide
lines M
an
ual
XML Element Description Valid Values Data Type Field
Size
Data
Element
Required
Q32a Race Other Asian-phone
raceotherasian-phone
This patient response data element should only
occur once per patient.
Example: raceotherasian-phone 1 /
raceotherasian-phone
Which groups best describe you?
You may select one or more
categories. Are you…
Other Asian ................. 1
MISSING/DK ........... M
NOT APPLICABLE .. X
Alphanumeric 1 Yes
Q32a Race None of Above Asian Indian-phone
racenoneofaboveasianindian-phone
This patient response data element should only
occur once per patient.
Example: racenoneofaboveasianindian-
phone 1 / racenoneofaboveasianindian-
phone
Which groups best describe you?
You may select one or more
categories. Are you…
NONE OF ABOVE .... 1
MISSING/DK ........... M
NOT APPLICABLE .. X
Alphanumeric 1 Yes
Q32b Race Native Hawaiian-phone
racenativehawaiian-phone
This patient response data element should only
occur once per patient.
Example: racenativehawaiian-phone 1 /
racenativehawaiian-phone
Which groups best describe you?
You may select one or more
categories. Are you…
Native Hawaiian ......... 1
MISSING/DK ........... M
NOT APPLICABLE .. X
Alphanumeric 1 Yes
Q32b Race Guamanian Chamorro-phone
raceguamanianchamorro-phone
This patient response data element should only
occur once per patient.
Example: raceguamanianchamorro-phone
1 /raceguamanianchamorro-phone
Which groups best describe you?
You may select one or more
categories. Are you…
Guamanian or
Chamorro .................... 1
MISSING/DK ........... M
NOT APPLICABLE .. X
Alphanumeric 1 Yes
A
pp
en
dix
L: X
ML
Data
File
Layo
ut fo
r Dis
pro
po
rtion
ate
No
vem
be
r 20
18
S
tratifie
d R
an
do
m S
am
plin
g (D
SR
S) H
ead
er R
eco
rd
Cen
ters
for M
ed
ica
re &
Med
icaid
Se
rvic
es
L
-25
Ou
tpatie
nt a
nd
Am
bu
lato
ry S
urg
ery
CA
HP
S S
urv
ey P
roto
co
ls a
nd
Gu
ide
lines M
an
ual
XML Element Description Valid Values Data Type Field
Size
Data
Element
Required
Q32b Race Samoan-phone
racesamoan-phone
This patient response data element should only
occur once per patient.
Example: racesamoan-phone 1 /
racesamoan-phone
Which groups best describe you?
You may select one or more
categories. Are you…
Samoan ....................... 1
MISSING/DK ........... M
NOT APPLICABLE .. X
Alphanumeric 1 Yes
Q32b Race Other Pacific Islander-phone
raceotherpacificislander-phone
This patient response data element should only
occur once per patient.
Example: raceotherpacificislander-phone
1 /raceotherpacificislander-phone
Which groups best describe you?
You may select one or more
categories. Are you…
Other Pacific
Islander ....................... 1
MISSING/DK ........... M
NOT APPLICABLE .. X
Alphanumeric 1 Yes
Q32b Race None of Above Pacific-phone
racenoneofabovepacific-phone
This patient response data element should only
occur once per patient.
Example: racenoneofabovepacific-phone
1 /racenoneofabovepacific-phone
Which groups best describe you?
You may select one or more
categories. Are you…
NONE OF ABOVE .... 1
MISSING/DK ........... M
NOT APPLICABLE .. X
Alphanumeric 1 Yes
Q33 Speak English
speakenglish This patient response data element should only
occur once per patient.
Example: speakenglish 1 /speakenglish
How well do you speak English? Very well .................... 1
Well ............................ 2
Not well ...................... 3
Not at all ..................... 4
MISSING/DK ........... M
Alphanumeric 1 Yes
Q34 Speak Other
speakother This patient response data element should only
occur once per patient.
Example: speakother 1 /speakother
Do you speak a language other
than English at home?
Yes, speak language
other than English ....... 1
No, speak English at
home ........................... 2
MISSING/DK ........... M
Alphanumeric 1 Yes
Ap
pen
dix
L: X
ML
Data
File
Layo
ut fo
r Dis
pro
po
rtion
ate
Stra
tified
Ran
do
m S
am
plin
g (D
SR
S) H
ead
er R
eco
rd
No
vem
be
r 20
18
L-2
6
Cen
ters
for M
ed
ica
re &
Med
icaid
Se
rvic
es
Ou
tpatie
nt a
nd
Am
bu
lato
ry S
urg
ery
CA
HP
S S
urv
ey P
roto
co
ls a
nd
Gu
ide
lines M
an
ual
XML Element Description Valid Values Data Type Field
Size
Data
Element
Required
Q35 Speak Other Specify
speakotherspecify This patient response data element should only
occur once per patient.
Example: speakotherspecify 1 /
speakotherspecify
What is that language? Spanish ....................... 1
Other ........................... 2
MISSING/DK ........... M
NOT APPLICABLE .. X
Alphanumeric 1 Yes
Q36 Help-mail
help This patient response data element should only
occur once per patient.
Example: help 1 /help
Did someone help you complete
this survey?
Yes .............................. 1
No ............................... 2
MISSING/DK ........... M
NOT APPLICABLE .. X
Alphanumeric 1 Yes
Q37 Help Read-mail
helpread This patient response data element should only
occur once per patient.
Example: helpread 1 /helpread
How did that person help you?
Check all that apply.
Read the questions
to me ........................... 1
MISSING/DK ........... M
NOT APPLICABLE .. X
Alphanumeric 1 Yes
Q37 Help Wrote-mail
helpwrote This patient response data element should only
occur once per patient.
