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CAHPS Hospice Survey
Quality Assurance
Guidelines
Version 6.0
September 2019
CAHPS® Hospice Survey
Quality Assurance Guidelines
ACKNOWLEDGEMENTS
These specifications were prepared under contract to the Centers for Medicare & Medicaid
Services (CMS) by the RAND Corporation, in collaboration with Health Services Advisory Group.
CMS is pleased to acknowledge the role of the Agency for Healthcare Research and Quality
(AHRQ), its Consumer Assessment of Healthcare Providers and Systems (CAHPS®1) grantees,
and Joan M. Teno, MD, MS in developing and testing the CAHPS Hospice Survey.
1
CAHPS® is a registered trademark of the Agency for Healthcare Research and Quality, a U.S. Government agency.
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CAHPS Hospice Survey
Quality Assurance Guidelines
Table of Contents
I. Reader’s Guide
1
Purpose of Quality Assurance Guidelines
CAHPS Hospice Survey Quality Assurance Guidelines V6.0 Contents
II. Introduction and Overview
5
Background
CAHPS Hospice Survey Instrument
CAHPS Hospice Survey Development and National Implementation Timeline
CAHPS Hospice Survey Data Collection and Submission Timeline
III. Program Requirements
15
Overview
Purpose of the CAHPS Hospice Survey Program Requirements
Hospice Communication with Patients and/or Their Caregivers
Roles and Responsibilities
Survey Vendor Analysis of CAHPS Hospice Survey Data
CAHPS Hospice Survey Minimum Business Requirements
CAHPS Hospice Survey Rules of Participation
IV. Communications and Technical Support
33
Overview
CAHPS Hospice Survey Information and Technical Assistance
General Information, Announcements and Updates
Communicate with CMS Regarding the CAHPS Hospice Survey
V. Sampling Protocol
35
Overview
Hospice Information Submission Requirements
Eligibility for the CAHPS Hospice Survey
Sample Frame Creation
Sampling Procedure
Method of Sampling
VI. Mail Only Survey Administration
43
Overview
Production of Questionnaire and Related Materials
Mailing of Materials
Data Receipt and Retention
Staff Training
Quality Control Guidelines
Monitoring and Quality Oversight
Safeguarding Decedent/Caregiver Confidentiality
Data Security
Data Retention and Storage
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VII. Telephone Only Survey Administration
59
Overview
Telephone Interviewing Systems
Telephone Attempts
Obtaining and Updating Telephone Numbers
Data Receipt and Retention
Quality Control Guidelines
Safeguarding Decedent/Caregiver Confidentiality
Data Security
71
VIII. Mixed Mode Survey Administration
Overview
Mail Protocol
Data Receipt and Retention of Mailed Questionnaires
Quality Control Guidelines for Mail Data
Telephone Protocol
Telephone Interviewing Systems
Receipt and Retention of Telephone Data
Quality Control Guidelines for Telephone Data Collection
Safeguarding Decedent/Caregiver Confidentiality
Data Security
IX. Data Coding and Data File Preparation
Overview
Random, Unique, De-Identified Tracking Number
File Specifications
Decision Rules and Coding Guidelines
Survey Skip Patterns
Disposition of Survey Codes
Definition of a Completed Survey
Survey Response Rate
X. Data Submission
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95
113
Overview
Data Submission Process
Data File Submission Dates
Survey Vendor Authorization Process
Preparation for Data Submission
Survey File Submission Naming Convention
Password Authentication
Organization of the CAHPS Hospice Survey Data Warehouse
File Encryption
Instructions for Accessing the CAHPS Hospice Survey Data Warehouse
Data Auditing, Validation Checks and Data Submission Reports
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XI. Oversight Activities
XII. Data Reporting
121
Overview
Oversight Activities
CAHPS Hospice Survey Quality Assurance Plan
Analysis of Submitted Data
Site Visits/Conference Calls
Non-compliance and Sanctions
125
Overview
Publicly Reported CAHPS Hospice Survey Measures
Scoring Overview
CAHPS Hospice Survey Provider Preview Reports
XIII. Exception Request Process
129
Overview
Exception Request Process
XIV. Discrepancy Report Process
131
Overview
Discrepancy Report Process
XV. Data Quality Checks
133
Overview
Traceable Data File Trail
Review of Data Files
Accuracy of Data Processing Activities
Summary
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XVI.
Appendices
A. Minimum Business Requirements
B. Survey Vendor Authorization Form
C. Data Warehouse Access Form for Vendors and Hospices
D. Sample File Layout
E. XML File Specification Version 6.0
• Sample XML File Layout Version 6.0
F. Interviewing Guidelines for Telephone Surveys
G. Frequently Asked Questions for Customer Support
H. Model Quality Assurance Plan
I. Exception Request Form
J. Discrepancy Report Form
K. Participation Exemption for Size Form
L. Attestation Statement
M. Examples of Additional Supplemental Questions for Survey
Vendor Use
N. CAHPS Hospice Mail Survey Materials (English)
• Survey Instrument
• Sample Initial Cover Letter
• Sample Follow-up Cover Letter
• OMB Paperwork Reduction Act Language
O. CAHPS Hospice Mail Survey Materials (Spanish)
• Survey Instrument
• Sample Initial Cover Letter
• Sample Follow-up Cover Letter
• OMB Paperwork Reduction Act Language
P. CAHPS Hospice Mail Survey Materials (Traditional Chinese)
• Survey Instrument
• Sample Initial Cover Letter
• Sample Follow-up Cover Letter
• OMB Paperwork Reduction Act Language
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Q. CAHPS Hospice Mail Survey Materials (Simplified
Chinese)
• Survey Instrument
• Sample Initial Cover Letter
• Sample Follow-up Cover Letter
• OMB Paperwork Reduction Act Language
R. CAHPS Hospice Mail Survey Materials (Russian)
• Survey Instrument
• Sample Initial Cover Letter
• Sample Follow-up Cover Letter
• OMB Paperwork Reduction Act Language
S. CAHPS Hospice Mail Survey Materials (Portuguese)
• Survey Instrument
• Sample Initial Cover Letter
• Sample Follow-up Cover Letter
• OMB Paperwork Reduction Act Language
T. CAHPS Hospice Mail Survey Materials (Vietnamese)
• Survey Instrument
• Sample Initial Cover Letter
• Sample Follow-up Cover Letter
• OMB Paperwork Reduction Act Language
U. CAHPS Hospice Mail Survey Materials (Polish)
• Survey Instrument
• Sample Initial Cover Letter
• Sample Follow-up Cover Letter
• OMB Paperwork Reduction Act Language
V. CAHPS Hospice Mail Survey Materials (Korean)
• Survey Instrument
• Sample Initial Cover Letter
• Sample Follow-up Cover Letter
• OMB Paperwork Reduction Act Language
W. Telephone Script (English)
X. Telephone Script (Spanish)
Y. Telephone Script (Russian)
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I. Reader’s Guide
Purpose of Quality Assurance Guidelines
The CAHPS Hospice Survey Quality Assurance Guidelines V6.0 manual has been developed by
CMS to standardize the survey data collection process and to ensure comparability of data reported
through the CAHPS Hospice Survey. This Reader’s Guide provides survey vendors and hospices
with a high-level overview and reference for essential information presented in the CAHPS
Hospice Survey Quality Assurance Guidelines V6.0 manual. Readers are directed to the related
chapters of the CAHPS Hospice Survey Quality Assurance Guidelines V6.0 manual for more detail.
CAHPS Hospice Survey Quality Assurance Guidelines V6.0 Contents
The CAHPS Hospice Survey Quality Assurance Guidelines V6.0 manual contains chapters that
address CAHPS Hospice Survey administration requirements. These include:
Introduction and Overview
This chapter includes a description of the CAHPS Hospice Survey initiative and the history of its
development. It also includes an overview of the CAHPS Hospice Survey data collection and
submission timeline.
Program Requirements
This chapter presents the Program Requirements, including the purpose of the CAHPS Hospice
Survey, communication with patients and/or their caregivers, the Roles and Responsibilities for
participating organizations (i.e., CMS, hospices and survey vendors), survey vendor analysis of
CAHPS Hospice Survey data, the Minimum Business Requirements to administer the CAHPS
Hospice Survey, and the Rules of Participation.
Communications and Technical Support
This chapter includes information about communications and technical support available to survey
vendors administering the CAHPS Hospice Survey and other interested parties.
Sampling Protocol
This chapter describes the procedures survey vendors should use to request the
decedents/caregivers list from their hospices, identify decedents/caregivers eligible for the survey,
construct a sample frame, and select a sample each month.
Modes of Survey Administration
The CAHPS Hospice Survey Quality Assurance Guidelines V6.0 chapters VI, VII and VIII describe
each of the three allowed modes of survey administration: Mail Only, Telephone Only and Mixed
Mode (mail with telephone follow-up). These chapters address the administration of the CAHPS
Hospice Survey, data receipt and retention and quality control guidelines for each of the three
modes. Each mode of survey administration requires adherence to a standardized protocol and
timeline.
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Data Coding and Data File Preparation
The CAHPS Hospice Survey utilizes standardized protocols for file specifications, coding and
submission of data. This chapter contains information about preparing the CAHPS Hospice Survey
data files for submission, including the procedure for assigning CAHPS Hospice Survey “Final
Survey Status” codes, information on the requirements for coding and interpreting ambiguous or
missing data elements in returned surveys, the definition of a completed survey, and the procedures
for calculating the survey response rate.
Data Submission
This chapter contains information about preparing and submitting survey data files to the CAHPS
Hospice Survey Data Warehouse, including the survey vendor authorization and switching survey
vendor processes, the survey vendor data submission registration process and the data submission
process, including the interpretation of the associated CAHPS Hospice Survey Data Submission
Reports.
Oversight Activities
This chapter provides information on the oversight activities that the CMS-sponsored CAHPS
Hospice Survey Project Team conducts to verify compliance with CAHPS Hospice Survey
protocols. These oversight activities include, but are not limited to: review of survey vendor’s
CAHPS Hospice Survey Quality Assurance Plan (QAP), analyses of submitted data, site
visits/conference calls, additional activities related to the administration of the CAHPS Hospice
Survey, and possible outcomes of non-compliance.
Data Reporting
This chapter describes the process for public reporting of CAHPS Hospice Survey results on the
Hospice Compare Web site.
Exception Request Process
This chapter describes the process for reviewing methodologies that vary from standard CAHPS
Hospice Survey protocols. The Exception Request Process is designed to allow for flexibility while
maintaining the integrity of the data for standardized reporting.
Discrepancy Report Process
This chapter describes the process for notifying CMS of any discrepancies from standard CAHPS
Hospice Survey protocols during the survey administration process.
Data Quality Checks
This chapter provides an overview describing the importance of data quality checks and examples
of data quality check activities as recommended by the CAHPS Hospice Survey Project Team.
Appendices
The Appendices include: the Minimum Business Requirements to administer the CAHPS Hospice
Survey; survey vendor authorization form; form for accessing the CAHPS Hospice Survey Data
Warehouse; data file layout specifications; telephone interviewing guidelines; frequently asked
questions for customer support; the survey vendor model QAP; the forms for submitting requests
for protocol exceptions, discrepancy reports, participation exemption for size, and attestation
statement; suggested supplemental questions; the CAHPS Hospice Survey mail materials (English,
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Reader’s Guide
Spanish, Traditional Chinese, Simplified Chinese, Russian, Portuguese, Vietnamese, Polish, and
Korean); and telephone scripts (English, Spanish, and Russian).
For More Information
For program information and to view important updates and announcements, visit the CAHPS
Hospice Survey Web site (www.hospicecahpssurvey.org).
To Provide Comments or Ask Questions
For information and technical assistance, contact the CAHPS Hospice Survey Project Team via
email at [email protected] or call 1-844-472-4621.
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II. Introduction and Overview
Background
Before the development of the CAHPS Hospice Survey, there was no official national standardized
survey to measure patient and family experiences with hospice care. The CAHPS Hospice Survey
uses detailed standardized survey administration protocols to allow for fair comparisons across
hospices.
CMS developed the CAHPS Hospice Survey with input from many stakeholders, including other
government agencies, industry stakeholders, consumer groups, and other key individuals and
organizations involved in hospice care. The survey was designed to measure and assess the
experiences of decedents who died while receiving hospice care as well as the experiences of their
caregivers. The survey aims to produce comparable data on decedents’/caregivers’ perspectives of
care that allow objective and meaningful comparisons across hospices on domains that are
important to consumers and create incentives for hospices to improve their quality of care.
Note: The term decedent/caregiver is used throughout this manual to identify the patient who died
while receiving hospice care (decedent) and the primary informal caregiver (i.e., family member
or friend) identified to receive and respond to the CAHPS Hospice Survey. The primary informal
caregiver is referred to as “caregiver” throughout this manual.
CAHPS Hospice Survey Development
The development process for the survey began in 2012 and included: a public request for
information about publicly available measures and important topics to measure (78 FR 5458); a
review of the existing literature on tools that measure experiences with end-of-life care;
exploratory interviews with caregivers of hospice decedents; a technical expert panel attended by
survey development and hospice care quality experts; cognitive interviews to test draft survey
content; incorporation of public responses to Federal Register Notices (78 FR 48234); and a field
test conducted by CMS in November and December 2013.
Thirty-three programs from 29 hospice organizations participated in the field test, which was
designed to assess survey administration procedures among hospices of varying size, geographic
region, chain status, ownership, and urbanicity. Respondents were caregivers of patients who died
while receiving hospice care in the prior two to five months. In all, 1,136 respondents, representing
the three main settings of hospice care (home; nursing home and inpatient, including freestanding
hospice inpatient unit; and acute care hospital) completed the field test survey. Further information
regarding the development and testing of the CAHPS Hospice Survey can be found in the Hospice
Experience of Care Survey: Development and Field Test Report available on the Home Page of
the CAHPS Hospice Survey Web site (www.hospicecahpssurvey.org).
National implementation of the CAHPS Hospice Survey began on January 1, 2015 with a dry run
conducted in at least one month (January, February or March) of the first quarter of 2015.
Beginning in April 2015, hospices were required to begin continuous monthly participation in the
CAHPS Hospice Survey. Hospices are required to contract with an approved CAHPS Hospice
Survey vendor to conduct the survey in order for the hospice to meet the Hospice Quality Reporting
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Introduction and Overview
September 2019
Program (HQRP) requirements. The dry run period was allowed for the initial implementation
year only; no further dry run periods will be scheduled.
Office of Management and Budget and Public Comment Process
The Office of Management and Budget’s (OMB’s) Paperwork Reduction Act clearance process
for the CAHPS Hospice Survey required two Federal Register Notices. The initial notice was
published in May 2014 (CMS-1609-P). A 30-day Federal Register Notice was published in August
2014. In November 2014, the OMB provided final approval for national implementation of the
CAHPS Hospice Survey. In November 2017, the OMB again reviewed and approved the CAHPS
Hospice Survey.
Submission of Final Instrument to the National Quality Forum
In March 2016, CMS submitted the six composite measures and two single-item global measures
from the 47-item CAHPS Hospice Survey instrument to the National Quality Forum (NQF) for
endorsement of performance measures for accountability and quality improvement that address
palliative care and end-of-life care. The NQF is a voluntary consensus and standard-setting
organization established to standardize healthcare quality measurement and reporting, as defined
by the National Technology Transfer and Advancement Act of 1995 and OMB Circular A-119.
On May 11, 2016, the NQF Review Committee met publicly to discuss the CAHPS Hospice
Survey.
The Board of Directors of the NQF formally endorsed the eight CAHPS Hospice Survey measures
on October 26, 2016. NQF endorsement represents the consensus of many healthcare providers,
consumer groups, professional associations, purchasers, federal agencies, and research and quality
organizations. The Board of Directors’ approval was the final step of vetting through the NQF’s
formal Consensus Development Process, which included input from multiple stakeholder groups,
review and voting. The CAHPS Hospice Survey thereby achieved special legal standing as a
voluntary consensus standard.
Preparation for CAHPS Hospice Survey Data Collection
Survey vendors interested in administering the CAHPS Hospice Survey must apply to participate
and attend all CAHPS Hospice Survey Training sessions. Training is offered via Webinar and
there is no associated fee. At a minimum, the survey vendor’s Project Manager must attend all
CAHPS Hospice Survey Training sessions. In addition, subcontractors and any other organizations
that are responsible for major functions of CAHPS Hospice Survey administration must attend all
CAHPS Hospice Survey Training sessions. Survey vendors that meet the CAHPS Hospice Survey
Minimum Business Requirements will be eligible to receive conditional approval to be a CAHPS
Hospice Survey vendor. Survey vendors will be eligible to receive full approval following
participation in the CAHPS Hospice Survey Training session and successful completion of the
post-training quiz.
To comply with CMS’ quality reporting requirements, all eligible hospices are required to contract
with an approved survey vendor to collect data using the CAHPS Hospice Survey on an ongoing
monthly basis. Participation in the CAHPS Hospice Survey is required to meet the pay for
reporting requirement of the HQRP for the associated fiscal year (FY) annual payment update
(APU).
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Introduction and Overview
The CAHPS Hospice Survey considers the decedent (i.e., the patient who died while in hospice
care) and his or her caregiver (i.e., family member or friend) as the unit of care. Each hospice must
provide specified decedent/caregiver data to its survey vendor on a monthly basis.
CAHPS Hospice Survey Mode Experiment
In order to achieve the goal of fair comparisons across all hospices that participate in the CAHPS
Hospice Survey, it is necessary to adjust for factors that are not directly related to hospice
performance but may affect how caregivers answer CAHPS Hospice Survey items. To ensure that
CAHPS Hospice Survey scores allow fair and standardized comparisons of hospices, in 2015 CMS
conducted a mode experiment to examine whether the mode of survey administration (Mail Only,
Telephone Only and Mixed Mode) in which caregivers respond to the survey systematically affects
CAHPS Hospice Survey results (42 CFR 418).
This mode experiment enabled CMS to determine if survey mode adjustments are needed, and if
they are needed, to develop them. Survey mode adjustments are intended to eliminate any
advantage or disadvantage in CAHPS Hospice Survey scores that might result for a hospice based
on the mode in which its caregivers respond to the CAHPS Hospice Survey.
CAHPS Hospice Survey Public Reporting
Official CAHPS Hospice Survey scores are publicly reported four times each year on the Hospice
Compare Web site (www.medicare.gov/hospicecompare). Scheduled refreshes for CAHPS
Hospice Survey data occur in February, May, August, and November. Public reporting of CAHPS
Hospice Survey results are comprised of a rolling eight quarters of survey data, with data submitted
quarterly by survey vendors via the CAHPS Hospice Survey Data Warehouse.
Hospice Compare Refresh Date
CAHPS Quarters Included
February 2019
May 2019
August 2019
November 2019
February 2020
May 2020
August 2020
November 2020
February 2021
May 2021
August 2021
November 2021
February 2022
May 2022
August 2022
November 2022
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Q2 2016 - Q1 2018
Q3 2016 - Q2 2018
Q4 2016 - Q3 2018
Q1 2017 - Q4 2018
Q2 2017 - Q1 2019
Q3 2017 - Q2 2019
Q4 2017 - Q3 2019
Q1 2018 - Q4 2019
Q2 2018 - Q1 2020
Q3 2018 - Q2 2020
Q4 2018 - Q3 2020
Q1 2019 - Q4 2020
Q2 2019 - Q1 2021
Q3 2019 - Q2 2021
Q4 2019 - Q3 2021
Q1 2020 - Q4 2021
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Introduction and Overview
September 2019
The CAHPS Hospice Survey data submitted are reviewed, cleaned, scored, and adjusted (including
adjustments for mode and case mix). Data from the mode experiment, as well as national
implementation data, were used to develop the mode adjustments and the variables used in the
case-mix model. Documents describing these coefficients and the case-mix adjustment process are
available on the Scoring and Analysis page of the CAHPS Hospice Survey Web site
(www.hospicecahpssurvey.org). This page includes the CAHPS Hospice Survey response rate,
and the CAHPS Hospice Survey case-mix adjustments for each question composing a publicly
reported CAHPS Hospice Survey measure top-, middle- or bottom-box score.
The CAHPS Hospice Survey results are available for preview by hospices via the Certification
and Survey Provider Enhanced Reports (CASPER) system approximately two months before
results are publicly reported on the Hospice Compare Web site. To learn more about how to utilize
the CASPER system go to: https://www.cms.gov/Medicare/Quality-Initiatives-PatientAssessment-Instruments/Hospice-Quality-Reporting/Downloads/Fact-Sheet_CASPER-QMReports_February-2018.pdf. After reviewing their CASPER report, a hospice may request a
review of their data by contacting the CAHPS Hospice Survey technical assistance team at:
[email protected]. Requests for review of Hospice CAHPS® Survey results must be
submitted via email. For more information about the review of hospice’s CAHPS Hospice Survey
data,
visit:
https://www.cms.gov/Medicare/Quality-Initiatives-Patient-AssessmentInstruments/Hospice-Quality-Reporting/Public-Reporting-CAHPS-Preview-Reports-andRequests-for-CMS-Review-of-CAHPS-Data.html.
The first public reporting of CAHPS Hospice Survey results occurred in February 2018 with 4,550
hospices appearing on Hospice Compare, and 2,795 of those hospices reporting their CAHPS
Hospice Survey scores; this is based on 622,320 completed surveys and covered hospice care
experiences for patients who died between the second quarter of 2015 and the first quarter of 2017
(4/1/2015 through 3/31/2017). Most recently, the August 2019 public reporting of CAHPS
Hospice Survey results included 4,767 hospices, of which 2,907 reported CAHPS Hospice Survey
scores; this is based on 656,620 completed surveys and covers hospice care experiences for
patients who died between the fourth quarter of 2016 and the third quarter of 2018 (10/1/2016
through
9/30/2018).
Publicly
reported
scores
are
available
at
https://www.medicare.gov/hospicecompare. The schedule of public reporting for 2019 can be
found in the Data Reporting chapter.
CAHPS Hospice Survey Instrument
The CAHPS Hospice Survey mail materials are available in English, Spanish, Chinese, Russian,
Portuguese, Vietnamese, Polish, and Korean. The Chinese mail survey is provided in both
traditional and simplified characters and targets both Mandarin and Cantonese speakers. The
CAHPS Hospice Survey telephone script is available in English, Spanish, and Russian.
The CAHPS Hospice Survey is administered using the Mail Only, Telephone Only or Mixed Mode
(mail with telephone follow-up). No other modes of survey administration are permitted.
The CAHPS Hospice Survey instrument consists of 47 questions, broken into three sections:
Core (Q1 – Q40), About Your Family Member (three questions) and About You (four questions).
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Introduction and Overview
Components of the CAHPS Hospice Survey Instrument
The standardized 47-question CAHPS Hospice Survey instrument includes the quality measures
listed below. Please note that measure labels were updated in 2018 in order to be more
understandable to users, although the items within each measure have not changed.
CAHPS Hospice Survey Quality Measures and Constituent Items
Composite Measures
Communication with Family (formerly Hospice Team Communication)
While your family member was in hospice care, how often did the hospice team keep
you informed about when they would arrive to care for your family member?
While your family member was in hospice care, how often did the hospice team
explain things in a way that was easy to understand?
How often did the hospice team listen carefully to you when you talked with them
about problems with your family member’s hospice care?
While your family member was in hospice care, how often did the hospice team keep
you informed about your family member’s condition?
While your family member was in hospice care, how often did the hospice team listen
carefully to you?
While your family member was in hospice care, how often did anyone from the
hospice team give you confusing or contradictory information about your family
member’s condition or care?
Getting Timely Help (formerly Getting Timely Care)
While your family member was in hospice care, when you or your family member
asked for help from the hospice team, how often did you get help as soon as you
needed it?
How often did you get the help you needed from the hospice team during evenings,
weekends, or holidays?
Treating Patient with Respect (formerly Treating Family Member with Respect)
While your family member was in hospice care, how often did the hospice team treat
your family member with dignity and respect?
While your family member was in hospice care, how often did you feel that the hospice
team really cared about your family member?
Emotional and Spiritual Support (formerly Getting Emotional and Religious Support)
While your family member was in hospice care, how much emotional support did you
get from the hospice team?
In the weeks after your family member died, how much emotional support did you get
from the hospice team?
Support for religious or spiritual beliefs includes talking, praying, quiet time, or other
ways of meeting your religious or spiritual needs. While your family member was in
hospice care, how much support for your religious and spiritual beliefs did you get
from the hospice team?
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Introduction and Overview
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Composite Measures (Cont’d)
Help for Pain and Symptoms (formerly Getting Help for Symptoms)
Did your family member get as much help with pain as he or she needed?
How often did your family member get the help he or she needed for trouble
breathing?
How often did your family member get the help he or she needed for trouble with
constipation?
How often did your family member get the help he or she needed from the hospice
team for feelings of anxiety or sadness?
Training Family to Care for Patient (formerly Getting Hospice Care Training)
Did the hospice team give you the training you needed about what side effects to watch
for from pain medicine?
Did the hospice team give you the training you needed about if and when to give more
pain medicine to your family member?
Did the hospice team give you the training you needed about how to help your family
member if he or she had trouble breathing?
Did the hospice team give you the training you needed about what to do if your family
member became restless or agitated?
Side effects of pain medicine include things like sleepiness. Did any member of the
hospice team discuss side effects of pain medicine with you or your family member?
Global Measures
Rating of this Hospice
Using any number from 0 to 10, where 0 is the worst hospice care possible and 10 is
the best hospice care possible, what number would you use to rate your family
member’s hospice care?
Willingness to Recommend this Hospice
Would you recommend this hospice to your friends and family?
CAHPS Hospice Survey Development and National Implementation Timeline
The following timeline outlines major events in the CAHPS Hospice Survey development process,
as well as anticipated dates for future national implementation events.
2012
September 2012 – CMS selects the RAND Corporation to coordinate the development and
field testing of the Hospice Experience of Care Survey instrument. The RAND Corporation
assembles a team comprised of Health Services Advisory Group and Joan M. Teno of
Brown University, among others, to support these activities.
December 2012 – Technical Expert Panel convened to discuss main survey content
domains and eligibility requirements for the field test
2013
January 2013 – A Federal Register Notice is published soliciting comments on the topic
areas on the draft pilot instrument
November and December 2013 – Field test of Hospice Experience of Care Survey
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Introduction and Overview
2014
February 2014 – CMS selects the RAND Corporation to support national implementation
of the Hospice Experience of Care Survey (subsequently referred to as the CAHPS Hospice
Survey, following approval from the Agency for Healthcare Research and Quality [AHRQ]
CAHPS Consortium). The RAND Corporation assembles a team comprised of Health
Services Advisory Group and Joan M. Teno of Brown University, among others, to support
these activities.
April 2014 – Technical Expert Panel convened to discuss national implementation
procedures
May 2014 – Initial notice of CAHPS Hospice Survey published in the FY 2015 Hospice
Wage Index and Payment Rate Update and Hospice Quality Reporting Requirements
Proposed Rule
August 2014 – The FY 2015 Hospice Wage Index and Payment Rate Update and Hospice
Quality Reporting Requirements Final Rule is published. The rule stipulates that eligible
hospices must participate in the CAHPS Hospice Survey to be eligible to receive the APU.
August 2014 – CAHPS Hospice Survey Quality Assurance Guidelines V1.0 manual is
released
August 2014 – Hospice Experience of Care Survey: Development and Field Test Report is
released
October 2014 – The first CAHPS Hospice Survey Training session is conducted via
Webinar
November 2014 – CAHPS Hospice Survey receives final clearance from OMB to
administer the 47-item CAHPS Hospice Survey instrument
November 2014 – English and Spanish translations of the survey instrument are made
available
December 2014 – Traditional Chinese and Simplified Chinese translations of the survey
instrument are made available for Mail Only mode of survey administration
2015
January 2015 – Dry run of the CAHPS Hospice Survey begins (patient deaths in January
2015; survey administration beginning in April 2015)
February 2015 – Dry run of the CAHPS Hospice Survey continues (patient deaths in
February 2015; survey administration beginning in May 2015)
February 2015 – Mode experiment of the CAHPS Hospice Survey begins (patient deaths
in February 2015; survey administration beginning in May 2015 and ending in October
2015)
March 2015 – Dry run of the CAHPS Hospice Survey concludes (patient deaths in March
2015; survey administration beginning in June 2015)
April 2015 – National implementation of the CAHPS Hospice Survey begins (ongoing
monthly participation beginning with patient deaths in April 2015 and survey
administration beginning in July 2015)
May 2015 – The FY 2016 Hospice Wage Index and Payment Rate Update and Hospice
Quality Reporting Requirements Proposed Rule is published
August 2015 – The FY 2016 Hospice Wage Index and Payment Rate Update and Hospice
Quality Reporting Requirements Final Rule is published
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Introduction and Overview
September 2019
September 2015 – CAHPS Hospice Survey Quality Assurance Guidelines V2.0 manual is
released
September 2015 – Russian and Portuguese translations of the survey instrument are made
available for Mail Only mode of survey administration
September 2015 – The second annual CAHPS Hospice Survey Training session is
conducted via Webinar
October 2015 – Mode experiment of the CAHPS Hospice Survey ends (patient deaths
through June 2015)
2016
February 2016 – CMS submits CAHPS Hospice Survey measures to NQF for its
endorsement
April 2016 – The FY 2017 Hospice Wage Index and Payment Rate Update and Hospice
Quality Reporting Requirements Proposed Rule is published
May 2016 – Vietnamese translation of the survey instrument is made available for Mail
Only mode of survey administration
August 2016 – The FY 2017 Hospice Wage Index and Payment Rate Update and Hospice
Quality Reporting Requirements Final Rule is published
September 2016 – CAHPS Hospice Survey Quality Assurance Guidelines V3.0 manual is
released
September 2016 – The third annual CAHPS Hospice Survey Training session is conducted
via Webinar
October 2016 – NQF endorses CAHPS Hospice Survey measures
December 2016 – Polish and Korean translations of the survey instrument are made
available for Mail Only mode of survey administration
December 2016 – CMS releases national CAHPS Hospice Survey data (national average
top-box scores from data collected from caregivers of patients who died while getting
hospice care between April 1, 2015 and March 31, 2016)
2017
May 2017 – CMS submits CAHPS Hospice Survey to OMB for re-approval
May 2017 – The FY 2018 Hospice Wage Index and Payment Rate Update and Hospice
Quality Reporting Requirements Proposed Rule is published
August 2017 – The FY 2018 Hospice Wage Index and Payment Rate Update and Hospice
Quality Reporting Requirements Final Rule is published
September 2017 – CAHPS Hospice Survey Quality Assurance Guidelines V4.0 manual is
released
September 2017 – The fourth annual CAHPS Hospice Survey Training session is
conducted via Webinar
November 2017 – OMB re-approved the CAHPS Hospice Survey
2018
February 2018 – First Public Reporting of CAHPS Hospice Survey results on Hospice
Compare, covering hospice care experiences from the second quarter of 2015 through the
first quarter of 2017 (4/1/2015 through 3/31/2017)
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Introduction and Overview
May 2018 – The FY 2019 Hospice Wage Index and Payment Rate Update and Hospice
Quality Reporting Requirements Proposed Rule is published
May 2018 – Second Public Reporting of CAHPS Hospice Survey results on Hospice
Compare, covering hospice care experiences from the third quarter of 2015 through the
second quarter of 2017 (7/1/2015 through 6/30/2017)
August 2018 – The FY 2019 Hospice Wage Index and Payment Rate Update and Hospice
Quality Reporting Requirements Final Rule is published
August 2018 – Third Public Reporting of CAHPS Hospice Survey results on Hospice
Compare, covering hospice care experiences from the fourth quarter of 2015 through the
third quarter of 2017 (10/1/2015 through 9/30/2017)
September 2018 – CAHPS Hospice Survey Quality Assurance Guidelines V5.0 manual is
released
September 2018 – The fifth annual CAHPS Hospice Survey Training session is conducted
via Webinar
November 2018 – Fourth Public Reporting of CAHPS Hospice Survey results on Hospice
Compare, covering hospice care experiences from the first quarter of 2016 through the
fourth quarter of 2017 (1/1/2016 through 12/31/2017)
2019
February 2019 – Fifth Public Reporting of CAHPS Hospice Survey results on Hospice
Compare, covering hospice care experiences from the second quarter of 2016 through the
first quarter of 2018 (4/1/2016 through 3/31/2018)
March 2019 – Russian translation of the survey instrument is made available for Telephone
Only and Mixed Mode of survey administration
May 2019 – The FY 2020 Hospice Wage Index and Payment Rate Update and Hospice
Quality Reporting Requirements Proposed Rule is published
May 2019 – Sixth Public Reporting of CAHPS Hospice Survey results on Hospice
Compare, covering hospice care experiences from the third quarter of 2016 through the
second quarter of 2018 (7/1/2016 through 6/30/2018)
August 2019 – The FY 2020 Hospice Wage Index and Payment Rate Update and Hospice
Quality Reporting Requirements Final Rule is published
August 2019 – Seventh Public Reporting of CAHPS Hospice Survey results on Hospice
Compare, covering hospice care experiences from the fourth quarter of 2016 through the
third quarter of 2018 (10/1/2016 through 9/30/2018)
September 2019 – CAHPS Hospice Survey Quality Assurance Guidelines V6.0 manual is
released
September 2019 – The sixth annual CAHPS Hospice Survey Training sessions are
conducted
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Introduction and Overview
September 2019
CAHPS Hospice Survey Data Collection and Submission Timeline
Data collection for sampled decedents/caregivers must be initiated two months following the
month of patient death. The data collection process must be completed within 42 calendar days
after initial contact. Submission of the data to the CAHPS Hospice Survey Data Warehouse will
occur quarterly. Please see the schedule for survey administration and data submission outlined in
the table below.
CAHPS Hospice Survey Administration and Data Submission Schedule
Initial Contact with
Data Submission to the
Month of Death
Sampled
CAHPS Hospice Survey
Decedents/Caregivers
Data Warehouse
April 2019
July 1, 2019
May 2019
August 1, 2019
November 13, 2019
June 2019
September 1, 2019
July 2019
October 1, 2019
August 2019
November 1, 2019
February 12, 2020
September 2019
December 1, 2019
October 2019
January 1, 2020
November 2019
February 1, 2020
May 13, 2020
December 2019
March 1, 2020
January 2020
April 1, 2020
February 2020
May 1, 2020
August 12, 2020
March 2020
June 1, 2020
April 2020
July 1, 2020
May 2020
August 1, 2020
November 11, 2020
June 2020
September 1, 2020
July 2020
October 1, 2020
August 2020
November 1, 2020
February 10, 2021
September 2020
December 1, 2020
October 2020
January 1, 2021
November 2020
February 1, 2021
May 12, 2021
December 2020
March 1, 2021
January 2021
April 1, 2021
February 2021
May 1, 2021
August 11, 2021
March 2021
June 1, 2021
April 2021
July 1, 2021
May 2021
August 1, 2021
November 10, 2021
June 2021
September 1, 2021
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III. Program Requirements
Overview
This chapter describes the Program Requirements, which include the purpose of the CAHPS
Hospice Survey, guidelines for communication with patients and caregivers, roles and
responsibilities for participating organizations, guidelines for analysis of CAHPS Hospice Survey
data, the Rules of Participation, and the Minimum Business Requirements to administer the
CAHPS Hospice Survey. Survey vendors administering the CAHPS Hospice Survey must meet
all of the CAHPS Hospice Survey Minimum Business Requirements.
Purpose of the CAHPS Hospice Survey Program Requirements
The CAHPS Hospice Survey and its administration protocols are designed to produce standardized
information about decedents’/caregivers’ perspectives of care that allows objective and
meaningful comparisons of hospices on topics that are important to consumers. Public reporting
of CAHPS Hospice Survey results creates incentives for hospices to improve the quality of care
while enhancing accountability in healthcare by increasing transparency.
In order to fulfill these goals, it is essential that, to the fullest extent possible:
caregivers respond to the CAHPS Hospice Survey, and
caregivers’ responses are informed only by the care their family members or friends
received from the hospice named on the survey
CMS carefully developed the CAHPS Hospice Survey and its administration protocols to achieve
the following outcomes:
increase the likelihood that caregivers will respond to the survey, and
ensure that the caregivers’ responses are unbiased and reflect only the decedents’ and
caregivers’ experiences of care
In order to ensure these outcomes:
The CAHPS Hospice Survey should be the first survey caregivers receive about their
family members’ or friends’ experiences of hospice care
Hospices and survey vendors (and anyone acting on their behalf) must not attempt to
influence how caregivers respond to CAHPS Hospice Survey items
CAHPS Hospice Survey results are intended to be used for quality improvement purposes, not for
marketing or promotional activities. Only the CAHPS Hospice Survey scores that are published
by CMS are the official scores. Scores derived from any other source are unofficial and should be
labeled as such.
The CAHPS Hospice Survey and the questions that comprise it are in the public domain and thus
can be used outside of official CAHPS Hospice Survey purposes (e.g., for non-CAHPS Hospice
Survey eligible decedents/caregivers). However, when used in an unofficial capacity, the CAHPS
Hospice Survey OMB Paperwork Reduction Act language must not be used and all references to
“CAHPS Hospice Survey” and “CMS” must be removed.
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Hospice Communication with Patients and/or Their Caregivers
The sections below are intended to provide survey vendors and hospices with guidance when
conducting quality improvement activities in conjunction with the CAHPS Hospice Survey.
Communicating with Patients and/or Their Caregivers about the CAHPS
Hospice Survey
CAHPS Hospice Survey guidelines allow hospices to communicate about the CAHPS Hospice
Survey with patients and/or their caregivers prior to administration of the survey. For example,
hospices may inform caregivers during the hospice admission process that they may receive the
CAHPS Hospice Survey. If a hospice wants to let caregivers know that they may receive a survey
and encourage them to complete it, the hospice must inform all caregivers. Certain types of
communications are not permitted because they may introduce bias in the survey results. For
instance, hospices/survey vendors are not allowed to:
ask any CAHPS Hospice Survey or CAHPS Hospice Survey-like questions of caregivers
prior to administration of the survey
attempt to influence or encourage caregivers to answer CAHPS Hospice Survey questions
in a particular way
imply that the hospice, its personnel or agents will be rewarded or gain benefits for positive
feedback from caregivers by asking caregivers to choose certain responses, or indicate that
the hospice is hoping for a given response, such as a “10,” “Definitely yes” or an “Always”
indicate that the hospice’s goal is for all caregivers to rate them as a “10,” “Definitely yes”
or an “Always”
offer incentives of any kind for participation in the survey
invite or ask the caregiver if they want to participate in a survey or suggest they can “opt
out” of the survey
show or provide the CAHPS Hospice Survey or cover letters to caregivers while they are
in the hospice or at any time prior to the administration of the survey
mail or distribute any pre-notification letters or postcards after patient death to inform
caregivers about the CAHPS Hospice Survey
Note: Hospices may not contact caregivers directly regarding survey responses.
Use of Other Hospice Surveys
In this section, CMS provides guidelines to employ when asking caregivers questions regarding
their family members’ or friends’ hospice care. CMS’ intent is to minimize the burden on
caregivers, prevent the introduction of bias to CAHPS Hospice Survey responses and not decrease
the likelihood that caregivers will complete the CAHPS Hospice Survey.
In general, activities and encounters that are intended to provide or assess clinical care or promote
patient/family well-being are permissible. However, activities and encounters that are primarily
intended to influence how caregivers, or which caregivers, respond to CAHPS Hospice Survey
items must be avoided. If patients or their caregivers are asked questions during their hospice care,
we suggest that such questions be worded in a neutral tone and not slanted toward a particular
outcome. Questions must not resemble CAHPS Hospice Survey items or their response
categories. In addition, references to CMS must not be included on any surveys that are not
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the official CAHPS Hospice Survey. Hospices should focus on overall quality of care rather than
the measures reported to CMS.
Caregivers should not be given any formal, CAHPS Hospice Survey-like, patient
experience/satisfaction survey before they receive the official CAHPS Hospice Survey. A formal
survey, regardless of the mode employed, is one in which the primary goal is to ask standardized
questions of a significant portion of a hospice’s patient/caregiver population.
When asking non-CAHPS Hospice Survey questions, do not use CAHPS Hospice Surveylike response categories (for instance, “Always,” “Usually,” “Sometimes,” or “Never”)
The following are examples of the types of questions that are not permissible:
• “On a scale of 0 to 10, how would you rate your family member’s hospice care?”
• “Is there a way we could always….?”
• “Did the hospice team explain things in a way you could understand?”
• “Overall, how would you rate the care you received from the hospice?”
Note: It is permissible for hospices to ask patients and/or their caregivers questions about their
care during their hospice stay or during bereavement calls when this is a normal part of quality
improvement activities, as long as the questions and/or response categories do not resemble the
CAHPS Hospice Survey.
The CAHPS Hospice Survey should be administered prior to administering any other survey after
the patient’s death. As noted above, it is permissible for patients and their caregivers to be asked
questions during their hospice stay when the focus is on the clinical care of the individual patient.
The hospice or its agents must not seek to influence which caregivers receive the CAHPS Hospice
Survey or how caregivers answer CAHPS Hospice Survey items.
Other Communications with Patients and/or Their Caregivers
When communicating with patients and/or their caregivers while in hospice care regarding their
healthcare, hospices should take care to avoid introducing bias in the way caregivers may answer
questions on the CAHPS Hospice Survey. Many of the guidelines above in the Communicating
with Patients and/or Their Caregivers about the CAHPS Hospice Survey and Use of Other Hospice
Surveys apply to general communications with patients and/or their caregivers.
Examples of statements that comply with CAHPS Hospice Survey protocols include:
• “We are looking for ways to improve your family member’s stay. Please share your
comments with us.”
• “What can we do to improve your family member’s care?”
• “We want to hear from you, please share your experience with us.”
• “Please let us know if you have any questions about your family member’s treatment
plan.”
• “Let us know if your family member’s room is not comfortable.”
Hospices should not:
• permit staff to wear buttons, stickers, etc. that state “Always” or “10”
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•
September 2019
emphasize CAHPS Hospice Survey response options in posters, white boards, rounding
questions, in-room televisions, or other media accessible to patients and/or their
caregivers. Examples of statements that do not comply with CAHPS Hospice Survey
protocols include:
o “We expect to be the best hospice possible.”
o “Our goal is to always address your needs.”
o “Let us know if we are not listening carefully to you.”
o “We treat our patients with dignity and respect.”
o “In order to provide the best possible care, please tell us how we can always…”
o “Our doctors and nurses always listen carefully to you.”
o “We want to always explain things to you in a way you can understand.”
o “We want you to recommend us to family and friends.”
Roles and Responsibilities
The following content clarifies the roles and responsibilities of participating organizations.
CMS Roles and Responsibilities
CMS supports the standardization of the survey administration and data collection methodologies
for measuring and reporting caregivers’ perspectives on their family members’ or friends’ hospice
care as follows:
Provides CAHPS Hospice Survey administration protocols through the CAHPS Hospice
Survey Quality Assurance Guidelines
Trains survey vendors to administer the CAHPS Hospice Survey
Provides technical support via CAHPS Hospice Survey Information and Technical
Assistance and distribute information about survey administration procedures and policy
updates on the CAHPS Hospice Survey Web site at www.hospicecahpssurvey.org
Processes data files submitted by survey vendors
Calculates and adjusts CAHPS Hospice Survey data for mode and case-mix effects prior
to public reporting
Generates preview reports containing CAHPS Hospice Survey results for participating
hospices prior to public reporting
Reports CAHPS Hospice Survey results publicly on the Hospice Compare Web site
(www.medicare.gov/hospicecompare)
Provides quality oversight to ensure that the CAHPS Hospice Survey is credible, useful
and practical to allow for valid comparisons to be made across hospices
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Program Requirements
Hospice Roles and Responsibilities
It is the responsibility of the Medicare-certified hospice to participate every month in the CAHPS
Hospice Survey.
If a hospice is eligible to participate, it must:
Contract with an approved CAHPS Hospice Survey vendor to administer the survey on
behalf of the hospice
Authorize the contracted survey vendor to collect and submit CAHPS Hospice Survey data
to the CAHPS Hospice Survey Data Warehouse on the hospice’s behalf by submitting a
CAHPS Hospice Survey Vendor Authorization Form (refer to Appendix B) 90 days prior
to the data submission deadline
• Once an organization authorizes a survey vendor, it is not necessary to provide
additional notification unless the organization chooses to de-authorize its survey
vendor and switch to a different survey vendor
Note: If an organization chooses to de-authorize its survey vendor and switch to a
different survey vendor, it must contact the CAHPS Hospice Survey Project Team
immediately to begin the transition process (refer to Appendix B). This change in
survey vendor can only take effect at the beginning of a calendar quarter, and the
timing of receipt of the request may affect when the change may be made.
Complete and submit a CAHPS Hospice Survey Data Warehouse Access Form for
Vendors and Hospices (refer to Appendix C) 90 days prior to the data submission deadline
Work with their approved survey vendor to determine a date each month by when to
provide their survey vendor with the monthly decedents/caregivers list
Compile and deliver a complete and accurate decedents/caregivers list to the survey vendor
by the agreed-upon date each month with the caregiver information that will enable the
survey vendor to administer the survey
Use a secure method to transmit decedents/caregivers lists to the survey vendor
Review data submission reports in the CAHPS Hospice Survey Data Warehouse to ensure
that the survey vendor has submitted data on time and without data problems
Preview CAHPS Hospice Survey results prior to public reporting
Avoid influencing caregivers in any way about whether to or how to answer the CAHPS
Hospice Survey. For example, a hospice may not suggest that caregivers decline to be
contacted for the survey or provide any information to caregivers about how to answer the
survey.
Note: If a hospice wants to let caregivers know that they may receive a survey and
encourage them to complete it, the hospice must inform all caregivers.
Understand the hospice’s responsibilities regarding participation in the HQRP, including
key date ranges and deadline dates
Some hospices may be exempt from participation for a given APU period. The scenarios under
which a Medicare-certified hospice provider can be exempted from participation in the CAHPS
Hospice Survey are described below:
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The Participation Exemption for Size process has been created to provide hospices meeting
the size criteria a means to request consideration for this exemption. For the calendar year
(CY) 2020 data collection period, Medicare-certified hospices that have served fewer than
50 survey-eligible decedents/caregivers in the period from January 1, 2019 through
December 31, 2019 can apply for an exemption from CAHPS Hospice Survey CY 2020
data collection and reporting requirements. To qualify for the survey exemption for CY
2020, hospices must submit a Participation Exemption for Size Form online via the
Participation Exemption for Size page of the CAHPS Hospice Survey Web site
(www.hospicecahpssurvey.org). For the CY 2020 data collection period, this form must be
submitted no later than December 31, 2020. The form must be completed in its entirety and
must be submitted each year the hospice intends to be considered for the Participation
Exemption for Size. Hospices are not eligible to receive the Participation Exemption for
Size if they do not submit a Participation Exemption for Size Form for the year. Hospices
that are eligible to apply for an exemption are encouraged to apply, even if they are
participating in CAHPS Hospice Survey data collection. Please see Appendix K for
specific information to be submitted on the Participation Exemption for Size Form.
• Hospices will need to include the total number of decedents for CY 2019, the total
number of patients discharged alive and the number of decedents who fall into each
ineligibility category (i.e., under the age of 18, died within 48 hours of admission to
hospice care, no caregiver of record [a decedent for whom no caregiver is listed in the
medical record or administrative data], caregiver is a non-familial legal guardian,
caregiver has a foreign home address, and no publicity decedents/caregivers).
Note: “No publicity” status is a rare and unusual request. “No publicity”
decedents/caregivers are those who initiate or voluntarily request at any time during their
hospice stay that the hospice: 1) not reveal the patient’s identity; and/or 2) not survey him
or her.
Note: For multiple hospice programs sharing one CMS Certification Number (CCN), the
survey-eligible decedents/caregivers count is the total from all programs sharing that
CCN.
The Participation Exemption for Newness is based on how recently the hospice received
its CCN (formerly known as the Medicare Provider Number). The criterion for this
exemption is that the hospice must have received its CCN on or after the first day of the
performance year for the CAHPS Hospice Survey. For example, a hospice must receive its
CCN on or after January 1, 2020 to be eligible for the Participation Exemption for Newness
for CY 2020. CMS will identify hospices eligible for this exemption. There is no form for
hospices to submit.
Note: The Participation Exemption for Newness is only applicable for the CY that the
hospice is assigned its CCN. Hospices that become eligible to participate in the CAHPS
Hospice Survey should begin participating during January of the year after they become
eligible. For example, if a hospice received its CCN any time in 2020, whether it is in
January 2020 or December 2020, it is exempt from survey administration for the remainder
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Program Requirements
of 2020. A hospice that receives its CCN any time in 2020 is required to start participating
in the CAHPS Hospice Survey beginning with January 2021 decedents.
Survey Vendor Roles and Responsibilities
CAHPS Hospice Survey vendors are subject to the following requirements:
Meet all of the CAHPS Hospice Survey Minimum Business Requirements
• No organization, firm or business that owns, operates or provides staffing for a hospice
is permitted to administer its own CAHPS Hospice Survey or administer the survey on
behalf of any other hospice in the capacity as a CAHPS Hospice Survey vendor. Such
organizations will not be approved by CMS as CAHPS Hospice Survey vendors.
Have physical plant resources available to handle the volume of surveys being
administered, in addition to systematic processes that effectively track sampled
decedents’/caregivers’ progress through the data collection process and caregivers’
responses to the survey. System resources are subject to oversight activities including site
visits to physical locations (including the physical locations of subcontractors and any other
organizations, if applicable).
Complete the CAHPS Hospice Survey Participation Form for Survey Vendors and request
approval to administer the CAHPS Hospice Survey. The CAHPS Hospice Survey
Participation Form for Survey Vendors will be available on the CAHPS Hospice Survey
Web site prior to the scheduled CAHPS Hospice Survey Training session.
Participate in and successfully complete all CAHPS Hospice Survey Training sessions
• The survey vendor’s designated CAHPS Hospice Survey Project Manager must also
complete a post-training quiz after participating in CAHPS Hospice Survey Training
sessions
Ensure that all survey vendor staff who work on the CAHPS Hospice Survey are trained
and follow the CAHPS Hospice Survey protocols and guidelines
Comply with all requirements of the Health Insurance Portability and Accountability Act
(HIPAA) Security and Privacy Rules during all survey administration and data collection
processes
• www.hhs.gov/HIPAA
Follow the Rules of Participation to administer the CAHPS Hospice Survey
Meet all CAHPS Hospice Survey due dates (including submission of QAPs and survey
materials for review) or risk revocation of approval to administer the CAHPS Hospice
Survey
Assign and train organizational staff with appropriate back-up responsibilities for coverage
of key staff
Work with the client hospice’s staff to create decedents/caregivers lists, including all data
elements needed
Designate a date each month by when the hospice must provide the decedents/caregivers
lists
Receive and perform checks of the decedents/caregivers lists provided by each hospice to
ensure that they include the entire eligible population and all required data elements,
including required counts
Update all decedent/caregiver administrative information available when updated
decedents/caregivers lists are received. In addition, perform quality checks to track and
verify changes from the original decedents/caregivers list.
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Prepare sample frame
Draw sample of decedents/caregivers according to the sampling protocols contained in the
CAHPS Hospice Survey Quality Assurance Guidelines manual
Administer the CAHPS Hospice Survey and oversee the quality of work of staff and
subcontractors, if applicable, according to protocols contained in the CAHPS Hospice
Survey Quality Assurance Guidelines manual
• Perform quality checks of all survey administration processes and document the
performance of the quality check activities
Verify that each contracted hospice has authorized the survey vendor to submit data on the
hospice’s behalf by submitting a notarized CAHPS Hospice Survey Vendor Authorization
Form at least 90 days prior to the first data submission deadline
Submit data files to the CAHPS Hospice Survey Data Warehouse in accordance with the
survey file layouts by the data submission deadlines
Request client hospices gain access to the CAHPS Hospice Survey Data Warehouse and
review CAHPS Hospice Survey Data Submission Reports
Review CAHPS Hospice Survey Data Submission Reports and confirm successful upload
of contracted hospices’ data files to the CAHPS Hospice Survey Data Warehouse
Maintain active contract(s) with hospice(s) in order to retain approval status (see CAHPS
Hospice Survey Minimum Business Requirements)
Complete and submit an annual Attestation Statement by the due date specified during
training and posted on the CAHPS Hospice Survey Web site
Note: If a survey vendor is non-compliant with program requirements for any of their
contracted hospices, the non-compliant action may affect that hospice’s APU for a given FY.
In addition, approved survey vendors that are non-compliant with CAHPS Hospice Survey
protocols may lose their CAHPS Hospice Survey approval status.
Customer Support Lines
Survey vendors who administer the CAHPS Hospice Survey must maintain a toll-free customer
support telephone line to answer questions about the CAHPS Hospice Survey, offering customer
support in all languages in which the survey vendor administers the survey. Survey vendors
conducting the Mail Only or Mixed Modes of survey administration must include contact
information for their customer support telephone line in the initial and follow-up cover letters.
Telephone lines must be staffed during business hours (see guidelines below), and have sufficient
capacity to handle incoming calls. Voicemail is acceptable during and after core business hours,
but must be regularly monitored and replied to within one to two business days. The voicemail
recording must specify that the caller can leave a message about the CAHPS Hospice Survey.
Survey vendors must document questions received and responses provided via a database or
tracking log.
In addition to the above requirements, the following guidelines are recommended for customer
support lines:
Staff telephone lines from 9 AM to 9 PM (survey vendor local time), Monday through
Friday
Maintain sufficient capacity so that 90 percent of incoming calls are answered “live” and
the average speed of answer is 30 seconds or less
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Program Requirements
Establish a “return call” standard of two business days for caller questions that cannot be
answered at the time of the initial call
Must be ready to support calls from the deaf or hearing impaired
A CAHPS Hospice Survey Frequently Asked Questions (FAQ) document for customer support
personnel and project staff is provided in Appendix G. Customer support personnel must use the
FAQ as a guide when answering caregivers’ questions about the survey.
Survey Vendor Analysis of CAHPS Hospice Survey Data
As with all survey vendor analyses, the survey vendor scores may differ from the official CMS
results. When providing hospices with survey data, survey vendors must communicate to
hospices that the survey vendor scores are not official CMS scores and should only be used
for quality improvement purposes. A Consent to Share question is not required by CMS in order
to share identifiable caregiver responses with hospices. If hospices or survey vendors choose to
use survey vendor provided scores in any way, they must indicate that they are not official CMS
scores. Each page of the report provided to hospices must contain the following statement: “This
report has been produced by [Survey Vendor] and does not represent official CAHPS Hospice
Survey results.” In addition, hospices should be informed by the survey vendor that any responses
that would identify a particular decedent/caregiver case must not be shared with direct care staff.
These results should be limited to management and/or quality improvement personnel.
CMS guidance regarding scoring and analysis (including adjustment for case mix and mode of
survey administration) is available on the Scoring and Analysis page of the CAHPS Hospice
Survey Web site (www.hospicecahpssurvey.org).
CAHPS Hospice Survey Minimum Business Requirements
A survey vendor must be approved by CMS in order to administer the CAHPS Hospice Survey
and submit CAHPS Hospice Survey data to the CAHPS Hospice Survey Data Warehouse. A
survey vendor must meet ALL of the CAHPS Hospice Survey Minimum Business Requirements
at the time the CAHPS Hospice Survey Participation Form is received. In addition, subcontractors
and any other organizations that are responsible for performing major CAHPS Hospice Survey
administration functions (e.g., mail/telephone operations) must also meet ALL of the CAHPS
Hospice Survey Minimum Business Requirements that pertain to that role at the time the CAHPS
Hospice Survey Participation Form is received (a subcontractor’s or any other organization’s
survey administration experience does not substitute for a survey vendor’s).
Approved CAHPS Hospice Survey vendors must fully comply with the CAHPS Hospice
Survey oversight activities
• The FY 2016 Hospice Wage Index and Payment Rate Update and Hospice Quality
Reporting Requirements Final Rule codified that approved CAHPS Hospice Survey
vendors are required to participate in CAHPS Hospice Survey oversight activities to
ensure compliance with CAHPS Hospice Survey requirements (Federal Register / Vol.
80, No. 151 / Thursday, August 6, 2015 / Rules and Regulations)
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Program Requirements
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The CAHPS Hospice Survey Minimum Business Requirements for an organization to become
approved to administer the CAHPS Hospice Survey are as follows:
Management Relationships:
Criteria
Survey Vendor
Current/Future
The following types of organizations are not eligible to
Relationships with
administer the CAHPS Hospice Survey (as an approved CAHPS
Hospices
Hospice Survey vendor):
• organizations or divisions within organizations that own or
operate a hospice or provide hospice services, even if the
division is run as a separate entity to the hospice;
• organizations that provide telehealth, monitoring of hospice
patients, or teleprompting services for the hospice; and
• organizations that provide staffing to hospices for providing
care to hospice patients, whether personal care aides or
skilled services staff.
Relevant Survey Experience:
Criteria
Survey Vendor
Number of Years in
Minimum four years
Business
Number of Years
Minimum of three years Mail, and/or Telephone, and/or Mixed
Conducting PatientMode patient-specific survey experience within the most recent
Specific Surveys
three- year time period
Sampling Experience
Two years prior experience selecting a random sample based on
specific eligibility criteria within the most recent two-year time
period
Work with contracted client(s) to obtain patient data for sampling
via Health Insurance Portability and Accountability Act(HIPAA) compliant electronic data transfer processes
Adequately document sampling process
Survey vendors are responsible for conducting the sampling
process and must not subcontract this activity
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Program Requirements
Survey Capability and Capacity:
Criteria
Survey Vendor
Personnel
Designated CAHPS Hospice Survey personnel:
• Project Director with minimum two years prior experience
conducting patient-specific surveys in the requested mode(s)
• Staff with minimum one year prior experience in sample
frame development and sample selection
• Programmer (subcontractor designee, if applicable) with
minimum one year prior experience receiving large encrypted
data files in different formats/software packages electronically
from an external organization; processing survey data needed
for survey administration and survey response data; preparing
data files for electronic submission; and submitting data files
to an external organization
• Call Center/Mail Center Supervisor (subcontractor designee,
if applicable) with minimum one year prior experience in role
Have appropriate organizational back-up staff for coverage of key
staff
Volunteers are not permitted to be involved in any aspect of the
CAHPS Hospice Survey administration process
Physical Plant and
Physical plant resources available to handle the volume of surveys
System Resources
being administered, including computer and technical equipment:
• A secure commercial work environment
• Home-based or virtual interviewers cannot be used to
administer the CAHPS Hospice Survey, nor may they conduct
any survey administration processes
• Physical facilities, electronic equipment and software to
collect, process and report data securely
• If offering telephone surveys, must have the equipment,
software and facilities to conduct computer-assisted telephone
interviewing (CATI) and to monitor interviewers
Electronic or alternative survey management system to:
• Track fielded surveys throughout the protocol, avoiding
respondent burden and losing respondents
• Assign random, unique, de-identified identification number
(Tracking ID) to track each sampled decedent/primary
informal caregiver (i.e., family member or friend of the
hospice patient)
Organizations that are approved to administer the CAHPS
Hospice Survey must conduct all of their business operations
within the United States. This requirement applies to all staff and
subcontractors or other organizations involved in survey
administration.
All System Resources are subject to oversight activities, including
site visits to physical locations
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Program Requirements
Criteria
Sample Frame
Creation
September 2019
Mail Administration
Telephone
Administration
Mixed Mode
Administration (Mail
with Telephone
Follow-up)
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Survey Vendor
A minimum of two years prior experience selecting a random
sample based on specific eligibility criteria in the most recent twoyear time period
Generate the sample frame data file that contains all individuals
who meet the eligible population criteria
Draw random sample of individuals for the survey who meet the
eligible population criteria
Mail survey administration activities are not to be conducted from
a residence, nor from a virtual office
Obtain and update addresses of sampled caregivers of hospice
decedents
Produce and print professional quality survey instruments and
materials according to guidelines; a sample of all mailing
materials must be submitted for review
Merge and print sample name and address on personalized mail
survey cover letters and print unique Tracking ID on the survey
questionnaire
Mail survey materials
Receive and process (key-enter or scan) completed questionnaires
Track and identify non-respondents for follow-up mailing
Assign final survey status codes to describe the final result of
work on each sampled record
Telephone interviews are not to be conducted from a residence,
nor from a virtual office
Obtain, verify and update telephone numbers
Develop CATI system
Collect telephone interview data for the survey using CATI
system; a sample of the telephone script and interviewer
screenshots must be submitted for review
Identify non-respondents for follow-up telephone calls
Schedule and conduct callbacks to non-respondents at varying
times of the day and different days of the week
Assign final survey status codes to reflect the final result of
attempts to obtain a completed interview with each sampled
record
Mail survey administration and telephone interviews are not to be
conducted from a residence, nor from a virtual office
Adhere to all Mail Only and Telephone Only survey
administration requirements (described above)
Track cases from mail survey through telephone follow-up
activities
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Criteria
Data Submission
Program Requirements
Data Security
Survey Vendor
Two years prior experience transmitting data via secure methods
(HIPAA-compliant)
Survey vendors are responsible for conducting data submission
and must not subcontract this process
Survey vendors must have the capacity to do the following actions
to submit quarterly data files:
• Register as a user of the CAHPS Hospice Survey Data
Warehouse
• Confirm contracted hospices have authorized survey vendor to
submit data on behalf of the hospice
• Import scanned or key-entered data from completed mail
surveys into a data file, if applicable
• Import (as necessary) data from CATI system into a data file,
if applicable
• 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 cases
• Export data from the electronic data collection system to the
required format for data submission, confirm that the data are
exported correctly and that the data submission files are
formatted correctly and contain the correct data headers and
data records
• Encrypt and submit data electronically in the specified format
to the CAHPS Hospice Survey Data Warehouse
• Work with CMS’ contractor to resolve data problems and data
submission issues
Survey vendors must have the capacity to do the following actions
to secure electronic data:
• Use a firewall and/or other mechanisms for preventing
unauthorized access to electronic files
• Implement access levels and security passwords so that only
authorized users have access to sensitive data
• Implement daily data back-up procedures that adequately
safeguard system data
• Test back-up files on a quarterly basis, at a minimum, to make
sure the files are easily retrievable and working
• Perform frequent saves to media to minimize data losses in the
event of power interruption
• Develop procedures for identifying and handling breaches of
confidential data
• Develop a disaster recovery plan for conducting ongoing
business operations in the event of a disaster
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Program Requirements
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Criteria
Data Retention and
Storage
Technical Assistance/
Customer Support
Organizational
Confidentiality
Requirements
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Survey Vendor
Survey vendors must have the capacity to do the following actions
to securely store all data related to survey administration:
• Store CAHPS Hospice Survey-related data files, including
decedents/caregivers lists and de-identified electronic data files
(e.g., sample frame, XML files, etc.), for all applicable survey
modes for a minimum of three years. Archived electronic data
files must be easily retrievable.
• Store de-identified returned mail questionnaires in a secure and
environmentally safe location (e.g., locked file cabinet, locked
closet or room), if applicable. Paper copies or optically scanned
images of the questionnaires must be retained for a minimum
of three years and be easily retrievable.
Two years prior experience providing telephone customer support
Provide toll-free customer support line:
• Offering customer support in all languages that the survey
vendor administers the survey in
• Returning calls within 24 - 48 hours
Survey vendors must have the capacity to do all of the following
actions:
• Develop confidentiality agreements which include language
related to HIPAA regulations and the protection of personal
identifying information (PII) and obtain signatures from all
personnel with access to survey information, including staff
and subcontractors or any other organizations involved in
survey administration and data collection. Confidentiality
agreements must be reviewed and re-signed periodically, at
the discretion of the survey vendor, but not to exceed more
than a three-year period.
• Execute Business Associate Agreements (BAA) in
accordance with HIPAA regulations
• Confirm that staff and subcontractors or other organizations
involved in survey administration are compliant with HIPAA
regulations in regard to decedent/caregiver protected health
information (PHI) and PII
• Establish protocols for secure file transmission. Emailing of
PHI or PII via unsecure email is prohibited.
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Program Requirements
Participation in Quality Control Activities and Documentation Requirements:
Criteria
Survey Vendor
Demonstrated Quality Incorporate well-documented quality control procedures (as
Control Procedures
applicable) for:
• Training of in-house staff and subcontractors or other
organizations involved in survey operations
• Printing, mailing and recording receipt of survey
questionnaires, if applicable
• Telephone administration of survey, if applicable
• Coding and verifying of survey data and survey-related
materials
• Scanning or keying-in survey data
• Preparation of final person-level data files for submission
• Submitting Discrepancy Reports immediately upon
discovering a discrepancy in following CAHPS Hospice
Survey protocols
• All other functions and processes that affect the
administration of the CAHPS Hospice Survey
Participate in any conference calls and site visits as part of overall
quality monitoring activities:
• 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
Documentation
Keep electronic or hard copy files of staff training and training
Requirements
dates
Maintain electronic documentation of telephone monitoring, if
applicable
Maintain documentation of mail production quality checks, if
applicable
Maintain documentation of all survey administration activities
and related quality checks for review during site visits
Develop a Quality Assurance Plan (QAP) for survey
administration in accordance with CAHPS Hospice Survey
Quality Assurance Guidelines and update the QAP at the time of
process and/or key personnel changes as part of retaining
participation status
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Program Requirements
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Adhere to all Protocols, Specifications and Agree to Participate in Training Sessions:
Criteria
Survey Vendor
Survey Training
Attend the Introduction to CAHPS Hospice Survey Training
session and all CAHPS Hospice Survey Update Training sessions
(at a minimum, survey vendor’s Project Manager and
subcontractors or other organizations involved in survey
administration assigned key roles must attend training)
Complete the post-training quiz measuring comprehension of
CAHPS Hospice Survey protocols
Administer the Survey Review and follow all procedures described in the CAHPS
According to All
Hospice Survey Quality Assurance Guidelines that are applicable
Survey Specifications
to the selected survey data collection mode(s)
Fully comply with the CAHPS Hospice Survey oversight
activities
Approved survey vendors are expected to maintain active
contract(s) for CAHPS Hospice Survey administration with client
hospice(s). An “active contract” is one in which the CAHPS
Hospice Survey vendor is authorized by hospice client(s) to collect
and submit CAHPS Hospice Survey data to the CAHPS Hospice
Survey Data Warehouse.
• If a CAHPS Hospice Survey vendor does not have any
contracted hospice clients within two years (a consecutive 24
months) of the date they received approval to administer the
CAHPS Hospice Survey, then that survey vendor’s
“Approved” status for CAHPS Hospice Survey administration
will be withdrawn
• If approval status is withdrawn, the organization must once
again follow the steps to apply for reconsideration for approval
to administer the CAHPS Hospice Survey
o If a survey vendor chooses to not re-apply at this time,
then a 24-month wait period will be required before the
organization is eligible to apply again
o If a CAHPS Hospice Survey vendor is approved for a
second term and does not have any contracted hospice
clients by the end of the second 24-month approved period,
a 24-month wait period will be required before the
organization is eligible to apply again
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Program Requirements
CAHPS Hospice Survey Rules of Participation
Survey vendors agree to the following Rules of Participation as found in the CAHPS Hospice
Survey Participation Form:
Submit CAHPS Hospice Survey Participation Form
Before attending the CAHPS Hospice Survey Training session, new survey vendors must
complete and submit a CAHPS Hospice Survey Participation Form online. The CAHPS
Hospice Survey Participation Form for Survey Vendors is available on the CAHPS
Hospice Survey Web site at www.hospicecahpssurvey.org on an annual basis prior to
training. By signing the CAHPS Hospice Survey Participation Form, survey vendors
signify agreement with all of the Rules of Participation, including all CAHPS Hospice
Survey oversight activities and survey administration due dates.
Survey vendors that meet the CAHPS Hospice Survey Minimum Business Requirements
will be eligible to receive conditional approval to be a CAHPS Hospice Survey vendor.
Once conditionally approved, the survey vendor must then participate in the CAHPS
Hospice Survey Training session. Survey vendors will be eligible to receive full approval
following participation in the CAHPS Hospice Survey Training session and successful
completion of the post-training quiz.
Note: Approval of the survey vendor’s participation status to administer the CAHPS
Hospice Survey is contingent upon successful completion of teleconference call(s) with the
CAHPS Hospice Survey Project Team, if requested, to discuss relevant survey experience,
organizational survey capability and capacity, and quality control procedures.
Consideration will be given to the applicant’s prior experience administering other CMS
CAHPS surveys, if any.
Attend CAHPS Hospice Survey Training Sessions
Survey vendors that intend to administer the CAHPS Hospice Survey must attend all
CAHPS Hospice Survey Training sessions sponsored by CMS. At a minimum, the survey
vendor’s Project Manager must participate in all CAHPS Hospice Survey Training
sessions. Subcontractors and any other organizations that are responsible for major
functions of CAHPS Hospice Survey administration (e.g., mail/telephone operations)
must attend all CAHPS Hospice Survey Training sessions. Survey vendors must
successfully complete a post-training quiz at the conclusion of each CAHPS Hospice
Survey Training session.
Review and Follow the CAHPS Hospice Survey Quality Assurance Guidelines and
Policy Protocols
The CAHPS Hospice Survey Quality Assurance Guidelines manual has been developed to
assure the standardization of the survey data collection process and the comparability of
reported data. Survey vendors must review and follow the CAHPS Hospice Survey Quality
Assurance Guidelines. In addition, survey vendors must follow all survey protocols,
including those posted on the CAHPS Hospice Survey Web site
(www.hospicecahpssurvey.org).
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Program Requirements
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Train Employees to be Compliant with HIPAA Regulations
Survey vendors must conduct trainings on an annual basis, at a minimum, regarding
HIPAA regulations for all staff participating in the CAHPS Hospice Survey. In addition,
survey vendors must confirm that subcontractors and any other organizations, if applicable,
have received training on HIPAA regulations.
Execute Business Associate Agreements
Survey vendors must execute Business Associate Agreements (BAA) in accordance with
HIPAA regulations
Complete an Attestation Document Annually
The survey vendor must review and attest (as determined by CMS) to the accuracy of the
organization’s data collection processes and compliance with the CAHPS Hospice Survey
Quality Assurance Guidelines.
Planned variations from survey administration protocols must be pre-approved by CMS
through the Exception Request process (see Appendix I). Variations from the survey
administration protocols that are not pre-approved by CMS must be reported to CMS
immediately upon discovery using a Discrepancy Report (see Appendix J). CMS may
determine that data collected in a non-approved manner may not be reported.
Develop CAHPS Hospice Survey QAP
Survey vendors must develop a QAP for survey administration in accordance with the
CAHPS Hospice Survey Quality Assurance Guidelines and update the QAP as part of their
participation. The Model QAP document (see Appendix H) must be used for developing
the QAP. The QAP must be updated, as necessary, to reflect changes in key personnel,
resources and processes (see Oversight Activities chapter for more information).
• Change in Key Personnel
A survey vendor must immediately notify the CAHPS Hospice Survey Project Team
of changes in its contact person or key staff and organizational structure (i.e., changes
in ownership, name and address) via email at [email protected]
Upon request, each survey vendor must submit their QAP and survey materials relevant to
that year’s CAHPS Hospice Survey administration (as determined by CMS) for review by
the CAHPS Hospice Survey Project Team.
Become a Registered User of the CAHPS Hospice Survey Data Warehouse
Survey vendors must submit CAHPS Hospice Survey data electronically via the CAHPS
Hospice Survey Data Warehouse using the prescribed file specifications. All survey
vendors participating in the CAHPS Hospice Survey must be registered users of the
CAHPS Hospice Survey Data Warehouse.
Participate in Oversight Activities Conducted by the CAHPS Hospice Survey Project
Team
Survey vendors, including subcontractors, must be prepared to participate in all oversight
activities, such as site visits and/or conference calls, as requested by the CAHPS Hospice
Survey Project Team, to confirm that correct survey protocols are followed. Failure to
comply with oversight activities may result in the revocation of approval to administer
the CAHPS Hospice Survey.
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IV. Communications and Technical Support
Overview
Organizations and individuals have access to a number of sources of information regarding the
CAHPS Hospice Survey. Several of these sources are listed below.
CAHPS Hospice Survey Information and Technical Assistance
For information and technical assistance, contact the CAHPS Hospice Survey Project Team:
via email at [email protected]
via telephone at 1-844-472-4621
When contacting the CAHPS Hospice Survey Project Team regarding a specific hospice, be sure
to provide the following information in your email or telephone voicemail:
Survey vendor name
Hospice six-digit CCN
Hospice name
For additional information and technical assistance related to the use of the CAHPS Hospice
Survey Data Warehouse or data submission issues, contact the CAHPS Hospice Survey Data
Coordination Team:
via email at [email protected]
via telephone at 1-703-413-1100, extension 5599
General Information, Announcements and Updates
To learn more about the CAHPS Hospice Survey and to view important new updates and
announcements, please visit the CAHPS Hospice Survey Web site at:
www.hospicecahpssurvey.org
Communicate with CMS Regarding the CAHPS Hospice Survey
To contact CMS regarding the CAHPS Hospice Survey, please email:
[email protected]
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V. Sampling Protocol
Overview
This chapter describes the procedures survey vendors should use to request the
decedents/caregivers list from their hospices, identify decedents/caregivers eligible for the survey,
construct a sample frame, and select a sample each month. The sampling procedures described in
this chapter were developed to ensure standardized administration of the CAHPS Hospice Survey
by all approved survey vendors and to ensure the comparability of the data and survey results that
are reported.
Data collection for the CAHPS Hospice Survey is conducted on a monthly basis. Survey vendors
select monthly samples of all decedents/caregivers who meet survey eligibility criteria for each
contracted hospice. For each monthly sample, survey administration must be initiated two calendar
months after the month of patient death. Submission to the CAHPS Hospice Survey Data
Warehouse is on a quarterly basis. Refer to the “CAHPS Hospice Survey Data Collection and
Submission Timeline” section in the Introduction and Overview chapter for the data submission
timeline.
Hospice Information Submission Requirements
Each hospice must submit the following information to the survey vendor in time for the survey
vendor to initiate the survey data collection protocols:
The decedents/caregivers list
Total count of all decedents served in the month (this count must include the number of
“no publicity” decedents/caregivers, but must not include live discharge patients)
Total number of hospice offices covered under a single CCN
• In this context, hospice offices mean separate administrative or practice offices for the
CCN, not to be confused with individual facilities or settings in which hospice care is
provided (e.g., homes, assisted living facilities, hospitals, hospice facilities, or hospice
houses)
Counts of cases ineligible due to:
• Live discharge
• Number of “no publicity” decedents/caregivers
“No Publicity” Decedents/Caregivers
“No publicity” status is a rare and unusual request. “No publicity” decedents/caregivers are those
who initiate or voluntarily request at any time during their stay that the hospice: 1) not reveal the
patient’s identity; and/or 2) not survey him or her. Hospices must retain documentation of the “no
publicity” request for a minimum of three years.
The vendor should review the definition of a “no publicity” decedent/caregiver with each hospice
to ensure the hospice understands when this may be used. If the number of “No publicity”
decedents/caregivers from any hospice is consistently high, the vendor should confirm the “no
publicity” count is correct.
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Sampling Protocol
September 2019
Counts
As stated above, each hospice must provide the total count of decedents served in the month, and
the counts of cases ineligible due to live discharge and request for no contact. Counts should be
accurate and add up correctly. If the counts submitted by the hospice appear to be inaccurate based
on the number of decedent/caregiver records submitted by that hospice, the vendor should followup with the hospice to confirm the counts are correct. The hospice must update the counts if they
are determined to be inaccurate.
Below are several examples of these counts.
Example 1: A hospice has 50 decedents in a month, including 2 decedents/caregivers who
voluntarily and expressly requested not to be contacted, as well as 10 patients discharged
alive. For this hospice, the Total Number of Decedents is 50, the Total Number of Live
Discharges is 10, the number of “No publicity” Decedents/Caregivers is 2, and there are
48 decedent/caregiver cases in the decedents/caregivers list.
Example 2: A hospice has 10 decedents in a month, including 1 decedent/caregiver who
voluntarily and expressly requested not to be contacted, as well as 15 patients discharged
alive. For this hospice, the Total Number of Decedents is 10, the Total Number of Live
Discharges is 15, the number of “No publicity” Decedents/Caregivers is 1, and there are 9
decedent/caregiver cases in the decedents/caregivers list.
Note: Hospices will submit three patient counts: total decedents (the number of cases included in
the decedents/caregivers list, plus the number of “no publicity” decedents/caregivers), the number
of “no publicity” decedents/caregivers and the number of live discharge patients. These counts
must include only hospice patients served by the CCN.
Decedents/Caregivers List
Hospices are required to supply a decedents/caregivers list to their survey vendor containing the
data elements below for each decedent, excluding “no publicity” decedents/caregivers, who died
within a calendar month while under the care of the hospice program (first day of month through
last day of month). The hospice must not apply eligibility criteria prior to providing the
decedents/caregivers list to their survey vendor; all decedents/caregivers in the month with the
exception of non-publicity decedents/caregivers must be submitted to the survey vendor.
Decedent name (first, middle [if available], last) and prefix/suffix
Decedent date of birth
Decedent date of death
Decedent sex
Decedent race/ethnicity
Decedent primary diagnosis
Decedent admission date for final episode of hospice care
Decedent payers (primary, secondary, other)
• The CAHPS Hospice Survey is intended to reflect the care received by decedents of all
payer types, not just Medicare. Therefore, decedents of all payer types are eligible for
sampling.
Decedent last location/setting of care (e.g., home, assisted living facility, nursing home,
acute care hospital, freestanding hospice inpatient unit)
Caregiver name (first, middle [if available], last) and prefix/suffix
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Sampling Protocol
Caregiver contact information, including mailing address, telephone number(s), email
address (if available)
Caregiver relationship to decedent (e.g., spouse/partner, child, sibling, other)
The CAHPS Hospice Survey is designed to be administered to the person who is most
knowledgeable about the hospice care received by the decedent (referred to here as the primary
informal caregiver). The hospice is responsible for identifying one primary informal caregiver
who may be eligible to receive and respond to the CAHPS Hospice Survey for each decedent.
The caregiver relationship to the decedent should fall into one of the following categories:
spouse/partner, parent (or step parent), child (or step child), other family member, friend,
or other. A non-familial legal guardian who does not fall into one of these categories cannot
be considered a primary informal caregiver for the purposes of the CAHPS Hospice
Survey.
• A caregiver relationship of “8 - No caregiver of record” should be used to identify
decedents who have no caregiver of record
One caregiver category does not automatically have preference over another. Hospices
should not prioritize a primary informal caregiver that is a family member over a friend, as
a friend may have more knowledge regarding the decedent’s hospice care than a family
member. The CAHPS Hospice Survey should be administered to the person most
knowledgeable about the care the decedent received at the hospice.
Staff members, employees of the hospice or the care setting in which the patient received
hospice care, or contracted/hired non-familial caregivers should not be considered primary
informal caregivers
Hospices should submit only one caregiver per decedent to the survey vendor. Survey vendors
should use the following information to determine the primary informal caregiver in instances
where the hospice provides multiple caregivers for a given decedent:
Select the caregiver with the most complete contact information. To determine most
complete, first consider caregiver name, then caregiver mailing address (if administering
the survey using Mail Only or Mixed Mode) or caregiver telephone number (if
administering the survey using Telephone Only mode).
If multiple caregivers have the same amount of contact information, select the record
highest on the list provided by the hospice
If two first names are embedded within the caregiver first name field (e.g., “Tom & Jane”),
and the remainder of the caregiver information is identical, the survey may be addressed to
both caregivers and telephone interviewers may ask to speak with either caregiver
Note: It is not permissible for a hospice to provide an updated primary informal caregiver once
the survey vendor has initiated contact.
The survey vendor must use the information that the hospice provides in the decedents/caregivers
list to identify survey-eligible decedents/caregivers and survey the sampled decedents/caregivers.
Survey vendors must develop a process to request missing/inaccurate information to be updated in
the decedents/caregivers list prior to survey administration. It is permissible for survey vendors to
request updated information about specific decedents/caregivers, rather than requesting a complete
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updated list. Survey vendors should track and document updates to previously missing
information.
Note: Survey vendors must not assume that if a hospice does not submit a monthly sample file
that there are zero survey-eligible decedents/caregivers for the month. The hospice must confirm
in writing that there are zero survey-eligible decedents/caregivers for the month. If no written
confirmation is received, then a Hospice Record for the hospice must not be uploaded and a
Discrepancy Report must be submitted.
Counts of Ineligibles
The hospice must submit to its survey vendor a count for each of the following ineligibility
categories:
Patient(s) discharged alive
• This includes patients who have the occurrence code “42” – Date of Revocation (only)
(FL 31-34) and patients who have the following Patient Status Codes (FL17):
o “01” – Discharge to Home or Self Care (Routine Discharge)
o “50” – Discharged/Transferred to a Hospice – “Hospice Home” (Routine or
Continuous Home Care [CHC])
o “51” – Discharged/Transferred to a Hospice – “Hospice Medical Facility”
(Inpatient Respite or General Inpatient Care [GIP])
Number of “no publicity” decedents/caregivers (“No publicity” status is a rare and unusual
request. “No publicity” decedents/caregivers are those who initiate or voluntarily request
at any time during their stay that the hospice: 1) not reveal the patient’s identity; and/or 2)
not survey him or her.)
