Form CMS-10102 HCAHPS Survey Instrument (Mail) and Supporting Materials

Attachment A
SUPPORTING STATEMENT – Part A:
National Implementation of the Hospital CAHPS Survey
CMS-10102
HCAHPS Survey Instrument (Mail) and Supporting Materials

March 2014

1

HCAHPS Survey
SURVEY INSTRUCTIONS




You should only fill out this survey if you were the patient during the hospital stay named in the
cover letter. Do not fill out this survey if you were not the patient.
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 Question 1

You may notice a number on the survey. This number is used to let us know if you
returned your survey so we don't have to send you reminders.
Please note: Questions 1-25 in this survey are part of a national initiative to measure the quality
care in hospitals. OMB #0938-0981

Please answer the questions in this
survey about your stay at the hospital
named on the cover letter. Do not
include any other hospital stays in your
answers.

3.

 Never
 Sometimes
3
 Usually
4
 Always
1
2

YOUR CARE FROM NURSES
1.

During this hospital stay, how
often did nurses treat you with
courtesy and respect?

 Never
 Sometimes
3
 Usually
4
 Always
1
2

2.

During this hospital stay, how
often did nurses listen carefully to
you?

During this hospital stay, how
often did nurses explain things in
a way you could understand?

4.

During this hospital stay, after you
pressed the call button, how often
did you get help as soon as you
wanted it?

 Never
 Sometimes
3
 Usually
4
 Always
9
 I never pressed the call button
1
2

 Never
 Sometimes
3
 Usually
4
 Always
1
2

March 2014

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of

YOUR CARE FROM DOCTORS
5.

During this hospital stay, how
often did doctors treat you with
courtesy and respect?

 Never
 Sometimes
3
 Usually
4
 Always
1
2

6.

During this hospital stay, how
often did doctors listen carefully
to you?

 Never
 Sometimes
3
 Usually
4
 Always
1
2

7.

During this hospital stay, how
often did doctors explain things in
a way you could understand?

 Never
2
 Sometimes
3
 Usually
4
 Always
1

THE HOSPITAL ENVIRONMENT
8.

During this hospital stay, how
often were your room and
bathroom kept clean?

 Never
2
 Sometimes
3
 Usually
4
 Always
1

9.

During this hospital stay, how
often was the area around your
room quiet at night?

 Never
 Sometimes
3
 Usually
4
 Always
1
2

YOUR EXPERIENCES IN THIS
HOSPITAL
10. During this hospital stay, did you
need help from nurses or other
hospital staff in getting to the
bathroom or in using a bedpan?




1

2

Yes
No  If No, Go to Question 12

11. How often did you get help in
getting to the bathroom or in
using a bedpan as soon as you
wanted?

 Never
 Sometimes
3
 Usually
4
 Always
1
2

12. During this hospital stay, did you
need medicine for pain?




1
2

Yes
No  If No, Go to Question 15

13. During this hospital stay, how
often was your pain well
controlled?

 Never
 Sometimes
3
 Usually
4
 Always
1
2

14. During this hospital stay, how
often did the hospital staff do
everything they could to help you
with your pain?

 Never
 Sometimes
3
 Usually
4
 Always
1
2

15. During this hospital stay, were you
given any medicine that you had
not taken before?




1
2

Yes
No  If No, Go to Question 18

16. Before giving you any new
medicine, how often did hospital
staff tell you what the medicine
was for?

 Never
 Sometimes
3
 Usually
4
 Always
1
2

19. During this hospital stay, did
doctors, nurses or other hospital
staff talk with you about whether
you would have the help you
needed when you left the
hospital?




1
2

20. During this hospital stay, did you
get information in writing about
what symptoms or health
problems to look out for after you
left the hospital?




1
2

17. Before giving you any new
medicine, how often did hospital
staff describe possible side
effects in a way you could
understand?

 Never
 Sometimes
3
 Usually
4
 Always
1
2

WHEN YOU LEFT THE HOSPITAL
18. After you left the hospital, did you
go directly to your own home, to
someone else’s home, or to
another health facility?