Example: helpwrote 1 /helpwrote
How did that person help you?
Check all that apply.
Wrote down the
answers I gave ............ 1
MISSING/DK ........... M
NOT APPLICABLE .. X
Alphanumeric 1 Yes
Q37 Help Answer-mail
helpanswer This patient response data element should only
occur once per patient.
Example: helpanswer 1 /helpanswer
How did that person help you?
Check all that apply.
Answered the
questions for me ......... 1
MISSING/DK ........... M
NOT APPLICABLE .. X
Alphanumeric 1 Yes
A
pp
en
dix
L: X
ML
Data
File
Layo
ut fo
r Dis
pro
po
rtion
ate
No
vem
be
r 20
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tratifie
d R
an
do
m S
am
plin
g (D
SR
S) H
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XML Element Description Valid Values Data Type Field
Size
Data
Element
Required
Q37 Help Translate-mail
helptranslate This patient response data element should only
occur once per patient.
Example: helptranslate 1 /
helptranslate
How did that person help you?
Check all that apply.
Translated the
questions into my
language ...................... 1
MISSING/DK ........... M
NOT APPLICABLE .. X
Alphanumeric 1 Yes
Q37 Help Other-mail
helpother This patient response data element should only
occur once per patient.
Example: helpother 1 /helpother
How did that person help you?
Check all that apply.
Helped in some
other way .................... 1
MISSING/DK ........... M
NOT APPLICABLE .. X
Alphanumeric 1 Yes
Q37 Help None-mail
helpnone This patient response data element should only
occur once per patient.
Example: helpnone 1 /helpnone
How did that person help you?
Check all that apply.
No one helped me
complete this survey ... 1
MISSING/DK ........... M
NOT APPLICABLE .. X
Alphanumeric 1 Yes
Appendix L: XML Data File Layout for Disproportionate Stratified Random Sampling (DSRS) Header Record November 2018
L-28 Centers for Medicare & Medicaid Services Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual
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Centers for Medicare & Medicaid Services Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual
APPENDIX M:
XML DATA FILE LAYOUT FOR ZERO SAMPLED FILE
Appendix M: XML Data File Layout for Zero Sampled File November 2018
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ZERO FILE SAMPLED XML DATA FILE LAYOUT
OUTPATIENT AND AMBULATORY CAHPS SURVEY
HEADER RECORD
The following section defines the format of the Header Record.
NOTE: Each element must have a closing tag that is the same as the opening tag but with a forward slash. Data element names do not contain
any spaces, underscores, or capital letters.
XML Element Description Valid Values Data Type Field
Size
Data
Element
Required
Type of Header Record
headertype
This header element should only occur once
per file.
Example: headertype 1 /headertype
Type of Header Record 0 = Zero Sampled Header
Record
Numeric 1 Yes
Provider Name
<providername
This header element should only occur once
per file.
Example: providername
SampleHOPDASCName /providername
This is the HOPD’s or ASC’s
Provider Name
— Alphanumeric 100 Yes
Provider Number
providernum
This header element will occur again as an
administration data element in the patient level
data record.
Example: providernum 123456 /
providernum
This is the HOPD’s or ASC’s
CMS Certification Number
(CCN, formerly known as the
Medicare Provider ID Number)
No Dashes or spaces
Valid 6- or 10-digit CMS
Certification Number
(CCN)
Alphanumeric 10 Yes
Ap
pen
dix
M: X
ML
Data
File
Layo
ut fo
r Ze
ro S
am
ple
d F
ile
No
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XML Element Description Valid Values Data Type Field
Size
Data
Element
Required
Sample Month
samplemonth This header element will occur again as an
administration data element in the patient level
data record.
Example: samplemonth 12 /
samplemonth
Survey vendors will select a
sample of patients who meet
survey eligibility criteria for each
calendar month. The Sample
Month is the month for which the
sample was selected.
MM
(1 – 12 = January –
December)
Numeric 2 Yes
Sample Year
sampleyear This header element will occur again as an
administration data element in the patient level
data record.
Example: sampleyear 2016 /
sampleyear
This is the calendar year in which
the survey is conducted.
YYYY
(2016 or greater)
Numeric 4 Yes
Survey Mode
surveymode
This header element will occur again as an
administration data element in the patient level
data record.
Example: surveymode 1 /surveymode
The survey mode, either mail
only, phone only, or mixed mode,
must be the same for all sample
members in each sample month in
the calendar quarter for all of the
HOPD or ASC locations under
the same CCN.
1 = Mail only
2 = Telephone only
3 = Mixed mode
Numeric 1 Yes
Type of Sampling
sampletype
This header element should only occur once
per file.
Example: sampletype 1 /sampletype
Type of sampling used. Note:
Sample Type must be the same
for all three months in each
quarter.
1 = Census
2 = Simple random
sampling
3 = Stratified systematic
sampling
4 = Proportionate
Stratified Random
sampling
5 = DSRS
Numeric 1 Yes
No
vem
be
r 20
18
A
pp
en
dix
M: X
ML
Data
File
Layo
ut fo
r Ze
ro S
am
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d F
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icaid
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XML Element Description Valid Values Data Type Field
Size
Data
Element
Required
Patients Served
patientsserved
This header element should only occur once
per file.
Example: patientsserved 5 /
patientsserved
This is the total number of
patients who had at least one
outpatient surgery or procedure
during the sample month at the
HOPD or ASC, regardless of
whether that patient or
surgery/procedure was OAS
CAHPS-eligible.
0 – 999999
M = Unknown/Missing
Alphanumeric 6 Yes
Patients on file(s) submitted to Vendor
patientsfile
This header element should only occur once
per file.