Eligibility for the CAHPS Hospice Survey
Decedents/caregivers are eligible for inclusion in the sample frame if they meet all of the following
criteria:
Decedents age 18 and over at time of death
• To determine if the decedent was age 18 or older at the time of death, use the date of
birth and date of death provided by the hospice to calculate the decedent’s age
Decedents with death at least 48 hours following last admission to hospice care
• To determine the 48-hour period, one would establish date of admission plus two
calendar days. See the below examples for clarification.
o Example 1: If the patient is admitted to the hospice on January 2 and passes away
on January 4; day one is January 3 and day two is January 4. The 48 hours after
admission would be met (admission [January 2] plus two days [January 3 and
January 4]).
o Example 2: If the patient is admitted to the hospice on January 2 and passes away
on January 3; day one is January 3 and there is no day two. The 48 hours after
admission would not be met.
Decedents for whom there is a caregiver of record
Decedents whose caregiver is someone other than a non-familial legal guardian
• A familial legal guardian falls into one of the six answer categories available provided
in the Sample File Layout of Appendix D (1 = Spouse/partner; 2 = Parent; 3 = Child;
4 = Other family member; 5 = Friend; 7 = Other). The hospice should only indicate the
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caregiver relationship as 6 = Legal guardian if the caregiver is a non-familial legal
guardian.
Decedents for whom the caregiver has a U.S. or U.S. Territory home address
If a survey vendor becomes aware that a decedent/caregiver case should have a “no publicity”
classification, then the “no publicity” decedent/caregiver must be excluded from the sample frame.
“No publicity” status is a rare and unusual request. “No publicity” decedents/caregivers are those
who initiate or voluntarily request at any time during their stay that the hospice: 1) not reveal the
patient’s identity; and/or 2) not survey him or her. Patients who are discharged alive will also be
excluded.
Note: Decedents/Caregivers must be included in the CAHPS Hospice Survey sample frame unless
the survey vendor has definitive evidence that a decedent/caregiver is ineligible. If information is
missing on a variable that affects survey eligibility when the sample frame is constructed, the
decedent/caregiver must be included in the sample frame. The only exception to this guideline is
the date of death; if any part (i.e., day, month or year) of the decedent’s date of death is missing,
the case must not be included in the sample frame, and the case must be included in the count of
“Missing Date of Death” submitted by the survey vendor to the CAHPS Hospice Survey Data
Warehouse.
Note: If a hospice or survey vendor becomes aware that the caregiver is under 18 years old prior
to drawing the sample, the caregiver must be excluded from the sample frame.
De-duplication for Multiple Hospice Stays
To ensure accurate counts are submitted to CMS, patients with multiple hospice admissions during
a given calendar month must be de-duplicated. The de-duplication process should include
reviewing decedent names, along with a secondary field, such as date of birth. The admission that
controls the handling of the case is dependent on the outcome associated with each admission. The
key for inclusion in the CAHPS Hospice Survey is death in the reference month while under
hospice care. For example:
If a patient is admitted on January 15, discharged alive on January 18, readmitted to the
hospice on January 22 and dies on January 26, then the patient’s last admission, January
22, controls the handling of the case. The fact that the patient died on January 26 (within
the same month) means that decedent/caregiver case will be included in the January
decedents/caregivers list. The January 18 live discharge is not counted among the live
discharges because the patient was re-admitted and died in January.
If a patient is admitted on January 15, discharged alive on January 18, readmitted to the
hospice on January 22 and passes away on February 3, then the patient will be included in
the January count of ineligibles due to live discharge provided to the survey vendor.
Additionally, the patient will be included in the February decedents/caregivers list as a
decedent.
Sample Frame Creation
Survey vendors participating in the CAHPS Hospice Survey are responsible for generating
complete, accurate and valid sample frame data files each month that contain all administrative
information on all decedents/caregivers who meet the eligible population criteria.
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Prior to generating the CAHPS Hospice Survey sample frame, survey vendors must apply
the eligibility criteria and remove ineligible decedents/caregivers from the
decedents/caregivers list received from the hospice. The steps below must be followed when
creating the sample frame:
Decedents/Caregivers whose eligibility status is uncertain must be included in the sample
frame
The sample frame for a particular month must include all survey-eligible
decedents/caregivers from the first through the last day of the month (e.g., for January, any
qualifying patient deaths from the 1st through 31st)
• Survey vendors must implement a de-duplication process to verify a decedent is
included only once in the decedents/caregivers list
Records with missing or incomplete decedent or caregiver names, addresses and/or
telephone numbers must not be removed from the sample frame
• If this record is drawn into the sample, then every attempt must be made to find the
correct name, address and/or telephone number. If the necessary decedent or caregiver
contact information is not found, the “Final Survey Status” must be coded as “10 –
Non-response: Bad/No Address,” “11 – Non-response: Bad/No Telephone Number,”
“12 – Non-response: Incomplete Caregiver Name,” or “13 – Non-response: Incomplete
Decedent Name.” (For more information, see the Data Coding and Data File
Preparation chapter.)
Survey vendors are required to provide counts of the (a) decedents served in the month (a count of
all records submitted by the hospice plus the count of “no publicity” decedents/caregivers), (b)
number of hospice offices covered by a single CCN (provided by the hospice), (c) patients
discharged alive (provided by the hospice), (d) “no publicity” decedents/caregivers (provided by
the hospice), (e) total number of cases available to be sampled, (f) total number of cases actually
drawn into the sample, (g) total number of decedent/caregivers excluded from the sample frame
because any part (i.e., day, month or year) of the decedent’s date of death is missing, and (h) total
number of ineligible decedents/caregivers as determined by the survey vendor applying the
following criteria:
Decedent was under the age of 18 at time of death
Decedent’s death was less than 48 hours following last admission to hospice care
Decedent has no caregiver of record
Decedent’s caregiver is a non-familial legal guardian
Decedent’s caregiver has an address outside the U.S. or U.S. Territories
Note: Survey vendors must retain counts of the number of ineligible decedents/caregivers in each
of the above categories (e.g., number of decedents under the age of 18, number of decedents with
no caregiver of record). This documentation is subject to review.
Note: The total number of ineligible decedents/caregivers should not include cases where the
decedent’s date of death is missing as those decedents/caregivers are accounted for in a separate
variable.
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The survey vendor must retain the original decedents/caregivers list, the sample frames (the entire
list of eligible CAHPS Hospice Survey decedents/caregivers from which each hospice’s sample is
drawn), the sample, and ineligibility counts in each category for a minimum of three years.
Sampling Procedure
Hospices with fewer than 50 survey-eligible decedents/caregivers during the prior calendar year
that submit the Participation Exemption for Size Form are exempt from the survey data collection
and reporting requirements. Hospices with 50 to 699 survey-eligible decedents/caregivers in the
prior year are required to survey all cases (conduct a census). Hospices with 700 or more surveyeligible decedents/caregivers in the prior year are required to survey a minimum sample of 700
using an equiprobable approach and may conduct a census, if desired. If an organization chooses
to survey more than a sample of 700 decedents/caregivers, all data are required to be submitted
to the CAHPS Hospice Survey Data Warehouse. Survey-eligible decedents/caregivers are defined
as that group of decedent and caregiver pairs that meet all the criteria for inclusion in the
survey sample.
Note: Hospices that share a common CCN must calculate the total number of survey-eligible
decedents/caregivers per CCN, not per individual hospice program.
Consistent Monthly Sampling
For ease of sampling within hospices large enough to conduct non-census sampling, CMS
recommends that survey vendors sample an approximately equal number of decedents/caregivers
each month, unless adjustments are required. Adjustments may only take place between calendar
quarters. Survey vendors have the option to allocate the yearly sample proportionately to each
month according to the expected proportional distribution of total survey-eligible
decedents/caregivers over four rolling quarters. Survey vendors must sample from every month in
the reporting period, even if they have already achieved the required number of sampled
decedents/caregivers.
Final Survey Sample
The final sample drawn each month must reflect a random sample of eligible decedents/caregivers
from the survey sample frame, or for those hospices conducting a census, all eligible
decedents/caregivers from the survey sample frame.
Method of Sampling
Sampling for the CAHPS Hospice Survey is based on the survey-eligible decedents/caregivers
(CAHPS Hospice Survey sample frame) for a calendar month. The equiprobable approach is
used, as every survey-eligible decedent/caregiver for a given month has the same probability of
being sampled.
Simple Random Sampling
Simple random sampling (SRS) is the most basic sampling technique. A group of
decedents/caregivers (a sample) is randomly selected from a larger group of survey-eligible
decedents/caregivers. Each decedent/caregiver is chosen entirely by chance, and each surveyeligible decedent/caregiver has an equal chance of being included in the sample.
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SRS Example 1: End of month percent random sample selection
Sampling for Hospice A is conducted only once for a given month
• Suppose Hospice A has 150 survey-eligible decedents/caregivers for a given month
and wishes to use a 50 percent sampling rate
o Randomly sort all 150 survey-eligible decedents/caregivers prior to sampling
o Then select 50 percent of the 150 survey-eligible decedents/caregivers for a
monthly sample size of 75 decedents/caregivers. Since the survey-eligible
decedents/caregivers list is already randomly sorted, the first 75 decedents may be
selected to form the monthly random sample.
SRS Example 2: Census sampling
Census sampling for Hospice B is required if the hospice served 50 to 699 survey-eligible
decedents/caregivers in the prior year
• Suppose Hospice B has 60 survey-eligible decedents/caregivers for a given month.
Since this hospice is using census sampling, each of the 60 survey-eligible
decedents/caregivers is included in the hospice’s CAHPS Hospice Survey sample.
Census sampling is also allowed if Hospice C served more than 700 survey-eligible
decedents/caregivers in the prior year and chooses to sample all survey-eligible
decedents/caregivers
• A census sample is considered SRS because each decedent/caregiver has an equal
chance (100 percent) of being included in the sample and the decedents/caregivers are
not stratified in any manner
Note: Other sampling scenarios may exist and the survey vendor should contact the CAHPS
Hospice Survey Project Team with any questions via email at [email protected] or
call 1-844-472-4621.
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VI. Mail Only Survey Administration
Overview
This chapter describes the guidelines for the Mail Only mode of CAHPS Hospice Survey
administration.
Data collection for sampled decedents/caregivers must be initiated two months following the
month of patient death. Survey vendors must send sampled caregivers a first questionnaire with a
cover letter within the first seven calendar days of the field period. A second questionnaire with a
follow-up cover letter must be sent to all sampled caregivers who did not respond to the first
questionnaire, approximately 21 calendar days after the first questionnaire mailing.
If survey administration is not initiated within the first seven days, surveys may be administered
by the survey vendor from the eighth to the tenth of the month without requesting prior approval
from CMS. In this situation, a Discrepancy Report must be submitted to notify CMS of the late
survey administration. In addition, the survey vendor must keep documentation regarding why the
survey was administered late. After the tenth of the month, approval must be requested from CMS
before the survey can be administered and a Discrepancy Report must be submitted if survey
administration begins late or does not occur for any month.
Note: If after the first mailing the survey vendor learns that a sampled decedent/caregiver is
ineligible for the CAHPS Hospice Survey, the survey vendor must not send the caregiver the second
questionnaire. After the sample has been drawn, any decedents/caregivers who are found to be
ineligible must not be removed or replaced in the sample. Instead, these decedents/caregivers are
assigned a “Final Survey Status” code of ineligible (2, 3, 4, 5, 6, or 14, as applicable). A
Decedent/Caregiver Administrative Record must be submitted for these decedents/caregivers. See
the Data Coding and Data File Preparation chapter for more information on assigning the “Final
Survey Status” codes.
Data collection must be closed out for a sampled caregiver by six weeks (42 calendar days)
following the mailing of the first questionnaire (initial contact). Caregivers who receive the
CAHPS Hospice Survey must not be offered incentives of any kind. Caregivers who do not
respond to the survey are assigned a “Final Survey Status” code of non-response (7, 8, 9, 10, 11,
12, 13, or 15, as applicable).
Survey vendors must include the “number-survey-attempts-mail” field in the Decedent/Caregiver
Administrative Record. This field is required when “survey-mode” in the Hospice Record is “1 –
Mail Only.” This field captures the mail wave attempt in which the final disposition of the survey
is determined. More information regarding the coding of the survey attempts field is presented in
the Data Coding and Data File Preparation chapter.
Survey vendors must make every reasonable effort to achieve optimal survey response rates and
to pursue contact with potential respondents until the data collection protocol is completed.
The basic tasks and timing for conducting the CAHPS Hospice Survey using the Mail Only mode
of survey administration are summarized below.
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Activity
Mail initial questionnaire with cover letter to
sampled caregivers
Mail second questionnaire with follow-up
cover letter to all sampled caregivers who do
not respond to the first survey mailing
Complete data collection
Submit data files to the CAHPS Hospice
Survey Data Warehouse by the data
submission deadline. No files will be accepted
after the submission deadline date.
Timing
Two months after the month of patient
death within the first seven calendar days of
the field period
Approximately 21 calendar days after the
first survey mailing
Within six weeks (42 calendar days) of the
first survey mailing
See the quarterly data submission deadlines
in the Introduction and Overview chapter
To reiterate, the first mail attempt must occur two months after the month of patient death within
the first seven calendar days of the field period. Data collection must then be completed no later
than six weeks (42 calendar days) after the initial mailing. To illustrate the timing of the survey
mailing, the example below is provided of a patient who died on April 18 while in hospice care.
Example:
The first survey is mailed out on July 1 (two months after month of patient’s death and
within the first seven calendar days of the field period)
If the caregiver has not returned the survey by July 22 (21 days after the initial mailing on
July 1), a second survey is mailed out
Data collection must be closed out on August 12 for this caregiver, which is six weeks (42
calendar days) from the July 1 initial mailing date:
• If the survey is returned on or before August 12, which is the last day of the survey
administration time period for this caregiver, then the survey is included in the final
survey data file and assigned a “Final Survey Status” code of either “1 – Completed
Survey” or “7 – Non-response: Break-off” based on the calculation of percent complete
as described in the Data Coding and Data File Preparation chapter
o If the survey is returned after August 12 (August 13, for example), which is
beyond the six weeks (42 calendar days) survey administration time period for
this caregiver, then the survey data are not included in the final survey data file
(however, a Decedent/Caregiver Administrative Record is submitted for
this caregiver) and a “Final Survey Status” code of “9 − Non-response: Nonresponse after Maximum Attempts” is assigned
Production of Questionnaire and Related Materials
The Mail Only mode of survey administration may be conducted in English, Spanish, Chinese,
Russian, Portuguese, Vietnamese, Polish, and Korean. Survey vendors are provided with the
CAHPS Hospice Survey questionnaires in English, Spanish, Chinese, Russian, Portuguese,
Vietnamese, Polish, and Korean, and initial and follow-up cover letters in English, Spanish,
Chinese, Russian, Portuguese, Vietnamese, Polish, and Korean. Survey vendors are not permitted
to make or use any other translations of the CAHPS Hospice Survey cover letters or questionnaires.
We strongly encourage hospices with a significant caregiver population that speaks Spanish,
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Chinese, Russian, Portuguese, Vietnamese, Polish, or Korean to offer the CAHPS Hospice Survey
in all applicable languages. We encourage hospices that serve patient populations that speak
languages other than those noted to request that CMS create an official translation of the CAHPS
Hospice Survey in those languages.
Each survey vendor must submit a sample of their CAHPS Hospice Survey mailing materials i.e.,
questionnaires, cover letters and outgoing envelopes) by the specified due date for review by the
CAHPS Hospice Survey Project Team. The due date for survey vendors to submit samples of their
CAHPS Hospice Survey mailing materials will be announced during the CAHPS Hospice Survey
Training session and posted on the CAHPS Hospice Survey Web site
(www.hospicecahpssurvey.org).
Mailings must include a personalized cover letter, a questionnaire and a business reply envelope.
The cover letters may be sent in both English and one of the official translations, and may be twosided, English on one side and one of the official translations on the other. Cover letters sent to
respondents must be personalized with the name of the decedent, caregiver and hospice. The letter
must also provide a toll-free number for respondents to call if they have questions. The cover of
the questionnaire must include the name of the hospice, and if applicable, may include the specific
hospice inpatient unit, acute care hospital or nursing home facility in which their family member
or friend resided.
For CAHPS Hospice Survey administration, the OMB Paperwork Reduction Act language must
appear in the mailing, either on the front of the cover letter or on the front or back of the
questionnaire in a font size of 10-point or larger. The OMB language cannot be printed on a
separate piece of paper. In addition, the OMB control number (OMB#0938-1257) and expiration
date (Expires December 31, 2020) must appear on the front page of the questionnaire.
To increase the likelihood that the respondent is the person within the sampled caregiver’s
household who is most knowledgeable about the decedent’s hospice care, language must be
included in the questionnaire, and optionally in the cover letter, clearly stating that the survey
should be given to the person in the household who knows the most about the hospice care received
by the decedent.
Required for the Mail Questionnaire
The CAHPS Hospice Survey Core questions (Q1 – Q40) must be placed at the beginning of the
survey. The order of the Core questions must not be altered and all the Core questions must remain
together. The “About Your Family Member” and “About You” questions must be placed after the
Core questions and cannot be eliminated from the questionnaire. The “About You” questions must
follow the “About Your Family Member” questions.
Survey vendors must adhere to the following specifications for the production of mail materials:
Question and answer category wording must not be changed
No changes are permitted in the order of the Core questions (Q1 – Q40)
No changes are permitted in the order of the “About Your Family Member” questions
No changes are permitted in the order of the “About You” questions
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No changes are permitted in the order of the response categories for the Core, “About Your
Family Member” or “About You” questions
Each question and answer categories must remain together in the same column and on the
same page
Response options must be listed vertically (see examples in Appendices N through V).
Response options that are listed horizontally or in a combined vertical and horizontal
format are not allowed. No matrix formats are permitted for question and answer
categories.
Dates are not permitted to be included on the questionnaire or the cover letters (e.g., print
date, mail date)
Formatting
Wording that is bolded or underlined in the questionnaire provided in the CAHPS Hospice
Survey Quality Assurance Guidelines manual must be emphasized in the same manner in
the survey vendor’s questionnaire
Arrow (i.e., ) placement in the questionnaire instructions and answer categories that
specifies skip patterns must not be changed
Section headings (e.g., “YOUR FAMILY MEMBER’S HOSPICE CARE”) must be
included on the questionnaire and must be bolded and capitalized, including the “SURVEY
INSTRUCTIONS” heading
Response options on the questionnaire may be incorporated as circles, ovals or squares
with no mixing of the characters within the questionnaire
Survey materials must be in a readable font (e.g., Arial) in a font size of 10-point or larger
Other Requirements
All survey content, including headers, instructions, questions, and answer categories, must
be printed verbatim and in the same order as shown on the questionnaires provided by CMS
Randomly generated, unique identifiers must be placed on the first or last page of the
questionnaire, at a minimum. Survey vendors may add other identifiers on the
questionnaire for tracking purposes (e.g., unit identifiers).
Neither the decedent’s nor the caregiver’s name may be printed on the questionnaire
The text indicating the purpose of the unique identifier (“You may notice a number on the
survey. This number is used to let us know if you returned your survey so we do not have
to send you reminders.”) must be printed either immediately after the survey instructions
on the questionnaire or on the cover letter, and may appear on both
The survey vendor’s return address must be printed on the last page of the questionnaire to
make sure that the questionnaire is returned to the correct address in the event that the
enclosed return envelope is misplaced by the caregiver
If the survey vendor’s name is included in the return address, then the survey vendor’s
business name must be used, not an alias or tag line
A mail wave indicator must be included on the survey
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Optional for the Mail Questionnaire
Survey vendors have some flexibility in formatting the CAHPS Hospice Survey questionnaire by
following the guidelines described below:
Small coding numbers, preferably in superscript, may be included next to the response
choices on the questionnaire
Hospice logos may be included on the questionnaire; however, other images and tag lines
are not permitted
The phrase “Use only blue or black ink” may be printed on the questionnaire
The name of the hospice may be printed on the questionnaire in Questions 2, 4 and 39, as
indicated below
• Question 2 – “In what locations did your family member receive care from [ABC
Hospice]?”
• Question 4 – “As you answer the rest of the questions in this survey, please think only
about your family member’s experience with [ABC Hospice].”
• Question 39 – “Please answer the following questions about your family member’s care
from [ABC Hospice]. Do not include care from other hospices in your answers.”
Page numbers may be included on the questionnaire
Color may be incorporated in the questionnaire
Language such as one of the following may be added to the bottom of each page of the
survey:
• Continue on next page
• Continue on reverse side
• Turn over to continue
• to continue
• Continue on back
• Turn over
Survey vendors should consider incorporating the following recommendations in formatting the
CAHPS Hospice Survey questionnaire to increase the likelihood of receiving a returned survey:
Two-column format that is used in Appendices N through V
Wide margins (at least 3/4 inch) so that the survey has sufficient white space to enhance
its readability
Supplemental Questions
Survey vendors may add up to 15 hospice-specific supplemental questions to the CAHPS Hospice
Survey following the guidelines described below (see Appendix M for examples of acceptable
supplemental questions):
Hospice-specific supplemental questions can be added immediately after the Core
questions (Q1 – Q40) or at the end of all the CAHPS Hospice Survey questions (Q1 – Q47)
• When supplemental questions are placed in between the Core questions and the “About
Your Family Member” questions, the “ABOUT YOUR FAMILY MEMBER”
heading must still be placed prior to the “About Your Family Member” questions
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Phrases must be added to indicate a transition from the CAHPS Hospice Survey questions
to the hospice-specific supplemental questions, regardless of whether the supplemental
questions are placed between the Core questions and the “About Your Family Member”
questions and/or after the “About You” questions. Examples of transitional phrases are as
follows:
• “Now we would like to gather some additional details on topics we have asked you
about before. These items use a somewhat different way of asking for your response
since they are getting at a slightly different way of thinking about the topics.”
• “The following questions focus on additional care your family member may have
received from [ABC Hospice].”
• “This next set of questions is to provide the hospice additional feedback about your
family member’s hospice care.”
Supplemental questions should be integrated into the CAHPS Hospice Survey and not be
a separate insert
• If the supplemental questions are printed on a separate sheet, then they must be included
as the last page of the materials
Hospice-specific supplemental questions must be identical for both mail wave attempts
Survey vendors must avoid hospice-specific supplemental questions that:
pose a burden to the caregiver (e.g., length and complexity of supplemental questions)
are worded very similarly to the CAHPS Hospice Survey Core questions
may cause the caregiver to terminate the survey (e.g., items that ask about sensitive
medical, health or personal topics)
ask the caregiver to explain why he or she chose a specific response; for example, it is not
acceptable to ask caregivers why they indicated that they would not recommend the hospice
to friends and family
request the use of the caregiver comments and/or responses as testimonials or for marketing
purposes
Note: A hospice cannot use any comments, even if they are anonymous, as testimonials or
for marketing purposes.
The number of supplemental questions added is left to the discretion of the survey vendor (up to
15 hospice-specific supplemental questions). The survey vendor must submit the maximum
number of supplemental survey items included in the survey in the “supplemental-question-count”
element in the Decedent/Caregiver Administrative Record for each survey (see Appendix E).
Each potential supplemental item counts as one question, whether or not the item is phrased
as a sentence or as a question
Each open-ended or free response question counts as one supplemental item
Cover Letters
Survey vendors are strongly encouraged to use the text in the body of the sample cover letters
provided (see Appendices N through V). Survey vendors must follow the guidelines described
below when altering the cover letter templates provided in this manual.
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Required for the Cover Letter
The cover letter must be printed on the hospice’s or survey vendor’s letterhead and must
include the signature of the hospice Administrator or survey vendor Project Director
• An electronic signature is permissible
Use of the Spanish, Chinese, Russian, Portuguese, Vietnamese, Polish, or Korean cover
letter is required if the survey vendor is sending a Spanish, Chinese, Russian, Portuguese,
Vietnamese, Polish, or Korean questionnaire to the caregiver
English must be the default language in the continental U.S. and Spanish must be the
default language in Puerto Rico
The following items must be included in the body of both the initial and follow-up cover
letter:
• Name and address of the sampled caregiver (“To Whom It May Concern” and “To the
caregiver of [Decedent Name]” are not acceptable salutations)
• Name of the decedent
Note: There may be instances in which a decedent and caregiver have the same name.
Quality control activities must be implemented to ensure the names on the cover letter
for the decedent and caregiver are correct.
•
•
•
•
•
•
The text “CMS pays for most of the hospice care in the U.S. It is CMS’ responsibility
to ensure that hospice patients and their family members and friends get high quality
care. One of the ways they can fulfill this responsibility is to find out directly from you
about the hospice care your family member or friend received.”
Language indicating that answers may be shared with the hospice for the purposes of
quality improvement
An explanation that participation in the survey is voluntary
Wording stating that the caregiver’s healthcare or benefits will not be affected whether
or not they participate in the survey
The hospice name, in order to make certain that the caregiver completes the survey
based on the care received from that hospice only
A toll-free customer support telephone number for the survey vendor:
o Customer support must be offered in all languages in which the survey vendor
administers the survey
o Survey vendors must be ready to support calls from the deaf or the hearing impaired
Note: Survey vendors are permitted to revise the toll-free number statement to include
the name of the survey vendor. For example: If you have any questions about the
enclosed survey, please call [SURVEY VENDOR NAME] at the toll-free number 1800-xxx-xxxx.
The OMB Paperwork Reduction Act language (located in Appendices N through V) must
appear on either the questionnaire or cover letter, and may appear on both, in a readable
font (e.g., Arial) at a minimum of 10-point
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Cover letter must not:
• be attached to the survey; doing so could compromise confidentiality
• attempt to bias, influence or encourage caregivers to answer CAHPS Hospice Survey
questions in a particular way
• imply that the hospice, its personnel or its agents will be rewarded or gain benefits if
caregivers answer CAHPS Hospice Survey questions in a particular way
• ask or imply that caregivers should choose certain responses; indicate that the hospice
is hoping for a given response, such as a “10,” “Definitely yes” or an “Always”
• indicate that the hospice’s goal is for all caregivers to rate them as a “10,” “Definitely
yes” or an “Always”
• offer incentives of any kind for participation in the survey
• include any content that attempts to advertise or market the hospice’s mission or
services
• offer caregivers the opportunity to complete the survey over the telephone
• include extraneous titles for caregiver (e.g., Aunt, Uncle)
• include dates (e.g., print date, mail date)
• include any promotional or marketing text
Optional for the Cover Letter
Cover letters may be double sided (English/Spanish, English/Chinese, English/Russian,
English/Portuguese, English/Vietnamese, English/Polish, or English/Korean)
Information may be added to the cover letters that indicates that the caregiver may request
a mail survey in English, Spanish, Chinese, Russian, Portuguese, Vietnamese, Polish, or
Korean
Survey vendor’s return address may be included on the cover letter to make sure the
questionnaire is returned to the correct address in the event that the enclosed return
envelope is misplaced by the caregiver. If the survey vendor’s name is included in the
return address, then the survey vendor’s business name must be used, not an alias or tag
line.
Any instructions that appear on the survey may be repeated in the cover letter
A bereavement customer support number (i.e., hospice bereavement contact number) may
appear on the cover letter
Note: Any variations to the questionnaire and/or cover letters, other than the optional items listed
above, will require an approved Exception Request prior to survey administration (see the
Exception Request Process chapter).
Mailing of Materials
The envelope in which the survey is mailed must be printed with the survey vendor’s address as
the return address. The envelope in which the survey is mailed must not be printed with any
banners such as “Important Information Enclosed”, “Please Reply Immediately” or messages such
as “Important Information from the Centers for Medicare & Medicaid Services Enclosed.” The
envelope should be printed with the survey vendor logo, the hospice logo, or both. In addition,
survey vendors may use window envelopes as a quality measure to ensure that each sampled
caregiver’s survey package is mailed to the address of record for that caregiver.
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Survey vendors must mail materials following the guidelines described below:
Attempts must be made to contact every survey-eligible decedent/caregiver drawn into the
sample, whether or not they have a complete mailing address. Survey vendors must use
commercial software or other means to update addresses provided by the hospice for
sampled decedents/caregivers. Mailings returned as undeliverable and for which no
updated address is available must be coded “10 − Non-response: Bad/No Address.” Survey
vendors must retain a record of attempts made to acquire missing addresses. All materials
relevant to survey administration are subject to review.
• Survey vendors have flexibility in not sending mail surveys to caregivers without
mailing addresses, such as the homeless. However, survey vendors must first make
every reasonable attempt to obtain a caregiver’s address including re-contacting the
hospice client to inquire about an address update for caregivers with no mailing
address. It is permissible for survey vendors to request updated information about
specific decedents/caregivers, rather than requesting a complete updated list. These
decedent/caregiver cases must not be removed or replaced in the sample.
Note: It is strongly recommended that survey vendors check the accuracy of sampled
caregivers’ contact information prior to survey fielding.
A self-addressed, stamped business return envelope must be enclosed in the survey
envelope along with the cover letter and questionnaire. The CAHPS Hospice Survey cannot
be administered without both a cover letter and self-addressed, stamped business return
envelope.
All mailings must be sent to each caregiver by name, and to the caregiver’s most current
address listed in the hospice record or retrieved by other means
For caregivers who request to be sent an additional questionnaire (either after the first or
second mailing), survey vendors must follow the guidelines below:
• It is acceptable to mail a replacement survey at the caregiver’s request within the 42
calendar day survey administration period; however, the survey administration timeline
does not restart
• After 42 calendar days from the first mailing, a replacement CAHPS Hospice Survey
must not be mailed-out, as the data collection timeframe of 42 calendar days after the
first mailing has expired
Hospices and survey vendors are not allowed to:
show or provide the CAHPS Hospice Survey or cover letters to patients or caregivers prior
to the administration of the survey, including while the patient is still under hospice care
mail or distribute any pre-notification letters or postcards after patient death to inform
caregivers about the CAHPS Hospice Survey
Note: In instances where the first wave mail survey is returned with all missing responses (i.e.,
without any questions answered – blank questionnaire), survey vendors must send a second survey
to the caregiver if the data collection time period has not expired. If the second mailing is returned
with all missing responses, then code the “Final Survey Status” as “8 – Non-response: Refusal.”
If the second mailing is not returned, then code the “Final Survey Status” as “9 – Non-response:
Non-response after Maximum Attempts.”
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Note: When the first survey is not returned, and the second survey is subsequently mailed and
returned with all missing responses, then code the “Final Survey Status” as “8 – Non-response:
Refusal.”
It is strongly recommended that all mailings be sent with first class postage or indicia to ensure
delivery in a timely manner and to maximize response rates, as first class mail is more likely to be
opened.
Data Receipt and Retention
Survey vendors may use key-entry or scanning to record returned survey data in their data
collection systems. Returned questionnaires must be tracked by date of receipt and key-entered or
scanned in a timely manner. If a caregiver returns two survey questionnaires, the survey vendor
must use only the first CAHPS Hospice Survey received with responses.
Survey vendors must maintain a crosswalk of their interim disposition codes to the CAHPS
Hospice Survey “Final Survey Status” codes and include the crosswalk in the survey vendor’s
QAP.
Survey vendors must follow the data entry decision rules and data storage requirements described
below.
Key-entry
Survey vendors’ key-entry processes must incorporate the following features:
Unique record verification system: The survey management system performs a check to
verify that the caregiver’s survey responses have not already been entered in the survey
management system
Valid range checks: The data entry system identifies responses/entries that are invalid or
out-of-range
Validation: Survey vendors must have a plan and process in place to verify the accuracy of
key-entered data. Survey vendors must confirm that key-entered data accurately capture
the responses on the original survey. Data from each survey must be key-entered
independently by at least two staff members, and a different staff member (preferably the
data entry supervisor) must reconcile any discrepancies.
Scanning
Survey vendors’ scanning software must accommodate the following:
Unique record verification system: The survey management system performs a check to
confirm that the caregiver’s survey responses have not already been entered in the survey
management system
Valid range checks: The software identifies invalid or out-of-range responses
Validation: Survey vendors must have a plan and process in place to confirm the accuracy
of scanned data. Survey vendors must make certain that scanned data accurately capture
the responses on the original survey. A staff member must reconcile any responses not
recognized by the scanning software.
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Decision Rules
Whether employing scanning or key-entry of mail questionnaires, survey vendors must use the
following decision rules to resolve common ambiguous situations. Survey vendors must follow
these guidelines to ensure standardization of data entry across hospices.
If a mark falls between two response options but is obviously closer to one than the other,
then select the choice to which the mark is closest
If a mark falls equidistant between two response options, then code the value for the item
as “M – Missing/Don't Know”
If a mark is missing, code the value for the item as “M – Missing/Don't Know.” Survey
vendors must not impute a response (see Data Coding and Data File Preparation chapter
for information on coding skip pattern questions).
If a line is drawn through one response option, then select the choice without the line, as
the intent is clear
For other than multi-mark questions, when more than one response option is marked, code
the value as “M – Missing/Don't Know”
Note: In instances where there are multiple marks but the caregiver’s intent is clear, survey
vendors should code the survey with the caregiver’s clearly identified intended response.
For CAHPS Hospice Survey multi-mark questions, the following guidelines should be
followed:
• Question 2, “In what locations did your family member receive care from this hospice?
Please choose one or more.” For Question 2, enter responses for all of the categories
that the respondent has selected.
• Question 43, “What was your family member’s race? Please choose one or more.” For
Question 43, enter responses for all of the categories that the respondent has selected.
Note: The decision on whether to key the responses to open-ended survey items, specifically, the
“Other” in Question 1 (response option 9) and Question 2 (response option 6), and “Some other
language” (response option 9) in Question 47, is up to each survey vendor. Survey vendors must
not include responses to open-ended survey items on the data files submitted to the CAHPS
Hospice Survey Data Warehouse. However, CMS encourages survey vendors to review the openended entries so that they can provide feedback to the CAHPS Hospice Survey Project Team about
adding additional preprinted response options to these survey items, if needed.
Staff Training
Training of personnel on the CAHPS Hospice Survey data collection protocols is key to successful
survey administration. Training of staff must be documented. This documentation must be
available for review upon request by the CAHPS Hospice Survey Project Team. The following
section addresses training provided to:
Project staff
Customer support personnel
Mail data entry personnel
Subcontractors and any other organizations responsible for major survey administration
functions
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Training of Project Staff
At a minimum, the survey vendor’s Project Manager, subcontractors and any other organizations
responsible for major survey administration functions (e.g., mail/telephone operations), if
applicable, must participate in all CAHPS Hospice Survey Training sessions sponsored by CMS.
Individuals who are involved with and work on any aspect of CAHPS Hospice Survey operations
(e.g., account managers, sampling specialists, quality assurance managers, programmers,
information technology staff) must be thoroughly trained by the survey vendor on CAHPS Hospice
Survey protocols and methodology to guarantee standardization of survey administration. Survey
vendors must also provide training to their hospice clients on preparation of the
decedents/caregivers lists.
Survey vendors must establish a process for training new project team members on CAHPS
Hospice Survey administration in a timely fashion. It is strongly recommended that staff members
are cross-trained in all aspects of the CAHPS Hospice Survey administration processes in case of
unforeseen staffing turnover or absence. Back-up staff for CAHPS Hospice Survey administration
responsibilities must be assigned to staff employed by the survey vendor.
Note: Volunteers are not permitted to be involved in any aspect of the CAHPS Hospice Survey
administration process.
Training of Customer Support Personnel
Survey vendors must train customer support personnel in CAHPS Hospice Survey protocols and
methodology to answer questions appropriately. Survey vendors must periodically (at a minimum
on a quarterly basis) assess the reliability and consistency of customer support personnel
responses. In addition, questions posed by surveyed caregivers should be reviewed regularly to
determine if there is a need to develop additional FAQ. All inquiries received and responses
provided through customer support must be documented. This documentation must be available
for review upon request by the CAHPS Hospice Survey Project Team.
Distressed Respondent Procedures:
• Of critical importance is the need for survey vendors to develop a “distressed
respondent protocol” to be incorporated into all interviewer and customer support
personnel training. Handling distressed respondent situations requires a balance
between keeping PII and PHI confidential and helping a person who needs assistance.
For survey research organizations, best interviewing practices recommend having a
distressed respondent protocol in place to balance the respondent’s right to
confidentiality and privacy with the need to provide assistance if the situation indicates
that the respondent’s health and safety are in jeopardy.
• If a respondent requests additional support, the CAHPS Hospice Survey Project Team
recommends that survey vendors’ telephone staff put the respondent in contact with the
appropriate local resource (generally a bereavement counselor or social worker on the
hospice team that provided care to their family member or friend). This potential
bereavement support is part of the services covered under the Medicare Hospice
Benefit.
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Training of Mail Data Entry Personnel
Survey vendors must address the following items when training data entry personnel:
use of data entry equipment and programs
survey specifications and protocols
survey instrument, question flow and skip patterns
data key-entry and/or scanning procedures
validation programs
decision rules/ambiguous responses
Training of Subcontractors and Any Other Organizations Responsible for Major
Survey Administration Functions
Survey vendors are responsible for the training and performance of subcontractors and any other
organizations they use. In addition, during survey administration, survey vendors are responsible
for providing quality oversight and monitoring of their subcontractor’s and/or other organization’s
work to confirm that they are in compliance with CAHPS Hospice Survey guidelines.
Subcontractors and any other organizations that are responsible for major CAHPS Hospice Survey
administration functions (e.g., mail/telephone operations) must attend the CAHPS Hospice Survey
Training.
Note: Survey vendors are responsible for sampling and data submission; and therefore, must not
subcontract these processes.
Quality Control Guidelines
Survey vendors are responsible for the quality of work performed by all staff members,
subcontractors and any other organizations, if applicable. Survey vendors must conduct on-site
verification of printing and mailing processes (strongly recommended on an annual basis, at a
minimum) and document the quality check activities conducted during the visit, regardless of
whether they are using internal staff, subcontractors or any other organizations to perform this
work.
To avoid mail administration errors and to make certain that questionnaires are delivered as
required, survey vendors must:
perform interval checking of printed mailing pieces for:
• fading, smearing and misalignment of printed materials
• appropriate survey contents, accurate address information and proper postage on the
survey sample packet
• assurance that all printed materials in a mailing envelope have the same unique
identifier
• inclusion of all eligible sampled decedents/caregivers in the sample mailing for that
month
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include seeded mailings in the survey mail production runs at minimum on a quarterly basis
• Seeded mailings are sent to designated CAHPS Hospice Survey vendor project staff
(other than the staff producing the materials) to check for timeliness of delivery,
accuracy of addresses, content of the mailing, and quality of the printed materials
o Quality checks of seeded mailing materials must be documented and retained in a
log or database
• Seeded mailings must be integrated into the hospice’s batched survey mailings, not sent
as a stand-alone mailing to CAHPS Hospice Survey vendor project staff
• Physical and/or scanned copies of seeded mailings must be retained for a minimum of
three years
perform address updates for missing or incorrect information
• Attempts must be made to update address information to confirm accuracy and correct
formatting
• It is permissible for survey vendors to request updated information about specific
decedents/caregivers, rather than requesting a complete updated list.
• In addition to working with client hospices to obtain the most current caregiver contact
information, survey vendors must employ other methods, such as the National Change
of Address (NCOA) and the United States Postal Service (USPS) Coding Accuracy
Support System (CASS) Certified Zip+4 software. Other means are also available to
update addresses for accurate mailings, such as:
o commercial software
o internet search engines
Note: If automated processes are being used to perform interval checks, then checks of the system
or equipment must be performed regularly. Survey vendors must retain a record of all quality
control activities and document these activities in the survey vendor’s QAP. All materials relevant
to survey administration are subject to review.
Monitoring and Quality Oversight
Survey vendors must establish a system for providing and documenting quality oversight and
monitoring of the CAHPS Hospice Survey administration and project staff, including
subcontractors and any other organizations. Quality check activities must be performed by a
different staff member than the individual who originally performed the specific project task(s). In
addition, survey vendors must:
Perform and document quality checks of all key events in survey administration including,
but not limited to: sample frame creation; sampling procedures; data receipt; data entry;
data submission; back-up systems; etc.
Perform and document quality checks of electronic programming code periodically, on an
annual basis, at a minimum
Monitor the performance of all staff involved with any aspect of programming, sample
frame creation, sampling, processing of response data (from receipt and handling of
returned surveys, through data entry, validation and edit checking) on an ongoing basis,
including conducting on-site verification of processes (strongly recommended on an annual
basis, at a minimum)
Ensure that staff, subcontractors and any other organizations are compliant with HIPAA
regulations
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Monitor the performance of subcontractors and any other organizations, including
conducting on-site verification of subcontractor processes (strongly recommended on an
annual basis, at a minimum)
Provide performance feedback to all project staff, subcontractors and any other
organizations through regular assessments, including special emphasis placed on the
detection and correction of identified performance problems
The CAHPS Hospice Survey Project Team will conduct site visits to survey vendors, their
subcontractors and any other organizations, if applicable, to review survey vendors’ operations,
monitoring, quality oversight practices, and documentation. As noted earlier, if a survey vendor is
non-compliant with program requirements for any of their contracted hospices, the hospice survey
data may not be reported.
Safeguarding Decedent/Caregiver Confidentiality
Survey vendors must take the following actions to further protect the confidentiality of
decedents/caregivers:
Prevent unauthorized access to confidential electronic and hard copy information by
restricting physical access to confidential data (use locks or password-protected entry
systems on rooms, file cabinets and areas where confidential data are stored)
• Store returned mail paper questionnaires and/or electronically scanned questionnaires
in a secure and environmentally safe location for a minimum of three years
Develop a confidentiality agreement which includes language related to HIPAA
regulations and the protection of PII, and obtain signatures from all personnel with access
to survey information, including staff and subcontractors and any other organizations, if
applicable, involved in survey administration and data collection
Note: Confidentiality agreements must be signed by all personnel upon employment.
Confidentiality agreements must be reviewed and re-signed periodically, at the discretion
of the survey vendor, but not to exceed more than a three-year period. The CAHPS Hospice
Survey Project Team recommends all personnel involved in the CAHPS Hospice Survey
review and re-sign confidentiality agreements on an annual basis.
Execute BAAs in accordance with HIPAA regulations
Confirm that staff, subcontractors and any other organizations, if applicable, are compliant
with HIPAA regulations in regard to decedent/caregiver PHI
Establish protocols for secure file transmission. Emailing of PHI via unsecure email is
prohibited.
Establish protocols for identifying security breaches and instituting corrective actions
Note: It is strongly recommended that the method used by contracted hospices to transmit
information (e.g., decedents/caregivers lists) to the survey vendor be reviewed by the hospice’s
HIPAA/Privacy Officer to confirm compliance with HIPAA regulations. Any materials (e.g., QAP,
questionnaires, cover letters, tracking forms) submitted by the survey vendor to the CAHPS
Hospice Survey Project Team must be blank templates and must not contain any
decedent/caregiver PHI.
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Survey vendors must have physical plant resources available to handle the volume of surveys being
administered, in addition to systematic processes that effectively track sampled
decedents’/caregivers’ progress through the data collection protocol and caregivers’ responses to
the survey. System resources are subject to oversight activities including site visits to physical
locations.
Data Security
Survey vendors must securely store caregiver identifying electronic data and responses to the
survey. Survey vendors must take the following actions to secure the data:
Use a firewall and/or other mechanisms for preventing unauthorized access to the
electronic files
Implement access levels and security passwords so that only authorized users have access
to sensitive data
Implement daily data back-up procedures that adequately safeguard system data
Test back-up files at a minimum on a quarterly basis to make sure the files are easily
retrievable and working
Perform frequent saves to media to minimize data losses in the event of power interruption
Develop a disaster recovery plan for conducting ongoing business operations in the event
of a disaster. The plan must be made available to the CAHPS Hospice Survey Project Team
upon request.
Data Retention and Storage
Survey vendors must store all CAHPS Hospice Survey files and survey administration related
data in a secure and environmentally controlled location for a minimum of three years, and it
must be easily retrievable, when needed.
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Overview
This chapter describes the guidelines for the Telephone Only mode of CAHPS Hospice Survey
administration.
Data collection for sampled decedents/caregivers must be initiated two months following the
month of patient death. Data collection may be completed by telephone only. Outbound calling
must be scheduled in a manner to ensure all cases have a first attempt within seven calendar days
of the start of the field period.
If survey administration is not initiated within the first seven days, surveys may be administered
by the survey vendor from the eighth to the tenth of the month without requesting prior approval
from CMS. In this situation, a Discrepancy Report must be submitted to notify CMS of the late
survey administration. In addition, the survey vendor must keep documentation regarding why the
survey was administered late. After the tenth of the month, approval must be requested from CMS
before the survey can be administered and a Discrepancy Report must be submitted if survey
administration begins late or does not occur for any month.
Note: If the survey vendor learns that a sampled decedent/caregiver is ineligible for the CAHPS
Hospice Survey, the survey vendor must not make further attempts to contact that caregiver. After
the sample has been drawn, any decedents/caregivers who are found to be ineligible must not be
removed or replaced in the sample. Instead, these decedents/caregivers are assigned the “Final
Survey Status” code of ineligible (2, 3, 4, 5, 6, or 14, as applicable). A Decedent/Caregiver
Administrative Record must be submitted for these decedents/caregivers. See the Data Coding and
Data File Preparation chapter for more information on assigning the “Final Survey Status” codes.
Data collection must be closed out for a sampled caregiver by six weeks (42 calendar days)
following the first call attempt. If it is known that the caregiver may be available in the latter part
of the 42 calendar day data collection time period (e.g., caregiver is on vacation the first two or
three weeks of the 42 calendar day field period and there would be an opportunity to reach the
caregiver closer to the end of the field period), then survey vendors must reserve some of the
allowable call attempts for the part of the field period for which the caregiver is available.
Telephone call attempts are to be made between the hours of 9 AM and 9 PM respondent time.
Caregivers who receive the CAHPS Hospice Survey must not be offered incentives of any kind.
Caregivers who do not respond to the survey are assigned a “Final Survey Status” code of nonresponse (7, 8, 9, 10, 11, 12, 13, or 15, as applicable).
Survey vendors must include the “number-survey-attempts-telephone” field in the
Decedent/Caregiver Administrative Record. This field is required when “survey-mode” in the
Hospice Record is “2 – Telephone Only.” This field captures the telephone attempt in which the
final disposition of the survey is determined. More information regarding the coding of the survey
attempts field is presented in the Data Coding and Data File Preparation chapter.
Survey vendors must make every reasonable effort to achieve optimal survey response rates and
to pursue contact with potential respondents until the data collection protocol is completed.
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The basic tasks and timing for conducting the CAHPS Hospice Survey using the Telephone Only
mode of survey administration are summarized below.
Activity
Initiate systematic telephone contact with
sampled caregivers
Complete telephone data collection
Submit data files to the CAHPS Hospice
Survey Data Warehouse by the data
submission deadline. No files will be accepted
after the submission deadline date.
Timing
Two months after the month of patient death
within the first seven calendar days of the
field period
Within six weeks (42 calendar days) after the
first attempt
See the quarterly data submission deadlines
in the Introduction and Overview chapter
To reiterate, the first telephone attempt must occur two months after the month of patient death
within the first seven calendar days of the field period. Data collection must then be completed no
later than six weeks (42 calendar days) after the initial telephone attempt. To illustrate the timing
of the attempts, the following example is provided of a patient who died on April 1 while in hospice
care.
Example:
The first telephone attempt is made on July 1 (two months after the month of patient’s
death and within the first seven calendar days of the field period)
Data collection must be closed out by August 12 for this caregiver, which is six weeks (42
calendar days) from the July 1 first telephone attempt date:
• If a telephone interview is completed on or before August 12, which is the last day of
the survey administration time period for this caregiver, then the survey data are
included in the final survey data file and assigned a “Final Survey Status” code of
either “1 – Completed Survey” or “7 – Non-response: Break-off” based on the
calculation of percent complete as described in the Data Coding and Data File
Preparation chapter
o If the survey is mistakenly completed after August 12 (August 13, for
example), which is beyond the six weeks (42 calendar days) survey
administration time period for this caregiver, then the survey data are not
included in the final survey data file (however, a Decedent/Caregiver
Administrative Record is submitted for this caregiver) and a “Final Survey
Status” code of “9 − Non-response: Non-response after Maximum Attempts”
is assigned (Please note, this would also require a Discrepancy Report to be
submitted.)
Survey vendors must make every reasonable effort to achieve optimal telephone response rates by
thoroughly familiarizing interviewers with the study purpose, carefully supervising interviewers,
retraining those interviewers having difficulty enlisting cooperation, and re-contacting reluctant
respondents at different times until the final data collection protocol is completed.
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Telephone Interviewing Systems
Telephone Script
Telephone data collection is permitted in English, Spanish, and Russian. English must be the
default language in the continental U.S. and Spanish must be the default language in Puerto Rico.
Survey vendors are provided standardized telephone scripts in English, Spanish, and Russian
(Appendices W, X, and Y) for CAHPS Hospice Survey administration. These telephone scripts
must be read verbatim without adding any other scripting or tag questions, such as “How are you?”
Survey vendors are not permitted to make or use any other language translations of the CAHPS
Hospice Survey telephone scripts. We strongly encourage hospices with a significant caregiver
population that speaks Spanish or Russian to offer the CAHPS Hospice Survey in these languages.
We encourage hospices that serve patient populations that speak languages other than those noted
to request CMS to create an official translation of the CAHPS Hospice Survey in those languages.
Each survey vendor must submit a copy of its CAHPS Hospice Survey telephone script and
interviewer CATI screenshots (including skip pattern logic) by the specified due date for review
by the CAHPS Hospice Survey Project Team. The due date for survey vendors to submit samples
of their CAHPS Hospice Survey telephone materials will be announced during the CAHPS
Hospice Survey Training session and posted on the CAHPS Hospice Survey Web site
(www.hospicecahpssurvey.org).
Required for the Telephone Script
The CAHPS Hospice Survey Core questions (Q1 – Q40) must be placed at the beginning of the
survey. The order of the Core questions must not be altered and all the Core questions must remain
together. The “About Your Family Member” and “About You” questions must be placed after the
Core questions and cannot be eliminated from the questionnaire. The “About You” questions must
follow the “About Your Family Member” questions.
Programming of the telephone scripts must follow the guidelines described below:
Question and answer category wording must not be changed
No changes are permitted in the order of the Core questions (Q1 – Q40)
No changes are permitted in the order of the “About Your Family Member” questions
No changes are permitted in the order of the “About You” questions
No changes are permitted in the order of the answer categories for the Core, “About Your
Family Member” or “About You” questions
All underlined content must be emphasized
• No other script content is to be emphasized; in particular, response options must be
read at the same even pace without any additional emphasis on any particular response
category
Note: It is not permissible to substitute capital letters for the text underlined in the
telephone script, as text that appears in uppercase letters throughout the CATI script must
not be read out loud. Survey vendors are permitted to indicate emphasis of underlined text
in a different manner if their CATI system does not permit underlining, such as placing
quotes (“”) or asterisks (**) around the text to be emphasized or italicizing the emphasized
words.
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All punctuation for the question and answer categories located in Appendices W and X
must be programmed
Only one language (English, Spanish, or Russian) may appear on the electronic
interviewing system screen
The survey vendor is responsible for programming the script(s) and specifications into their
electronic telephone interviewing system software
• The transitional statements found throughout the telephone script are part of the
structured script and must be read. An example of a transitional phrase that must be
read can be found before Question 39 (Q39 Intro): “Please answer the following
questions about your family member’s care from [ABC Hospice]. Do not include care
from other hospices in your answers.”
• Do not program a specific response category as the default option
• All probes located throughout the telephone script must be included on the CATI screen
Survey vendors must have a process in place to address caregivers’ requests to verify the survey
legitimacy or to answer questions about the survey.
Supplemental Questions
Survey vendors may add up to 15 hospice-specific supplemental questions to the CAHPS Hospice
Survey following the guidelines described below (see Appendix M for examples of acceptable
supplemental questions):
Hospice-specific supplemental questions can be added immediately after the CAHPS
Hospice Survey Core questions (Q1 – Q40) or at the end of all the CAHPS Hospice Survey
questions (Q1 – Q47)
Phrases must be added to indicate a transition from the CAHPS Hospice Survey questions
to the hospice-specific supplemental questions, regardless of whether the supplemental
questions are placed between the Core questions and the “About Your Family Member”
questions and/or after the “About You” questions. Examples of transitional phrases are as
follows:
• “Now we would like to gather some additional details on topics we have asked you
about before. These items use a somewhat different way of asking for your response
since they are getting at a slightly different way of thinking about the topics.”
• “The following questions focus on additional care your family member may have
received from [ABC Hospice].”
• “This next set of questions is to provide the hospice additional feedback about your
family member’s hospice care.”
Survey vendors must avoid hospice-specific supplemental questions that:
pose a burden to the respondent (e.g., number, length and complexity of supplemental
questions)
are worded very similarly to the CAHPS Hospice Survey Core questions
may cause the caregiver to terminate the survey (e.g., items that ask about sensitive
medical, health or personal topics)
ask the caregiver to explain why he or she chose a specific response; for example, it is not
acceptable to ask caregivers why they indicated that they would not recommend the hospice
to friends and family
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request the use of the caregiver comments and/or responses as testimonials or for marketing
purposes
Note: A hospice cannot use any comments, even if they are anonymous, as testimonials or
for marketing purposes.
The number of supplemental questions added is left to the discretion of the survey vendor (up to
15 hospice-specific supplemental questions). The survey vendor must submit the maximum
number of supplemental survey items included in the survey in the “supplemental-question-count”
element in the Decedent/Caregiver Administrative Record for each survey (see Appendix E).
Each potential supplemental item counts as one question, whether or not the item is phrased
as a sentence or as a question
Each open-ended or free response question counts as one supplemental item
Interviewing Systems
Telephone data collection must be conducted using CATI and live interviewers. The CATI system
employed by survey vendors must be electronically linked to their survey management system to
enable responses obtained from the electronic telephone interviewing system to be automatically
added to the survey management system. Paper surveys administered by telephone and the use of
touch-tone or speech-enabled interactive voice response (IVR) are not acceptable. An electronic
telephone interviewing system uses standardized scripts and design specifications. The survey
vendor is responsible for programming the scripts and specifications into their electronic telephone
interviewing software. Regardless of caregiver response, the interviewer must record all responses
from the telephone interview.
Survey administration must be conducted in accordance with the Telephone Consumer
Protection Act (TCPA) regulations
• Cell phone numbers must be identified so that CATI systems with auto dialers do not
call cell phone numbers without the permission of the respondent. Survey vendors may
identify cell phone numbers through a commercial database and hospices may identify
cell phone numbers upon patient admission.
• Predictive dialing may be used as long as there is a live interviewer to interact with the
caregiver, and the system is compliant with Federal Trade Commission (FTC) and
Federal Communications Commission (FCC) regulations
Survey vendors may program the caller ID to display “on behalf of [HOSPICE NAME],”
with the permission and compliance of the hospice’s HIPAA/Privacy Officer. Survey
vendors must not program the caller ID to display only “[HOSPICE NAME].”
Monitoring/Recording Telephone Calls
Survey vendors must be aware of and follow applicable state regulations when monitoring and/or
recording telephone attempts, including those that permit monitoring/recording of telephone calls
only after the interviewer states, “This call may be monitored [and/or recorded] for quality
improvement purposes.” This statement is found at the end of the INTRO section of the CAHPS
Hospice Survey Telephone Script located in Appendices W, X, and Y.
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Telephone Attempts
Survey vendors must attempt to reach each and every caregiver in the sample. Telephone call
attempts are to be made between the hours of 9 AM and 9 PM respondent time. Repeated attempts
must be made until the caregiver is contacted, found ineligible or five attempts have been made.
After five attempts to contact the caregiver have been made, no further attempts are to be made. A
telephone attempt is defined as one of the following:
The telephone rings six times with no answer
The interviewer reaches a wrong number
An answering machine/voicemail is reached. In this case the interviewer must not leave a
message.
The interviewer reaches a household member and is told that the caregiver is not available
to come to the telephone or has a new telephone number. The interviewer must not leave a
message.
The interviewer reaches the caregiver and is asked to call back at a more convenient time
• The call back must be scheduled at the caregiver’s convenience, if at all possible. When
requested, survey vendors must schedule a telephone call back that accommodates a
caregiver’s request for a specific day and time (i.e., between the hours of 9 AM and 9
PM respondent time within the 42 calendar day data collection period). If survey
vendors schedule a specific time to call back the caregiver, then an attempt to reach the
caregiver must be made at the scheduled time.
The interviewer gets a busy signal
• At the discretion of the survey vendor a single telephone attempt can consist of three
consecutive busy signals obtained at approximately 20-minute intervals
The interviewer reaches a disconnected number
If, during a telephone attempt, the sampled caregiver indicates that someone within the household
is more knowledgeable about the hospice care that the decedent received, the more knowledgeable
person may be a proxy respondent. If a sampled caregiver indicates that he or she never oversaw,
was not involved in, or is not knowledgeable about the hospice care provided to the decedent,
interviewers may ask if someone else in the household is knowledgeable about the decedent’s
hospice care. If such a person exists, he or she may be a proxy respondent. Interviewers must not
accept individuals outside of the sampled caregiver’s household as proxy respondents. Should no
knowledgeable individual be identified within the household, the decedent/caregiver case must be
coded as ineligible using code “6 – Ineligible: Never Involved in Decedent Care.”
Sampled caregivers are to be called up to five times unless the sampled caregiver (or an eligible
proxy caregiver) completes the survey, is found to be ineligible or explicitly refuses to complete
the survey (or if someone refuses on behalf of the caregiver).
If the survey vendor learns that a decedent/caregiver is ineligible for the CAHPS Hospice
Survey, the caregiver must not receive any further telephone attempts
If the caregiver does not speak the language(s) in which the survey vendor administers the
survey, the interviewer must thank the caregiver for his or her time and terminate the
interview
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Survey vendors must adhere to the following guidelines in their attempts to contact caregivers:
Telephone attempts are made at various times of the day, on different days of the week and
in different weeks to maximize the probability that the survey vendor will contact the
caregiver
Note: More than one telephone attempt may be made in a week (seven calendar days).
However, the five telephone attempts cannot be made in just one week (seven calendar
days). The five call attempts must span more than one week (eight or more days) and it is
strongly recommended that call attempts also include weekends, to account for caregivers
who are temporarily unavailable.
Confirm the identity of the caregiver using the full name provided in the
decedents/caregivers list prior to disclosing any identifiable information (e.g., decedent
name)
Caregivers who call back after an initial contact can be scheduled for an interview or
forwarded to an available interviewer
Interviewers must not leave messages on answering machines or with household members,
since this could violate a caregiver’s privacy. Survey vendors must instead attempt to recontact the caregiver to complete the CAHPS Hospice Survey.
When a caregiver requests to complete a telephone survey already in progress at a later
date, a call back should be scheduled. At the time of the call back, the interview should
resume with the next question where the caregiver left off from the previous call.
If on the fifth attempt, the caregiver requests to schedule an appointment to complete the
survey, it is permissible to schedule that appointment and call the caregiver back provided
that the appointment is within the 42 calendar day data collection time period. If on the call
back at the scheduled time, no connection is made with the caregiver, then no further
contact may be attempted. This additional (sixth) call attempt would be coded as “5 – Fifth
Telephone Attempt” in “number-survey-attempts-telephone” for data submission.
Note: The call back must be scheduled at the caregiver’s convenience, if at all possible.
When requested, survey vendors must schedule a telephone call back that accommodates
a caregiver’s request for a specific day and time (i.e., between the hours of 9 AM and 9
PM respondent time within the 42 calendar day data collection period), in order to ensure
a reasonable response rate for the hospice.
Survey vendors must take the following steps to contact difficult-to-reach caregivers:
If the caregiver’s telephone number is incorrect, make every effort to find the correct
telephone number. If the person answering the telephone knows how to reach the caregiver,
the new information must be used.
If the caregiver is away temporarily, he or she must be contacted upon return, provided that
it is within the data collection time period. If it is known that the caregiver may be available
in the latter part of the 42 calendar day data collection time period (e.g., caregiver is on
vacation the first two or three weeks of the 42 calendar day data collection time period and
there would be an opportunity to reach the caregiver closer to the end of the data collection
time period), then survey vendors must reserve some of the allowable call attempts for the
part of the field period for which the caregiver is available.
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If the call is inadvertently dropped and the interview is interrupted, the caregiver should be
re-contacted immediately to complete the remainder of the survey. This re-contact does not
constitute an additional call attempt.
If the interviewer reaches a healthcare facility staff member, the interviewer must request
to get in touch with the sampled caregiver. Inform the healthcare facility staff member that
the survey is part of a national initiative sponsored by the United States Department of
Health and Human Services. The results of the survey will help hospices understand what
they are doing well and what needs improvement.
If the staff member indicates that the caregiver is unable to complete the survey (e.g., due
to mental or physical incapacity), the interviewer should thank the staff member and code
the attempt appropriately.
Note: Caregivers, if otherwise eligible, residing in healthcare facilities such as an assisted
living facility, long-term care facility or nursing home are to be included in the CAHPS
Hospice Survey sample frame and attempts to contact the caregiver to administer the
survey must be made to those decedents/caregivers drawn into the sample.
Note: Healthcare facility telephone numbers cannot be placed on the survey vendor’s donot-call list, even if requested by the healthcare facility staff.
If the interviewer reaches a number that appears to be a business, the interviewer must
request to speak to the caregiver.
• If asked who is calling, the interviewer should respond by providing their name and the
survey vendor’s name
• If asked what they are calling about, the interviewer should respond by stating they are
working with the hospice and the U.S. Department of Health and Human Services to
conduct a survey about hospice care
• If speaking with the caregiver who states they are at work and cannot speak, the
interviewer should attempt to reschedule the call for a time that is more convenient for
the caregiver, or obtain an alternate phone number at which to reach the caregiver
Obtaining and Updating Telephone Numbers
Survey vendors normally obtain telephone numbers from the hospice’s records. Survey vendors
must use commercial software or other means to update telephone numbers provided by the
hospice for sampled caregivers when they have been determined to be missing or incorrect.
Requisite attempts must be made to contact every eligible caregiver in the sample, whether or not
there is a complete and correct telephone number for the caregiver when the sample is created.
Survey vendors must retain a record of attempts to acquire missing telephone numbers. All
materials relevant to survey administration are subject to review.
Survey vendors must attempt to obtain updated telephone numbers through commercial locating
services, internet or other means. To obtain the most current caregiver contact information, survey
vendors must employ various methods for updating telephone numbers:
Running update program software against the sample file just before or after uploading
data to survey management systems
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Utilizing commercial software, internet directories and/or directory assistance
Contacting the hospice to request updated telephone numbers. If contacting the hospice to
request updated contact information, it is permissible for survey vendors to request updated
information about specific decedents/caregivers, rather than requesting a complete updated
list.
Note: It is strongly recommended that survey vendors check the accuracy of sampled
caregivers’ contact information prior to survey fielding.
Data Receipt and Retention
Survey vendors must record the date of the telephone interview and must link survey responses
from the telephone interview to their survey management system, regardless of the interviewing
system employed. Survey vendors must maintain a crosswalk of their interim disposition codes to
the CAHPS Hospice Survey “Final Survey Status” codes and include the crosswalk in the survey
vendor’s QAP.
Data Storage
Survey vendors must retain all CAHPS Hospice Survey files and survey administration related
data collected through an electronic telephone interviewing system in a secure and
environmentally controlled location for a minimum of three years, and it must be easily retrievable,
when needed.
Quality Control Guidelines
Survey vendors are responsible for the quality of work performed by all staff members,
subcontractors and any other organizations, if applicable. Survey vendors must employ the
following guidelines for proper interviewer training, monitoring and oversight regardless of
whether they are using internal staff, subcontractors or any other organizations to perform this
work.
Interviewer Training
Properly trained and consistently monitored interviewers ensure that standardized, non-directive
interviews are conducted. Interviewers conducting the telephone survey must be trained prior to
interviewing (see Appendices F and G for more information on interviewing guidelines).
Interviewers must be trained to:
read questions exactly as worded in the script, use non-directive probes and maintain a
neutral and professional relationship with the caregiver
• During the course of the survey, use of neutral acknowledgment words such as the
following is permitted:
o Thank you
o Alright
o Okay
o I understand, or I see
o Yes, Ma’am
o Yes, Sir
read the script from the telephone screens (reciting the survey from memory can lead to
unnecessary errors and missed updates to the scripts)
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read response options exactly as worded and at an even pace without emphasis on any
particular response category
record responses to survey questions only after the caregiver has responded to the
questions; that is, interviewers must not pre-code response choices
understand the definition of each disposition code and appropriately assign interim or final
call disposition codes, when applicable
redirect calls to another interviewer when the decedent or caregiver is personally or
professionally known to the initial interviewer
adjust the pace of the CAHPS Hospice Survey interview to be conducive to the needs of
the caregiver
Distressed Respondent Procedures:
• Of critical importance is the need for survey vendors to develop a “distressed
respondent protocol,” to be incorporated into all interviewer and customer support
personnel training. Handling distressed respondent situations requires a balance
between keeping PII and PHI confidential and helping a person who needs assistance.
For survey research organizations, best interviewing practices recommend having a
distressed respondent protocol in place to balance the respondent’s right to
confidentiality and privacy with the need to provide assistance if the situation indicates
that the respondent’s health and safety are in jeopardy.
• If a respondent requests additional support, the CAHPS Hospice Survey Project Team
recommends that survey vendors’ telephone staff put the respondent in contact with the
appropriate local resource (generally a bereavement counselor or social worker on the
hospice team that provided care to their family member or friend). This potential
bereavement support is part of the services covered under the Medicare Hospice
Benefit.
Note: If a survey vendor uses a subcontractor(s) or any other organization(s) to conduct telephone
interviewing, then the survey vendor is responsible for attending/participating in the
subcontractor’s or other organization’s telephone interviewer training to confirm compliance with
CAHPS Hospice Survey protocols and guidelines. Survey vendors must conduct on-site
verification of subcontractor’s interviewing processes (strongly recommended on an annual basis,
at a minimum).
Telephone Monitoring and Oversight
Each survey vendor employing the Telephone Only mode of survey administration must institute
a telephone monitoring and evaluation program. Telephone monitoring is not to be conducted from
a residence. The telephone monitoring and evaluation program must include, but is not limited to,
the following oversight activities:
Survey vendors must monitor at least 10 percent of all CAHPS Hospice Survey interviews,
interviewer survey response coding, dispositions, and call attempts in their entirety
(English, Spanish, and Russian) through silent monitoring of interviewers using the
electronic telephone interviewing system software or an alternative system. Silent
monitoring capability must include the ability to monitor calls on-site and from remote
locations. All staff conducting CAHPS Hospice Survey interviews must be included in the
monitoring. Additionally, it is required that survey vendors provide “floor rounding” in
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their call-center(s) to visually observe and ensure the professionalism of the telephone
interviewers.
Survey vendors using a subcontractor(s) or any other organization(s) must monitor at least
10 percent of the subcontractor’s or other organization’s CAHPS Hospice Survey
telephone interviews, interviewer survey response coding, dispositions, and call attempts
in their entirety (English, Spanish, and Russian), provide feedback to the subcontractor’s
or other organization’s interviewers about their performance, and confirm that the
subcontractor’s or other organization’s interviewers correct any areas that need
improvement. Feedback must be provided to interviewers as soon as possible following a
monitoring session.
Note: In addition to the survey vendor’s monitoring of 10 percent of its subcontractors’ or
other organizations’ interviews, the CAHPS Hospice Survey Project Team also expects
that a survey vendor’s subcontractor(s) or other organization(s) will conduct internal
monitoring of their telephone interviewers as a matter of good business practice. While it
is preferred that each organization continue to monitor 10 percent of CAHPS Hospice
Survey interviews (for an overall total of 20 percent), it is permissible for the survey vendor
and its subcontractor(s) or other organization(s) to conduct a combined total of at least 10
percent monitoring, as long as each organization conducts a portion of the monitoring.
Therefore, the survey vendor, its subcontractor(s) and other organization(s) can determine
the ratio of monitoring that each organization conducts, as long as the combined total
meets or exceeds 10 percent. Please note that CAHPS Hospice Survey interviews
monitored concurrently by the survey vendor and its subcontractor(s) and other
organization(s) do not contribute separately to each organization’s monitoring time.
Interviewers who are found to be consistently unable to follow the script verbatim, employ
proper probes, remain objective and courteous, be clearly understood, or operate the
electronic telephone interviewing system competently must be identified and retrained or,
if necessary, replaced
In organizations where interviewers assign interim or final disposition codes, the
assignment of codes must be reviewed by a supervisor
Survey vendors must retain a record of all quality control activities and document these activities
in the survey vendor’s QAP. All materials relevant to survey administration are subject to review.
Safeguarding Decedent/Caregiver Confidentiality
Survey vendors must take the following actions to further protect the confidentiality of
decedents/caregivers:
Prevent unauthorized access to confidential electronic and hard copy information by
restricting physical access to confidential data (use locks or password-protected entry
systems on rooms, file cabinets and areas where confidential data are stored)
Develop a confidentiality agreement which includes language related to HIPAA
regulations and the protection of PII, and obtain signatures from all personnel with access
to survey information, including staff and subcontractors and any other organizations, if
applicable, involved in survey administration and data collection
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Note: Confidentiality agreements must be signed by all personnel upon employment.
Confidentiality agreements must be reviewed and re-signed periodically, at the discretion
of the survey vendor, but not to exceed more than a three-year period. The CAHPS Hospice
Survey Project Team recommends all personnel involved in the CAHPS Hospice Survey
review and re-sign confidentiality agreements on an annual basis.
Execute BAAs in accordance with HIPAA regulations
Confirm that staff, subcontractors and any other organizations, if applicable, are compliant
with HIPAA regulations in regard to decedent/caregiver PHI
Establish protocols for secure file transmission. Emailing of PHI via unsecure email is
prohibited.
Establish protocols for identifying security breaches and instituting corrective actions
Note: It is strongly recommended that the method used by contracted hospices to transmit
information (e.g., decedents/caregivers lists) to the survey vendor be reviewed by the hospice’s
HIPAA/Privacy Officer to confirm compliance with HIPAA regulations. Any materials (e.g., QAP,
questionnaires, cover letters, tracking forms) submitted by the survey vendor to the CAHPS
Hospice Survey Project Team must be blank templates and must not contain any
decedent/caregiver PHI.
Survey vendors must have physical plant resources available to handle the volume of surveys being
administered, in addition to systematic processes that effectively track sampled caregivers’
progress through the data collection protocol and caregivers’ responses to the survey. System
resources are subject to oversight activities including site visits to physical locations.
Data Security
Survey vendors must securely store caregiver identifying electronic data and responses to the
survey. Survey vendors must take the following actions to secure the data:
Use a firewall and/or other mechanisms for preventing unauthorized access to the
electronic files
Implement access levels and security passwords so that only authorized users have access
to sensitive data
Implement daily data back-up procedures that adequately safeguard system data
Test back-up files at a minimum on a quarterly basis to make sure the files are easily
retrievable and working
Perform frequent saves to media to minimize data losses in the event of power interruption
Develop a disaster recovery plan for conducting ongoing business operations in the event
of a disaster. The plan must be made available to the CAHPS Hospice Survey Project Team
upon request.
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VIII. Mixed Mode Survey Administration
Overview
This chapter describes the guidelines for the Mixed Mode of the CAHPS Hospice Survey
administration, which is a combination of an initial mailing of the questionnaire with telephone
follow-up.
Data collection for sampled decedents/caregivers must be initiated two months following the
month of patient death within the first seven calendar days of the field period. Survey vendors
must send sampled caregivers a questionnaire with a cover letter within the first seven calendar
days of the field period, then conduct a maximum of five telephone attempts to non-respondents
beginning approximately 21 calendar days after mailing the questionnaire.
If survey administration is not initiated within the first seven days, surveys may be administered
by the survey vendor from the eighth to the tenth of the month without requesting prior approval
from CMS. In this situation, a Discrepancy Report must be submitted to notify CMS of the late
survey administration. In addition, the survey vendor must keep documentation regarding why the
survey was administered late. After the tenth of the month, approval must be requested from CMS
before the survey can be administered and a Discrepancy Report must be submitted if survey
administration begins late or does not occur for any month.
Note: Reversing the protocol (telephone attempts followed by mail attempt) is not allowed.
Note: If the survey vendor learns that a sampled decedent/caregiver is ineligible for the CAHPS
Hospice Survey, no further attempts can be made to contact that caregiver. After the sample has
been drawn, any decedents/caregivers who are found to be ineligible must not be removed or
replaced in the sample. Instead, these decedents/caregivers are assigned a “Final Survey Status”
code of ineligible (2, 3, 4, 5, 6, or 14, as applicable). A Decedent/Caregiver Administrative Record
must be submitted for these decedents/caregivers. See the Data Coding and Data File Preparation
chapter for more information on assigning the “Final Survey Status” codes.
Data collection must be closed out for a sampled caregiver by six weeks (42 calendar days)
following the mailing of the questionnaire (initial contact). If the caregiver did not return a mail
survey and it is known that the caregiver may be available in the latter part of the 21 calendar day
telephone component of the field period, and there would be an opportunity to reach the caregiver
closer to the end of the telephone component of the field period, then survey vendors must use the
entire 21 calendar day telephone component field period to schedule telephone calls. Telephone
call attempts are to be made between the hours of 9 AM and 9 PM, respondent time. Caregivers
who receive the CAHPS Hospice Survey must not be offered incentives of any kind. Caregivers
who do not respond to the survey are assigned a “Final Survey Status” code of non-response (7, 8,
9, 10, 11, 12, 13, or 15, as applicable).
Note: Should a caregiver call the toll-free number to do the interview by telephone, they cannot
complete the interview prior to the start of the telephone follow-up window and should be
scheduled for a call back during the telephone data collection time period.
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Survey vendors must include the “number-survey-attempts-telephone” field in the
Decedent/Caregiver Administrative Record. This field is required when “survey-mode” in the
Hospice Record is “3 – Mixed Mode” and “survey-completion-mode” is “2 – Mixed Modephone.” If the survey is completed/dispositioned during the telephone phase of the Mixed Mode,
the “number-survey-attempts-telephone” captures the telephone attempt in which the final
disposition of the survey is determined. More information regarding the survey attempts field is
presented in the Data Coding and Data File Preparation chapter.
Survey vendors must make every reasonable effort to achieve optimal survey response rates and
to pursue contact with potential respondents until the data collection protocol is completed.
The basic tasks and timing for conducting the CAHPS Hospice Survey using the Mixed Mode of
survey administration are summarized below.
Activity
Send mail questionnaire with cover letter to
sampled caregiver
Initiate systematic telephone contact for all
non-respondents to the survey mailing
Complete data collection
Submit data files to the CAHPS Hospice
Survey Data Warehouse by the data
submission deadline. No files will be accepted
after the submission deadline date.
Timing
Two months after the month of patient death
within the first seven calendar days of the
field period
Approximately 21 calendar days after
mailing of the questionnaire. The first
telephone attempt must be made in the first
seven days of the telephone field period (i.e.,
from 21 to 28 calendar days after mailing the
questionnaire).
Over the next 21 calendar days and within
six weeks (42 calendar days) after the initial
mailing
See the quarterly data submission deadlines
in the Introduction and Overview chapter
To reiterate, the mailing of the survey must occur two months after the month of patient death
within the first seven calendar days of the field period. Data collection then must be completed no
later than six weeks (42 calendar days) after the mailing of the questionnaire. The first telephone
attempt must be made in the first seven days of the telephone field period (i.e., from 21 to 28
calendar days after mailing the questionnaire). If the mail questionnaire is received during the
telephone field period, telephone attempts must cease.
To illustrate the timing of survey mailing and telephone follow-up, the following example is
provided of a patient who died on April 30 while in hospice care.
Example:
The survey is mailed out on July 1 (two months after patient’s death)
If the caregiver has not returned the survey by July 22 (21 days after the initial mailing on
July 1) telephone contact must be initiated
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Example:
Data collection must be closed out on August 12 for this caregiver, which is six weeks (42
calendar days) from the July 1 initial mailing date:
• If a telephone interview is completed on or before August 12, which is the last day of
the survey administration time period for this caregiver, then the survey data are included
in the final survey data file and assigned a “Final Survey Status” code of either “1 –
Completed Survey” or “7 – Non-response: Break-off” based on the calculation of percent
complete as described in the Data Coding and Data File Preparation chapter
• If the survey is mistakenly completed after August 12 (August 13, for example), which
is beyond the six weeks (42 calendar days) survey administration time period for this
caregiver, then the survey data are not included in the final survey data file (however, a
Decedent/Caregiver Administrative Record is submitted for this caregiver) and a
“Final Survey Status” code of “9 − Non-response: Non-response after Maximum
Attempts” is assigned (Please note, this would also require a Discrepancy Report to be
submitted.)
Mail Protocol
This section describes the guidelines for the mail phase of the Mixed Mode of survey
administration.
Production of Questionnaire and Related Materials
The mail phase of the Mixed Mode of survey administration can be conducted in English and
Spanish. Survey vendors are provided with the CAHPS Hospice Survey questionnaires and cover
letters in English, Spanish, and Russian (Appendices N, O, and R). Survey vendors are not
permitted to make or use any other translations of the CAHPS Hospice Survey cover letter or
questionnaire. We strongly encourage hospices with a significant caregiver population that speaks
Spanish or Russian to offer the CAHPS Hospice Survey in those languages. We encourage
hospices that serve patient populations that speak languages other than those noted to request CMS
to create an official translation of the CAHPS Hospice Survey in those languages.
Each survey vendor must submit a sample of their CAHPS Hospice Survey mailing materials (i.e.,
questionnaires, cover letters and outgoing envelopes) by the specified due date for review by the
CAHPS Hospice Survey Project Team. The due date for survey vendors to submit samples of their
CAHPS Hospice Survey mailing materials will be announced during the CAHPS Hospice Survey
Training session and posted on the CAHPS Hospice Survey Web site
(www.hospicecahpssurvey.org).
Mailings must include a personalized cover letter, a questionnaire and a business reply envelope.
The cover letters may be sent in English, Spanish, and Russian and may be two-sided, English on
one side and Spanish or Russian on the other. Cover letters sent to respondents must be
personalized with the name of the decedent, caregiver and hospice. The letter must also provide a
toll-free number for respondents to call if they have questions. The cover of the questionnaire must
include the name of the hospice, and if applicable, may include the specific hospice inpatient unit,
acute care hospital or nursing home facility in which their family member or friend resided.
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For CAHPS Hospice Survey administration, the OMB Paperwork Reduction Act language must
appear in the mailing, either on the front of the cover letter or on the front or back of the
questionnaire in a font size of 10-point or larger. The OMB language cannot be printed on a
separate piece of paper. In addition, the OMB control number (OMB#0938-1257) and expiration
date (Expires December 31, 2020) must appear on the front page of the questionnaire.
To increase the likelihood that the respondent is the person within the sampled caregiver’s
household who is most knowledgeable about the decedent’s hospice care, language must be
included in the questionnaire, and optionally in the cover letter, clearly stating that the survey
should be given to the person in the household who knows the most about the hospice care received
by the decedent.
Required for the Mail Questionnaire
The CAHPS Hospice Survey Core questions (Q1 – Q40) must be placed at the beginning of the
survey. The order of the Core questions must not be altered and all the Core questions must remain
together. The “About Your Family Member” and “About You” questions must be placed after the
Core questions and cannot be eliminated from the questionnaire. The “About You” questions must
follow the “About Your Family Member” questions.
Survey vendors must adhere to the following specifications for the production of mail materials:
Question and answer category wording must not be changed
No changes are permitted in the order of the Core questions (Q1 – Q40)
No changes are permitted in the order of the “About Your Family Member” questions
No changes are permitted in the order of the “About You” questions
No changes are permitted in the order of the response categories for the Core, “About Your
Family Member” or “About You” questions
Each question and answer categories must remain together in the same column and on the
same page
Response options must be listed vertically (see examples in Appendices N and O).
Response options that are listed horizontally or in a combined vertical and horizontal
format are not allowed. No matrix formats are permitted for question and answer
categories.
Dates are not permitted to be included on the questionnaire or the cover letters (e.g., print
date, mail date)
Formatting
Wording that is bolded or underlined in the questionnaire provided in the CAHPS Hospice
Survey Quality Assurance Guidelines manual must be emphasized in the same manner in
the survey vendor’s questionnaire
Arrow (i.e., ) placement in the questionnaire instructions and answer categories that
specifies skip patterns must not be changed
Section headings (e.g., “YOUR FAMILY MEMBER’S HOSPICE CARE”) must be
included on the questionnaire and must be bolded and capitalized, including the “SURVEY
INSTRUCTIONS” heading
Response options on the questionnaire may be incorporated as circles, ovals or squares
with no mixing of the characters within the questionnaire
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Survey materials must be in a readable font (e.g., Arial) in a font size of 10-point or larger
Other Requirements
All survey content, including headers, instructions, questions, and answer categories, must
be printed verbatim and in the same order as shown on the questionnaires provided by CMS
Randomly generated, unique identifiers must be placed on the first or last page of the
questionnaire, at a minimum. Survey vendors may add other identifiers on the
questionnaire for tracking purposes (e.g., unit identifiers).