 Own home
 Someone else’s home
3
 Another health
1
2

facility 

If Another, Go to
Question 21

Yes
No

Yes
No

OVERALL RATING OF HOSPITAL
Please answer the following questions
about your stay at the hospital named
on the cover letter. Do not include any
other hospital stays in your answers.
21. Using any number from 0 to 10,
where 0 is the worst hospital
possible and 10 is the best
hospital possible, what number
would you use to rate this hospital
during your stay?

0
1
2
2
3
3
4
4
5
5
6
6
7
7
8
8
9
9
10
10
0

Worst hospital possible

1

Best hospital possible

22. Would you recommend this
hospital to your friends and
family?

 Definitely no
 Probably no
3
 Probably yes
4
 Definitely yes
1
2

ABOUT YOU
There are only a few remaining items
left.
26. During this hospital stay, were you
admitted to this hospital through
the Emergency Room?

 Yes
 No

1
2

UNDERSTANDING YOUR CARE
WHEN YOU LEFT THE HOSPITAL
23. During this hospital stay, staff
took my preferences and those of
my family or caregiver into
account in deciding what my
health care needs would be when I
left.

 Strongly disagree
 Disagree
3
 Agree
4
 Strongly agree
1
2

24. When I left the hospital, I had a
good understanding of the things I
was responsible for in managing
my health.

 Strongly disagree
 Disagree
3
 Agree
4
 Strongly agree
1
2

27. In general, how would you rate
your overall health?

 Excellent
 Very good
3
 Good
4
 Fair
5
 Poor
1
2

28. In general, how would you rate
your overall mental or emotional
health?

 Excellent
 Very good
3
 Good
4
 Fair
5
 Poor
1
2

29. What is the highest grade or level
of school that you have
completed?

 8th grade or less
 Some high school, but did not

1

25. When I left the hospital, I clearly
understood the purpose for taking
each of my medications.

 Strongly disagree
 Disagree
3
 Agree
4
 Strongly agree
5
 I was not given any medication
1
2

when I left the hospital

2



5

6

3
4

graduate
High school graduate or GED
Some college or 2-year degree
4-year college graduate
More than 4-year college degree

30. Are you of Spanish, Hispanic or
Latino origin or descent?

 No, not Spanish/Hispanic/Latino
2
 Yes, Puerto Rican
3
 Yes, Mexican, Mexican American,
1

Chicano
 Yes, Cuban
5
 Yes, other
Spanish/Hispanic/Latino
4

31. What is your race? Please choose
one or more.

 White
 Black or African American
3
 Asian
4
 Native Hawaiian or other Pacific
1
2



5

Islander
American Indian or Alaska
Native

32. What language do you mainly
speak at home?

 English
2
 Spanish
3
 Chinese
4
 Russian
5
 Vietnamese
6
 Portuguese
9
 Some other language (please
1

print): _____________________

THANK YOU
Please return the completed survey in the postage-paid envelope.

[NAME OF SURVEY VENDOR OR SELF-ADMINISTERING HOSPITAL]
[RETURN ADDRESS OF SURVEY VENDOR OR SELF-ADMINISTERING
HOSPITAL]

Questions 1-22 and 26-32 are part of the HCAHPS Survey and are works of the U.S.
Government. These HCAHPS questions are in the public domain and therefore are NOT
subject to U.S. copyright laws. The three Care Transitions Measure® questions (Questions
23-25) are copyright of The Care Transitions Program® (www.caretransitions.org).