Example: patientsfile 5 /patientsfile
Number of patients included on
the file that the vendor received
for this HOPD or ASC.
0 – 999999 Numeric 6 Yes
Eligible Patients
eligiblepatients
This header element should only occur once
per file.
Example: eligiblepatients 0 /
eligiblepatients
This is the number of patients in
the file submitted by the HOPD or
ASC that meet survey eligibility
criteria in the sample month.
0 Numeric 1 Yes
Sampled Patients
sampledpatients
This header element should only occur once
per file.
Example: sampledpatients 0 /
sampledpatients
This is the number of patients
selected for the survey during the
sample month. This value can be
zero only if all of the patients
included on the file that the
HOPD or ASC provided for the
sample month were ineligible for
the survey.
0 Numeric 1 Yes
Appendix M: XML Data File Layout for Zero Sampled File November 2018
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Centers for Medicare & Medicaid Services Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual
APPENDIX N:
MODEL QUALITY ASSURANCE PLAN (QAP) OUTLINE
Appendix N: Model Quality Assurance Plan (QAP) Outline November 2018
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INSTRUCTIONS FOR PREPARING A SURVEY VENDOR QUALITY ASSURANCE PLAN
Vendors that have met the minimum requirements and received interim approval, can begin
conducting OAS CAHPS on behalf of client facilities. To become fully approved, vendors must
complete the final step in the approval process: the submission of an acceptable Quality
Assurance Plan (QAP). The QAP must be submitted within 6 weeks of the data submission
deadline date after vendor’s first quarterly submission of OAS CAHPS data. It must be updated
and resubmitted annually on or before April 30 and whenever the survey vendor makes key staff
or protocol changes.
This purpose of this document is to serve as instructions for survey vendors to help them develop
a QAP that describes their specific plans for implementation and compliance with all guidelines
required to implement the OAS CAHPS Survey.
The vendor’s QAP should include the sections listed below. The specific requirements for these
sections are described in the pages that follow.
I. Organization Background and Staff Experience
II. Initial Communications with HOPDs and ASCs
III. Work Plan for Each Approved Mode of Data Collection
IV. Sampling Plan
V. Survey Implementation Plan
VI. Data Security, Confidentiality, and Privacy Plan
VII. Exceptions Request Process and Discrepancy Notification Reporting
VIII. Questionnaire and Materials Attachments
To facilitate review of the QAP, each vendor should use the outline format noted above.
I. ORGANIZATION BACKGROUND AND STAFF EXPERIENCE
In this section of the QAP, each OAS CAHPS Survey vendor must provide the following
information:
• Your organization’s name, address, and telephone number. If your organization has
multiple locations, include the address of both the main location and the address of the
Appendix N: Model Quality Assurance Plan (QAP) Outline November 2018
Centers for Medicare & Medicaid Services N-2 Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual
locations at which the primary operations, including sampling, data collection, and data
processing activities, are being conducted.
• Describe the history and affiliation with any other organization (e.g., other company or
university affiliation). Include the scope of business, number of years in business, and
number of years of survey experience.
• Describe your organization’s survey experience conducting person-level surveys using
each approved data collection mode that is allowed for the OAS CAHPS Survey,
specifically, mail-only, CATI-only, and mixed mode (mail with CATI follow-up).
Describe other CAHPS survey experience if applicable. You must discuss each data
collection mode for which you have received approval, regardless of whether you have
any HOPD or ASC clients that are using that mode.
• Provide an organizational chart that shows the names and titles of staff members,
including subcontractors, that are responsible for each of the following tasks:
a. Overall project management, including tracking and supervision of all tasks below.
b. Explaining the nature of the project to hospitals and ASCs, including determining
whether their facility is eligible.
c. Sampling procedures, including creation of the sample frame, selection of the sample,
and assignment of a unique identification number to each sampled patient.
d. Data collection procedures, including overseeing implementation of the data collection
mode for which your organization has been approved.
e. Data receipt and data entry/scanning procedures.
f. File development and submission processes.
The organizational chart should also clearly specify all staff reporting relationships, including
those staff who are responsible for managing subcontractors. It should designate which
individuals have responsibility for quality assurance oversight. A list of individuals with QA
oversight responsibility by task must be included.
• Summarize the background and experience of the individuals who are responsible for the
tasks listed in the organizational chart above, including a description of any
subcontractors serving in these roles. The description of each individual’s experience
should include a discussion of how the person’s qualifications are relevant to the OAS
CAHPS Survey tasks that he or she is expected to perform. Resumes should be available
upon request.
November 2018 Appendix N: Model Quality Assurance Plan (QAP) Outline
Centers for Medicare & Medicaid Services N-3 Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual
Initial Communications with HOPDs and ASCs
• When working with hospitals to explain the study, how do you determine whether a
particular hospital has one or more eligible HOPDs or departments that meet the
eligibility criteria for inclusion in the OAS CAHPS Survey? What questions do hospitals
have and how do you address these questions? What information or specific website links
do you provide the hospitals to help them make this determination?
• When working with ASCs to explain the study, how do you determine eligibility? What
questions do ASCs have and how do you address these questions? What information or
specific website links do you provide the ASCs to help them make this determination?
II. WORK PLAN
• Describe how your organization is implementing the OAS CAHPS Survey for each mode
for which your organization has been approved. This section of your QAP must describe
the entire process that your organization is following, including:
a. how you are obtaining the sample frame and selecting the sample;
b. how you are fielding the survey, receiving and processing the data;
c. the procedures that you are following to prepare and submit final files; and
d. the type of quality control procedures you are following at each stage to ensure data
quality.
• For each step above, you must specify the name of the individual who is responsible for
conducting and providing oversight of each specific activity.