Neither the decedent’s nor the caregiver’s name may be printed on the questionnaire
The text indicating the purpose of the unique identifier (“You may notice a number on the
survey. This number is used to let us know if you returned your survey so we do not have
to send you reminders.”) must be printed either immediately after the survey instructions
on the questionnaire or on the cover letter, and may appear on both
The survey vendor’s return address must be printed on the last page of the questionnaire to
make sure that the questionnaire is returned to the correct address in the event that the
enclosed return envelope is misplaced by the caregiver
If the survey vendor’s name is included in the return address, then the survey vendor’s
business name must be used, not an alias or tag line
Optional for the Mail Questionnaire
Survey vendors have some flexibility in formatting the CAHPS Hospice Survey questionnaire by
following the guidelines described below:
Small coding numbers, preferably in superscript, may be included next to the response
choices on the questionnaire
Hospice logos may be included on the questionnaire; however, other images and tag lines
are not permitted
The phrase “Use only blue or black ink” may be printed on the questionnaire
The name of the hospice may be printed on the questionnaire in Questions 2, 4 and 39, as
indicated below
• Question 2 – “In what locations did your family member receive care from [ABC
Hospice]?”
• Question 4 – “As you answer the rest of the questions in this survey, please think only
about your family member’s experience with [ABC Hospice].”
• Question 39 – “Please answer the following questions about your family member’s care
from [ABC Hospice]. Do not include care from other hospices in your answers.”
Page numbers may be included on the questionnaire
Color may be incorporated in the questionnaire
Language such as one of the following may be added to the bottom of each page of the
survey:
• Continue on next page
• Continue on reverse side
• Turn over to continue
• to continue
• Continue on back
• Turn over
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Survey vendors should consider incorporating the following recommendations in formatting the
CAHPS Hospice Survey questionnaire to increase the likelihood of receiving a returned survey:
Two-column format that is used in Appendices N, O, and R
Wide margins (at least 3/4 inch) so that the survey has sufficient white space to enhance
its readability
Supplemental Questions
Survey vendors may add up to 15 hospice-specific supplemental questions to the CAHPS Hospice
Survey following the guidelines described below (see Appendix M for examples of acceptable
supplemental questions):
For Mixed Mode, the same survey questions added to the mail survey for a given hospice
must be added to the telephone CATI script
Hospice-specific supplemental questions can be added immediately after the Core
questions (Q1 – Q40) or at the end of all the CAHPS Hospice Survey questions (Q1 – Q47)
• When supplemental questions are placed in between the Core questions and the “About
Your Family Member” questions, the “ABOUT YOUR FAMILY MEMBER”
heading must still be placed prior to the “About Your Family Member” questions
Phrases must be added to indicate a transition from the CAHPS Hospice Survey questions
to the hospice-specific supplemental questions, regardless of whether the supplemental
questions are placed between the Core questions and the “About Your Family Member”
questions and/or after the “About You” questions. Examples of transitional phrases are as
follows:
• “Now we would like to gather some additional details on topics we have asked you
about before. These items use a somewhat different way of asking for your response
since they are getting at a slightly different way of thinking about the topics.”
• “The following questions focus on additional care your family member may have
received from [ABC Hospice].”
• “This next set of questions is to provide the hospice additional feedback about your
family member’s hospice care.”
Supplemental questions should be integrated into the CAHPS Hospice Survey and not be
a separate insert
• If the supplemental questions are printed on a separate sheet, then they must be included
as the last page of the materials
Survey vendors must avoid hospice-specific supplemental questions that:
pose a burden to the caregiver (e.g., length, and complexity of supplemental questions)
are worded very similarly to the CAHPS Hospice Survey Core questions
may cause the caregiver to terminate the survey (e.g., items that ask about sensitive
medical, health or personal topics)
ask the caregiver to explain why he or she chose a specific response; for example, it is not
acceptable to ask caregivers why they indicated that they would not recommend the hospice
to friends and family
request the use of the caregiver comments and/or responses as testimonials or for marketing
purposes
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Note: A hospice cannot use any comments, even if they are anonymous, as testimonials or for
marketing purposes.
The number of supplemental questions added is left to the discretion of the survey vendor (up to
15 hospice-specific supplemental questions). The survey vendor must submit the maximum
number of supplemental survey items included in the survey in the “supplemental-question-count”
element in the Decedent/Caregiver Administrative Record for each survey (see Appendix E).
Each potential supplemental item counts as one question, whether or not the item is phrased
as a sentence or as a question
Each open-ended or free response question counts as one supplemental item
Cover Letter
Survey vendors are strongly encouraged to use the text in the body of the sample initial cover letter
(see Appendices N, O, and R). Survey vendors must follow the guidelines described below when
altering the cover letter templates provided in this manual.
Required for the Cover Letter
The cover letter must be printed on the hospice’s or survey vendor’s letterhead and must
include the signature of the hospice Administrator or survey vendor Project Director
• An electronic signature is permissible
Use of the Spanish cover letter is required if the survey vendor is sending a Spanish
questionnaire and a Russian cover letter is required if the survey vendor is sending a
Russian questionnaire to the caregiver
English must be the default language in the continental U.S. and Spanish must be the
default language in Puerto Rico
The following items must be included in the body of the cover letter:
• Name and address of the sampled caregiver (“To Whom It May Concern” and “To the
caregiver of [Decedent Name]” are not acceptable salutations)
• Name of the decedent
Note: There may be instances in which a decedent and caregiver have the same name.
Quality control activities must be implemented to ensure the names on the cover letter
for the decedent and caregiver are correct.
•
•
•
•
•
The text “CMS pays for most of the hospice care in the U.S. It is CMS’ responsibility
to ensure that hospice patients and their family members and friends get high quality
care. One of the ways they can fulfill this responsibility is to find out directly from you
about the hospice care your family member or friend received.”
Language indicating that answers may be shared with the hospice for the purposes of
quality improvement
An explanation that participation in the survey is voluntary
Wording stating that the caregiver’s healthcare or benefits will not be affected whether
or not they participate in the survey
The hospice name, in order to make certain that the caregiver completes the survey
based on the care received from that hospice only
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A toll-free customer support telephone number for the survey vendor:
o Customer support must be offered in all languages in which the survey vendor
administers the survey
o Survey vendors must be ready to support calls from the deaf or the hearing impaired
Note: Survey vendors are permitted to revise the toll-free number statement to include
the name of the survey vendor. For example: If you have any questions about the
enclosed survey, please call [SURVEY VENDOR NAME] at the toll-free number 1800-xxx-xxxx.
The OMB Paperwork Reduction Act language (located in Appendices N, O, and R) must
appear on either the questionnaire or cover letter, and may appear on both, in a readable
font (e.g., Arial) at a minimum of 10-point
Cover letter must not:
• be attached to the survey; doing so could compromise confidentiality
• attempt to bias, influence or encourage caregivers to answer CAHPS Hospice Survey
questions in a particular way
• imply that the hospice, its personnel or its agents will be rewarded or gain benefits if
caregivers answer CAHPS Hospice Survey questions in a particular way
• ask or imply that caregivers should choose certain responses; indicate that the hospice
is hoping for a given response, such as a “10,” “Definitely yes” or an “Always”
• indicate that the hospice’s goal is for all caregivers to rate them as a “10,” “Definitely
yes” or an “Always”
• offer incentives of any kind for participation in the survey
• include any content that attempts to advertise or market the hospice’s mission or
services
• offer caregivers the opportunity to complete the survey over the telephone
• include extraneous titles for caregiver (e.g., Aunt, Uncle)
• include dates (e.g., print date, mail date)
• include any promotional or marketing text
Optional for the Cover Letter
Cover letters may be double sided (English on one side and Spanish or Russian on the
other)
Information may be added to the English cover letter (in English, Spanish, or Russian) that
indicates that the caregiver may request a mail survey in Spanish or Russian
Survey vendor’s return address may be included on the cover letter to make sure that the
questionnaire is returned to the correct address in the event that the enclosed return
envelope is misplaced by the caregiver. If the survey vendor’s name is included in the
return address, then the survey vendor’s business name must be used, not an alias or tag
line.
Any instructions that appear on the survey may be repeated in the cover letter
A bereavement customer support number (i.e., hospice bereavement contact number) may
appear on the cover letter
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Note: Any variations to the questionnaire and/or cover letter, other than the optional items listed
above, will require an approved Exception Request prior to survey administration (see the
Exception Request Process chapter).
Mailing of Materials
The envelope in which the survey is mailed must be printed with the survey vendor’s address as
the return address. The envelope in which the survey is mailed must not be printed with any
banners such as “Important Information Enclosed,” “Please Reply Immediately” or messages such
as “Important Information from the Centers for Medicare & Medicaid Services Enclosed.” The
envelope should be printed with the survey vendor logo, the hospice logo, or both. In addition,
survey vendors may use window envelopes as a quality measure to ensure that each sampled
caregiver’s survey package is mailed to the address of record for that caregiver.
Survey vendors must mail materials following the guidelines described below:
Attempts must be made to contact every survey-eligible decedent/caregiver drawn into the
sample, whether or not they have a complete mailing address. Survey vendors must use
commercial software or other means to update addresses provided by the hospice for
sampled decedents/caregivers. (Mailings returned as undeliverable and for which no
updated address is available must be sent to the telephone portion of Mixed Mode.) Survey
vendors must retain a record of attempts made to acquire missing addresses. All materials
relevant to survey administration are subject to review.
• Survey vendors have flexibility in not sending mail surveys to caregivers without
mailing addresses, such as the homeless. However, survey vendors must first make
every reasonable attempt to obtain a caregiver’s address including re-contacting the
hospice client to inquire about an address update for caregivers with no mailing
address. If contacting the hospice to request updated contact information, it is
permissible for survey vendors to request updated information about specific
decedents/caregivers, rather than requesting a complete updated list. These
decedent/caregiver cases must not be removed or replaced in the sample.
Note: It is strongly recommended that survey vendors check the accuracy of sampled
caregivers’ contact information prior to survey fielding.
A self-addressed, stamped business return envelope must be enclosed in the survey
envelope along with the cover letter and questionnaire. The CAHPS Hospice Survey cannot
be administered without both a cover letter and self-addressed, stamped business return
envelope.
All mailings must be sent to each caregiver by name, and to the caregiver’s most current
address listed in the hospice record or retrieved by other means
For caregivers who request to be sent an additional questionnaire, survey vendors must
follow the guidelines below:
• It is acceptable to mail a replacement survey at the caregiver’s request within the first
21 calendar days of the 42 calendar day survey administration period; however, the
survey administration timeline does not restart
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After 21 calendar days from the mailing, a replacement CAHPS Hospice Survey must
not be mailed-out, as the telephone portion of the Mixed Mode protocol must be
initiated
Hospices and survey vendors are not allowed to:
show or provide the CAHPS Hospice Survey or cover letters to patients or caregivers prior
to the administration of the survey, including while the patient is still under hospice care
mail or distribute any pre-notification letters or postcards after patient death to inform
caregivers about the CAHPS Hospice Survey
Note: In instances where returned mail surveys have all missing responses (i.e., without any
questions answered – blank questionnaire), initiate telephone contact after 21 days of mailing the
questionnaire.
It is strongly recommended that the mailing be sent with first class postage or indicia to ensure
delivery in a timely manner and to maximize response rates, as first class mail is more likely to be
opened.
Data Receipt and Retention of Mailed Questionnaires
Survey vendors utilizing the Mixed Mode of survey administration must keep track of the mode
in which each survey was completed (i.e., mail or telephone). If a caregiver returned the CAHPS
Hospice Survey mail questionnaire with enough of the questions applicable to all (ATA)
decedents/caregivers answered for the survey to be considered a completed survey (based on the
calculation of percent complete; for more information see the Data Coding and Data File
Preparation chapter), then the survey vendor must: 1.) retain documentation in their survey
management system that the caregiver completed the survey in the mail phase of the Mixed Mode
of survey administration; and, 2.) assign the appropriate “Survey Completion Mode” in the
administrative record for this decedent/caregiver (see the Data Coding and Data File Preparation
chapter for more information).
Survey vendors may use key-entry or scanning to record returned survey data in their data
collection systems. Returned questionnaires must be tracked by date of receipt and key-entered or
scanned in a timely manner. If a caregiver completes the CAHPS Hospice Survey via the telephone
and a questionnaire is subsequently returned by the caregiver, the survey vendor must use the
telephone CAHPS Hospice Survey responses since they were completed first.
Survey vendors must maintain a crosswalk of their interim disposition codes to the CAHPS
Hospice Survey “Final Survey Status” codes and include the crosswalk in the survey vendor’s
QAP.
Survey vendors must follow the data entry decision rules and data storage requirements described
below.
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Key-entry
Survey vendors’ key-entry processes must incorporate the following features:
Unique record verification system: The survey management system performs a check to
verify that the caregiver’s survey responses have not already been entered in the survey
management system
Valid range checks: The data entry system identifies responses/entries that are invalid or
out-of-range
Validation: Survey vendors must have a plan and process in place to verify the accuracy of
key-entered data. Survey vendors must confirm that key-entered data accurately capture
the responses on the original survey. Data from each survey must be key-entered
independently by at least two staff members, and a different staff member (preferably the
data entry supervisor) must reconcile any discrepancies.
Scanning
Survey vendors’ scanning software must accommodate the following:
Unique record verification system: The survey management system performs a check to
confirm that the caregiver’s survey responses have not already been entered in the survey
management system
Valid range checks: The software identifies invalid or out-of-range responses
Validation: Survey vendors must have a plan and process in place to confirm the accuracy
of scanned data. Survey vendors must make certain that scanned data accurately capture
the responses on the original survey. A staff member must reconcile any responses not
recognized by the scanning software.
Decision Rules for Mail Data
Whether employing scanning or key-entry of mail questionnaires, survey vendors must use the
following decision rules to resolve common ambiguous situations. Survey vendors must follow
these guidelines to ensure standardization of data entry across hospices.
If a mark falls between two response options but is obviously closer to one than the other,
then select the choice to which the mark is closest
If a mark falls equidistant between two response options, then code the value for the item
as “M – Missing/Don’t Know”
If a mark is missing, code the value for the item as “M – Missing/Don’t Know.” Survey
vendors must not impute a response (see Data Coding and Data File Preparation chapter
for information on coding skip pattern questions).
If a line is drawn through one response option, then select the choice without the line, as
the intent is clear
For other than multi-mark questions, when more than one response option is marked, code
the value as “M – Missing/Don’t Know”
Note: In instances where there are multiple marks but the caregiver’s intent is clear, survey
vendors should code the survey with the caregiver’s clearly identified intended response.
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For CAHPS Hospice Survey multi-mark questions, the following guidelines should be
followed:
• Question 2, “In what locations did your family member receive care from this hospice?
Please choose one or more.” For Question 2, enter responses for all of the categories
that the respondent has selected.
• Question 43, “What was your family member’s race? Please choose one or more.” For
Question 43, enter responses for all of the categories that the respondent has selected.
Note: The decision on whether to key the responses to open-ended survey items, specifically, the
“Other” in Question 1 (response option 9) and Question 2 (response option 6), and “Some other
language” (response option 9) in Question 47, is up to each survey vendor. Survey vendors must
not include responses to open-ended survey items on the data files submitted to the CAHPS
Hospice Survey Data Warehouse. However, CMS encourages survey vendors to review the openended entries so that they can provide feedback to the CAHPS Hospice Survey Project Team about
adding additional preprinted response options to these survey items, if needed.
Storage of Mail Data
Survey vendors must store returned paper questionnaires or scanned images of paper
questionnaires in a secure and environmentally controlled location for a minimum of three years.
Paper questionnaires or scanned images must be easily retrievable.
Quality Control Guidelines for Mail Data
Survey vendors are responsible for the quality of work performed by all staff members,
subcontractors and any other organizations, if applicable. Survey vendors must conduct on-site
verification of printing and mailing processes (strongly recommended on an annual basis, at a
minimum) and document the quality check activities conducted during the visit, regardless of
whether they are using internal staff, subcontractors or any other organizations to perform this
work.
To avoid mail administration errors and to make certain that questionnaires are delivered as
required, survey vendors must:
perform interval checking of printed mailing pieces for:
• fading, smearing and misalignment of printed materials
• appropriate survey contents, accurate address information and proper postage on the
survey sample packet
• assurance that all printed materials in a mailing envelope have the same unique
identifier
• inclusion of all eligible sampled decedents/caregivers in the sample mailing for that
month
include seeded mailings in the survey mail production runs at minimum on a quarterly basis
• Seeded mailings are sent to designated CAHPS Hospice Survey vendor project staff
(other than the staff producing the materials) to check for timeliness of delivery,
accuracy of addresses, content of the mailing, and quality of the printed materials
o Quality checks of seeded mailing materials must be documented and retained in a
log or database
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•
Seeded mailings must be integrated into the hospice’s batched survey mailings, not sent
as a stand-alone mailing to CAHPS Hospice Survey vendor project staff
• Physical and/or scanned copies of seeded mailings must be retained for a minimum of
three years
perform address updates for missing or incorrect information
• Attempts must be made to update address information to confirm accuracy and correct
formatting
• If contacting a hospice to request updated contact information, the survey vendor must
ask for updates for all records, not individual decedent/caregiver cases
• In addition to working with client hospices to obtain the most current caregiver contact
information, survey vendors must employ other methods, such as the NCOA and the
USPS CASS Certified Zip+4 software. Other means are also available to update
addresses for accurate mailings, such as:
o commercial software
o internet search engines
Note: If automated processes are being used to perform interval checks, then checks of the system
or equipment must be performed regularly. Survey vendors must retain a record of all quality
control activities and document these activities in the survey vendor’s QAP. All materials relevant
to survey administration are subject to review.
Telephone Protocol
If the mail questionnaire has not been returned within 21 calendar days following the mailing to
sampled caregivers, survey vendors must follow the CAHPS Hospice Survey telephone survey
protocol. This section describes guidelines for the telephone phase of the Mixed Mode of survey
administration. Survey vendors must conduct a maximum of five telephone attempts to nonrespondents from the questionnaire mailing. The first telephone attempt must be made in the first
seven days of the telephone field period (i.e., from 21 to 28 calendar days after mailing the
questionnaire).
Survey vendors should make every reasonable effort to achieve optimal telephone response rates,
such as thoroughly familiarizing interviewers with the study purpose, carefully supervising
interviewers, retraining those interviewers having difficulty enlisting cooperation, and recontacting reluctant respondents at different times until the data collection protocol is completed.
Telephone Interviewing Systems
Telephone Script
Telephone data collection is permitted in English, Spanish, and Russian. English must be the
default language in the continental U.S. and Spanish must be the default language in Puerto Rico.
Survey vendors are provided standardized telephone scripts in English, Spanish, and Russian
(Appendices W, X, and Y) for CAHPS Hospice Survey administration. These telephone scripts
must be read verbatim without adding any other scripting or tag questions, such as “How are you?”
Survey vendors are not permitted to make or use any other language translations of the CAHPS
Hospice Survey telephone scripts. We strongly encourage hospices with a significant caregiver
population that speaks Spanish or Russian to offer the CAHPS Hospice Survey in this language.
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We encourage hospices that serve patient populations that speak languages other than those noted
to request CMS to create an official translation of the CAHPS Hospice Survey in those languages.
Each survey vendor must submit a copy of its CAHPS Hospice Survey telephone script and
interviewer CATI screenshots (including skip pattern logic) by the specified due date for review
by the CAHPS Hospice Survey Project Team. The due date for survey vendors to submit samples
of their CAHPS Hospice Survey telephone materials will be announced during the CAHPS
Hospice Survey Training session and posted on the CAHPS Hospice Survey Web site
(www.hospicecahpssurvey.org).
Required for the Telephone Script
The CAHPS Hospice Survey Core questions (Q1 – Q40) must be placed at the beginning of the
survey. The order of the Core questions must not be altered and all the Core questions must remain
together. The “About Your Family Member” and “About You” questions must be placed after the
Core questions and cannot be eliminated from the questionnaire. The “About You” questions must
follow the “About Your Family Member” questions.
Programming of the telephone scripts must follow the guidelines described below:
Question and answer category wording must not be changed
No changes are permitted in the order of the Core questions (Q1 – Q40)
No changes are permitted in the order of the “About Your Family Member” questions
No changes are permitted in the order of the “About You” questions
No changes are permitted in the order of the answer categories for the Core, “About Your
Family Member” or “About You” questions
All underlined content must be emphasized
• No other script content is to be emphasized; in particular, response options must be
read at the same even pace without any additional emphasis on any particular response
category
Note: It is not permissible to substitute capital letters for the text underlined in the
telephone script, as text that appears in uppercase letters throughout the CATI script must
not be read out loud. Survey vendors are permitted to indicate emphasis of underlined text
in a different manner if their CATI system does not permit underlining, such as placing
quotes (“”) or asterisks (**) around the text to be emphasized, or italicizing the
emphasized words.
All punctuation for the question and answer categories located in Appendices W, X, and Y
must be programmed
Only one language (English, Spanish, or Russian) may appear on the electronic
interviewing system screen
The survey vendor is responsible for programming the script(s) and specifications into their
electronic telephone interviewing system software
• The transitional statements found throughout the telephone script are part of the
structured script and must be read. An example of a transitional phrase that must be
read can be found before Question 39 (Q39 Intro): “Please answer the following
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questions about your family member’s care from [ABC Hospice]. Do not include care
from other hospices in your answers.”
Do not program a specific response category as the default option
All probes located throughout the telephone script must be included on the CATI screen
Survey vendors must have a process in place to address caregivers’ requests to verify the survey
legitimacy or to answer questions about the survey.
Supplemental Questions
Survey vendors may add up to 15 hospice-specific supplemental questions to the CAHPS Hospice
Survey, following the guidelines described below (see Appendix M for examples of acceptable
supplemental questions):
For Mixed Mode, the same supplemental questions added to the mail survey for a given
hospice must be added to the telephone CATI script
Hospice-specific supplemental questions can be added immediately after the CAHPS
Hospice Survey Core questions (Q1 – Q40) or at the end of all the CAHPS Hospice Survey
questions (Q1 – Q47)
Phrases must be added to indicate a transition from the CAHPS Hospice Survey questions
to the hospice-specific supplemental questions, regardless of whether the supplemental
questions are placed between the Core questions and the “About Your Family Member”
questions and/or after the “About You” questions. Examples of transitional phrases are as
follows:
• “Now we would like to gather some additional details on topics we have asked you
about before. These items use a somewhat different way of asking for your response
since they are getting at a slightly different way of thinking about the topics.”
• “The following questions focus on additional care your family member may have
received from [ABC Hospice].”
• “This next set of questions is to provide the hospice additional feedback about your
family member’s hospice care.”
Survey vendors must avoid hospice-specific supplemental questions that:
pose a burden to the respondent (e.g., number, length, and complexity of supplemental
questions)
are worded very similarly to the CAHPS Hospice Survey Core questions
may cause the caregiver to terminate the survey (e.g., items that ask about sensitive
medical, health or personal topics)
ask the caregiver to explain why he or she chose a specific response; for example, it is not
acceptable to ask caregivers why they indicated that they would not recommend the hospice
to friends and family
request the use of the caregiver comments and/or responses as testimonials or for marketing
purposes
Note: A hospice cannot use any comments, even if they are anonymous, as testimonials or
for marketing purposes.
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The number of supplemental questions added is left to the discretion of the survey vendor (up to
15 hospice-specific supplemental questions). The survey vendor must submit the maximum
number of supplemental survey items included in the survey in the “supplemental-question-count”
element in the Decedent/Caregiver Administrative Record for each survey (see Appendix E).
Each potential supplemental item counts as one question, whether or not the item is phrased
as a sentence or as a question
Each open-ended or free response question counts as one supplemental item
Interviewing Systems
Telephone data collection must be conducted using CATI and live interviewers. The CATI system
employed by survey vendors must be electronically linked to their survey management system to
enable responses obtained from the electronic telephone interviewing system to be automatically
added to the survey management system. Paper surveys administered by telephone and the use of
touch-tone or speech-enabled IVR are not acceptable. An electronic telephone interviewing system
uses standardized scripts and design specifications. The survey vendor is responsible for
programming the scripts and specifications into their electronic telephone interviewing software.
Regardless of caregiver response, the interviewer must record all responses from the telephone
interview.
Survey administration must be conducted in accordance with the TCPA regulations
• Cell phone numbers must be identified so that CATI systems with auto dialers do not
call cell phone numbers without the permission of the respondent. Survey vendors may
identify cell phone numbers through a commercial database and hospices may identify
cell phone numbers upon patient admission.
• Predictive dialing may be used as long as there is a live interviewer to interact with the
caregiver, and the system is compliant with FTC and FCC regulations.
Survey vendors may program the caller ID to display “on behalf of [HOSPICE NAME],”
with the permission and compliance of the hospice’s HIPAA/Privacy Officer. Survey
vendors must not program the caller ID to display only “[HOSPICE NAME].”
Monitoring/Recording Telephone Calls
Survey vendors must be aware of and follow applicable state regulations when monitoring and/or
recording telephone attempts, including those that permit monitoring/recording of telephone calls
only after the interviewer states, “This call may be monitored [and/or recorded] for quality
improvement purposes.” This statement is found at the end of the INTRO section of the CAHPS
Hospice Survey Telephone Script located in Appendices W, X, and Y.
Telephone Attempts
Survey vendors must attempt to reach each and every non-respondent to the mail survey.
Telephone call attempts are to be made between the hours of 9 AM and 9 PM respondent time.
Repeated attempts must be made until the caregiver is contacted, found ineligible or five attempts
have been made. After five attempts to contact the caregiver have been made, no further attempts
are to be made. A telephone attempt is defined as one of the following:
The telephone rings six times with no answer
The interviewer reaches a wrong number
An answering machine/voicemail is reached. In this case the interviewer must not leave a
message.
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The interviewer reaches a household member and is told that the caregiver is not available
to come to the telephone or has a new telephone number. The interviewer must not leave a
message.
The interviewer reaches the caregiver and is asked to call back at a more convenient time
• The call back must be scheduled at the caregiver’s convenience, if at all possible. When
requested, survey vendors must schedule a telephone call back that accommodates a
caregiver’s request for a specific day and time (i.e., between the hours of 9 AM and 9
PM respondent time within the 42 calendar day data collection period). If survey
vendors schedule a specific time to call back the caregiver, then an attempt to reach the
caregiver must be made at the scheduled time.
The interviewer gets a busy signal
• At the discretion of the survey vendor a single telephone attempt can consist of three
consecutive busy signals obtained at approximately 20-minute intervals
The interviewer reaches a disconnected number
If, during a telephone attempt, the sampled caregiver indicates that someone within the household
is more knowledgeable about the hospice care that the decedent received, the more knowledgeable
person may be a proxy respondent. If a sampled caregiver indicates that he or she never oversaw,
was not involved in, or is not knowledgeable about the hospice care provided to the decedent,
interviewers may ask if someone else in the household is knowledgeable about the decedent’s
hospice care. If such a person exists, he or she may be a proxy respondent. Interviewers must not
accept individuals outside of the sampled caregiver’s household as proxy respondents. Should no
knowledgeable individual be identified within the household, the decedent/caregiver case must be
coded as ineligible using code “6 – Ineligible: Never Involved in Decedent Care.”
Sampled caregivers are to be called up to five times unless the sampled caregiver (or an eligible
proxy caregiver) completes the survey, is found to be ineligible or explicitly refuses to complete
the survey (or if someone refuses on behalf of the caregiver).
If the survey vendor learns that a decedent/caregiver is ineligible for the CAHPS Hospice
Survey, the caregiver must not receive any further telephone attempts
If the caregiver does not speak the language(s) in which the survey vendor administers the
survey, the interviewer must thank the caregiver for his or her time and terminate the
interview
If the caregiver’s mail survey is received by the survey vendor after calling begins, the
caregiver must not receive any further telephone attempts
Survey vendors must adhere to the following guidelines in their attempts to contact caregivers:
Telephone attempts are made at various times of the day, on different days of the week and
in different weeks to maximize the probability that the survey vendor will contact the
caregiver
Note: More than one telephone attempt may be made in a week (seven calendar days).
However, the five telephone attempts cannot be made in just one week (seven calendar
days). The five call attempts must span more than one week (eight or more days) and it is
strongly recommended that call attempts also include weekends, to account for caregivers
who are temporarily unavailable.
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Confirm the identity of the caregiver using the full name provided in the
decedents/caregivers list prior to disclosing any identifiable information (e.g., decedent
name)
Caregivers who call back after an initial contact can be scheduled for an interview or
forwarded to an available interviewer
Interviewers must not leave messages on answering machines or with household members,
since this could violate a caregiver’s privacy. Survey vendors must instead attempt to recontact the caregiver to complete the CAHPS Hospice Survey.
When a caregiver requests to complete a telephone survey already in progress at a later
date, a call back should be scheduled. At the time of the call back, the interview should
resume with the next question where the caregiver left off from the previous call.
If on the fifth attempt, the caregiver requests to schedule an appointment to complete the
survey, it is permissible to schedule that appointment and call the caregiver back provided
that the appointment is within the 42 calendar day data collection time period. If on the call
back at the scheduled time, no connection is made with the caregiver, then no further
contact may be attempted. This additional (sixth) call attempt would be coded as “5 – Fifth
Telephone Attempt” in “number-survey-attempts-telephone” for data submission.
Note: The CAHPS Hospice Survey Project Team strongly recommends that, when
requested, telephone call back scheduling accommodate a caregiver’s request for a
specific day and time in order to ensure a reasonable response rate for the hospice.
Survey vendors must take the following steps to contact difficult-to-reach caregivers:
If the caregiver’s telephone number is incorrect, make every effort to find the correct
telephone number. If the person answering the telephone knows how to reach the caregiver,
the new information must be used.
If the caregiver is away temporarily, he or she must be contacted upon return, provided that
it is within the data collection time period. If it is known that the caregiver may be available
in the latter part of the 21 calendar day telephone data collection time period (e.g., caregiver
is on vacation the first two weeks of the 21 calendar day telephone component of the data
collection time period and there would be an opportunity to reach the caregiver closer to
the end of the data collection time period), then survey vendors must reserve some of the
allowable calls for the part of the field period for which the caregiver is available.
If the call is inadvertently dropped and the interview is interrupted, the caregiver should be
re-contacted immediately to complete the remainder of the survey. This re-contact does not
constitute an additional call attempt.
If the interviewer reaches a healthcare facility staff member, the interviewer must request
to get in touch with the sampled caregiver. Inform the healthcare facility staff member that
the survey is part of a national initiative sponsored by the United States Department of
Health and Human Services. The results of the survey will help hospices understand what
they are doing well and what needs improvement.
If the staff member indicates that the caregiver is unable to complete the survey (e.g., due
to mental or physical incapacity), the interviewer should thank the staff member and code
the attempt appropriately.
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Note: Caregivers, if otherwise eligible, residing in healthcare facilities such as an assisted
living facility, long-term care facility or nursing home are to be included in the CAHPS
Hospice Survey sample frame and attempts to contact the caregiver to administer the
survey must be made to those decedents/caregivers drawn into the sample.
Note: Healthcare facility telephone numbers cannot be placed on the survey vendor’s donot-call list, even if requested by the healthcare facility staff.
If the interviewer reaches a number that appears to be a business, the interviewer must
request to speak to the caregiver.
• If asked who is calling, the interviewer should respond by providing their name and the
survey vendor’s name
• If asked what they are calling about, the interviewer should respond by stating they are
working with the hospice and the U.S. Department of Health and Human Services to
conduct a survey about hospice care
• If speaking with the caregiver who states they are at work and cannot speak, the
interviewer should attempt to reschedule the call for a time that is more convenient for
the caregiver, or obtain an alternate phone number at which to reach the caregiver
Obtaining and Updating Telephone Numbers
Survey vendors normally obtain telephone numbers from the hospice’s records. Survey vendors
must use commercial software or other means to update telephone numbers provided by the
hospice for sampled caregivers when they have been determined to be missing or incorrect.
Requisite attempts must be made to contact every non-respondent to the mail survey, whether or
not there is a complete and correct telephone number for the caregiver when the sample is created.
Survey vendors must retain a record of attempts to acquire missing telephone numbers. All
materials relevant to survey administration are subject to review.
Survey vendors must attempt to obtain updated telephone numbers through commercial locating
services, internet or other means. To obtain the most current caregiver contact information, survey
vendors must employ various methods for updating telephone numbers:
Running update program software against the sample file just before or after uploading
data to survey management systems
Utilizing commercial software, internet directories and/or directory assistance
Contacting the hospice to request updated telephone numbers. If contacting the hospice to
request updated contact information, the survey vendor must ask for updates for all records,
not individual decedent/caregiver cases.
Note: It is strongly recommended that survey vendors check the accuracy of sampled
caregivers’ contact information prior to survey fielding.
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Receipt and Retention of Telephone Data
Survey vendors utilizing the Mixed Mode of survey administration must keep track of the mode
in which the survey was completed (i.e., mail or telephone). If a caregiver completed the CAHPS
Hospice Survey by telephone with enough of the questions ATA decedents/caregivers answered
for the survey to be considered a completed survey (based on the calculation of percent complete;
for more information see the Data Coding and Data File Preparation chapter), then the survey
vendor must:
retain documentation in their survey management system that the caregiver completed the
survey in the telephone phase of the Mixed Mode of survey administration
assign the appropriate “survey-completion-mode” in the administrative record for this
decedent/caregiver (see the Data Coding and Data File Preparation chapter for more
information)
document the telephone attempt “number-survey-attempts-telephone” in which the “Final
Survey Status” is determined. For example, if the interview was conducted and finished
with the caregiver on the fourth telephone attempt then the survey vendor must document
the “number-survey-attempts-telephone” as “4 – Fourth Telephone Attempt.” Please see
the Data Coding and Data File Preparation chapter for more information on coding the
“number-survey-attempts-telephone” field.
Survey vendors must record the date of the telephone interview and must link survey responses
from the telephone interview to their survey management system, regardless of the interviewing
system employed. Survey vendors must maintain a crosswalk of their interim disposition codes to
the CAHPS Hospice Survey “Final Survey Status” codes and include the crosswalk in the survey
vendor’s QAP.
Storage of Telephone Data
Survey vendors must retain all CAHPS Hospice Survey files and survey administration related
data collected through an electronic telephone interviewing system in a secure and
environmentally controlled location for a minimum of three years, and it must be easily retrievable,
when needed.
Quality Control Guidelines for Telephone Data Collection
Survey vendors are responsible for the quality of work performed by all staff members,
subcontractors and any other organizations, if applicable. Survey vendors must employ the
following guidelines for proper interviewer training, monitoring, and oversight regardless of
whether they are using internal staff, subcontractors or any other organizations to perform this
work.
Interviewer Training
Properly trained and consistently monitored interviewers ensure that standardized, non-directive
interviews are conducted. Interviewers conducting the telephone survey must be trained prior to
interviewing (see Appendices F and G for more information on interviewing guidelines).
Interviewers must be trained to:
read questions exactly as worded in the script, use non-directive probes and maintain a
neutral and professional relationship with the caregiver
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•
During the course of the survey, use of neutral acknowledgment words such as the
following is permitted:
o Thank you
o Alright
o Okay
o I understand, or I see
o Yes, Ma’am
o Yes, Sir
read the script from the telephone screens (reciting the survey from memory can lead to
unnecessary errors and missed updates to the scripts)
read response options exactly as worded and at an even pace without emphasis on any
particular response category
record responses to survey questions only after the caregiver has responded to the
questions; that is, interviewers must not pre-code response choices
understand the definition of each disposition code and appropriately assign interim or final
call disposition codes, when applicable
redirect calls to another interviewer when the decedent or caregiver is personally or
professionally known to the initial interviewer
adjust the pace of the CAHPS Hospice Survey interview to be conducive to the needs of
the caregiver
Distressed Respondent Procedures:
• Of critical importance is the need for survey vendors to develop a “distressed
respondent protocol,” to be incorporated into all interviewer and customer support
personnel training. Handling distressed respondent situations requires a balance
between keeping PII and PHI confidential and helping a person who needs assistance.
For survey research organizations, best interviewing practices recommend having a
distressed respondent protocol in place to balance the respondent’s right to
confidentiality and privacy with the need to provide assistance if the situation indicates
that the respondent’s health and safety are in jeopardy.
• If a respondent requests additional support, the CAHPS Hospice Survey Project Team
recommends that survey vendors’ telephone staff put the respondent in contact with the
appropriate local resource (generally a bereavement counselor or social worker on the
hospice team that provided care to their family member or friend). This potential
bereavement support is part of the services covered under the Medicare Hospice
Benefit.
Note: If a survey vendor uses a subcontractor(s) or any other organization(s) to conduct telephone
interviewing, then the survey vendor is responsible for attending/participating in the
subcontractor’s or other organization’s telephone interviewer training to confirm compliance with
CAHPS Hospice Survey protocols and guidelines. Survey vendors must conduct on-site
verification of subcontractor’s interviewing processes (strongly recommended on an annual basis,
at a minimum).
Telephone Monitoring and Oversight
Each survey vendor employing the Mixed Mode of survey administration must institute a
telephone monitoring and evaluation program, during the telephone phase of the protocol.
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Telephone monitoring is not to be conducted from a residence. The telephone monitoring and
evaluation program must include, but is not limited to, the following oversight activities:
Survey vendors must monitor at least 10 percent of all CAHPS Hospice Survey interviews,
interviewer survey response coding, dispositions, and call attempts in their entirety
(English, Spanish, and Russian) through silent monitoring of interviewers using the
electronic telephone interviewing system software or an alternative system. Silent
monitoring capability must include the ability to monitor calls on-site and from remote
locations. All staff conducting CAHPS Hospice Survey interviews must be included in the
monitoring. Additionally, it is required that survey vendors provide “floor rounding” in
their call-center(s) to visually observe and ensure the professionalism of the telephone
interviewers.
Survey vendors using a subcontractor(s) or any other organization(s) must monitor at least
10 percent of the subcontractor’s or other organization’s CAHPS Hospice Survey
telephone interviews, interviewer survey response coding, dispositions, and call attempts
in their entirety (English, Spanish, and Russian), provide feedback to the subcontractor’s
or other organization’s interviewers about their performance, and confirm that the
subcontractor’s or other organization’s interviewers correct any areas that need
improvement. Feedback must be provided to interviewers as soon as possible following a
monitoring session.
Note: In addition to the survey vendor’s monitoring of 10 percent of its subcontractors’ or
other organizations’ interviews, the CAHPS Hospice Survey Project Team also expects
that a survey vendor’s subcontractor(s) or other organization(s) will conduct internal
monitoring of their telephone interviewers as a matter of good business practice. While it
is preferred that each organization continue to monitor 10 percent of CAHPS Hospice
Survey interviews (for an overall total of 20 percent), it is permissible for the survey vendor
and its subcontractor(s) or other organization(s) to conduct a combined total of at least 10
percent monitoring, as long as each organization conducts a portion of the monitoring.
Therefore, the survey vendor, its subcontractor(s) and other organization(s) can determine
the ratio of monitoring that each organization conducts, as long as the combined total
meets or exceeds 10 percent. Please note that CAHPS Hospice Survey interviews
monitored concurrently by the survey vendor and its subcontractor(s) and other
organization(s) do not contribute separately to each organization’s monitoring time.
Interviewers who are found to be consistently unable to follow the script verbatim, employ
proper probes, remain objective and courteous, be clearly understood, or operate the
electronic telephone interviewing system competently must be identified and retrained or,
if necessary, replaced
In organizations where interviewers assign interim or final disposition codes, the
assignment of codes must be reviewed by a supervisor
Survey vendors must retain a record of all quality control activities and document these activities
in the survey vendor’s QAP. All materials relevant to survey administration are subject to review.
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Safeguarding Decedent/Caregiver Confidentiality
Survey vendors must take the following actions to further protect the confidentiality of
decedents/caregivers:
Prevent unauthorized access to confidential electronic and hard copy information by
restricting physical access to confidential data (use locks or password-protected entry
systems on rooms, file cabinets and areas where confidential data are stored)
• Store returned mail paper questionnaires and/or electronically scanned questionnaires
in a secure and environmentally safe location for a minimum of three years
Develop a confidentiality agreement which includes language related to HIPAA
regulations and the protection of PII, and obtain signatures from all personnel with access
to survey information, including staff and subcontractors and any other organizations, if
applicable, involved in survey administration and data collection
Note: Confidentiality agreements must be signed by all personnel upon employment.
Confidentiality agreements must be reviewed and re-signed periodically, at the discretion
of the survey vendor, but not to exceed more than a three-year period. The CAHPS Hospice
Survey Project Team recommends all personnel involved in the CAHPS Hospice Survey
review and re-sign confidentiality agreements on an annual basis.
Execute BAAs in accordance with HIPAA regulations
Confirm that staff, subcontractors and any other organizations, if applicable, are compliant
with HIPAA regulations in regard to decedent/caregiver PHI
Establish protocols for secure file transmission. Emailing of PHI via unsecure email is
prohibited.
Establish protocols for identifying security breaches and instituting corrective actions
Note: It is strongly recommended that the method used by contracted hospices to transmit
information (e.g., decedents/caregivers lists) to the survey vendor be reviewed by the hospice’s
HIPAA/Privacy Officer to confirm compliance with HIPAA regulations. Any materials (e.g., QAP,
questionnaires, cover letters, tracking forms) submitted by the survey vendor to the CAHPS
Hospice Survey Project Team must be blank templates and must not contain any
decedent/caregiver PHI.
Survey vendors must have physical plant resources available to handle the volume of surveys being
administered, in addition to systematic processes that effectively track sampled
decedents’/caregivers’ progress through the data collection protocol and caregivers’ responses to
the survey. System resources are subject to oversight activities including site visits to physical
locations.
Data Security
Survey vendors must securely store caregiver identifying electronic data and responses to the
survey. Survey vendors must take the following actions to secure the data:
Use a firewall and/or other mechanisms for preventing unauthorized access to the
electronic files
Implement access levels and security passwords so that only authorized users have access
to sensitive data
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Implement daily data back-up procedures that adequately safeguard system data
Test back-up files at a minimum on a quarterly basis to make sure the files are easily
retrievable and working
Perform frequent saves to media to minimize data losses in the event of power interruption
Develop a disaster recovery plan for conducting ongoing business operations in the event
of a disaster. The plan must be made available to the CAHPS Hospice Survey Project Team
upon request.
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IX. Data Coding and Data File Preparation
Overview
The CAHPS Hospice Survey uses standardized protocols for file specifications, coding and
submission of data. This chapter provides information about preparing data files for submission to
the CAHPS Hospice Survey Data Warehouse including requirements for assigning the random,
unique, de-identified decedent/caregiver identification number; XML file specifications; coding
and interpreting ambiguous or missing data elements in returned surveys; survey disposition codes;
and determining the rate of response.
Random, Unique, De-identified Tracking Number
The survey vendor must assign each decedent/caregiver in the sample a random, unique,
identification number (Decedent ID). This Decedent ID is used to follow cases through the data
collection process and report whether the survey for each decedent/caregiver has been returned or
needs a repeat mailing or telephone follow-up. Any de-identified combination of up to 16 letters
and numbers may be used. The Decedent ID must not include any combination of letters or
numbers that can otherwise identify the decedent or caregiver. For example, the date of death
(month, date and/or year), the birth date (month, date and/or year) and hospice ID number (e.g.,
decedent hospice record number) must not be combined in any manner to generate the Decedent
ID. Each month, sampled decedents/caregivers must be assigned a new Decedent ID; numbers
must not be repeated from month to month, or used in a sequential numbering order unless the
decedents/caregivers list is randomized prior to the assignment of the Decedent ID.
File Specifications
The survey vendor must submit their data files to the CAHPS Hospice Survey Data Warehouse
before the quarterly submission deadline listed in the “CAHPS Hospice Survey Administration
and Data Submission Schedule” table (see Introduction and Overview chapter). Survey vendors
are required to submit their data files to the CAHPS Hospice Survey Data Warehouse in the XML
file format.
Hospices with zero survey-eligible decedents/caregivers (zero cases) in a month must still submit
a Vendor Record and Hospice Record for that month.
Note: “Zero cases” submissions must not be used when hospices or survey vendors missed
surveying eligible decedents/caregivers, such as when hospices do not submit the
decedents/caregivers list for the month to their survey vendor in a timely manner, or do not confirm
in writing that the hospice had zero eligible decedents/caregivers in a month. In situations such as
these, a Discrepancy Report must be completed and submitted. Survey vendors must confirm if a
hospice had any decedents/caregivers in a month if the hospice does not submit a sample file for
any month.
XML File Specifications
CAHPS Hospice Survey data are to be submitted using an XML file format. Survey vendors are
permitted to submit multiple XML files as long as all three months of data for given CCNs are in
their own XML files. Survey vendors may also submit one XML file containing all months of data
for all CCNs. If, for example, a survey vendor has 10 client hospices, the survey vendor may
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submit anywhere between 1 and 10 XML files for the quarter, but months of data for one CCN
may not be split among multiple files. For the vendor’s final submission(s) each quarter, a
separate file for each month of data is not permitted.
If a survey vendor submits multiple data files for a CCN in any quarter, the most recently submitted
record will completely overwrite any previous record for that CCN, and only the most recently
submitted file will be stored in the CAHPS Hospice Survey Data Warehouse. If, for example, a
survey vendor submits an XML file containing 10 CCNs, and later in the same quarter submits a
new XML file containing only one of those 10 CCNs, only the one CCN that appears in both files
will be overwritten by the later submission.
No substitutions for valid data element values are acceptable. For the full listing of valid values,
details on the XML file specifications and a sample XML file layout, see Appendix E.
Each XML file consists of four parts:
1. Vendor Record
2. Hospice Record
3. Decedent/Caregiver Administrative Record
4. Survey Results Record
1. Vendor Record
Each quarterly data file submitted by a survey vendor begins with the Vendor Record. The Vendor
Record contains information on the date and number of submissions, and is applicable to every
record in the file.
The Vendor Record must appear once per file, and the year, month and day of the
submission must correspond to the date on which the file is submitted to the CAHPS
Hospice Survey Data Warehouse
The file submission number is an ordinal variable that represents the number of
submissions for the given date. This number will usually be 1.
2. Hospice Record
The second part of the data submission file is the Hospice Record. There are three Hospice Records
per CCN contained within the file, one for each month of the quarter. The Hospice Record contains
identification and sampling information that is applicable to every survey record in that month for
the given hospice. The Hospice Record includes such variables as: hospice name; CCN; National
Provider Identifier (NPI); survey mode; the total number of decedent cases received from the
hospice in the month; the number of live discharge patients reported by the hospice in the month;
the number of cases excluded from the sample frame because the decedent’s date of death is
missing; the number of “no publicity” decedents/caregivers reported by the hospice in the month;
the number of decedents/caregivers determined by the survey vendor to be ineligible (pre-sample
and post-sample); the number of available cases for the sample and the number of sampled cases;
the sample size for the month; and the number of hospice offices.
Note: Survey vendors must not assume that if a hospice does not submit a monthly sample file
that there are zero survey-eligible decedents/caregivers for the month. The hospice must confirm
in writing that there are zero survey-eligible decedents/caregivers for the month. If no written
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confirmation is received, then a Hospice Record for that month must not be uploaded and a
Discrepancy Report must be submitted.
The “available-sample”, “sampled-cases” and “sample-size” variables are calculated as follows:
The “available-sample” field should equal the total number of decedents from the CCN in
the month, minus the number of “no-publicity” decedents/caregivers (“no-publicity”), the
number of decedents missing date of death (“missing-dod”) and the number of
decedents/caregivers found ineligible prior to sampling (“ineligible-presample”).
“available-sample” should be calculated as:
Available Sample = Total Decedents – (No Publicity + Missing DOD + Ineligible
Pre-sample)
The “sampled-cases” field should equal the total number of decedents/caregivers drawn
into the sample for the month. For CCNs using census sampling, the “sampled-cases” field
should equal the “available-sample” field (“available-sample”) because all cases available
for sampling are drawn into the sample.
“sampled-cases” should be calculated as:
Sampled Cases = Available Sample – Any cases not drawn into the sample
In calculating the “sample-size” field, the number of survey-eligible
decedents/caregivers in the sample frame in the month must not include
decedents/caregivers who are determined to be ineligible or excluded, regardless of
whether they are selected for the survey sample.
If a decedent/caregiver is selected for the survey sample and is later determined to be
ineligible (i.e., “Final Survey Status” code of “2 – Ineligible: Deceased,” “3 – Ineligible:
Not in Eligible Population,” “4 – Ineligible: Language Barrier,” “5 – Ineligible:
Mental/Physical Incapacity, “6 – Ineligible: Never Involved in Decedent Care,” or “14 –
Ineligible: Institutionalized”), then the decedent/caregiver must be subtracted from the
number of survey-eligible decedents/caregivers in the month and must be included in the
“ineligible-post-sample” field.
“sample-size” should be calculated as:
Sample Size = Sampled Cases – Any cases with an ineligible “Final Survey Status” code
(2, 3, 4, 5, 6, and/or 14)
When hospices sample 100 percent of the survey-eligible decedents/caregivers (i.e., a
census), the “sample-type” must be coded as “2 – Census Sample.” See the Sampling
Protocol chapter for information on sampling options.
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Note: A Hospice Record must still be submitted for hospices with zero survey-eligible
decedents/caregivers (zero cases) in a month.
The chart below contains examples of the correct calculations of the decedent/caregiver counts
included in the Hospice Record:
Sample
Type
Total
Decedents
No
Publicity
Missing
Date of
Death
Ineligible
Presample
Available
Sample
Sampled
Cases
Ineligible
Postsample
Sample
Size
Census
100
1
1
5
93
93
13
80
Census
10
0
0
1
9
9
2
7
100
2
0
3
95
75
5
70
500
5
1
24
470
200
50
150
Simple
Random
Sample
Simple
Random
Sample
3. Decedent/Caregiver Administrative Record
The third part of the data submission file is the Decedent/Caregiver Administrative Record. This
contains information on each sampled decedent/caregiver in the file including the Decedent ID;
final survey status; survey completion mode, if applicable; language in which the survey was
administered or attempted to be administered; lag time; and supplemental question count. In
addition, this section should contain the following information for the decedent: date of birth, date
of death, sex, race/ethnicity, primary diagnosis, admission date for final episode of hospice care,
payers, last location/setting of care, and caregiver relationship to decedent.
The following guidelines must be followed when submitting the Decedent/Caregiver
Administrative Records:
All fields in the Decedent/Caregiver Administrative Record must have a valid value.
Use the appropriate code (e.g., “M – Missing/Don’t Know,” “8888”) for all missing
fields, with the following exception:
• The “language” field must be completed with the appropriate valid value indicating
the survey language in which survey administration was attempted (English,
Spanish, Chinese, Russian, Portuguese, Vietnamese, Polish, or Korean), even if a
caregiver does not complete the survey
Decedent/Caregiver Administrative Record information must be submitted for all
decedents/caregivers selected for the survey sample (e.g., cases included in the “sampledcases” count), including decedents/caregivers found to be ineligible after the start of survey
administration (“ineligible-post-sample”)
The “survey-completion-mode” field must be submitted if the “survey-mode” in the
Hospice Record is “3 – Mixed Mode” and the “Final Survey Status” is “1 – Completed
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Survey,” “6 – Ineligible: Never Involved in Decedent Care” or “7 – Non-response: Breakoff”
Note: “survey-completion-mode” is not a required field for “survey-mode” of “1 – Mail
Only” and “2 – Telephone Only.”
The “number-survey-attempts-telephone” field is coded with the attempt that corresponds
to the time of final survey status determination and must be submitted when:
• the “survey-mode” in the Hospice Record is “2 – Telephone Only”
• the “survey-mode” in the Hospice Record is “3 – Mixed Mode” and “surveycompletion-mode” is “2 – Mixed Mode-phone”
Note: “number-survey-attempts-telephone” is not a required field for “survey-mode” of
“1 – Mail Only.” If this field (“number-survey-attempts-telephone”) is included with
“survey-mode” of “1 – Mail Only,” then code “number-survey-attempts-telephone” as
“88 – Not Applicable.”
The “number-survey-attempts-mail” field is coded with the attempt that corresponds to the
time of final survey status determination and must be submitted when:
• the “survey-mode” in the Hospice Record is “1 – Mail Only”
Note: “number-survey-attempts-mail” is not a required field for “survey-mode” of “2 –
Telephone Only” or “3 – Mixed Mode.” If this field “number-survey-attempts-mail” is
included with “survey-mode” of “2 – Telephone Only” or “3 – Mixed Mode” then code
“number-survey-attempts-mail” as “88 – Not Applicable.”
Note: The “number-survey-attempts-telephone” and the “number-survey-attempts-mail”
fields are submitted in accordance with the requirements identified above for all CAHPS
Hospice Survey “Final Survey Status” codes.
The “lag-time” is calculated for each decedent/caregiver in the sample and is defined as
the number of days between the decedent’s date of death and the date that data collection
activities ended for the decedent/caregiver (e.g., date of receipt of mail survey and/or
comment from caregiver indicating the appropriate “Final Survey Status” code)
• All surveys (i.e., “Final Survey Status” codes of 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11,
1 2 , 1 3 , 1 4 , 1 5 , or M) must contain the actual lag time
Note: If the code “33 – No response Collected” is used for interim data submissions,
calculation of lag time is not required.
The following are brief illustrations of how lag time would be determined for each
“Final Survey Status” (“survey-status”):
• Completed Survey (code 1): Lag time is the number of days between the decedent’s
date of death and the receipt of a completed mail survey or the completion of a
telephone survey
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•
•
•
•
•
•
•
•
•
•
•
•
•
•
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Ineligible: Deceased (code 2): Lag time is the number of days between the
decedent’s date of death and the notification date indicating that the caregiver is
deceased
Ineligible: Not in Eligible Population (code 3): Lag time is the number of days
between the decedent’s date of death and the notification date indicating that the
decedent/caregiver is not eligible for the CAHPS Hospice Survey
Ineligible: Language Barrier (code 4): Lag time is the number of days between the
decedent’s date of death and the notification date indicating that a language barrier
prevents the caregiver from completing the CAHPS Hospice Survey
Ineligible: Mental/Physical Incapacity (code 5): Lag time is the number of days
between the decedent’s date of death and the notification date indicating that a mental
or physical incapacity prevents the caregiver from completing the CAHPS Hospice
Survey
Ineligible: Never Involved in Decedent Care (code 6): Lag time is the number of days
between the decedent’s date of death and the notification date indicating that the
caregiver was never involved in hospice care for the decedent
Non-response: Break-off (code 7): Lag time is the number of days between the
decedent’s date of death and the notification date that the caregiver “breaks off” or fails
to complete the CAHPS Hospice Survey after the survey has started
Non-response: Refusal (code 8): Lag time is the number of days between the
decedent’s date of death and the notification date that the caregiver (or someone on the
caregiver’s behalf) refuses to take the CAHPS Hospice Survey
Non-response: Non-response after Maximum Attempts (code 9): Lag time is the
number of days between the decedent’s date of death and the date of the maximum
attempt (mail: non-return of the second mailing of survey; telephone and mixed: fifth
call attempt) to administer the CAHPS Hospice Survey
Non-response: Bad/No Address (code 10): Lag time is the number of days between
the decedent’s date of death and the date it is determined that the caregiver’s actual
mailing address is not viable
Non-response: Bad/No Telephone Number (code 11): Lag time is the number of days
between the decedent’s date of death and the date it is determined that the caregiver’s
actual telephone number is not viable
Non-response: Incomplete Caregiver Name (code 12): Lag time is the number of
days between the decedent’s date of death and the date it is determined that the
caregiver’s complete name is not available
Non-response: Incomplete Decedent Name (code 13): Lag time is the number of days
between the decedent’s date of death and the date it is determined that the decedent’s
complete name is not available
Ineligible: Institutionalized (code 14): Lag time is the number of days between the
decedent’s date of death and the notification date indicating that the caregiver is
institutionalized
Non-response: Hospice Disavowal (code 15): Lag time is the number of days between
the decedent’s date of death and the notification date indicating that the decedent did
not receive care from any hospice or the named hospice
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To illustrate the calculation of lag time where a caregiver did not respond to the survey, two
examples are provided:
Example A: Lag Time Calculation – Mail
Mode of Survey Administration Mail Only
March 16
Decedent Date of Death
June 1 (77 days after death)
Date of First Mail Attempt
Date of Follow-up Mail Attempt June 22 (21 days after first mail attempt)
July 13 (42 calendar days after first mail attempt)
Date Data Collection Activities
Ended for this
Caregiver never returned the CAHPS Hospice
Decedent/Caregiver
Survey
Code as “9 – Non-response: Non-response after
CAHPS Hospice Survey Final
Maximum Attempts” because the data collection
Status
protocol of 42 days has been reached and the
caregiver has not returned the CAHPS Hospice
Survey
Calculated as 119 days (number of days between
Lag Time
the patient’s death [March 16] to the date data
collection activities ended [July 13])
Example B: Lag Time Calculation – Telephone
Mode of Survey Administration Telephone Only
March 16
Decedent Date of Death
June 1 (77 days after decedent death)
Date of First Attempt
July 13 (42 calendar days after the first telephone
Date Data Collection Activities
attempt)
Ended for this
Code
as “9 – Non-response: Non-response after
CAHPS Hospice Survey Final
Maximum Attempts” because the data collection
Status
protocol of 42 calendar days had ended and the
caregiver had not been reached although five
attempts were made
Calculated as 119 days (number of days between
Lag Time
the decedent’s death [March 16] to the date data
collection activities ended [July 13])
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To illustrate the calculation of lag time when a caregiver responds and completes the survey, one
example is provided:
Example C: Lag Time Calculation – Mail
Mode of Survey Administration Mail Only
March 16
Decedent Date of Death
June 1 (77 days after death)
Date of First Mail Attempt
June 14
Date of Response
Code as “1 – Completed Survey,” “6 – Ineligible:
CAHPS Hospice Survey Final
Never Involved in Decedent Care” or “7 – NonStatus
response: Break-off”
Calculated as 90 days (number of days between the
Lag Time
patient’s death [March 16] to the date response was
received [June 14])
The “supplemental-question-count” field must be submitted when the “Final Survey
Status” is “1 – Completed Survey,” “6 – Ineligible: Never Involved in Decedent Care” or
“7 – Non-response: Break-off.” The value submitted is the count of supplemental
questions included in the survey for the given decedent/caregiver (whether or not the
supplemental questions were asked or contained responses).
4. Survey Results Record
The fourth part of the data submission file is the Survey Results Record. This set of records
contains the actual survey responses from each caregiver who responded to the CAHPS Hospice
Survey.
The Survey Results Record is required only when “Final Survey Status” in the Decedent/Caregiver
Administrative Record is coded “1 – Completed Survey,” “6 – Ineligible: Never Involved in
Decedent Care” or “7 – Non-response: Break-off.” When the Survey Results Record is included,
all response fields must have a valid value, which may include “M – Missing/Don’t Know” and
“88 – Not Applicable.” The opening and closing XML tags (which enclose
the Survey Results Record) are not necessary when there are no survey responses to submit for a
given decedent/caregiver.
Note: The Survey Results Record is not required for “Final Survey Status” of anything other than
“1 – Completed Survey,” “6 – Ineligible: Never Involved in Decedent Care” or “7 – Nonresponse: Break-off;” however, if the Survey Results Record is included, then all fields must have
a valid value.
The following guidelines must be followed when submitting the Survey Results Records:
Enter all survey responses as provided by the caregiver for each survey item
For Question 41, “What is the highest grade or level of school that your family member
completed?” if a caregiver indicates that he or she does not know the decedent’s
education, the interviewer should code “<7> RESPONDENT INDICATES THAT HE OR
SHE DOES NOT KNOW FAMILY MEMBER’S LEVEL OF EDUCATION.” This should
not be recoded to “M – Missing/Don’t Know” in the data file.
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Caregivers may select more than one response category in Question 2, “In what locations
did your family member receive care from this hospice? Please choose one or more”
and in Question 43, “What was your family member’s race? Please choose one or more.”
• For mail and telephone surveys, enter all of the categories that the caregiver has
selected. If the caregiver responds “Yes” to a category, enter “1.” If the caregiver
responds “No” to a category, enter “0.” If the caregiver does not provide a response to
any of the categories or skips the question, enter “M – Missing/Don’t Know.”
Note: A valid value must be submitted for each category in Question 2 and Question 43.
If the same caregiver completes two surveys for the same decedent (e.g., the caregiver
returns both mail surveys), the survey vendor must use the first CAHPS Hospice Survey
received
Decision Rules and Coding Guidelines
The CAHPS Hospice Survey decision rules and coding guidelines have been developed to address
situations in which survey responses are ambiguous, missing or incorrectly provided, and to
capture appropriate information for data submission. Survey vendors must adhere to the decision
rules and coding guidelines included in the survey administration chapters to ensure valid and
consistent coding of these situations.
Survey Skip Patterns
There are several items in the CAHPS Hospice Survey that can and should be skipped by certain
respondents. These items form skip patterns. Ten questions in the CAHPS Hospice Survey serve
as screener questions (Questions 3, 4, 13, 15, 17, 21, 24, 26, 28, and 32) that determine whether
the associated dependent questions require an answer. The following decision rules are provided
to assist in the coding of caregiver responses to skip pattern questions.
Do not correct a screener question by imputing a response based on the caregiver’s answers
to the dependent questions. Enter the value provided by the caregiver.
For mail questionnaire skip patterns:
• If the screener question is left blank, code it as “M – Missing/Don’t Know.” In this
scenario, code any appropriately skipped dependent questions as “M – Missing/Don’t
Know.” Do not impute responses based on how the caregiver answers questions.
• In instances where the caregiver made an error in the skip pattern, dependent questions
are coded with the response provided by the caregiver. That is, survey vendors must
not “clean” or correct skip pattern errors on surveys completed by a caregiver.
• Dependent questions that are appropriately skipped should be coded as “88 – Not
Applicable”
For telephone questionnaire skip patterns:
• In instances where the caregiver answers “I don’t know” or refuses to answer the
screener question, code response option of “M – Missing/Don’t Know”
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When answer options of “M – Missing/Don’t Know” are used for coding screener
questions, the skip pattern should be programmed into the electronic telephone
interviewing system. The resulting associated dependent questions should be coded as
“M – Missing/Don’t Know.”
Appropriately skipped dependent questions should be coded as “88 – Not Applicable”
Note: For telephone administration, skip patterns should be programmed into the electronic
telephone interviewing system. Coding may be done automatically by the telephone
interviewing system or later during data preparation.
Disposition of Survey Codes
Maintaining up-to-date dispositions of survey codes is a required part of the CAHPS Hospice
Survey administration process. Using the random, unique, de-identified Decedent ID, the survey
vendor assigns each decedent/caregiver in the sample a survey status code, which is used to track
and report whether the caregiver has completed the survey or requires further follow-up.
Typically, survey status codes are either interim (which indicate the status of each sampled
decedent/caregiver during the data collection period) or final (which indicate the final outcome of
each decedent/caregiver surveyed at the end of data collection, that is – “Final Survey Status”).
Interim disposition codes are to be used only for internal tracking purposes. The data files that
are submitted to the CAHPS Hospice Survey Data Warehouse must contain the CAHPS Hospice
Survey “ Final Survey Status” codes. Interim survey status codes allow the survey vendor to
calculate and report the number of completed questionnaires and the response rate at any time
during the data collection period. After data collection is completed, the survey vendor assigns
each sampled decedent/caregiver a “Final Survey Status” code.
Code Description
The following provides details on the assignment of the “Final Survey Status” field.
1
Completed Survey
Survey vendors assign a “Final Survey Status” code of “1 – Completed Survey” when the
caregiver answers at least 50 percent of the questions ATA decedents/caregivers. For detailed
information on a completed survey, refer to “Definition of a Completed Survey” in this section.
2
Ineligible: Deceased
Survey vendors assign a “Final Survey Status” code of “2 – Ineligible: Deceased” when the
caregiver is deceased by time of survey administration.
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Ineligible: Not in Eligible Population
Survey vendors assign a “Final Survey Status” code of “3 – Ineligible: Not in Eligible
Population” when there is evidence that the decedent/caregiver does not meet the following
eligibility criteria:
Decedent age 18 and over at time of death
Decedent with death at least 48 hours following last admission to hospice care
Decedent for whom there is a caregiver of record
Decedent whose caregiver is someone other than a non-familial legal guardian
Decedent for whom the caregiver has a U.S. or U.S. Territory home address
In addition, should it be determined that a patient is still living or that his or her last admission
to the hospice resulted in a live discharge, then survey vendors should assign “Final Survey
Status” code of “3 – Ineligible: Not in Eligible Population.”
Note: Cases ineligible due to live discharge or “no publicity” should not be included in
decedents/caregivers lists received from hospices. Survey vendors should work closely with
hospices that have not removed these patients prior to submitting the decedents/caregivers list
to ensure that subsequent file submissions do not include such patients. In addition, a
Discrepancy Report must be filed for cases that are included in the decedents/caregivers list
and drawn into the sample that are later determined to be a live discharge or “no publicity.”
4
Ineligible: Language Barrier
Survey vendors assign a “Final Survey Status” code of “4 – Ineligible: Language Barrier”
when there is evidence that the caregiver does not read or speak the language in which the
survey is being administered.
5
Ineligible: Mental/Physical Incapacity
Survey vendors assign a “Final Survey Status” code of “5 – Ineligible: Mental/Physical
Incapacity” when the caregiver is unable to complete the survey because he/she is mentally or
physically incapacitated. This includes caregivers who are visually/hearing impaired.
6
Ineligible: Never Involved in Decedent Care
Survey vendors assign a “Final Survey Status” code of “6 – Ineligible: Never Involved in
Decedent Care” when the answer to Question 3, “While your family member was in hospice
care, how often did you take part in or oversee care for him or her?” is “Never” or when
calling the household the sampled caregiver indicates that he/she was not involved in the
patient’s hospice care and no alternative caregiver respondent resides in the household (coded
“NOT INVOLVED IN CARE AND NO PROXY IDENTIFIED” on INTRO of the CATI
script).
7
Non-response: Break-off
Survey vendors assign a “Final Survey Status” code of “7 – Non-response: Break-off” when a
caregiver provides a response to at least one CAHPS Hospice Survey Core question, but
answered too few ATA questions to meet the criteria for a completed survey.
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Non-response: Refusal
Survey vendors assign a “Final Survey Status” code of “8 – Non-response: Refusal” when a
caregiver returns a blank survey with no completed questions with a note stating they do
not wish to participate, or when a caregiver verbally refuses to complete the survey. Surveys
completed by a respondent outside of the sampled caregiver household are coded as “8 – Nonresponse: Refusal.”
Note: If a caregiver returns a survey with a note stating they do not wish to participate or if a
caregiver verbally refuses to complete the survey, but the caregiver has already answered at
least one survey question, the case should be coded as “1 – Completed Survey” or “7 – Nonresponse: Break-off,” as appropriate, and the survey results should be submitted.
Note: Respondents who reside outside of the household of the sampled caregiver are not
permitted. In the event that it is determined a survey has been completed by a respondent
outside of the sampled caregiver household, the decedent/caregiver is assigned a “Final
Survey Status” code of “8 – Non-response: Refusal.” The survey vendor submits the
Decedent/Caregiver Administrative Record but does not submit the survey responses. The
survey vendor retains a copy of such a survey and any accompanying documentation. If a
survey is returned with a note or someone verbally refuses on behalf of the decedent/caregiver,
the survey vendor should code the survey as “8 – Non-Response: Refusal.”
9
Non-response: Non-response after Maximum Attempts
Survey vendors assign a “Final Survey Status” code of “9 – Non-response: Non-response
after Maximum Attempts” when one of the following occurs:
There is no evidence to suggest that a caregiver’s contact information is bad (e.g., bad
address in Mail Only methodology, bad telephone number in Telephone Only, and both
bad address and bad telephone number in a Mixed Mode methodology), or
If after the maximum number of attempts (two mail attempts for Mail Only; five telephone
attempts for Telephone Only; and one mail attempt and five telephone attempts for Mixed
Mode), the caregiver has not completed the survey by the end of the survey administration
time period (i.e., 42 calendar days from initial contact), or
If the survey is returned by mail or completed by telephone more than 42 calendar days
from initial contact
10 Non-response: Bad/No Address
This disposition code applies only to the Mail Only mode. Survey vendors assign a “Final
Survey Status” code of “10 – Non-response: Bad/No Address” when there is evidence that a
caregiver’s address is bad (e.g., the post office returns the questionnaire to the survey vendor).
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11 Non-response: Bad/No Telephone Number
This disposition code applies to the Telephone Only and Mixed Modes of administration.
For the Telephone Only mode, survey vendors assign a “Final Survey Status” code of “11 –
Non-response: Bad/No Telephone Number” when there is evidence that a caregiver’s
telephone number is bad (e.g., no telephone number available or a disconnected telephone
number). For the Mixed Mode, “11 – Non-response: Bad/No Telephone Number” is used when
there is evidence that a caregiver’s address and telephone number are both bad.
12 Non-response: Incomplete Caregiver Name
Survey vendors assign a “Final Survey Status” code of “12 – Non-response: Incomplete
Caregiver Name” when there is evidence that the full caregiver name is unavailable (e.g.,
survey vendor re-contacted the hospice client to inquire about an update for missing or partial
name information).
13 Non-response: Incomplete Decedent Name
Survey vendors assign a “Final Survey Status” code of “13 – Non-response: Incomplete
Decedent Name” when there is evidence that the full decedent name is unavailable (e.g., survey
vendor re-contacted the hospice client to inquire about an update for missing or partial name
information).
14 Ineligible: Institutionalized
Survey vendors assign a “Final Survey Status” code of “14 – Ineligible: Institutionalized” to a
decedent/caregiver case when the caregiver is unable to complete the survey because he/she is
identified to be institutionalized. This includes caregivers who are in a psychiatric facility,
nursing home or correctional institution.
15 Non-response: Hospice Disavowal
Survey vendors assign a “Final Survey Status” code of “15 – Non-response: Hospice
Disavowal” when a caregiver indicates that a decedent did not receive care from any hospice
or the named hospice. This may occur when a mail survey is returned with a note from the
caregiver, through a call to the project toll-free number or during telephone interviewing.
Assigning Bad Address and/or Bad Telephone Number Disposition Codes
The “Final Survey Status” codes of “9 – Non-response: Non-response after Maximum Attempts,”
“10 – Non-response: Bad/No Address” and “11 – Non-response: Bad/No Telephone Number” are
assigned based on the viability of the address and telephone number for the caregiver. Survey
vendors must track the viability of the mailing address and telephone number for each caregiver
during survey administration. In general, the contact information is assumed to be viable unless
there is sufficient evidence to suggest otherwise. If the evidence is insufficient, the survey vendor
must continue attempting to contact the caregiver until the required number of attempts has been
exhausted.
Note: Attempts must be made to contact every survey-eligible decedent/caregiver drawn into the
sample, whether or not they have a complete mailing address and/or telephone number. Survey
vendors have flexibility in not sending mail surveys to caregivers without mailing addresses,
such as the homeless. However, survey vendors must first make every reasonable attempt to obtain
a caregiver’s address including re-contacting the hospice client to inquire about an address
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update for caregivers with no mailing address. Survey vendors must use commercial software or
other means to update addresses and/or telephone numbers provided by the hospice for sampled
decedents/caregivers. It is permissible for survey vendors to request updated information about
specific decedents/caregivers, rather than requesting a complete updated list. If the survey vendor
is unsuccessful in obtaining a viable mailing address and/or telephone number, they must retain
a record of their attempts to acquire the missing information. These decedent/caregiver cases must
not be removed or replaced in the sample. All materials relevant to survey administration are
subject to review by CMS.
The following examples illustrate what constitutes sufficient or insufficient evidence of nonviability. For a Mail Only survey, sufficient evidence regarding the non-viability of a caregiver’s
address includes:
the hospice does not provide an address in the decedents/caregivers list, and the survey
vendor is unable to obtain an address for the caregiver
mail is returned marked “Address Unknown”
mail is returned marked “Moved – No Forwarding Address”
For a Mail Only survey,insufficient evidence regarding the non-viability of a caregiver’s
address includes:
address updating search does not result in an exact “match.” If the search does not result
in an exact “match,” the survey vendor must attempt to mail using the address that is
available.
For all modes of administration except Mail Only, sufficient evidence regarding the non-viability
of caregiver’s telephone number includes:
the hospice does not provide a telephone number in the decedents/caregivers list, and
the survey vendor is unable to obtain a telephone number for the caregiver
the telephone interviewer dials the caregiver’s telephone number and receives a message
that the telephone number is non-working or out of order, and no updated number is
available or obtained
the telephone interviewer dials the caregiver’s telephone number, speaks to a person, and
is informed that he/she has the wrong telephone number and other attempts to obtain the
correct telephone number are not successful
For all modes of administration except Mail Only, insufficient evidence regarding the non-viability
of a caregiver’s telephone number includes:
the survey vendor obtaining a busy signal every time a telephone attempt is made
The following table summarizes how survey vendors assign the “Final Survey Status” codes of “9
– Non-response: Non-response after Maximum Attempts,” “10 – Non-response: Bad/No Address”
and “11 – Non-response: Bad/No Telephone Number” after assessing the caregiver’s contact
information for viability. Due to the nature of the information available in the three modes of
survey administration, different coding rules apply for surveys administered in each mode.
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Mail Only Methodology
Assigning Final Survey Status/Disposition Codes 9, 10 and 11
Viable Address and No
Response After Maximum
Evidence of a Bad/No Address
Final Survey Status Code
Attempts
9
10
Telephone Only Methodology
Assigning Final Survey Status/Disposition Codes 9, 10 and 11
Viable Telephone Number and
Evidence of a Bad/No
No Response After Maximum
Telephone Number
Final Survey Status Code
Attempts
9
11
Mixed Mode Methodology
Assigning Final Survey Status/Disposition Codes 9, 10 and 11
Viable Address and/or
Evidence of Both a Bad/No
Telephone Number and No
Address and a Bad/No
Response After Maximum
Final Survey Status Code
Telephone Number
Attempts
9
11
Assigning Missing or Incomplete Caregiver Name Disposition Codes
Depending upon the completeness of the caregiver name, the “Final Survey Status” codes of “3 –
Ineligible: Not in Eligible Population” and “12 – Non-response: Incomplete Caregiver Name” are
assigned. Respondents with no caregiver name or an incomplete caregiver name are not removed
from the sample frame. If there is no caregiver name or the first or last name of the caregiver is
missing or incomplete, survey vendors must make every reasonable attempt to obtain the
caregiver's full name, including re-contacting the hospice client to inquire about an update for
decedents/caregivers with missing or partial name information. If all of the caregiver name is
missing after every reasonable attempt has been made to obtain the caregiver’s full name and the
decedent/caregiver case has been selected for the sample, the decedent/caregiver case must be
considered “Decedent has no caregiver of record” and coded with a “Final Survey Status” of “3 –
Ineligible: Not in Eligible Population.”
Caregivers with incomplete name information must not be administered the survey. Caregivers with
incomplete name information that have been selected for the sample must be coded with a “Final
Survey Status” of “12 – Non-response: Incomplete Caregiver Name.” This non-response
disposition code must not be removed from the denominator of the response rate calculation.
Assigning Missing or Incomplete Decedent Name Disposition Code
Survey vendors must assign the code “13 – Non-response: Incomplete Decedent Name” when there
is evidence that the full decedent name is unavailable. Decedent/Caregiver cases with no decedent
name or an incomplete decedent name are not removed from the sample frame. If there is no
decedent name or the first or last name of the decedent is missing or incomplete, survey vendors
must make every reasonable attempt to obtain the decedent’s full name, including re-contacting
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the hospice client to inquire about an update for decedents/caregivers with missing or partial name
information.
Caregivers of decedents with incomplete name information must not be administered the survey.
This non-response disposition code must not be removed from the denominator of the response
rate calculation.
Definition of a Completed Survey
Survey vendors should be aware that a survey can be considered “complete” for CAHPS
Hospice Survey purposes even if a caregiver does not answer all items. Survey vendors assign a
“Final Survey Status” code of “1 – Completed Survey” to decedent/caregiver cases when at least
50 percent of the questions ATA decedents/caregivers (Questions 1 – 4, 6 – 13, 15, 17, 21, 24, 26,
28, 30 – 32, and 35 – 47) are answered. Appropriately skipped questions and the following
questions are not included in the calculation of percentage complete: 5, 14, 16, 18 – 20, 22, 23,
25, 27, 29, 33, and 34.
The following steps describe how to determine if a survey is completed:
Step 1 – Sum the number of questions that have been answered by the caregiver that are
ATA decedents/caregivers
R = total number of questions answered
Step 2 – Divide the total number of questions answered by 34, which is the total
number of questions ATA decedents/caregivers, and then multiply by 100
Percentage Complete = (R/34) x 100
Step 3 – If the Percentage Complete is at least 50 percent, then assign the survey a “Final
Survey Status” code of “1 – Completed Survey”
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Survey Response Rate
The survey response rate formula below is included for informational purposes only; survey vendors
are not required to perform this calculation.
Total Number of Completed Surveys
Response Rate =
Total Number of Surveys Fielded – Total Number of Ineligible Surveys
Total Number of Completed Surveys is the total number of surveys with a “Final
Survey Status” of 1
Total Number of Surveys Fielded is the total sample, which includes “Final Survey
Status” codes of 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, and M
Total Number of Ineligible Surveys is the total number of surveys with a “Final Survey
Status” code of 2, 3, 4, 5, 6, and 14
It is important to emphasize that the remaining non-response disposition codes (i.e., “7 – Nonresponse: Break-off,” “8 – Non-response: Refusal,” “9 – Non-response: Non-response after
Maximum Attempts,” “10 – Non-response: Bad/No Address,” “11 – Non-response: Bad/No
Telephone Number,” “12 – Non-response: Incomplete Caregiver Name,” “13 – Non-response:
Incomplete Decedent Name,” and “15 – Non-response: Hospice Disavowal”) are not removed
from the denominator of the response rate calculation.
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X. Data Submission
Overview
The CAHPS Hospice Survey uses a standardized protocol for the preparation and submission of
all data. This section describes the preparation, registration and submission of survey data files to
the CAHPS Hospice Survey Data Warehouse. If any problems occur when submitting data to the
CAHPS Hospice Survey Data Warehouse, the CAHPS Hospice Survey Data Coordination Team
can be reached by sending an email message to [email protected]. Submission
to the CAHPS Hospice Survey Data Warehouse is on a quarterly basis. Refer to the “CAHPS
Hospice Survey Data Collection and Submission Timeline” section in the Introduction and
Overview chapter for the data submission timeline.
Data Submission Process
The CAHPS Hospice Survey Data Coordination Team has developed a secure data warehouse
hosted by the RAND Corporation. This data warehouse operates as a secure file transfer system
that survey vendors will use to submit survey data to CMS and where survey vendors and hospices
may review CAHPS Hospice Survey Data Submission Reports. Use of the CAHPS Hospice
Survey Data Warehouse for data submission does not require installation of special software or a
licensing fee on the part of survey vendors, except for the purchase of Symantec File Share
Encryption software (formerly PGP) for file encryption. The interface for the data warehouse is
user friendly and requires minimal training.
Data File Submission Dates
As previously specified in this manual, survey vendors are required to submit data quarterly.
Survey vendors may submit an interim data file prior to the final submission date. Submitting an
interim data file will provide survey vendors an opportunity to test the data submission process
before they have to submit the final data file and correct any data file errors/problems.
Note: Survey vendors may submit interim data any time during the quarter; however, fully
corrected data files must be submitted by 11:59 PM Eastern Time on the required submission date.
The data files with the latest timestamp for each CCN will be retained.
Survey Vendor Authorization Process
Hospices must submit documentation to the CAHPS Hospice Survey Data Coordination Team
authorizing survey vendors to collect and submit data on their behalf before survey vendors can
access the data submission application hosted by the RAND Corporation. Upon receipt of the
CAHPS Hospice Survey Vendor Authorization Form (see Appendix B), the CAHPS Hospice
Survey Data Coordination Team will confirm the authenticity of the authorizing entity verifying
contact information at both the hospice and survey vendor level. Only then will the hospice be
added to the list of hospices authorizing that survey vendor.
If a survey vendor attempts to submit the hospice’s survey data without authorization, the entire
file containing the unauthorized CCN will be rejected by the CAHPS Hospice Survey Data
Warehouse. The survey vendor will need to contact the hospice about the authorization, and resubmit the data once authorization is obtained.
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Switching Survey Vendors
Hospices that choose to switch from one survey vendor to another can only do so at the beginning
of a calendar quarter. In order to switch from one survey vendor to another, the Hospice
Administrator must complete and resubmit the CAHPS Hospice Survey Vendor Authorization
Form (see Appendix B) one calendar quarter (90 days) prior to the first time data will be submitted
to the CAHPS Hospice Survey Data Warehouse by the new survey vendor. If a hospice is
switching survey vendors, the second page of the CAHPS Hospice Survey Vendor Authorization
Form must be completed, indicating the calendar quarter the hospice plans to switch to the new
survey vendor.