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Sample Initial Cover Letter for the HCAHPS Survey
[HOSPITAL LETTERHEAD]
[SAMPLED PATIENT NAME]
[ADDRESS]
[CITY, STATE ZIP]
Dear [SAMPLED PATIENT NAME]:
Our records show that you were recently a patient at [NAME OF HOSPITAL] and discharged
on [DATE OF DISCHARGE]. Because you had a recent hospital stay, we are asking for your
help. This survey is part of an ongoing national effort to understand how patients view their
hospital experience. Hospital results will be publicly reported and made available on the
Internet at www.medicare.gov/hospitalcompare. These results will help consumers make
important choices about their hospital care, and will help hospitals improve the care they
provide.
Questions 1-25 in the enclosed survey are part of a national initiative sponsored by the United
States Department of Health and Human Services to measure the quality of care in hospitals.
Your participation is voluntary and will not affect your health benefits.
We hope that you will take the time to complete the survey. Your participation is greatly
appreciated. After you have completed the survey, please return it in the pre-paid envelope.
Your answers may be shared with the hospital for purposes of quality improvement.
[OPTIONAL: You may notice a number on the survey. This number is used to let us know if
you returned your survey so we don’t have to send you reminders.]
If you have any questions about the enclosed survey, please call the toll-free number 1-800xxx-xxxx. Thank you for helping to improve health care for all consumers.
Sincerely,

[HOSPITAL ADMINISTRATOR]
[HOSPITAL NAME]

Note: The OMB Paperwork Reduction Act language must be included in the mailing. This
language can be either on the front or back of the cover letter or questionnaire, but cannot be a
separate mailing. The exact OMB Paperwork Reduction Act language is included in this
appendix. Please refer to the Mail Only, and Mixed Mode sections, for specific letter
guidelines.

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Sample Follow-up Cover Letter for the HCAHPS Survey
[HOSPITAL LETTERHEAD]
[SAMPLED PATIENT NAME]
[ADDRESS]
[CITY, STATE ZIP]
Dear [SAMPLED PATIENT NAME]:
Our records show that you were recently a patient at [NAME OF HOSPITAL] and discharged
on [DATE OF DISCHARGE]. Approximately three weeks ago we sent you a survey regarding
your hospitalization. If you have already returned the survey to us, please accept our thanks and
disregard this letter. However, if you have not yet completed the survey, please take a few
minutes and complete it now.
Because you had a recent hospital stay, we are asking for your help. This survey is part of an
ongoing national effort to understand how patients view their hospital experience. Hospital
results will be publicly reported and made available on the Internet at
www.medicare.gov/hospitalcompare. These results will help consumers make important
choices about their hospital care, and will help hospitals improve the care they provide.
Questions 1-25 in the enclosed survey are part of a national initiative sponsored by the United
States Department of Health and Human Services to measure the quality of care in hospitals.
Your participation is voluntary and will not affect your health benefits. Please take a few
minutes and complete the enclosed survey. After you have completed the survey, please return
it in the pre-paid envelope. Your answers may be shared with the hospital for purposes of
quality improvement. [OPTIONAL: You may notice a number on the survey. This number is
used to let us know if you returned your survey so we don’t have to send you reminders.]
If you have any questions about the enclosed survey, please call the toll-free number 1-800xxx-xxxx. Thank you again for helping to improve health care for all consumers.
Sincerely,

[HOSPITAL ADMINISTRATOR]
[HOSPITAL NAME]

Note: The OMB Paperwork Reduction Act language must be included in the mailing. This
language can be either on the front or back of the cover letter or questionnaire, but cannot be a
separate mailing. The exact OMB Paperwork Reduction Act language is included in this
appendix. Please refer to the Mail Only, and Mixed Mode sections, for specific letter
guidelines.
3

OMB Paperwork Reduction Act Language
The OMB Paperwork Reduction Act language must be included in the survey mailing. This
language can be either on the front or back of the cover letter or questionnaire, but cannot be a
separate mailing. The following is the language that must be used:
English Version
“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 0938-0981. The time required to complete this
information collected is estimated to average 8 minutes for questions 1-25 on the survey,
including the time to review instructions, search existing data resources, gather the data needed,
and complete and review the information collection. If you have any comments concerning the
accuracy of the time estimate(s) or suggestions for improving this form, please write to: Centers
for Medicare & Medicaid Services, 7500 Security Boulevard, C1-25-05, Baltimore, MD 212441850.”

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