• Include a copy of a schedule or timeline that you are following to ensure that you are able
to conduct all activities within the timeframes specified in the OAS CAHPS Survey
protocols. The timeline must describe when that activity will be completed (for example,
x weeks after sample selection, or y weeks after mailing the first questionnaire). The
timeline must include receipt of files from HOPDs and ASCs, sample selection, each step
of the mailout or telephone implementation, data file cleaning, and data file preparation
and submission.
III. SAMPLING PLAN
• Describe how you are working with your client facilities to ensure that the HOPDs and
ASCs understand patient survey eligibility criteria and the measures you take to ensure
that all patient information needed for sample selection is included on the file that is
Appendix N: Model Quality Assurance Plan (QAP) Outline November 2018
Centers for Medicare & Medicaid Services N-4 Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual
submitted and that the monthly patient files are submitted in time for you to select the
sample and initiate the survey within 21 days after the sample month ends.
• Describe how HOPDs or ASCs submit the monthly patient files to your organization and
how you check those files. That is, describe the steps that you take to ensure that the ASC
or HOPD has included all required data on the monthly patient files and the checks you
make to ensure that the same patient information is not included more than once on the
monthly patient information file. Describe how the transmission is done to ensure
security of these Health Insurance Portability and Accountability Act (HIPAA) data.
• Describe how you create the sample frame. This section should describe the process you
are using to develop a sampling frame that complies with the OAS CAHPS Survey
protocol. Specifically, you must explain how you are creating the frame, what patient
survey eligibility criteria you are using, and the types of patients who are being excluded
and how those cases are being identified. Please make sure your QAP addresses each of
the following questions:
a. How do you check monthly patient information files to determine if any required data for
a patients is incomplete?
b. What do you do if information is missing from the monthly patient information files?
c. What are the eligibility and exclusion criteria that you use to determine which patients are
eligible and which patients should be excluded from the sample frame? Refer to
Chapter IV, Sampling Procedures—Patient Eligibility Criteria.
d. How do you know whether your client HOPDs and ASCS have included all patients on
the monthly patient files? Do you obtain and retain documentation from the HOPDs and
ASCs about which patient records were excluded and the reasons those patients were
excluded from the monthly patient information files?
e. How do you know whether all eligible ASCs within the CCN, or all eligible HOPDs
within the CCN, are submitting patient files?
f. Do you check the monthly patient information files to ensure that patients are only listed
once on the file? If so, what information and process do you use to identify and remove
patients who may have been listed on the monthly patient information file more than
once?
g. What process (system or procedures) do you use to identify and remove patients who
have been included in the survey sample in the last 5 months?
November 2018 Appendix N: Model Quality Assurance Plan (QAP) Outline
Centers for Medicare & Medicaid Services N-5 Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual
h. What process (system, software, or procedure) do you use to assign a unique sample
identification (SID) to each sample patient?
i. OAS CAHPS Survey vendors are expected to calculate and use a sample rate for each
ASC and HOPD client to ensure that an even distribution of patients is sampled over a
12-month period. How do you determine a sample rate for each ASC and HOPD?
j. How is the sample selected? How is the sampling rate at each facility determined? What
software program do you use to generate the seed number and assign random numbers
used for sampling?
k. What documentation about sample frame creation do you retain and for how long? Where
do you document the seed numbers? Note that the replication of sample selection will be
part of the Site Visit process. Vendors should have documentation and systems in place
for this type of audit.
l. If the ASC or HOPD is also conducting other patient experience surveys, what
procedures do you follow to ensure that the sample for OAS CAHPS is selected first, and
is a random selection that is representative of the monthly patient records?
m. Which of the four acceptable sampling methods (SRS, SSS, PSRS, and DSRS) has your
organization implemented on OAS CAHPS?
• Describe the quality control checks that you are performing on the sampling activities,
how frequently are those checks are being performed, and by whom. Indicate what
percentage of the sample frame or sample file is being checked, and describe the
documentation that you maintain to verify that the quality control procedures have taken
place. Note that this documentation may be requested by the OAS CAHPS Survey
Coordination Team at any time.
• If applicable, describe any sampling exceptions that you have requested or for which your
organization has been approved. Explain the exceptions request and the specific
procedures you are or will be following to implement the approved exception.
IV. SURVEY IMPLEMENTATION PLAN
• Describe the system resources that you are using to implement your approved survey
mode(s). This includes a description of the relevant hardware or software. For example,
describe the electronic telephone interviewing systems, mailing equipment, scanning or
data entry equipment, and case management system that you are using.
• Describe training that is being given to all staff working on the OAS CAHPS Survey
project, including telephone interviewers (if applicable), mail survey production staff,
Appendix N: Model Quality Assurance Plan (QAP) Outline November 2018
Centers for Medicare & Medicaid Services N-6 Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual
and data receipt/data processing/data entry staffs. If you are using any subcontractors for
any roles, describe how the subcontractor’s staff are being trained. Include a discussion
of quality control procedures that you or your subcontractor are implementing during
training to ensure compliance with OAS CAHPS Survey protocols. Describe the
documentation that is being kept to provide evidence of this quality control.
• Describe the toll-free customer support telephone line that you are offering, including the
actual telephone number, how customer support staff are being trained, and who is
responsible for training and responding to questions related to the OAS CAHPS Survey.
Also include information on the days of the week and times of the day that you are
staffing the customer support line and how you are handling after-hours contacts, and
include text of any recordings that are being used. Include a discussion of quality control
procedures that are being implemented to ensure compliance with OAS CAHPS Survey
protocols and describe documentation that is being kept to provide evidence of this
quality control. (Reference Chapter VI.)