If a hospice is considering switching survey vendors, it must contact the CAHPS Hospice
Survey Project Team right away. Early contact with the CAHPS Hospice Survey Project Team
will help make a successful transition to the new survey vendor. Be aware that in the past some
hospices have suffered a two percent reduction in Medicare payments due to an unsuccessful
transition to a new survey vendor.
Survey vendors or hospices can contact the CAHPS Hospice Survey Project Team at
[email protected] or 1-844-472-4621 for assistance with the process for switching
survey vendors. The following items must be completed on the CAHPS Hospice Survey Vendor
Authorization Form before a new survey vendor can be successfully authorized:
1. The Name of the Current CAHPS Hospice Survey Vendor that is being De-authorized.
2. The Name of the New CAHPS Hospice Survey Vendor with the start date, which
corresponds to the first month of the quarter based on the death of the patient, for which
the new survey vendor will be collecting CAHPS Hospice Survey data on behalf of the
hospice.
Note: If a hospice wishes to change CAHPS Hospice Survey vendors, it may do so ONLY
at the beginning of a calendar quarter. A quarter is based on the calendar year and
corresponds to the month of patient death.
• Quarter 4 2019 begins with October 2019 patient deaths (caregivers to be surveyed
January 2020). The CAHPS Hospice Survey Vendor Authorization Form must be
submitted by January 2020.
• Quarter 1 2020 begins with January 2020 patient deaths (caregivers to be surveyed
April 2020). The CAHPS Hospice Survey Vendor Authorization Form must be
submitted by April 2020.
• Quarter 2 2020 begins with April 2020 patient deaths (caregivers to be surveyed July
2020). The CAHPS Hospice Survey Vendor Authorization Form must be submitted by
July 2020.
• Quarter 3 2020 begins with July 2020 patient deaths (caregivers to be surveyed October
2020). The CAHPS Hospice Survey Vendor Authorization Form must be submitted by
October 2020.
• Quarter 4 2020 begins with October 2020 patient deaths (caregivers to be surveyed
January 2021). The CAHPS Hospice Survey Vendor Authorization Form must be
submitted by January 2021.
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Preparation for Data Submission
Each survey vendor participating in the CAHPS Hospice Survey is required to designate a primary
Data Administrator within their organization responsible for submitting survey data to the CAHPS
Hospice Survey Data Warehouse on behalf of hospice clients. In addition to the primary Data
Administrator, each survey vendor must designate a second person within the organization to act
as the Back-up Data Administrator who will also have access to the CAHPS Hospice Survey Data
Warehouse. Survey vendors may also designate an optional third Data Administrator. The Data
Administrators will be designated as the main point of contact between the CAHPS Hospice
Survey Data Coordination Team and the survey vendor regarding issues related to uploading files
to the CAHPS Hospice Survey Data Warehouse. In addition, the Data Administrators will have
primary responsibility for ensuring that the survey vendor follows procedures for preparing and
submitting survey data according to CMS requirements as outlined in this manual. The CAHPS
Hospice Survey Data Coordination Team must be notified of any personnel changes to the survey
vendor’s Data Administrator roles by submitting a new CAHPS Hospice Survey Data Warehouse
Access Form for Vendors and Hospices. The new Data Administrator will be required to create a
new password for the survey vendor’s CAHPS Hospice Survey Data Warehouse account.
The CAHPS Hospice Survey Data Warehouse allows for data submission by survey vendors and
review of data submission reports by both hospices and survey vendors. Hospices may designate
up to three individuals within their organization who will have access to CAHPS Hospice Survey
Data Submission Reports. The CAHPS Hospice Survey Data Coordination Team must be notified
of any personnel changes to the hospice’s designees by submitting a new CAHPS Hospice Survey
Data Warehouse Access Form for Vendors and Hospices. The new designee will be required to
create a new password for the hospice’s CAHPS Hospice Survey Data Warehouse account.
Survey vendors and hospices may designate their Data Administrators by completing the CAHPS
Hospice Survey Data Warehouse Access Form for Vendors and Hospices (see Appendix C) and
emailing or mailing it to the CAHPS Hospice Survey Data Coordination Team. Once the CAHPS
Hospice Survey Data Coordination Team has verified the information on the form and, for survey
vendors, confirmed that a survey vendor has been authorized by one or more hospice clients to
submit data on their behalf, a folder will be created in the CAHPS Hospice Survey Data Warehouse
(https://kiteworks.rand.org) for each survey vendor and hospice designee. Each person authorized
to use the CAHPS Hospice Survey Data Warehouse will receive an automated email containing a
link that will direct them to the CAHPS Hospice Survey Data Warehouse login screen where they
will be able to choose a password, login to the CAHPS Hospice Survey Data Warehouse and access
their secure folder.
Survey File Submission Naming Convention
In submitting CAHPS Hospice Survey data files, survey vendors must use the following file
naming convention:
vendorname.mmddyy.submission#.xml.pgp
Where
vendorname = name of survey vendor
mm = number of the month of submission (justify leading zero)
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dd = day of the month of submission (justify leading zero)
yy = 2 digit year of submission
submission# = submission number for each date
Example: XYZResearch.060115.1.xml.pgp
Each file uploaded to the CAHPS Hospice Survey Data Warehouse must have a unique name,
even if the prior file uploaded was rejected from the Warehouse for any reason. Any file uploaded
with an identical file name to a prior file cannot be processed.
Note: Files submitted must include a record for every decedent/caregiver included in the
“sampled-cases” count (for the interim data submission, the record for a decedent/caregiver for
whom the survey vendor has not yet completed the survey must be coded with the disposition code
“33 – No Response Collected”).
Password Authentication
Upon successful authentication of the survey vendor’s or hospice designee’s username and
password, users will have access to their organization’s designated folder in the CAHPS Hospice
Survey Data Warehouse. Survey vendors and hospice designees will receive an email directing
them to the CAHPS Hospice Survey Data Warehouse, where they can login using their email
address as the login ID. On their first login, all users will be prompted to choose a new password
(passwords must be at least 8 characters in length and contain at least one of each of the following
classes of characters: uppercase letters, lowercase letters, numbers, and special characters).
Organization of the CAHPS Hospice Survey Data Warehouse
Survey vendors will upload data files to a secure CAHPS Hospice Survey Data Warehouse hosted
by the RAND Corporation. Each survey vendor will have its own folder in the CAHPS Hospice
Survey Data Warehouse and will not be able to see, locate or access another survey vendor’s folder.
Hospices will have their own folders in the CAHPS Hospice Survey Data Warehouse and will not
be able to see, locate or access any survey vendor’s or other hospice’s folder. Documents and files
of interest to all survey vendors and hospices will be placed in the top level folder of the CAHPS
Hospice Survey Data Warehouse and will be visible and available for download by any authorized
user of the CAHPS Hospice Survey Data Warehouse.
File Encryption
All survey vendors must adhere to file format specifications and, as an additional security
precaution, are required to encrypt survey data files using Symantec File Share Encryption
(formerly PGP and still widely known as and referred to in this document as PGP) prior to
submitting files to the CAHPS Hospice Survey Data Warehouse. This software is a widely used,
commercially available data encryption computer program that provides cryptographic privacy
and authentication for data communication. Each survey vendor is responsible for purchasing a
license if they do not already use Symantec File Share Encryption. The software is available from
http://www.symantec.com/file-share-encryption?fid=encryption. Prior versions of PGP software
may also be used for encryption.
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Files must be encrypted using the CAHPS Hospice Survey PGP Public Key before they are
uploaded to the CAHPS Hospice Survey Data Warehouse. The CAHPS Hospice Survey Data
Coordination Team will provide all survey vendors with the PGP Public Key by placing a copy of
the Public Key in the survey vendor’s folder of the CAHPS Hospice Survey Data Warehouse. Data
files submitted to the CAHPS Hospice Survey Data Warehouse that are not encrypted will be
rejected and must be resubmitted.
Any file uploaded to the survey vendor’s folder that does not have the “.pgp” extension, indicating
the prescribed PGP encryption, will be quarantined and automatically deleted. An automated email
will be sent to the survey vendor’s Data Administrators, informing them they have uploaded a file
that does not comply with the established naming standards and that the file therefore will not be
processed and will need to be resubmitted correctly. The CAHPS Hospice Survey Data
Coordination Team will also be notified by automated email that the event occurred.
Instructions for Accessing the CAHPS Hospice Survey Data Warehouse
The process for survey vendors and hospices to access the CAHPS Hospice Survey Data
Warehouse is as follows:
1. The Data Administrator must submit a Data Warehouse Access Form (see Appendix C) as
an email attachment to [email protected], by mail, or by FedEx.
2. The Data Administrator will receive an email from the CAHPS Hospice Survey Data
Coordination Team with an invitation to the CAHPS Hospice Survey Data Warehouse.
This email will contain a link to the CAHPS Hospice Survey Data Warehouse
(https://kiteworks.rand.org).
3. After clicking the link, the Data Administrator will be routed to the login page where he/she
will be prompted for his/her user ID and a password
4. On the first login only, the Data Administrator will be presented with a page to change
his/her password
5. Once the password has been updated, the Data Administrator will be transferred to the “All
files” tab of the CAHPS Hospice Survey Data Warehouse, where they will select the name
of their organization
6. For vendors, selecting the “Upload” button within their organization’s “Hospice” folder
will allow the user to upload their organization’s files.
Note: Hospice Data Administrators can only view and download reports. They may not submit
files to the CAHPS Hospice Survey Data Warehouse.
Data Auditing, Validation Checks and Data Submission Reports
The CAHPS Hospice Survey Data Coordination Team will audit the data files as they are
submitted by survey vendors for compliance with the file specifications outlined in the chapter on
Data Coding and Data File Preparation in this manual. Survey vendors and hospices are
responsible for accessing and reviewing the CAHPS Hospice Survey Data Submission Reports.
Data Audit and Validation
The data audit process conducted by the CAHPS Hospice Survey Data Coordination Team
involves conducting various data checks of the survey data submitted by survey vendors. After a
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file has been submitted to the CAHPS Hospice Survey Data Warehouse, the survey vendor and
hospice will receive an automated email confirming the file submission.
Once submitted, an automated program will check for the appropriate file extension “.pgp” to
indicate that a survey file has been encrypted. As described above, any file uploaded to the CAHPS
Hospice Survey Data Warehouse that does not have the “.pgp” extension will be automatically
deleted. In such instances, an automated email will be sent to the survey vendor’s Data
Administrator and Back-up Data Administrator informing them that a new report is available. The
report will state that they have uploaded a file that does not comply with the established naming
standards, and that the file will not be processed; and therefore, a corrected file will need to be
resubmitted prior to the deadline. If the file has been sent with the correct “.pgp” extension, the
survey vendor will not receive this email. Both the confirmation email and the incorrect encryption
email will be sent within two hours of the file upload.
Successfully submitted files will be put through a series of edit checks such as:
Morphological tests (appropriate character set, naming conventions, etc.)
Checks for the presence of required data fields
Range checks of data fields
Survey vendors’ and hospices’ designated Data Administrators will receive a second email
indicating that the CAHPS Hospice Survey Data Submission Reports comprised from the edit
checks listed above are available for viewing in their respective folders in the CAHPS Hospice
Survey Data Warehouse. Reports will be posted by 5 PM Eastern Time on the next business day
after upload. CAHPS Hospice Survey Data Submission Reports for hospices will include
information only for their hospice; reports for survey vendors will include information for all
hospices whose data were included in the data submission.
Note: Each set of CAHPS Hospice Survey Data Submission Reports will correspond to only the
data included in that XML file. If a survey vendor chooses to submit each CCN in a different XML
file, the survey vendor will be responsible for reviewing the CAHPS Hospice Survey Data
Submission Reports for each separate XML file.
Note: Survey vendors must retain all received emails indicating a successful upload of data to the
CAHPS Hospice Survey Data Warehouse, and be prepared to provide copies of these emails upon
request.
Survey vendors are responsible for uploading a corrected file by the submission deadline. If the
data file uploaded passes the edit checks described above, no additional action is required. If the
uploaded data file fails any of the edit checks, it will be noted in the report uploaded to the survey
vendor’s and hospice’s CAHPS Hospice Survey Data Warehouse folder. Survey vendors and
hospices will need to review their CAHPS Hospice Survey Data Submission Reports to determine
what errors were found in the files, and survey vendors will be required to resubmit a corrected
survey data file. Hospices will receive updated reports after new data are submitted for their
hospice, until their dataset has passed all edit checks. Survey vendors will receive reports for each
data submission.
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Data Submission Reports
Four CAHPS Hospice Survey Data Submission Reports are accessible by hospices and survey
vendors. The reports will contain information related to each data submission as well as a summary
of submissions for each hospice. The reports are as follows:
Data Submission Detail Report (Part I): This report indicates whether or not the data
submitted by the survey vendor was accepted and processed. If the uploaded file fails to
conform to the correct XML specifications, the file will not be processed and the remainder
of the reports will not be generated. A corrected file will need to be resubmitted prior to
the data submission deadline.
Data Submission Detail Report (Part II): This report indicates if the submitted data
passed data quality checks. If any values are out of range, “Data Value Checks Status” will
show as “Rejected,” the report will list all of the errors in the file, and the survey vendor
must submit a new file. If all data values pass the data quality checks, “Data Value Checks
Status” will show as “Accepted,” and no further action is needed.
Survey Status Summary Report: This report lists whether a Hospice Record was
accepted, the sample size, the number of decedent/caregiver administrative records, the
number of valid survey status codes, and the number of completed surveys for each hospice
contained within the file. These are listed separately by month of death, and overall.
Review and Correction Report: For hospices, this report lists the number of valid and
invalid responses to each variable in the file. For survey vendors, this report lists the
frequency of values for each variable in the file.
Note: All hospices should review the Data Submission Reports after they are uploaded to their
CAHPS Hospice Survey Data Warehouse folder.
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XI. Oversight Activities
Overview
In order to verify compliance with CAHPS Hospice Survey protocols, the CMS-sponsored CAHPS
Hospice Survey Project Team conducts oversight of participating survey vendors. This chapter
describes the oversight activities for the CAHPS Hospice Survey. All materials and procedures
relevant to survey administration are subject to review. Signing the CAHPS Hospice Survey
Participation Form for Survey Vendors and Attestation Statement signifies agreement with
all of the Rules of Participation, including all CAHPS Hospice Survey oversight activities.
Oversight Activities
Survey vendors are required to participate in CAHPS Hospice Survey oversight activities. The
purpose of the oversight activities is to ensure that approved survey vendors follow the CAHPS
Hospice Survey administration protocols; and thereby ensure the comparability of CAHPS
Hospice Survey data across hospices. These oversight activities include, but are not limited to, the
following:
CAHPS Hospice Survey Quality Assurance Plan
The CAHPS Hospice Survey Quality Assurance Plan (QAP) is a comprehensive working
document that is developed, and periodically revised, by survey vendors in order to
document their current processes for the administration of the CAHPS Hospice Survey and
correct implementation of standard protocols. The QAP should also be used as a training
tool for project staff, subcontractors and any other organizations, if applicable. The CAHPS
Hospice Survey Project Team reviews survey vendor QAPs to ensure that the survey
vendor’s stated processes are compliant with CAHPS Hospice Survey protocols. Any
approved Exception Requests must be thoroughly discussed in the QAP.
CAHPS Hospice Survey Materials
Materials relevant to CAHPS Hospice Survey administration, including mailing materials
(i.e., questionnaires, cover letters and outgoing envelopes) and/or telephone scripts and
interviewer CATI screenshots (including skip pattern logic), are required to be submitted
for each approved mode of survey administration. CMS may also request additional
survey-related materials for review, as needed.
Analysis of Submitted Data
All survey data submitted to the CAHPS Hospice Survey Data Warehouse by survey
vendors are reviewed by the CAHPS Hospice Survey Data Coordination Team. This
review includes, but is not limited to, statistical and comparative analyses; preparation of
data for reporting; and other activities as required by CMS. If data anomalies are found,
follow-up will occur with the survey vendor.
Site Visits/Conference Calls
All survey vendors (and their subcontractors and any other organizations, if applicable) are
required to participate in site visits and/or conference calls conducted by the CAHPS
Hospice Survey Project Team. The site visits allow the CAHPS Hospice Survey Project
Team to review and observe systems, procedures, facilities, resources, and documentation
related to administering the CAHPS Hospice Survey. The conference calls allow the
CAHPS Hospice Survey Project Team to discuss issues with the survey vendor related to
administration of the CAHPS Hospice Survey.
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Additional Activities
Additional activities as specified by CMS may be conducted.
Note: If the site visit/conference call or any other oversight activity conducted by the CAHPS
Hospice Survey Project Team suggests that actual survey processes differ from CAHPS Hospice
Survey protocols, immediate corrective actions may be required and sanctions may be applied.
CAHPS Hospice Survey Quality Assurance Plan
Survey vendors approved to administer the CAHPS Hospice Survey are obligated to develop and
continually update a QAP. The QAP is a comprehensive working document that outlines the
survey vendor’s implementation of, and compliance with, the CAHPS Hospice Survey guidelines.
The main purposes of the QAP are as follows:
Provide documentation of survey vendors’ understanding, application and compliance with
the CAHPS Hospice Survey Quality Assurance Guidelines. The following components
must be addressed:
1. Organizational background and structure for project
2. Work plan for survey administration
3. Survey and data management system and quality controls
4. Confidentiality, privacy and security procedures
5. Discussion of results of quality control activities
Serve as the organization-specific guide for administering the CAHPS Hospice Survey,
training project staff to conduct the survey and conducting quality control and oversight.
The QAP should be developed in enough step-by-step detail, including flow charts,
tracking forms and diagrams, such that the survey methodology is easily replicable
by a new staff member assigned to CAHPS Hospice Survey operations.
Ensure high quality data collection and continuity in survey processes
The QAP should be free of extraneous information and must provide sufficient detail so that the
CAHPS Hospice Survey Project Team can determine the survey vendor’s adherence to survey
administration guidelines and that rigorous quality checks and controls have been put in place.
The CAHPS Hospice Survey Project Team will notify survey vendors of the due date to submit a
QAP to the CAHPS Hospice Survey Project Team. All QAPs must be dated and all changes from
prior versions must be clearly identified (e.g., use Microsoft Word track changes). At a minimum,
the updated QAP should specifically address the following items:
Changes in survey administration processes, including any process changes due to
revisions outlined in the CAHPS Hospice Survey Quality Assurance Guidelines
A discussion of the results of the quality control checks performed in the prior year
A discussion of the challenges faced by the survey vendor and/or client hospices in survey
administration in the prior year, and how those challenges were addressed
Changes in key staff
Changes in resources
Along with the QAP, survey vendors may be required to submit other materials relevant to the
CAHPS Hospice Survey administration, when requested by CMS. The CAHPS Hospice Survey
Project Team’s acceptance of a submitted QAP and corresponding survey materials does not
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constitute or imply approval or endorsement of the survey vendor’s CAHPS Hospice Survey
administration processes.
A Model QAP can be found in Appendix H. It is required that survey vendors use the Model QAP
as a template for developing and updating their own QAP. The Model QAP can be downloaded
from the CAHPS Hospice Survey Web site (www.hospicecahpssurvey.org).
Analysis of Submitted Data
The CAHPS Hospice Survey Data Coordination Team reviews and analyzes all survey data
submitted to the CAHPS Hospice Survey Data Warehouse in order to ensure the integrity of the
data. If significant issues are identified, the survey vendor may be contacted. Survey vendors must
adhere to all submission requirements as specified in the CAHPS Hospice Survey Quality
Assurance Guidelines manual, as well as the deadline dates posted on the CAHPS Hospice Survey
Web site. Please monitor the CAHPS Hospice Survey Web site for additional data submission
information and updates.
Site Visits/Conference Calls
The CAHPS Hospice Survey Project Team will conduct site visits and/or conference calls with
survey vendors to verify compliance with the CAHPS Hospice Survey protocols. The size and
composition of the review team will vary.
Site visits may be announced and scheduled in advance, or they may be unannounced. Survey
vendors will be given a three-day window during which an unannounced site visit may be
conducted.
The CAHPS Hospice Survey Project Team works with the survey vendor in advance of the site
visit to discuss agenda items that will be covered during the site visit. The CAHPS Hospice Survey
Project Team conducts its site reviews in the presence of the survey vendor’s staff, and a
confidentiality agreement is signed by all parties at the start of the site visit. The CAHPS Hospice
Survey Project Team may also review any additional information or facilities determined to be
necessary to complete the site visit, including work performed by subcontractors and any other
organizations, if applicable. Survey vendors must make their subcontractors and any other
organizations available to participate in the site visits and conference calls.
During the site visit and/or conference call, the CAHPS Hospice Survey Project Team will review
the survey vendor’s survey systems and will assess compliance to protocols based on the CAHPS
Hospice Survey Quality Assurance Guidelines. All materials relevant to survey administration will
be subject to review. The systems and program review includes, but is not necessarily limited to:
Survey management
Communication with and training of staff, client hospices, subcontractors, and any other
organizations
Data systems
Sampling procedures
Printed materials
Printing, mailing and other related facilities
Telephone materials, interview areas and other related facilities
Telephone interviews
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Data receipt and entry
Storage facilities
Confidentiality, privacy and security
Written documentation of survey processes to include documentation of quality check
activities conducted
Specific and/or randomly selected records covering a time period to include the data in the
most recent report period, or earlier
In addition to other activities, the CAHPS Hospice Survey Project Team will observe and review
data systems and processes, which may require access to confidential records and/or PHI. The site
visit includes a review of sampling procedures. The CAHPS Hospice Survey Project Team will
review specific data records and trace the documentation of activities from the receipt of the
decedents/caregivers list through the uploading of the data to the CAHPS Hospice Survey Data
Warehouse. The Project Director/Project Manager at a minimum must be physically present during
the site visit. If any CAHPS Hospice Survey processes are automated, then the programmer must
be available during the site visit to review the programming. The site visit may also include
interviews with key staff members and interactions with project staff, subcontractors and any other
organizations, if applicable. Any information observed or obtained during the site visit will remain
confidential, as per CMS guidelines. After the site visit, the CAHPS Hospice Survey Project Team
will provide the survey vendor with a summary of findings from the site visit, and may pose followup questions and/or request additional information as needed.
After the site visit or conference call, survey vendors will be given a defined time period in which
to correct any problems and provide follow-up documentation of corrections for review. Survey
vendors will be subject to follow-up site visits and/or conference calls, as needed.
Non-compliance and Sanctions
Non-compliance with CAHPS Hospice Survey protocols, including program requirements, timely
submission of data and materials and participation and cooperation in oversight activities, may
result in sanctions being applied to a hospice or its survey vendor including:
increased oversight activities
loss of approved status to administer the CAHPS Hospice Survey
application of the appropriate footnote(s) to CAHPS Hospice Survey results reported on
the Hospice Compare Web site
suppression of publicly reported scores, as needed
other sanctions as deemed appropriate by CMS
Note: Hospices that contract with a survey vendor should be aware that non-compliance by
either hospices or survey vendors could result in these, or other, sanctions. Be aware that a
survey vendor that loses approved status cannot submit data to the CAHPS Hospice Survey Data
Warehouse; and therefore, cannot help the hospice in meeting CMS compliance requirements.
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XII. Data Reporting
Overview
This chapter describes the public reporting of the CAHPS Hospice Survey results on the Hospice
Compare Web site (https://www.medicare.gov/hospicecompare). All currently active hospices are
reported on Hospice Compare and in the downloadable database. CAHPS Hospice Survey measure
scores are calculated across a rolling eight quarters and are published quarterly. The CAHPS
Hospice Survey data submitted by each survey vendor is reviewed, cleaned, scored, and adjusted
(including adjustments for case-mix and mode). Information describing the calculation of CAHPS
Hospice Survey Top-, Middle- and Bottom-Box scores and the case-mix adjustment methods for
the CAHPS Hospice Survey measures is available on the Scoring and Analysis tab on the CAHPS
Hospice Survey Web site (www.hospicecahpssurvey.org).
Reporting Periods
(Dates of Death)
01/1/2017 – 12/31/2018
04/1/2017 – 03/31/2019
07/1/2017 – 06/30/2019
10/1/2017 – 09/30/2019
01/1/2018 – 12/31/2019
Provider Preview
Period
September 2019
December 2019
March 2020
June 2020
September 2020
Hospice Compare
Refresh Dates
November 2019
February 2020
May 2020
August 2020
November 2020
Publicly Reported CAHPS Hospice Survey Measures
Hospice Compare reports results for eight measures. There are six composite measures, which are
comprised of multiple survey questions, and two single-item or global measures, which are the
results of one survey question each. The eight measures are:
Composite Measures
1. Communication with Family (Q6, Q8, Q9, Q10, Q14, Q35)
2. Getting Timely Help (Q5, Q7)
3. Treating Patient with Respect (Q11, Q12)
4. Emotional and Spiritual Support (Q36, Q37, Q38)
5. Help for Pain and Symptoms (Q16, Q22, Q25, Q27)
6. Training Family to Care for Patient (Q18, Q19, Q20, Q23, Q29)
Global Measures
1. Rating of this Hospice (Q39)
2. Willingness to Recommend this Hospice (Q40)
Scoring Overview
CMS calculates the “top-box,” “middle-box” and “bottom-box” scores for the questions in the
eight CAHPS Hospice Survey measures. If a survey respondent does not respond to a question for
which he or she is eligible, a score is not calculated for that respondent for that question. With one
exception, all responses to questions for which a respondent was eligible are used in the score
calculation. The exception is the Training Family to Care for Patient measure; for this measure,
the measure score is calculated only among those respondents who indicated that their family
member received hospice care at home or in an assisted living facility.
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For all questions, the “top-box” score for each response is calculated as a “100” if the most positive
response category(ies) for that question is selected or a “0” otherwise. The “bottom-box” score for
each response is calculated as a “100” if the least positive response category(ies) for that question
is selected or a “0” otherwise.
Different questions have different response options. Responses are categorized as “top-box,”
“middle-box” or “bottom-box” as follows:
Response Scale
Top-Box
Response
(most positive)
Middle-Box
Response
Bottom-Box
Response
(least positive)
Never/Sometimes/Usually/Always Always
Usually
Never/Sometimes/Usually/Always
(Question 10 only)*
No/Yes, Somewhat/Yes,
Definitely
Definitely No/Probably
No/Probably Yes/Definitely Yes
Rating 0-10, where 10 is the most
positive
Too Little/Right Amount/Too
Much**
Never
Sometimes
Never;
Sometimes
Always; Usually
Yes, Definitely
Yes, Somewhat
No
Definitely Yes
Probably Yes
9 or 10
7 or 8
Probably No;
Definitely No
0-6
Right Amount
N/A***
Too Little; Too
Much / Too
Little**
* Question 10 is “While your family member was in hospice care, how often did anyone from the hospice team give you confusing
or contradictory information about your family member’s condition or care?”
**Prior to Q3 2018, the bottom box for this response scale was defined as ‘too little’ and ‘too much.’ Beginning with Q3 2018
decedent data, the bottom box was defined as ‘too little;’ responses of ‘too much’ were not included in scoring.
***The response options for this response scale are grouped into top- and bottom-box scores only.
The “Top-box” score is the proportion of respondents who gave the most positive response or
responses to the question. For example, “Always” is generally the top-box response when a
question’s response options are Never, Sometimes, Usually, or Always.
The “Middle-box” score is the proportion of respondents who gave the intermediate response or
responses to the question. For example, “Usually” is generally the middle-box response when a
question’s response options are Never, Sometimes, Usually, or Always. There is no middle box
score when the response options are Too little, Right amount or Too much.
The “Bottom-box” score is the proportion of respondents who gave the least positive response or
responses. For example, “Sometimes” and “Never” are generally the bottom-box response when a
question’s response options are Never, Sometimes, Usually, or Always.
There are two special situations that have slightly different rules. First, the “Emotional and
Spiritual Support” measure does not have a middle-box score; only top-box and bottom-box scores
are reported. Additionally, the scoring is reversed for the question that asks, “While your family
member was in hospice care, how often did anyone from the hospice team give you confusing or
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contradictory information about your family member’s condition or care?” For this question,
“Never” is the top-box response and “Always” and “Usually” are the bottom-box responses.
Adjusting Results
CAHPS Hospice Survey results are adjusted for survey mode and case-mix prior to public
reporting. Only adjusted results are publicly reported and considered the official CAHPS Hospice
Survey results. The adjusted results may differ from the unadjusted results. Please see the Scoring
and Analysis page of the CAHPS Hospice Survey Web site (www.hospicecahpssurvey.org) for
more information on these data adjustments, as well as additional information regarding CAHPS
Hospice Survey scores.
Footnotes
Some hospices have footnotes displayed with their measure scores on Hospice Compare. These
footnotes are used to describe the reason a hospice does not have measure scores displayed, or any
potential issues with the hospice’s measure scores. There are six footnotes used for CAHPS
Hospice Survey scores, shown below:
Footnote 6 indicates that the number of cases is too small to report. This footnote is applied
if there are fewer than 30 completed surveys for the hospice for the reporting period, or
there were fewer than 11 answers for the measure.
Footnote 7 indicates that results are based on a shorter time period than required
Footnote 8 indicates that data were suppressed by CMS
Footnote 9 indicates that there were discrepancies in the data collection process, as reported
by survey vendors to CMS. Hospices should direct any questions regarding discrepancies
to their survey vendors.
Footnote 10 indicates that none of the required data were submitted for this reporting period
Footnote 11 indicates that results are not available for this reporting period. This footnote
is applied when the hospice is too new or too small to be required to participate in the
CAHPS Hospice Survey, or when no cases meet the criteria for a measure for the reporting
period.
CAHPS Hospice Survey Provider Preview Reports
Prior to each quarterly release of data on Hospice Compare, hospice providers are given the
opportunity to review their Hospice CAHPS results during a 30-day preview period using the
Hospice CAHPS Provider Preview Report. The purpose of these reports is to give providers the
opportunity to preview their CAHPS Hospice Survey results on each measure prior to public
display on Hospice Compare. CAHPS Hospice Provider Preview Reports can be accessed via
Certification and Survey Provider Enhanced Reports (CASPER) application, which is accessible
from a Hospice’s “Welcome to the CMS QIES Systems for Providers” page.
Providers will not be able to access their preview reports after 60 days from the report release date.
CMS encourages providers to download and save their Hospice Provider Preview Reports for
future reference as they will no longer be available in CASPER after this 60-day period.
Note: Some hospices may not have their scores publicly reported. There are various reasons this
could occur; for example, the hospice could be too small or too new to be required to participate
in the CAHPS Hospice Survey, or there may be fewer than 30 completed surveys for the hospice
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over the 8-quarter reporting period. If a hospice’s scores are not publicly reported, the Provider
Preview Report will display “Not available,” along with a footnote that explains why.
Thirty Day CAHPS Hospice Survey Preview Period
Hospices will have 30 days to preview their CAHPS Hospice Survey measure results beginning
on the date the reports are made available by CMS. Should the hospice provider believe the data
are inaccurate, a provider may request CMS review of the data contained within the CAHPS
Hospice Provider Preview Report.
As noted above, the data presented in the CAHPS Hospice Provider Preview Report is adjusted
for mode and case mix. This means it may not match the data the hospice may be receiving from
their survey vendor. A mismatch of this type does not imply the data in the Preview Report is
inaccurate.
Requests for review of a hospice’s CAHPS Hospice Survey results must be submitted via email
to: [email protected]. Please note, this is a different address than the one used for
review requests involving HIS data. The procedure to request CMS’ review of the CAHPS Hospice
Survey
data
during
the
30-day
Preview
Period
can
be
found
at
https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/HospiceQuality-Reporting/Public-Reporting-CAHPS-Preview-Reports-and-Requests-for-CMS-Reviewof-CAHPS-Data.html
All other questions related to the Hospice Quality Reporting Program should be directed to the
Hospice Quality Help Desk at [email protected]. Technical questions about
the CAHPS Hospice Survey should be directed to [email protected] or call toll free
at 1-844-472-4621.
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XIII. Exception Request Process
Overview
The Exception Request Process and Exception Request Form have been established to handle
alternative methodologies that vary from standard CAHPS Hospice Survey protocols. The
proposed alternative methodology(ies) must not be implemented until the submitted Exception
Request Form has been approved.
Exception Request Process
The Exception Request Process has been created to provide survey vendors with more flexibility
to meet individual organizations' need for certain variations from protocol, while still maintaining
the integrity of the data for standardized reporting. The Exception Request Form must be
completed with sufficient detail, including clearly defined timeframes, for the CAHPS Hospice
Survey Project Team to make an informed decision. The requested exception from protocol must
not be implemented prior to receiving approval from the CAHPS Hospice Survey Project Team.
Exception Requests will be limited to a two-year approval timeframe. The two-year time
period will begin from the date of approval.
To request an exception, survey vendors are required to complete and submit an Exception Request
Form online via the CAHPS Hospice Survey Web site (www.hospicecahpssurvey.org). The form
is designed to capture information on the proposed alternative to the standard protocol(s). The
hospice CCN(s) must be included on the form.
Survey vendors must complete and submit all Exception Request Forms on behalf of their
client hospice(s)
Survey vendors may submit one Exception Request Form on behalf of multiple hospices
with the same Exception Request. Survey vendors must include a list of contracted
hospices and each hospice CCN on whose behalf they are submitting the Exception
Request.
A new Exception Request Form must be submitted for hospices not included in the original
request
Exception Request Category
Survey vendors must request an exception for alternative strategies not identified in the CAHPS
Hospice Survey Quality Assurance Guidelines manual.
Note: No alternative modes of survey administration will be permitted other than those prescribed
for the survey (Mail Only, Telephone Only and Mixed Mode [mail with telephone follow-up]).
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Exception Request Review Process
The Exception Request will be reviewed by the CAHPS Hospice Survey Project Team. The review
will include an assessment of the methodological soundness of the proposed alternative and the
potential for introducing bias. Depending on the type of exception, a review of procedures and/or
a site visit or conference call may be required. The CAHPS Hospice Survey Project Team will
notify survey vendors whether or not their exception has been approved. If the request is not
approved, the CAHPS Hospice Survey Project Team will provide an explanation. Survey vendors
then have the option of appealing the decision.
Survey vendors have five business days from the date of the Exception Request denial notification
email to submit an appeal. To request an appeal, survey vendors must resubmit the Exception
Request Form (checking the box marked “Appeal of Exception Denial”) and provide further
information that addresses the explanation for the denial. The appeal is then submitted to the
CAHPS Hospice Survey Project Team for re-review. The second review will take approximately
10 business days.
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XIV. Discrepancy Report Process
Overview
The Discrepancy Report Process and the Discrepancy Report Form have been established for use
by survey vendors to notify the CAHPS Hospice Survey Project Team of any discrepancies in
following standard CAHPS Hospice Survey protocols. Survey vendors are required to immediately
notify the CAHPS Hospice Survey Project Team of any discrepancies in following the standard
CAHPS Hospice Survey protocols which have been encountered during survey administration.
Discrepancy Report Process
On occasion, a survey vendor may identify discrepancies from CAHPS Hospice Survey protocols
that require corrections to procedures and/or electronic processing to realign the activity to comply
with CAHPS Hospice Survey protocols. Survey vendors are required to notify CMS of these
discrepancies. In its oversight role, the CAHPS Hospice Survey Project Team may also identify
discrepancies that require correction. Examples of discrepancies include, but are not limited to,
missing survey-eligible decedents/caregivers from a particular month, survey administration
begins late or does not occur for any month, sampled eligible decedent/caregiver found to be
ineligible, or computer programming that caused an otherwise survey-eligible decedent/caregiver
to be excluded from the sample frame.
Survey vendors must complete and submit Discrepancy Report Forms on behalf of their
client hospice(s)
Survey vendors are required to complete and submit a Discrepancy Report Form to
formally notify CMS immediately upon discovery of the discrepancy. The Discrepancy
Report Form must be submitted online via the CAHPS Hospice Survey Web site
(www.hospicecahpssurvey.org). This report informs the CAHPS Hospice Survey Project
Team of the nature, timing, cause, and extent of the discrepancy, as well as the proposed
correction and timeline to correct the discrepancy. The hospice CCN(s) must be included
on the form.
• The value “Unknown” is acceptable in an initial Discrepancy Report Form if the
eligible and sample decedents/caregivers affected are not known at the time of
submission but these values should be provided in an update
Survey vendors must notify all affected client hospices that a Discrepancy Report has been
submitted
Discrepancy Report Review Process
The Discrepancy Report will be thoroughly reviewed by the CAHPS Hospice Survey Project
Team. Notification of the outcome of the review may not be forthcoming until all the data for the
affected reporting periods have been submitted and reviewed. Email notification will be distributed
to the organization submitting the Discrepancy Report Form once the outcome of the review has
been determined. Hospices are encouraged to contact their survey vendor to inquire about the
outcome of the review. In addition, a footnote may be applied to publicly reported CAHPS Hospice
Survey results to indicate that these results are derived from data whose collection or processing
deviated from established CAHPS Hospice Survey protocols. The footnote will be applied until
the affected data are no longer included in publicly reported data.
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Depending on the nature and extent of the discrepancy, a formal review of the survey vendor’s
procedures, and/or a site visit or conference call may be conducted. The CAHPS Hospice Survey
Project Team will notify survey vendors if additional information is required to document and
correct the issue. Please note, CMS requires survey vendors to complete and submit Discrepancy
Report Forms. CMS will not revoke a survey vendor’s approval status due to submission of a
Discrepancy Report, unless corrective actions are not successfully implemented. CMS will,
however, consider revoking a survey vendor’s approval if the survey vendor is found to have
repeated unreported discrepancies.
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XV. Data Quality Checks
Overview
Survey vendors must implement quality assurance processes to verify the integrity of the collected
and submitted CAHPS Hospice Survey data. This chapter describes suggested quality check
activities that survey vendors may implement, and should not be considered an exhaustive list of
possible quality check activities that can be used by survey vendors. It is important to note that
quality check activities must be performed by a different staff member than the individual who
originally performed the specific project task. The goals of conducting quality check activities are
to minimize the probability of errors occurring in the handling of the data throughout the various
steps of data processing; to verify that required fields are present and protocols are met; and to
identify and explain unusual or unexpected changes in the data files. Therefore, quality checks
must be operationalized for all of the key components or steps of survey administration and data
processing.
Traceable Data File Trail
Survey vendors must save both original and processed CAHPS Hospice Survey data files for a
minimum of three years. This allows for easier identification of issues. The information below
provides suggestions regarding CAHPS Hospice Survey-related file retention:
Preserve a copy of every file received in original form and leave unchanged (including files
received from hospice clients)
Record general summary information such as total number of decedent/caregiver cases,
survey-eligible size, decedent month, etc.
Institute version controls for datasets, reports and any software code and programs used for
collecting and processing CAHPS Hospice Survey data records
• Do not delete old data files
• Keep intermediate data files, not just original and final versions
Review of Data Files
Survey vendors should examine their own data files and all clients’ data files for any unusual or
unexpected changes, including missing data. Trending or comparing data elements for individual
hospices over different time periods is one technique that can be used to determine whether any
unusual or unexpected changes have occurred. While the presence of such a change does not
necessarily mean an error has occurred, it should prompt survey vendors to further evaluate the
data in order to verify the difference(s). Listed below are suggested activities:
Verify that data are associated with the correct hospice CCN
Investigate data for notable changes in the counts of decedents/caregivers and eligible
decedents/caregivers
Prior to processing the decedents/caregivers list, run frequency/percentage tables for all
administrative variables received from the hospice (e.g., sex, race, last location), and
compare to same-variable tables from previous months.
• Look for missing administrative data elements (e.g., decedent primary diagnosis,
decedent date of birth), and follow-up with the hospice immediately upon receipt of the
decedents/caregivers list
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Prior to preparing data files for submission to the CAHPS Hospice Survey Data
Warehouse, run frequency/percentage tables for all survey variables stored for a given
hospice and month; compare to same-variable tables from previous months
• Verify that the number of administrative records matches the value for the sample size
for the given month
• Check that Hospice Record variables match back to raw data summary statistics for the
time period
• Review a random selection of administrative records as a quality check against original
raw decedent/caregiver data. This same activity can be performed for actual survey
records.
• Verify that required data elements for all decedents/caregivers in the CAHPS Hospice
Survey sample frame are submitted to the CAHPS Hospice Survey Data Warehouse
Accuracy of Data Processing Activities
In order to ensure that CAHPS Hospice Survey data are valid and reliable, data processing
activities must be conducted in accordance with required protocols. Data quality checks should be
implemented to verify that the required protocols have been followed. Examples of data quality
check activities include:
Verify that every eligible decedent/caregiver has a chance of being sampled
Evaluate the frequency of break-off surveys and/or unanswered questions, and investigate
possible causes
Review CAHPS Hospice Survey Data Submission Reports to confirm data submission
activity is correct and as expected
Review quarterly submission results from the Review and Correction Report to confirm a
match with the frequency tables completed during previous quality check activities as
described above
Summary
This chapter highlights a number of possible activities to assist survey vendors in developing
procedures for data quality checks. The information contained in this chapter is intended for
instructional purposes and is not considered to be all-inclusive. The CAHPS Hospice Survey
Project Team will conduct site visits to survey vendors that will include review of survey
administration operations along with the documentation of quality checks that have been
conducted.
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Appendix A
Minimum Business Requirements
CAHPS Hospice Survey
Minimum Business Requirements
A survey vendor must meet ALL of the Survey Vendor Minimum Business Requirements at the
time the CAHPS Hospice Survey Participation Form is received (a subcontractor’s or other
organization’s survey administration experience does not substitute for a survey vendor’s). In
addition, subcontractors and any other organizations that are responsible for performing major
CAHPS Hospice Survey administration functions (e.g., mail/telephone operations) must also
meet all of the CAHPS Hospice Survey Minimum Business Requirements that pertain to that
role. The minimum business requirements for an organization to become approved to administer
the CAHPS Hospice Survey are as follows:
Management Relationships:
Criteria
Survey Vendor
Current/Future
The following types of organizations are not eligible to administer
Relationships with
the CAHPS Hospice Survey (as an approved CAHPS Hospice
Hospices
Survey vendor):
• organizations or divisions within organizations that own or
operate a hospice or provide hospice services, even if the
division is run as a separate entity to the hospice;
• organizations that provide telehealth, monitoring of hospice
patients, or teleprompting services for the hospice; and
• organizations that provide staffing to hospices for providing
care to hospice patients, whether personal care aides or skilled
services staff.
Relevant Survey Experience:
Criteria
Survey Vendor
Number of Years in
Minimum four years
Business
Number of Years
Minimum of three years Mail, and/or Telephone, and/or Mixed
Conducting PatientMode patient-specific survey experience within the most recent
Specific Surveys
three-year time period
Sampling Experience
Two years prior experience selecting a random sample based on
specific eligibility criteria within the most recent two-year time
period
Work with contracted client(s) to obtain patient data for sampling
via Health Insurance Portability and Accountability Act- (HIPAA)
compliant electronic data transfer processes
Adequately document sampling process
Survey vendors are responsible for conducting the sampling
process and must not subcontract this activity
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Survey Capability and Capacity:
Criteria
Survey Vendor
Personnel
Designated CAHPS Hospice Survey personnel:
• Project Director with minimum two years prior experience
conducting patient-specific surveys in the requested mode(s)
• Staff with minimum one year prior experience in sample frame
development and sample selection
• Programmer (subcontractor designee, if applicable) with
minimum one year prior experience receiving large encrypted
data files in different formats/software packages electronically
from an external organization; processing survey data needed
for survey administration and survey response data; preparing
data files for electronic submission; and submitting data files to
an external organization
• Call Center/Mail Center Supervisor (subcontractor designee, if
applicable) with minimum one year prior experience in role
Have appropriate organizational back-up staff for coverage of key
staff
Volunteers are not permitted to be involved in any aspect of the
CAHPS Hospice Survey administration process
Physical Plant and
Physical plant resources available to handle the volume of surveys
System Resources
being administered, including computer and technical equipment:
• A secure commercial work environment
• Home-based or virtual interviewers cannot be used to
administer the CAHPS Hospice Survey, nor may they conduct
any survey administration processes
• Physical facilities and electronic equipment and software to
collect, process and report data securely
• If offering telephone surveys, must have the equipment,
software and facilities to conduct computer-assisted telephone
interviewing (CATI) and to monitor interviewers
Electronic or alternative survey management system to:
• Track fielded surveys throughout the protocol, avoiding
respondent burden and losing respondents
• Assign random, unique, de-identified identification number
(Tracking ID) to track each sampled decedent/primary informal
caregiver (i.e., family member or friend of the hospice patient)
Organizations that are approved to administer the CAHPS Hospice
Survey must conduct all of their business operations within the
United States. This requirement applies to all staff and
subcontractors or other organizations involved in survey
administration.
All System Resources are subject to oversight activities, including
site visits to physical locations
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Criteria
Sample Frame
Creation
Mail Administration
Telephone
Administration
Mixed Mode
Administration (Mail
with Telephone
Follow-up)
Survey Vendor
A minimum of two years prior experience selecting a random
sample based on specific eligibility criteria in the most recent twoyear time period
Generate the sample frame data file that contains all individuals
who meet the eligible population criteria
Draw random sample of individuals for the survey who meet the
eligible population criteria
Mail survey administration activities are not to be conducted from
a residence, nor from a virtual office
Obtain and update addresses of sampled caregivers of hospice
decedents
Produce and print professional quality survey instruments and
materials according to guidelines; a sample of all mailing materials
must be submitted for review
Merge and print sample name and address on personalized mail
survey cover letters and print unique Tracking ID on the survey
questionnaire
Mail out survey materials
Receive and process (key-enter or scan) completed questionnaires
Track and identify non-respondents for follow-up mailing
Assign final survey status codes to describe the final result of work
on each sampled record
Telephone interviews are not to be conducted from a residence, nor
from a virtual office
Obtain, verify and update telephone numbers
Develop CATI system
Collect telephone interview data for the survey using CATI system;
a sample of the telephone script and interviewer screenshots must
be submitted for review
Identify non-respondents for follow-up telephone calls
Schedule and conduct callbacks to non-respondents at varying
times of the day and different days of the week
Assign final survey status codes to reflect the final result of
attempts to obtain a completed interview with each sampled record
Mail survey administration and telephone interviews are not to be
conducted from a residence, nor from a virtual office
Adhere to all Mail Only and Telephone Only survey administration
requirements (described above)
Track cases from mail survey through telephone follow-up
activities
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Criteria
Data Submission
Data Security
4
Survey Vendor
Two years prior experience transmitting data via secure methods
(HIPAA-compliant)
Survey vendors are responsible for conducting data submission
and must not subcontract this process
Survey vendors must have the capacity to do the following actions
to submit quarterly data files:
• Register as a user of the CAHPS Hospice Survey Data
Warehouse
• Confirm contracted hospices have authorized survey vendor to
submit data on behalf of the hospice
• Import scanned or key-entered data from completed mail
surveys into a data file, if applicable
• Import (as necessary) data from CATI system into a data file,
if applicable
• 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 cases
• Export data from the electronic data collection system to the
required format for data submission, confirm that the data are
exported correctly and that the data submission files are
formatted correctly and contain the correct data headers and
data records
• Encrypt and submit data electronically in the specified format
to the CAHPS Hospice Survey Data Warehouse
• Work with CMS’ contractor to resolve data problems and data
submission issues
Survey vendors must have the capacity to do the following actions
to secure electronic data:
• Use a firewall and/or other mechanisms for preventing
unauthorized access to electronic files
• Implement access levels and security passwords so that only
authorized users have access to sensitive data
• Implement daily data back-up procedures that adequately
safeguard system data
• Test back-up files on a quarterly basis, at a minimum, to make
sure the files are easily retrievable and working
• Perform frequent saves to media to minimize data losses in the
event of power interruption
• Develop procedures for identifying and handling breaches of
confidential data
• Develop a disaster recovery plan for conducting ongoing
business operations in the event of a disaster
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Criteria
Data Retention and
Storage
Technical Assistance/
Customer Support
Organizational
Confidentiality
Requirements
Survey Vendor
Survey vendors must have the capacity to do the following actions
to securely store all data related to survey administration:
• Store CAHPS Hospice Survey-related data files, including
decedents/caregivers lists and de-identified electronic data files
(e.g., sample frame, XML files, etc.), for all applicable survey
modes for a minimum of three years. Archived electronic data
files must be easily retrievable.
• Store de-identified returned mail questionnaires in a secure and
environmentally safe location (e.g., locked file cabinet, locked
closet or room), if applicable. Paper copies or optically scanned
images of the questionnaires must be retained for a minimum
of three years and be easily retrievable.
Two years prior experience providing telephone customer support
Provide toll-free customer support line:
• Offering customer support in all languages that the survey
vendor administers the survey in
• Returning calls within 24-48 hours
Survey vendors must have the capacity to do all of the following
actions:
• Develop confidentiality agreements which include language
related to HIPAA regulations and the protection of personal
identifying information (PII) and obtain signatures from all
personnel with access to survey information, including staff
and all subcontractors or other organizations involved in survey
administration and data collection. Confidentiality agreements
must be reviewed and re-signed periodically, at the discretion
of the survey vendor, but not to exceed more than a three-year
period.
• Execute Business Associate Agreement(s) (BAA) in
accordance with HIPAA regulations
• Confirm that staff and subcontractors or other organizations
involved in survey administration are compliant with HIPAA
regulations in regard to decedent/caregiver protected health
information (PHI) and PII
• Establish protocols for secure file transmission. Emailing of
PHI or PII via unsecure email is prohibited.
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Participation in Quality Control Activities and Documentation Requirements:
Criteria
Survey Vendor
Demonstrated Quality Incorporate well-documented quality control procedures (as
Control Procedures
applicable) for:
• Training of in-house staff and subcontractors or other
organizations involved in survey operations
• Printing, mailing and recording receipt of survey
questionnaires, if applicable
• Telephone administration of survey, if applicable
• Coding and verifying of survey data and survey-related
materials
• Scanning or keying-in survey data
• Preparation of final person-level data files for submission
• Submitting Discrepancy Reports immediately upon
discovering a discrepancy in following CAHPS Hospice
Survey protocols
• All other functions and processes that affect the administration
of the CAHPS Hospice Survey
Participate in any conference calls and site visits as part of overall
quality monitoring activities:
• 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
Documentation
Keep electronic or hard copy files of staff training and training
Requirements
dates
Maintain electronic documentation of telephone monitoring, if
applicable
Maintain documentation of mail production quality checks, if
applicable
Maintain documentation of all survey administration activities and
related quality checks for review during site visits
Develop a Quality Assurance Plan (QAP) for survey
administration in accordance with CAHPS Hospice Survey Quality
Assurance Guidelines and update the QAP at the time of process
and/or key personnel changes as part of retaining participation
status
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Adhere to all Protocols, Specifications and Agree to Participate in Training Sessions:
Criteria
Survey Vendor
Survey Training
Attend the Introduction to CAHPS Hospice Survey Training
session and all CAHPS Hospice Survey Update Training sessions
(at a minimum, survey vendor’s Project Manager and
subcontractors or other organizations involved in survey
administration assigned key roles must attend training)
Complete the post-training quiz measuring comprehension of
CAHPS Hospice Survey protocols
Administer the Survey Review and follow all procedures described in the CAHPS
According to All
Hospice Survey Quality Assurance Guidelines that are applicable
Survey Specifications
to the selected survey data collection mode(s)
Fully comply with the CAHPS Hospice Survey oversight activities
Approved survey vendors are expected to maintain active
contract(s) for CAHPS Hospice Survey administration with client
hospice(s). An “active contract” is one in which the CAHPS
Hospice Survey vendor is authorized by hospice client(s) to collect
and submit CAHPS Hospice Survey data to the CAHPS Hospice
Survey Data Warehouse.
• If a CAHPS Hospice Survey vendor does not have any
contracted hospice clients within two years (a consecutive 24
months) of the date they received approval to administer the
CAHPS Hospice Survey, then that survey vendor’s
“Approved” status for CAHPS Hospice Survey administration
will be withdrawn
• If approval status is withdrawn, the organization must once
again follow the steps to apply for reconsideration for approval
to administer the CAHPS Hospice Survey
o If a survey vendor chooses to not re-apply at this time, then
a 24-month wait period will be required before the
organization is eligible to apply again
o If a CAHPS Hospice Survey vendor is approved for a
second term and does not have any contracted hospice
clients by the end of the second 24-month approved period,
a 24-month wait period will be required before the
organization is eligible to apply again
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Appendix B
Survey Vendor Authorization Form
CAHPS Hospice Survey
Survey Vendor Authorization Form
Hospice agencies must authorize an approved CAHPS Hospice Survey vendor to submit data on
their behalf for the administration of the CAHPS Hospice Survey.
In order to authorize a survey vendor or switch to a new survey vendor, a hospice
representative must complete the CAHPS Hospice Survey Vendor Authorization Form and
submit it to the RAND Corporation one calendar quarter (90 days) prior to the first time
data will be submitted to the CAHPS Hospice Survey Data Warehouse by that vendor. The
individual who completes this form for the hospice will be considered the CAHPS Hospice Survey
Administrator for that hospice. Hospices should also designate, on the form, an individual within
the hospice organization to serve as the main point of contact with the CAHPS Hospice Survey
Project Team.
If a hospice wishes to change CAHPS Hospice Survey vendors, it may do so ONLY at the
beginning of a calendar quarter. Note: A quarter is based on the calendar year (CY) and will
correspond to the month of patient death. For example, Quarter 1 2020 begins with January 2020
patient deaths (caregivers to be surveyed April 2020).
This form must be signed and dated in the presence of a notary public, notarized and sent to the
RAND Corporation. Please note, when completing the CAHPS Hospice Survey Vendor
Authorization Form pertaining to multiple hospice agencies, it is appropriate to attach a list to the
form (signed and dated by the CAHPS Hospice Survey Administrator) of all the applicable
hospices (hospice names and CMS Certification Numbers [CCNs]). Please check the box on the
form indicating that a separate document is attached and indicate the number of hospice names
and CCNs listed on the separate sheet.
If sent via U.S. Mail, send to:
RAND Corporation
ATTN: Survey Research Group - Data Reduction
CAHPS Hospice Survey
1776 Main Street
Santa Monica, CA 90401
If sent via Federal Express, UPS or other overnight delivery service, send to:
RAND Corporation
ATTN: Survey Research Group - Data Reduction
CAHPS Hospice Survey
1776 Main Street
Santa Monica, CA 90401
Phone: (310) 393-0411, extension 5599
Note: After submission of the CAHPS Hospice Survey Vendor Authorization Form, no further
action is required by the hospice to notify CMS of their survey vendor selection. The RAND
Corporation communicates to CMS which hospice agencies have authorized a survey vendor to
administer the CAHPS Hospice Survey on their behalf.
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CAHPS Hospice Survey
Survey Vendor Authorization Form
I, ________________________________ (print CAHPS Hospice Survey Administrator’s
name), acknowledge and accept the role and all of the responsibilities of the CAHPS Hospice
Survey Administrator for CCN _________________________ (print CMS Certification
Number
or
“see
attached
list
of
CCNs”
if
multiple);
______________________________________________ (print name of hospice or “see
attached list of hospices”).
In this role I will be responsible for:
1) Authorizing a survey vendor to collect data for ____________________________ (print
name of hospice or “See attached list”) as part of the CAHPS Hospice Survey and to submit
data to CMS on behalf of the hospice.
2) Notifying CMS and the RAND Corporation immediately if the hospice de-authorizes a
survey vendor by completing a new Vendor Authorization Form.
3) Designating an individual within the hospice organization to serve as the main point of
contact with the CAHPS Hospice Survey Project Team.
4) Notifying the CAHPS Hospice Survey Project Team if my role as the CAHPS Hospice
Survey Administrator for the hospice will no longer be valid and identifying my successor
by submitting a new Vendor Authorization Form.
By signing this form, I authorize ____________________________ (print CAHPS Hospice
Survey vendor name) to collect data for the hospice I represent as part of the CAHPS Hospice
Survey and to submit data to CMS on behalf of the hospice.
Hospice Administrator First and Last Name:
Hospice Administrator Signature:
Date:
Title:
Phone Number: (
)
Email:
Hospice Mailing Address:
City:
State:
Zip Code:
Hospice Point of Contact for the CAHPS Hospice Survey Project Team (if different from
administrator):
First and Last Name:
Phone Number: (
) __________________________________________________________
Email: _______________________________________________________________________
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Name of Old Survey Vendor (De-authorizing), or “n/a” if no prior vendor:
______________________________________________________________________________
Name of Survey Vendor Authorizing*:
______________________________________________________________________________
Start date for Vendor Authorizing (based on decedent month of death)
See below before filling in start date **: __________________________________
*Approved Survey Vendors may be located at: www.hospicecahpssurvey.org/en/approved-vendorlist.
**Note: If a hospice wishes to change CAHPS Hospice Survey vendors, it may do so ONLY at the
beginning of a calendar quarter. A quarter is based on the calendar year and corresponds to the
month of patient death.
• Quarter 3 2019 begins with July 2019 patient deaths (caregivers to be surveyed October 2019)
• Quarter 4 2019 begins with October 2019 patient deaths (caregivers to be surveyed January
2020)
• Quarter 1 2020 begins with January 2020 patient deaths (caregivers to be surveyed April 2020)
• Quarter 2 2020 begins with April 2020 patient deaths (caregivers to be surveyed July 2020)
• Quarter 3 2020 begins with July 2020 patient deaths (caregivers to be surveyed October 2020)
• Quarter 4 2020 begins with October 2020 patient deaths (caregivers to be surveyed January
2021)
Notary Public Signature:
Stamp:
Notary Public Date:
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Appendix C
Data Warehouse Access Form
CAHPS Hospice Survey
Data Warehouse Access Form for Vendors and Hospices
The CAHPS Hospice Survey Data Warehouse is maintained by the RAND Corporation. All survey
vendors contracting with hospices to implement the CAHPS Hospice Survey must have a user
account in the CAHPS Hospice Survey Data Warehouse. All hospices must also have a user
account in order to monitor data submission activities.
Provide contact information below for your organization’s Data Administrator and Back-up Data
Administrator. Complete contact information is required to authorize a user account. Your form
must be received one calendar quarter (90 days) prior to the first time data will be submitted
to the CAHPS Hospice Survey Data Warehouse.
Please note: By submitting a new form, your organization is indicating a change to its Data
Administrator and/or Back-up Data Administrator. Administrators listed on prior Data
Warehouse Access Forms will no longer have access to the Data Warehouse.
Date Form Submitted:
Your Organization’s Name(s):
For Hospices Only Your Organization’s CCN(s):
OR:
CCN List is attached (Indicate number of hospices on list ______ )
Data Administrator
First and Last Name:
Phone Number: ( _____ )
Email: ____________
Back-up Data Administrator
First and Last Name:
Phone Number: ( _____ )
Email: ____________
Additional Data Administrator (Optional)
First and Last Name:
Phone Number: ( _____ )
Email: ____________
Submit completed forms to the CAHPS Hospice Survey Data Coordination Team:
As an email attachment to: [email protected]
By mail or Fedex to: RAND Corporation, CAHPS Hospice Survey
ATTN: Survey Research Group - Data Reduction
1776 Main Street
Santa Monica, CA 90401
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Appendix D
Sample File Layout
CAHPS Hospice Survey
Sample File Layout
Below is an example of a sample file layout. Please note the following:
1. The Sample File Layout is used to facilitate the standardized administration of the CAHPS
Hospice Survey and includes the data elements necessary for data submission, sampling and
proper record keeping. The decedent/caregiver identifying information and other italicized
Data Element fields will not be submitted to the CAHPS Hospice Survey Data Warehouse.
2. CMS strongly recommends that survey vendors collect all data elements whether or
not they are required for data submission.
Sample File Layout
Data Element
Length
Value Labels and Use
Provider Name
100
Provider ID
10
NPI
10
Facility Name 1
100
Number of Hospice
Offices
10
Total Number of
Live Discharges
10
Total Number of
Decedents
10
Name of the hospice
CMS Certification Number (CCN)
[formerly known as Medicare Provider
Number]
National Provider Identifier (NPI)
Name of hospice, inpatient or nursing
home facility, if applicable
The total number of hospice offices
operating within this CCN. These are
separate administrative or practice offices
for the CCN, not to be confused with
individual facilities or settings in which
hospice care is provided.
Number of patients who were discharged
alive during the month
Number of decedents during the month
for the hospice CCN only (calculated as
the number of records provided by hospice
for the CCN plus the number of “no
publicity” cases)
Required
for Data
Submission
Yes
Yes
No
No
Yes
Yes
Yes
1
A caregiver may associate their family member’s care with the facility where hospice care was received,
rather than the actual name of the hospice organization. Therefore, "Facility Name" refers to the name of
the facility (e.g., name of the assisted living facility, nursing home, hospital, or hospice house) where care
was received. For example, if the decedent received care from Hospice ABC while in Facility XYZ,
Facility XYZ is the "Facility Name."
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Sample File Layout
Data Element
“No Publicity”
Decedents/Caregivers
Hospice
Decedent/Caregiver ID
Caregiver First Name
Caregiver Middle
Initial
Caregiver Last Name
Caregiver Prefix Name
Caregiver Suffix Name
Decedent First Name
Decedent Middle
Initial
Decedent Last Name
Decedent Prefix Name
Decedent Suffix Name
Length
10
16
“No publicity” decedents/caregivers are
those who initiate or voluntarily request at
any time during their stay that the hospice:
1) not reveal the patient’s identity; and/or
2) not survey him or her. Hospices must
retain documentation of the “no publicity”
request for a minimum of three years.
Hospice-generated ID submitted to survey
vendor
Yes
No
30
1
30
6
10
30
Name information used to personalize
materials to caregiver
No
1
30
6
10
Decedent Sex
1
Decedent Hispanic
1
Decedent Race
1
Decedent Date of
Birth
8
2
Value Labels and Use
Required
for Data
Submission
1 = Male
2 = Female
M = Missing
1 = Hispanic
2 = Non-Hispanic
M = Missing
1 = White
2 = Black or African American
3 = Asian
4 = Native Hawaiian or Pacific Islander
5 = American Indian or Alaska Native
6 = More than one race
7 = Other
M = Missing
MMDDYYYY
Used by survey vendor to calculate
decedent age to confirm decedent meets
eligibility criteria
Yes
Yes
Yes
Yes
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Sample File Layout
Data Element
Length
Decedent Date of
Death
8
Decedent Hospice
Admission Date
8
Decedent Last
Location/Setting of
Care
2
Decedent Payer
Primary
1
Value Labels and Use
MMDDYYYY
Used by survey vendor to calculate
decedent age to confirm decedent meets
eligibility criteria
MMDDYYYY
Decedent admission date for his/her final
episode of hospice care. Used by survey
vendor to confirm decedent meets
eligibility criteria.
1 = Home (Do not include assisted living
or any other facility)
2 = Assisted living
3 = Long-term care facility or non-skilled
nursing facility
4 = Skilled nursing facility
5 = Inpatient hospital
6 = Inpatient hospice facility
7 = Long-term care facility (hospital)
8 = Inpatient psychiatric facility
9 = Location not otherwise specified
10 = Hospice facility
M = Missing
The Valid Values are derived from the
Healthcare Common Procedure Coding
System (HCPCS) Codes: Q Codes for
Hospices.
1 = Medicare
2 = Medicaid
3 = Private
4 = Uninsured/No payer
5 = Program for All Inclusive Care for the
Elderly (PACE)
6 = Other
M = Missing
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Required
for Data
Submission
Yes
Yes
Yes
Yes
3
Sample File Layout
Data Element
Decedent Payer
Secondary
Decedent Payer Other
Length
1
1
Value Labels and Use
1 = Medicare
2 = Medicaid
3 = Private
4 = Uninsured/No payer
5 = Program for All Inclusive Care for the
Elderly (PACE)
6 = Other
M = Missing
1 = Medicare
2 = Medicaid
3 = Private
4 = Uninsured/No payer
5 = Program for All Inclusive Care for the
Elderly (PACE)
6 = Other
M = Missing
ICD-10 codes must be 3-8 characters. All
codes use an alphabetic lead character.
Most codes use numeric characters for the
second and third characters, though some
codes have an alphabetic third character.
Required
for Data
Submission
Yes
Yes
Do not submit descriptions of diagnoses
that are not in the ICD-10 format, and do
not submit Z-level codes, which represent
reasons for encounters, not diagnoses.
Decedent Primary
Diagnosis
4
8
Examples of ICD-10 codes in the correct
format are:
G20 – Parkinson’s disease
G30.9 – Alzheimer's disease, unspecified
I50.22 – Chronic systolic (congestive)
heart failure
C7A.024 – Malignant carcinoid tumor of
the descending colon
V00.818A – Other accident with
wheelchair (powered): Initial encounter
MMMMMMMM = Missing
Yes
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Sample File Layout
Data Element
Caregiver Mailing
Address 1
Caregiver Mailing
Address 2
Caregiver Mailing
City
Caregiver Mailing
State
Length
50
Street address or post office box (address
information used in protocols that have a
mail mode of survey administration)
No
50
Mailing address 2nd line (if needed)
No
50
Mailing city
No
2
Two-character state abbreviation
No
Caregiver Mailing
Zip Code
9
Caregiver Telephone
Number 1
10
Caregiver Telephone
Number 2
10
Caregiver Telephone
Number 3
10
Caregiver Email
Address
30
Caregiver Relationship
to the Decedent
Value Labels and Use
Required
for Data
Submission
1
Nine-digit zip code; no hyphen, separators
or de-limiters (i.e., 5-digit zip code
followed by 4-digit extension)
Three-digit area code plus 7-digit
telephone number; no dashes, separators
or de-limiters (telephone information used
in protocols that involve a telephone
component as part of the mode of
administration)
Three-digit area code plus 7-digit
telephone number; no dashes, separators
or de-limiters (telephone information used
in protocols that involve a telephone
component as part of the mode of
administration)
Three-digit area code plus 7-digit
telephone number; no dashes, separators
or de-limiters (telephone information used
in protocols that involve a telephone
component as part of the mode of
administration)
No
No
No
No
Email address of caregiver
No
1 = Spouse/Partner
2 = Parent
3 = Child
4 = Other family member
5 = Friend
6 = Legal guardian (non-familial)
7 = Other
8 = No caregiver of record
M = Missing
Yes
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Sample File Layout
Data Element
Caregiver Language
6
Length
1
Value Labels and Use
1 = English
2 = Spanish
3 = Chinese
4 = Russian
5 = Portuguese
6 = Vietnamese
7 = Polish
8 = Korean
9 = Other
M = Missing
Required
for Data
Submission
No
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Appendix E
XML File Specification
Version 6.0
CAHPS Hospice Survey XML File Specification Version 6.0
CAHPS Hospice Survey XML File Specification
Version 6.0
This XML File Specification (Version 6.0) applies to Q1 2020 decedents/caregivers and forward.
Each file submission can include all months in the quarter for all hospices (per CCN).
A CAHPS Hospice Survey XML file is made up of 4 parts: 1) Vendor Record, 2) Hospice (Provider) Record, 3) Decedent/Caregiver Administrative Record, and 4)
Survey Results Record.
There should be only one Vendor Record for each CAHPS Hospice Survey XML file. There should be a Hospice Record for each month of the quarter for each CCN if
the hospice was a client of the vendor for the month and sent a sample file (or confirmed zero decedents). Each decedent within the CAHPS Hospice Survey XML file
should have a Decedent/Caregiver Administrative Record; and if survey results are being submitted for the decedent, they should have a Survey Results Record.
Each field (except several conditional items – see Data Element Required field for more details) of the Vendor Record, Hospice Record, and Decedent/Caregiver
Administrative Record requires an entry for a valid data submission.
Survey Results Records are not required for a valid data submission but if survey results are included, then all fields must have an entry. Survey Results Records are
required if the final is “1 – Completed Survey,” “6 – Ineligible: Never Involved in Decedent Care” or “7 – Non-response: Break-off.”
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CAHPS Hospice Survey XML File Specification Version 6.0
XML Element
Attributes
Description
Valid Values
Data Type
Max
Field
Size
Data Element
Required
The following section defines the format of the Vendor Record.
This is the opening element of the file. The closing tag for this element will be at the end of the file. Attributes describe the element and are included
within the opening and closing <>
Opening Tag, defines a
None
N/A
NA
N/A Yes
N/A
submission by the survey
vendor
Each element must have a closing tag that is the same as the opening tag but with a forward slash. This vendordata element should only occur once per
file.
Sub-element of vendordata
Example: Vendor Business Name
None
The name of the survey vendor.
100 Yes
Must be vendor's business name Alphanumeric
Character
up to 100 alphanumeric
characters.
Sub-element of vendordata
Sub-element of vendordata
Sub-element of vendordata
September 2019
Each element must have a closing tag that is the same as the opening tag but with a forward slash. This vendordata element should only occur once per
file.
Example: 2020
YYYY
None
The year in which the file is submitted.
Numeric
4
Yes
YYYY = (2020 or greater)
(cannot be 9999)
Each element must have a closing tag that is the same as the opening tag but with a forward slash. This vendordata element should only occur once per
file.
Example: 1
MM
None
The month in which the file is submitted.
Numeric
2
Yes
MM = (1 - 12)
(cannot be 00, 13 - 99)
Each element must have a closing tag that is the same as the opening tag but with a forward slash. This vendordata element should only occur once per
file.
Example: 31
DD
None
The day in which the file is submitted.
Numeric
2
Yes
DD = (1 - 31)
(cannot be 00, 32 - 99)
Centers for Medicare and Medicaid Services
(CMS)
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CAHPS Hospice Survey XML File Specification Version 6.0
XML Element
Sub-element of vendordata
Attributes
Description
Valid Values
Data Type
Max
Field
Size
Data Element
Required
Each element must have a closing tag that is the same as the opening tag but with a forward slash. This vendordata element should only occur once per
file.
Example: 1
1 - 99
None
Ordinal number of the submission for the day.
Numeric
2
Yes
The submission count re-starts with every new day
of the file submission.
The following section defines the format of the Hospice Record. There should be one hospicedata record for each month of the survey.
Each element must have a closing tag that is the same as the opening tag but with a forward slash. This hospicedata element should only occur once for
each hospicedata record in the file. There should be one hospicedata record for each month of the survey.
Opening Tag, defines the
None
N/A
NA
N/A Yes
N/A
hospice record of monthly
sample data. There must be a
separate hospicedata group for
each month from which
decedents/caregivers were
sampled.
Each element must have a closing tag that is the same as the opening tag but with a forward slash. This hospicedata element should only occur once for
each hospicedata record in the file. There should be one hospicedata record for each month of the survey.
Sub-element of hospicedata
Example: 2020
YYYY
None
The year of death for the decedents included in
Numeric
4
Yes
this Hospice Record.
YYYY = (2020 or greater)
(cannot be 9999)
Sub-element of hospicedata
September 2019
Each element must have a closing tag that is the same as the opening tag but with a forward slash. This hospicedata element should only occur once for
each hospicedata record in the file. There should be one hospicedata record for each month of the survey.
Example: 1
None
The month of death for the decedents included in MM
Numeric
2
Yes
MM = (1 - 12)
this Hospice Record.
(cannot be 00, 13 - 99)
Centers for Medicare and Medicaid Services
(CMS)
Page 3 of 40
CAHPS Hospice Survey XML File Specification Version 6.0
XML Element
Sub-element of hospicedata
Sub-element of hospicedata
Sub-element of hospicedata
Sub-element of hospicedata
Attributes
Description
Valid Values
Data Type
Max
Field
Size
Data Element
Required
Each element must have a closing tag that is the same as the opening tag but with a forward slash. This hospicedata element should only occur once for
each hospicedata record in the file. There should be one hospicedata record for each month of the survey.
Example: Sample Hospice
N/A
None
The name of the hospice represented by the
Alphanumeric
100 Yes
survey.
Character
Each element must have a closing tag that is the same as the opening tag but with a forward slash. This hospicedata element should only occur once for
each hospicedata record in the file. There should be one hospicedata record for each month of the survey.
Example: 123456
None
The ID number (CCN) of the hospice represented Valid 6-digit CMS Certification Alphanumeric
10
Yes
Number (formerly known as
by the survey.
Character
Medicare Provider Number)
Each element must have a closing tag that is the same as the opening tag, but with a forward slash. This hospicedata element should only occur once for
each hospicedata record in the file. There should be one hospicedata record for each month of the survey.
Example: 1234567890
Valid 10 digit National
None
The National Provider Identifier (NPI) of the
Alphanumeric
10
Yes
Provider Identifier
hospice represented by the survey.
Character
M = Missing
Each element must have a closing tag that is the same as the opening tag but with a forward slash. This hospicedata element should only occur once for
each hospicedata record in the file. There should be one hospicedata record for each month of the survey.
Example: 1
None
The mode of survey administration.
Alphanumeric
1
Yes
1 - Mail Only
The survey mode must be the same for all three
Character
2 - Telephone Only
months within a quarter.
3 - Mixed Mode
8 - Not Applicable (no
decedents in the sampled
month)
September 2019
Centers for Medicare and Medicaid Services
(CMS)
Page 4 of 40
CAHPS Hospice Survey XML File Specification Version 6.0
XML Element
Sub-element of hospicedata
Sub-element of hospicedata
Sub-element of hospicedata
Sub-element of hospicedata
September 2019
Attributes
Description
Valid Values
Data Type
Max
Field
Size
Data Element
Required
Each element must have a closing tag that is the same as the opening tag but with a forward slash. This hospicedata element should occur three times,
once for each month of data collection, for each provider in the file.
Example: 150
M = Missing
None
The total number of decedents in the hospice in
Alphanumeric
10
Yes
the month including “no-publicity”
Character
decedents/caregivers.
Each element must have a closing tag that is the same as the opening tag but with a forward slash. This hospicedata element should occur three times,
once for each month of data collection, for each provider in the file.
Example: 5
None
The number of patients who were discharged alive M = Missing
Alphanumeric
10
Yes
during the month.
Character
Each element must have a closing tag that is the same as the opening tag but with a forward slash. This hospicedata element should occur three times,
once for each month of data collection, for each provider in the file.
Example: 1
The number of “no publicity”
Alphanumeric
10
Yes
M = Missing
None
decedents/caregivers during the month who
Character
initiated or voluntarily requested that they not be
revealed as a patient and/or whose caregiver
requested that they not be surveyed, and were
excluded from the file.
Each element must have a closing tag that is the same as the opening tag but with a forward slash. This hospicedata element should occur three times,
once for each month of data collection, for each provider in the file.
Example: 5
None
The number of decedents/caregivers not included N/A
Numeric
10
Yes
in the sample frame for the month because any
part (i.e., day, month, or year) of the decedent's
date of death is missing.
Centers for Medicare and Medicaid Services
(CMS)
Page 5 of 40
CAHPS Hospice Survey XML File Specification Version 6.0
XML Element
Sub-element of hospicedata
Sub-element of hospicedata
September 2019
Attributes
Description
Valid Values
Data Type
Max
Field
Size
Data Element
Required
Each element must have a closing tag that is the same as the opening tag but with a forward slash. This hospicedata element should occur three times,
once for each month of data collection, for each provider in the file.
Example: 5
None
The number of decedents/caregivers determined to N/A
Numeric
10
Yes
be ineligible for the month prior to sampling, for
any of the following reasons:
1. Decedent was under the age of 18
2. Decedent’s death was less than 48 hours
following last admission to hospice care
3. Decedent has no caregiver of record
4. Decedent’s caregiver is a non-familial legal
guardian
5. Decedent’s caregiver has an address outside the
U.S. or U.S. Territories
This count should NOT include cases that are
ineligible because of missing date of death.
Each element must have a closing tag that is the same as the opening tag but with a forward slash. This hospicedata element should occur three times,
once for each month of data collection, for each provider in the file.
Example: 139
None
The total number of decedents from the CCN in
Numeric
10
Yes
N/A
the month, minus the number of “no publicity”
decedents/caregivers (), the number
of decedents missing date of death () and the number of decedents/caregivers
found ineligible prior to sampling ().
Centers for Medicare and Medicaid Services
(CMS)
Page 6 of 40
CAHPS Hospice Survey XML File Specification Version 6.0
XML Element
Sub-element of hospicedata
Sub-element of hospicedata
Sub-element of hospicedata
September 2019
Attributes
Description
Valid Values
Data Type
Max
Field
Size
Data Element
Required
Each element must have a closing tag that is the same as the opening tag but with a forward slash. This hospicedata element should occur three times,
once for each month of data collection, for each provider in the file.
Example: 139
None
The total number of decedents/caregivers drawn N/A
Numeric
10
Yes
into the sample for the month. For CCNs using
census sampling, the “Sampled Cases” field
should equal the “Available Sample” field
() because all cases available
for sampling are drawn into the sample.
Each element must have a closing tag that is the same as the opening tag but with a forward slash. This hospicedata element should occur three times,
once for each month of data collection, for each provider in the file.
Example: 136
N/A
None
The number of eligible decedents/caregivers
Numeric
10
Yes
drawn into the sample for the month, not
including ineligible pre-sample () or ineligible post-sample () cases.
Each element must have a closing tag that is the same as the opening tag but with a forward slash. This hospicedata element should occur three times,
once for each month of data collection, for each provider in the file.
Example: 3
None
Number of decedents/caregivers in the sample for N/A
Numeric
10
Yes
the month with a “Final Survey Status” code of: “2
– Ineligible: Deceased,” “3 – Ineligible: Not in
Eligible Population,” “4 – Ineligible: Language
Barrier,” “5 – Ineligible: Mental/Physical
Incapacity,” “6 – Ineligible: Never Involved in
Decedent Care,” or “14 – Institutionalized.”
Centers for Medicare and Medicaid Services
(CMS)
Page 7 of 40
CAHPS Hospice Survey XML File Specification Version 6.0
XML Element
Sub-element of hospicedata
Sub-element of hospicedata
Closing tag for hospicedata
September 2019
Attributes
Description
Valid Values
Data Type
Max
Field
Size
Data Element
Required
Each element must have a closing tag that is the same as the opening tag but with a forward slash. This hospicedata element should only occur once for
each hospicedata record in the file. There should be one hospicedata record for each month of the survey.
Example: 1
None
The type of sampling used for the month.
Numeric
1
Yes
1 - Simple Random Sample
2 - Census Sample
8 - Not applicable (no
decedents in the sampled
Each element must have a closing tag that is the same as the opening tag but with a forward slash. This hospicedata element should only occur once for
each provider in the file.
Example: 3
None
The total number of hospice offices operating
Numeric
10
Yes
N/A
within this CCN. These are separate administrative
or practice offices for the CCN, not to be confused
with individual facilities or settings in which
hospice care is provided.
None
Note: This closing element for the hospice record is required in the XML document, however, it contains no data. This hospicedata
element should only occur once for each hospicedata record in the file. There should be one hospicedata record for each month of the
survey.
Centers for Medicare and Medicaid Services
(CMS)
Page 8 of 40
CAHPS Hospice Survey XML File Specification Version 6.0
XML Element
Attributes
Description
Valid Values
Data Type
Max
Field
Size
Data Element
Required
The following section defines the format of the Decedent/Caregiver Administrative Record.
This is the opening element of the decedent/caregiver level data record. The closing tag for this element will be at the end of the decedent/caregiver level
data record. Note: The section includes the opening and closing tags and all the tags between these two tags.
Opening Tag, defines the
The section is required in the XML file, if at least one decedent/caregiver is being submitted. If the is 0, and no
decedent level data record of
decedent/caregiver data is being submitted, the section should not be included in the XML file. This decedent/caregiver level data
monthly survey data
element should only occur once per decedent/caregiver.
N/A
N/A
None
NA
N/A Yes
Each element must have a closing tag that is the same as the opening tag but with a forward slash. This decedentleveldata element also occurs in the
previous hospicedata record, and will occur again as a data element in the caregiver response record.
Sub-element of
Example: 123456
decedentleveldata
None
The ID number (CCN) of the hospice represented Valid 6-digit CMS Certification Alphanumeric
10
Yes
by the survey.
Number (formerly known as
Character
Medicare Provider Number)
Sub-element of
decedentleveldata
Sub-element of
decedentleveldata
September 2019
Each element must have a closing tag that is the same as the opening tag but with a forward slash. This decedentleveldata element will occur again as a
data element in the caregiver response record.
Example: 12345
None
The unique de-identified decedent/caregiver ID
N/A
Alphanumeric
16
Yes
assigned by the survey vendor to uniquely identify
Character
the survey.
Each element must have a closing tag that is the same as the opening tag but with a forward slash. This decedentleveldata data element should only occur
once per decedent/caregiver.
Example: 1999
None
The year the decedent was born as provided by the YYYY
Numeric
4
Yes
(cannot be 9999)
hospice.
Use 8888 only if unable to
obtain information by the data
submission due date.
