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

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
of 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?

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

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

YOUR CARE FROM DOCTORS
5.

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

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

6.

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

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

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

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?

 Yes
 No  If No, Go to Question 12

1

2

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
have any pain?

 Yes
2 No  If No, Go to Question 15
1

13. During this hospital stay, how often
did hospital staff talk with you about
how much pain you had?

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

8.

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

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

14. During this hospital stay, how often
did hospital staff talk with you about
how to treat your pain?

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

9.

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

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

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

 Yes
2 No  If No, Go to Question 18

1

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

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

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

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

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

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

 Yes
2 No
1

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

 Yes
 No

1
2

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

Worst hospital possible

Best hospital possible

22. Would you recommend this hospital
to your friends and family?
1 Definitely no
2 Probably no
3 Probably yes
4 Definitely yes

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

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
2 No
1

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

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

I left the hospital

2


4
5
6
3

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?

32. What language do you mainly speak
at home?

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

2

Chicano
4 Yes, Cuban
5 Yes, other Spanish/Hispanic/Latino
31. What is your race? Please choose
one or more.

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

_____________________

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



5

Islander
American Indian or Alaska Native

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 Eric A. Coleman, MD, MPH, all rights reserved.

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 (mm/dd/yyyy)]. 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 1-800-xxxxxxx. 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.

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 (mm/dd/yyyy)]. 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 1-800-xxxxxxx. 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.

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, C1-05-17, Baltimore, MD 212441850. Expiration Date: 07/31/2018.”