• Describe the production and mailout process for mail surveys, if applicable, including
who is responsible for the process and what quality control checks are being implemented
at each stage (for example, monitoring the quality and content of mail survey packages,
use of seeded mailings, and frequency of checks). Describe all quality control checks that
are being implemented and documented to ensure that the OAS CAHPS Survey protocols
are being followed. (Reference Chapter V.)
• Describe the receipt and data entry or scanning process for mail surveys, if applicable,
including who is responsible for the process and what quality control checks are being
implemented at the questionnaire receipt, data entry, or scanning phase, and how
frequently those checks are being made. Describe all quality control checks that are being
implemented and documented to ensure that the OAS CAHPS Survey protocols are being
followed. (Reference Chapter V.)
• Describe the process for implementing the telephone survey, if applicable, including who
is responsible for training and monitoring interviewer performance, how training and
monitoring are being documented, and what systems and procedures are being used to
ensure that all interviewing is conducted according to the OAS CAHPS Survey protocols
(for example, varying times of day that calls are attempted and tracking the status of call
attempts). If you are using a telephone survey subcontractor, describe oversight activities
you are conducting to ensure that the subcontractor is in compliance with OAS CAHPS
Survey protocols. (Reference Chapter VI.)
• If you are approved for mixed-mode administration, you must address all of the
paragraphs above regarding both mail and telephone processes. In addition, you must
November 2018 Appendix N: Model Quality Assurance Plan (QAP) Outline
Centers for Medicare & Medicaid Services N-7 Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual
include a discussion of the control system used to monitor case status as the case
transitions from the mail phase of the survey to the telephone follow-up phase. Describe
how you keep track of surveys that are returned while the telephone follow-up phase is in
effect. Describe the processes that you have in place to ensure that sample members who
have returned a completed survey are not called after the completed survey is received.
How do you determine which completed survey to retain (mail or telephone interview
data) if the sample member returns a completed survey and participates in a telephone
interview? (Reference Chapter VII.)
• Describe the processes you are using to create data files and submit them to the OAS
CAHPS Data Center through the OAS CAHPS Survey website. Discuss quality control
checks that are being implemented during file creation, including how these checks are
being documented. (Reference Chapter XI.)
V. DATA SECURITY, CONFIDENTIALITY, AND PRIVACY PLAN
• Describe the measures that you are taking to ensure data security, including a discussion
of the use of passwords, file encryption, backup systems, and any other measures to
ensure the security of OAS CAHPS Survey data. Describe how often passwords are
changed. For both hardcopy questionnaires and electronic data files, describe how and for
how long these materials will be stored and when and how they will be destroyed.
(Reference Chapter VIII.)
• Describe how individuals will be authorized and deauthorized to access personally
identifiable information (PII). Include information about how confidentiality agreements
are being implemented among vendor staff and any subcontractor staff. Describe how
affidavits of confidentiality are being documented, background checks are being
conducted, and confidentiality training procedures are being implemented. Include a copy
of the confidentiality agreement that is being used as an appendix in your QAP. Vendors
must ensure compliance with HIPAA requirements. Describe the measures that are being
taken to protect respondent privacy and ensure compliance with HIPAA requirements.
Describe the required HIPAA training of staff working on OAS CAHPS. If you are using
any subcontractors for any roles, describe how the subcontractor’s staff are being trained
on HIPAA. Include information about how unauthorized individuals are being prevented
from accessing PII and the survey data in physical and electronic format. (Reference
Chapter VIII.)
• If you are approved for telephone surveys, include a screenshot or text indicating the
voluntary nature of the sample member’s participation.
• Provide a general description of the disaster recovery plan for OAS CAHPS Survey data
in the event of a disaster.
Appendix N: Model Quality Assurance Plan (QAP) Outline November 2018
Centers for Medicare & Medicaid Services N-8 Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual
VI. EXCEPTIONS REQUEST PROCESS AND DISCREPANCY NOTIFICATION
REPORTING
• Describe any Exceptions Requests that you have or plan to request or document that you
have none but agree to comply with the process outlined in Chapter XV.
• Document your understanding of the Discrepancy Notification Reporting protocol
outlined in Chapter XV and that you agree to comply with the process.
VII. QUESTIONNAIRE AND MATERIALS ATTACHMENTS
• Attach a copy of your formatted mail survey questionnaire if you are approved for mail-
only or mixed-mode administration in each language you offer to clients. Be sure to
include the cover page and back page in each language.
• If you are approved for telephone-only or mixed-mode administration, attach all
screenshots from your telephone interview program—beginning with the introductory
screens and ending with the last question in the interview. If your interview includes the
Consent to Share Identifying Information question, please include a screen shot of this
question as well. Include screenshots of the telephone interview in each language you
offer to clients.
• If you are approved for mail-only or mixed-mode administration, include a copy of your
cover letter(s) in each language you offer to clients.
Centers for Medicare & Medicaid Services Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual
APPENDIX O:
EXCEPTIONS REQUEST FORM
Appendix O: Exceptions Request Form November 2018
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OUTPATIENT AND AMBULATORY SURGERY CAHPS SURVEY EXCEPTIONS REQUEST FORM
Use the Exceptions Request Form to report a planned deviation from the standard OAS CAHPS protocols. You may request the same exceptions for multiple Hospital Outpatient Departments (HOPDs) or Ambulatory Surgery Centers (ASCs) with which you contract, if applicable.
To submit this form online, please go to https://oascahps.org/ .
I. Exception Request
Select an exception request classification, and provide the specific reason for your exception request
1a. Date Submitted: <inserted by system>
1b. Exception Request Classification (Select one)
New Exception Request
Update list of applicable HOPDs and ASCs on a previous Exception Request
Update other information on a previous Exception Request
Appeal of denial of a previous Exception Request
1c. Specify Reason for Exception Request:
For example: “We request 5 additional business days to complete the phone attempts for three of our contracted facilities.”