Centers for Medicare and Medicaid Services
(CMS)
Page 9 of 40
CAHPS Hospice Survey XML File Specification Version 6.0
XML Element
Sub-element of
decedentleveldata
Sub-element of
decedentleveldata
Sub-element of
decedentleveldata
Sub-element of
decedentleveldata
September 2019
Attributes
Description
Valid Values
Data Type
Max
Field
Size
Data Element
Required
Each element must have a closing tag that is the same as the opening tag but with a forward slash. This decedentleveldata data element should only occur
once per decedent/caregiver.
Example: 1
None
The month the decedent was born as provided by MM
Numeric
2
Yes
MM = (1 - 12)
the hospice.
(cannot be 00, 13 - 99)
Use 88 only if unable to obtain
information by the data
submission due date.
Each element must have a closing tag that is the same as the opening tag but with a forward slash. This decedentleveldata data element should only occur
once per decedent/caregiver.
Example: 1
None
The day the decedent was born as provided by the DD
Numeric
2
Yes
DD = (1 - 31)
hospice.
(cannot be 00, 32 - 99)
Use 88 only if unable to obtain
information by the data
submission due date.
Each element must have a closing tag that is the same as the opening tag but with a forward slash. This decedentleveldata data element should only occur
once per decedent/caregiver.
Example: 2020
YYYY
None
The year the decedent died as provided by the
Numeric
4
Yes
YYYY = (2020 or greater)
hospice.
(cannot be 9999)
Each element must have a closing tag that is the same as the opening tag but with a forward slash. This decedentleveldata data element should only occur
once per decedent/caregiver.
Example: 1
None
The month the decedent died as provided by the MM
Numeric
2
Yes
MM = (1 - 12)
hospice.
(cannot be 00, 13 - 99)
Centers for Medicare and Medicaid Services
(CMS)
Page 10 of 40
CAHPS Hospice Survey XML File Specification Version 6.0
XML Element
Sub-element of
decedentleveldata
Sub-element of
decedentleveldata
Sub-element of
decedentleveldata
September 2019
Attributes
Description
Valid Values
Data Type
Max
Field
Size
Data Element
Required
Each element must have a closing tag that is the same as the opening tag but with a forward slash. This decedentleveldata data element should only occur
once per decedent/caregiver.
Example: 1
None
The day the decedent died as provided by the
Numeric
2
Yes
DD
hospice.
DD = (1 - 31)
(cannot be 00, 32 - 99)
Each element must have a closing tag that is the same as the opening tag but with a forward slash. This decedentleveldata data element should only occur
once per decedent/caregiver.
Example: 2019
None
The year the decedent was admitted for final
Numeric
4
Yes
YYYY
episode of hospice care as provided by the
YYYY = (2009 or later)
hospice.
(cannot be 9999)
Use 8888 only if unable to
obtain information by the data
submission due date.
Each element must have a closing tag that is the same as the opening tag but with a forward slash. This decedentleveldata data element should only occur
once per decedent/caregiver.
Example: 1
None
The month the decedent was admitted for final
MM
Numeric
2
Yes
episode of hospice care as provided by the
MM = (1 - 12)
hospice.
(cannot be 00, 13 - 99)
Use 88 only if unable to obtain
information by the data
submission due date.
Centers for Medicare and Medicaid Services
(CMS)
Page 11 of 40
CAHPS Hospice Survey XML File Specification Version 6.0
XML Element
Sub-element of
decedentleveldata
Sub-element of
decedentleveldata
Sub-element of
decedentleveldata
September 2019
Attributes
Description
Valid Values
Data Type
Max
Field
Size
Data Element
Required
Each element must have a closing tag that is the same as the opening tag but with a forward slash. This decedentleveldata data element should only occur
once per decedent/caregiver.
Example: 1
DD
None
The day the decedent was admitted for final
Numeric
2
Yes
DD = (1 - 31)
episode of hospice care as provided by the
(cannot be 00, 32 - 99)
hospice.
Use 88 only if unable to obtain
information by the data
submission due date.
Each element must have a closing tag that is the same as the opening tag but with a forward slash. This decedentleveldata data element should only occur
once per decedent/caregiver.
Example: 1
None
The decedent's sex as provided by the hospice.
Alphanumeric
1
Yes
1 - Male
Character
2 - Female
M - Missing
Each element must have a closing tag that is the same as the opening tag but with a forward slash. This decedentleveldata data element should only occur
once per decedent/caregiver.
Example: 2
None
The indication whether on not decedent was
Alphanumeric
1
Yes
1 - Hispanic
Hispanic as provided by the hospice.
Character
2 - Non-Hispanic
M - Missing
Centers for Medicare and Medicaid Services
(CMS)
Page 12 of 40
CAHPS Hospice Survey XML File Specification Version 6.0
XML Element
Sub-element of
decedentleveldata
Attributes
Description
Valid Values
Data Type
Max
Field
Size
Data Element
Required
Each element must have a closing tag that is the same as the opening tag but with a forward slash. This decedentleveldata data element should only occur
once per decedent/caregiver.
Example: 1
None
The decedent's race as provided by the hospice.
Alphanumeric
1
Yes
1 - White
Character
2 - Black or African American
3 - Asian
4 - Native Hawaiian or Pacific
Islander
5 - American Indian or Alaska
Native
Sub-element of
decedentleveldata
6 - More than one race
7 - Other
M - Missing
Each element must have a closing tag that is the same as the opening tag but with a forward slash. This decedentleveldata data element should only occur
once per decedent/caregiver.
Example: 1
None
The caregiver relationship to the decedent as
Alphanumeric
1
Yes
1 - Spouse/partner
provided by the hospice.
Character
2 - Parent
3 - Child
4 - Other family member
5 - Friend
6 - Legal guardian
7 - Other
8 - No caregiver of record
M - Missing
September 2019
Centers for Medicare and Medicaid Services
(CMS)
Page 13 of 40
CAHPS Hospice Survey XML File Specification Version 6.0
XML Element
Sub-element of
decedentleveldata
Attributes
Description
Valid Values
Data Type
Max
Field
Size
Data Element
Required
Each element must have a closing tag that is the same as the opening tag but with a forward slash. This decedentleveldata data element should only occur
once per decedent/caregiver.
Example: 1
None
The decedent's primary payer for healthcare
Alphanumeric
1
Yes
1 - Medicare
services as provided by the hospice.
Character
2 - Medicaid
3 - Private
4 - Uninsured/no payer
5 - Program for All Inclusive
Care for the Elderly (PACE)
6 - Other
M - Missing
Each element must have a closing tag that is the same as the opening tag but with a forward slash. This decedentleveldata data element should only occur
once per decedent/caregiver.
Sub-element of
Example: 2
decedentleveldata
None
The decedent's secondary payer for healthcare
Alphanumeric
1
Yes
1 - Medicare
services as provided by the hospice.
Character
2 - Medicaid
3 - Private
4 - Uninsured/no payer
5 - Program for All Inclusive
Care for the Elderly (PACE)
6 - Other
M - Missing
September 2019
Centers for Medicare and Medicaid Services
(CMS)
Page 14 of 40
CAHPS Hospice Survey XML File Specification Version 6.0
XML Element
Sub-element of
decedentleveldata
Sub-element of
decedentleveldata
September 2019
Attributes
Description
Valid Values
Data Type
Max
Field
Size
Data Element
Required
Each element must have a closing tag that is the same as the opening tag but with a forward slash. This decedentleveldata data element should only occur
once per decedent/caregiver.
Example: 3
Yes
None
The decedent's other payer for healthcare services 1 - Medicare
Alphanumeric
1
as provided by the hospice.
Character
2 - Medicaid
3 - Private
4 - Uninsured/no payer
5 - Program for All Inclusive
Care for the Elderly (PACE)
6 - Other
M - Missing
Each element must have a closing tag that is the same as the opening tag but with a forward slash. This decedentleveldata data element should only occur
once per decedent/caregiver.
Example: 1
None
The decedent's last location/setting of hospice care 1 - Home
Alphanumeric
2
Yes
as provided by the hospice.
Character
2 - Assisted living
3 - Long-term care facility or
non-skilled nursing facility
4 - Skilled nursing facility
5 - Inpatient hospital
6 - Inpatient hospice facility
7 - Long-term care facility
8 - Inpatient psychiatric facility
9 - Location not otherwise
10 - Hospice facility
M - Missing
Centers for Medicare and Medicaid Services
(CMS)
Page 15 of 40
CAHPS Hospice Survey XML File Specification Version 6.0
XML Element
Sub-element of
decedentleveldata
Sub-element of
decedentleveldata
September 2019
Attributes
Description
Valid Values
Data Type
Max
Field
Size
Data Element
Required
Each element must have a closing tag that is the same as the opening tag but with a forward slash. This is an optional data element at this time but may
be required in the future.
Example: Facility
None
The name of the assisted living facility, nursing
Alphanumeric
100 Yes
Facility name up to 100
home, hospital, or hospice facility/hospice house alphanumeric characters.
Character
where the patient received care, if applicable
N/A = Missing/Not Applicable
(optional).
Each element must have a closing tag that is the same as the opening tag but with a forward slash. This decedentleveldata data element should only occur
once per decedent/caregiver.
Example: G30.9
None
The decedent's primary diagnosis provided by the ICD-10 code for the primary
Alphanumeric
8
Yes
hospice. ICD-10 codes must be 3-8 characters.
diagnosis of the decedent.
Character
All codes use an alphabetic lead character; most MMMMMMMM=Missing
codes use numeric characters for the second and
third character, though a small number have a
third character that is alphabetic. Do not submit
descriptions of diagnoses that are not in the ICD10 format, and do not submit Z-level codes, which
represent reasons for encounters, not diagnoses.
Centers for Medicare and Medicaid Services
(CMS)
Page 16 of 40
CAHPS Hospice Survey XML File Specification Version 6.0
XML Element
Sub-element of
decedentleveldata
Attributes
Description
Valid Values
Data Type
Max
Field
Size
Data Element
Required
Each element must have a closing tag that is the same as the opening tag but with a forward slash. This decedentleveldata data element should only occur
once per caregiver/decedent.
Example: 1
None
The disposition of the survey. For the final
1 - Completed Survey
Alphanumeric
2
Yes
quarterly submission for each CCN, no cases
Character
2 - Ineligible: Deceased
should be coded 33 or M.
3 - Ineligible: Not in Eligible
Population
4 - Ineligible: Language Barrier
5 - Ineligible: Mental/Physical
Incapacity
6 - Ineligible: Never Involved
in Decedent Care
7 - Non-response: Break-off
8 - Non-response: Refusal
9 - Non-response: Nonresponse after Maximum
Attempts
10 - Non-response: Bad/No
Address
11 - Non-response: Bad/No
Telephone Number
12 - Non-response: Incomplete
Caregiver Name
13 - Non-response: Incomplete
Decedent Name
14 - Ineligible: Institutionalized
15 - Non-response: Hospice
Disavowal
33 - No Response Collected
(used only for interim data file
submission)
M - Missing
September 2019
Centers for Medicare and Medicaid Services
(CMS)
Page 17 of 40
CAHPS Hospice Survey XML File Specification Version 6.0
XML Element
Sub-element of
decedentleveldata
Sub-element of
decedentleveldata
September 2019
Attributes
Description
Valid Values
Data Type
Max
Field
Size
Data Element
Required
Each element must have a closing tag that is the same as the opening tag but with a forward slash. This tag is required if the survey mode is Mixed Mode
and the “Final Survey Status” is “1 – Completed Survey,” “6 – Ineligible: Never Involved in Decedent Care” or “7 – Non-response: Break-off.” The
values entered must match a value corresponding to the survey mode defined in the Hospice Record section of the XML file. If the XML Element
is other than Mixed Mode, this tag should not be included in the XML file.
Example: 88
No, required only if
None
The survey mode used to complete a survey
Numeric
2
1 - Mixed Mode-mail
administered via the Mixed Mode. For Mail Only 2 - Mixed Mode-phone
survey mode is
Mixed and Survey
or Telephone Only, code 88.
88 - Not Applicable
Status is “1 –
Completed Survey,”
“6 – Ineligible: Never
Involved in Decedent
Care” or “7 – Nonresponse: Break-off.”
Each element must have a closing tag that is the same as the opening tag but with a forward slash. This tag is required if the survey mode is Telephone
Only or Mixed Mode with a survey completion mode answer of “2 - Mixed Mode-phone.” If the XML Element is other than Telephone
Only or Mixed Mode (phone), this tag does not need to be included in the XML file.
Example: 88
No, conditionally
None
The number of telephone contact attempts per
Numeric
2
1 - First Telephone Attempt
survey with a survey mode of Telephone Only or
required only if the
2 - Second Telephone Attempt
survey mode is
Mixed Mode. For Mail Only or Mixed Mode
(completed by mail), code 88.
Telephone Only
3 - Third Telephone Attempt
Mode or Mixed
Mode with survey
4 - Fourth Telephone Attempt
completion mode: “2
5 - Fifth Telephone Attempt
– Mixed Mode88 - Not Applicable
phone.”
Centers for Medicare and Medicaid Services
(CMS)
Page 18 of 40
CAHPS Hospice Survey XML File Specification Version 6.0
XML Element
Sub-element of
decedentleveldata
Sub-element of
decedentleveldata
Sub-element of
decedentleveldata
September 2019
Attributes
Description
Valid Values
Data Type
Max
Field
Size
Data Element
Required
Each element must have a closing tag that is the same as the opening tag but with a forward slash. This tag is required if the survey mode is Mail Only. If
the XML Element is other than Mail Only, this tag does not need to be included in the XML file.
Example: 1
None
The mail wave for which “Final Survey Status”
Numeric
2
No, conditionally
1 - First Wave Mailing
code is determined per survey with a survey mode 2 - Second Wave Mailing
required only if the
of Mail Only. For Telephone Only or Mixed
survey mode is Mail
88 - Not Applicable
Mode, code 88.
Only.
Each element must have a closing tag that is the same as the opening tag but with a forward slash. This decedentleveldata data element should only occur
once per decedent/caregiver.
Example: 1
None
The survey language in which the survey was
Numeric
2
Yes
1 - English
administered (English, Spanish, Chinese, Russian, 2 - Spanish
Portuguese, Vietnamese, Polish, Korean). Only
3 - Chinese
code 88 if survey not administered.
4 - Russian
5 - Portuguese
6 - Vietnamese
7 - Polish
8 - Korean
88 - Not Applicable
Each element must have a closing tag that is the same as the opening tag but with a forward slash. This decedentleveldata data element should only occur
once per decedent/caregiver. Note: The Lag Time should not be coded as "Missing."
Example: 106
None
The number of days between decedent date of
Numeric
3
Yes
0 - 365
death and the date that data collection activities
888 - Not Applicable
ended for the decedent/caregiver.
(use only for interim data file
submission)
Centers for Medicare and Medicaid Services
(CMS)
Page 19 of 40
CAHPS Hospice Survey XML File Specification Version 6.0
XML Element
Sub-element of
decedentleveldata
Attributes
Description
Valid Values
Data Type
Max
Field
Size
Data Element
Required
Each element must have a closing tag that is the same as the opening tag but with a forward slash. This decedentleveldata data element should only occur
once per decedent/caregiver.
Example: 4
None
A count of supplemental questions added to the
Alphanumeric
2
No. Required only if
0 - 15
questionnaire.
Character
“Final Survey Status”
M - Missing
is “1 – Completed
Survey,” “6 –
Ineligible: Never
Involved in Decedent
Care” or “7 – Nonresponse: Break-off.”
The following section defines the format of the Survey Results Record (caregiver response).
Note: Survey Results Records (caregiver response) are not required for a valid data submission; however, if survey results are included then all fields must have an entry.
Survey Results Record (caregiver response) is required if the final is "1 - Completed survey," "6 - Ineligible: Never Involved in Decedent Care," or "7 - Nonresponse: Break-off."
Opening Tag, defines the
decedent response data record
within the caregiver level data
record of monthly survey data
Sub-element of
caregiverresponse
September 2019
This is the opening element of the caregiver response record. The closing tag for this element will be at the end of the caregiver response record.
Note: There will be one section for each caregiver if survey results are being submitted for the caregiver. The
section includes the opening and closing tags and all the tags between these two tags. This section is required
in the XML file only if survey results are being submitted for the caregiver. If survey results are not being submitted for the caregiver the
section should not be submitted. This caregiver response element should only occur once per decedent.
N/A
N/A
None
NA
N/A Yes
Each element must have a closing tag that is the same as the opening tag but with a forward slash. This caregiverresponse element also occurs in the
previous hospicedata record and decedentleveldata record.
Example: 123456
None
The ID number (CCN) of the hospice represented Valid 6-digit CMS Certification Alphanumeric
by the survey.
Character
Number (formerly known as
Medicare Provider Number).
Centers for Medicare and Medicaid Services
(CMS)
10
Yes
Page 20 of 40
CAHPS Hospice Survey XML File Specification Version 6.0
XML Element
Sub-element of
caregiverresponse
Sub-element of
caregiverresponse
Sub-element of
caregiverresponse
September 2019
Attributes
Description
Valid Values
Data Type
Max
Field
Size
Data Element
Required
Each element must have a closing tag that is the same as the opening tag but with a forward slash. This element also occurs in the previous
decedentleveldata record.
Example: 12345
None
The unique de-identified decedent/caregiver ID
Alphanumeric
16
Yes
N/A
assigned by the hospice to uniquely identify the
Character
survey.
Each element must have a closing tag that is the same as the opening tag but with a forward slash. This caregiver response data element should only
occur once per caregiver.
Example: 1
None
Question 1: Related.
Alphanumeric
1
Yes
1 - My spouse or partner
Character
2 - My parent
3 - My mother-in-law or fatherin-law
4 - My grandparent
5 - My aunt or uncle
6 - My sister or brother
7 - My child
8 - My friend
9 - Other
M - Missing/Don't Know
Each element must have a closing tag that is the same as the opening tag but with a forward slash. This caregiver response data element should only
occur once per caregiver. If the check box for 'Home' is selected, enter value '1' for this data element. If the check box for 'Home' is not selected (and at
least one other check box for location is selected), enter value '0' for this data element. If none of the check boxes for this question are selected on the
survey, enter the value 'M' for this data element and for all other data elements.
Example: 1
None
Question 2: Location: at home.
Alphanumeric
1
Yes
1 - Home
Character
0 - Not home
M - Missing/Don't Know
Centers for Medicare and Medicaid Services
(CMS)
Page 21 of 40
CAHPS Hospice Survey XML File Specification Version 6.0
XML Element
Sub-element of
caregiverresponse
Sub-element of
caregiverresponse
Attributes
Description
Valid Values
Data Type
Max
Field
Size
Data Element
Required
Each element must have a closing tag that is the same as the opening tag but with a forward slash. This caregiver response data element should only
occur once per caregiver. If the check box for 'Assisted living facility' is selected, enter value '1' for this data element. If the check box for 'Assisted
living facility' is not selected (and at least one other check box for location is selected), enter value '0' for this data element. If none of the check boxes
for this question are selected on the survey, enter the value 'M' for this data element and for all other data elements.
Example: 0
None
Question 2: Location: assisted living facility.
Alphanumeric
1
Yes
1 - Assisted living facility
Character
0 - Not assisted living facility
M - Missing/Don't Know
Each element must have a closing tag that is the same as the opening tag but with a forward slash. This caregiver response data element should only
occur once per caregiver. If the check box for 'Nursing Home' is selected, enter value '1' for this data element. If the check box for 'Nursing Home' is not
selected (and at least one other check box for location is selected), enter value '0' for this data element. If none of the check boxes for this question are
selected on the survey, enter the value 'M' for this data element and for all other data elements.
Example: 0
None
Question 2: Location: nursing home.
Alphanumeric
1
Yes
1 - Nursing home
Character
0 - Not nursing home
M - Missing/Don't Know
Sub-element of
caregiverresponse
Each element must have a closing tag that is the same as the opening tag but with a forward slash. This caregiver response data element should only
occur once per caregiver. If the check box for 'Hospital' is selected, enter value '1' for this data element. If the check box for 'Hospital' is not selected
(and at least one other check box for location is selected), enter value '0' for this data element. If none of the check boxes for this question are selected on
the survey, enter the value 'M' for this data element and for all other data elements.
Example: 0
None
September 2019
Question 2: Location: hospital.
1 - Hospital
0 - Not hospital
M - Missing/Don't Know
Centers for Medicare and Medicaid Services
(CMS)
Alphanumeric
Character
1
Yes
Page 22 of 40
CAHPS Hospice Survey XML File Specification Version 6.0
XML Element
Sub-element of
caregiverresponse
Attributes
Description
Valid Values
Data Type
Max
Field
Size
Data Element
Required
Each element must have a closing tag that is the same as the opening tag but with a forward slash. This caregiver response data element should only
occur once per caregiver. If the check box for 'Hospice facility/hospice house' is selected, enter value '1' for this data element. If the check box for
'Hospice facility/hospice house' is not selected (and at least one other check box for location is selected), enter value '0' for this data element. If none of
the check boxes for this question are selected on the survey, enter the value 'M' for this data element and for all other data elements.
Example: 0
None
Question 2: Location: hospice facility/hospice
house.
1 - Hospice facility/hospice
house
Alphanumeric
Character
1
Yes
0 - Not hospice facility/hospice
house
Sub-element of
caregiverresponse
Sub-element of
caregiverresponse
September 2019
M - Missing/Don't Know
Each element must have a closing tag that is the same as the opening tag but with a forward slash. This caregiver response data element should only
occur once per caregiver. If the check box for 'Other' is selected, enter value '1' for this data element.
If the check box for 'Other' is not selected (and at least one other check box for location is selected), enter value '0' for this data element.
If none of the check boxes for this question are selected on the survey, enter the value 'M' for this data element and for all other data elements.
Example: 0
None
Question 2: Location: other.
Alphanumeric
1
Yes
1 - Other
Character
0 - Not other
M - Missing/Don't Know
Each element must have a closing tag that is the same as the opening tag but with a forward slash. This caregiver response data element should only
occur once per caregiver.
Example: 4
None
Question 3: Oversee.
Alphanumeric
1
Yes
1 - Never
Character
2 - Sometimes
3 - Usually
4 - Always
M - Missing/Don't Know
Centers for Medicare and Medicaid Services
(CMS)
Page 23 of 40
CAHPS Hospice Survey XML File Specification Version 6.0
XML Element
Sub-element of
caregiverresponse
Sub-element of
caregiverresponse
Sub-element of
caregiverresponse
Attributes
Description
Valid Values
Data Type
Max
Field
Size
Data Element
Required
Each element must have a closing tag that is the same as the opening tag but with a forward slash. This caregiver response data element should only
occur once per caregiver.
Example: 1
None
Question 4: Need help.
Alphanumeric
2
Yes
1 - Yes
Character
2 - No
88 - Not Applicable
M - Missing/Don't Know
Each element must have a closing tag that is the same as the opening tag but with a forward slash. This caregiver response data element should only
occur once per caregiver.
Example: 4
None
Question 5: Get help.
Alphanumeric
2
Yes
1 - Never
Character
2 - Sometimes
3 - Usually
4 - Always
88 - Not Applicable
M - Missing/Don't Know
Each element must have a closing tag that is the same as the opening tag but with a forward slash. This caregiver response data element should only
occur once per caregiver.
Example: 4
Yes
None
Question 6: Hospice inform.
Alphanumeric
2
1 - Never
Character
2 - Sometimes
3 - Usually
4 - Always
88 - Not Applicable
M - Missing/Don't Know
September 2019
Centers for Medicare and Medicaid Services
(CMS)
Page 24 of 40
CAHPS Hospice Survey XML File Specification Version 6.0
XML Element
Sub-element of
caregiverresponse
Sub-element of
caregiverresponse
Sub-element of
caregiverresponse
Attributes
Description
Valid Values
Data Type
Max
Field
Size
Data Element
Required
Each element must have a closing tag that is the same as the opening tag but with a forward slash. This caregiver response data element should only
occur once per caregiver.
Example: 4
None
Question 7: Help as soon as need.
Alphanumeric
2
Yes
1 - Never
Character
2 - Sometimes
3 - Usually
4 - Always
88 - Not Applicable
M - Missing/Don't Know
Each element must have a closing tag that is the same as the opening tag but with a forward slash. This caregiver response data element should only
occur once per caregiver.
Example: 4
Yes
None
Question 8: Hospice explain.
Alphanumeric
2
1 - Never
Character
2 - Sometimes
3 - Usually
4 - Always
88 - Not Applicable
M - Missing/Don't Know
Each element must have a closing tag that is the same as the opening tag but with a forward slash. This caregiver response data element should only
occur once per caregiver.
Example: 4
Question 9: Hospice inform.
Alphanumeric
None
2
Yes
1 - Never
Character
2 - Sometimes
3 - Usually
4 - Always
88 - Not Applicable
M - Missing/Don't Know
September 2019
Centers for Medicare and Medicaid Services
(CMS)
Page 25 of 40
CAHPS Hospice Survey XML File Specification Version 6.0
XML Element
Sub-element of
caregiverresponse
Sub-element of
caregiverresponse
Sub-element of
caregiverresponse
Attributes
Description
Valid Values
Data Type
Max
Field
Size
Data Element
Required
Each element must have a closing tag that is the same as the opening tag but with a forward slash. This caregiver response data element should only
occur once per caregiver.
Example: 4
None
Question 10: Hospice confuse.
Alphanumeric
2
Yes
1 - Never
Character
2 - Sometimes
3 - Usually
4 - Always
88 - Not Applicable
M - Missing/Don't Know
Each element must have a closing tag that is the same as the opening tag but with a forward slash. This caregiver response data element should only
occur once per caregiver.
Example: 4
2
Yes
None
Question 11: Hospice dignity.
Alphanumeric
1 - Never
Character
2 - Sometimes
3 - Usually
4 - Always
88 - Not Applicable
M - Missing/Don't Know
Each element must have a closing tag that is the same as the opening tag but with a forward slash. This caregiver response data element should only
occur once per caregiver.
Example: 4
2
Yes
None
Question 12: Hospice cared.
Alphanumeric
1 - Never
Character
2 - Sometimes
3 - Usually
4 - Always
88 - Not Applicable
M - Missing/Don't Know
September 2019
Centers for Medicare and Medicaid Services
(CMS)
Page 26 of 40
CAHPS Hospice Survey XML File Specification Version 6.0
XML Element
Sub-element of
caregiverresponse
Sub-element of
caregiverresponse
Sub-element of
caregiverresponse
Attributes
Description
Valid Values
Data Type
Max
Field
Size
Data Element
Required
Each element must have a closing tag that is the same as the opening tag but with a forward slash. This caregiver response data element should only
occur once per caregiver.
Example: 1
None
Question 13: Hospice talk.
Alphanumeric
2
Yes
1 - Yes
Character
2 - No
88 - Not Applicable
M - Missing/Don't Know
Each element must have a closing tag that is the same as the opening tag but with a forward slash. This caregiver response data element should only
occur once per caregiver.
Example: 4
Question 14: Hospice talk and listen.
None
Alphanumeric
2
Yes
1 - Never
Character
2 - Sometimes
3 - Usually
4 - Always
88 - Not Applicable
M - Missing/Don't Know
Each element must have a closing tag that is the same as the opening tag but with a forward slash. This caregiver response data element should only
occur once per caregiver.
Example: 1
None
Question 15: Pain.
Alphanumeric
2
Yes
1 - Yes
Character
2 - No
88 - Not Applicable
M - Missing/Don't Know
September 2019
Centers for Medicare and Medicaid Services
(CMS)
Page 27 of 40
CAHPS Hospice Survey XML File Specification Version 6.0
XML Element
Sub-element of
caregiverresponse
Sub-element of
caregiverresponse
Sub-element of
caregiverresponse
Sub-element of
caregiverresponse
Attributes
Description
Valid Values
Data Type
Max
Field
Size
Data Element
Required
Each element must have a closing tag that is the same as the opening tag but with a forward slash. This caregiver response data element should only
occur once per caregiver.
Example: 1
None
Yes
2
Question 16: Pain help.
Alphanumeric
1 - Yes, definitely
Character
2 - Yes, somewhat
3 - No
88 - Not Applicable
M - Missing/Don't Know
Each element must have a closing tag that is the same as the opening tag but with a forward slash. This caregiver response data element should only
occur once per caregiver.
Example: 1
2
Yes
None
Question 17: Pain medicine.
Alphanumeric
1 - Yes
Character
2 - No
88 - Not Applicable
M - Missing/Don't Know
Each element must have a closing tag that is the same as the opening tag but with a forward slash. This caregiver response data element should only
occur once per caregiver.
Example: 1
None
Question 18: Pain medication info.
Alphanumeric
2
Yes
1 - Yes, definitely
Character
2 - Yes, somewhat
3 - No
88 - Not Applicable
M - Missing/Don't Know
Each element must have a closing tag that is the same as the opening tag but with a forward slash. This caregiver response data element should only
occur once per caregiver.
Example: 1
None
Question 19: Pain medicine watch.
Alphanumeric
2
Yes
1 - Yes, definitely
Character
2 - Yes, somewhat
3 - No
88 - Not Applicable
M - Missing/Don't Know
September 2019
Centers for Medicare and Medicaid Services
(CMS)
Page 28 of 40
CAHPS Hospice Survey XML File Specification Version 6.0
XML Element
Sub-element of
caregiverresponse
Sub-element of
caregiverresponse
Sub-element of
caregiverresponse
Attributes
Description
Valid Values
Data Type
Max
Field
Size
Data Element
Required
Each element must have a closing tag that is the same as the opening tag but with a forward slash. This caregiver response data element should only
occur once per caregiver.
Example: 4
None
Question 20: Pain medicine train.
1 - Yes, definitely
Alphanumeric
2
Yes
Character
2 - Yes, somewhat
3 - No
4 - I did not need to give pain
medicine to my family member
88 - Not Applicable
M - Missing/Don't Know
Each element must have a closing tag that is the same as the opening tag but with a forward slash. This caregiver response data element should only
occur once per caregiver.
Example: 1
None
Question 21: Breath.
Alphanumeric
2
Yes
1 - Yes
Character
2 - No
88 - Not Applicable
M - Missing/Don't Know
Each element must have a closing tag that is the same as the opening tag but with a forward slash. This caregiver response data element should only
occur once per caregiver.
Example: 4
None
2
Yes
Question 22: Breath help.
Alphanumeric
1 - Never
Character
2 - Sometimes
3 - Usually
4 - Always
88 - Not Applicable
M - Missing/Don't Know
September 2019
Centers for Medicare and Medicaid Services
(CMS)
Page 29 of 40
CAHPS Hospice Survey XML File Specification Version 6.0
XML Element
Sub-element of
caregiverresponse
Sub-element of
caregiverresponse
Sub-element of
caregiverresponse
September 2019
Attributes
Description
Valid Values
Data Type
Max
Field
Size
Data Element
Required
Each element must have a closing tag that is the same as the opening tag but with a forward slash. This caregiver response data element should only
occur once per caregiver.
Example: 4
Question 23: Breath train.
Alphanumeric
2
Yes
None
1 - Yes, definitely
Character
2 - Yes, somewhat
3 - No
4 - I did not need to help my
family member with trouble
breathing
88 - Not Applicable
M - Missing/Don't Know
Each element must have a closing tag that is the same as the opening tag but with a forward slash. This caregiver response data element should only
occur once per caregiver.
Example: 1
None
Question 24: Constipation.
Alphanumeric
2
Yes
1 - Yes
Character
2 - No
88 - Not Applicable
M - Missing/Don't Know
Each element must have a closing tag that is the same as the opening tag but with a forward slash. This caregiver response data element should only
occur once per caregiver.
Example: 4
None
1 - Never
Yes
Question 25: Constipation help.
Alphanumeric
2
Character
2 - Sometimes
3 - Usually
4 - Always
88 - Not Applicable
M - Missing/Don't Know
Centers for Medicare and Medicaid Services
(CMS)
Page 30 of 40
CAHPS Hospice Survey XML File Specification Version 6.0
XML Element
Sub-element of
caregiverresponse
Sub-element of
caregiverresponse
Sub-element of
caregiverresponse
Sub-element of
caregiverresponse
Attributes
Description
Valid Values
Data Type
Max
Field
Size
Data Element
Required
Each element must have a closing tag that is the same as the opening tag but with a forward slash. This caregiver response data element should only
occur once per caregiver.
Example: 1
None
Question 26: Sad.
Alphanumeric
2
Yes
1 - Yes
Character
2 - No
88 - Not Applicable
M - Missing/Don't Know
Each element must have a closing tag that is the same as the opening tag but with a forward slash. This caregiver response data element should only
occur once per caregiver.
Example: 4
2
Yes
None
Question 27: Sad get help.
Alphanumeric
1 - Never
Character
2 - Sometimes
3 - Usually
4 - Always
88 - Not Applicable
M - Missing/Don't Know
Each element must have a closing tag that is the same as the opening tag but with a forward slash. This caregiver response data element should only
occur once per caregiver.
Example: 1
None
Question 28: Restless.
Alphanumeric
2
Yes
1 - Yes
Character
2 - No
88 - Not Applicable
M - Missing/Don't Know
Each element must have a closing tag that is the same as the opening tag but with a forward slash. This caregiver response data element should only
occur once per caregiver.
Example: 1
None
Alphanumeric
2
Yes
Question 29: Restless train.
1 - Yes, definitely
Character
2 - Yes, somewhat
3 - No
88 - Not Applicable
M - Missing/Don't Know
September 2019
Centers for Medicare and Medicaid Services
(CMS)
Page 31 of 40
CAHPS Hospice Survey XML File Specification Version 6.0
XML Element
Sub-element of
caregiverresponse
Sub-element of
caregiverresponse
Sub-element of
caregiverresponse
September 2019
Attributes
Description
Valid Values
Data Type
Max
Field
Size
Data Element
Required
Each element must have a closing tag that is the same as the opening tag but with a forward slash. This caregiver response data element should only
occur once per caregiver.
Example: 4
None
2
Question 30: Move train.
Alphanumeric
Yes
1 - Yes, definitely
Character
2 - Yes, somewhat
3 - No
4 - I did not need to move my
family member
88 - Not Applicable
M - Missing/Don't Know
Each element must have a closing tag that is the same as the opening tag but with a forward slash. This caregiver response data element should only
occur once per caregiver.
Example: 1
None
Question 31: Expect info.
1 - Yes, definitely
Alphanumeric
2
Yes
Character
2 - Yes, somewhat
3 - No
88 - Not Applicable
M - Missing/Don't Know
Each element must have a closing tag that is the same as the opening tag but with a forward slash. This caregiver response data element should only
occur once per caregiver.
Example: 1
None
Question 32: Received nursing home.
Alphanumeric
1 - Yes
2
Yes
Character
2 - No
88 - Not Applicable
M - Missing/Don't Know
Centers for Medicare and Medicaid Services
(CMS)
Page 32 of 40
CAHPS Hospice Survey XML File Specification Version 6.0
XML Element
Sub-element of
caregiverresponse
Sub-element of
caregiverresponse
Sub-element of
caregiverresponse
Attributes
Description
Valid Values
Data Type
Max
Field
Size
Data Element
Required
Each element must have a closing tag that is the same as the opening tag but with a forward slash. This caregiver response data element should only
occur once per caregiver.
Example: 4
None
Question 33: Cooperate hospice and nursing
Alphanumeric
2
Yes
1 - Never
home.
Character
2 - Sometimes
3 - Usually
4 - Always
88 - Not Applicable
M - Missing/Don't Know
Each element must have a closing tag that is the same as the opening tag but with a forward slash. This caregiver response data element should only
occur once per caregiver.
Example: 4
None
Question 34: Difference between hospice and
Alphanumeric
2
Yes
1 - Never
nursing home.
Character
2 - Sometimes
3 - Usually
4 - Always
88 - Not Applicable
M - Missing/Don't Know
Each element must have a closing tag that is the same as the opening tag but with a forward slash. This caregiver response data element should only
occur once per caregiver.
Example: 4
None
Question 35: Hospice listening carefully to
Alphanumeric
2
Yes
1 - Never
caregiver.
Character
2 - Sometimes
3 - Usually
4 - Always
88 - Not Applicable
M - Missing/Don't Know
September 2019
Centers for Medicare and Medicaid Services
(CMS)
Page 33 of 40
CAHPS Hospice Survey XML File Specification Version 6.0
XML Element
Sub-element of
caregiverresponse
Sub-element of
caregiverresponse
Sub-element of
caregiverresponse
September 2019
Attributes
Description
Valid Values
Data Type
Max
Field
Size
Data Element
Required
Each element must have a closing tag that is the same as the opening tag but with a forward slash. This caregiver response data element should only
occur once per caregiver.
Example: 1
None
Question 36: Caregiver beliefs respected.
Alphanumeric
2
Yes
1 - Too little
Character
2 - Right amount
3 - Too much
88 - Not Applicable
M - Missing/Don't Know
Each element must have a closing tag that is the same as the opening tag but with a forward slash. This caregiver response data element should only
occur once per caregiver.
Example: 1
None
Question 37: Caregiver emotion.
Yes
Alphanumeric
2
1 - Too little
Character
2 - Right amount
3 - Too much
88 - Not Applicable
M - Missing/Don't Know
Each element must have a closing tag that is the same as the opening tag but with a forward slash. This caregiver response data element should only
occur once per caregiver.
Example: 1
None
Question 38: Caregiver emotion after.
Alphanumeric
2
Yes
1 - Too little
Character
2 - Right amount
3 - Too much
88 - Not Applicable
M - Missing/Don't Know
Centers for Medicare and Medicaid Services
(CMS)
Page 34 of 40
CAHPS Hospice Survey XML File Specification Version 6.0
XML Element
Sub-element of
caregiverresponse
Sub-element of
caregiverresponse
Attributes
Description
Valid Values
Data Type
Max
Field
Size
Data Element
Required
Each element must have a closing tag that is the same as the opening tag but with a forward slash. This caregiver response data element should only
occur once per caregiver.
Example: 8
0 - Worst hospice care possible Alphanumeric
None
Question 39: Rate hospice.
2
Yes
1
Character
2
3
4
5
6
7
8
9
10 - Best hospice care possible
88 - Not Applicable
M - Missing/Don't Know
Each element must have a closing tag that is the same as the opening tag but with a forward slash. This caregiver response data element should only
occur once per caregiver.
Example: 4
None
Question 40: Hospice recommended.
Alphanumeric
2
Yes
1 - Definitely no
Character
2 - Probably no
3 - Probably yes
4 - Definitely yes
88 - Not Applicable
M - Missing/Don't Know
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CAHPS Hospice Survey XML File Specification Version 6.0
XML Element
Sub-element of
caregiverresponse
Attributes
Description
Valid Values
Data Type
Max
Field
Size
Data Element
Required
Each element must have a closing tag that is the same as the opening tag but with a forward slash. This caregiver response data element should only
occur once per caregiver.
Example: 4
None
Question 41: Decedent education.
Alphanumeric
1
Yes
1 - 8th grade or less
Character
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
Sub-element of
caregiverresponse
7- Don't Know
M - Missing/Don't Know
Each element must have a closing tag that is the same as the opening tag but with a forward slash. This caregiver response data element should only
occur once per caregiver.
Example: 1
None
Question 42: Decedent Latino.
Alphanumeric
1
Yes
1 - No, not
Character
Spanish/Hispanic/Latino
2 - Yes, Puerto Rican
3 - Yes, Mexican, Mexican
American, Chicano/a
4 - Yes, Cuban
5 - Yes, other
Spanish/Hispanic/Latino
M - Missing/Don't Know
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CAHPS Hospice Survey XML File Specification Version 6.0
XML Element
Sub-element of
caregiverresponse
Sub-element of
caregiverresponse
Sub-element of
caregiverresponse
Attributes
Valid Values
Data Type
Max
Field
Size
Data Element
Required
Each element must have a closing tag that is the same as the opening tag but with a forward slash. This caregiver response data element should only
occur once per caregiver. If the check box for the race 'White' is selected, enter value '1' for this data element
If the check box for the race 'White' is not selected (and at least one other check box for race is selected), enter value '0' for this data element. If none of
the check boxes for the race question are selected on the survey, enter the value 'M' for this data element and for all other race data elements.
Example: 1
None
Question 43: Race, White.
Alphanumeric
1
Yes
1 - White
Character
0 - Not White
M - Missing/Don't Know
Each element must have a closing tag that is the same as the opening tag but with a forward slash. This caregiver response data element should only
occur once per caregiver. If the check box for the race 'Black or African-American' is selected, enter value '1' for this data element. If the check box for
the race 'Black or African-American' is not selected (and at least one other check box for race is selected), enter value '0' for this data element. If none of
the check boxes for the race question are selected on the survey, enter the value 'M' for this data element and for all other race data elements.
Example: 0
None
Question 43: Race, African-American.
1 - Black or African-American Alphanumeric
Character
0 - Not Black or AfricanAmerican
1
Yes
M - Missing/Don't Know
Each element must have a closing tag that is the same as the opening tag but with a forward slash. This caregiver response data element should only
occur once per caregiver. If the check box for the race 'Asian' is selected, enter value '1' for this data element
If the check box for the race 'Asian' is not selected (and at least one other check box for race is selected), enter value '0' for this data element. If none of
the check boxes for the race question are selected on the survey, enter the value 'M' for this data element and for all other race data elements.
Example: 0
None
September 2019
Description
Question 43: Race, Asian.
1 - Asian
0 - Not Asian
M - Missing/Don't Know
Centers for Medicare and Medicaid Services
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Alphanumeric
Character
1
Yes
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CAHPS Hospice Survey XML File Specification Version 6.0
XML Element
Sub-element of
caregiverresponse
Attributes
Sub-element of
caregiverresponse
Valid Values
Data Type
Max
Field
Size
Data Element
Required
Each element must have a closing tag that is the same as the opening tag but with a forward slash. This caregiver response data element should only
occur once per caregiver. If the check box for the race 'Native Hawaiian or Pacific Islander' is selected, enter value '1' for this data element. If the check
box for the race 'Native Hawaiian or Pacific Islander' is not selected (and at least one other check box for race is selected), enter value '0' for this data
element. If none of the check boxes for the race question are selected on the survey, enter the value 'M' for this data element and for all other race data
elements.
Example: 0
None
Description
Question 43: Race, Pacific Islander.
Alphanumeric
1
Yes
1 - Native Hawaiian or other
Character
Pacific Islander
0 - Not Native Hawaiian or
other Pacific Islander
M - Missing/Don't Know
Each element must have a closing tag that is the same as the opening tag but with a forward slash. This caregiver response data element should only
occur once per caregiver. If the check box for the race 'American Indian or Alaska native' is selected, enter value '1' for this data element. If the check
box for the race 'American Indian or Alaska native' is not selected (and at least one other check box for race is selected), enter value '0' for this data
element. If none of the check boxes for the race question are selected on the survey, enter the value 'M' for this data element and for all other race data
elements.
Example: 0
None
Question 43: Race, American Indian/Alaska
1
Yes
1 - American Indian or Alaska Alphanumeric
Native.
Character
native
0 - Not American Indian or
Alaska native
M - Missing/Don't Know
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CAHPS Hospice Survey XML File Specification Version 6.0
XML Element
Sub-element of
caregiverresponse
Sub-element of
caregiverresponse
Sub-element of
caregiverresponse
September 2019
Attributes
Description
Valid Values
Data Type
Max
Field
Size
Data Element
Required
Each element must have a closing tag that is the same as the opening tag but with a forward slash. This caregiver response data element should only
occur once per caregiver.
Example: 1
Question 44: Caregiver, age.
Alphanumeric
1
Yes
None
1 - 18 to 24
Character
2 - 25 to 34
3 - 35 to 44
4 - 45 to 54
5 - 55 to 64
6 - 65 to 74
7 - 75 to 84
8 - 85 or older
M - Missing/Don't Know
Each element must have a closing tag that is the same as the opening tag but with a forward slash. This caregiver response data element should only
occur once per caregiver.
Example: 1
None
Question 45: Caregiver, sex.
Alphanumeric
1
Yes
1 - Male
Character
2 - Female
M - Missing/Don't Know
Each element must have a closing tag that is the same as the opening tag but with a forward slash. This caregiver response data element should only
occur once per caregiver.
Example: 4
1 - 8th grade or less
1
Yes
None
Question 46: Caregiver, education.
Alphanumeric
2 - Some high school but did
Character
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
M - Missing/Don't Know
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CAHPS Hospice Survey XML File Specification Version 6.0
XML Element
Sub-element of
caregiverresponse
Attributes
Description
Valid Values
Data Type
Max
Field
Size
Data Element
Required
Each element must have a closing tag that is the same as the opening tag but with a forward slash. This caregiver response data element should only
occur once per caregiver.
Example: 4
None
Question 47: Language spoken at home.
Alphanumeric
1
Yes
1 - English
Character
2 - Spanish
3 - Chinese
4 - Russian
5 - Portuguese
6 - Vietnamese
7 - Polish
8 - Korean
9 - Some other language
M - Missing/Don't Know
Note: This tag is required in the XML file, however, it contains no data. This caregiverresponse element should only occur once per
caregiver.
None
Closing tag for
caregiverresponse
None
Note: This tag is required in the XML file, however, it contains no data. This decedentleveldata element should only occur once per
decedent/caregiver.
Closing tag for
decedentleveldata
None
Note: This tag is required in the XML file, however, it contains no data. This vendordata element should only occur once per file.
Closing tag for
vendordata
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CAHPS Hospice Survey
Sample XML File Layout Version 6.0
Vendor Business Name
2020
1
31
1
-
2020
1
Sample Hospice
123456
1234567890
1
150
5
1
5
5
139
139
136
3
1
3
-
123456
12345
1999
1
1
2020
1
1
2019
1
1
1
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CAHPS Hospice Survey
Sample XML File Layout Version 6.0
2
1
1
1
2
3
1
Facility
G30.9
1
88
88
1
1
106
4
-
123456
12345
1
1
0
0
0
0
0
4
1
4
4
4
4
4
4
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Sample XML File Layout Version 6.0
4
4
1
4
1
1
1
1
1
4
1
4
4
1
4
1
4
1
1
4
1
1
4
4
4
1
1
1
8
4
4
1
1
0
0
0
0
1
1
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CAHPS Hospice Survey
Sample XML File Layout Version 6.0
4
4
-
123456
1234567
1995
1
1
2020
1
2
2018
2
1
1
2
1
1
1
2
3
1
Facility
310.11
1
88
88
1
1
106
4
-
123456
4
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Sample XML File Layout Version 6.0
1234567
1
1
0
0
0
0
0
4
1
4
4
4
4
4
4
4
4
1
4
1
1
1
1
1
4
1
4
4
1
4
1
4
1
1
4
1
1
4
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CAHPS Hospice Survey
Sample XML File Layout Version 6.0
4
4
1
1
1
8
4
4
1
1
0
0
0
0
1
1
4
4
-
2020
2
Sample Hospice 2
456123
4567890123
1
140
4
1
0
6
133
133
128
5
1
3
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CAHPS Hospice Survey
Sample XML File Layout Version 6.0
-
456123
345612
1994
1
2
2020
2
1
2020
1
1
1
2
1
1
1
2
3
1
Facility
310.11
1
88
88
1
1
106
4
-
456123
345612
1
1
0
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CAHPS Hospice Survey
Sample XML File Layout Version 6.0
0
0
0
0
4
1
4
4
4
4
4
4
4
4
1
4
1
1
1
1
1
4
1
4
4
1
4
1
4
1
1
4
1
1
4
4
4
1
1
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CAHPS Hospice Survey
Sample XML File Layout Version 6.0
1
8
4
4
1
1
0
0
0
0
1
1
4
4
-
456123
51234
1993
1
3
2020
2
3
2020
1
1
1
2
1
1
1
2
3
1
Facility
310.11
1
88
88
1
1
106
4
-
456123
51234
1
1
0
0
0
0
0
4
1
4
4
4
4
4
4
4
4
1
4
1
1
1
1
1
4
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Sample XML File Layout Version 6.0
1
4
4
1
4
1
4
1
1
4
1
1
4
4
4
1
1
1
8
4
4
1
1
0
0
0
0
1
1
4
4
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Appendix F
Interviewing Guidelines for Telephone Surveys
CAHPS Hospice Survey
Interviewing Guidelines for Telephone Surveys
Overview
These guidelines address expectations for interviewers conducting the CAHPS Hospice Survey by
telephone. To collect the highest quality data possible, telephone interviewers must follow these
guidelines while conducting telephone interviews.
As an interviewer, your role in the success of this survey is important. You will interact with many
caregivers and you are the person who assures the caregivers that their participation is important.
Due to the nature of this survey, you may encounter caregivers who express grief or other
emotions; therefore, it will be necessary for you to familiarize yourself with your organization’s
Distressed Respondent Procedures.
General Interviewing Techniques
As an interviewer you must:
study and thoroughly familiarize yourself with the frequently asked questions (FAQ) list
before you begin conducting telephone interviews so that you are knowledgeable about
the CAHPS Hospice Survey
read all questions and response choices in the indicated order and exactly as worded, so
that all caregivers are answering the same question. Questions that are re-worded can bias
the caregiver’s response and the overall survey results.
not attempt to increase the likelihood of the caregiver providing one answer over another
answer
read all transitional statements
never skip over a question because you think the caregiver has answered it already
speak in a courteous tone
• During the course of the survey, use of neutral acknowledgement words such as the
following is permitted:
o Thank you
o Alright
o Okay
o I understand, or I see
o Yes, Ma’am
o Yes, Sir
read the script from the interviewer screens (reciting the survey from memory can lead to
unnecessary errors and missed updates to the script)
adjust the pace of the CAHPS Hospice Survey interview to be conducive to the needs of
the caregiver
maintain a professional and neutral relationship with the caregiver at all times
not provide personal information or opinions about the survey
listen carefully to any caregiver questions and offer concise responses. You may not
provide extra information or lengthy explanations.
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not leave messages on answering machines or with household members. Interviewers
should attempt to re-contact the caregiver to complete the CAHPS Hospice Survey.
tell the caregiver that there are no more questions and thank the caregiver for his or her
time at the end of the survey. The interviewer may say, “Have a good (day/evening).” if
appropriate.
not administer the CAHPS Hospice Survey to any caregiver whom you know personally
or professionally
Introduction and Refusal Avoidance
For optimal response rates, it is important that telephone interviewers attempt to avoid telephone
refusals from the caregiver. The introduction and initial moments of the interview are critical to
gaining cooperation from the caregiver.
Interviewers must:
read the telephone script introductions verbatim, unless the caregiver interrupts to ask a
question or voices a concern
speak clearly and politely to establish a rapport with the caregiver
avoid long pauses
not rush through the introduction
be prepared to answer questions about the survey by familiarizing themselves with the
survey and the FAQ document
attempt to gain cooperation; if the caregiver refuses, the interviewer should politely end
the call. The interviewer should not argue with or antagonize the caregiver.
request to speak with the sampled caregiver if calling the caregiver number and a business
is reached. If the caregiver states they are at work and cannot speak, the interviewer should
attempt to reschedule the call for a time that is more convenient for the caregiver, or obtain
an alternate phone number at which to reach the caregiver.
request to get in touch with the sampled caregiver if the interviewer reaches a healthcare
facility staff member. Inform the healthcare facility staff member that the survey is part of
a national initiative sponsored by the United States Department of Health and Human
Services. The results of the survey will help hospices understand what they are doing well
and what needs improvement.
If the staff member indicates that the caregiver is unable to complete the survey (e.g., due
to mental or physical incapacity), the interviewer should thank the staff member and code
the attempt appropriately.
Note: Caregivers, if otherwise eligible, residing in healthcare facilities such as an
assisted living facility, long-term care facility or nursing home are to be included in the
CAHPS Hospice Survey sample frame and attempts to contact the caregiver to administer
the survey must be made to those decedents/caregivers drawn into the sample.
Note: Healthcare facility telephone numbers cannot be placed on the survey vendor’s donot-call list, even if requested by the healthcare facility staff.
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Answering Questions and Probing
Telephone interviewers need to probe when a caregiver fails to give a complete or an adequate
answer. Interviewers must never interpret caregiver answers. Interviewers must not ask the
caregiver probing questions about their health such as “How are you feeling today?” before asking
the CAHPS Hospice Survey questions.
Interviewer probes must be neutral and must not increase the likelihood of the caregiver
providing one answer over another answer. Probes should stimulate the caregiver to give
answers that meet the question’s objectives.
Types of probes:
• Repeat the question or the answer categories
• Interviewer says:
o “Take a minute to think about it.” REPEAT QUESTION, IF APPROPRIATE
o “So, would you say that it is…” REPEAT ANSWER CATEGORIES
o “Which would be closer?” REPEAT ANSWER CATEGORIES THAT ARE
CLOSEST TO THE CAREGIVER’S RESPONSE
Interviewers must not interpret survey answers for the caregiver
Conventions on Telephone Survey Instruments
All text that appears in lowercase letters must be read out loud
Text in UPPERCASE letters must not be read out loud
• However, YES and NO response options can be read, if appropriate
Text that is underlined must be emphasized
Characters in < > must not be read
[Square brackets] are used to show programming instructions that must not actually
appear on electronic telephone interviewing system screens
MISSING/DON’T KNOW (DK) is a valid response option for each item in the electronic
telephone interviewing system scripts. This allows the telephone interviewer to go to the
next question if a caregiver is unable to provide a response for a given question (or
refuses to provide a response). In the survey file layouts, a value of “MISSING/DK” is
coded as “M – Missing/Don't Know.”
Skip patterns should be programmed into the electronic telephone system
• Appropriately skipped questions should be coded as “88 – Not Applicable.” For
example, if a caregiver answers “No” to Question 4 of the CAHPS Hospice Survey, the
program should skip Question 5, and go to Question 6. Question 5 must then be coded
as “88 – Not Applicable.” Coding may be done automatically by the telephone
interviewing system or later during data preparation.
• When a response to a screener question is not obtained, the screener question and any
questions in the skip pattern should be coded as “M – Missing/Don't Know.” For
example, if the caregiver does not provide an answer to Question 4 of the CAHPS
Hospice Survey and the interviewer selects “MISSING/DK” to Question 4, then the
telephone interviewing system should be programmed to skip Question 5, and go to
Question 6. Question 5 must then be coded as “M – Missing/Don't Know.” Coding may
be done automatically by the telephone interviewing system or later during data
preparation.
There must be only one language (i.e., English, Spanish, or Russian) that appears on the
electronic telephone interviewing system screen
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Appendix G
Frequently Asked Questions
for Customer Support
CAHPS Hospice Survey
Frequently Asked Questions for Customer Support
Overview
This document provides customer support guidance on responding to frequently asked questions
(FAQ) from caregivers answering the CAHPS Hospice Survey. It should be used for all three
modes of survey administration. The FAQ provide answers to general questions about the survey,
concerns about participating in the survey and questions about completing/returning the survey.
Survey vendors may amend the document to be specific to their operations or revise individual
responses for clarity.
Note: Survey vendors conducting the CAHPS Hospice Survey must NOT attempt to influence
caregivers in a particular way. For example, the survey vendor conducting the CAHPS Hospice
Survey must NOT say, imply or persuade caregivers to respond to items in a particular way. In
addition, survey vendors must NOT indicate or imply in any manner that the hospice, its personnel
or its agents will appreciate or gain benefits if caregivers respond to the items in a particular way.
Please refer to the “Program Requirements” section of the CAHPS Hospice Survey Quality
Assurance Guidelines for more information on communicating with caregivers.
I. General Questions About the Survey
Who is conducting this survey? Who is sponsoring this survey?
I’m an interviewer from the research organization [SURVEY VENDOR NAME].
[HOSPICE NAME] has asked our organization to help conduct this survey to enable them
to get feedback from caregivers whose family member or friend recently died while in
hospice care.
What is the purpose of the survey? How will the data be used?
The survey is part of a national initiative sponsored by the United States Department of
Health and Human Services (HHS) to measure the quality of care in hospices.
The survey is designed to measure caregiver’s perspectives on hospice care for public
reporting. The data collected from the survey will be provided to consumers to help them
make informed choices when selecting a hospice. It will also be used to help improve the
quality of care provided by hospices. Your participation is important.
How can I verify this survey is legitimate?
You can contact [HOSPICE NAME] at [TELEPHONE NUMBER] for information about
the survey.
NOTE: SURVEY VENDORS MUST OBTAIN CONTACT INFORMATION FROM THE
HOSPICE ABOUT WHO TO CONTACT TO VERIFY THE LEGITIMACY OF THE
SURVEY.
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Is there a government agency that I can contact to find out more about this
survey?
Yes, you can contact the Centers for Medicare & Medicaid Services (CMS), a federal
agency within the Department of Health and Human Services (HHS) through the CAHPS
Hospice Survey Technical Assistance telephone number at 1-844-472-4621 or by email at
[email protected].
Are my answers confidential? Who will see my answers?
Your answers will be seen by the research staff, and may be shared with the hospice for
purposes of quality improvement.
How long will this take?
The survey takes about 11 minutes [OR SURVEY VENDOR SPECIFY].
NOTE: THE NUMBER OF MINUTES WILL DEPEND ON WHETHER THE SURVEY IS
INTEGRATED WITH HOSPICE-SPECIFIC SUPPLEMENTAL QUESTIONS.
What questions will be asked?
The survey asks questions about the experiences your family member or friend had while
receiving care and services from the hospice. There will be questions asking you about any
problems they may have had receiving care or services. It also asks you to rate different
types of care and services your family member or friend may have received.
How did you get my name? How was I chosen for the survey?
Your name was randomly selected from all recent patient deaths from [HOSPICE NAME].
Where can I find the results of the survey?
Official CAHPS Hospice Survey scores are publicly reported four times each year on the
Hospice Compare Web site (www.medicare.gov/hospicecompare). Scheduled refreshes for
CAHPS Hospice Survey data occur in February, May, August, and November. Public
reporting of CAHPS Hospice Survey results are comprised of a rolling eight quarters of
survey data, with data submitted quarterly by survey vendors via the CAHPS Hospice
Survey Data Warehouse.
II. Concerns About Participating in the Survey
I don’t do surveys.
I understand, however I hope you will consider participating. This is a very important study
for [HOSPICE NAME]. The results of the survey will help them understand what they are
doing well and what needs improvement.
I’m not interested.
[HOSPICE NAME] could really use your help. Could you tell me why you’re not interested
in participating?
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I'm extremely busy. I don't really have the time.
I know your time is limited; however, it is a very important survey, and I really appreciate
your help today. The interview will take about 11 minutes [OR SURVEY VENDOR
SPECIFY]. Perhaps we could get started and see what the questions are like. We can stop
any time you like.
[IF NECESSARY:] The interview can be broken into parts, if necessary; you don’t have to
do the whole thing in one session.
[IF NECESSARY:] I can schedule it for any time that is convenient for you, including
evenings or weekends if you prefer.
NOTE: THE NUMBER OF MINUTES WILL DEPEND ON WHETHER THE SURVEY IS
INTEGRATED WITH HOSPICE-SPECIFIC SUPPLEMENTAL QUESTIONS.
You called my cell phone. Can you call back after [CAREGIVER SPECIFY
TIME]?
Yes, we can call you back at [CAREGIVER SPECIFIED TIME].
[IF “NO,” SET FUTURE DATE/TIME FOR CALL BACK.]
NOTE: TELEPHONE CALL ATTEMPTS ARE TO BE MADE BETWEEN THE HOURS
OF 9 AM AND 9 PM, RESPONDENT TIME, UNLESS AN ALTERNATIVE TIME IS
REQUESTED BY THE CAREGIVER.
I don’t want to answer a lot of personal questions.
I understand your concern. 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. Why don’t we get
started and you can see what the questions are like?
I’m very unhappy with [HOSPICE NAME] and I don’t see why I should help
them with this survey.
I’m sorry you’re unhappy. This is a good reason for you to participate. Your responses will
help the hospice understand what improvements are needed.
Do I have to complete the survey? What happens if I do not? Why should I?
Your participation is voluntary. There are no penalties for not participating. But, it is a very
important survey and your answers will help us to improve the quality of care [HOSPICE
NAME] provides and will also help other consumers make informed decisions when they
choose a hospice for themselves or their family members or friends.
Will I get junk mail if I answer this survey?
No, you will not get any junk mail as a result of answering this survey.
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I am on the Do Not Call List. Are you supposed to be calling me?
The Do Not Call List prohibits sales and telemarketing calls. We’re not selling anything
nor asking for money. We are a survey research firm. Your hospice has asked us to help
conduct this survey.
I don’t want to buy anything.
We’re not selling anything or asking for money. We want to ask you some questions about
the care and services provided by [HOSPICE NAME].
III. Questions About Completing/Returning the Survey
Is there a deadline to fill out the survey?
[FOR MAIL SURVEY:] Since we need to contact so many people, it would really help if
you could return it within the next several days.
[FOR TELEPHONE SURVEY:] We need to finish all the interviews as soon as possible,
but since we need to contact so many people, it would really help if we could do the
interview right now. If you don’t have the time, maybe I could schedule an appointment
for sometime within the next several days.
Where do I put my name and address on the questionnaire?
You should not write your name or address on the questionnaire. Each survey has been
assigned an identification number that allows us to keep track of which caregivers have
returned a completed questionnaire.
The caregiver you have reached is in a healthcare facility.
This is [INTERVIEWER NAME] calling from [SURVEY VENDOR]. We are conducting
a survey about hospice care. For this survey, we need to speak directly to [SAMPLED
CAREGIVER NAME]. Is [SAMPLED CAREGIVER NAME] available?
[IF NECESSARY:] We are doing a very important study that is part of a national initiative
sponsored by the United States Department of Health and Human Services. The results of
the survey will help hospices understand what they are doing well and what needs
improvement.
NOTE: CAREGIVERS IN HEALTHCARE FACILITIES SUCH AS ASSISTED LIVIING
FACILITIES, LONG-TERM CARE FACILITIES OR NURSING HOMES ARE ELIGIBLE
FOR THE SURVEY.
I would like to complete the survey online, is that an option?
No, the CAHPS Hospice Survey can only be completed by [DEPENDING ON MODE:
mail / telephone / mail or telephone] at this time.
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Appendix H
Model Quality Assurance Plan
CAHPS Hospice Survey
Model Quality Assurance Plan
Overview and Background
Survey vendors that are approved to administer the CAHPS Hospice Survey will be required to
submit a Quality Assurance Plan (QAP). The QAP is a comprehensive working document that
must describe the survey vendor’s implementation of and compliance with all required protocols
to administer the CAHPS Hospice Survey. The QAP also serves as a key resource in the training
of staff and subcontractors and any other organization responsible for performing CAHPS Hospice
Survey administration functions.
The purpose of this document is to serve as a model or guide in the preparation of a survey vendor’s
QAP in order to ensure that all required items are addressed in sufficient detail for review by the
CAHPS Hospice Survey Project Team. Following review by the CAHPS Hospice Survey Project
Team, the survey vendor will be provided with feedback that indicates whether the QAP has been
accepted, conditionally accepted (pending completion of required follow-up items – usually
minor) or requires revision (major changes needed in order for the QAP to be considered
complete).
The QAP should be free of extraneous information and must provide sufficient detail so that the
CAHPS Hospice Survey Project Team can determine a survey vendor’s adherence to survey
administration guidelines and that rigorous quality checks and/or controls have been put in place.
In addition, examples of templates, logs, tracking tools or other relevant documentation should be
included as appendices to the QAP.
The following sections below outline the required content to be addressed and the specified
sequence that must be followed in the survey vendor’s QAP.
Organizational Background and Structure
1. Provide survey vendor contact information on the first page of the QAP. Please include:
A. Survey vendor name
B. Survey vendor’s mailing address
C. Name and contact information for the person who heads the organization or the survey
research portion of the organization.
D. Physical location, if mailing address is different
E. Web site address, if one is available
F. Name of contact person, his or her direct telephone number and email address
G. Name of backup contact person, his or her direct telephone number and email address
H. Number of contracted client hospices per mode
I. Survey vendor’s approved survey mode(s)
J. Date of the QAP
Note: It is very important that the CAHPS Hospice Survey Project Team be able to reach
your organization in case of problems with the data or other operational issues.
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Survey vendors must update and resubmit their QAP at the time of process and/or key
personnel changes as part of retaining participation status.
2. Briefly describe the survey vendor’s history and affiliations, including the scope of business
and number of years in business.
3. Describe the survey vendor’s survey experience with all patient populations, including a
description of the mode(s) of survey administration and the number of years conducted, for
each mode the survey vendor is approved to administer the CAHPS Hospice Survey.
4. Provide and attach a CAHPS Hospice Survey organizational chart that identifies, by name
and title, the staff and subcontractors or other organization, if applicable, responsible for each
of the major project tasks. Include in the organizational chart the reporting relationships for all
CAHPS Hospice Survey project staff, and identify any key staff who work from remote
locations. Also, please specify the name and title of the staff members (primary and
secondary/back-up) who perform the following project tasks:
A. Overall project management, including training and supervision
B. Tracking of key survey events
C. Creation of the sample frame
D. Drawing the sample
E. Assignment of the random, unique, de-identified decedent/caregiver identification
numbers
F. Administering the survey by the approved mode (Mail Only, Telephone Only, Mixed
Mode)
G. Data receipt and data entry
H. Data submission
1. List all staff members authorized to upload data to the CAHPS Hospice Survey Data
Warehouse
I. Quality checks of all key events including, but not limited to, survey administration,
sample frame creation, data entry, data submission, electronic back-up systems, etc.
5. Describe the background and qualifications of all key personnel (e.g., Project Director, Project
Manager, Sampling Manager, Programmer, Call Center/Mail Center Supervisor) involved in
the CAHPS Hospice Survey, including a description of the capabilities of all subcontractors
and any other organizations that are responsible for major functions of CAHPS Hospice Survey
administration and the survey vendor’s experience with these organizations, if applicable.
Background and qualifications of all key personnel, subcontractors and any other organizations
responsible for major functions of CAHPS Hospice Survey administration should include
experience in conducting patient-specific surveys and experience in the appropriate project
task(s) assigned to the project staff. Staff resumes are not required; however, these resumes
may be requested during oversight activities.
6.
2
Identify who participated in the CAHPS Hospice Survey Training session in the current year.
Describe the training that has been or will be provided to all personnel involved in CAHPS
Hospice Survey processes, including subcontractors and any other organizations, if
subcontractors and any other organizations are used during the CAHPS Hospice Survey
process. Survey vendors must also describe training that they provide to their client hospices.
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Work Plan for Survey Administration
This section of the QAP should be written in a manner so that a new member of the CAHPS
Hospice Survey team could carry out the processes necessary to administer the CAHPS
Hospice Survey. The QAP should provide sufficient detail for this person to completely
understand and accurately follow the processes to administer the survey, and should include
a comprehensive timeline of key events (number of days between key events), showing who
will do what, when they will do it and how they will get it done. The QAP should be free of
extraneous information. The emphasis should be on providing concise explanations of required
CAHPS Hospice Survey processes.
Note: If survey vendors are approved for multiple modes of survey administration, they must
separately list responses for each mode.
7. Provide the information requested below for the survey vendor’s approved mode(s) of survey
administration, including a timeline of key survey administration events.
A. Mail Only – describe the process for updating addresses, producing mailing materials,
including seeded mailings, and the process for mailing out the surveys (Mail Only Survey
Administration chapter)
B. Telephone Only – describe the process for updating telephone numbers, programming
and operating the interviewing systems and contacting sampled caregivers (Telephone
Only Survey Administration chapter)
1. Describe how interviewers respond to respondents who request or are in need of
bereavement services
2. Describe how interviewers redirect the call when the decedent or caregiver is
personally or professionally known by the initial interviewer
3. Describe how caregivers with multiple telephone numbers are handled, including
how the telephone numbers are prioritized
C. Mixed Mode – see above for Mail Only and Telephone Only (Mixed Mode Survey
Administration chapter)
D. Describe your organization’s Distressed Respondent Procedures
8. Provide a count of the maximum number of supplemental questions added to the CAHPS
Hospice Survey. Identify where the supplemental questions are placed. List the transition
statement(s) placed before the supplemental questions (include this information for each
hospice, as applicable).
9. Describe the steps involved in creating the sample frame and selecting the sample size. Do not
include programming code.
A. Describe the process for receiving and updating the decedent/caregiver information,
including electronic security utilized for exchange of decedents/caregivers lists between
client hospices and survey vendor. Describe what the hospice will provide for sample
frame creation.
1. Include a list of all data elements the hospice will provide
B. Describe the database(s)/document(s) that will be used to identify the eligible
decedents/caregivers
C. Describe the method of sampling to be used, including the process for selecting the
sample size (Sampling Protocol chapter)
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D. Describe the procedure for ensuring hospices with sufficient eligible population sizes
sample at least 700 decedents/caregivers in a 12-month timeframe
E. List the CAHPS Hospice Survey eligibility and exclusion criteria and describe the
process for applying them to determine decedent/caregiver eligibility for inclusion in the
CAHPS Hospice Survey sample frame (Sampling Protocol chapter)
F. Describe the de-duplication process for multiple hospice stays and to verify that a
decedent is provided only once in the decedents/caregivers list
G. If administering the survey in multiple languages, identify the languages and describe
how the survey language to be administered to the eligible caregiver is chosen
10. Describe the process and steps used to assign the random, unique, de-identified
decedent/caregiver identification numbers.
Note: Identification numbers must not be based on a coding structure that could potentially
reveal decedent/caregiver identities, such as those that incorporate the decedent’s/caregiver’s
last name, initials, date of birth, hospice account number, month, date, etc.
11. List all Exception Requests for which the survey vendor has received approval and describe
how these approved Exception Requests are incorporated into the CAHPS Hospice Survey
processes.
12. Describe the data receipt and data entry procedures. Do not include programming code.
A. Describe how the surveys are handled and recorded when they are returned by mail, if
applicable, or completed by telephone, if applicable
B. Describe the use of the decision rules, if applicable
C. Describe the scanning procedure, if applicable
D. Describe how and when in the process the “Final Survey Status” code is assigned
E. Provide the crosswalk of your organization’s interim disposition codes to CAHPS
Hospice Survey “Final Survey Status” codes, if applicable
13. Describe the data preparation and submission procedures. Do not include programming code.
A. Describe the process of updating the eligibility status of decedents/caregivers (i.e.,
process for updating any missing fields in the decedents/caregivers list received from the
hospice)
B. Describe the process for converting data into XML files and uploading the data to the
CAHPS Hospice Survey Data Warehouse
C. Describe the time frames for completing data submission, including the estimated time
to generate, review and submit the data before the data submission deadline
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Survey and Data Management System and Quality Controls
14. Describe the system resources (hardware and software) available, if not previously described
in sections above, such as:
A. Telephone (CATI) interviewing systems
B. Mailing equipment
C. Scanning systems
D. Software used for tracking, assigning de-identified numbers, generating sample frame,
producing mail survey packets, telephone survey administration, XML file generation
E. Address and telephone number updating resources
15. Describe the customer support telephone line and how it is operated.
A. Identify who is responsible for responding to questions regarding the CAHPS Hospice
Survey
B. Specify the customer support telephone number
C. Include a written transcript of the voicemail message that specifies the caller can leave a
message about the CAHPS Hospice Survey
D. Include the hours of live/voicemail operations for the customer support line and the time
frame for returning voicemail messages
E. Describe how survey vendor provides customer support in all languages that the survey
vendor administers the survey in
F. Describe how the survey vendor is ready to support calls from the deaf or the hearing
impaired
G. Describe how survey vendor will handle respondents who request or are in need of
bereavement services
H. Describe how customer support calls, including the resolution of the inquiry, are
documented
16. Tracking of key events should be part of a survey vendor’s quality oversight processes.
Describe how key events are tracked throughout the survey process, including, but not limited
to:
A. Receipt of the decedents/caregivers list
B. Creation of the sample frame
C. Drawing the sample
D. Assignment of random, unique, de-identified decedent/caregiver identification numbers
E. Administering the survey by the approved mode(s) of administration
F. Data receipt
G. Data entry
H. Data submission
I. Data retention
17. Identify the specific timeline for incorporating the CAHPS Hospice Survey Quality Assurance
Guidelines V6.0 changes into the survey vendor’s survey administration processes.
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For items 18 – 23, please include the following in your description:
Identify who performs the checks
Identify what checks are performed
Identify how the checks are performed
Identify how frequently the checks occur
Identify the number or percentage of records that are checked
Identify the documentation that provides evidence that the checks are performed
18. Describe the process for monitoring on-site work and subcontractors’ or any other
organizations’ work to ensure high quality results. Include monitoring of telephone
interviewers, if applicable, and checks of printed mailing materials, if applicable.
19. Describe the quality control checks implemented to validate that eligibility and exclusion
criteria are applied correctly and that sample frame creation is accurate.
A. Describe the method used to verify the sample is a random selection (unless using 100
percent census sample)
20. Describe the quality control process to validate the accuracy of manual data entry and/or
electronic scanning procedures, if applicable. Include the quality control process to verify the
accuracy of the application of CAHPS Hospice Survey decision rules for processing mail
surveys.
21. Describe the quality control checks of telephone (CATI) procedures, if applicable, to confirm
that programming is accurate and in accordance with CAHPS Hospice Survey protocols, and
that data integrity is maintained.
22. Describe the quality control process to validate the accuracy of data submission, including the
review of the CAHPS Hospice Survey Data Submission Reports.
23. Describe the process for electronic back-up, including the quality control checks that are in
place to ensure the back-up files are retrievable.
Confidentiality, Privacy and Security Procedures
24. Provide a copy of the blank confidentiality agreements that are signed by staff and
subcontractors or any other organizations involved in any aspect of survey administration. In
addition, describe the process that all staff, subcontractors and any other organizations follow
in reviewing and signing confidentiality agreements, including the timeframe for re-signing.
25. Describe the physical and electronic security and storage procedures to protect
decedent/caregiver-identified files, survey questionnaires, audio-recorded interviews, and
sample files, including the length of time that the survey materials will be retained.
26. Describe the disaster recovery plan for conducting ongoing business operations in the event
of a disaster.
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QAP Update: Discussion of Results of Quality Control Activities
27. Discuss the results and “lessons learned” from the quality review activities listed below.
Describe in detail the outcomes of these reviews.
A. Describe CAHPS Hospice Survey administration challenges and how these were handled
B. Describe the discovery of any variations from CAHPS Hospice Survey protocols and
how these variations were corrected
C. Describe the process for communicating the results of your quality checks to upper
management
D. Describe any opportunities for improvement to your CAHPS Hospice Survey
administration processes that were identified
E. Document in the QAP any changes in survey administration resulting from quality
process improvement activities
Other
28. Include any forms used in CAHPS Hospice Survey administration that may assist the CAHPS
Hospice Survey Project Team in reviewing the survey vendor’s processes (e.g., tracking logs,
sample frame format, etc.).
Note: These items should be templates only and must not contain any protected health
information (PHI).
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Appendix I
Exception Request Form
CAHPS Hospice Survey
Exception Request Form
The Exception Request Form must be completed and submitted online on the CAHPS
Hospice Survey Web site (www.hospicecahpssurvey.org). The hospice(s) for which this
Exception Request relates to must be listed in Section II along with each hospice’s CMS
Certification Number (CCN). All required fields are indicated with an asterisk (*).
NOTE: This form does not accept any special characters or symbols in the text boxes. Use
only alphanumeric characters when completing this form.
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Appendix J
Discrepancy Report Form
CAHPS Hospice Survey
Discrepancy Report Form
The Discrepancy Report Form must be completed and submitted online on the CAHPS
Hospice Survey Web site (www.hospicecahpssurvey.org). The requested information
regarding the affected hospices must be provided in Section III in order to complete the
CAHPS Hospice Survey Discrepancy Report. All required fields are indicated with an asterisk
(*). If all of the information is not immediately available, survey vendors must submit an
initial Discrepancy Report alerting CMS of the issue and subsequently update the Discrepancy
Report with the remaining required information once available. When updating a Discrepancy
Report, please note that the initial report is retained in its entirety; therefore, it is necessary
only to provide the remaining required information pertaining to the original submission,
referencing the Original Report Form ID.
NOTE: This form does not accept any special characters or symbols in the text boxes. Use
only alphanumeric characters when completing this form.
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Appendix K
Participation Exemption for Size Form
CAHPS Hospice Survey
Participation Exemption for Size Form
The Participation Exemption for Size Form must be completed and submitted online on the
CAHPS Hospice Survey Website (www.hospicecahpssurvey.org).
All required fields are indicated with an asterisk (*). Note: For multiple hospice programs
sharing one CCN, the survey-eligible decedent/caregiver count is the total from all
facilities.
The Participation Exemption for Size Form has been successfully submitted once you are
redirected to a “Thank you for your submission” page.
1. Enter the total number of patients who died while in hospice care between January 1, 2019 and December 31, 2019
(CY 2019) *
2. Enter the total number of patients during CY 2019 who fall into the following categories. Do not include a patient in more than one of the following categories:
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Appendix L
Attestation Statement
CAHPS Hospice Survey
Attestation Statement
All of the data collected and submitted to the Centers for Medicare & Medicaid Services (CMS)
for the Consumer Assessment of Healthcare Providers and Systems (CAHPS) Hospice Survey by
[name of survey vendor] and all our subcontractors and any other organizations (if applicable)
engaged in survey activities are accurate and complete. This includes the following:
1. Meet and comply with the CAHPS Hospice Survey Minimum Business Requirements
specified in the CAHPS Hospice Survey Quality Assurance Guidelines
2. Review and adhere to the CAHPS Hospice Survey Quality Assurance Guidelines and
policy updates
3. Update annual CAHPS Hospice Survey Quality Assurance Plan to be complete,
comprehensive and accurate
4. Attest to the accuracy of data collection activities
5. Comply with all requirements of the Health Insurance Portability and Accountability Act
(HIPAA) Security and Privacy Rules in conducting all survey administration and data
collection activities
6. Maintain confidentiality and security of all CAHPS Hospice Survey decedent/caregiverrelated and survey-related data
7. Meet all CAHPS Hospice Survey due dates (including data submission)
8. Report any problems or discrepancies to CMS in a timely manner
9. Participate and cooperate (including subcontractors and any other organizations
responsible for major functions of the CAHPS Hospice Survey) in all oversight activities
conducted by the CAHPS Hospice Survey Project Team
The statements herein are true, complete and accurate to the best of my knowledge.
Survey Vendor Name: ___________________________________________________________
Project Director or Authorized Representative Name: __________________________________
Title: _________________________________________________________________________
Signature: _____________________________________________________________________
Date: _________________________________________________________________________
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Appendix M
Examples of Additional Supplemental Questions
for Survey Vendor Use
CAHPS Hospice Survey
Examples of Additional Supplemental Questions
for Survey Vendor Use
S1.
While your family member was in hospice care, how often did you have a hard time
speaking with or understanding members of the hospice team because you spoke different
languages?
3
4
1
2
S2.
Never
Sometimes
Usually
Always
In thinking about your experiences with hospice, was there anything that went especially
well or that you wish had gone differently for you and your family member? Please tell us
about those experiences.
Special Medical Equipment 1
S3.
Special medical equipment includes things like hospital beds, wheelchairs or oxygen.
While your family member was in hospice care, did your family member need special
medical equipment?
1
2
S4.
Yes
No If No, please go to Question S6
Did your family member get the equipment as soon as he or she needed it?
1
2
Yes
No
1
The items regarding special medical equipment were designed and tested to assess care within a home setting.
Care should be taken when interpreting results from respondents whose family members did not receive care in a
home setting. It is recommended that Question S3 be used as a screener for the subsequent Special Medical
Equipment items.
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S5.
Was the equipment picked up in a timely manner when your family member no longer
needed it?
1
2
Yes
No
Personal Care Needs 2
S6.
Personal care needs include bathing, dressing, eating meals, and changing bedding. While
your family member was in hospice care, how often did your family member get as much
help with personal care as he or she needed?
3
4
1
2
Never
Sometimes
Usually
Always
Hospice Care Received in a Hospital or Hospice Facility
S7.
Some people receive hospice care while they are in a hospital or hospice facility. Did your
family member receive care from this hospice while he or she was in a hospital or hospice
facility?
1
2
S8.
While your family member was in hospice care, did you speak to a doctor as often as you
needed?
3
1
2
S9.
Yes
No If No, please go to the End
Yes, definitely
Yes, somewhat
No
While your family member was in hospice care, was his or her room and bathroom kept
clean?
3
1
2
Yes, definitely
Yes, somewhat
No
2
The item regarding personal care needs was designed and tested to assess care within nursing home or inpatient
settings. Care should be taken when interpreting results from respondents whose family members received care only
in a home setting.
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Appendix N
Mail Survey Materials (English)
CAHPS® Hospice Survey
Please answer the survey questions about the care the patient received from this
hospice:
[NAME OF HOSPICE]
All of the questions in this survey will ask about the experiences with this
hospice.
If you want to know more about this survey, please call [TOLL FREE NUMBER]. All
calls to that number are free.
OMB#0938-1257
Expires December 31, 2020
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CAHPS® Hospice Survey
SURVEY INSTRUCTIONS
♦
Please give this survey to the person in your household who knows the most about
the hospice care received by the person listed on the survey cover letter.
♦
Use a dark colored pen to fill out the survey.
♦
Place an X directly inside the square indicating a response, like in the sample below.
Yes
No
♦
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 If Yes, Go to Question 1
No
_____________________________________________________________________
THE HOSPICE PATIENT
1. How are you related to the person
listed on the survey cover letter?