II. Description of Exception Request
2a. Purpose of requested exception (e.g., sampling, data issues).
For example: “The purpose is to allow us to complete the required telephone attempts for three of the facilities for which we collect data. A flu epidemic has spread through our area resulting in many telephone interviewers being unable to work for several days in a row.”
2b. How and when will the exception be implemented?
For example: “Instead of the final calling day being Friday, February 6, 2017, we will continue calling Friday, February 6 through Wednesday, February 11. The extension in the data collection period will allow us to finalize all outstanding phone cases.”
2c. Provide evidence that exception will not affect survey results.
For example: “This procedure will not impact survey results because it only applies to the mail cover letter.” Or “If the extension is granted it will not impact our ability to meet the data submission deadline.”
Appendix O: Exceptions Request Form November 2018
O-2 Centers for Medicare & Medicaid Services Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual
III. Which HOPDs and ASCs are impacted by this Exception Request?
Vendor should revise the Exception Request if additional facilities (CCNs) need to be added after the initial Exception Request was submitted.
If you have multiple CCNs, please enter them as a comma separated list, as shown in the example below. Do not include dashes in the CCN. After entering your CCN(s), click on the "Lookup Facility Names" button.
For example: “111111,222222,333333,44C4444444,55C5555555”
Lookup Facility Names.
To submit this form, visit the Outpatient and Ambulatory Surgery CAHPS Survey website at https://oascahps.org/ . If you have any problems completing the online Exceptions Request Form, please e-mail the OAS CAHPS Survey Coordination Team at [email protected] for assistance.
Centers for Medicare & Medicaid Services Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual
APPENDIX P:
DISCREPANCY NOTIFICATION REPORT
Appendix P: Discrepancy Notification Report November 2018
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OUTPATIENT AND AMBULATORY SURGERY CAHPS SURVEY DISCREPANCY NOTIFICATION REPORT
Use the Discrepancy Notification Report (DNR) to notify the OAS CAHPS Survey Coordination Team of any unplanned deviation from the OAS CAHPS protocols that occurred.
To submit this form online, please go to https://oascahps.org/ .
Date Submitted: inserted by system
I. Discrepancy Notification Report
One Discrepancy Notification Report (DNR) is required for each discrepancy reason. If you have multiple CCNs with the same discrepancy reason, please include all CCNs on one DNR. If you have more than one discrepancy reason, you will need to submit a DNR for each discrepancy reason. To complete this form, please complete the following sections:
• Section I—Select the affected Survey Quarter and the reason for the discrepancy from the
drop down boxes.
• Section II—Enter all CCNs that are impacted by the discrepancy reason.
• Section III—Provide a detailed description of the discrepancy being reported for each
CCN and include the number of affected patients. If you do not know the number of
affected patients, please enter UNK. If the number of affected patients is not applicable,
enter NA.
• Section IV—Include a description of the corrective action your organization has taken to
address the discrepancy.
• Section V—Provide any additional information about the discrepancy that you feel the
OAS CAHPS Survey Coordination Team will need.
• Section V—Submit.
Appendix P: Discrepancy Notification Report November 2018
Centers for Medicare & Medicaid Services P-2 Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual
II. Affected Facility or Facilities
Please enter the CCN(s) for which you are filing this discrepancy. If you have multiple CCNs, please enter them as a comma separated list, as shown in the example below. Do not include dashes in the CCN. After entering your CCN(s), click on the “Lookup Facility Names” button.
Example: 111111,222222,333333,44C4444444,55C5555555
Lookup Facility Names.
III. Describe Discrepancy
Please complete the items below in detail for each facility listed. Include adequate information so the OAS CAHPS team can fully understand this discrepancy and its root cause.
For example: “We had to mail the surveys after the deadline (21 days after the end of the sample month), because our vendor offices were closed due to inclement weather.” Or “It has come to our attention that an error occurred during data collection and the answers to Q8, Q9, and Q10 were all recorded as “refused” due to a programing error.”
If “Late Start” is selected from the Discrepancy Reason dropdown list, the DNR’s table will appear as
shown below.
If any other discrepancy reason is selected from the Discrepancy Reason dropdown list, the DNR’s table
will appear as shown below.
November 2018 Appendix P: Discrepancy Notification Report
Centers for Medicare & Medicaid Services P-3 Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual
IV Corrective Action
Describe the corrective action(s) that will be taken to address discrepancy. Include the proposed timeline for the corrective action(s).
For example: “We have increased staff hours ensure that all mail surveys are sent no later than 2 days after the deadline.” Or “We have implemented quality control procedures and automated checks to prevent this type of programing error in the future. The CATI system now allows data to be recorded for all items. In future survey periods the CATI instrument will be tested in both the development and live survey environments.”
V. Additional information
Provide additional information that will help the OAS CAHPS Survey Coordination Team understand the discrepancy.
For example: “Due to a blizzard the data collection facility was closed for two days before the mailing deadline for the OAS CAHPS Surveys.” Or “This has been corrected for the current survey quarter. All additional survey data collected will not be impacted by this problem.”
VI. Submit
A Discrepancy Notification form will be submitted for the CCN(s) listed above when you click the "Submit" button below. Please verify that the list is correct. If it is not correct, please edit your CCN(s) above and click the Lookup button again.
To submit this form, visit the Outpatient and Ambulatory Surgery CAHPS Survey website at https://oascahps.org/ . If you have any problems completing the online Discrepancy Notification Form, please e-mail the OAS CAHPS Survey Coordination Team at [email protected] for assistance.
Appendix P: Discrepancy Notification Report November 2018
Centers for Medicare & Medicaid Services P-4 Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual
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Centers for Medicare & Medicaid Services Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual
APPENDIX Q:
EXCLUDED PROCEDURAL CODES
Appendix Q: Excluded Procedural Codes November 2018
Centers for Medicare & Medicaid Services Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual
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Centers for Medicare & Medicaid Services Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual Q-1
The CPT codes29
listed below fall within the range for Codes for Surgery but are not considered
to be eligible for OAS CAHPS. They are grouped by category within the Codes for Surgery.
Additional CPT codes within the eligible range may also be excluded; however, the vendor must
submit an Exceptions Request Form (ERF) to document the codes to be excluded.
Category
10030–19499: Integumentary System
11042 Debridement, subcutaneous tissue; first 20sq cm or less
11045 Debridement, subcutaneous tissue; each additional 20 sq cm, or part
thereof
16020, 16025, 16030 Dressings or debridement of partial-thickness burns, initial or
subsequent (small, medium, or large)
Category
20000–29999: Musculoskeletal System
29000 Application of halo type body case
29010 Application of Risser jacket, localizer, body; only
29015 Application of Risser jacket, localizer, body; including head
29020 Application of turnbuckle jacket, body; only
29025 Application of turnbuckle jacket, body; including head
29035 Application of body cast, shoulder to hips;
29040 Application of body cast, shoulder to hips; including head, Minerva
type
29044 Application of body cast, shoulder to hips; including 1 thigh
29046 Application of body cast, shoulder to hips; including both thighs
29049 Application, cast; figure-of-eight
29055 Application, cast; figure-of-eight, shoulder spica
29058 Application, cast; figure-of-eight, plaster Velpeau
29 CPT only copyright 2019 American Medical Association. All rights reserved.
Appendix Q: Excluded Procedural Codes November 2018
Centers for Medicare & Medicaid Services Q-2 Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual
Category
20000–29999: Musculoskeletal System
29065 Application, cast; figure-of-eight, shoulder to hand (long arm)
29075 Application, cast; figure-of-eight, elbow to finger (short arm)
29085 Application, cast; figure-of-eight, hand and lower forearm (gauntlet)
29086 Application, cast; figure-of-eight, finger (e.g., contracture)
29105 Application of long arm splint (shoulder to hand)
29125 Application of short arm splint (forearm to hand); static
29126 Application of short arm splint (forearm to hand); dynamic
29130 Application of finger splint; static
29131 Application of finger splint; dynamic
29200 Strapping; thorax
29240 Strapping; shoulder
29260 Strapping; elbow or wrist
29280 Strapping; hand or finger
29305 Application of hip spica cast; 1 leg
29325 Application of hip spica cast; 1 and one-half spica or both legs
29345 Application of long leg cast (thigh to toes)
29355 Application of long leg cast (thigh to toes); walker or ambulatory type
29358 Application of long leg cast brace
29365 Application of cylinder cast (thigh to ankle)
29405 Application of short leg cast (below knee to toes)
29425 Application of short leg cast (below knee to toes); walking or
ambulatory type
29435 Application of patellar tendon bearing (PTB) cast
29440 Adding walker to previously applied cast
29445 Application of rigid total contact leg cast
29450 Application of clubfoot cast with molding or manipulation, long or
short leg
November 2018 Appendix Q: Excluded Procedural Codes
Centers for Medicare & Medicaid Services Q-3 Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual
Category
20000–29999: Musculoskeletal System
29505 Application of long leg splint
29515 Application of short leg splint
29520 Strapping hip
29530 Strapping knee
29540 Strapping ankle/or foot
29550 Strapping toes
29580 Strapping using unna boot (compression dressing for stasis ulcers and
other venous insufficiencies of the leg)
29581 Application of multilayer compression system; leg (below knee),
including ankle and foot
29582 Application of multilayer compression system; thigh and leg,
including ankle and foot, when performed
29583 Application of multilayer compression system; upper arm and forearm
29584 Application of multilayer compression system; upper arm, forearm,
hand, and fingers
29700 Removal or bivalving; gauntlet, boot or body cast
29705 Removal or bivalving; full arm or full leg cast
29710 Removal or bivalving; shoulder or hip spica, Minerva, or Risser
jacket, etc.
29715 Removal or bivalving; turnbuckle jacket
29720 Repair of spica, body cast or jacket
29730 Windowing of cast
29740 Wedging of cast (except clubfoot casts)
29750 Wedging of clubfoot cast
29799 Unlisted procedure, casting, or strapping
Category
33010–37799: Cardiovascular System
36400 Venipuncture, younger than age 3 years; femoral or jugular vein
Appendix Q: Excluded Procedural Codes November 2018
Centers for Medicare & Medicaid Services Q-4 Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual
Category
33010–37799: Cardiovascular System
36405 Venipuncture, younger than age 3 years; scalp vein
36406 Venipuncture, younger than age 3 years; other vein
36415 Collection of venous blood by venipuncture
36416 Collection of capillary blood specimen
36420 Venipuncture, cutdown; younger than age 1 year
36425 Venipuncture, cutdown; age 1 or over
36430 Transfusion of blood components
36440 Push transfusion, blood, 2 years or younger
36450 Exchange transfusion, blood, newborn
36455 Exchange transfusion, blood, other than newborn
36460 Transfusion, intrauterine, fetal
36468 Single or multiple injections of sclerosing solutions, spider veins
(telangiectasia); limb or trunk
36469 Single or multiple injections of sclerosing solutions, spider veins
(telangiectasia); face
36470 Injection of sclerosing solution, single vein
36471 Injection of sclerosing solution, multiple veins, same leg
36591 Collection of blood specimen from a completely implantable venous
access device
36592 Collection of blood specimen using established central or peripheral
catheter, venous, not otherwise specified
36600 Arterial puncture, withdrawal of blood for diagnosis
36620 Arterial catheterization or cannulation for sampling, monitoring or
transfusion (separate procedure); percutaneous
36625 Arterial catheterization or cannulation for sampling, monitoring or
transfusion (separate procedure); cutdown
36660 Catheterization, umbilical artery, newborn, for diagnosis or therapy
November 2018 Appendix Q: Excluded Procedural Codes
Centers for Medicare & Medicaid Services Q-5 Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual
Category
50010–53899: Urinary System
51701 Insertion of non-indwelling bladder catheter
51702 Insertion of temporary indwelling bladder catheter
Category
59000–59899: Maternity Care and Delivery
59020 Fetal contraction stress test
59025 Fetal contraction non-stress test
Appendix Q: Excluded Procedural Codes November 2018
Centers for Medicare & Medicaid Services Q-6 Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual
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Centers for Medicare & Medicaid Services Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual
APPENDIX R:
EXAMPLE PATIENT FILE LAYOUT
Appendix R: Example Patient File Layout November 2018
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Centers for Medicare & Medicaid Services Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual R-1
EXAMPLE OF A PATIENT FILE LAYOUT
OAS CAHPS SURVEY
The following table is an example of a patient file layout. Survey vendors may use this layout as
an example template of the patient data needed from a client hospital outpatient department
(HOPD) or ambulatory surgery center (ASC). Information on patient eligibility criteria and
proper construction of the patient information file can be found in Chapter IV.