3
1
2
6
7
8
9
4
5
2
My spouse or partner
My parent
My mother-in-law or father-inlaw
My grandparent
My aunt or uncle
My sister or brother
My child
My friend
Other (please print):
2. For this survey, the phrase "family
member" refers to the person
listed on the survey cover letter.
In what locations did your family
member receive care from this
hospice? Please choose one or
more.
3
4
5
6
1
2
Home
Assisted living facility
Nursing home
Hospital
Hospice facility/hospice house
Other (please print):
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YOUR ROLE
3. While your family member was in
hospice care, how often did you
take part in or oversee care for
him or her?
1
3
4
2
Never If Never, go to
Question 41
Sometimes
Usually
Always
YOUR FAMILY MEMBER’S
HOSPICE CARE
As you answer the rest of the
questions in this survey, please think
only about your family member's
experience with the hospice named
on the survey cover.
4. For this survey, the hospice team
includes all the nurses, doctors,
social workers, chaplains and
other people who provided
hospice care to your family
member. While your family
member was in hospice care, did
you need to contact the hospice
team during evenings, weekends,
or holidays for questions or help
with your family member’s care?
1
2
Yes
No If No, go to Question 6
5. How often did you get the help
you needed from the hospice
team during evenings, weekends,
or holidays?
3
4
1
2
Never
Sometimes
Usually
Always
6. While your family member was in
hospice care, how often did the
hospice team keep you informed
about when they would arrive to
care for your family member?
1 Never
2 Sometimes
3 Usually
4 Always
7. While your family member was in
hospice care, when you or your
family member asked for help
from the hospice team, how often
did you get help as soon as you
needed it?
3
4
1
2
Never
Sometimes
Usually
Always
8. While your family member was in
hospice care, how often did the
hospice team explain things in a
way that was easy to understand?
2
3
4
1
Never
Sometimes
Usually
Always
9. While your family member was in
hospice care, how often did the
hospice team keep you informed
about your family member’s
condition?
2
3
4
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Never
Sometimes
Usually
Always
3
10. While your family member was in
hospice care, how often did
anyone from the hospice team
give you confusing or
contradictory information about
your family member’s condition or
care?
3
4
1
2
2
3
4
Never
Sometimes
Usually
Always
Never
Sometimes
Usually
Always
3
4
2
2
4
15. While your family member was in
hospice care, did he or she have
any pain?
1
2
2
3
1
Never
Sometimes
Usually
Always
Yes
No If No, go to Question 17
2
Yes
No If No, go to Question 15
Yes, definitely
Yes, somewhat
No
17. While your family member was in
hospice care, did he or she
receive any pain medicine?
1
13. While your family member was in
hospice care, did you talk with the
hospice team about any problems
with your family member’s
hospice care?
1
Never
Sometimes
Usually
Always
16. Did your family member get as
much help with pain as he or she
needed?
12. While your family member was in
hospice care, how often did you
feel that the hospice team really
cared about your family member?
1
3
4
1
2
11. While your family member was in
hospice care, how often did the
hospice team treat your family
member with dignity and respect?
1
14. How often did the hospice team
listen carefully to you when you
talked with them about problems
with your family member’s
hospice care?
Yes
No If No, go to Question 21
18. Side effects of pain medicine
include things like sleepiness. Did
any member of the hospice team
discuss side effects of pain
medicine with you or your family
member?
2
3
1
Yes, definitely
Yes, somewhat
No
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
19. Did the hospice team give you the
training you needed about what
side effects to watch for from pain
medicine?
2
3
1
Yes, definitely
Yes, somewhat
No
20. Did the hospice team give you the
training you needed about if and
when to give more pain medicine
to your family member?
2
3
4
1
Yes, definitely
Yes, somewhat
No
I did not need to give pain
medicine to my family member
21. While your family member was in
hospice care, did your family
member ever have trouble
breathing or receive treatment for
trouble breathing?
1
2
Yes
No If No, go to Question 24
22. How often did your family member
get the help he or she needed for
trouble breathing?
2
3
4
1
Never
Sometimes
Usually
Always
23. Did the hospice team give you the
training you needed about how to
help your family member if he or
she had trouble breathing?
2
3
4
1
Yes, definitely
Yes, somewhat
No
I did not need to help my family
member with trouble breathing
24. While your family member was in
hospice care, did your family
member ever have trouble with
constipation?
2
1
Yes
No If No, go to Question 26
25. How often did your family member
get the help he or she needed for
trouble with constipation?
3
4
1
2
Never
Sometimes
Usually
Always
26. While your family member was in
hospice care, did he or she show
any feelings of anxiety or
sadness?
1
2
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
Yes
No If No, go to Question 28
5
27. How often did your family member
get the help he or she needed
from the hospice team for feelings
of anxiety or sadness?
2
3
4
1
2
3
1
Never
Sometimes
Usually
Always
28. While your family member was in
hospice care, did he or she ever
become restless or agitated?
2
1
Yes
No If No, go to Question 30
29. Did the hospice team give you the
training you needed about what to
do if your family member became
restless or agitated?
2
3
1
Yes, definitely
Yes, somewhat
No
30. Moving your family member
includes things like helping him or
her turn over in bed, or get in and
out of bed or a wheelchair. Did the
hospice team give you the training
you needed about how to safely
move your family member?
3
4
1
2
6
31. Did the hospice team give you as
much information as you wanted
about what to expect while your
family member was dying?
Yes, definitely
Yes, somewhat
No
HOSPICE CARE RECEIVED IN A
NURSING HOME
32. Some people receive hospice care
while they are living in a nursing
home. Did your family member
receive care from this hospice
while he or she was living in a
nursing home?
2
1
Yes
No If No, go to Question 35
33. While your family member was in
hospice care, how often did the
nursing home staff and hospice
team work well together to care
for your family member?
2
3
4
1
Never
Sometimes
Usually
Always
Yes, definitely
Yes, somewhat
No
I did not need to move my
family member
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
34. While your family member was in
hospice care, how often was the
information you were given about
your family member by the
nursing home staff different from
the information you were given by
the hospice team?
3
4
1
2
Never
Sometimes
Usually
Always
YOUR OWN EXPERIENCE WITH
HOSPICE
35. While your family member was in
hospice care, how often did the
hospice team listen carefully to
you?
3
4
1
2
37. While your family member was in
hospice care, how much
emotional support did you get
from the hospice team?
2
3
1
Too little
Right amount
Too much
38. In the weeks after your family
member died, how much
emotional support did you get
from the hospice team?
2
3
1
Too little
Right amount
Too much
Never
Sometimes
Usually
Always
36. Support for religious or spiritual
beliefs includes talking, praying,
quiet time, or other ways of
meeting your religious or spiritual
needs. While your family member
was in hospice care, how much
support for your religious and
spiritual beliefs did you get from
the hospice team?
3
1
2
Too little
Right amount
Too much
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
7
OVERALL RATING OF HOSPICE
CARE
39. Please answer the following
questions about your family
member’s care from the hospice
named on the survey cover. Do
not include care from other
hospices in your answers.
ABOUT YOUR FAMILY MEMBER
41. What is the highest grade or level
of school that your family member
completed?
2
1
4
5
6
3
Using any number from 0 to 10,
where 0 is the worst hospice care
possible and 10 is the best
hospice care possible, what
number would you use to rate
your family member’s hospice
care?
0
1 1
2 2
3 3
4 4
5 5
6 6
7 7
8 8
9 9
10 10
0
Worst hospice care possible
3
4
2
8
42. Was your family member of
Hispanic, Latino, or Spanish
origin or descent?
2
3
1
4
5
Best hospice care possible
40. Would you recommend this
hospice to your friends and
family?
1
7
Definitely no
Probably no
Probably yes
Definitely yes
8th grade or less
Some high school but did not
graduate
High school graduate or GED
Some college or 2-year degree
4-year college graduate
More than 4-year college
degree
Don’t know
No, not Spanish/Hispanic/Latino
Yes, Puerto Rican
Yes, Mexican, Mexican
American, Chicano/a
Yes, Cuban
Yes, Other Spanish/Hispanic/
Latino
43. What was your family member’s
race? Please choose one or more.
2
3
4
1
5
White
Black or African American
Asian
Native Hawaiian or other Pacific
Islander
American Indian or Alaska
Native
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
ABOUT YOU
44. What is your age?
2
3
4
5
6
7
8
1
2
18 to 24
25 to 34
35 to 44
45 to 54
55 to 64
65 to 74
75 to 84
85 or older
1
4
5
6
3
45. Are you male or female?
1
2
Male
Female
46. What is the highest grade or level
of school that you have
completed?
8th grade or less
Some high school but did not
graduate
High school graduate or GED
Some college or 2-year degree
4-year college graduate
More than 4-year college
degree
47. What language do you mainly
speak at home?
2
3
4
5
6
7
8
9
1
English
Spanish
Chinese
Russian
Portuguese
Vietnamese
Polish
Korean
Some other language (please
print):
THANK YOU
Please return the completed survey in the postage-paid envelope.
[NAME OF SURVEY VENDOR]
[RETURN ADDRESS OF SURVEY VENDOR]
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
9
10
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
CAHPS® Hospice Survey
Please answer the survey questions about the care the patient received from this
hospice:
[NAME OF HOSPICE]
All of the questions in this survey will ask about the experiences with this
hospice.
If you want to know more about this survey, please call [TOLL FREE NUMBER]. All
calls to that number are free.
OMB#0938-1257
Expires December 31, 2020
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
11
CAHPS® Hospice Survey
SURVEY INSTRUCTIONS
♦
♦
♦
♦
Please give this survey to the person in your household who knows the most about
the hospice care received by the person listed on the survey cover letter.
Use a dark colored pen to fill out the survey.
Answer all the questions by completely filling in the circle to the left of your answer.
0 Yes
No
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 If Yes, Go to Question 1
0 No
_____________________________________________________________________
THE HOSPICE PATIENT
1. How are you related to the person
listed on the survey cover letter?
0
20
30
1
0
50
60
70
80
90
4
12
My spouse or partner
My parent
My mother-in-law or father-inlaw
My grandparent
My aunt or uncle
My sister or brother
My child
My friend
2. For this survey, the phrase "family
member" refers to the person
listed on the survey cover letter.
In what locations did your family
member receive care from this
hospice? Please choose one or
more.
0
20
30
40
50
60
1
Home
Assisted living facility
Nursing home
Hospital
Hospice facility/hospice house
Other (please print):
Other (please print):
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
YOUR ROLE
3. While your family member was in
hospice care, how often did you
take part in or oversee care for
him or her?
0
1
0
30
40
2
Never If Never, go to
Question 41
Sometimes
Usually
Always
YOUR FAMILY MEMBER’S
HOSPICE CARE
As you answer the rest of the
questions in this survey, please think
only about your family member's
experience with the hospice named
on the survey cover.
4. For this survey, the hospice team
includes all the nurses, doctors,
social workers, chaplains and
other people who provided
hospice care to your family
member. While your family
member was in hospice care, did
you need to contact the hospice
team during evenings, weekends,
or holidays for questions or help
with your family member’s care?
0
20
1
Yes
No If No, go to Question 6
5. How often did you get the help
you needed from the hospice
team during evenings, weekends,
or holidays?
0
0
30
40
1
Never
2
Sometimes
Usually
Always
6. While your family member was in
hospice care, how often did the
hospice team keep you informed
about when they would arrive to
care for your family member?
0
20
30
40
1
Never
Sometimes
Usually
Always
7. While your family member was in
hospice care, when you or your
family member asked for help
from the hospice team, how often
did you get help as soon as you
needed it?
0
20
30
40
1
Never
Sometimes
Usually
Always
8. While your family member was in
hospice care, how often did the
hospice team explain things in a
way that was easy to understand?
0
20
30
40
1
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
Never
Sometimes
Usually
Always
13
9. While your family member was in
hospice care, how often did the
hospice team keep you informed
about your family member’s
condition?
0
20
30
40
1
0
20
1
Never
Sometimes
Usually
Always
10. While your family member was in
hospice care, how often did
anyone from the hospice team
give you confusing or
contradictory information about
your family member’s condition or
care?
0
20
30
40
1
13. While your family member was in
hospice care, did you talk with the
hospice team about any problems
with your family member’s
hospice care?
Never
Sometimes
0
20
30
40
1
Never
Sometimes
Usually
Always
15. While your family member was in
hospice care, did he or she have
any pain?
Usually
Always
11. While your family member was in
hospice care, how often did the
hospice team treat your family
member with dignity and respect?
0
20
Yes
No If No, go to Question 17
16. Did your family member get as
much help with pain as he or she
needed?
1
Never
2
Sometimes
1
Yes, definitely
Usually
2
Yes, somewhat
0
0
30
Always
12. While your family member was in
hospice care, how often did you
feel that the hospice team really
cared about your family member?
0
20
30
40
1
14
No If No, go to Question 15
14. How often did the hospice team
listen carefully to you when you
talked with them about problems
with your family member’s
hospice care?
1
0
0
30
40
Yes
Never
No
17. While your family member was in
hospice care, did he or she
receive any pain medicine?
0
0
1
Yes
2
No If No, go to Question 21
Sometimes
Usually
Always
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
18. Side effects of pain medicine
include things like sleepiness. Did
any member of the hospice team
discuss side effects of pain
medicine with you or your family
member?
0
20
30
1
Yes, definitely
Yes, somewhat
0
20
30
Yes, definitely
Yes, somewhat
No
20. Did the hospice team give you the
training you needed about if and
when to give more pain medicine
to your family member?
0
0
30
40
1
Yes, definitely
2
Yes, somewhat
No
I did not need to give pain
medicine to my family member
21. While your family member was in
hospice care, did your family
member ever have trouble
breathing or receive treatment for
trouble breathing?
0
20
1
0
20
30
40
1
Never
Sometimes
Usually
Always
No
19. Did the hospice team give you the
training you needed about what
side effects to watch for from pain
medicine?
1
22. How often did your family member
get the help he or she needed for
trouble breathing?
Yes
No If No, go to Question 24
23. Did the hospice team give you the
training you needed about how to
help your family member if he or
she had trouble breathing?
0
0
30
40
1
Yes, definitely
2
Yes, somewhat
No
I did not need to help my family
member with trouble breathing
24. While your family member was in
hospice care, did your family
member ever have trouble with
constipation?
0
20
1
Yes
No If No, go to Question 26
25. How often did your family member
get the help he or she needed for
trouble with constipation?
0
0
30
40
1
Never
2
Sometimes
Usually
Always
26. While your family member was in
hospice care, did he or she show
any feelings of anxiety or
sadness?
0
20
1
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
Yes
No If No, go to Question 28
15
27. How often did your family member
get the help he or she needed
from the hospice team for feelings
of anxiety or sadness?
0
20
30
40
1
0
0
30
Never
1
Yes, definitely
Sometimes
2
Yes, somewhat
Usually
Always
28. While your family member was in
hospice care, did he or she ever
become restless or agitated?
0
0
1
Yes
2
No If No, go to Question 30
29. Did the hospice team give you the
training you needed about what to
do if your family member became
restless or agitated?
0
0
30
1
Yes, definitely
2
Yes, somewhat
No
30. Moving your family member
includes things like helping him or
her turn over in bed, or get in and
out of bed or a wheelchair. Did the
hospice team give you the training
you needed about how to safely
move your family member?
0
0
30
40
16
31. Did the hospice team give you as
much information as you wanted
about what to expect while your
family member was dying?
1
Yes, definitely
2
Yes, somewhat
No
I did not need to move my
family member
No
HOSPICE CARE RECEIVED IN A
NURSING HOME
32. Some people receive hospice care
while they are living in a nursing
home. Did your family member
receive care from this hospice
while he or she was living in a
nursing home?
0
0
1
Yes
2
No If No, go to Question 35
33. While your family member was in
hospice care, how often did the
nursing home staff and hospice
team work well together to care
for your family member?
0
0
30
40
1
Never
2
Sometimes
Usually
Always
34. While your family member was in
hospice care, how often was the
information you were given about
your family member by the
nursing home staff different from
the information you were given by
the hospice team?
0
0
30
40
1
Never
2
Sometimes
Usually
Always
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
YOUR OWN EXPERIENCE WITH
HOSPICE
35. While your family member was in
hospice care, how often did the
hospice team listen carefully to
you?
0
20
30
40
1
Never
0
20
30
Usually
Always
Too little
Right amount
Too much
37. While your family member was in
hospice care, how much
emotional support did you get
from the hospice team?
0
20
30
1
Too little
Right amount
Too much
38. In the weeks after your family
member died, how much
emotional support did you get
from the hospice team?
0
0
30
39. Please answer the following
questions about your family
member’s care from the hospice
named on the survey cover. Do
not include care from other
hospices in your answers.
Sometimes
36. Support for religious or spiritual
beliefs includes talking, praying,
quiet time, or other ways of
meeting your religious or spiritual
needs. While your family member
was in hospice care, how much
support for your religious and
spiritual beliefs did you get from
the hospice team?
1
OVERALL RATING OF
HOSPICE CARE
1
Too little
2
Right amount
Using any number from 0 to 10,
where 0 is the worst hospice care
possible and 10 is the best
hospice care possible, what
number would you use to rate
your family member’s hospice
care?
0
0
20
30
40
50
60
70
80
90
100
0
0 Worst hospice care possible
1
1
2
3
4
5
6
7
8
9
10 Best hospice care possible
40. Would you recommend this
hospice to your friends and
family?
0
0
30
40
1
Definitely no
2
Probably no
Probably yes
Definitely yes
Too much
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
17
ABOUT YOUR FAMILY MEMBER
41. What is the highest grade or level
of school that your family member
completed?
0
20
1
0
40
50
60
3
0
7
8th grade or less
Some high school but did not
graduate
High school graduate or GED
0
20
30
0
50
4
18
0
0
30
40
1
White
2
Black or African American
0
5
Some college or 2-year degree
Asian
Native Hawaiian or other Pacific
Islander
American Indian or Alaska
Native
4-year college graduate
ABOUT YOU
More than 4-year college
degree
Don’t know
44. What is your age?
0
20
30
40
50
60
70
80
1
42. Was your family member of
Hispanic, Latino, or Spanish
origin or descent?
1
43. What was your family member’s
race? Please choose one or more.
No, not Spanish/Hispanic/Latino
Yes, Puerto Rican
Yes, Mexican, Mexican
American, Chicano/a
Yes, Cuban
Yes, Other Spanish/Hispanic/
Latino
18 to 24
25 to 34
35 to 44
45 to 54
55 to 64
65 to 74
75 to 84
85 or older
45. Are you male or female?
0
20
1
Male
Female
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
46. What is the highest grade or level
of school that you have
completed?
0
20
1
0
40
50
60
3
8th
grade or less
Some high school but did not
graduate
High school graduate or GED
Some college or 2-year degree
4-year college graduate
More than 4-year college
degree
47. What language do you mainly
speak at home?
0
0
30
40
50
60
70
80
90
1
English
2
Spanish
Chinese
Russian
Portuguese
Vietnamese
Polish
Korean
Some other language (please
print):
THANK YOU
Please return the completed survey in the postage-paid envelope.
[NAME OF SURVEY VENDOR]
[RETURN ADDRESS OF SURVEY VENDOR]
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
19
20
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
CAHPS® Hospice Survey
Please answer the survey questions about the care the patient received from this
hospice:
[NAME OF HOSPICE]
All of the questions in this survey will ask about the experiences with this
hospice.
If you want to know more about this survey, please call [TOLL FREE NUMBER]. All
calls to that number are free.
OMB#0938-1257
Expires December 31, 2020
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
21
CAHPS® Hospice Survey
SURVEY INSTRUCTIONS
♦
♦
♦
Please give this survey to the person in your household who knows the most about
the hospice care received by the person listed on the survey cover letter.
Use a dark colored pen to fill out the survey.
Answer all the questions by completely filling in the circle to the left of your answer.
O Yes
♦
No
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 If Yes, Go to Question 1
O
No
_____________________________________________________________________
THE HOSPICE PATIENT
1. How are you related to the person
listed on the survey cover letter?
O
O
3O
1
My spouse or partner
2
My parent
O
5O
6O
7O
8O
9O
4
My mother-in-law or father-inlaw
My grandparent
My aunt or uncle
My sister or brother
My child
My friend
2. For this survey, the phrase
"family member" refers to the
person listed on the survey cover
letter. In what locations did your
family member receive care from
this hospice? Please choose one
or more.
O
2O
3O
4O
5O
6O
1
Home
Assisted living facility
Nursing home
Hospital
Hospice facility/hospice house
Other (please print):
Other (please print):
_________________________
22
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
YOUR ROLE
3. While your family member was in
hospice care, how often did you
take part in or oversee care for
him or her?
O
1
O
3O
4O
2
Never If Never, go to
Question 41
Sometimes
Usually
Always
YOUR FAMILY MEMBER’S
HOSPICE CARE
As you answer the rest of the
questions in this survey, please think
only about your family member's
experience with the hospice named
on the survey cover.
4. For this survey, the hospice team
includes all the nurses, doctors,
social workers, chaplains and
other people who provided
hospice care to your family
member. While your family
member was in hospice care, did
you need to contact the hospice
team during evenings, weekends,
or holidays for questions or help
with your family member’s care?
O
2O
1
Yes
No If No, go to Question 6
5. How often did you get the help
you needed from the hospice
team during evenings, weekends,
or holidays?
O
O
3O
4O
1
Never
2
Sometimes
Usually
Always
6. While your family member was in
hospice care, how often did the
hospice team keep you informed
about when they would arrive to
care for your family member?
O
2O
3O
4O
1
Never
Sometimes
Usually
Always
7. While your family member was in
hospice care, when you or your
family member asked for help
from the hospice team, how often
did you get help as soon as you
needed it?
O
2O
3O
4O
1
Never
Sometimes
Usually
Always
8. While your family member was in
hospice care, how often did the
hospice team explain things in a
way that was easy to understand?
O
2O
3O
4O
1
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
Never
Sometimes
Usually
Always
23
9.
While your family member was in
hospice care, how often did the
hospice team keep you informed
about your family member’s
condition?
O
2O
3O
4O
1
O
2O
1
Never
Sometimes
Usually
Always
10. While your family member was in
hospice care, how often did
anyone from the hospice team
give you confusing or
contradictory information about
your family member’s condition or
care?
O
2O
3O
4O
1
13. While your family member was in
hospice care, did you talk with the
hospice team about any problems
with your family member’s
hospice care?
Never
Sometimes
O
2O
3O
4O
1
Never
Sometimes
Usually
Always
15. While your family member was in
hospice care, did he or she have
any pain?
Usually
Always
11. While your family member was in
hospice care, how often did the
hospice team treat your family
member with dignity and respect?
O
2O
Yes
No If No, go to Question 17
16. Did your family member get as
much help with pain as he or she
needed?
1
Never
2
Sometimes
1
Yes, definitely
Usually
2
Yes, somewhat
O
O
3O
Always
12. While your family member was in
hospice care, how often did you
feel that the hospice team really
cared about your family member?
O
2O
3O
4O
1
24
No If No, go to Question 15
14. How often did the hospice team
listen carefully to you when you
talked with them about problems
with your family member’s
hospice care?
1
O
O
3O
4O
Yes
Never
No
17. While your family member was in
hospice care, did he or she
receive any pain medicine?
O
O
1
Yes
2
No If No, go to Question 21
Sometimes
Usually
Always
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
18. Side effects of pain medicine
include things like sleepiness. Did
any member of the hospice team
discuss side effects of pain
medicine with you or your family
member?
O
2O
3O
1
Yes, definitely
Yes, somewhat
O
2O
3O
Yes, definitely
Yes, somewhat
No
20. Did the hospice team give you the
training you needed about if and
when to give more pain medicine
to your family member?
O
O
3O
4O
1
Yes, definitely
2
Yes, somewhat
No
I did not need to give pain
medicine to my family member
21. While your family member was in
hospice care, did your family
member ever have trouble
breathing or receive treatment for
trouble breathing?
O
2O
1
O
2O
3O
4O
1
Never
Sometimes
Usually
Always
No
19. Did the hospice team give you the
training you needed about what
side effects to watch for from pain
medicine?
1
22. How often did your family member
get the help he or she needed for
trouble breathing?
Yes
No If No, go to Question 24
23. Did the hospice team give you the
training you needed about how to
help your family member if he or
she had trouble breathing?
O
O
3O
4O
1
Yes, definitely
2
Yes, somewhat
No
I did not need to help my family
member with trouble breathing
24. While your family member was in
hospice care, did your family
member ever have trouble with
constipation?
O
2O
1
Yes
No If No, go to Question 26
25. How often did your family member
get the help he or she needed for
trouble with constipation?
O
O
3O
4O
1
Never
2
Sometimes
Usually
Always
26. While your family member was in
hospice care, did he or she show
any feelings of anxiety or
sadness?
O
2O
1
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
Yes
No If No, go to Question 28
25
27. How often did your family member
get the help he or she needed
from the hospice team for feelings
of anxiety or sadness?
O
2O
3O
4O
1
O
O
3O
Never
1
Yes, definitely
Sometimes
2
Yes, somewhat
Usually
Always
28. While your family member was in
hospice care, did he or she ever
become restless or agitated?
O
2O
1
Yes
No If No, go to Question 30
29. Did the hospice team give you the
training you needed about what to
do if your family member became
restless or agitated?
O
2O
3O
1
O
2O
3O
4O
Yes, somewhat
No
Yes, definitely
Yes, somewhat
No
I did not need to move my
family member
HOSPICE CARE RECEIVED IN A
NURSING HOME
32. Some people receive hospice care
while they are living in a nursing
home. Did your family member
receive care from this hospice
while he or she was living in a
nursing home?
O
O
1
Yes
2
No If No, go to Question 35
O
O
3O
4O
1
Never
2
Sometimes
Usually
Always
34. While your family member was in
hospice care, how often was the
information you were given about
your family member by the
nursing home staff different from
the information you were given by
the hospice team?
O
O
3O
4O
26
No
33. While your family member was in
hospice care, how often did the
nursing home staff and hospice
team work well together to care
for your family member?
Yes, definitely
30. Moving your family member
includes things like helping him or
her turn over in bed, or get in and
out of bed or a wheelchair. Did the
hospice team give you the training
you needed about how to safely
move your family member?
1
31. Did the hospice team give you as
much information as you wanted
about what to expect while your
family member was dying?
1
Never
2
Sometimes
Usually
Always
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
YOUR OWN EXPERIENCE WITH
HOSPICE
35. While your family member was in
hospice care, how often did the
hospice team listen carefully to
you?
O
2O
3O
4O
1
Never
O
2O
3O
Usually
Always
Too little
Right amount
Too much
37. While your family member was in
hospice care, how much
emotional support did you get
from the hospice team?
O
2O
3O
1
Too little
Right amount
Too much
38. In the weeks after your family
member died, how much
emotional support did you get
from the hospice team?
O
O
3O
39. Please answer the following
questions about your family
member’s care from the hospice
named on the survey cover. Do
not include care from other
hospices in your answers.
Sometimes
36. Support for religious or spiritual
beliefs includes talking, praying,
quiet time, or other ways of
meeting your religious or spiritual
needs. While your family member
was in hospice care, how much
support for your religious and
spiritual beliefs did you get from
the hospice team?
1
OVERALL RATING OF
HOSPICE CARE
1
Too little
2
Right amount
Using any number from 0 to 10,
where 0 is the worst hospice care
possible and 10 is the best
hospice care possible, what
number would you use to rate
your family member’s hospice
care?
O
O
2O
3O
4O
5O
6O
7O
8O
9O
10O
0
0 Worst hospice care possible
1
1
2
3
4
5
6
7
8
9
10 Best hospice care possible
40. Would you recommend this
hospice to your friends and
family?
O
O
3O
4O
1
Definitely no
2
Probably no
Probably yes
Definitely yes
Too much
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
27
ABOUT YOUR FAMILY MEMBER
41. What is the highest grade or level
of school that your family member
completed?
O
2O
1
O
4O
5O
6O
3
O
7
8th grade or less
Some high school but did not
graduate
High school graduate or GED
Some college or 2-year degree
4-year college graduate
More than 4-year college
degree
Don’t know
ABOUT YOU
44. What is your age?
O
2O
3O
4O
5O
6O
7O
8O
1
O
2O
42. Was your family member of
Hispanic, Latino, or Spanish
origin or descent?
O
2O
3O
O
O
4
5
25 to 34
35 to 44
45 to 54
55 to 64
65 to 74
75 to 84
85 or older
45. Are you male or female?
1
1
18 to 24
Male
Female
No, not Spanish/Hispanic/Latino
Yes, Puerto Rican
Yes, Mexican, Mexican
American, Chicano/a
Yes, Cuban
Yes, Other Spanish/Hispanic/
Latino
43. What was your family member’s
race? Please choose one or more.
O
2O
3O
4O
1
O
5
28
White
Black or African American
Asian
Native Hawaiian or other Pacific
Islander
American Indian or Alaska
Native
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
46. What is the highest grade or level
of school that you have
completed?
O
2O
1
O
4O
5O
6O
3
8th
grade or less
Some high school but did not
graduate
High school graduate or GED
Some college or 2-year degree
4-year college graduate
More than 4-year college
degree
47. What language do you mainly
speak at home?
O
O
3O
4O
5O
6O
7O
8O
9O
1
English
2
Spanish
Chinese
Russian
Portuguese
Vietnamese
Polish
Korean
Some other language (please
print):
_______________________
THANK YOU
Please return the completed survey in the postage-paid envelope.
[NAME OF SURVEY VENDOR]
[RETURN ADDRESS OF SURVEY VENDOR]
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
29
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Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
Sample Initial Cover Letter for the CAHPS Hospice Survey
[HOSPICE OR VENDOR LETTERHEAD]
[SAMPLED CAREGIVER NAME]
[ADDRESS]
[CITY, STATE ZIP]
Dear [SAMPLED CAREGIVER NAME]:
[HOSPICE NAME] is conducting a survey about the hospice services that patients and their
families receive. You were selected for this survey because you were identified as the caregiver
of [DECEDENT NAME]. We realize this may be a difficult time for you, but we hope that you
will help us learn about the quality of care that you and your family member or friend received
from the hospice.
Questions [NOTE THE QUESTION NUMBERS] in the enclosed survey are part of a national
initiative sponsored by the United States Department of Health and Human Services (HHS) to
measure the quality of care in hospices. The Centers for Medicare & Medicaid Services (CMS),
which is part of HHS, is conducting this survey to improve hospice care. CMS pays for most of
the hospice care in the U.S. It is CMS’ responsibility to ensure that hospice patients and their
family members and friends get high quality care. One of the ways they can fulfill this
responsibility is to find out directly from you about the hospice care your family member or
friend received. Your participation is voluntary and will not affect any health care or benefits you
receive.
We hope that you will take the time to complete the survey. After you have completed the
survey, please return it in the pre-paid envelope. Your answers may be shared with the hospice
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 hospice care for all consumers.
Sincerely,
[HOSPICE ADMINISTRATOR]
[HOSPICE NAME]
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
31
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Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
Sample Follow-up Cover Letter for the CAHPS Hospice
Survey
[HOSPICE OR VENDOR LETTERHEAD]
[SAMPLED CAREGIVER NAME]
[ADDRESS]
[CITY, STATE ZIP]
Dear [SAMPLED CAREGIVER NAME]:
Our records show that you were recently a caregiver for [DECEDENT NAME] at [NAME OF
HOSPICE]. Approximately three weeks ago, we sent you a survey regarding the care you and your
family member or friend received from this hospice. If you have already returned the survey to us,
please accept our thanks and disregard this letter. However, if you have not done so already, we
would greatly appreciate it if you would take the time to complete this important questionnaire.
We hope that you will take this opportunity to help us learn about the quality of care your family
member or friend received. The results from this survey will be used to help ensure that all
Americans get the highest quality hospice care.
Questions [NOTE THE QUESTION NUMBERS] in the enclosed survey are part of a national
initiative sponsored by the United States Department of Health and Human Services (HHS) to
measure the quality of care in hospices. The Centers for Medicare & Medicaid Services (CMS)
pays for most of the hospice care in the U.S. It is CMS’ responsibility to ensure that hospice
patients and their family members and friends get high quality care. One of the ways they can
fulfill this responsibility is to find out directly from you about the hospice care your family member
or friend received. Your participation is voluntary and will not affect any health care or benefits
you receive.
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 hospice 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 hospice care for all consumers.
Sincerely,
[HOSPICE ADMINISTRATOR]
[HOSPICE NAME]
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
33
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Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
OMB Paperwork Reduction Act Language
The OMB Paperwork Reduction Act language must appear in the mailing, either on the cover
letter or on the front or back of the questionnaire. In addition, the OMB control number must
appear on the front page of the questionnaire. 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 0938-1257 (Expires December 31, 2020). The time
required to complete this information collection is estimated to average 11 minutes for questions
1 – 40, the “About Your Family Member” questions and the “About You” questions 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.”
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
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CAHPS Hospice Survey Quality Assurance Guidelines V6.0
Appendix O
Mail Survey Materials (Spanish)
CAHPS® Encuesta de Hospicio
Por favor conteste las preguntas en esta encuesta sobre la atencion que recibio este
paciente de este hospicio:
[NAME OF HOSPICE]
Todas las preguntas en esta encuesta se tratan sobre las experiencias de este
paciente con este hospicio.
Si desea saber más sobre este estudio, llama a [TOLL FREE NUMBER]. Todas las
llamadas son gratis.
OMB#0938-1257
Vence el 31 de diciembre, 2020
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
1
CAHPS® Encuesta de Hospicio
INSTRUCCIONES PARA LA ENCUESTA
♦
Por favor entréguele esta encuesta a la persona de su hogar que sepa más sobre
los cuidados que recibió de este centro la persona cuyo nombre aparece en la
carta de presentación de esta encuesta.
♦
Use un bolígrafo de tinta negra para completar el cuestionario.
♦
Marque con una ‘X’ el cuadrito para indicar su respuesta. Vea el siguiente ejemplo:
Sí
No
♦
A veces hay que saltarse alguna pregunta. Cuando esto ocurra, una flecha a la
derecha de la respuesta le indicará a qué pregunta hay que pasar. Por ejemplo:
Sí
No
Si contestó Sí, pase a la Pregunta 1 en la Página 1
_____________________________________________________________________
EL PACIENTE DEL HOSPICIO
1. ¿Qué relación tiene con usted la
persona cuyo nombre aparece en
la carta de presentación de esta
encuesta?
3
4
5
6
7
8
9
1
2
Es mi esposo/a o pareja
Es mi padre/madre
Es mi suegro/a
Es mi abuelo/a
Es mi tío/a
Es mi hermano/a
Es mi hijo/a
Es un/a amigo/a
Otro (por favor imprima):
2. Para esta encuesta, utilizaremos
las palabras “su familiar” para
referirnos a la persona cuyo
nombre aparece en la carta de
presentación de esta encuesta.
¿En qué lugar o lugares recibió su
familiar los cuidados de este
hospicio? Marque uno o más.
2
1
3
5
4
_______________________
6
En su casa
En un hogar de asistencia
parcial
En una casa de ancianos y
convalecencia
En un hospital
En un centro u hogar de
hospicio
Otro (Por favor imprima):
_______________________
2
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
SU PAPEL
3. Mientras su familiar estuvo bajo
los cuidados del hospicio, ¿con
qué frecuencia supervisó usted o
participó en dichos cuidados?
1
Nunca
4
A veces
La mayoría de las veces
Siempre
2
3
Si contestó Nunca,
pase a la Pregunta
41
LOS CUIDADOS QUE EL
HOSPICIO PROPORCIONÓ A SU
FAMILIAR
Al responder el resto de las
preguntas de esta encuesta, por
favor piense sólo en la experiencia
de su familiar con el hospicio
nombrado en la portada de esta
encuesta.
4. Para esta encuesta, el equipo del
hospicio incluye a todos los
doctores, enfermeras,
trabajadores sociales, religiosos y
demás personas que le
proporcionaron cuidados
paliativos a su familiar. Mientras
su familiar estaba bajo los
cuidados del hospicio, ¿tuvo
usted que ponerse en contacto
con el equipo del hospicio durante
la noche, en fin de semana o en
día festivo porque tenía alguna
duda o necesitaba ayuda para el
cuidado de su familiar?
2
1
Sí
No
5. ¿Con qué frecuencia obtuvo la
ayuda que necesitaba del equipo
del hospicio durante la noche, en
fin de semana o en día festivo?
2
3
4
1
Nunca
A veces
La mayoría de las veces
Siempre
6. Mientras su familiar estaba bajo
los cuidados del hospicio, ¿con
qué frecuencia el equipo de
personal del hospicio lo mantuvo
a usted informado de cuando iban
a llegar a cuidar a su familiar?
3
4
1
2
Nunca
A veces
La mayoría de las veces
Siempre
7. Mientras su familiar estaba bajo
los cuidados de este hospicio,
cuando usted o un miembro de su
familia le pedían ayuda al equipo
del hospicio, ¿con qué frecuencia
obtenían la ayuda tan pronto
como la necesitaban?
3
4
1
2
Nunca
A veces
La mayoría de las veces
Siempre
Si contestó No, pase a la
Pregunta 6
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
3
8. Mientras su familiar estaba bajo
los cuidados del hospicio, ¿con
qué frecuencia el equipo del
hospicio explicaba las cosas de
un modo fácil de entender?
2
3
4
1
3
4
1
Nunca
A veces
La mayoría de las veces
Siempre
2
9. Mientras su familiar estaba bajo
los cuidados del hospicio, ¿con
qué frecuencia el equipo del
hospicio lo mantenía a usted
informado sobre el estado de su
familiar?
2
3
4
1
Nunca
A veces
La mayoría de las veces
Siempre
3
4
2
Nunca
A veces
La mayoría de las veces
Siempre
3
4
1
Nunca
A veces
La mayoría de las veces
Siempre
13. Mientras su familiar estaba bajo
los cuidados del hospicio, ¿habló
usted con el equipo del hospicio
sobre algún problema relacionado
con los cuidados de su familiar?
1
2
Sí
No
Si contestó No, pase a la
Pregunta 15
14. ¿Con qué frecuencia el equipo del
hospicio lo escuchó con atención
cuando usted les habló sobre
problemas relacionados con los
cuidados de su familiar?
2
3
4
1
4
Nunca
A veces
La mayoría de las veces
Siempre
12. Mientras su familiar estaba bajo
los cuidados del hospicio, ¿con
qué frecuencia sintió usted que al
equipo del hospicio realmente le
importaba su familiar?
2
10. Mientras su familiar estaba bajo
los cuidados del hospicio, ¿con
qué frecuencia alguien del equipo
del hospicio le dio a usted
informes confusos o
contradictorios sobre el estado o
los cuidados de su familiar?
1
11. Mientras su familiar estaba bajo
los cuidados del hospicio, ¿con
qué frecuencia el equipo del
centro trataba a su familiar con
dignidad y respeto?
Nunca
A veces
La mayoría de las veces
Siempre
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
15. Mientras su familiar estaba bajo
los cuidados de este hospicio,
¿tuvo él/ella algún tipo de dolor?
1
2
Sí
No
Si contestó No, pase a la
Pregunta 17
16. ¿Recibió su familiar toda la ayuda
que necesitaba contra el dolor?
2
3
1
Sí, definitivamente
Sí, más o menos
No
17. Mientras su familiar estaba bajo
los cuidados del hospicio, ¿le
dieron a él o a ella algún
medicamento contra el dolor?
2
1
Sí
No
Si contestó No, pase a la
Pregunta 21
18. Entre los efectos secundarios de
la medicina contra el dolor está la
somnolencia. ¿Algún personal del
equipo del hospicio habló con
usted o su familiar sobre los
efectos secundarios del
medicamento contra el dolor?
Sí, definitivamente
2 Sí, más o menos
3 No
1
19. ¿El equipo del hospicio le dio la
capacitación que usted necesitaba
para saber de qué efectos
secundarios del medicamento
contra el dolor tenía usted que
estar pendiente?
Sí, definitivamente
2 Sí, más o menos
3 No
1
20. ¿El equipo del hospicio le dio a
usted la capacitación que usted
necesitaba para saber si había
que darle a su familiar más
medicamento contra el dolor y, si
sí, cuándo dárselo?
3
4
1
2
Sí, definitivamente
Sí, más o menos
No
No tuve necesidad de dar
medicamento para el dolor a mi
familiar
21. Mientras su familiar estaba bajo
los cuidados de este hospicio,
¿en algún momento tuvo su
familiar dificultad para respirar o
recibió tratamiento para su
dificultad para respirar?
2
1
Sí
No
Si contestó No, pase a
la Pregunta 24
22. ¿Con qué frecuencia su familiar
recibió la ayuda que necesitaba
para su dificultad para respirar?
3
4
1
2
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
Nunca
A veces
La mayoría de las veces
Siempre
5
23. ¿El equipo del hospicio le dio a
usted la capacitación que usted
necesitaba para saber cómo
ayudar a su familiar si él/ella tenía
problemas para respirar?
3
4
1
2
Sí, definitivamente
Sí, más o menos
No
No tuve que ayudar a mi familiar
con problemas para respirar
24. Mientras su familiar estaba bajo
los cuidados de este hospicio,
¿en algún momento tuvo su
familiar problemas de
estreñimiento?
2
1
Sí
No
Si contestó No, pase a
la Pregunta 26
25. ¿Con qué frecuencia su familiar
recibió la ayuda que necesitaba
para sus problemas de
estreñimiento?
2
3
4
1
Nunca
A veces
La mayoría de las veces
Siempre
26. Mientras su familiar estaba bajo
los cuidados del hospicio, ¿en
algún momento él/ella sitió
ansiedad o tristeza?
1
2
6
Sí
No
Si contestó No, pase a la
Pregunta 28
27. ¿Con qué frecuencia su familiar
recibió del equipo del hospicio la
ayuda que necesitaba para su
ansiedad o tristeza?
2
3
4
1
Nunca
A veces
La mayoría de las veces
Siempre
28. Mientras su familiar estaba bajo
los cuidados de este hospicio,
¿en algún momento se puso su
familiar inquieto o agitado?
1
2
Sí
No
Si contestó No, pase a la
Pregunta 30
29. ¿El equipo del hospicio le dio a
usted la capacitación que usted
necesitaba para saber qué hacer
si su familiar se ponía inquieto o
agitado?
2
3
1
Sí, definitivamente
Sí, más o menos
No
30. Mover a su familiar incluye
acciones como ayudarlo/a a darse
la vuelta en la cama, o meterse y
salir de la cama o sentarse y
levantarse de una silla de ruedas.
¿El equipo del hospicio le dio a
usted la capacitación que usted
necesitaba para saber cómo
mover a su familiar de manera
segura?
2
3
4
1
Sí, definitivamente
Sí, más o menos
No
No tuve que mover a mi familiar
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
31. ¿Le dio el equipo del hospicio
tanta información como usted
quería sobre qué acontecimientos
esperar mientras su familiar
estuviera muriéndose?
3
1
2
Sí, definitivamente
Sí, más o menos
No
CUIDADOS DE HOSPICIO
BRINDADOS EN UN HOGAR DE
ANCIANOS Y CONVALECENCIA
32. Algunas personas que viven en un
hogar de ancianos o de
convalecencia reciben allí mismo
los cuidados de hospicio que
necesitan. ¿Su familiar recibió
cuidados paliativos de este
hospicio cuando vivía en una casa
de convalecencia?
2
1
Sí
No
Nunca
2 A veces
3 La mayoría de las veces
4 Siempre
1
SU PROPIA EXPERIENCIA CON EL
CENTRO DE HOSPICIO
35. Mientras su familiar estaba bajo
los cuidados de este hospicio,
¿con qué frecuencia el equipo del
hospicio le escuchó a usted con
atención?
2
3
4
1
Si contestó No, pase a la
Pregunta 35
33. Mientras su familiar estaba bajo
los cuidados de este hospicio,
¿con qué frecuencia el equipo del
hospicio y el personal del hogar
de ancianos y convalecencia se
pusieron de acuerdo y acoplaron
bien para proporcionarle los
cuidados a su familiar?
Nunca
2 A veces
3 La mayoría de las veces
4 Siempre
1
34. Mientras su familiar estaba bajo
los cuidados de este hospicio,
¿con qué frecuencia los informes
que el personal de la casa de
convalecencia le daban sobre su
familiar eran diferentes de los
informes que le daba el equipo del
hospicio?
Nunca
A veces
La mayoría de las veces
Siempre
36. Apoyo respecto a sus creencias
religiosas o espirituales incluye
hablar, rezar, momentos de
recogimiento, u otras maneras de
satisfacer sus necesidades
religiosas o espirituales. Mientras
su familiar estaba bajo los
cuidados de este hospicio,
¿cuánto apoyo recibió usted
respecto a sus creencias
religiosas y espirituales por parte
del equipo del hospicio?
3
1
2
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
Demasiado poco
Justo el necesario
Demasiado
7
37. Mientras su familiar estaba bajo
los cuidados de este hospicio,
¿cuánto apoyo emocional recibió
usted del equipo del hospicio?
2
3
1
Demasiado poco
Justo el necesario
Demasiado
38. Durante las semanas posteriores
a la muerte de su familiar, ¿recibió
usted todo el apoyo emocional
que usted quería por parte del
equipo del hospicio?
Demasiado poco
Justo el necesario
3 Demasiado
1
2
CALIFICACIÓN GENERAL DE LOS
CUIDADOS DEL HOSPICIO
39. Por favor conteste las siguientes
preguntas sobre los cuidados
paliativos que recibió su familiar
por parte del hospicio cuyo
nombre aparece en la portada de
esta encuesta. No incluya en sus
respuestas cuidados
proporcionados por otros centros.
Usando un número del 0 al 10, el 0
siendo los peores cuidados de
hospicio posibles y 10 los mejores
cuidados paliativos posibles de
un hospicio, ¿qué número usaría
para calificar los cuidados que
recibió su familiar por parte de
este hospicio?
0
2
3
4
5
6
7
8
9
10
1
0 Los peores cuidados
posibles de un hospicio
1
2
3
4
5
6
7
8
9
10 Los mejores cuidados
posibles de un hospicio
40. ¿Le recomendaría este hospicio a
sus amigos y familiares?
3
4
1
2
8
Definitivamente no
Probablemente no
Probablemente sí
Definitivamente sí
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
SOBRE SU FAMILIAR
41. ¿Cuál es el grado o nivel escolar
más alto que ha completado su
familiar?
2
1
3
4
5
6
7
8 años de escuela o menos
Estudios de escuela secundaria,
pero sin graduarse
Graduado de escuela de
secundaria, o diploma de la
secundaria), o su equivalente (o
GED)
Algunos cursos universitarios o
un título universitario de un
programa de 2 años
Título universitario de 4 años
Título universitario de más de 4
años
No sé
42. ¿Su familiar es de origen hispano,
latino o español?
1
3
2
5
4
No, ni hispano, ni latino, ni
español
Sí, puertorriqueño
Sí, mexicano, mexicanoamericano, chicano
Sí, cubano
Sí, de otro origen hispano, latino
o español
43. ¿A qué raza pertenece su
familiar? Marque una o más.
3
4
1
2
5
Blanca
Negra o afroamericana
Asiática
Nativa de Hawái u otras Islas
del Pacífico
Indígena americana o nativa de
Alaska
SOBRE USTED
44. ¿Qué edad tiene usted?
2
3
4
5
6
7
8
1
de 18 a 24 años
de 25 a 34 años
de 35 a 44 años
de 45 a 54 años
de 55 a 64 años
de 65 a 74 años
de 75 a 84 años
85 años o más
45. ¿Es usted hombre o mujer?
2
1
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
Hombre
Mujer
9
46. ¿Cuál es el grado o nivel escolar
más alto que ha completado?
2
1
3
4
5
6
47. ¿En qué idioma habla usted
principalmente en casa?
8 años de escuela o menos
Estudios de escuela secundario,
pero sin graduarse
Graduado de escuela de
secundaria o diploma de la
secundaria), o su equivalente (o
GED)
Algunos cursos universitarios o
un título universitario de un
programa de 2 años
Título universitario de 4 años
Título universitario de más de 4
años
3
4
5
6
7
8
9
1
2
Inglés
Español
Chino
Ruso
Portugués
Vietnamita
Polaco
Coreano
Otro idioma (Por favor imprima):
________________________
GRACIAS
Por favor regrese la encuesta completa en el sobre con el porte o franqueo
pagado.
[NAME OF SURVEY VENDOR]
[RETURN ADDRESS OF SURVEY VENDOR]
10
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
CAHPS® Encuesta de Hospicio
Por favor conteste las preguntas en esta encuesta sobre la atencion que recibio este
paciente de este hospicio:
[NAME OF HOSPICE]
Todas las preguntas en esta encuesta se tratan sobre las experiencias de este
paciente con este hospicio.
Si desea saber más sobre este estudio, llama a [TOLL FREE NUMBER]. Todas las
llamadas son gratis.
OMB#0938-1257
Vence el 31 de diciembre, 2020
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
11
CAHPS® Encuesta de Hospicio
INSTRUCCIONES PARA LA ENCUESTA
♦
Por favor entréguele esta encuesta a la persona de su hogar que sepa más sobre
los cuidados que recibió de este centro la persona cuyo nombre aparece en la
carta de presentación de esta encuesta.
♦
Use un bolígrafo de tinta negra para completar el cuestionario.
♦
Conteste todas las preguntas y llene completamente el círculo que aparece a la
izquierda de la respuesta que usted seleccione.
0
Sí
No
♦
A veces hay que saltarse alguna pregunta. Cuando esto ocurra, una flecha a la
derecha de la respuesta le indicará a qué pregunta hay que pasar. Por ejemplo:
Sí
Si contestó Sí, pase a la Pregunta 1 en la Página 1
0 No
______________________________________________________________________
El PACIENTE DEL HOSPICIO
1. ¿Qué relación tiene con usted la
persona cuyo nombre aparece en
la carta de presentación de esta
encuesta?
0
20
30
40
50
60
70
80
90
1
Es mi esposo/a o pareja
2. Para esta encuesta, utilizaremos
las palabras “su familiar” para
referirnos a la persona cuyo
nombre aparece en la carta de
presentación de esta encuesta.
¿En qué lugar o lugares recibió su
familiar los cuidados de este
hospicio? Marque uno o más.
Es mi padre/madre
1
En su casa
Es mi suegro/a
2
En un hogar de asistencia
parcial
En una casa de ancianos y
convalecencia
En un hospital
0
0
Es mi abuelo/a
0
Es mi tío/a
3
Es mi hermano/a
0
50
4
Es mi hijo/a
Es un/a amigo/a
Otro (Por favor imprima):
0
6
_______________________
En un centro u hogar de
hospicio
Otro (Por favor imprima):
_______________________
12
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
SU PAPEL
3. Mientras su familiar estuvo bajo
los cuidados del hospicio, ¿con
qué frecuencia supervisó usted o
participó en dichos cuidados?
0
1
0
30
40
2
Nunca
Si contestó Nunca,
pase a la Pregunta
41
0
0
30
40
1
Nunca
2
A veces
La mayoría de las veces
Siempre
A veces
La mayoría de las veces
Siempre
LOS CUIDADOS QUE EL
HOSPICIO PROPORCIONÓ A SU
FAMILIAR
Al responder el resto de las
preguntas de esta encuesta, por
favor piense sólo en la experiencia
de su familiar con el hospicio
nombrado en la portada de esta
encuesta.
4. Para esta encuesta, el equipo del
hospicio incluye a todos los
doctores, enfermeras,
trabajadores sociales, religiosos y
demás personas que le
proporcionaron cuidados
paliativos a su familiar. Mientras
su familiar estaba bajo los
cuidados del hospicio, ¿tuvo
usted que ponerse en contacto
con el equipo del hospicio durante
la noche, en fin de semana o en
día festivo porque tenía alguna
duda o necesitaba ayuda para el
cuidado de su familiar?
0
0
5. ¿Con qué frecuencia obtuvo la
ayuda que necesitaba del equipo
del hospicio durante la noche, en
fin de semana o en día festivo?
1
Sí
2
No
6. Mientras su familiar estaba bajo
los cuidados del hospicio, ¿con
qué frecuencia el equipo de
personal del hospicio lo mantuvo
a usted informado de cuando iban
a llegar a cuidar a su familiar?
0
0
30
40
1
Nunca
2
A veces
La mayoría de las veces
Siempre
7. Mientras su familiar estaba bajo
los cuidados de este hospicio,
cuando usted o un miembro de su
familia le pedían ayuda al equipo
del hospicio, ¿con qué frecuencia
obtenían la ayuda tan pronto
como la necesitaban?
0
20
30
40
1
Nunca
A veces
La mayoría de las veces
Siempre
Si contestó No, pase a la
Pregunta 6
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
13
8. Mientras su familiar estaba bajo
los cuidados del hospicio, ¿con
qué frecuencia el equipo del
hospicio explicaba las cosas de
un modo fácil de entender?
0
20
30
40
1
0
20
30
40
1
Nunca
A veces
La mayoría de las veces
Siempre
9. Mientras su familiar estaba bajo
los cuidados del hospicio, ¿con
qué frecuencia el equipo del
hospicio lo mantenía a usted
informado sobre el estado de su
familiar?
0
20
30
40
1
Nunca
A veces
La mayoría de las veces
14
Nunca
A veces
La mayoría de las veces
Siempre
12. Mientras su familiar estaba bajo
los cuidados del hospicio, ¿con
qué frecuencia sintió usted que al
equipo del hospicio realmente le
importaba su familiar?
0
0
30
40
1
Nunca
2
A veces
La mayoría de las veces
Siempre
Siempre
10. Mientras su familiar estaba bajo
los cuidados del hospicio, ¿con
qué frecuencia alguien del equipo
del hospicio le dio a usted
informes confusos o
contradictorios sobre el estado o
los cuidados de su familiar?
0
0
30
40
11. Mientras su familiar estaba bajo
los cuidados del hospicio, ¿con
qué frecuencia el equipo del
centro trataba a su familiar con
dignidad y respeto?
1
Nunca
2
A veces
13. Mientras su familiar estaba bajo
los cuidados del hospicio, ¿habló
usted con el equipo del hospicio
sobre algún problema relacionado
con los cuidados de su familiar?
0
20
1
Sí
No
Si contestó No, pase a la
Pregunta 15
La mayoría de las veces
Siempre
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
14. ¿Con qué frecuencia el equipo del
hospicio lo escuchó con atención
cuando usted les habló sobre
problemas relacionados con los
cuidados de su familiar?
0
20
30
40
1
Nunca
A veces
La mayoría de las veces
Siempre
15. Mientras su familiar estaba bajo
los cuidados de este hospicio,
¿tuvo él/ella algún tipo de dolor?
0
0
1
Sí
2
No
Si contestó No, pase a la
Pregunta 17
18. Entre los efectos secundarios de
la medicina contra el dolor está la
somnolencia. ¿Algún personal del
equipo del hospicio habló con
usted o su familiar sobre los
efectos secundarios del
medicamento contra el dolor?
0 Sí, definitivamente
20 Sí, más o menos
30 No
1
19. ¿El equipo del hospicio le dio la
capacitación que usted
necesitaba para saber de qué
efectos secundarios del
medicamento contra el dolor tenía
usted que estar pendiente?
0 Sí, definitivamente
0 Sí, más o menos
30 No
1
16. ¿Recibió su familiar toda la ayuda
que necesitaba contra el dolor?
0
20
30
1
Sí, definitivamente
Sí, más o menos
No
17. Mientras su familiar estaba bajo
los cuidados del hospicio, ¿le
dieron a él o a ella algún
medicamento contra el dolor?
0
0
1
Sí
2
No
2
20. ¿El equipo del hospicio le dio a
usted la capacitación que usted
necesitaba para saber si había
que darle a su familiar más
medicamento contra el dolor y, si
sí, cuándo dárselo?
0
0
30
40
1
2
Si contestó No, pase a la
Pregunta 21
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
Sí, definitivamente
Sí, más o menos
No
No tuve necesidad de dar
medicamento para el dolor a
mi familiar
15
21. Mientras su familiar estaba bajo
los cuidados de este hospicio,
¿en algún momento tuvo su
familiar dificultad para respirar o
recibió tratamiento para su
dificultad para respirar?
0 Sí
2
0 No
1
Si contestó No, pase a la
Pregunta 24
22. ¿Con qué frecuencia su familiar
recibió la ayuda que necesitaba
para su dificultad para respirar?
0
20
30
40
1
Nunca
0
20
30
40
La mayoría de las veces
0
20
16
Nunca
2
A veces
La mayoría de las veces
Siempre
26. Mientras su familiar estaba bajo
los cuidados del hospicio, ¿en
algún momento él/ella sitió
ansiedad o tristeza?
1
Sí
2
No
Si contestó No, pase a la
Pregunta 28
Siempre
Sí, definitivamente
Sí, más o menos
No
No tuve que ayudar a mi familiar
con problemas para respirar
24. Mientras su familiar estaba bajo
los cuidados de este hospicio,
¿en algún momento tuvo su
familiar problemas de
estreñimiento?
1
0
0
30
40
1
0
0
A veces
23. ¿El equipo del hospicio le dio a
usted la capacitación que usted
necesitaba para saber cómo
ayudar a su familiar si él/ella tenía
problemas para respirar?
1
25. Con qué frecuencia su familiar
recibió la ayuda que necesitaba
para sus problemas de
estreñimiento?
27. ¿Con qué frecuencia su familiar
recibió del equipo del hospicio la
ayuda que necesitaba para su
ansiedad o tristeza?
0
20
30
40
1
Nunca
A veces
La mayoría de las veces
Siempre
28. Mientras su familiar estaba bajo
los cuidados de este hospicio,
¿en algún momento se puso su
familiar inquieto o agitado?
0
20
1
Sí
No
Si contestó No, pase a la
Pregunta 30
Sí
No
Si contestó No, pase a la
Pregunta 26
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
29. ¿El equipo del hospicio le dio a
usted la capacitación que usted
necesitaba para saber qué hacer
si su familiar se ponía inquieto o
agitado?
0
20
30
1
Sí, definitivamente
Sí, más o menos
No
30. Mover a su familiar incluye
acciones como ayudarlo/a a darse
la vuelta en la cama, o meterse y
salir de la cama o sentarse y
levantarse de una silla de ruedas.
¿El equipo del hospicio le dio a
usted la capacitación que usted
necesitaba para saber cómo
mover a su familiar de manera
segura?
0
0
30
40
1
Sí, definitivamente
2
Sí, más o menos
No
No tuve que mover a mi familiar
31. ¿Le dio el equipo del hospicio
tanta información como usted
quería sobre qué acontecimientos
esperar mientras su familiar
estuviera muriéndose?
0
20
30
1
Sí, definitivamente
Sí, más o menos
No
CUIDADOS DE HOSPICIO
BRINDADOS EN UN HOGAR DE
ANCIANOS Y CONVALECENCIA
32. Algunas personas que viven en
un hogar de ancianos o de
convalecencia reciben allí mismo
los cuidados de hospicio que
necesitan. ¿Su familiar recibió
cuidados paliativos de este
hospicio cuando vivía en una casa
de convalecencia?
0
0
1
Sí
2
No
Si contestó No, pase a la
Pregunta 35
33. Mientras su familiar estaba bajo
los cuidados de este hospicio,
¿con qué frecuencia el equipo del
hospicio y el personal del hogar
de ancianos y convalecencia se
pusieron de acuerdo y acoplaron
bien para proporcionarle los
cuidados a su familiar?
0
20
30
40
1
Nunca
A veces
La mayoría de las veces
Siempre
34. Mientras su familiar estaba bajo
los cuidados de este hospicio,
¿con qué frecuencia los informes
que el personal de la casa de
convalecencia le daban sobre su
familiar eran diferentes de los
informes que le daba el equipo del
hospicio?
0
0
30
40
1
Nunca
2
A veces
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
La mayoría de las veces
Siempre
17
SU PROPIA EXPERIENCIA CON EL
CENTRO DE HOSPICIO
35. Mientras su familiar estaba bajo
los cuidados de este hospicio,
¿con qué frecuencia el equipo del
hospicio le escuchó a usted con
atención?
0
20
30
40
1
Nunca
A veces
0
20
30
Siempre
0
20
30
Demasiado poco
Justo el necesario
18
Justo el necesario
Demasiado
Justo el necesario
Demasiado
preguntas sobre los cuidados
paliativos que recibió su familiar
por parte del hospicio cuyo
nombre aparece en la portada de
esta encuesta. No incluya en sus
respuestas cuidados
proporcionados por otros centros.
Usando un número del 0 al 10, el 0
siendo los peores cuidados de
hospicio posibles y 10 los mejores
cuidados paliativos posibles de
un hospicio, ¿qué número usaría
para calificar los cuidados que
recibió su familiar por parte de
este hospicio?
0
0
Demasiado
Demasiado poco
Demasiado poco
39. Por favor conteste las siguientes
37. Mientras su familiar estaba bajo
los cuidados de este hospicio,
¿cuánto apoyo emocional recibió
usted del equipo del hospicio?
1
0
20
30
1
CALIFICACIÓN GENERAL DE LOS
CUIDADOS DEL HOSPICIO
La mayoría de las veces
36. Apoyo respecto a sus creencias
religiosas o espirituales incluye
hablar, rezar, momentos de
recogimiento, u otras maneras de
satisfacer sus necesidades
religiosas o espirituales. Mientras
su familiar estaba bajo los
cuidados de este hospicio,
¿cuánto apoyo recibió usted
respecto a sus creencias
religiosas y espirituales por parte
del equipo del hospicio?
1
38. Durante las semanas posteriores
a la muerte de su familiar, ¿recibió
usted todo el apoyo emocional
que usted quería por parte del
equipo del hospicio?
0
20
30
40
50
60
70
80
90
100
1
0 Los peores cuidados
posibles de un hospicio
1
2
3
4
5
6
7
8
9
10 Los mejores cuidados
posibles de un hospicio
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
40. ¿Le recomendaría este hospicio a
sus amigos y familiares?
0
20
30
40
1
43. ¿A qué raza pertenece su
familiar? Marque una o más.
0
0
30
40
Definitivamente no
1
Blanca
Probablemente no
2
Negra o afroamericana
Probablemente sí
Definitivamente sí
SOBRE SU FAMILIAR
0
5
41. ¿Cuál es el grado o nivel escolar
más alto que ha completado su
familiar?
0
0
1
8 años de escuela o menos
2
Estudios de escuela secundaria,
pero sin graduarse
Graduado de escuela de
secundaria, o diploma de la
secundaria), o su equivalente (o
GED)
Algunos cursos universitarios o
un título universitario de un
programa de 2 años
Título universitario de 4 años
0
3
0
4
0
60
5
0
7
Título universitario de más de 4
años
No sé
42. ¿Su familiar es de origen hispano,
latino o español?
0
1
0
0
2
3
0
0
4
5
Asiática
Nativa de Hawái u otras Islas
del Pacífico
Indígena americana o nativa de
Alaska
SOBRE USTED
44. ¿Qué edad tiene usted?
0
0
30
40
50
60
70
80
1
de 18 a 24 años
2
de 25 a 34 años
de 35 a 44 años
de 45 a 54 años
de 55 a 64 años
de 65 a 74 años
de 75 a 84 años
85 años o más
45. ¿Es usted hombre o mujer?
0
20
1
Hombre
Mujer
No, ni hispano, ni latino, ni
español
Sí, puertorriqueño
Sí, mexicano, mexicanoamericano, chicano
Sí, cubano
Sí, de otro origen hispano, latino
o español
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
19
46. ¿Cuál es el grado o nivel escolar
más alto que ha completado?
0
20
1
0
3
0
4
0
60
5
47. ¿En qué idioma habla usted
principalmente en casa?
0
0
30
40
50
60
70
80
90
8 años de escuela o menos
1
Inglés
Estudios de escuela secundario,
pero sin graduarse
Graduado de escuela de
secundaria o diploma de la
secundaria), o su equivalente (o
GED)
Algunos cursos universitarios o
un título universitario de un
programa de 2 años
Título universitario de 4 años
2
Español
Título universitario de más de 4
años
Chino
Ruso
Portugués
Vietnamita
Polaco
Coreano
Otro idioma (Por favor imprima):
________________________
GRACIAS
Por favor regrese la encuesta completa en el sobre con el porte o franqueo
pagado.
[NAME OF SURVEY VENDOR]
[RETURN ADDRESS OF SURVEY VENDOR]
20
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
CAHPS® Encuesta de Hospicio
Por favor conteste las preguntas en esta encuesta sobre la atencion que recibio este
paciente de este hospicio:
[NAME OF HOSPICE]
Todas las preguntas en esta encuesta se tratan sobre las experiencias de este
paciente con este hospicio.
Si desea saber más sobre este estudio, llama a [TOLL FREE NUMBER]. Todas las
llamadas son gratis.
OMB#0938-1257
Vence el 31 de diciembre, 2020
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
21
CAHPS® Encuesta de Hospicio
INSTRUCCIONES PARA LA ENCUESTA
♦
♦
♦
Por favor entréguele esta encuesta a la persona de su hogar que sepa más sobre
los cuidados que recibió de este centro la persona cuyo nombre aparece en la
carta de presentación de esta encuesta.
Use un bolígrafo de tinta negra para completar el cuestionario.
Conteste todas las preguntas y llene completamente el círculo que aparece a la
izquierda de la respuesta que usted seleccione.
O
♦
Sí
No
A veces hay que saltarse alguna pregunta. Cuando esto ocurra, una flecha a la
derecha de la respuesta le indicará a qué pregunta hay que pasar. Por ejemplo:
Sí Si contestó Sí, pase a la Pregunta 1 en la Página 1
O No
_____________________________________________________________________
EL PACIENTE DEL HOSPICIO
1. ¿Qué relación tiene con usted la
persona cuyo nombre aparece en
la carta de presentación de esta
encuesta?
1O
2O
3O
4O
5O
6O
7O
8O
9O
Es mi esposo/a o pareja
Es mi padre/madre
Es mi suegro/a
Es mi abuelo/a
Es mi tío/a
Es mi hermano/a
Es mi hijo/a
Es un/a amigo/a
Otro (Por favor imprima):
2. Para esta encuesta, utilizaremos
las palabras “su familiar” para
referirnos a la persona cuyo
nombre aparece en la carta de
presentación de esta encuesta.
¿En qué lugar o lugares recibió su
familiar los cuidados de este
hospicio? Marque uno o más.
1O
2O
3O
4O
5O
_______________________
6O
En su casa
En un hogar de asistencia
parcial
En una casa de ancianos y
convalecencia
En un hospital
En un centro u hogar de
hospicio
Otro (Por favor imprima):
________________________
22
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
SU PAPEL
3. Mientras su familiar estuvo bajo
los cuidados del hospicio, ¿con
qué frecuencia supervisó usted o
participó en dichos cuidados?
1O
Nunca
Si contestó Nunca,
pase a la Pregunta 41
2O
A veces
La mayoría de las veces
4O Siempre
3O
LOS CUIDADOS QUE EL HOSPICIO
PROPORCIONÓ A SU FAMILIAR
Al responder el resto de las
preguntas de esta encuesta, por
favor piense sólo en la experiencia
de su familiar con el hospicio
nombrado en la portada de esta
encuesta.
4. Para esta encuesta, el equipo del
hospicio incluye a todos los
doctores, enfermeras,
trabajadores sociales, religiosos y
demás personas que le
proporcionaron cuidados
paliativos a su familiar. Mientras
su familiar estaba bajo los
cuidados del hospicio, ¿tuvo
usted que ponerse en contacto
con el equipo del hospicio durante
la noche, en fin de semana o en
día festivo porque tenía alguna
duda o necesitaba ayuda para el
cuidado de su familiar?
1O
2O
Sí
No
Si contestó No, pase a la
Pregunta 6
5. ¿Con qué frecuencia obtuvo la
ayuda que necesitaba del equipo
del hospicio durante la noche, en
fin de semana o en día festivo?
1O
Nunca
A veces
3O La mayoría de las veces
4O Siempre
2O
6. Mientras su familiar estaba bajo
los cuidados del hospicio, ¿con
qué frecuencia el equipo de
personal del hospicio lo mantuvo
a usted informado de cuando iban
a llegar a cuidar a su familiar?
1O
Nunca
A veces
3O La mayoría de las veces
4O Siempre
2O
7. Mientras su familiar estaba bajo
los cuidados de este hospicio,
cuando usted o un miembro de su
familia le pedían ayuda al equipo
del hospicio, ¿con qué frecuencia
obtenían la ayuda tan pronto
como la necesitaban?
1O
Nunca
A veces
3O La mayoría de las veces
4O Siempre
2O
8. Mientras su familiar estaba bajo
los cuidados del hospicio, ¿con
qué frecuencia el equipo del
hospicio explicaba las cosas de
un modo fácil de entender?
1O
Nunca
A veces
3O La mayoría de las veces
4O Siempre
2O
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
23
9. Mientras su familiar estaba bajo
los cuidados del hospicio, ¿con
qué frecuencia el equipo del
hospicio lo mantenía a usted
informado sobre el estado de su
familiar?
1O
13. Mientras su familiar estaba bajo
los cuidados del hospicio, ¿habló
usted con el equipo del hospicio
sobre algún problema relacionado
con los cuidados de su familiar?
1O
2O
Nunca
A veces
3O La mayoría de las veces
4O Siempre
Sí
No
2O
10. Mientras su familiar estaba bajo
los cuidados del hospicio, ¿con
qué frecuencia alguien del equipo
del hospicio le dio a usted
informes confusos o
contradictorios sobre el estado o
los cuidados de su familiar?
Si contestó No, pase a la
Pregunta 15
14. ¿Con qué frecuencia el equipo del
hospicio lo escuchó con atención
cuando usted les habló sobre
problemas relacionados con los
cuidados de su familiar?
1O
Nunca
A veces
3O La mayoría de las veces
4O Siempre
2O
1O
Nunca
A veces
3O La mayoría de las veces
4O Siempre
2O
15. Mientras su familiar estaba bajo
los cuidados de este hospicio,
¿tuvo él/ella algún tipo de dolor?
11. Mientras su familiar estaba bajo
los cuidados del hospicio, ¿con
qué frecuencia el equipo del
centro trataba a su familiar con
dignidad y respeto?
1O
Nunca
A veces
3O La mayoría de las veces
4O Siempre
24
Sí
No
Si contestó No, pase a la
Pregunta 17
16. ¿Recibió su familiar toda la ayuda
que necesitaba contra el dolor?
Sí, definitivamente
Sí, más o menos
3O No
2O
12. Mientras su familiar estaba bajo
los cuidados del hospicio, ¿con
qué frecuencia sintió usted que al
equipo del hospicio realmente le
importaba su familiar?
Nunca
2O A veces
3O La mayoría de las veces
4O Siempre
2O
1O
2O
1O
1O
17. Mientras su familiar estaba bajo
los cuidados del hospicio, ¿le
dieron a él o a ella algún
medicamento contra el dolor?
1O
2O
Sí
No
Si contestó No, pase a la
Pregunta 21
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
18. Entre los efectos secundarios de
la medicina contra el dolor está la
somnolencia. ¿Algún personal del
equipo del hospicio habló con
usted o su familiar sobre los
efectos secundarios del
medicamento contra el dolor?
1O
Sí, definitivamente
2O Sí, más o menos
3O No
19. ¿El equipo del hospicio le dio la
capacitación que usted
necesitaba para saber de qué
efectos secundarios del
medicamento contra el dolor tenía
usted que estar pendiente?
21. Mientras su familiar estaba bajo
los cuidados de este hospicio,
¿en algún momento tuvo su
familiar dificultad para respirar o
recibió tratamiento para su
dificultad para respirar?
1O
2O
Sí
No
Si contestó No, pase a
la Pregunta 24
22. ¿Con qué frecuencia su familiar
recibió la ayuda que necesitaba
para su dificultad para respirar?
1O
Nunca
A veces
3O La mayoría de las veces
4O Siempre
2O
1O
Sí, definitivamente
Sí, más o menos
3O No
2O
20. ¿El equipo del hospicio le dio a
usted la capacitación que usted
necesitaba para saber si había
que darle a su familiar más
medicamento contra el dolor y, si
sí, cuándo dárselo?
1O
Sí, definitivamente
Sí, más o menos
3O No
4O No tuve necesidad de dar
medicamento para el dolor a mi
familiar
23. ¿El equipo del hospicio le dio a
usted la capacitación que usted
necesitaba para saber cómo
ayudar a su familiar si él/ella tenía
problemas para respirar?
1O
Sí, definitivamente
Sí, más o menos
3O No
4O No tuve que ayudar a mi familiar
con problemas para respirar
2O
2O
24. Mientras su familiar estaba bajo
los cuidados de este hospicio,
¿en algún momento tuvo su
familiar problemas de
estreñimiento?
1O
2O
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
Sí
No
Si contestó No, pase a la
Pregunta 26
25
25. ¿Con qué frecuencia su familiar
recibió la ayuda que necesitaba
para sus problemas de
estreñimiento?
1O
Nunca
A veces
3O La mayoría de las veces
4O Siempre
2O
1O
Sí, definitivamente
Sí, más o menos
3O No
2O
26. Mientras su familiar estaba bajo
los cuidados del hospicio, ¿en
algún momento él/ella sitió
ansiedad o tristeza?
1O
2O
Sí
No
Si contestó No, pase a la
Pregunta 28
27. ¿Con qué frecuencia su familiar
recibió del equipo del hospicio la
ayuda que necesitaba para su
ansiedad o tristeza?
1O
Nunca
A veces
3O La mayoría de las veces
4O Siempre
2O
28. Mientras su familiar estaba bajo
los cuidados de este hospicio,
¿en algún momento se puso su
familiar inquieto o agitado?
1O
2O
26
Sí
No
29. ¿El equipo del hospicio le dio a
usted la capacitación que usted
necesitaba para saber qué hacer
si su familiar se ponía inquieto o
agitado?
30. Mover a su familiar incluye
acciones como ayudarlo/a a darse
la vuelta en la cama, o meterse y
salir de la cama o sentarse y
levantarse de una silla de ruedas.
¿El equipo del hospicio le dio a
usted la capacitación que usted
necesitaba para saber cómo
mover a su familiar de manera
segura?
1O
Sí, definitivamente
Sí, más o menos
3O No
4O No tuve que mover a mi familiar
2O
31. ¿Le dio el equipo del hospicio
tanta información como usted
quería sobre qué acontecimientos
esperar mientras su familiar
estuviera muriéndose?
1O
Sí, definitivamente
Sí, más o menos
3O No
2O
Si contestó No, pase a la
Pregunta 30
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
CUIDADOS DE HOSPICIO
BRINDADOS EN UN HOGAR DE
ANCIANOS Y CONVALECENCIA
32. Algunas personas que viven en
un hogar de ancianos o de
convalecencia reciben allí mismo
los cuidados de hospicio que
necesitan. ¿Su familiar recibió
cuidados paliativos de este
hospicio cuando vivía en una casa
de convalecencia?
1O
2O
Sí
No
Si contestó No, pase a la
Pregunta 35
33. Mientras su familiar estaba bajo
los cuidados de este hospicio,
¿con qué frecuencia el equipo del
hospicio y el personal del hogar
de ancianos y convalecencia se
pusieron de acuerdo y acoplaron
bien para proporcionarle los
cuidados a su familiar?
1O
Nunca
A veces
3O La mayoría de las veces
4O Siempre
2O
34. Mientras su familiar estaba bajo
los cuidados de este hospicio,
¿con qué frecuencia los informes
que el personal de la casa de
convalecencia le daban sobre su
familiar eran diferentes de los
informes que le daba el equipo del
hospicio?
SU PROPIA EXPERIENCIA CON EL
CENTRO DE HOSPICIO
35. Mientras su familiar estaba bajo
los cuidados de este hospicio,
¿con qué frecuencia el equipo del
hospicio le escuchó a usted con
atención?
1O
Nunca
A veces
3O La mayoría de las veces
4O Siempre
2O
36. Apoyo respecto a sus creencias
religiosas o espirituales incluye
hablar, rezar, momentos de
recogimiento, u otras maneras de
satisfacer sus necesidades
religiosas o espirituales. Mientras
su familiar estaba bajo los
cuidados de este hospicio,
¿cuánto apoyo recibió usted
respecto a sus creencias
religiosas y espirituales por parte
del equipo del hospicio?
1O
Demasiado poco
Justo el necesario
3O Demasiado
2O
37. Mientras su familiar estaba bajo
los cuidados de este hospicio,
¿cuánto apoyo emocional recibió
usted del equipo del hospicio?
1O
Demasiado poco
Justo el necesario
3O Demasiado
2O
1O
Nunca
A veces
3O La mayoría de las veces
4O Siempre
2O
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
27
38. Durante las semanas posteriores
a la muerte de su familiar, ¿recibió
usted todo el apoyo emocional
que usted quería por parte del
equipo del hospicio?
1O
Demasiado poco
Justo el necesario
3O Demasiado
40. ¿Le recomendaría este hospicio a
sus amigos y familiares?
1O
Definitivamente no
Probablemente no
3O Probablemente sí
4O Definitivamente sí
2O
2O
SOBRE SU FAMILIAR
CALIFICACIÓN GENERAL DE LOS
CUIDADOS DEL HOSPICIO
39. Por favor conteste las siguientes
preguntas sobre los cuidados
paliativos que recibió su familiar
por parte del hospicio cuyo
nombre aparece en la portada de
esta encuesta. No incluya en sus
respuestas cuidados
proporcionados por otros centros.
Usando un número del 0 al 10, el 0
siendo los peores cuidados de
hospicio posibles y 10 los mejores
cuidados paliativos posibles de
un hospicio, ¿qué número usaría
para calificar los cuidados que
recibió su familiar por parte de
este hospicio?
0O
1O
2O
3O
4O
5O
6O
7O
8O
9O
10O
28
0 Los peores cuidados
posibles de un hospicio
1
2
3
4
5
6
7
8
9
10 Los mejores cuidados
posibles de un hospicio
41. ¿Cuál es el grado o nivel escolar
más alto que ha completado su
familiar?
1O
2O
3O
4O
5O
6O
7O
8 años de escuela o menos
Estudios de escuela secundaria,
pero sin graduarse
Graduado de escuela de
secundaria, o diploma de la
secundaria), o su equivalente (o
GED)
Algunos cursos universitarios o
un título universitario de un
programa de 2 años
Título universitario de 4 años
Título universitario de más de 4
años
No sé
42. ¿Su familiar es de origen hispano,
latino o español?
1O
2O
3O
4O
5O
No, ni hispano, ni latino, ni
español
Sí, puertorriqueño
Sí, mexicano, mexicanoamericano, chicano
Sí, cubano
Sí, de otro origen hispano, latino
o español
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
43. ¿A qué raza pertenece su
familiar? Marque una o más.
46. ¿Cuál es el grado o nivel escolar
más alto que ha completado?
1O
1O
2O
2O
Blanca
Negra o afroamericana
3O Asiática
4O Nativa de Hawái u otras Islas
del Pacífico
5O Indígena americana o nativa de
Alaska
3O
4O
SOBRE USTED
44. ¿Qué edad tiene usted?
1O
2O
3O
4O
5O
6O
7O
8O
5O
6O
de 18 a 24 años
de 25 a 34 años
de 35 a 44 años
de 45 a 54 años
de 55 a 64 años
de 65 a 74 años
de 75 a 84 años
85 años o más
8 años de escuela o menos
Estudios de escuela secundario,
pero sin graduarse
Graduado de escuela de
secundaria o diploma de la
secundaria), o su equivalente (o
GED)
Algunos cursos universitarios o
un título universitario de un
programa de 2 años
Título universitario de 4 años
Título universitario de más de 4
años
47. ¿En qué idioma habla usted
principalmente en casa?
1O
2O
3O
4O
45. ¿Es usted hombre o mujer?
5O
6O
1O
Hombre
2O Mujer
7O
8O
9O
Inglés
Español
Chino
Ruso
Portugués
Vietnamita
Polaco
Coreano
Otro idioma (Por favor imprima):
________________________
GRACIAS
Por favor regrese la encuesta completa en el sobre con el porte o franqueo
pagado.
[NAME OF SURVEY VENDOR]
[RETURN ADDRESS OF SURVEY VENDOR]
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
29
30
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
Sample Initial Cover Letter for the CAHPS Hospice Survey
[HOSPICE OR VENDOR LETTERHEAD]
[SAMPLED CAREGIVER NAME]
[ADDRESS]
[CITY, STATE ZIP]
Estimado/a [SAMPLED CAREGIVER NAME]:
[HOSPICE NAME] está llevando a cabo una encuesta sobre los servicios de cuidados paliativos
que los pacientes y sus familias reciben. Se le ha seleccionado a usted para este estudio porque
ha sido identificado como la persona encargada del cuidado de [DECEDENT NAME].
Entendemos que éste debe de ser un momento difícil para usted, pero esperamos que pueda
ayudarnos a conocer la calidad de la atención que usted y su familiar o amigo recibieron del
hospicio.
Las preguntas [NOTE THE QUESTION NUMBERS] del cuestionario adjunto son parte de una
iniciativa nacional patrocinada por el Departamento de Salud y Servicios Humanos (HHS) de los
Estados Unidos para evaluar la calidad de la atención de los hospicios. Los Centros de Servicios
de Medicare y Medicaid (CMS, por sus siglas en inglés), que es una parte del HHS, está
realizando esta encuesta con el fin de mejorar los cuidados paliativos. El CMS paga la mayoría
de los cuidados paliativos de los EE.UU. El CMS tiene la responsabilidad de garantizar que los
pacientes de los hospicios así como los miembros de su familia y amigos reciban atención de alta
calidad. Una de las maneras en que puede cumplir con esta responsabilidad es enterarse
directamente por usted de la calidad de los cuidados paliativos que recibió su familiar o amigo.
Su participación es voluntaria y no afectará los beneficios o la atención médica que usted recibe.
Esperamos que se tome el tiempo para contestar la encuesta. Después de haber llenado la
encuesta, por favor envíela en el sobre con el porte o franqueo pagado. Sus respuestas se
compartirán con el hospicio con el fin de mejorar la calidad. [OPTIONAL: Podrá ver que hay un
número en la encuesta. Ese número sirve para que sepamos si usted devolvió la encuesta y así no
tengamos que enviarle recordatorios.]
Si tiene alguna pregunta sobre la encuesta adjunta, no dude en llamarnos a nuestro número
gratuito 1-800-XXX-XXXX.
Gracias por ayudar a mejorar los cuidados paliativos para todos los consumidores.
Atentamente,
[HOSPICE ADMINISTRATOR]
[HOSPICE NAME]
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
31
32
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
Sample Follow-up Cover Letter for the CAHPS Hospice
Survey
[HOSPICE OR VENDOR LETTERHEAD]
[SAMPLED CAREGIVER NAME]
[ADDRESS]
[CITY, STATE ZIP]
Estimado/a [SAMPLED CAREGIVER NAME]:
Nuestros registros indican que recientemente usted fue una de las personas encargadas del
cuidado de [DECEDENT NAME] en [NAME OF HOSPICE]. Hace aproximadamente tres
semanas, le enviamos una encuesta sobre la atención que usted y su familiar o amigo recibieron
en ese hospicio. Si ya nos devolvió la encuesta, por favor acepte nuestras disculpas y haga caso
omiso de esta carta. Si no lo ha hecho ya, le agradeceríamos que se tomara el tiempo de contestar
este importante cuestionario.
Esperamos que usted aproveche esta oportunidad para ayudarnos a saber qué calidad de
atención recibió su familiar o amigo. Los resultados de esta encuesta se utilizarán para ayudar a
garantizar que todos los estadounidenses reciban la más alta calidad de cuidados paliativos.
Las preguntas [NOTE THE QUESTION NUMBERS] del cuestionario adjunto son parte de una
iniciativa nacional patrocinada por el Departamento de Salud y Servicios Humanos (HHS) de los
Estados Unidos para evaluar la calidad de la atención de los hospicios. Los Centros de Servicios
de Medicare y Medicaid (CMS, por sus siglas en inglés), que es una parte del HHS, está
realizando esta encuesta con el fin de mejorar los cuidados paliativos. El CMS paga la mayoría
de los cuidados paliativos de los EE.UU. El CMS tiene la responsabilidad de garantizar que los
pacientes de los hospicios así como los miembros de su familia y amigos reciban atención de alta
calidad. Una de las maneras en que puede cumplir con esta responsabilidad es enterarse
directamente por usted de la calidad de los cuidados paliativos que recibió su familiar o amigo.
Su participación es voluntaria y no afectará los beneficios o la atención médica que usted recibe.
Por favor, tómese unos minutos para contestar la encuesta adjunta. Después de haber llenado la
encuesta, por favor envíela en el sobre con el porte o franqueo pagado. Sus respuestas se
compartirán con el hospicio con el fin de mejorar la calidad. [OPTIONAL: Podrá ver que hay un
número en la encuesta. Ese número sirve para que sepamos si usted devolvió la encuesta y así no
tengamos que enviarle recordatorios.]
Si tiene alguna pregunta sobre la encuesta adjunta, no dude en llamarnos a nuestro número
gratuito 1-800-XXX-XXXX.
Gracias por ayudar a mejorar los cuidados paliativos para todos los consumidores.
Atentamente,
[HOSPICE ADMINISTRATOR]
[HOSPICE NAME]
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
33
34
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
OMB Paperwork Reduction Act Language
The OMB Paperwork Reduction Act language must appear in the mailing, either on the cover
letter or on the front or back of the questionnaire. In addition, the OMB control number must
appear on the front page of the questionnaire. The following is the language that must be used:
Spanish Version
“Según la Ley de Reducción de Trámites (Paperwork Reduction Act) de 1995, no se exige que
una persona responda a la recopilación de información a menos que la solicitud de recopilación
tenga un número válido de control de la OMB. El número válido de control de la OMB para esta
recopilación de información es el 0938-1257 (Vence el 31 de diciembre, 2020). Se calcula que el
tiempo que se necesita para llenar esta recopilación de información es, en promedio, de 11
minutos para las preguntas 1 – 40, al iqual que las prequntas Sobre Sue Familiar y Sobre Usted
de la encuesta. En este cálculo se incluye el tiempo que la persona tarda en leer las instrucciones,
buscar en los recursos existentes de datos, reunir los datos necesarios y llenar y repasar la
recopilación de información. Si usted tiene comentarios relacionados con la exactitud del cálculo
de tiempo o si tiene sugerencias para mejorar este formulario, escriba a: Centers for Medicare &
Medicaid Services, 7500 Security Boulevard, C1- 25-05, Baltimore, MD 21244-1850.”
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
35
36
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
Appendix P
Mail Survey Materials (Traditional Chinese)
CAHPS® 安寧療護問卷調查
請根據患者從以下安寧療護機構所得到的服務回答下列調查問題:
[NAME OF HOSPICE]
在此問卷中所有的問題都與這個安寧療護機構的經驗有關.
如果您想知道更多有關此問卷的資訊, 請打免費電話 [TOLL FREE NUMBER]. 所有打到這
個號碼的電話都是免費的.
OMB# 0938-1257
2020 年 12 月 31 日到期
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
1
患者名字已列在問卷調查的首頁，請將此問卷交給您家中最瞭解患者所接受到安寧療護
的人.
問卷調查填寫指南
♦
此問卷需用深色的筆填寫.
♦
請直接在選項前面的方框內畫“X”作為回答， 如下所示：
是
☐ 否
♦
問卷中有時會指示您跳過一些問題, 如以下情況, 您會看到一個箭頭, 旁邊的指示會
告訴您接下來要回答哪一個問題, 如下所示:
是 如果選擇“是”，請跳至問題 1
☐ 否
安寧療護患者
1. 您與問卷調查首頁中所列的患者是什
麼關係？
☐我的配偶或伴侶
2
☐我的父母
3
☐我的岳母（婆婆）或岳父（公
1
公）
☐我的（外）祖父/母
5
☐我的姑姑（姨媽）或叔叔（舅
4
舅）
☐我的姐妹或兄弟
7
☐ 我的孩子
8
☐我的朋友
9
☐其他（請用正楷填寫）：
2. 在此次問卷調查中,詞語“家屬”是
指在問卷調查的首頁中所列之患者.
您的家屬在什麼地方接受了該機構的
安寧療護服務？ 請選擇一項或多項.
☐家
2
☐輔助生活機構
3
☐療養院
4
☐醫院
5
☐安寧療護機構/安養院
6
☐其他（請用正楷填寫）:
1
____________________________
6
_____________________________________________
2
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
您的角色
3. 在您的家屬接受安寧療護期間，您多
經常參與或監督他或她所接受的安寧
療護？
1
☐從未
如果選擇“從未”，請跳
至問題 41
☐有時
3
☐經常
4
☐總是
2
在回答問卷中所有問題的時候，請只考
慮您的家屬在本調查問卷附件中所列的
安寧療護機構的經驗.
4. 在此問卷中，安寧療護小組包括所有
護士、醫生、社工、靈性輔導師以及
其他曾經向您的家屬提供安寧療護的
人. 在您的家屬接受安寧療護期間您
是否曾需要在夜間、週末或假日裏聯
絡安寧療護小組，對家屬的護理提出
問題或者尋求幫助呢？
1
如果選擇“否”，請跳至問
題6
5. 在夜間、週末或假日裏，您多常能從
安寧療護小組那裏得到所需的幫助？
☐從未
2
☐有時
3
☐經常
4
☐總是
1
☐從未
2
☐有時
3
☐經常
4
☐總是
1
7. 在您的家屬接受安寧療護期間，當您
或者您的家屬向安寧療護小組求助的
時候，多常能立即得到所需的幫助？
您的家屬的安寧療護
☐是
2
☐否
6. 在您的家屬接受安寧療護期間，安寧
療護小組多常會通知您他們將何時到
場來照料您的家屬？
☐從未
2
☐有時
3
☐經常
4
☐總是
1
8. 在您的家屬接受安寧療護期間，安寧
療護小組有多經常能用清晰易懂的方
式向您解釋事情？
☐從未
2
☐有時
3
☐經常
4
☐總是
1
9. 在您的家屬接受安寧療護期間，安寧
療護小組多經常會通知您讓您瞭解您
家屬的情況？
☐從未
2
☐有時
3
☐經常
4
☐總是
1
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
3
10. 在您的家屬接受安寧療護期間，對於
您家屬的狀況或護理情況，安寧療護
小組的成員有多常提供您令人困惑或
相互矛盾的資訊？
14. 在您與安寧療護小組討論家屬的安寧
療護中出現的問題時，他們多經常會
認真傾聽？
☐從未
2
☐有時
3
☐經常
4
☐總是
1
☐從未
2
☐有時
3
☐經常
4
☐總是
1
11. 在您的家屬接受安寧療護期間，安寧
療護小組有多常以有尊嚴和尊重的態
度對待您的家屬？
☐從未
2
☐有時
3
☐經常
4
☐總是
1
如果選擇“否”，請跳至
問題 17
☐是的，當然是
2
☐是的，某種程度上是
3
☐否
1
☐從未
2
☐有時
3
☐經常
4
☐總是
17. 在您的家屬接受安寧療護期間，他或
她是否服用了任何止痛的藥物？
1
☐是
2
☐否
1
13. 在您的家屬接受安寧療護期間，您是
否有跟安寧療護小組討論過任何在安
寧療護中遇到的問題？
1
4
☐是
2
☐否
1
16. 您的家屬是否得到過所須的幫助以緩
解他或她的疼痛？
12. 在您的家屬接受安寧療護期間，安寧
療護小組有多常讓您感到他們真的關
心您的家屬？
☐是
2
☐否
15. 在您的家屬接受安寧療護期間，他或
她是否有任何疼痛？
如果選擇“否”，請跳至問
題 15
如果選擇“否”，請跳至
問題 21
18. 止痛藥物有副作用，其中包括嗜
睡，安寧療護小組是否曾與您或者
您的家屬討論過止痛藥物的副作
用？
☐是的，當然是
2
☐是的，某種程度上是
3
☐否
1
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
19. 關於使用止痛藥物時需要注意哪些副
作用，安寧療護小組是否提供您所需
的訓練？
☐是的，當然是
2
☐是的，某種程度上是
3
☐否
1
20. 關於是否與何時要給您的家屬服用 更
多劑量的止痛藥物，安寧療護小組是
否提供過您所需的訓練？
☐是的，當然是
2
☐是的，某種程度上是
3
☐否
4
☐我不需要給我的家屬服用任何止
1
痛藥物
21. 在您的家屬接受安寧療護期間 , 您
的家屬是否曾有過呼吸困難或者接受
過呼吸困難的治療？
☐是
2
☐否
1
如果選擇“否”，請跳至
問題 24
22. 您的家屬多常能在呼吸困難的時候得
到了他或她所需的幫助？
☐從未
2
☐有時
3
☐經常
4
☐總是
1
23. 關於在家屬呼吸困難時如何給予幫
助，安寧療護小組是否提供過您所需
的訓練？
☐是的，當然是
2
☐是的，某種程度上是
3
☐否
4
☐我不需要幫助我的家屬解決呼吸
1
困難問題
24. 在您的家屬接受安寧療護期間，您的
家屬是否曾有便秘問題？
☐是
2
☐否
1
如果選擇“否”，請跳至
問題 26
25. 遇到便秘問題的時候，您的家屬有多
常得到所需的幫助？
☐從未
2
☐有時
3
☐經常
4
☐總是
1
26. 在您的家屬接受安寧療護期間， 他
或 她是否曾表現出焦慮或悲傷的跡
象？
☐是
2
☐否
1
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
如果選擇“否”，請跳至
問 28
5
27. 在您的家屬感到焦慮或悲傷時，他或
她有多常能從安寧療護小組處得到所
需的幫助？
☐從未
2
☐有時
3
☐經常
4
☐總是
31. 關於家屬瀕臨死亡時會發生的事，安
寧療護小組是否盡可能地向您提供了
你所想要的相關資訊？
☐是的，當然是
2
☐是的，某種程度上是
3
☐否
1
1
在療養院中得到的安寧療護
28. 在您的家屬接受安寧療護期間，他
或 她是否曾變得不安或激動？
☐是
2
☐否
1
如果選擇“否”，請跳至
問題 30
29. 關於在家屬變得不安或激動時應該如
何處理，安寧療護小組是否提供過您
所需的訓練？
☐是的，當然是
2
☐是的，某種程度上是
3
☐否
1
☐是的，當然是
2
☐是的，某種程度上是
3
☐否
4
☐我不需要移動我的家屬
6
☐是
2
☐否
1
如果選擇“否”，請跳至
問題 35
33. 在您的家屬接受安寧療護期間，療養
院工作人員和安寧療護小組多經常能
協調一致來照顧您的家屬？
☐從未
2
☐有時
3
☐經常
4
☐總是
1
30. 搬動您的家屬包括幫助他或她在床上
翻身，或者上下床和上下輪椅等等.
安寧療護小組是否提供過您所需的訓
練來安全搬動您的家屬呢？
1
32. 有些人是在療養院中接受安寧療護服
務的.您的家屬是否在他或她於療養院
居住期間從該安寧療護醫院接受安寧
療護服務？
34. 在您的家屬接受安寧療護期間，療養
院工作人員給您的資訊與安寧療護小
組給您的資訊不一樣的情況多經常發
生？
☐從未
2
☐有時
3
☐經常
4
☐總是
1
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
您自己的與安寧療護有關的經
歷
35. 在您的家屬接受安寧療護期間，安寧
療護小組多經常認真聽您說話？
☐從未
2
☐有時
3
☐經常
4
☐總是
安寧療護整體評分
39. 根據您的家屬從問卷首頁所示的安寧
療護得到的服務，回答以下問題.在回
答時請不要將其他安寧療護的服務考
慮在內.
1
請用 0 到 10 的數字表示，0 代表最差
的安寧療護服務，10 則代表最好的安
寧療護. 您會用哪個數字評價您家屬
的安寧療護？
☐
1
☐
2
☐
3
☐
4
☐
5
☐
6
☐
7
☐
8
☐
9
☐
10
☐
0
36. 對宗教或靈性上的支援包括談話、 禱
告、靈修或其他以滿足您宗教需要或
靈性需求的方式.在您的家屬接受安寧
療護期間，您從安寧療護小組得到了
多少對宗教和靈性上的支持？
☐太少
2
☐適中
3
☐太多
1
37. 在您的家屬接受安寧療護期間，您從
安寧療護小組得到了多少的情感支
持？
☐太少
2
☐適中
3
☐太多
1
0 最差的安寧療護
1
2
3
4
5
6
7
8
9
10 最好的安寧療護
40. 您會向您的朋友和家人推薦該安寧療
護機構嗎？
☐當然不會
2
☐可能不會
3
☐可能會
4
☐當然會
1
38. 在您的家屬去世後的幾周，您從安寧
療護小組得到了多少情感支持？
☐太少
2
☐適中
3
☐太多
1
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
7
有關您的家屬
關於您自己
41. 您的家屬已完成的最高學校年級或最
高學歷是？
44. 您的年齡是？
☐ 18 至 24
2
☐ 25 至 34
3
☐ 35 至 44
4
☐ 45 至 54
5
☐ 55 至 64
6
☐ 65 至 74
7
☐ 75 至 84
8
☐ 85 及以上
1
☐國/初中 (8年級) 或以下
2
☐上過高中，但是沒有畢業
3
☐高中畢業或高中同等學歷
4
☐上過大學或兩年制大學學位
5
☐四年制大學畢業
6
☐四年以上大學學位
7
☐不知道
1
42. 您的家屬是否是西班牙裔、拉丁裔、
西班牙後裔或有西班牙血統？
1
☐否，不是西班牙人/西班牙裔/拉
丁裔
45. 您的性別是？
☐男
2
☐女
1
☐是，是波多黎各人
3
☐是，是墨西哥人、墨西哥裔美國
2
人或奇卡諾人
☐是，是古巴人
5
☐是，是其他西班牙人/西班牙裔/
4
拉丁裔人
43. 您的家屬的種族是？請選擇一項或多
項.
☐白人
2
☐黑人或非裔美國人
3
☐亞洲人
4
☐夏威夷島原住民或其他太平洋島
1
民
5
8
☐印第安人或阿拉斯加原住民
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
46. 您已完成的最高學校年級或最高學歷
是？
47. 您在家裏主要講哪種語言？
☐英語
2
☐西班牙語
3
☐中文
4
☐俄語
5
☐葡萄牙語
6
☐越南語
7
☐波蘭文
8
☐韓文
9
☐其他語言（請用正楷填寫）：
1
☐國/初中 (8年級) 或以下
2
☐上過高中，但是沒有畢業
3
☐高中畢業或高中同等學歷
4
☐上過大學或兩年制大學學位
5
☐四年制大學畢業
6
☐四年以上大學學位
1
__________________________
謝謝.
請完成填寫此問卷後將其放入已付郵費的信封中寄回.
[NAME OF SURVEY VENDOR]
[RETURN ADDRESS OF SURVEY VENDOR]
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
9
10
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
CAHPS® 安寧療護問卷調查
請根據患者從以下安寧療護機構所得到的服務回答下列調查問題:
[NAME OF HOSPICE]
在此問卷中所有的問題都與這個安寧療護機構的經驗有關.
如果您想知道更多有關此問卷的資訊, 請打免費電話 [TOLL FREE NUMBER]. 所有打到這
個號碼的電話都是免費的.
OMB# 0938-1257
2020 年 12 月 31 日到期
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
11
患者名字已列在問卷調查的首頁，請將此問卷交給您家中最瞭解患者所接受到安寧療護
的人.
問卷調查填寫指南
♦
此問卷需用深色的筆填寫.
♦
請直接在選項前面的圓圈內畫“X”作為回答，如下所示：
是
否
♦
問卷中有時會指示您跳過一些問題, 如以下情況, 您會看到一個箭頭, 旁邊的指示會
告訴您接下來要回答哪一個問題, 如下所示：
是
如果選擇“是”，請跳至問題 1
否
安寧療護患者
1. 您與問卷調查首頁中所列的患者是什
麼關係？
0 我的配偶或伴侶
2
0 我的父母
3
0 我的岳母（婆婆）或岳父（公公）
4
0 我的（外）祖父/母
5
0 我的姑姑（姨媽）或叔叔（舅舅）
6
0 我的姐妹或兄弟
7
0 我的孩子
8
0 我的朋友
9
0 其他（請用正楷填寫）：
1
2. 在此次問卷調查中,詞語“家屬”是
指在問卷調查的首頁中所列之患者.
您的家屬在什麼地方接受了該機構的
安寧療護服務？ 請選擇一項或多項.
0家
2
0 輔助生活機構
3
0 療養院
4
0 醫院
5
0 安寧療護機構/安養院
6
0 其他（請用正楷填寫）:
1
____________________________
_____________________________________________
12
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
您的角色
3. 在您的家屬接受安寧療護期間，您多
經常參與或監督他或她所接受的安寧
療護？
1
0 從未
如果選擇“從未”，請跳至
問題 41
0 有時
3
0 經常
4
0 總是
2
在回答問卷中所有問題的時候，請只考
慮您的家屬在本調查問卷附件中所列的
安寧療護機構的經驗.
4. 在此問卷中，安寧療護小組包括所有
護士、醫生、社工、靈性輔導師以及
其他曾經向您的家屬提供安寧療護的
人. 在您的家屬接受安寧療護期間您
是否曾需要在夜間、週末或假日裏聯
絡安寧療護小組，對家屬的護理提出
問題或者尋求幫助呢？
1
如果選擇“否”，請跳至問題
6
5. 在夜間、週末或假日裏，您多常能從
安寧療護小組那裏得到所需的幫助？
0 從未
2
0 有時
3
0 經常
4
0 總是
1
0 從未
2
0 有時
3
0 經常
4
0 總是
1
7. 在您的家屬接受安寧療護期間，當您
或者您的家屬向安寧療護小組求助的
時候，多常能立即得到所需的幫助？
您的家屬的安寧療護
0是
2
0否
6. 在您的家屬接受安寧療護期間，安寧
療護小組多常會通知您他們將何時到
場來照料您的家屬？
0 從未
2
0 有時
3
0 經常
4
0 總是
1
8. 在您的家屬接受安寧療護期間，安寧
療護小組有多經常能用清晰易懂的方
式向您解釋事情？
0 從未
2
0 有時
3
0 經常
4
0 總是
1
9. 在您的家屬接受安寧療護期間，安寧
療護小組多經常會通知您讓您瞭解您
家屬的情況？
0 從未
2
0 有時
3
0 經常
4
0 總是
1
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
13
10. 在您的家屬接受安寧療護期間，對於
您家屬的狀況或護理情況，安寧療護
小組的成員有多常提供您令人困惑或
相互矛盾的資訊？
14. 在您與安寧療護小組討論家屬的安寧
療護中出現的問題時，他們多經常會
認真傾聽？
0 從未
2
0 有時
3
0 經常
4
0 總是
1
0 從未
2
0 有時
3
0 經常
4
0 總是
1
11. 在您的家屬接受安寧療護期間，安寧
療護小組有多常以有尊嚴和尊重的態
度對待您的家屬？
0 從未
2
0 有時
3
0 經常
4
0 總是
1
如果選擇“否”，請跳至問
題 17
0 是的，當然是
2
0 是的，某種程度上是
3
0否
1
0 從未
2
0 有時
3
0 經常
4
0 總是
17. 在您的家屬接受安寧療護期間，他或
她是否服用了任何止痛的藥物？
1
0是
2
0否
1
13. 在您的家屬接受安寧療護期間，您是
否有跟安寧療護小組討論過任何在安
寧療護中遇到的問題？
1
14
0是
2
0否
1
16. 您的家屬是否得到過所須的幫助以緩
解他或她的疼痛？
12. 在您的家屬接受安寧療護期間，安寧
療護小組有多常讓您感到他們真的關
心您的家屬？
0是
2
0否
15. 在您的家屬接受安寧療護期間，他或
她是否有任何疼痛？
如果選擇“否”，請跳至問題
15
如果選擇“否”，請跳至問
題 21
18. 止痛藥物有副作用，其中包括嗜
睡，安寧療護小組是否曾與您或者
您的家屬討論過止痛藥物的副作
用？
0 是的，當然是
2
0 是的，某種程度上是
3
0否
1
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
19. 關於使用止痛藥物時需要注意哪些副
作用，安寧療護小組是否提供您所需
的訓練？
0 是的，當然是
2
0 是的，某種程度上是
3
0否
1
20. 關於是否與何時要給您的家屬服用 更
多劑量的止痛藥物，安寧療護小組是
否提供過您所需的訓練？
0 是的，當然是
2
0 是的，某種程度上是
3
0否
4
0 我不需要給我的家屬服用任何止
1
痛藥物
21. 在您的家屬接受安寧療護期間 , 您
的家屬是否曾有過呼吸困難或者接受
過呼吸困難的治療？
0是
2
0否
1
如果選擇“否”，請跳至
問題 24
22. 您的家屬多常能在呼吸困難的時候得
到了他或她所需的幫助？
0 從未
2
0 有時
3
0 經常
4
0 總是
1
23. 關於在家屬呼吸困難時如何給予幫
助，安寧療護小組是否提供過您所需
的訓練？
0 是的，當然是
2
0 是的，某種程度上是
3
0否
4
0 我不需要幫助我的家屬解決呼吸
1
困難問題
24. 在您的家屬接受安寧療護期間，您的
家屬是否曾有便秘問題？
0是
2
0否
1
如果選擇“否”，請跳至問
題 26
25. 遇到便秘問題的時候，您的家屬有多
常得到所需的幫助？
0 從未
2
0 有時
3
0 經常
4
0 總是
1
26. 在您的家屬接受安寧療護期間， 他
或 她是否曾表現出焦慮或悲傷的跡
象？
0是
2
0否
1
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
如果選擇“否”，請跳至問
28
15
27. 在您的家屬感到焦慮或悲傷時，他或
她有多常能從安寧療護小組處得到所
需的幫助？
0 從未
2
0 有時
3
0 經常
4
0 總是
31. 關於家屬瀕臨死亡時會發生的事，安
寧療護小組是否盡可能地向您提供了
你所想要的相關資訊？
0 是的，當然是
2
0 是的，某種程度上是
3
0否
1
1
在療養院中得到的安寧療護
28. 在您的家屬接受安寧療護期間，他
或 她是否曾變得不安或激動？
0是
2
0否
1
如果選擇“否”，請跳至問
題 30
29. 關於在家屬變得不安或激動時應該如
何處理，安寧療護小組是否提供過您
所需的訓練？
0 是的，當然是
2
0 是的，某種程度上是
3
0否
1
0 是的，當然是
2
0 是的，某種程度上是
3
0否
4
0 我不需要移動我的家屬
16
0是
2
0否
1
如果選擇“否”，請跳至問
題 35
33. 在您的家屬接受安寧療護期間，療養
院工作人員和安寧療護小組多經常能
協調一致來照顧您的家屬？
0 從未
2
0 有時
3
0 經常
4
0 總是
1
30. 搬動您的家屬包括幫助他或她在床上
翻身，或者上下床和上下輪椅等等.
安寧療護小組是否提供過您所需的訓
練來安全搬動您的家屬呢？
1
32. 有些人是在療養院中接受安寧療護服
務的.您的家屬是否在他或她於療養院
居住期間從該安寧療護醫院接受安寧
療護服務？
34. 在您的家屬接受安寧療護期間，療養
院工作人員給您的資訊與安寧療護小
組給您的資訊不一樣的情況多經常發
生？
0 從未
2
0 有時
3
0 經常
4
0 總是
1
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
您自己的與安寧療護有關的經
歷
35. 在您的家屬接受安寧療護期間，安寧
療護小組多經常認真聽您說話？
0 從未
2
0 有時
3
0 經常
4
0 總是
安寧療護整體評分
39. 根據您的家屬從問卷首頁所示的安寧
療護得到的服務，回答以下問題.在回
答時請不要將其他安寧療護的服務考
慮在內.
1
請用 0 到 10 的數字表示，0 代表最差
的安寧療護服務，10 則代表最好的安
寧療護. 您會用哪個數字評價您家屬
的安寧療護？
0 0 最差的安寧療護
1
01
2
02
3
03
4
04
5
05
6
06
7
07
8
08
9
09
10
0 10 最好的安寧療護
0
36. 對宗教或靈性上的支援包括談話、 禱
告、靈修或其他以滿足您宗教需要或
靈性需求的方式.在您的家屬接受安寧
療護期間，您從安寧療護小組得到了
多少對宗教和靈性上的支持？
0 太少
2
0 適中
3
0 太多
1
37. 在您的家屬接受安寧療護期間，您從
安寧療護小組得到了多少的情感支
持？
0 太少
2
0 適中
3
0 太多
1
40. 您會向您的朋友和家人推薦該安寧療
護機構嗎？
0 當然不會
2
0 可能不會
3
0 可能會
4
0 當然會
1
38. 在您的家屬去世後的幾周，您從安寧
療護小組得到了多少情感支持？
0 太少
2
0 適中
3
0 太多
1
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
17
有關您的家屬
關於您自己
41. 您的家屬已完成的最高學校年級或最
高學歷是？
44. 您的年齡是？
0 18 至 24
2
0 25 至 34
3
0 35 至 44
4
0 45 至 54
5
0 55 至 64
6
0 65 至 74
7
0 75 至 84
8
0 85 及以上
1
0國/初中 (8年級) 或以下
2
0上過高中，但是沒有畢業
3
0高中畢業或高中同等學歷
4
0上過大學或兩年制大學學位
5
0四年制大學畢業
6
0四年以上大學學位
7
0不知道
1
42. 您的家屬是否是西班牙裔、拉丁裔、
西班牙後裔或有西班牙血統？
1
0否，不是西班牙人/西班牙裔/拉丁
裔
45. 您的性別是？
0男
2
0女
1
0是，是波多黎各人
3
0是，是墨西哥人、墨西哥裔美國人
2
或奇卡諾人
0是，是古巴人
5
0是，是其他西班牙人/西班牙裔/拉
4
丁裔人
43. 您的家屬的種族是？請選擇一項或多
項.
0白人
2
0黑人或非裔美國人
3
0亞洲人
4
0夏威夷島原住民或其他太平洋島民
5
0印第安人或阿拉斯加原住民
1
18
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
46. 您已完成的最高學校年級或最高學歷
是？
47. 您在家裏主要講哪種語言？
0英語
2
0西班牙語
3
0中文
4
0俄語
5
0葡萄牙語
6
0越南語
7
0波蘭文
8
0韓文
9
0 其他語言（請用正楷填寫）：
1
0國/初中 (8年級) 或以下
2
0上過高中，但是沒有畢業
3
0高中畢業或高中同等學歷
4
0上過大學或兩年制大學學位
5
0四年制大學畢業
6
0四年以上大學學位
1
__________________________
謝謝.
請完成填寫此問卷後將其放入已付郵費的信封中寄回.
[NAME OF SURVEY VENDOR]
[RETURN ADDRESS OF SURVEY VENDOR]
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
19
20
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
CAHPS® 安寧療護問卷調查
請根據患者從以下安寧療護機構所得到的服務回答下列調查問題:
[NAME OF HOSPICE]
在此問卷中所有的問題都與這個安寧療護機構的經驗有關.
如果您想知道更多有關此問卷的資訊, 請打免費電話 [TOLL FREE NUMBER]. 所有打到這
個號碼的電話都是免費的.
OMB# 0938-1257
2020 年 12 月 31 日到期
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
21
患者名字已列在問卷調查的首頁，請將此問卷交給您家中最瞭解患者所接受到安寧療護
的人.
問卷調查填寫指南
♦
此問卷需用深色的筆填寫.
♦
請直接在選項前面的圓圈內畫“X”作為回答， 如下所示：
♦
是
否
問卷中有時會指示您跳過一些問題, 如以下情況, 您會看到一個箭頭, 旁邊的指示會
告訴您接下來要回答哪一個問題, 如下所示 :
是
否
如果選擇“是”，請跳至問題 1
安寧療護患者
1. 您與問卷調查首頁中所列的患者是什
麼關係？
O 我的配偶或伴侶
2
O 我的父母
3
O 我的岳母（婆婆）或岳父（公
1
公）
O 我的（外）祖父/母
5
O 我的姑姑（姨媽）或叔叔（舅
4
舅）
2. 在此次問卷調查中,詞語“家屬”是
指在問卷調查的首頁中所列之患者.
您的家屬在什麼地方接受了該機構的
安寧療護服務？ 請選擇一項或多項.
O家
2
O 輔助生活機構
3
O 療養院
4
O 醫院
5
O 安寧療護機構/安養院
6
O 其他（請用正楷填寫）:
1
____________________________
O 我的姐妹或兄弟
O 我的孩子
8
O 我的朋友
9
O 其他（請用正楷填寫）：
6
7
_____________________________________________
22
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
您的角色
3. 在您的家屬接受安寧療護期間，您多
經常參與或監督他或她所接受的安寧
療護？
1
O 從未
如果選擇“從未”，請跳
至問題 41
O 有時
3
O 經常
4
O 總是
2
在回答問卷中所有問題的時候，請只考
慮您的家屬在本調查問卷附件中所列的
安寧療護機構的經驗.
4. 在此問卷中，安寧療護小組包括所有
護士、醫生、社工、靈性輔導師以及
其他曾經向您的家屬提供安寧療護的
人. 在您的家屬接受安寧療護期間您
是否曾需要在夜間、週末或假日裏聯
絡安寧療護小組，對家屬的護理提出
問題或者尋求幫助呢？
1
如果選擇“否”，請跳至問
題6
5. 在夜間、週末或假日裏，您多常能從
安寧療護小組那裏得到所需的幫助？
O 從未
O 有時
3
O 經常
4
O 總是
1
2
O 從未
2
O 有時
3
O 經常
4
O 總是
1
7. 在您的家屬接受安寧療護期間，當您
或者您的家屬向安寧療護小組求助的
時候，多常能立即得到所需的幫助？
您的家屬的安寧療護
O是
2
O否
6. 在您的家屬接受安寧療護期間，安寧
療護小組多常會通知您他們將何時到
場來照料您的家屬？
O 從未
2
O 有時
3
O 經常
4
O 總是
1
8. 在您的家屬接受安寧療護期間，安寧
療護小組有多經常能用清晰易懂的方
式向您解釋事情？
O 從未
2
O 有時
3
O 經常
4
O 總是
1
9. 在您的家屬接受安寧療護期間，安寧
療護小組多經常會通知您讓您瞭解您
家屬的情況？
O 從未
2
O 有時
3
O 經常
4
O 總是
1
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
23
10. 在您的家屬接受安寧療護期間，對於
您家屬的狀況或護理情況，安寧療護
小組的成員有多常提供您令人困惑或
相互矛盾的資訊？
O 從未
2
O 有時
3
O 經常
4
O 總是
1
11. 在您的家屬接受安寧療護期間，安寧
療護小組有多常以有尊嚴和尊重的態
度對待您的家屬？
O 從未
2
O 有時
3
O 經常
4
O 總是
14. 在您與安寧療護小組討論家屬的安寧
療護中出現的問題時，他們多經常會
認真傾聽？
O 從未
2
O 有時
3
O 經常
4
O 總是
1
15. 在您的家屬接受安寧療護期間，他或
她是否有任何疼痛？
O是
2
O否
1
1
16. 您的家屬是否得到過所須的幫助以緩
解他或她的疼痛？
2
17. 在您的家屬接受安寧療護期間，他或
她是否服用了任何止痛的藥物？
O 從未
2
O 有時
3
O 經常
4
O 總是
1
1
2
13. 在您的家屬接受安寧療護期間，您是
否有跟安寧療護小組討論過任何在安
寧療護中遇到的問題？
1
24
O 是的，當然是
O 是的，某種程度上是
3
O否
1
12. 在您的家屬接受安寧療護期間，安寧
療護小組有多常讓您感到他們真的關
心您的家屬？
O是
2
O否
如果選擇“否”，請跳至問
題 17
如果選擇“否”，請跳至問題
15
O是
O否
如果選擇“否”，請跳至問
題 21
18. 止痛藥物有副作用，其中包括嗜
睡，安寧療護小組是否曾與您或者
您的家屬討論過止痛藥物的副作
用？
O 是的，當然是
2
O 是的，某種程度上是
3
O否
1
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
19. 關於使用止痛藥物時需要注意哪些副
作用，安寧療護小組是否提供您所需
的訓練？
O 是的，當然是
2
O 是的，某種程度上是
3
O否
1
20. 關於是否與何時要給您的家屬服用 更
多劑量的止痛藥物，安寧療護小組是
否提供過您所需的訓練？
O 是的，當然是
O 是的，某種程度上是
3
O否
4
O 我不需要給我的家屬服用任何止
1
2
痛藥物
21. 在您的家屬接受安寧療護期間 , 您
的家屬是否曾有過呼吸困難或者接受
過呼吸困難的治療？
O是
2
O否
1
如果選擇“否”，請跳至
問題 24
22. 您的家屬多常能在呼吸困難的時候得
到了他或她所需的幫助？
O 從未
2
O 有時
3
O 經常
4
O 總是
1
23. 關於在家屬呼吸困難時如何給予幫
助，安寧療護小組是否提供過您所需
的訓練？
O 是的，當然是
2
O 是的，某種程度上是
3
O否
4
O 我不需要幫助我的家屬解決呼吸
1
困難問題
24. 在您的家屬接受安寧療護期間，您的
家屬是否曾有便秘問題？
O是
2
O否
1
如果選擇“否”，請跳至問
題 26
25. 遇到便秘問題的時候，您的家屬有多
常得到所需的幫助？
O 從未
O 有時
3
O 經常
4
O 總是
1
2
26. 在您的家屬接受安寧療護期間， 他
或 她是否曾表現出焦慮或悲傷的跡
象？
O是
2
O否
1
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
如果選擇“否”，請跳至問
28
25
27. 在您的家屬感到焦慮或悲傷時，他或
她有多常能從安寧療護小組處得到所
需的幫助？
O 從未
2
O 有時
3
O 經常
4
O 總是
31. 關於家屬瀕臨死亡時會發生的事，安
寧療護小組是否盡可能地向您提供了
你所想要的相關資訊？
O 是的，當然是
2
O 是的，某種程度上是
3
O否
1
1
在療養院中得到的安寧療護
28. 在您的家屬接受安寧療護期間，他
或 她是否曾變得不安或激動？
O是
2
O否
1
如果選擇“否”，請跳至問
題 30
29. 關於在家屬變得不安或激動時應該如
何處理，安寧療護小組是否提供過您
所需的訓練？
O 是的，當然是
O 是的，某種程度上是
3
O否
1
2
O 是的，當然是
2
O 是的，某種程度上是
3
O否
4
O 我不需要移動我的家屬
26
O是
2
O否
1
如果選擇“否”，請跳至問
題 35
33. 在您的家屬接受安寧療護期間，療養
院工作人員和安寧療護小組多經常能
協調一致來照顧您的家屬？
O 從未
2
O 有時
3
O 經常
4
O 總是
1
30. 搬動您的家屬包括幫助他或她在床上
翻身，或者上下床和上下輪椅等等.
安寧療護小組是否提供過您所需的訓
練來安全搬動您的家屬呢？
1
32. 有些人是在療養院中接受安寧療護服
務的.您的家屬是否在他或她於療養院
居住期間從該安寧療護醫院接受安寧
療護服務？
34. 在您的家屬接受安寧療護期間，療養
院工作人員給您的資訊與安寧療護小
組給您的資訊不一樣的情況多經常發
生？
O 從未
2
O 有時
3
O 經常
4
O 總是
1
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
您自己的與安寧療護有關的經
歷
35. 在您的家屬接受安寧療護期間，安寧
療護小組多經常認真聽您說話？
O 從未
2
O 有時
3
O 經常
4
O 總是
安寧療護整體評分
39. 根據您的家屬從問卷首頁所示的安寧
療護得到的服務，回答以下問題.在回
答時請不要將其他安寧療護的服務考
慮在內.
1
36. 對宗教或靈性上的支援包括談話、 禱
告、靈修或其他以滿足您宗教需要或
靈性需求的方式.在您的家屬接受安寧
療護期間，您從安寧療護小組得到了
多少對宗教和靈性上的支持？
O 太少
2
O 適中
3
O 太多
1
37. 在您的家屬接受安寧療護期間，您從
安寧療護小組得到了多少的情感支
持？
O 太少
2
O 適中
3
O 太多
1
38. 在您的家屬去世後的幾周，您從安寧
療護小組得到了多少情感支持？
O 太少
2
O 適中
3
O 太多
1
請用 0 到 10 的數字表示，0 代表最差
的安寧療護服務，10 則代表最好的安
寧療護. 您會用哪個數字評價您家屬
的安寧療護？
O 0 最差的安寧療護
1
O1
2
O2
3
O3
4
O4
5
O5
6
O6
7
O7
8
O8
9
O9
10
O 10 最好的安寧療護
0
40. 您會向您的朋友和家人推薦該安寧療
護機構嗎？
O 當然不會
O 可能不會
3
O 可能會
4
O 當然會
1
2
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
27
有關您的家屬
關於您自己
41. 您的家屬已完成的最高學校年級或最
高學歷是？
O國/初中 (8年級) 或以下
2
O上過高中，但是沒有畢業
3
O高中畢業或高中同等學歷
4
O上過大學或兩年制大學學位
5
O四年制大學畢業
6
O四年以上大學學位
7
O不知道
1
42. 您的家屬是否是西班牙裔、拉丁裔、
西班牙後裔或有西班牙血統？
44. 您的年齡是？
O 18 至 24
2
O 25 至 34
3
O 35 至 44
4
O 45 至 54
5
O 55 至 64
6
O 65 至 74
7
O 75 至 84
8
O 85 及以上
1
45. 您的性別是？
O男
2
O女
1
1
O否，不是西班牙人/西班牙裔/拉丁
裔
O是，是波多黎各人
3
O是，是墨西哥人、墨西哥裔美國
2
人或奇卡諾人
O是，是古巴人
O是，是其他西班牙人/西班牙裔/拉
4
5
丁裔人
43. 您的家屬的種族是？請選擇一項或多
項.
O白人
O黑人或非裔美國人
3
O亞洲人
4
O夏威夷島原住民或其他太平洋島
1
2
民
5
28
O印第安人或阿拉斯加原住民
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
46. 您已完成的最高學校年級或最高學歷
是？
47. 您在家裏主要講哪種語言？
O英語
O西班牙語
3
O中文
4
O俄語
5
O葡萄牙語
6
O越南語
7
O波蘭文
8
O韓文
9
O 其他語言（請用正楷填寫）：
1
O國/初中 (8年級) 或以下
O上過高中，但是沒有畢業
3
O高中畢業或高中同等學歷
4
O上過大學或兩年制大學學位
5
O四年制大學畢業
6
O四年以上大學學位
1
2
2
__________________________
謝謝.
請完成填寫此問卷後將其放入已付郵費的信封中寄回.
[NAME OF SURVEY VENDOR]
[RETURN ADDRESS OF SURVEY VENDOR]
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
29
30
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
Sample Initial Cover Letter for the CAHPS Hospice Survey
[HOSPICE OR VENDOR LETTERHEAD]
[SAMPLED CAREGIVER NAME]
[ADDRESS]
[CITY, STATE ZIP]
親愛的[SAMPLED CAREGIVER NAME]：
[HOSPICE NAME]正在對患者及其家屬接受的安寧療護服務進行調查. 您被抽中參加此次
調查，是因為您曾是[DECEDENT NAME]的護理員. 我們知道您現在心裡可能很難受，但
是我們希望您能幫助我們瞭解安寧療護機構為您和您的家人或者朋友提供的護理品質情況.
所附的調查問題[NOTE THE QUESTION NUMBERS]是美國衛生及公共服務部（HHS）為
了衡量安寧療護機構的護理品質所倡議的一項全國調查的一部分. 這項調查由HHS的下屬
機構聯邦醫療保險及各州醫療補助服務中心（CMS）開展，目的是為了改善寧養護理品
質. 美國大部分寧養護理都由CMS支付費用，CMS有責任確保安寧療護患者及其家屬和朋
友能得到優質護理服務. 要履行這個責任，其中一個方法就是直接向您瞭解您的家屬或朋
友得到的安寧療護護理情況. 你的參與純屬自願，您的健康護理或福利不受任何影響.
我們希望您能花些時間填寫這項調查. 填寫完後，請用郵資預付的信封將它寄回給我們.
您的答案可能會與安寧療護機構分享，以便改進品質. [OPTIONAL：您可能會注意到調查
問卷上有個編號. 這個編號是用來告訴我們您是否寄回了調查問卷，這樣我們就無需向您
發送提醒.]
如果您對所附的調查有任何疑問，請撥打我們的免費電話1-800-xxx-xxxx. 感謝您為改善
所有消費者的安寧療護護理所提供的幫助.
敬啟
[HOSPICE ADMINISTRATOR]
[HOSPICE NAME]
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
31
32
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
Sample Follow-up Cover Letter for the CAHPS Hospice
Survey
[HOSPICE OR VENDOR LETTERHEAD]
[SAMPLED CAREGIVER NAME]
[ADDRESS]
[CITY, STATE ZIP]
親愛的[SAMPLED CAREGIVER NAME]：
我們的記錄顯示您最近在[HOSPICE NAME]為[DECEDENT NAME]提供了護理. 大約三周
前，我們給您發送了一份有關您和您的家人或朋友在這件安寧療護機構所接受的護理的調
查. 如果您已經將調查寄回給我們，請接受我們的謝意，並忽略此信. 但是如果您還沒有
寄出，如果您能花些時間完成這份重要的調查問卷，我們將不勝感激.
我們希望您能借此機會幫助我們瞭解您的家人或朋友所受到的護理品質情況. 這份調查
的結果將用來幫助確保所有美國人都能受到最高品質的寧養護理服務.
所附的調查問題[NOTE THE QUESTION NUMBERS]是美國衛生及公共服務部（HHS）為
了衡量安寧療護機構的護理品質所倡議的一項全國調查的一部分. 這項調查由HHS的下屬
機構聯邦醫療保險及各州醫療補助服務中心（CMS）開展，目的是為了改善寧養護理品
質. 美國大部分寧養護理都由CMS支付費用，CMS有責任確保安寧療護患者及其家屬和朋
友能得到優質護理服務. 要履行這個責任，其中一個方法就是直接向您瞭解您的家屬或朋
友得到的安寧療護護理情況. 你的參與純屬自願，您的健康護理或福利不受任何影響.
請花幾分鐘的時間填寫所附的調查. 填寫完後，請用郵資預付的信封將它寄回給我們. 您
的答案可能會與安寧療護機構分享，以便改進品質. [OPTIONAL：您可能會注意到調查問
卷上有個編號. 這個編號是用來告訴我們您是否寄回了調查問卷，這樣我們就無需向您發
送提醒.]
如果您對所附的調查有任何疑問，請撥打我們的免費電話1-800-xxx-xxxx. 感謝您為改善
所有消費者的安寧療護護理所提供的幫助.
敬啟
[HOSPICE ADMINISTRATOR]
[HOSPICE NAME]
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
33
34
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
OMB Paperwork Reduction Act Language
The OMB Paperwork Reduction Act language must appear in the mailing, either on the cover
letter or on the front or back of the questionnaire. In addition, the OMB control number must
appear on the front page of the questionnaire. The following is the language that must be used:
Traditional Chinese Version
“根據1995年《文書削減法》的規定，除非顯示有效的OMB管制編號，否則無人需要回應
資訊收集。此次資訊收集的有效OMB管制編號為0938-1257 (2020年12月31日到期)。完成
此次資訊收集中1 - 40項問題“關於你的家人”及“關於你”部分所需時間估計為平均11
分鐘，包括閱覽說明、搜索現有資料資源、收集所需資料，以及完成和審核收集到的資訊
的時間。如果你對估計的時間準確性有任何意見，或對改善這份表格有任何建議，請寫信
至: Centers for Medicare & Medicaid Services, 7500 Security Boulevard, Mail Stop C1-25-05,
Baltimore, MD 21244-1850.”
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
35
36
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
Appendix Q
Mail Survey Materials (Simplified Chinese)
CAHPS® 安宁疗护问卷调查
请根据患者从以下安宁疗护机构所得到的服务回答下列调查问题:
[NAME OF HOSPICE]
在此问卷中所有的问题都与这个安宁疗护机构的经验有关.
如果您想知道更多有关此问卷的信息, 请打免费电话 [TOLL FREE NUMBER]. 所有打到这
个号码的电话都是免费的.
OMB# 0938-1257
2020 年 12 月 31 日到期
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
1
患者名字已列在问卷调查的首页，请将此问卷交给您家中最了解患者所接受到安宁疗护
的人
问卷填写指南
♦
此问卷需用深色的笔填写.
♦
请直接在选项前面的方框内画“X”作为回答， 如下所示：
是
☐ 否
♦
调查中有些地方会提示您跳过一些问题.在这种情况下，您会看到一个箭头，旁边的提
示信息会告诉您接下来要回答哪个问题，如下所示：
是
如果选择“是”，请跳至问题 1
☐ 否
安宁疗护患者
1. 您与调查问卷附件中所列的患者是什
么关系？
☐ 我的配偶或伴侣
2
☐ 我的父母
3
☐ 我的岳母（婆婆）或岳父（公
1
公）
☐ 我的（外）祖父/母
5
☐ 我的姑姑（姨妈）或叔叔（舅
4
舅）
2. 在此次问卷调查中,词语“家属”是指
在问卷调查的首页中所列之患者.您的
家属在什么地方接受了该机构的安宁
疗护服务？ 请选择一项或多项.
☐家
2
☐ 辅助生活机构
3
☐ 疗养院
4
☐ 医院
5
☐ 安宁疗护机构/赡养院
6
☐ 其他（请用正楷填写）：
1
☐ 我的姐妹或兄弟
7
☐ 我的孩子
8
☐ 我的朋友
9
☐ 其他（请用正楷填写）：
6
2
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
您的角色
3. 在您的家属接受安宁疗护期间，您有
多少机会参与或监督安宁疗护？
6. 在您的家属接受安宁疗护期间，安宁
疗护小组多常会通知您他们将何时到
场来照料您的家属？
☐ 从未
2
☐ 有时
3
☐ 经常
4
☐ 总是
1
1
☐ 从未
如果选择“从未”，请
跳至问题 41
☐ 有时
3
☐ 经常
4
☐ 总是
2
您的家属的安宁疗护
在回答问卷中所有问题的时候，请只考
虑您的家属在本调查问卷附件中所列的
安宁疗护机构的经验.
4. 在此问卷中，安宁疗护小组包括所有
护士、医生、社工、灵性辅导师以及
其他曾经向您的家属提供安宁疗护的
人. 在您的家属接受安宁疗护期间您
是否曾需要在夜间、周末或假日里联
络安宁疗护小组，对家属的护理提出
问题或者寻求帮助呢？
7. 在您的家属接受安宁疗护期间，当您
或者您的家属向安宁疗护小组求助的
时候，多常能立即得到所需的帮助？
☐ 从未
2
☐ 有时
3
☐ 经常
4
☐ 总是
1
8. 在您的家属接受安宁疗护期间，安宁
疗护小组有多经常能用清晰易懂的方
式向您解释事情？
☐ 从未
2
☐ 有时
3
☐ 经常
4
☐ 总是
1
☐是
2
☐否
1
如果选择“否”，请跳至
问题 6
5. 在夜间、周末或假日里，您多常能从
安宁疗护小组那里得到所需的帮助？
☐ 从未
2
☐ 有时
3
☐ 经常
4
☐ 总是
1
9. 在您的家属接受安宁疗护期间，安宁
疗护小组多经常会通知您让您了解您
家属的情况？
☐ 从未
2
☐ 有时
3
☐ 经常
4
☐ 总是
1
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
3
10. 在您的家属接受安宁疗护期间，对于
您家属的状况或护理情况，安宁疗护
小组的成员有多常提供您令人困惑或
相互矛盾的信息？
14. 在您与安宁疗护小组讨论家属的安宁
疗护中出现的问题时，他们多经常会
认真倾听？
☐ 从未
2
☐ 有时
3
☐ 经常
4
☐ 总是
1
☐ 从未
2
☐ 有时
3
☐ 经常
4
☐ 总是
1
11. 在您的家属接受安宁疗护期间，安宁
疗护小组有多常以有尊严和尊重的态
度对待您的家属？
☐ 从未
2
☐ 有时
3
☐ 经常
4
☐ 总是
1
如果选择“否”，请跳至
问题 17
☐ 是的，当然是
2
☐ 是的，某种程度上是
3
☐否
1
☐ 从未
2
☐ 有时
3
☐ 经常
4
☐ 总是
17. 在您的家属接受安宁疗护期间，他或
她是否服用了任何止痛的药物？
1
☐是
2
☐否
1
13. 在您的家属接受安宁疗护期间，您是
否有跟安宁疗护小组讨论过任何在安
宁疗护中遇到的问题？
1
4
☐是
2
☐否
1
16. 您的家属是否得到过所须的帮助以缓
解他或她的疼痛？
12. 在您的家属接受安宁疗护期间，安宁
疗护小组有多常让您感到他们真的关
心您的家属？
☐是
2
☐否
15. 在您的家属接受安宁疗护期间，他或
她是否有任何疼痛？
如果选择“否”，请跳至
问题 15
如果选择“否”，请跳至
问题 21
18. 止痛药物有副作用，其中包括嗜
睡，安宁疗护小组是否曾与您或者
您的家属讨论过止痛药物的副作
用？
☐ 是的，当然是
2
☐ 是的，某种程度上是
3
☐否
1
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
19. 关于使用止痛药物时需要注意哪些副
作用，安宁疗护小组是否提供您所需
的训练？
☐ 是的，当然是
2
☐ 是的，某种程度上是
3
☐否
1
20. 关于是否与何时要给您的家属服用更
多剂量的止痛药物，安宁疗护小组是
否提供过您所需的训练？
☐ 是的，当然是
2
☐ 是的，某种程度上是
3
☐否
4
☐ 我不需要给我的家属服用任何
1
止痛药物
21. 在您的家属接受安宁疗护期间 , 您的
家属是否曾有过呼吸困难或者接受过
呼吸困难的治疗？
☐是
2
☐否
1
如果选择“否”，请跳至
问题 24
22. 您的家属多经常能在呼吸困难的时候
得到了他或她所需的帮助？
☐ 从未
2
☐ 有时
3
☐ 经常
4
☐ 总是
1
23. 关于在家属呼吸困难时如何给予帮
助，安宁疗护小组是否提供过您所需
的训练?？
☐ 是的，当然是
2
☐ 是的，某种程度上是
3
☐否
4
☐ 我不需要帮助我的家属解决呼
1
吸困难问题
24. 在您的家属接受安宁疗护期间，您的
家属是否曾有便秘问题？
☐是
2
☐否
1
如果选择“否”，请跳至
问题 26
25. 您的家属多经常能在遭遇便秘问题的
时候得到他或她所需的帮助？
☐ 从未
2
☐ 有时
3
☐ 经常
4
☐ 总是
1
26. 在您的家属接受安宁疗护期间， 他
或她是否曾表现出焦虑或悲伤的迹
象？
☐是
2
☐否
1
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
如果选择“否”，请跳至
问 28
5
27. 在您的家属感到焦虑或悲伤时，他或
她有多常能从安宁疗护小组处得到所
需的帮助？
☐ 从未
2
☐ 有时
3
☐ 经常
4
☐ 总是
☐ 是的，当然是
2
☐ 是的，某种程度上是
3
☐否
1
1
在疗养院中得到的安宁疗护
28. 在您的家属接受安宁疗护期间，他
或 她是否曾变得不安或激动？
☐是
2
☐否
1
如果选择“否”，请跳至
问题 30
29. 关于在家属变得不安或激动时应该如
何处理，安宁疗护小组是否提供过您
所需的训练？
☐ 是的，当然是
2
☐ 是的，某种程度上是
3
☐否
1
☐ 是的，当然是
2
☐ 是的，某种程度上是
3
☐否
4
☐ 我不需要移动我的家属
6
32. 有些人是在疗养院中接受安宁疗护服
务的.您的家属是否在他或她于疗养院
居住期间从该安宁疗护医院接受安宁
疗护服务？
☐是
2
☐否
1
如果选择“否”，请跳至
问题 35
33. 在您的家属接受安宁疗护期间，疗养
院工作人员和安宁疗护小组多经常能
协调一致来照顾您的家属？
☐ 从未
2
☐ 有时
3
☐ 经常
4
☐ 总是
1
30. 搬动您的家属包括帮助他或她在床上
翻身，或者上下床和上下轮椅等等。
安宁疗护小组是否提供过您所需的训
练来安全搬动您的家属呢？
1
31. 关于家属濒临死亡时会发生的事，安
宁疗护小组是否尽可能地向您提供了
你所想要的相关信息？
34. 在您的家属接受安宁疗护期间，疗养
院工作人员给您的信息与安宁疗护小
组给您的信息不一样的情况多经常发
生？
☐ 从未
2
☐ 有时
3
☐ 经常
4
☐ 总是
1
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
您自己的与安宁疗护有关的经
历
35. 在您的家属接受安宁疗护期间，安宁
疗护小组多经常认真听您说话？
☐ 从未
2
☐ 有时
3
☐ 经常
4
☐ 总是
安宁疗护整体评分
39. 根据您的家属从问卷首页所示的安宁
疗护得到的服务，回答以下问题.在回
答时请不要将其他安宁疗护的服务考
虑在内.
1
请用 0 到 10 的数字表示，0 代表最差
的安宁疗护服务，10 则代表最好的安
宁疗护. 您会用哪个数字评价您家属
的安宁疗护？
☐
1
☐
2
☐
3
☐
4
☐
5
☐
6
☐
7
☐
8
☐
9
☐
10
☐
0
36. 对宗教或灵性上的支持包括谈话、 祷
告、灵修或其他以满足您宗教需要或
灵性需求的方式.在您的家属接受安宁
疗护期间，您从安宁疗护小组得到了
多少对宗教和灵性上的支持？
☐ 太少
2
☐ 适中
3
☐ 太多
1
37. 在您的家属接受安宁疗护期间，您从
安宁疗护小组得到了多少的情感支
持？
☐ 太少
2
☐ 适中
3
☐ 太多
1
0 最差的安宁疗护
1
2
3
4
5
6
7
8
9
10 最好的安宁疗护
40. 您会向您的朋友和家人推荐该安宁疗
护机构吗？
☐ 当然不会
2
☐ 可能不会
3
☐ 可能会
4
☐ 当然会
1
38. 在您的家属去世后的几周，您从安宁
疗护小组得到了多少情感支持？
☐ 太少
2
☐ 适中
3
☐ 太多
1
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
7
关于您的家属
关于您自己
41. 您的家属已完成的最高学校年级或最
高学历是？
☐ 初中 (8年级) 或以下
2
☐ 上过高中，但是没有毕业
3
☐ 高中毕业或高中同等学历
4
☐ 上过大学或两年制大学学位
5
☐ 四年制大学毕业
6
☐ 四年以上大学学位
7
☐ 不知道
1
42. 您的家属是否是西班牙裔、拉丁裔、
西班牙后裔或有西班牙血统？
44. 您的年龄是？
☐ 18 至 24
2
☐ 25 至 34
3
☐ 35 至 44
4
☐ 45 至 54
5
☐ 55 至 64
6
☐ 65 至 74
7
☐ 75 至 84
8
☐ 85 及以上
1
45. 您的性别是？
☐男
2
☐女
1
1
☐ 否，不是西班牙人/西班牙裔/拉
丁裔
☐ 是，是波多黎各人
3
☐ 是 , 是墨西哥人 、 墨西哥裔美
2
国 人或齐卡诺人
☐ 是，是古巴人
5
☐ 是，是其他西班牙人/西班牙裔/
4
拉丁裔人
43. 您的家属的种族是？请选择一项或多
项.
☐ 白人
2
☐ 黑人或非裔美国人
3
☐ 亚洲人
4
☐ 夏威夷岛原住民或其他太平洋
1
岛民
5
8
☐ 印第安人或阿拉斯加原住民
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
46. 您已完成的最高学校年级或最高学历
是？
47. 您在家里主要讲哪种语言？
☐ 英语
2
☐ 西班牙语
3
☐ 中文
4
☐ 俄语
5
☐ 葡萄牙语
6
☐ 越南語
7
☐ 波兰文
8
☐ 韩文
9
☐ 其他语言（请用正楷填写）：
1
☐ 初中 (8年级) 或以下
2
☐ 上过高中，但是没有毕业
3
☐ 高中毕业或高中同等学历
4
☐ 上过大学或两年制大学学位
5
☐ 四年制大学毕业
6
☐ 四年以上大学学位
1
谢谢.
请完成填写此问卷后将其放入已付邮费的信封中寄回.
[NAME OF SURVEY VENDOR]
[RETURN ADDRESS OF SURVEY VENDOR]
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
9
10
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
CAHPS® 安宁疗护问卷调查
请根据患者从以下安宁疗护机构所得到的服务回答下列调查问题:
[NAME OF HOSPICE]
在此问卷中所有的问题都与这个安宁疗护机构的经验有关.
如果您想知道更多有关此问卷的信息, 请打免费电话 [TOLL FREE NUMBER]. 所有打到这
个号码的电话都是免费的.
OMB# 0938-1257
2020 年 12 月 31 日到期
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
11
患者名字已列在问卷调查的首页，请将此问卷交给您家中最了解患者所接受到安宁疗护
的人
问卷填写指南
♦
此问卷需用深色的笔填写.
♦
请直接在选项前面的圆圈内画“X”作为回答， 如下所示：
是
0
♦
否
调查中有些地方会提示您跳过一些问题.在这种情况下，您会看到一个箭头，旁边的提
示信息会告诉您接下来要回答哪个问题，如下所示：
是
0
如果选择“是”，请跳至问题 1
否
安宁疗护患者
1. 您与调查问卷附件中所列的患者是什
么关系？
0 我的配偶或伴侣
2
0 我的父母
3
0 我的岳母（婆婆）或岳父（公公）
4
0 我的（外）祖父/母
5
0 我的姑姑（姨妈）或叔叔（舅舅）
6
0 我的姐妹或兄弟
7
0 我的孩子
8
0 我的朋友
9
0 其他（请用正楷填写）：
1
12
2. 在此次问卷调查中,词语“家属”是指
在问卷调查的首页中所列之患者.您的
家属在什么地方接受了该机构的安宁
疗护服务？ 请选择一项或多项.
0家
2
0 辅助生活机构
3
0 疗养院
4
0 医院
5
0 安宁疗护机构/赡养院
6
0 其他（请用正楷填写）：
1
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
您的角色
3. 在您的家属接受安宁疗护期间，您有
多少机会参与或监督安宁疗护？
6. 在您的家属接受安宁疗护期间，安宁
疗护小组多常会通知您他们将何时到
场来照料您的家属？
0 从未
2
0 有时
3
0 经常
4
0 总是
1
1
0 从未
如果选择“从未”，请跳
至问题 41
0 有时
3
0 经常
4
0 总是
2
您的家属的安宁疗护
在回答问卷中所有问题的时候，请只考
虑您的家属在本调查问卷附件中所列的
安宁疗护机构的经验.
4. 在此问卷中，安宁疗护小组包括所有
护士、医生、社工、灵性辅导师以及
其他曾经向您的家属提供安宁疗护的
人. 在您的家属接受安宁疗护期间您
是否曾需要在夜间、周末或假日里联
络安宁疗护小组，对家属的护理提出
问题或者寻求帮助呢？
0是
2
0否
1
如果选择“否”，请跳至问
题6
5. 在夜间、周末或假日里，您多常能从
安宁疗护小组那里得到所需的帮助？
0 从未
2
0 有时
3
0 经常
4
0 总是
1
7. 在您的家属接受安宁疗护期间，当您
或者您的家属向安宁疗护小组求助的
时候，多常能立即得到所需的帮助？
0 从未
2
0 有时
3
0 经常
4
0 总是
1
8. 在您的家属接受安宁疗护期间，安宁
疗护小组有多经常能用清晰易懂的方
式向您解释事情？
0 从未
2
0 有时
3
0 经常
4
0 总是
1
9. 在您的家属接受安宁疗护期间，安宁
疗护小组多经常会通知您让您了解您
家属的情况？
0 从未
2
0 有时
3
0 经常
4
0 总是
1
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
13
10. 在您的家属接受安宁疗护期间，对于
您家属的状况或护理情况，安宁疗护
小组的成员有多常提供您令人困惑或
相互矛盾的信息？
14. 在您与安宁疗护小组讨论家属的安宁
疗护中出现的问题时，他们多经常会
认真倾听？
0 从未
2
0 有时
3
0 经常
4
0 总是
1
0 从未
2
0 有时
3
0 经常
4
0 总是
1
11. 在您的家属接受安宁疗护期间，安宁
疗护小组有多常以有尊严和尊重的态
度对待您的家属？
0 从未
2
0 有时
3
0 经常
4
0 总是
1
如果选择“否”，请跳至问
题 17
0 是的，当然是
2
0 是的，某种程度上是
3
0否
1
0 从未
2
0 有时
3
0 经常
4
0 总是
17. 在您的家属接受安宁疗护期间，他或
她是否服用了任何止痛的药物？
1
0是
2
0否
1
13. 在您的家属接受安宁疗护期间，您是
否有跟安宁疗护小组讨论过任何在安
宁疗护中遇到的问题？
1
14
0是
2
0否
1
16. 您的家属是否得到过所须的帮助以缓
解他或她的疼痛？
12. 在您的家属接受安宁疗护期间，安宁
疗护小组有多常让您感到他们真的关
心您的家属？
0是
2
0否
15. 在您的家属接受安宁疗护期间，他或
她是否有任何疼痛？
如果选择“否”，请跳至问
题 15
如果选择“否”，请跳至问
题 21
18. 止痛药物有副作用，其中包括嗜
睡，安宁疗护小组是否曾与您或者
您的家属讨论过止痛药物的副作
用？
0 是的，当然是
2
0 是的，某种程度上是
3
0否
1
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
19. 关于使用止痛药物时需要注意哪些副
作用，安宁疗护小组是否提供您所需
的训练？
0 是的，当然是
2
0 是的，某种程度上是
3
0否
1
20. 关于是否与何时要给您的家属服用更
多剂量的止痛药物，安宁疗护小组是
否提供过您所需的训练？
0 是的，当然是
2
0 是的，某种程度上是
3
0否
4
0 我不需要给我的家属服用任何止
1
痛药物
21. 在您的家属接受安宁疗护期间 , 您的
家属是否曾有过呼吸困难或者接受过
呼吸困难的治疗？
0是
2
0否
1
如果选择“否”，请跳至问
题 24
22. 您的家属多经常能在呼吸困难的时候
得到了他或她所需的帮助？
0 从未
2
0 有时
3
0 经常
4
0 总是
1
23. 关于在家属呼吸困难时如何给予帮
助，安宁疗护小组是否提供过您所需
的训练?？
0 是的，当然是
2
0 是的，某种程度上是
3
0否
4
0 我不需要帮助我的家属解决呼吸
1
困难问题
24. 在您的家属接受安宁疗护期间，您的
家属是否曾有便秘问题？
0是
2
0否
1
如果选择“否”，请跳至问
题 26
25. 您的家属多经常能在遭遇便秘问题的
时候得到他或她所需的帮助？
0 从未
2
0 有时
3
0 经常
4
0 总是
1
26. 在您的家属接受安宁疗护期间， 他
或她是否曾表现出焦虑或悲伤的迹
象？
0是
2
0否
1
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
如果选择“否”，请跳至问
28
15
27. 在您的家属感到焦虑或悲伤时，他或
她有多常能从安宁疗护小组处得到所
需的帮助？
0 从未
2
0 有时
3
0 经常
4
0 总是
0 是的，当然是
2
0 是的，某种程度上是
3
0否
1
1
在疗养院中得到的安宁疗护
28. 在您的家属接受安宁疗护期间，他
或 她是否曾变得不安或激动？
0是
2
0否
1
如果选择“否”，请跳至问
题 30
29. 关于在家属变得不安或激动时应该如
何处理，安宁疗护小组是否提供过您
所需的训练？
0 是的，当然是
2
0 是的，某种程度上是
3
0否
1
0 是的，当然是
2
0 是的，某种程度上是
3
0否
4
0 我不需要移动我的家属
16
32. 有些人是在疗养院中接受安宁疗护服
务的.您的家属是否在他或她于疗养院
居住期间从该安宁疗护医院接受安宁
疗护服务？
0是
2
0否
1
如果选择“否”，请跳至问
题 35
33. 在您的家属接受安宁疗护期间，疗养
院工作人员和安宁疗护小组多经常能
协调一致来照顾您的家属？
0 从未
2
0 有时
3
0 经常
4
0 总是
1
30. 搬动您的家属包括帮助他或她在床上
翻身，或者上下床和上下轮椅等等。
安宁疗护小组是否提供过您所需的训
练来安全搬动您的家属呢？
1
31. 关于家属濒临死亡时会发生的事，安
宁疗护小组是否尽可能地向您提供了
你所想要的相关信息？
34. 在您的家属接受安宁疗护期间，疗养
院工作人员给您的信息与安宁疗护小
组给您的信息不一样的情况多经常发
生？
0 从未
2
0 有时
3
0 经常
4
0 总是
1
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
您自己的与安宁疗护有关的经
历
35. 在您的家属接受安宁疗护期间，安宁
疗护小组多经常认真听您说话？
0 从未
2
0 有时
3
0 经常
4
0 总是
安宁疗护整体评分
39. 根据您的家属从问卷首页所示的安宁
疗护得到的服务，回答以下问题.在回
答时请不要将其他安宁疗护的服务考
虑在内.
1
请用 0 到 10 的数字表示，0 代表最差
的安宁疗护服务，10 则代表最好的安
宁疗护. 您会用哪个数字评价您家属
的安宁疗护？
0 0 最差的安宁疗护
1
01
2
02
3
03
4
04
5
05
6
06
7
07
8
08
9
09
10
0 10 最好的安宁疗护
0
36. 对宗教或灵性上的支持包括谈话、 祷
告、灵修或其他以满足您宗教需要或
灵性需求的方式.在您的家属接受安宁
疗护期间，您从安宁疗护小组得到了
多少对宗教和灵性上的支持？
0 太少
2
0 适中
3
0 太多
1
37. 在您的家属接受安宁疗护期间，您从
安宁疗护小组得到了多少的情感支
持？
0 太少
2
0 适中
3
0 太多
1
40. 您会向您的朋友和家人推荐该安宁疗
护机构吗？
0 当然不会
2
0 可能不会
3
0 可能会
4
0 当然会
1
38. 在您的家属去世后的几周，您从安宁
疗护小组得到了多少情感支持？
0 太少
2
0 适中
3
0 太多
1
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
17
关于您的家属
关于您自己
41. 您的家属已完成的最高学校年级或最
高学历是？
0 初中 (8年级) 或以下
2
0 上过高中，但是没有毕业
3
0 高中毕业或高中同等学历
4
0 上过大学或两年制大学学位
5
0 四年制大学毕业
6
0 四年以上大学学位
7
0 不知道
1
42. 您的家属是否是西班牙裔、拉丁裔、
西班牙后裔或有西班牙血统？
44. 您的年龄是？
0 18 至 24
2
0 25 至 34
3
0 35 至 44
4
0 45 至 54
5
0 55 至 64
6
0 65 至 74
7
0 75 至 84
8
0 85 及以上
1
45. 您的性别是？
0男
2
0女
1
1
0 否，不是西班牙人/西班牙裔/拉丁
裔
0 是，是波多黎各人
3
0 是 , 是墨西哥人 、 墨西哥裔美国
2
人或齐卡诺人
0 是，是古巴人
5
0 是，是其他西班牙人/西班牙裔/拉
4
丁裔人
43. 您的家属的种族是？请选择一项或多
项.
0 白人
2
0 黑人或非裔美国人
3
0 亚洲人
4
0 夏威夷岛原住民或其他太平洋岛
1
民
5
18
0 印第安人或阿拉斯加原住民
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
46. 您已完成的最高学校年级或最高学历
是？
47. 您在家里主要讲哪种语言？
0 英语
2
0 西班牙语
3
0 中文
4
0 俄语
5
0 葡萄牙语
6
0 越南語
7
0 波兰文
8
0 韩文
9
0 其他语言（请用正楷填写）：
1
0 初中 (8年级) 或以下
2
0 上过高中，但是没有毕业
3
0 高中毕业或高中同等学历
4
0 上过大学或两年制大学学位
5
0 四年制大学毕业
6
0 四年以上大学学位
1
谢谢.
请完成填写此问卷后将其放入已付邮费的信封中寄回.
[NAME OF SURVEY VENDOR]
[RETURN ADDRESS OF SURVEY VENDOR]
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
19
20
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
CAHPS® 安宁疗护问卷调查
请根据患者从以下安宁疗护机构所得到的服务回答下列调查问题:
[NAME OF HOSPICE]
在此问卷中所有的问题都与这个安宁疗护机构的经验有关.
如果您想知道更多有关此问卷的信息, 请打免费电话 [TOLL FREE NUMBER]. 所有打到这
个号码的电话都是免费的.
OMB# 0938-1257
2020 年 12 月 31 日到期
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
21
患者名字已列在问卷调查的首页，请将此问卷交给您家中最了解患者所接受到安宁疗护
的人
问卷填写指南
♦
此问卷需用深色的笔填写.
♦
请直接在选项前面的圆圈内画“X”作为回答， 如下所示：
是
否
♦
调查中有些地方会提示您跳过一些问题.在这种情况下，您会看到一个箭头，旁边的提
示信息会告诉您接下来要回答哪个问题，如下所示：
是
如果选择“是”，请跳至问题 1
否
安宁疗护患者
1. 您与调查问卷附件中所列的患者是什
么关系？
O 我的配偶或伴侣
2
O 我的父母
3
O 我的岳母（婆婆）或岳父（公
1
公）
O 我的（外）祖父/母
5
O 我的姑姑（姨妈）或叔叔（舅
4
舅）
2. 在此次问卷调查中,词语“家属”是指
在问卷调查的首页中所列之患者.您的
家属在什么地方接受了该机构的安宁
疗护服务？ 请选择一项或多项.
O家
2
O 辅助生活机构
3
O 疗养院
4
O 医院
5
O 安宁疗护机构/赡养院
6
O 其他（请用正楷填写）：
1
O 我的姐妹或兄弟
7
O 我的孩子
8
O 我的朋友
9
O 其他（请用正楷填写）：
6
22
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
您的角色
3. 在您的家属接受安宁疗护期间，您有
多少机会参与或监督安宁疗护？
6. 在您的家属接受安宁疗护期间，安宁
疗护小组多常会通知您他们将何时到
场来照料您的家属？
O 从未
2
O 有时
3
O 经常
4
O 总是
1
1
O 从未
如果选择“从未”，请
跳至问题 41
O 有时
3
O 经常
4
O 总是
2
您的家属的安宁疗护
7. 在您的家属接受安宁疗护期间，当您
或者您的家属向安宁疗护小组求助的
时候，多常能立即得到所需的帮助？
O 从未
2
O 有时
3
O 经常
4
O 总是
1
在回答问卷中所有问题的时候，请只考
虑您的家属在本调查问卷附件中所列的
安宁疗护机构的经验.
4. 在此问卷中，安宁疗护小组包括所有
护士、医生、社工、灵性辅导师以及
其他曾经向您的家属提供安宁疗护的
人. 在您的家属接受安宁疗护期间您
是否曾需要在夜间、周末或假日里联
络安宁疗护小组，对家属的护理提出
问题或者寻求帮助呢？
O是
2
O否
1
如果选择“否”，请跳至
问题 6
5. 在夜间、周末或假日里，您多常能从
安宁疗护小组那里得到所需的帮助？
O 从未
2
O 有时
3
O 经常
4
O 总是
8. 在您的家属接受安宁疗护期间，安宁
疗护小组有多经常能用清晰易懂的方
式向您解释事情？
O 从未
2
O 有时
3
O 经常
4
O 总是
1
9. 在您的家属接受安宁疗护期间，安宁
疗护小组多经常会通知您让您了解您
家属的情况？
1
O 从未
2
O 有时
3
O 经常
4
O 总是
1
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
23
10. 在您的家属接受安宁疗护期间，对于
您家属的状况或护理情况，安宁疗护
小组的成员有多常提供您令人困惑或
相互矛盾的信息？
O 从未
2
O 有时
3
O 经常
4
O 总是
1
11. 在您的家属接受安宁疗护期间，安宁
疗护小组有多常以有尊严和尊重的态
度对待您的家属？
O 从未
2
O 有时
3
O 经常
4
O 总是
1
14. 在您与安宁疗护小组讨论家属的安宁
疗护中出现的问题时，他们多经常会
认真倾听？
O 从未
2
O 有时
3
O 经常
4
O 总是
1
15. 在您的家属接受安宁疗护期间，他或
她是否有任何疼痛？
O是
2
O否
1
如果选择“否”，请跳至
问题 17
16. 您的家属是否得到过所须的帮助以缓
解他或她的疼痛？
O 是的，当然是
2
O 是的，某种程度上是
3
O否
1
12. 在您的家属接受安宁疗护期间，安宁
疗护小组有多常让您感到他们真的关
心您的家属？
O 从未
2
O 有时
3
O 经常
4
O 总是
17. 在您的家属接受安宁疗护期间，他或
她是否服用了任何止痛的药物？
1
O是
2
O否
1
13. 在您的家属接受安宁疗护期间，您是
否有跟安宁疗护小组讨论过任何在安
宁疗护中遇到的问题？
O是
2
O否
1
24
如果选择“否”，请跳至问
题 15
如果选择“否”，请跳至
问题 21
18. 止痛药物有副作用，其中包括嗜
睡，安宁疗护小组是否曾与您或者
您的家属讨论过止痛药物的副作
用？
O 是的，当然是
2
O 是的，某种程度上是
3
O否
1
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
19. 关于使用止痛药物时需要注意哪些副
作用，安宁疗护小组是否提供您所需
的训练？
O 是的，当然是
2
O 是的，某种程度上是
3
O否
1
20. 关于是否与何时要给您的家属服用更
多剂量的止痛药物，安宁疗护小组是
否提供过您所需的训练？
O 是的，当然是
2
O 是的，某种程度上是
3
O否
4
O 我不需要给我的家属服用任何止
1
痛药物
21. 在您的家属接受安宁疗护期间 , 您的
家属是否曾有过呼吸困难或者接受过
呼吸困难的治疗？
O是
2
O否
1
如果选择“否”，请跳至
问题 24
22. 您的家属多经常能在呼吸困难的时候
得到了他或她所需的帮助？
O 从未
2
O 有时
3
O 经常
4
O 总是
1
23. 关于在家属呼吸困难时如何给予帮
助，安宁疗护小组是否提供过您所需
的训练?？
O 是的，当然是
2
O 是的，某种程度上是
3
O否
4
O 我不需要帮助我的家属解决呼吸
1
困难问题
24. 在您的家属接受安宁疗护期间，您的
家属是否曾有便秘问题？
O是
2
O否
1
如果选择“否”，请跳至
问题 26
25. 您的家属多经常能在遭遇便秘问题的
时候得到他或她所需的帮助？
O 从未
2
O 有时
3
O 经常
4
O 总是
1
26. 在您的家属接受安宁疗护期间， 他
或她是否曾表现出焦虑或悲伤的迹
象？
O是
2
O否
1
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
如果选择“否”，请跳至
问 28
25
27. 在您的家属感到焦虑或悲伤时，他或
她有多常能从安宁疗护小组处得到所
需的帮助？
O 从未
2
O 有时
3
O 经常
4
O 总是
O 是的，当然是
2
O 是的，某种程度上是
3
O否
1
1
在疗养院中得到的安宁疗护
28. 在您的家属接受安宁疗护期间，他
或 她是否曾变得不安或激动？
O是
2
O否
1
如果选择“否”，请跳至
问题 30
29. 关于在家属变得不安或激动时应该如
何处理，安宁疗护小组是否提供过您
所需的训练？
O 是的，当然是
2
O 是的，某种程度上是
3
O否
1
O 是的，当然是
2
O 是的，某种程度上是
3
O否
4
O 我不需要移动我的家属
26
32. 有些人是在疗养院中接受安宁疗护服
务的.您的家属是否在他或她于疗养院
居住期间从该安宁疗护医院接受安宁
疗护服务？
O是
2
O否
1
如果选择“否”，请跳至
问题 35
33. 在您的家属接受安宁疗护期间，疗养
院工作人员和安宁疗护小组多经常能
协调一致来照顾您的家属？
O 从未
2
O 有时
3
O 经常
4
O 总是
1
30. 搬动您的家属包括帮助他或她在床上
翻身，或者上下床和上下轮椅等等。
安宁疗护小组是否提供过您所需的训
练来安全搬动您的家属呢？
1
31. 关于家属濒临死亡时会发生的事，安
宁疗护小组是否尽可能地向您提供了
你所想要的相关信息？
34. 在您的家属接受安宁疗护期间，疗养
院工作人员给您的信息与安宁疗护小
组给您的信息不一样的情况多经常发
生？
O 从未
2
O 有时
3
O 经常
4
O 总是
1
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
您自己的与安宁疗护有关的经
历
35. 在您的家属接受安宁疗护期间，安宁
疗护小组多经常认真听您说话？
O 从未
2
O 有时
3
O 经常
4
O 总是
安宁疗护整体评分
39. 根据您的家属从问卷首页所示的安宁
疗护得到的服务，回答以下问题.在回
答时请不要将其他安宁疗护的服务考
虑在内.