Data elements in the patient file layout shown below that will not be included on the data
file submitted to the OAS CAHPS Data Center are bolded and italicized.
SAMPLE PATIENT LAYOUT
Data Element
Field
Size Value Labels and Use
Required for
XML
Data Submission
Facility Name 100 Name of HOPD or ASC. Yes
CMS Certification
Number (CCN) 10
Valid 6- or 10-digit CMS Certification Number
(CCN, formerly known as the Medicare Provider
ID Number).
Yes
Sample Month 2 OAS CAHPS Survey sampling month.
MM Yes
Sample Year 4 Year of sample month.
YYYY Yes
No. of Patients Served 6
Total number of patients who had at least one
outpatient surgery or procedure during the sample
month at the HOPD or ASC, regardless of whether
the patient or procedure was OAS CAHPS eligible.
Yes
Patient First Name 30
The name of the patient is needed to generate and
send personalized mail survey materials to sample
members and/or for telephone survey data
collection.
No
(continued)
SAMPLE PATIENT LAYOUT (CONTINUED)
Data Element
Field
Size Value Labels and Use
Required for
XML
Data Submission
Patient Middle Initial 1
The name of the patient is needed to generate and
send personalized mail survey materials to sample
members and/or for telephone survey data
collection.
No
Appendix R: Example Patient File Layout November 2018
R-2 Centers for Medicare & Medicaid Services Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual
Data Element
Field
Size Value Labels and Use
Required for
XML
Data Submission
Patient Last Name 30
The name of the patient is needed to generate and
send personalized mail survey materials to sample
members and/or for telephone survey data
collection.
No
Patient Date of Birth 8
Patient’s birthdate. Used by survey vendor to
determine eligibility and to calculate patient age
prior to submitting data to the OAS CAHPS Data
Center.
MMDDYYYY
No
Gender 1
Patient’s gender.
1 = Male
2 = Female
M = Unknown/Missing
Yes
Language (if available
from patient record) 1
Identify the language the patient speaks. Needed
for survey administration.
1 = English
2 = Spanish
3 = Chinese
4 = Korean
5 = Other
M = Unknown/Missing
No
Patient Mailing Address
1 50
Patient’s street or post office box number.
Address information needed for survey
administration.
No
Patient Mailing Address
2 50 Second line of patient address (if needed). No
Patient Address City 50 Mailing address city. No
Patient Address State 2 Mailing address state. Use 2-character postal
abbreviation. No
(continued)
SAMPLE PATIENT LAYOUT (CONTINUED)
Data Element
Field
Size Value Labels and Use
Required for
XML
Data Submission
Patient Address Zip
Code 9
9-digit Mailing Address Zip Code.
(5-digit zip code followed by 4-digit extension; no
hyphens, separators or delimiters)
No
November 2018 Appendix R: Example Patient File Layout
Centers for Medicare & Medicaid Services R-3 Outpatient and Ambulatory Surgery CAHPS Survey Protocols and Guidelines Manual
Data Element
Field
Size Value Labels and Use
Required for
XML
Data Submission
Telephone Number
including area code 10
Patient’s primary telephone number. Needed for
survey administration.
Include 3-digit area code and 7-digit number: no
dashes or spaces, separators, or delimiters.
No
Cell Phone Indicator 1
Indication if the telephone number provided is a
cell phone. Needed for telephone survey
administration.
1 = Yes
2 = No
M = Unknown /Missing
No
Medical Record
Number 20 Patient’s Medical Record Number. No
Procedural Codes 5
Eligible CPT-430
codes (within the Codes for
Surgery range – 10021-69990) or G-Code
(G0104, G0105, G0121, and G0260). Used by
vendor to determine Surgical Category. NOTE: if
multiple eligible CPT codes and G-codes, list the
primary code first. Vendors will categorize the
surgery type based on the first code listed if there
are multiples.
No
Date of Procedure 8
Date in which the outpatient surgery or
procedure was performed. Needed for survey
administration.
MMDDYYYY
No
Name of Location
Where
Surgery/Procedure
Occurred
20
If HOPD or ASC has multiple locations, provide
name of the location where patient received
surgery or procedure. This may not be the official
name of the facility. Needed for survey
administration.
No
30 CPT only copyright 2019 American Medical Association. All rights reserved.