1
36. 对宗教或灵性上的支持包括谈话、 祷
告、灵修或其他以满足您宗教需要或
灵性需求的方式.在您的家属接受安宁
疗护期间，您从安宁疗护小组得到了
多少对宗教和灵性上的支持？
O 太少
2
O 适中
3
O 太多
1
37. 在您的家属接受安宁疗护期间，您从
安宁疗护小组得到了多少的情感支
持？
O 太少
2
O 适中
3
O 太多
请用 0 到 10 的数字表示，0 代表最差
的安宁疗护服务，10 则代表最好的安
宁疗护. 您会用哪个数字评价您家属
的安宁疗护？
O
1
O
2
O
3
O
4
O
5
O
6
O
7
O
8
O
9
O
10
O
0
0 最差的安宁疗护
1
2
3
4
5
6
7
8
9
10 最好的安宁疗护
1
40. 您会向您的朋友和家人推荐该安宁疗
护机构吗？
O 当然不会
2
O 可能不会
3
O 可能会
4
O 当然会
1
38. 在您的家属去世后的几周，您从安宁
疗护小组得到了多少情感支持？
O 太少
2
O 适中
3
O 太多
1
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
27
关于您的家属
关于您自己
41. 您的家属已完成的最高学校年级或最
高学历是？
O
2
O
3
O
4
O
5
O
6
O
7
O
1
初中 (8年级) 或以下
上过高中，但是没有毕业
高中毕业或高中同等学历
上过大学或两年制大学学位
四年制大学毕业
四年以上大学学位
不知道
42. 您的家属是否是西班牙裔、拉丁裔、
西班牙后裔或有西班牙血统？
1
O
否，不是西班牙人/西班牙裔/拉
丁裔
O
3
O
是，是波多黎各人
O
5
O
是，是古巴人
2
4
44. 您的年龄是？
O 18 至 24
2
O 25 至 34
3
O 35 至 44
4
O 45 至 54
5
O 55 至 64
6
O 65 至 74
7
O 75 至 84
8
O 85 及以上
1
45. 您的性别是？
O男
2
O女
1
是 , 是墨西哥人 、 墨西哥裔美
国 人或齐卡诺人
是，是其他西班牙人/西班牙裔/
拉丁裔人
43. 您的家属的种族是？请选择一项或多
项.
O
2
O
3
O
4
O
1
5
28
O
白人
黑人或非裔美国人
亚洲人
夏威夷岛原住民或其他太平洋
岛民
印第安人或阿拉斯加原住民
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
46. 您已完成的最高学校年级或最高学历
是？
O
2
O
3
O
4
O
5
O
6
O
1
47. 您在家里主要讲哪种语言？
O
2
O
3
O
4
O
5
O
6
O
7
O
8
O
9
O
1
初中 (8年级) 或以下
上过高中，但是没有毕业
高中毕业或高中同等学历
上过大学或两年制大学学位
四年制大学毕业
四年以上大学学位
英语
西班牙语
中文
俄语
葡萄牙语
越南語
波兰文
韩文
其他语言（请用正楷填写）：
谢谢.
请完成填写此问卷后将其放入已付邮费的信封中寄回.
[NAME OF SURVEY VENDOR]
[RETURN ADDRESS OF SURVEY VENDOR]
Centers for Medicare & Medicaid Services
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Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
Sample Initial Cover Letter for the CAHPS Hospice Survey
[HOSPICE OR VENDOR LETTERHEAD]
[SAMPLED CAREGIVER NAME]
[ADDRESS]
[CITY, STATE ZIP]
亲爱的[SAMPLED CAREGIVER NAME]：
[HOSPICE NAME]正在对患者及其家属接受的安宁疗护服务进行调查.您被抽中参加此次
调查，是因为您曾是[DECEDENT NAME]的护理员.我们知道您现在心里可能很难受，但
是我们希望您能帮助我们了解安宁疗护机构为您和您的家人或者朋友提供的护理质量情况.
所附的调查问题[NOTE THE QUESTION NUMBERS]是美国卫生及公共服务部（HHS）为
了衡量安宁疗护机构的护理质量所倡议的一项全国调查的一部分. 这项调查由HHS的下属
机构联邦医疗保险及各州医疗补助服务中心（CMS）开展，目的是为了改善安宁疗护护
理质量. 美国大部分安宁疗护护理都由CMS支付费用，CMS有责任确保安宁疗护患者及其
家属和朋友能得到优质护理服务. 要履行这个责任，其中一个方法就是直接向您了解您的
家属或朋友得到的安宁疗护护理情况.你的参与纯属自愿，您的健康护理或福利不受任何
影响.
我们希望您能花些时间填写这项调查.填写完后，请用邮资预付的信封将它寄回给我们.您
的答案可能会与安宁疗护机构分享，以便改进质量.[OPTIONAL：您可能会注意到调查问
卷上有个编号.这个编号是用来告诉我们您是否寄回了调查问卷，这样我们就无需向您发
送提醒.]
如果您对所附的调查有任何疑问，请拨打我们的免费电话1-800-xxx-xxxx.感谢您为改善所
有消费者的安宁疗护护理所提供的帮助.
敬启
[HOSPICE ADMINISTRATOR]
[HOSPICE NAME]
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
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Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
Sample Follow-up Cover Letter for the CAHPS Hospice
Survey
[HOSPICE OR VENDOR LETTERHEAD]
[SAMPLED CAREGIVER NAME]
[ADDRESS]
[CITY, STATE ZIP]
亲爱的[SAMPLED CAREGIVER NAME]：
我们的记录显示您最近在[HOSPICE NAME]为[DECEDENT NAME]提供了护理. 大约三周
前，我们给您发送了一份有关您和您的家人或朋友在这件安宁疗护机构所接受的护理的调
查.如果您已经将调查寄回给我们，请接受我们的谢意，并忽略此信.但是如果您还没有寄
出，如果您能花些时间完成这份重要的调查问卷，我们将不胜感激.
我们希望您能借此机会帮助我们了解您的家人或朋友所受到的护理质量情况.这份调查的
结果将用来帮助确保所有美国人都能受到最高质量的安宁疗护护理服务.
所附的调查问题[NOTE THE QUESTION NUMBERS]是美国卫生及公共服务部（HHS）为
了衡量安宁疗护机构的护理质量所倡议的一项全国调查的一部分. 这项调查由HHS的下属
机构联邦医疗保险及各州医疗补助服务中心（CMS）开展，目的是为了改善安宁疗护护
理质量. 美国大部分安宁疗护护理都由CMS支付费用，CMS有责任确保安宁疗护患者及其
家属和朋友能得到优质护理服务. 要履行这个责任，其中一个方法就是直接向您了解您的
家属或朋友得到的安宁疗护护理情况. 你的参与纯属自愿，您的健康护理或福利不受任何
影响.
请花几分钟的时间填写所附的调查.填写完后，请用邮资预付的信封将它寄回给我们.您的
答案可能会与安宁疗护机构分享，以便改进质量.[OPTIONAL：您可能会注意到调查问卷
上有个编号.这个编号是用来告诉我们您是否寄回了调查问卷，这样我们就无需向您发送
提醒.]
如果您对所附的调查有任何疑问，请拨打我们的免费电话1-800-xxx-xxxx.感谢您为改善所
有消费者的安宁疗护护理所提供的帮助.
敬启
[HOSPICE ADMINISTRATOR]
[HOSPICE NAME]
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
33
34
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
OMB Paperwork Reduction Act Language
The OMB Paperwork Reduction Act language must appear in the mailing, either on the cover
letter or on the front or back of the questionnaire. In addition, the OMB control number must
appear on the front page of the questionnaire. The following is the language that must be used:
Simplified Chinese Version
“根据1995年削减公文法案(Paperwork Reduction Act), 除非资料收集文件附有正式的OMB
号码，任何人都无须对此类文件作出回应。这份数据收集文件的正式OMB号码是09381257 (2020年12月31日到期)。完成这份数据收集中1 - 40项问题“关于你的家人”及“关
于你”部分所需时间估计是平均11分钟，这包括阅读指示、查询现有数据来源、收集所需
数据及完成并检查填写的数据。如果您对估计时间的准确性有任何指教或有改进本表格的
建议，请写信到: Centers for Medicare & Medicaid Services, 7500 Security Boulevard, C1-2505, Baltimore, MD 21244-1850.”
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
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CAHPS Hospice Survey Quality Assurance Guidelines V6.0
Appendix R
Mail Survey Materials (Russian)
Анкетирование на тему хосписной помощи CAHPS®
Ответьте, пожалуйста, на вопросы относительно ухода за пациентом в этом хосписе:
[NAME OF HOSPICE]
Все вопросы данной анкеты связаны с работой данного хосписа.
Если Вы желаете получить более подробную информацию о данной анкете, позвоните,
пожалуйста, по тел. [TOLL FREE NUMBER]. Все звонки на данный номер являются
бесплатными.
OMB# 0938-1257
действителен до 31 декабря 2020 г
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
1
Дайте заполнить эту анкету члену семьи, наиболее осведомленному об уходе,
который получил в хосписе человек, указанный в сопроводительном письме.
ИНСТРУКЦИИ К АНКЕТЕ
♦
Для заполнения анкеты используйте чернила темного цвета.
♦
Поставьте Х непосредственно внутри квадратика возле ответа, как показано в примере
ниже.
Да
☐ Нет
♦
Иногда Вам будет предложено пропустить несколько вопросов анкеты. В таком случае
Вы увидите стрелку с указанием перехода к следующему вопросу, на который Вам
необходимо ответить, как здесь:
Да
Если ответ «Да», перейдите к Вопросу 1
☐ Нет
ПАЦИЕНТ ХОСПИСА
1. Какова Ваша степень родства с
пациентом, указанным в
сопроводительном письме к данной
анкете?
1
☐ Мой/моя супруг/а или
2. В данной анкете фраза «член
семьи» относится к человеку,
указанному в сопроводительном
письме. Где именно (в каких
местах) член Вашей семьи получал
помощь хосписа? Выберите один
или несколько вариантов ответа.
☐ Дома
2
☐ В доме престарелых
3
☐ В центре сестринского ухода
4
☐ В больнице
5
☐ В хосписе
6
☐ Другое (впишите печатными
1
партнер/ша
☐ Мой родитель
3
☐ Моя/мой теща/свекровь или
2
тесть/свекр
☐ Мой/моя дедушка/бабушка
5
☐ Моя/мой тетя или дядя
6
☐ Моя/мой сестра или брат
7
☐ Мой ребенок
8
☐ Мой друг
9
☐ Другое (впишите, пожалуйста,
4
буквами, пожалуйста):
_____________________________
печатными буквами):
____________________________
2
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
ВАША РОЛЬ
3. Пока член Вашей семьи получал
хосписную помощь, как часто Вы
принимали в ней участие либо
наблюдали?
1
☐ Ни разу
Если ответ «ни
разу», перейдите к
вопросу 41
☐ Иногда
3
☐ Как правило
4
☐ Постоянно
2
ХОСПИСНАЯ ПОМОЩЬ ЧЛЕНУ
ВАШЕЙ СЕМЬИ
Что касается ответов на все остальные
вопросы в данной анкете, просим Вас
учитывать исключительно опыт члена
Вашей семьи с хосписом, указанном в
сопроводительном письме.
4. Для данной анкеты хосписная
команда включает весь средний
медицинский персонал, докторов,
социальных работников,
священников и других людей,
обеспечивающих хосписный уход за
членом Вашей семьи. Когда член
Вашей семьи получал хосписный
уход, приходилось ли Вам
обращаться к хосписной команде с
вопросами или за помощью по
поводу ухода за ним по вечерам, в
выходные или праздничные дни?
☐ Да
2
☐ Нет
5. Как часто Вы получали
необходимую Вам помощь
хосписной команды по вечерам, в
выходные или праздничные дни?
☐ Ни разу
2
☐ Иногда
3
☐ Как правило
4
☐ Всегда
1
6. Когда член Вашей семьи получал
хосписный уход, как часто
хосписная команда информировала
Вас о времени своего прибытия для
оказания ему помощи?
☐ Ни разу
2
☐ Иногда
3
☐ Как правило
4
☐ Всегда
1
7. Когда член Вашей семьи получал
хосписный уход, и он или Вы
обращались к хосписной команде за
помощью, как часто вы получали
ее своевременно?
☐ Ни разу
2
☐ Иногда
3
☐ Как правило
4
☐ Всегда
1
1
Если ответ «Нет»,
перейдите к Вопросу 6
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
3
8. Когда член Вашей семьи получал
хосписный уход, как часто
хосписная команда предоставляла
объяснения в простой и доступной
форме?
☐ Ни разу
2
☐ Иногда
3
☐ Как правило
4
☐ Всегда
1
9.
Когда член Вашей семьи получал
хосписный уход, как часто
хосписная команда информировала
Вас о его состоянии?
☐ Ни разу
2
☐ Иногда
3
☐ Как правило
4
☐ Всегда
12. Когда член Вашей семьи получал
хосписный уход, как часто Вы
испытывали ощущение, что
хосписная команда действительно
заботится о нем?
1
10. Когда член Вашей семьи получал
хосписный уход, как часто кто-либо
из хосписной команды
предоставлял Вам нечеткую либо
противоречивую информацию о
состоянии здоровья или уходе за
членом Вашей семьи?
☐ Ни разу
2
☐ Иногда
3
☐ Как правило
4
☐ Всегда
☐ Ни разу
2
☐ Иногда
3
☐ Как правило
4
☐ Всегда
1
☐ Ни разу
2
☐ Иногда
3
☐ Как правило
4
☐ Всегда
1
1
11. Когда член Вашей семьи получал
хосписный уход, как часто
хосписная команда относилась к
нему с достоинством и уважением?
13. Когда член Вашей семьи получал
хосписный уход, обсуждали ли Вы с
хосписной командой проблемы,
которые возникали у Вас во время
ухода за ним?
☐ Да
2
☐ Нет
1
Если ответ «Нет»,
перейдите к Вопросу 15
14. Как часто хосписная команда
внимательно Вас выслушивала,
когда Вы рассказывали о
проблемах, возникающих во время
ухода за членом Вашей семьи?
☐ Ни разу
2
☐ Иногда
3
☐ Как правило
4
☐ Всегда
1
4
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
15. Когда член Вашей семьи получал
хосписный уход, испытывал ли он
боль?
☐ Да
2
☐ Нет
1
Если ответ «Нет»,
перейдите к Вопросу 17
16. Получал член Вашей семьи всю
возможную необходимую ему
помощь, когда испытывал боль?
☐ Да, несомненно
2
☐ Да, можно так сказать
3
☐ Нет
1
17. Когда член Вашей семьи получал
хосписный уход, получал ли он
какие-то обезболивающие
препараты?
☐ Да
2
☐ Нет
1
Если ответ «Нет»,
перейдите к Вопросу 21
18. Побочные эффекты
обезболивающих препаратов
включают, например,
сонливость. Обсуждал ли ктолибо из хосписной команды с
Вами или членом Вашей семьи
побочные эффекты
обезболивающих препаратов?
☐ Да, несомненно
2
☐ Да, можно так сказать
3
☐ Нет
1
19. Проводила ли с Вами хосписная
команда необходимое обучение на
тему побочных эффектов, за
которыми необходимо следить при
приеме обезболивающих
препаратов?
☐ Да, несомненно
2
☐ Да, можно так сказать
3
☐ Нет
1
20. Проводила ли с Вами хосписная
команда необходимое обучение
относительно того, в каких случаях
и когда необходимо увеличивать
дозу обезболивающего препарата
члену Вашей семьи?
☐ Да, несомненно
2
☐ Да, можно так сказать
3
☐ Нет
4
☐ У меня не было необходимости
1
давать обезболивающие
препараты члену моей семьи
21. Когда член Вашей семьи получал
хосписный уход, были ли у него
проблемы с дыханием или получал
ли он лечение в связи с
затруднением дыхания?
☐ Да
2
☐ Нет
1
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
Если ответ «Нет»,
перейдите к Вопросу 24
5
22. Как часто член Вашей семьи
получал всю необходимую помощь
вследствие затрудненного
дыхания?
☐ Ни разу
2
☐ Иногда
3
☐ Как правило
4
☐ Всегда
1
23. Проводила ли с Вами хосписная
команда обучение по
предоставлению помощи члену
Вашей семьи, когда он испытывает
проблемы с дыханием?
☐ Да, несомненно
2
☐ Да, можно так сказать
3
☐ Нет
4
☐ У меня не было необходимости
1
оказывать помощь члену моей
семьи по поводу проблем с
дыханием
24. Когда член Вашей семьи получал
хосписный уход, были ли у него
запоры?
☐ Да
2
☐ Нет
1
Если ответ «Нет»,
перейдите к Вопросу 26
25. Как часто член Вашей семьи
получал необходмую помощь
вследствие запоров?
☐ Ни разу
2
☐ Иногда
3
☐ Как правило
4
☐ Всегда
26. Когда член Вашей семьи получал
хосписный уход, испытывал ли он
чувства тревоги или грусти?
☐ Да
2
☐ Нет
1
Если ответ «Нет»,
перейдите к Вопросу 28
27. Как часто член Вашей семьи
получал необходимую помощь
хосписной команды по поводу
чувств тревоги или грусти?
☐ Ни разу
2
☐ Иногда
3
☐ Как правило
4
☐ Всегда
1
28. Когда член Вашей семьи получал
хосписный уход, испытывал ли он
ощущение беспокойства или
возбуждения?
☐ Да
2
☐ Нет
1
Если ответ «Нет»,
перейдите к Вопросу 30
29. Проводила ли с Вами хосписная
команда обучение на тему того, что
делать в случае, если член Вашей
семьи испытывает ощущение
беспокойства или возбуждения?
☐ Да, несомненно
2
☐ Да, можно так сказать
3
☐ Нет
1
1
6
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
30. Передвигать члена Вашей семьи
означает помочь ему перевернуться
в кровати, подняться/лечь в
кровать или пересесть в
инвалидную коляску. Проводила
ли с Вами хосписная команда
необходимое обучение на тему того,
каким образом Вы можете
безопасно передвигать члена Вашей
семьи?
☐ Да, несомненно
2
☐ Да, можно так сказать
3
☐ Нет
4
☐ У меня не было необходимости
1
передвигать члена моей семьи
31. Предоставляла ли Вам хосписная
команда всю необходимую
информацию относительно того,
чего ожидать, когда умирал член
Вашей семьи?
☐ Да, несомненно
2
☐ Да, можно так сказать
3
☐ Нет
1
ХОСПИСНЫЙ УХОД В ЦЕНТРЕ
СЕСТРИНСКОГО УХОДА
32. Некоторые люди получают
хосписный уход, проживая в центре
сестринского ухода. Получал ли
член Вашей семьи уход от данного
хосписа, проживая в центре
сестринского ухода?
☐ Да
2
☐ Нет
1
Если ответ «Нет»,
перейдите к Вопросу 35
33. Пока член Вашей семьи получал
хосписный уход, как часто
сотрудники центра сестринского
ухода эффективно сотрудничали с
хосписной командой, чтобы вместе
заботиться о члене Вашей семьи?
☐ Ни разу
2
☐ Иногда
3
☐ Как правило
4
☐ Всегда
1
34. Пока член Вашей семьи получал
хосписный уход, как часто
информация о члене Вашей семьи,
которую Вы получали от
сотрудников центра сестринского
ухода, отличалась от данных,
предоставленных хосписной
командой?
☐ Ни разу
2
☐ Иногда
3
☐ Как правило
4
☐ Всегда
1
ВАШ ОПЫТ С ХОСПИСОМ
35. Когда член Вашей семьи получал
хосписный уход, как часто
хосписная команда внимательно
выслушивала Вас?
☐ Ни разу
2
☐ Иногда
3
☐ Как правило
4
☐ Всегда
1
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
7
36. Поддержка религиозных или
духовных убеждений подразумевает
беседы, молитвы, уединение или
другие способы удовлетворения
религиозных или духовных
потребностей. Когда член Вашей
семьи получал хосписный уход,
насколько велика была поддержка
Ваших религиозных или духовных
убеждений со стороны хосписной
команды?
☐ Слишком мала
2
☐ Достаточная
3
☐ Чрезмерная
1
37. Когда член Вашей семьи получал
хосписный уход, насколько велика
была эмоциональная поддержка со
стороны хосписной команды?
☐ Слишком мала
2
☐ Достаточная
3
☐ Чрезмерная
38. В ближайшие недели после смерти
члена Вашей семьи, насколько
велика была эмоциональная
поддержка со стороны хосписной
команды?
☐ Слишком мала
2
☐ Достаточная
3
☐ Чрезмерная
8
УХОДА
39. Ответьте, пожалуйста, на
следующие вопросы относительно
ухода за членом Вашей семьи
хосписом, указанным в
сопроводительном письме к данной
анкете. Просим в своих ответах не
упоминать об уходе, полученном в
других хосписах.
Используя шкалу от 0 до 10, где 0
означает наихудшее качество, а 10
— наилучшее качество хосписного
ухода, которое только можно
представить, оцените хосписный
уход за членом Вашей семьи?
0
☐
0 Наихудшее качество
хосписного ухода, которое
только можно представить
☐1
2
☐2
3
☐3
4
☐4
5
☐5
6
☐6
7
☐7
8
☐8
9
☐9
10
☐ 10 Наилучшее качество
1
1
1
ОБЩАЯ ОЦЕНКА ХОСПИСНОГО
хосписного ухода, которое
только можно представить
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
40. Порекомендовали ли бы Вы
данный хоспис своим друзьям и
семье?
☐ Точно нет
2
☐ Скорее всего, нет
3
☐ Скорее всего, да
4
☐ Да, несомненно
1
ИНФОРМАЦИЯ О ЧЛЕНЕ
ВАШЕЙ СЕМЬИ
41. Какое образование получил член
Вашей семьи?
☐ 8 классов и меньше
2
☐ Учился в старших классах, но не
1
окончил школу
☐ Окончил среднюю школу
4
☐ Колледж или диплом о
3
42. Был ли член Вашей семьи
испанского либо латиноамериканского происхождения?
1
☐ Нет, он не испанского/латиноамериканского происхождения
☐ Да, он пуэрториканец
3
☐ Да, он мексиканец, мексикано2
американец, американец
мексиканского происхождения
☐ Да, он кубинец
5
☐ Да, другого испанского/латино4
американского происхождения
43. К какой расовой группе
принадлежал член Вашей семьи?
Выберите, пожалуйста, один или
несколько вариантов ответа.
☐ Белая раса
2
☐ Черная раса или афро1
американец
двухгодичном обучении
5
☐ Четырехгодичное законченное
высшее образование
6
☐ Обучение свыше четырех лет
высшего образования
7
☐ Не знаю
☐ Азиат
4
☐ Коренной гаваец или уроженец
3
других островов Тихого океана
5
☐ Американский индеец или
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
уроженец Аляски
9
ИНФОРМАЦИЯ О ВАС
46. Какое образование Вы получили?
☐ 8 классов и меньше
2
☐ Учился в старших классах, но не
44. Сколько Вам лет?
1
☐ От 18 до 24 лет
2
☐ От 25 до 34 лет
3
☐ От 35 до 44 лет
4
☐ От 45 до 54 лет
5
☐ От 55 до 64 лет
6
☐ От 65 до 74 лет
7
☐ От 75 до 84 лет
8
☐ 85 лет или старше
1
45. Ваш пол?
окончил школу
☐ Окончил среднюю школу
4
☐ Колледж или диплом о
3
двухгодичном обучении
5
☐ Четырехгодичное законченное
высшее образование
6
☐ Обучение свыше четырех лет
высшего образования
47. На каком языке Вы в основном
общаетесь дома?
☐ Мужской
2
☐ Женский
☐ Английский
2
☐ Испанский
3
☐ Китайский
4
☐ Русский
5
☐ Португальский
6
☐ Вьетнамский
7
☐ Польский
8
☐ корейском
9
☐ Другой язык (укажите
1
1
печатными буквами):
Спасибо
Отправьте, пожалуйста, заполненную анкету в конверте с предварительно
оплаченным почтовым сбором.
[NAME OF SURVEY VENDOR]
[RETURN ADDRESS OF SURVEY VENDOR]
10
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
Анкетирование на тему хосписной помощи CAHPS®
Ответьте, пожалуйста, на вопросы относительно ухода за пациентом в этом хосписе:
[NAME OF HOSPICE]
Все вопросы данной анкеты связаны с работой данного хосписа.
Если Вы желаете получить более подробную информацию о данной анкете, позвоните,
пожалуйста, по тел. [TOLL FREE NUMBER]. Все звонки на данный номер являются
бесплатными.
OMB# 0938-1257
действителен до 31 декабря 2020 г
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
11
Дайте заполнить эту анкету члену семьи, наиболее осведомленному об уходе,
который получил в хосписе человек, указанный в сопроводительном письме.
ИНСТРУКЦИИ К АНКЕТЕ
♦
Для заполнения анкеты используйте чернила темного цвета.
♦
Ответьте на все вопросы, закрашивая кружок, относящийся к нужному ответу.
Да
Нет
0
♦
Иногда Вам будет предложено пропустить несколько вопросов анкеты. В таком случае
Вы увидите стрелку с указанием перехода к следующему вопросу, на который Вам
необходимо ответить, как здесь:
Да
0
Если ответ «Да», перейдите к Вопросу 1
Нет
ПАЦИЕНТ ХОСПИСА
1. Какова Ваша степень родства с
пациентом, указанным в
сопроводительном письме к данной
анкете?
0 Мой/моя супруг/а или партнер/ша
2
0 Мой родитель
3
0 Моя/мой теща/свекровь или
1
тесть/свекр
0 Мой/моя дедушка/бабушка
5
0 Моя/мой тетя или дядя
6
0 Моя/мой сестра или брат
7
0 Мой ребенок
8
0 Мой друг
9
0 Другое (впишите, пожалуйста,
4
2. В данной анкете фраза «член семьи»
относится к человеку, указанному в
сопроводительном письме. Где
именно (в каких местах) член Вашей
семьи получал помощь хосписа?
Выберите один или несколько
вариантов ответа.
0 Дома
2
0 В доме престарелых
3
0 В центре сестринского ухода
4
0 В больнице
5
0 В хосписе
6
0 Другое (впишите печатными
1
буквами, пожалуйста):
______________________________
печатными буквами):
______________________________
12
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
ВАША РОЛЬ
5.
3. Пока член Вашей семьи получал
хосписную помощь, как часто Вы
принимали в ней участие либо
наблюдали?
1
0 Ни разу
Как часто Вы получали
необходимую Вам помощь хосписной
команды по вечерам, в выходные
или праздничные дни?
0 Ни разу
2
0 Иногда
3
0 Как правило
4
0 Всегда
1
Если ответ «ни разу»,
перейдите к вопросу
41
0 Иногда
3
0 Как правило
4
0 Постоянно
2
6.
ХОСПИСНАЯ ПОМОЩЬ
ЧЛЕНУ ВАШЕЙ СЕМЬИ
Что касается ответов на все
остальные вопросы в данной анкете,
просим Вас учитывать
исключительно опыт члена Вашей
семьи с хосписом, указанном в
сопроводительном письме.
4. Для данной анкеты хосписная
команда включает весь средний
медицинский персонал, докторов,
социальных работников,
священников и других людей,
обеспечивающих хосписный уход за
членом Вашей семьи. Когда член
Вашей семьи получал хосписный
уход, приходилось ли Вам
обращаться к хосписной команде с
вопросами или за помощью по
поводу ухода за ним по вечерам, в
выходные или праздничные дни?
0 Да
2
0 Нет
1
Когда член Вашей семьи получал
хосписный уход, как часто хосписная
команда информировала Вас о
времени своего прибытия для
оказания ему помощи?
0 Ни разу
2
0 Иногда
3
0 Как правило
4
0 Всегда
1
7.
Когда член Вашей семьи получал
хосписный уход, и он или Вы
обращались к хосписной команде за
помощью, как часто вы получали ее
своевременно?
0 Ни разу
2
0 Иногда
3
0 Как правило
4
0 Всегда
1
8.
Когда член Вашей семьи получал
хосписный уход, как часто хосписная
команда предоставляла объяснения
в простой и доступной форме?
Если ответ «Нет»,
перейдите к Вопросу 6
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
0 Ни разу
2
0 Иногда
3
0 Как правило
4
0 Всегда
1
13
Когда член Вашей семьи получал
хосписный уход, как часто хосписная
команда информировала Вас о его
состоянии?
9.
0 Ни разу
2
0 Иногда
3
0 Как правило
4
0 Всегда
1
10.
0 Да
2
0 Нет
1
Когда член Вашей семьи получал
хосписный уход, как часто кто-либо
из хосписной команды предоставлял
Вам нечеткую либо противоречивую
информацию о состоянии здоровья
или уходе за членом Вашей семьи?
0 Ни разу
2
0 Иногда
3
0 Как правило
4
0 Всегда
1
11.
13. Когда член Вашей семьи получал
хосписный уход, обсуждали ли Вы с
хосписной командой проблемы,
которые возникали у Вас во время
ухода за ним?
Когда член Вашей семьи получал
хосписный уход, как часто хосписная
команда относилась к нему с
достоинством и уважением?
0 Ни разу
2
0 Иногда
3
0 Как правило
4
0 Всегда
14. Как часто хосписная команда
внимательно Вас выслушивала,
когда Вы рассказывали о проблемах,
возникающих во время ухода за
членом Вашей семьи?
0 Ни разу
2
0 Иногда
3
0 Как правило
4
0 Всегда
1
15. Когда член Вашей семьи получал
хосписный уход, испытывал ли он
боль?
0 Да
2
0 Нет
1
1
12.
0 Ни разу
2
0 Иногда
3
0 Как правило
4
0 Всегда
14
Если ответ «Нет»,
перейдите к Вопросу 17
16. Получал член Вашей семьи всю
возможную необходимую ему
помощь, когда испытывал боль?
0 Да, несомненно
2
0 Да, можно так сказать
3
0 Нет
1
Когда член Вашей семьи получал
хосписный уход, как часто Вы
испытывали ощущение, что
хосписная команда действительно
заботится о нем?
1
Если ответ «Нет»,
перейдите к Вопросу 15
17. Когда член Вашей семьи получал
хосписный уход, получал ли он
какие-то обезболивающие
препараты?
0 Да
2
0 Нет
1
Если ответ «Нет»,
перейдите к Вопросу 21
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
18. Побочные эффекты
обезболивающих препаратов
включают, например, сонливость.
Обсуждал ли кто-либо из
хосписной команды с Вами или
членом Вашей семьи побочные
эффекты обезболивающих
препаратов?
0 Да, несомненно
2
0 Да, можно так сказать
3
0 Нет
21. Когда член Вашей семьи получал
хосписный уход, были ли у него
проблемы с дыханием или получал
ли он лечение в связи с
затруднением дыхания?
0 Да
2
0 Нет
1
1
22. Как часто член Вашей семьи
получал всю необходимую помощь
вследствие затрудненного дыхания?
19. Проводила ли с Вами хосписная
команда необходимое обучение на
тему побочных эффектов, за
которыми необходимо следить при
приеме обезболивающих
препаратов?
0 Да, несомненно
2
0 Да, можно так сказать
3
0 Нет
1
0 Ни разу
2
0 Иногда
3
0 Как правило
4
0 Всегда
1
23. Проводила ли с Вами хосписная
команда обучение по
предоставлению помощи члену
Вашей семьи, когда он испытывает
проблемы с дыханием?
20. Проводила ли с Вами хосписная
команда необходимое обучение
относительно того, в каких случаях и
когда необходимо увеличивать дозу
обезболивающего препарата члену
Вашей семьи?
0 Да, несомненно
2
0 Да, можно так сказать
3
0 Нет
4
0 У меня не было необходимости
0 Да, несомненно
2
0 Да, можно так сказать
3
0 Нет
4
0 У меня не было необходимости
1
оказывать помощь члену моей
семьи по поводу проблем с
дыханием
1
давать обезболивающие препараты
члену моей семьи
Если ответ «Нет»,
перейдите к Вопросу 24
24. Когда член Вашей семьи получал
хосписный уход, были ли у него
запоры?
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
0 Да
2
0 Нет
1
Если ответ «Нет»,
перейдите к Вопросу 26
15
29. Проводила ли с Вами хосписная
команда обучение на тему того, что
делать в случае, если член Вашей
семьи испытывает ощущение
беспокойства или возбуждения?
25. Как часто член Вашей семьи
получал необходмую помощь
вследствие запоров?
0 Ни разу
2
0 Иногда
3
0 Как правило
4
0 Всегда
1
0 Да, несомненно
2
0 Да, можно так сказать
3
0 Нет
1
26. Когда член Вашей семьи получал
хосписный уход, испытывал ли он
чувства тревоги или грусти?
0 Да
2
0 Нет
1
Если ответ «Нет»,
перейдите к Вопросу 28
27. Как часто член Вашей семьи
получал необходимую помощь
хосписной команды по поводу чувств
тревоги или грусти?
0 Ни разу
2
0 Иногда
3
0 Как правило
4
0 Всегда
1
1
16
0 Да, несомненно
2
0 Да, можно так сказать
3
0 Нет
4
0 У меня не было необходимости
1
передвигать члена моей семьи
28. Когда член Вашей семьи получал
хосписный уход, испытывал ли он
ощущение беспокойства или
возбуждения?
0 Да
2
0 Нет
30. Передвигать члена Вашей семьи
означает помочь ему перевернуться
в кровати, подняться/лечь в кровать
или пересесть в инвалидную
коляску. Проводила ли с Вами
хосписная команда необходимое
обучение на тему того, каким
образом Вы можете безопасно
передвигать члена Вашей семьи?
Если ответ «Нет»,
перейдите к Вопросу 30
31. Предоставляла ли Вам хосписная
команда всю необходимую
информацию относительно того, чего
ожидать, когда умирал член Вашей
семьи?
0 Да, несомненно
2
0 Да, можно так сказать
3
0 Нет
1
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
ХОСПИСНЫЙ УХОД В ЦЕНТРЕ
СЕСТРИНСКОГО УХОДА
32. Некоторые люди получают
хосписный уход, проживая в центре
сестринского ухода. Получал ли член
Вашей семьи уход от данного
хосписа, проживая в центре
сестринского ухода?
0 Да
2
0 Нет
ВАШ ОПЫТ С ХОСПИСОМ
35. Когда член Вашей семьи получал
хосписный уход, как часто хосписная
команда внимательно выслушивала
Вас?
0 Ни разу
2
0 Иногда
3
0 Как правило
4
0 Всегда
1
1
Если ответ «Нет»,
перейдите к Вопросу 35
33. Пока член Вашей семьи получал
хосписный уход, как часто
сотрудники центра сестринского
ухода эффективно сотрудничали с
хосписной командой, чтобы вместе
заботиться о члене Вашей семьи?
0 Ни разу
2
0 Иногда
3
0 Как правило
4
0 Всегда
1
34. Пока член Вашей семьи получал
хосписный уход, как часто
информация о члене Вашей семьи,
которую Вы получали от
сотрудников центра сестринского
ухода, отличалась от данных,
предоставленных хосписной
командой?
36. Поддержка религиозных или
духовных убеждений подразумевает
беседы, молитвы, уединение или
другие способы удовлетворения
религиозных или духовных
потребностей. Когда член Вашей
семьи получал хосписный уход,
насколько велика была поддержка
Ваших религиозных или духовных
убеждений со стороны хосписной
команды?
0 Слишком мала
2
0 Достаточная
3
0 Чрезмерная
1
37. Когда член Вашей семьи получал
хосписный уход, насколько велика
была эмоциональная поддержка со
стороны хосписной команды?
0 Ни разу
2
0 Иногда
3
0 Как правило
4
0 Всегда
1
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
0 Слишком мала
2
0 Достаточная
3
0 Чрезмерная
1
17
38. В ближайшие недели после смерти
члена Вашей семьи, насколько
велика была эмоциональная
поддержка со стороны хосписной
команды?
0 Слишком мала
2
0 Достаточная
3
0 Чрезмерная
1
ОБЩАЯ ОЦЕНКА ХОСПИСНОГО
УХОДА
39. Ответьте, пожалуйста, на следующие
вопросы относительно ухода за
членом Вашей семьи хосписом,
указанным в сопроводительном
письме к данной анкете. Просим в
своих ответах не упоминать об уходе,
полученном в других хосписах.
Используя шкалу от 0 до 10, где 0
означает наихудшее качество, а 10 —
наилучшее качество хосписного
ухода, которое только можно
представить, оцените хосписный
уход за членом Вашей семьи?
0
0
0
01
2
02
3
03
4
04
5
05
6
06
7
07
8
08
9
09
10
0 10
Наихудшее качество
хосписного ухода, которое
только можно представить
1
18
40. Порекомендовали ли бы Вы данный
хоспис своим друзьям и семье?
0 Точно нет
2
0 Скорее всего, нет
3
0 Скорее всего, да
4
0 Да, несомненно
1
ИНФОРМАЦИЯ О ЧЛЕНЕ ВАШЕЙ
СЕМЬИ
41. Какое образование получил член
Вашей семьи?
0 8 классов и меньше
2
0 Учился в старших классах, но не
1
окончил школу
0 Окончил среднюю школу
4
0 Колледж или диплом о
3
двухгодичном обучении
5
0 Четырехгодичное законченное
высшее образование
6
0 Обучение свыше четырех лет
высшего образования
7
0 Не знаю
42. Был ли член Вашей семьи
испанского либо латиноамериканского происхождения?
1
0 Нет, он не испанского/латино-
американского происхождения
0 Да, он пуэрториканец
3
0 Да, он мексиканец, мексикано2
американец, американец
мексиканского происхождения
0 Да, он кубинец
5
0 Да, другого испанского/латино4
Наилучшее качество
хосписного ухода, которое
только можно представить
американского происхождения
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
43. К какой расовой группе
принадлежал член Вашей семьи?
Выберите, пожалуйста, один или
несколько вариантов ответа.
46. Какое образование Вы получили?
0 8 классов и меньше
2
0 Учился в старших классах, но не
1
окончил школу
0 Белая раса
2
0 Черная раса или афро-американец
3
0 Азиат
4
0 Коренной гаваец или уроженец
1
0 Окончил среднюю школу
4
0 Колледж или диплом о
3
двухгодичном обучении
5
других островов Тихого океана
5
высшее образование
0 Американский индеец или
6
уроженец Аляски
0 Обучение свыше четырех лет
высшего образования
ИНФОРМАЦИЯ О ВАС
44. Сколько Вам лет?
0 Четырехгодичное законченное
47. На каком языке Вы в основном
общаетесь дома?
0 Английский
2
0 Испанский
3
0 Китайский
4
0 Русский
5
0 Португальский
6
0 Вьетнамский
7
0 Польский
8
0 корейском
9
0 Другой язык (укажите печатными
1
0 От 18 до 24 лет
2
0 От 25 до 34 лет
3
0 От 35 до 44 лет
4
0 От 45 до 54 лет
5
0 От 55 до 64 лет
6
0 От 65 до 74 лет
7
0 От 75 до 84 лет
8
0 85 лет или старше
1
буквами):
45. Ваш пол?
____________________________
0 Мужской
2
0 Женский
1
Спасибо
Отправьте, пожалуйста, заполненную анкету в конверте с предварительно
оплаченным почтовым сбором.
[NAME OF SURVEY VENDOR]
[RETURN ADDRESS OF SURVEY VENDOR]
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
19
20
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
Анкетирование на тему хосписной помощи CAHPS®
Ответьте, пожалуйста, на вопросы относительно ухода за пациентом в этом хосписе:
[NAME OF HOSPICE]
Все вопросы данной анкеты связаны с работой данного хосписа.
Если Вы желаете получить более подробную информацию о данной анкете, позвоните,
пожалуйста, по тел. [TOLL FREE NUMBER]. Все звонки на данный номер являются
бесплатными.
OMB# 0938-1257
действителен до 31 декабря 2020 г
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
21
Дайте заполнить эту анкету члену семьи, наиболее осведомленному об уходе, который
получил в хосписе человек, указанный в сопроводительном письме.
ИНСТРУКЦИИ К АНКЕТЕ
♦
Для заполнения анкеты используйте чернила темного цвета.
♦
Ответьте на все вопросы, закрашивая кружок, относящийся к нужному ответу.
♦
Да
O
Нет
Иногда Вам будет предложено пропустить несколько вопросов анкеты. В таком случае
Вы увидите стрелку с указанием перехода к следующему вопросу, на который Вам
необходимо ответить, как здесь:
Да
O
Нет
Если ответ «Да», перейдите к Вопросу 1
ПАЦИЕНТ ХОСПИСА
1. Какова Ваша степень родства с
пациентом, указанным в
сопроводительном письме к данной
анкете?
O Мой/моя супруг/а или партнер/ша
2
O Мой родитель
3
O Моя/мой теща/свекровь или
1
4
тесть/свекр
O Мой/моя дедушка/бабушка
O Моя/мой тетя или дядя
6
O Моя/мой сестра или брат
7
O Мой ребенок
8
O Мой друг
9
O Другое (впишите, пожалуйста,
5
2. В данной анкете фраза «член семьи»
относится к человеку, указанному в
сопроводительном письме. Где
именно (в каких местах) член Вашей
семьи получал помощь хосписа?
Выберите один или несколько
вариантов ответа.
1
O Дома
O В доме престарелых
O В центре сестринского ухода
4
O В больнице
5
O В хосписе
6
O Другое (впишите печатными
2
3
буквами, пожалуйста):
___________________________
печатными буквами):
____________________________
22
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
ВАША РОЛЬ
3. Пока член Вашей семьи получал
хосписную помощь, как часто Вы
принимали в ней участие либо
наблюдали?
1
O Ни разу
5. Как часто Вы получали
необходимую Вам помощь хосписной
команды по вечерам, в выходные
или праздничные дни?
O Ни разу
O Иногда
3
O Как правило
4
O Всегда
1
2
Если ответ «ни разу»,
перейдите к вопросу
41
O Иногда
3
O Как правило
4
O Постоянно
2
ХОСПИСНАЯ ПОМОЩЬ
ЧЛЕНУ ВАШЕЙ СЕМЬИ
Что касается ответов на все
остальные вопросы в данной анкете,
просим Вас учитывать
исключительно опыт члена Вашей
семьи с хосписом, указанном в
сопроводительном письме.
4. Для данной анкеты хосписная
команда включает весь средний
медицинский персонал, докторов,
социальных работников,
священников и других людей,
обеспечивающих хосписный уход за
членом Вашей семьи. Когда член
Вашей семьи получал хосписный
уход, приходилось ли Вам
обращаться к хосписной команде с
вопросами или за помощью по
поводу ухода за ним по вечерам, в
выходные или праздничные дни?
1
2
O Да
O Нет
6. Когда член Вашей семьи получал
хосписный уход, как часто хосписная
команда информировала Вас о
времени своего прибытия для
оказания ему помощи?
O Ни разу
O Иногда
3
O Как правило
4
O Всегда
1
2
7. Когда член Вашей семьи получал
хосписный уход, и он или Вы
обращались к хосписной команде за
помощью, как часто вы получали ее
своевременно?
O Ни разу
2
O Иногда
3
O Как правило
4
O Всегда
1
8. Когда член Вашей семьи получал
хосписный уход, как часто хосписная
команда предоставляла объяснения
в простой и доступной форме?
Если ответ «Нет»,
перейдите к Вопросу 6
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
O Ни разу
2
O Иногда
3
O Как правило
4
O Всегда
1
23
9.
Когда член Вашей семьи получал
хосписный уход, как часто хосписная
команда информировала Вас о его
состоянии?
O Ни разу
O Иногда
3
O Как правило
4
O Всегда
1
O Да
2
O Нет
1
2
10.
Когда член Вашей семьи получал
хосписный уход, как часто кто-либо
из хосписной команды предоставлял
Вам нечеткую либо противоречивую
информацию о состоянии здоровья
или уходе за членом Вашей семьи?
O Ни разу
O Иногда
3
O Как правило
4
O Всегда
1
2
11.
13. Когда член Вашей семьи получал
хосписный уход, обсуждали ли Вы с
хосписной командой проблемы,
которые возникали у Вас во время
ухода за ним?
Когда член Вашей семьи получал
хосписный уход, как часто хосписная
команда относилась к нему с
достоинством и уважением?
O Ни разу
2
O Иногда
3
O Как правило
4
O Всегда
14. Как часто хосписная команда
внимательно Вас выслушивала,
когда Вы рассказывали о проблемах,
возникающих во время ухода за
членом Вашей семьи?
O Ни разу
2
O Иногда
3
O Как правило
4
O Всегда
1
15. Когда член Вашей семьи получал
хосписный уход, испытывал ли он
боль?
1
2
O Да
O Нет
1
12.
O Ни разу
O Иногда
3
O Как правило
4
O Всегда
2
24
Если ответ «Нет»,
перейдите к Вопросу 17
16. Получал член Вашей семьи всю
возможную необходимую ему
помощь, когда испытывал боль?
Когда член Вашей семьи получал
хосписный уход, как часто Вы
испытывали ощущение, что
хосписная команда действительно
заботится о нем?
1
Если ответ «Нет»,
перейдите к Вопросу 15
O Да, несомненно
O Да, можно так сказать
3
O Нет
1
2
17. Когда член Вашей семьи получал
хосписный уход, получал ли он
какие-то обезболивающие
препараты?
O Да
2
O Нет
1
Если ответ «Нет»,
перейдите к Вопросу 21
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
18. Побочные эффекты
обезболивающих препаратов
включают, например, сонливость.
Обсуждал ли кто-либо из
хосписной команды с Вами или
членом Вашей семьи побочные
эффекты обезболивающих
препаратов?
O Да, несомненно
O Да, можно так сказать
3
O Нет
22. Как часто член Вашей семьи
получал всю необходимую помощь
вследствие затрудненного дыхания?
O Ни разу
O Иногда
3
O Как правило
4
O Всегда
1
2
1
2
19. Проводила ли с Вами хосписная
команда необходимое обучение на
тему побочных эффектов, за
которыми необходимо следить при
приеме обезболивающих
препаратов?
23. Проводила ли с Вами хосписная
команда обучение по
предоставлению помощи члену
Вашей семьи, когда он испытывает
проблемы с дыханием?
O Да, несомненно
2
O Да, можно так сказать
3
O Нет
4
O У меня не было необходимости
1
O Да, несомненно
2
O Да, можно так сказать
3
O Нет
1
20. Проводила ли с Вами хосписная
команда необходимое обучение
относительно того, в каких случаях и
когда необходимо увеличивать дозу
обезболивающего препарата члену
Вашей семьи?
O Да, несомненно
2
O Да, можно так сказать
3
O Нет
4
O У меня не было необходимости
оказывать помощь члену моей
семьи по поводу проблем с
дыханием
24. Когда член Вашей семьи получал
хосписный уход, были ли у него
запоры?
O Да
2
O Нет
1
1
25. Как часто член Вашей семьи
получал необходмую помощь
вследствие запоров?
давать обезболивающие
препараты члену моей семьи
21. Когда член Вашей семьи получал
хосписный уход, были ли у него
проблемы с дыханием или получал
ли он лечение в связи с
затруднением дыхания?
O Да
2
O Нет
Если ответ «Нет»,
перейдите к Вопросу 26
O Ни разу
2
O Иногда
3
O Как правило
4
O Всегда
1
1
Если ответ «Нет»,
перейдите к Вопросу 24
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
25
26. Когда член Вашей семьи получал
хосписный уход, испытывал ли он
чувства тревоги или грусти?
1
2
O Да
O Нет
Если ответ «Нет»,
перейдите к Вопросу 28
27. Как часто член Вашей семьи
получал необходимую помощь
хосписной команды по поводу чувств
тревоги или грусти?
O Ни разу
O Иногда
3
O Как правило
4
O Всегда
1
2
1
Если ответ «Нет»,
перейдите к Вопросу 30
29. Проводила ли с Вами хосписная
команда обучение на тему того, что
делать в случае, если член Вашей
семьи испытывает ощущение
беспокойства или возбуждения?
O Да, несомненно
O Да, можно так сказать
3
O Нет
1
2
26
O Да, несомненно
2
O Да, можно так сказать
3
O Нет
4
O У меня не было необходимости
1
передвигать члена моей семьи
28. Когда член Вашей семьи получал
хосписный уход, испытывал ли он
ощущение беспокойства или
возбуждения?
O Да
2
O Нет
30. Передвигать члена Вашей семьи
означает помочь ему перевернуться
в кровати, подняться/лечь в кровать
или пересесть в инвалидную
коляску. Проводила ли с Вами
хосписная команда необходимое
обучение на тему того, каким
образом Вы можете безопасно
передвигать члена Вашей семьи?
31. Предоставляла ли Вам хосписная
команда всю необходимую
информацию относительно того, чего
ожидать, когда умирал член Вашей
семьи?
O Да, несомненно
2
O Да, можно так сказать
3
O Нет
1
ХОСПИСНЫЙ УХОД В ЦЕНТРЕ
СЕСТРИНСКОГО УХОДА
32. Некоторые люди получают
хосписный уход, проживая в центре
сестринского ухода. Получал ли член
Вашей семьи уход от данного
хосписа, проживая в центре
сестринского ухода?
O Да
2
O Нет
1
Если ответ «Нет»,
перейдите к Вопросу 35
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
33. Пока член Вашей семьи получал
хосписный уход, как часто
сотрудники центра сестринского
ухода эффективно сотрудничали с
хосписной командой, чтобы вместе
заботиться о члене Вашей семьи?
O Ни разу
O Иногда
3
O Как правило
4
O Всегда
1
2
36. Поддержка религиозных или
духовных убеждений подразумевает
беседы, молитвы, уединение или
другие способы удовлетворения
религиозных или духовных
потребностей. Когда член Вашей
семьи получал хосписный уход,
насколько велика была поддержка
Ваших религиозных или духовных
убеждений со стороны хосписной
команды?
O Слишком мала
2
O Достаточная
3
O Чрезмерная
1
34. Пока член Вашей семьи получал
хосписный уход, как часто
информация о члене Вашей семьи,
которую Вы получали от
сотрудников центра сестринского
ухода, отличалась от данных,
предоставленных хосписной
командой?
O Ни разу
2
O Иногда
3
O Как правило
4
O Всегда
37. Когда член Вашей семьи получал
хосписный уход, насколько велика
была эмоциональная поддержка со
стороны хосписной команды?
O Слишком мала
O Достаточная
3
O Чрезмерная
1
1
ВАШ ОПЫТ С ХОСПИСОМ
35. Когда член Вашей семьи получал
хосписный уход, как часто хосписная
команда внимательно выслушивала
Вас?
2
38. В ближайшие недели после смерти
члена Вашей семьи, насколько
велика была эмоциональная
поддержка со стороны хосписной
команды?
O Ни разу
O Иногда
3
O Как правило
4
O Всегда
1
O Слишком мала
O Достаточная
3
O Чрезмерная
1
2
2
Centers for Medicare & Medicaid Services
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27
ОБЩАЯ ОЦЕНКА ХОСПИСНОГО
УХОДА
39. Ответьте, пожалуйста, на следующие
вопросы относительно ухода за
членом Вашей семьи хосписом,
указанным в сопроводительном
письме к данной анкете. Просим в
своих ответах не упоминать об уходе,
полученном в других хосписах.
Используя шкалу от 0 до 10, где 0
означает наихудшее качество, а 10 —
наилучшее качество хосписного
ухода, которое только можно
представить, оцените хосписный
уход за членом Вашей семьи?
0
O
0
O1
2
O2
3
O3
4
O4
5
O5
6
O6
7
O7
8
O8
9
O9
10
O 10
Наихудшее качество
хосписного ухода, которое
только можно представить
40. Порекомендовали ли бы Вы данный
хоспис своим друзьям и семье?
O Точно нет
2
O Скорее всего, нет
3
O Скорее всего, да
4
O Да, несомненно
1
ИНФОРМАЦИЯ О ЧЛЕНЕ ВАШЕЙ
СЕМЬИ
41. Какое образование получил член
Вашей семьи?
1
2
3
4
O 8 классов и меньше
O Учился в старших классах, но не
окончил школу
O Окончил среднюю школу
O Колледж или диплом о
двухгодичном обучении
O Четырехгодичное законченное
высшее образование
6
O Обучение свыше четырех лет
высшего образования
7
O Не знаю
1
5
42. Был ли член Вашей семьи
испанского либо латиноамериканского происхождения?
Наилучшее качество
хосписного ухода, которое
только можно представить
1
2
3
O Нет, он не испанского/латино-
американского происхождения
O Да, он пуэрториканец
O Да, он мексиканец, мексикано-
американец, американец
мексиканского происхождения
4
O Да, он кубинец
5
O Да, другого испанского/латиноамериканского происхождения
28
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
46. Какое образование Вы получили?
43. К какой расовой группе
принадлежал член Вашей семьи?
Выберите, пожалуйста, один или
несколько вариантов ответа.
1
2
O Белая раса
2
O Черная раса или афро-американец
3
O Азиат
4
O Коренной гаваец или уроженец
1
3
4
44. Сколько Вам лет?
окончил школу
O Окончил среднюю школу
O Колледж или диплом о
двухгодичном обучении
O Четырехгодичное законченное
высшее образование
6
O Обучение свыше четырех лет
высшего образования
5
других островов Тихого океана
5
O Американский индеец или
уроженец Аляски
ИНФОРМАЦИЯ О ВАС
O 8 классов и меньше
O Учился в старших классах, но не
47. На каком языке Вы в основном
общаетесь дома?
O Английский
O Испанский
3
O Китайский
4
O Русский
5
O Португальский
6
O Вьетнамский
7
O Польский
8
O корейском
9
O Другой язык (укажите печатными
1
O От 18 до 24 лет
2
O От 25 до 34 лет
3
O От 35 до 44 лет
4
O От 45 до 54 лет
5
O От 55 до 64 лет
6
O От 65 до 74 лет
7
O От 75 до 84 лет
8
O 85 лет или старше
1
2
буквами):
45. Ваш пол?
______________________________________________
O Мужской
2
O Женский
1
Спасибо
Отправьте, пожалуйста, заполненную анкету в конверте с предварительно
оплаченным почтовым сбором.
[[NAME OF SURVEY VENDOR]
[RETURN ADDRESS OF SURVEY VENDOR]
Centers for Medicare & Medicaid Services
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Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
Sample Initial Cover Letter for the CAHPS Hospice Survey
[HOSPICE OR VENDOR LETTERHEAD]
[SAMPLED CAREGIVER NAME]
[ADDRESS]
[CITY, STATE ZIP]
Уважаемый/ая [SAMPLED CAREGIVER NAME]
[HOSPICE NAME] проводит исследование на тему хосписных услуг, оказываемых пациентам
и членам их семей. Вас отобрали для участия в данном опросе, потому что Вы были указаны
как опекун [DECEDENT NAME]. Мы понимаем, что это тяжелое для Вас время, но все же мы
надеемся на то, что Вы поможете нам узнать о качестве ухода, предоставленного хосписом
Вам, члену Вашей семьи или другу.
Вопросы [NOTE THE QUESTION NUMBERS] в приложенной анкете являются частью
национальной инициативы оценки качества хосписного ухода, финансируемой
Департаментом здравоохранения и социального обеспечения США. Центры обеспечения
услуг по программам «Медикэр» и «Медикэйд» (Centers for Medicare & Medicaid Services —
CMS), которые являются частью Департамента здравоохранения и социального обеспечения,
проводят данное исследование с целью улучшения качества хосписного ухода. CMS
оплачивает большинство хосписных услуг в США, поэтому несет ответственность за то, чтобы
пациенты хосписа, члены их семей и друзья получали высококачественное обслуживание.
Один из способов выполнения такого обязательства — получить непосредственно от Вас
информацию о хосписном уходе, предоставленном члену Вашей семьи либо другу. Ваше
участие является добровольным и никоим образом не повлияет на получаемое Вами
медицинское обеспечение или льготы.
Мы надеемся, что Вы найдете время на заполнение данной анкеты. После того как Вы
заполните анкету, отправьте ее, пожалуйста, в конверте с предварительно оплаченным
почтовым сбором. Ваши ответы будут объединены с ответами других респондентов и могут
быть предоставлены хоспису с целью повышения качества. [OPTIONAL: На анкете указан
номер. Данный номер поможет нам определить, вернули ли Вы нам анкету, чтобы нам не
пришлось отправлять Вам напоминания.]
Если у Вас возникли какие-либо вопросы по поводу прилагаемой анкеты, позвоните нам по
бесплатному номеру 1-800-xxx-xxxx. Благодарим Вас за помощь! Ваше участие позволит
улучшить хосписный уход для всех клиентов.
С уважением,
[HOSPICE ADMINISTRATOR]
[HOSPICE NAME]
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
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32
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
Sample Follow-up Cover Letter for the CAHPS Hospice Survey
[HOSPICE OR VENDOR LETTERHEAD]
[SAMPLED CAREGIVER NAME]
[ADDRESS]
[CITY, STATE ZIP]
Уважаемый/ая [SAMPLED CAREGIVER NAME]
Согласно имеющейся у нас информации, Вы являлись опекуном [HOSPICE NAME] в
[DECEDENT NAME]. Приблизительно три недели назад мы отправили Вам анкету,
касающуюся ухода, предоставленного хосписом Вам и члену Вашей семьи или Вашему другу.
Если Вы уже отправили анкету обратно, примите, пожалуйста, нашу благодарность и не
обращайте внимания на данное письмо. Если же Вы еще не отправили анкету, мы будем очень
благодарны, если Вы уделите время и все же заполните этот важнейший опросник.
Мы надеемся, что Вы поможете нам узнать о качестве ухода, предоставленного члену Вашей
семьи или другу. Результаты данного исследования будут использованы для того, чтобы
гарантировать каждому американцу наивысшее качество хосписного ухода.
Вопросы [NOTE THE QUESTION NUMBERS] в приложенной анкете являются частью
национальной инициативы оценки качества хосписного ухода, финансируемой
Департаментом здравоохранения и социального обеспечения США. Центры обеспечения
услуг по программам «Медикэр» и «Медикэйд» (Centers for Medicare & Medicaid Services —
CMS), которые являются частью Департамента здравоохранения и социального обеспечения,
проводят данное исследование с целью улучшения качества хосписного ухода. CMS
оплачивает большинство хосписных услуг в США, поэтому несет ответственность за то, чтобы
пациенты хосписа, члены их семей и друзья получали высококачественное обслуживание.
Один из способов выполнения такого обязательства — получить непосредственно от Вас
информацию о хосписном уходе, предоставленном члену Вашей семьи либо другу. Ваше
участие является добровольным и никоим образом не повлияет на получаемое Вами
медицинское обеспечение или льготы.
Уделите, пожалуйста, несколько минут, чтобы заполнить прилагаемую анкету. После того как
Вы заполните анкету, отправьте ее, пожалуйста, в конверте с предварительно оплаченным
почтовым сбором. Ваши ответы могут быть предоставлены хоспису с целью повышения
качества. [OPTIONAL: На анкете указан номер. Данный номер поможет нам определить,
вернули ли Вы нам анкету, чтобы нам не пришлось отправлять Вам напоминания.]
Если у Вас возникли какие-либо вопросы по поводу прилагаемой анкеты, позвоните нам по
бесплатному номеру 1-800-xxx-xxxx. Благодарим Вас за помощь! Ваше участие позволит
улучшить хосписный уход для всех клиентов.
С уважением,
[HOSPICE ADMINISTRATOR]
[HOSPICE NAME]
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
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Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
OMB Paperwork Reduction Act Language
The OMB Paperwork Reduction Act language must appear in the mailing, either on the cover letter
or on the front or back of the questionnaire. In addition, the OMB control number must appear on
the front page of the questionnaire. The following is the language that must be used:
Russian Version
“В соответствии с Законом о Сокращении Бумажного Документооборота от 1995 года, не
требуется, чтобы какое-либо лицо отвечало на просьбу о предоставлении информации, за
исключением того случая, если на этой просьбе будет указан действительный контрольный
номер ОМВ (Управления Менеджмента и Бюджета). Действительный контрольный номер
Управления ОМВ для данного сбора информации следующий: № 0938- 1257 (действителен до
31 декабря 2020 г). Расчётное время, требуемое для полного сбора данной информации, – в
среднем 11 минут для ответа на с 1-го по 40-й вопросы анкеты – «О Члене Вашей Семьи» и «О
Вас», включая время, необходимое для ознакомления с инструкциями, для поиска
существующих источников информации, а также для сбора необходимых данных, заполнения
и проверки собранной информации. Если у вас имеются какие-либо замечания по поводу
точности оценки требуемого времени, или какие-либо рекомендации, просьба написать по
следующему адресу: Centers for Medicare & Medicaid Services, 7500 Security Boulevard, C1-2505, Baltimore, MD 21244-1850.”
Centers for Medicare & Medicaid Services
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CAHPS Hospice Survey Quality Assurance Guidelines V6.0
Appendix S
Mail Survey Materials (Portuguese)
Inquérito CAHPS® Sobre Centros de Cuidados Paliativos
Responda às questões do inquérito sobre os cuidados que o doente recebeu neste centro de
cuidados paliativos:
[NAME OF HOSPICE]
Todas as questões deste inquérito irão cobrir as experiências neste centro de cuidados
paliativos.
Se desejar obter mais informações sobre este inquérito, ligue para [TOLL FREE NUMBER].
Todas as chamadas para este número são grátis.
OMB# 0938-1257
Caduca a 31 de dezembro de 2020
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
1
Dê este inquérito à pessoa no seu agregado familiar que melhor conhece os cuidados
paliativos recebidos pela pessoa indicada na carta de apresentação do inquérito.
INSTRUÇÕES DO INQUÉRITO
♦
♦
Utilize uma caneta de cor escura para preencher o inquérito.
Coloque um X diretamente dentro do quadrado indicando a resposta, como no exemplo a
seguir.
Sim
♦
☐ Não
Por vezes, ser-lhe-á pedido que salte algumas questões neste inquérito. Quando tal acontecer,
verá uma seta com uma nota indicando que questão deve responder a seguir, como se mostra
a seguir:
Sim
Se Sim, passe para a Questão 1
☐ Não
O DOENTE DO CENTRO DE
CUIDADOS PALIATIVOS
1. Qual a sua relação com a pessoa
indicada na carta de apresentação do
inquérito?
☐ Meu cônjugue ou parceiro
2
☐ Meu pai ou mãe
3
☐ Meu sogro ou sogra
4
☐ Meu avô ou avó
5
☐ Meu tio ou tia
6
☐ Meu irmão ou irmã
7
☐ Meu filho ou filha
8
☐ Meu amigo ou amiga
9
☐ Outro (escrever em letras de
1
2. Neste inquérito, "familiar" refere-se à
pessoa indicada na carta de
apresentação do inquérito. Em que
locais o seu familiar recebeu cuidados
neste centro? Selecione um ou mais.
☐ Casa
2
☐ Unidades de residência assistida
3
☐ Casa de repouso
4
☐ Hospital
5
☐ Unidades de cuidados paliativos
6
☐ Outro (escrever em letras de
1
imprensa):
____________________________
imprensa):
______________________________________________
2
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
O SEU PAPEL
3. Enquanto o seu familiar esteve no
centro de cuidados paliativos, com que
frequência participou ou
supervisionou os cuidados prestados?
5. Com que frequência obteve a
assistência de que necessitou da parte
da equipa do centro de cuidados
paliativos durante a noite, fins de
semana ou feriados?
☐ Nunca
2
☐ Por vezes
3
☐ Frequentemente
4
☐ Sempre
1
1
☐ Nunca
Se Nunca, passe para a
Questão 41
☐ Por vezes
3
☐ Frequentemente
4
☐ Sempre
2
OS CUIDADOS PALIATIVOS DO
SEU FAMILIAR
Ao responder às restantes questões deste
inquérito, pense na experiência do seu
familiar no centro de cuidados paliativos
indicado na carta de apresentação.
4. Neste inquérito, a equipa do centro de
cuidados paliativos inclui todos os
enfermeiros, médicos, assistentes
sociais, capelães e outras pessoas que
prestaram cuidados paliativos ao seu
familiar. Enquanto o seu familiar
esteve no centro de cuidados
paliativos, precisou de contactar a
equipa do centro durante a noite, fins
de semana ou feriados para tirar
dúvidas ou obter assistência com os
cuidados do seu familiar?
☐ Sim
2
☐ Não
6. Enquanto o seu familiar esteve no
centro de cuidados paliativos, com que
frequência a equipa do centro de
cuidados paliativos o manteve
informado sobre quando iria chegar
para prestar cuidados ao seu familiar?
☐ Nunca
2
☐ Por vezes
3
☐ Frequentemente
4
☐ Sempre
1
7. Enquanto o seu familiar esteve no
centro de cuidados paliativos, quando
pediu ou quando o seu familiar pediu
assistência da parte da equipa do
centro de cuidados paliativos, com que
frequência a obteve assim que
precisou dela?
☐ Nunca
2
☐ Por vezes
3
☐ Frequentemente
4
☐ Sempre
1
1
Se Não, passe para a
Questão 6
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
3
8. Enquanto o seu familiar esteve no
centro de cuidados paliativos, com que
frequência a equipa do centro de
cuidados paliativos explicou as coisas
de uma forma fácil de compreender?
☐ Nunca
2
☐ Por vezes
3
☐ Frequentemente
4
☐ Sempre
11. Enquanto o seu familiar esteve no
centro de cuidados paliativos, com que
frequência a equipa do centro de
cuidados paliativos tratou o seu
familiar com dignidade e respeito?
☐ Nunca
2
☐ Por vezes
3
☐ Frequentemente
4
☐ Sempre
1
1
9. Enquanto o seu familiar esteve no
centro de cuidados paliativos, com que
frequência a equipa do centro de
cuidados paliativos o manteve
informado sobre a condição do seu
familiar?
☐ Nunca
2
☐ Por vezes
3
☐ Frequentemente
4
☐ Sempre
12. Enquanto o seu familiar esteve no
centro de cuidados paliativos, com que
frequência sentiu que a equipa do
centro de cuidados paliativos
realmente se importava com o seu
familiar?
☐ Nunca
2
☐ Por vezes
3
☐ Frequentemente
4
☐ Sempre
1
1
10. Enquanto o seu familiar esteve no
centro de cuidados paliativos, com que
frequência um membro da equipa do
centro de cuidados paliativos lhe deu
informação confusa ou contraditória
sobre a condição ou cuidados do seu
familiar?
13. Enquanto o seu familiar esteve no
centro de cuidados paliativos, falou
com a equipa do centro de cuidados
paliativos sobre quaisquer problemas
com os cuidados paliativos prestados
ao seu familiar?
☐ Sim
2
☐ Não
1
☐ Nunca
2
☐ Por vezes
3
☐ Frequentemente
4
☐ Sempre
1
4
Se Não, passe para a
Questão 15
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
14. Com que frequência a equipa do
centro de cuidados paliativos o
escutou atentamente quando lhe falou
sobre problemas com os cuidados
paliativos prestados ao seu familiar?
1
☐ Nunca
2
☐ Por vezes
3
☐ Frequentemente
4
☐ Sempre
15. Enquanto o seu familiar esteve no
centro de cuidados paliativos, ele(a)
sentiu qualquer dor?
☐ Sim
2
☐ Não
1
Se Não, passe para a
Questão 17
16. O seu familiar recebeu a assistência
para as dores que necessitava?
☐ Sim, sem dúvida
2
☐ Sim, de certa forma
3
☐ Não
1
17. Enquanto o seu familiar esteve no
centro de cuidados paliativos, ele(a)
tomou algum medicamento para as
dores?
☐ Sim
2
☐ Não
1
Se Não, passe para a
Questão 21
18. Os efeitos secundários dos
medicamentos para as dores
incluem efeitos secundários, como
sonolência. Algum membro da
equipa do centro de cuidados
paliativos discutiu consigo, ou com o
seu familiar, os efeitos secundários
dos medicamentos para as dores?
☐ Sim, sem dúvida
2
☐ Sim, de certa forma
3
☐ Não
1
19. A equipa do centro de cuidados
paliativos deu-lhe a formação
necessária sobre que efeitos
secundários dos medicamentos para
as dores deveria vigiar?
☐ Sim, sem dúvida
2
☐ Sim, de certa forma
3
☐ Não
1
20. A equipa do centro de cuidados
paliativos deu-lhe a formação
necessária sobre se e quando deveria
dar mais medicamentos para as dores
ao seu familiar?
☐ Sim, sem dúvida
2
☐ Sim, de certa forma
3
☐ Não
4
☐ Não tive de dar medicamento para
1
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
as dores ao meu familiar
5
21. Enquanto o seu familiar esteve no
centro de cuidados paliativos, ele(a)
teve problemas a respirar ou recebeu
tratamento para a dificuldade em
respirar?
☐ Sim
2
☐ Não
1
Se Não, passe para a
Questão 24
22. Com que frequência o seu familiar
obteve a assistência necessária para a
dificuldade em respirar?
☐ Nunca
2
☐ Por vezes
3
☐ Frequentemente
4
☐ Sempre
1
25. Com que frequência o seu familiar
obteve a assistência necessária para
problemas de prisão de ventre?
☐ Nunca
2
☐ Por vezes
3
☐ Frequentemente
4
☐ Sempre
1
26. Enquanto o seu familiar esteve no
centro de cuidados paliativos, ele(a)
mostrou sentimentos de ansiedade ou
tristeza?
☐ Sim
2
☐ Não
1
23. A equipa do centro de cuidados
paliativos deu-lhe a formação
necessária sobre como ajudar o seu
familiar caso ele(a) tivesse problemas
a respirar?
Se Não, passe para a
Questão 28
27. Com que frequência o seu familiar
obteve a assistência necessária por
parte da equipa do centro de cuidados
paliativos para sentimentos de
ansiedade ou tristeza?
☐ Nunca
2
☐ Por vezes
3
☐ Frequentemente
4
☐ Sempre
1
☐ Sim, sem dúvida
2
☐ Sim, de certa forma
3
☐ Não
4
☐ Não precisei de dar assistência ao
1
meu familiar para a dificuldade
em respirar
24. Enquanto o seu familiar esteve no
centro de cuidados paliativos, ele(a)
teve problemas de prisão de ventre?
☐ Sim
2
☐ Não
1
6
28. Enquanto o seu familiar esteve no
centro de cuidados paliativos, ele(a)
alguma vez ficou inquieto(a) ou
agitado(a)?
☐ Sim
2
☐ Não
1
Se Não, passe para a
Questão 30
Se Não, passe para a
Questão 26
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
29. A equipa do centro de cuidados
paliativos deu-lhe a formação
necessária sobre o que fazer se o seu
familiar ficasse inquieto ou agitado?
☐ Sim, sem dúvida
2
☐ Sim, de certa forma
3
☐ Não
1
30. Mover o seu familiar inclui atividades
como ajudá-lo a virar-se na cama, a ir
para a cama ou a sair da mesma ou a
levantar-se e sentar-se numa cadeira
de rodas. A equipa do centro de
cuidados paliativos deu-lhe a
formação necessária sobre como
mover o seu familiar de forma segura?
☐ Sim, sem dúvida
2
☐ Sim, de certa forma
3
☐ Não
4
☐ Não tive de mover o meu familiar
1
31. A equipa do centro de cuidados
paliativos deu-lhe a informação
desejada sobre o que esperar
enquanto o seu familiar estivesse a
morrer?
☐ Sim, sem dúvida
2
☐ Sim, de certa forma
3
☐ Não
1
CUIDADOS PALIATIVOS
PRESTADOS EM CASA DE
REPOUSO
32. Algumas pessoas recebem cuidados
paliativos quando estão a viver numa
casa de repouso. O seu familiar
recebeu cuidados paliativos deste
centro quando ele(a) estava a viver
numa casa de repouso?
☐ Sim
2
☐ Não
1
Se Não, passe para a
Questão 35
33. Enquanto o seu familiar esteve no
centro de cuidados paliativos, com
que frequência as equipas da casa de
repouso e do centro de cuidados
paliativos colaboraram eficientemente
nos cuidados prestados ao seu
familiar?
☐ Nunca
2
☐ Por vezes
3
☐ Frequentemente
4
☐ Sempre
1
34. Enquanto o seu familiar esteve no
centro de cuidados paliativos, com
que frequência a informação que
recebeu sobre o seu familiar da
equipa da casa de repouso diferiu da
informação que recebeu da equipa do
centro de cuidados paliativos?
☐ Nunca
2
☐ Por vezes
3
☐ Frequentemente
4
☐ Sempre
1
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
7
A SUA PRÓPRIA EXPERIÊNCIA
COM O CENTRO DE CUIDADOS
PALIATIVOS
35. Enquanto o seu familiar esteve no
centro de cuidados paliativos, com que
frequência a equipa do centro de
cuidados paliativos o escutou
atentamente?
☐ Nunca
2
☐ Por vezes
3
☐ Frequentemente
4
☐ Sempre
1
37. Enquanto o seu familiar esteve no
centro de cuidados paliativos, quanto
apoio emocional recebeu da equipa do
centro de cuidados paliativos?
☐ Muito pouco
2
☐ A quantidade certa
3
☐ Demasiado
1
38. Nas semanas após a morte do seu
familiar, quanto apoio emocional
recebeu da equipa do centro de
cuidados paliativos?
☐ Muito pouco
2
☐ A quantidade certa
3
☐ Demasiado
1
36. O apoio às crenças espirituais ou
religiosas inclui falar, rezar, tempo de
reflexão, ou outras formas de atender
às suas necessidades espirituais ou
religiosas. Enquanto o seu familiar
esteve no centro de cuidados
paliativos, quanto apoio recebeu da
equipa do centro de cuidados
paliativos às suas crenças espirituais
ou religiosas?
☐ Muito pouco
2
☐ A quantidade certa
3
☐ Demasiado
1
8
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
CLASSIFICAÇÃO GERAL DO
CENTRO DE CUIDADOS
PALIATIVOS
39. Responda às seguintes questões acerca
dos cuidados prestados ao seu familiar
pelo centro de cuidados paliativos
indicado na carta de apresentação do
inquérito. Não inclua nas suas
respostas cuidados prestados por
outros centros de cuidados paliativos.
Usando qualquer número de 0 a 10,
sendo 0 os piores cuidados paliativos
possíveis e 10 os melhores cuidados
paliativos possíveis, que número
selecionaria para classificar os
cuidados paliativos do seu familiar?
0
☐
0
☐1
2
☐2
3
☐3
4
☐4
5
☐5
6
☐6
7
☐7
8
☐8
9
☐9
10
☐ 10
Os piores cuidados paliativos
possíveis
1
40. Recomendaria este centro de cuidados
paliativos aos seus amigos e
familiares?
☐ Definitivamente não
2
☐ Provavelmente não
3
☐ Provavelmente sim
4
☐ Definitivamente sim
1
SOBRE O SEU FAMILIAR
41. Qual foi o nível de escolaridade mais
elevado que o seu familiar concluiu?
☐ 8o ano ou menos
2
☐ Frequentou o liceu, mas não
1
acabou
3
☐ Acabou o liceu ou fez o exame de
Desenvolvimento Educativo Geral
(General Educational
Development, GED)
4
☐ Frequentou o ensino universitário
ou completou um curso de 2 anos
☐ Curso de 4 anos
6
☐ Curso superior a 4 anos
7
☐ Não sabe
5
Os melhores cuidados
paliativos possíveis
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
9
42. O seu familiar era de origem ou
descendência Hispânica, Latina ou
Espanhola?
1
SOBRE SI
44. Qual a sua idade?
☐ 18 a 24
2
☐ 25 a 34
3
☐ 35 a 44
4
☐ 45 a 54
5
☐ 55 a 64
6
☐ 65 a 74
7
☐ 75 a 84
8
☐ 85 ou mais
☐ Não, não
1
Espanhol/Hispânico/Latino
☐ Sim, Porto Riquenho
3
☐ Sim, Mexicano, Mexicano
2
Americano, Chicano
☐ Sim, Cubano
5
☐ Sim, Outro
4
Espanhol/Hispânico/Latino
43. Qual era a raça do seu familiar?
Selecione um ou mais.
☐ Branca
2
☐ Negra ou Africano Americano
3
☐ Asiática
4
☐ Nativo do Havai ou outra Ilha do
1
45. Qual o seu sexo?
☐ Masculino
2
☐ Feminino
1
Pacífico
5
☐ Índio Americano ou Nativo do
Alasca
10
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
46. Qual foi o nível de escolaridade mais
elevado que concluiu?
47. Que língua fala maioritariamente em
casa?
☐ 8o ano ou menos
2
☐ Frequentou o liceu, mas não
1
acabou
3
☐ Acabou o liceu ou fez o exame de
Desenvolvimento Educativo Geral
(General Educational
Development, GED)
4
☐ Inglês
2
☐ Espanhol
3
☐ Chinês
4
☐ Russo
5
☐ Português
6
☐ Vietnamita
7
☐ Polonesa
8
☐ Coreano
9
☐ Outra língua (escrever em letras de
1
☐ Frequentou o ensino universitário
ou completou um curso de 2 anos
☐ Curso de 4 anos
6
☐ Curso superior a 4 anos
5
imprensa):
___________________________
OBRIGADO.
Devolva o inquérito preenchido no envelope com portes pagos.
[NAME OF SURVEY VENDOR]
[RETURN ADDRESS OF SURVEY VENDOR]
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
11
12
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
Inquérito CAHPS® Sobre Centros de Cuidados Paliativos
Responda às questões do inquérito sobre os cuidados que o doente recebeu neste centro de
cuidados paliativos:
[NAME OF HOSPICE]
Todas as questões deste inquérito irão cobrir as experiências neste centro de cuidados
paliativos.
Se desejar obter mais informações sobre este inquérito, ligue para [TOLL FREE NUMBER].
Todas as chamadas para este número são grátis.
OMB# 0938-1257
Caduca a 31 de dezembro de 2020
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
13
Dê este inquérito à pessoa no seu agregado familiar que melhor conhece os cuidados
paliativos recebidos pela pessoa indicada na carta de apresentação do inquérito.
INSTRUÇÕES DO INQUÉRITO
♦
Utilize uma caneta de cor escura para preencher o inquérito.
♦
Coloque um X diretamente dentro da oval indicando a resposta, como no exemplo a seguir.
Sim
Não
♦
Por vezes, ser-lhe-á pedido que salte algumas questões neste inquérito. Quando tal acontecer,
verá uma seta com uma nota indicando que questão deve responder a seguir, como se mostra
a seguir:
Sim
Se Sim, passe para a Questão 1
Não
O DOENTE DO CENTRO DE
CUIDADOS PALIATIVOS
1. Qual a sua relação com a pessoa
indicada na carta de apresentação do
inquérito?
2. Neste inquérito, "familiar" refere-se à
pessoa indicada na carta de
apresentação do inquérito. Em que
locais o seu familiar recebeu cuidados
neste centro? Selecione um ou mais.
1
0 Casa
0 Unidades de residência assistida
0 Casa de repouso
4
0 Hospital
5
0 Unidades de cuidados paliativos
6
0 Outro (escrever em letras de
2
0 Meu cônjugue ou parceiro
2
0 Meu pai ou mãe
3
0 Meu sogro ou sogra
4
0 Meu avô ou avó
5
0 Meu tio ou tia
6
0 Meu irmão ou irmã
7
0 Meu filho ou filha
8
0 Meu amigo ou amiga
9
0 Outro (escrever em letras de
1
3
imprensa):
_____________________________
imprensa):
_____________________________
14
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
O SEU PAPEL
3. Enquanto o seu familiar esteve no
centro de cuidados paliativos, com que
frequência participou ou
supervisionou os cuidados prestados?
1
0 Nunca
Se Nunca, passe para a
Questão 41
0 Por vezes
0 Frequentemente
4
0 Sempre
2
3
OS CUIDADOS PALIATIVOS DO
SEU FAMILIAR
Ao responder às restantes questões deste
inquérito, pense na experiência do seu
familiar no centro de cuidados paliativos
indicado na carta de apresentação.
4. Neste inquérito, a equipa do centro de
cuidados paliativos inclui todos os
enfermeiros, médicos, assistentes
sociais, capelães e outras pessoas que
prestaram cuidados paliativos ao seu
familiar. Enquanto o seu familiar
esteve no centro de cuidados
paliativos, precisou de contactar a
equipa do centro durante a noite, fins
de semana ou feriados para tirar
dúvidas ou obter assistência com os
cuidados do seu familiar?
1
2
0 Sim
0 Não
6. Enquanto o seu familiar esteve no
centro de cuidados paliativos, com que
frequência a equipa do centro de
cuidados paliativos o manteve
informado sobre quando iria chegar
para prestar cuidados ao seu familiar?
0 Nunca
0 Por vezes
3
0 Frequentemente
4
0 Sempre
1
2
7. Enquanto o seu familiar esteve no
centro de cuidados paliativos, quando
pediu ou quando o seu familiar pediu
assistência da parte da equipa do
centro de cuidados paliativos, com que
frequência a obteve assim que
precisou dela?
0 Nunca
2
0 Por vezes
3
0 Frequentemente
4
0 Sempre
1
8. Enquanto o seu familiar esteve no
centro de cuidados paliativos, com que
frequência a equipa do centro de
cuidados paliativos explicou as coisas
de uma forma fácil de compreender?
0 Nunca
0 Por vezes
3
0 Frequentemente
4
0 Sempre
1
2
Se Não, passe para a Questão
6
5. Com que frequência obteve a
assistência de que necessitou da parte
da equipa do centro de cuidados
paliativos durante a noite, fins de
semana ou feriados?
0 Nunca
0 Por vezes
3
0 Frequentemente
4
0 Sempre
1
2
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
15
9. Enquanto o seu familiar esteve no
centro de cuidados paliativos, com que
frequência a equipa do centro de
cuidados paliativos o manteve
informado sobre a condição do seu
familiar?
0 Nunca
2
0 Por vezes
3
0 Frequentemente
4
0 Sempre
0 Nunca
0 Por vezes
3
0 Frequentemente
4
0 Sempre
1
1
2
10. Enquanto o seu familiar esteve no
centro de cuidados paliativos, com que
frequência um membro da equipa do
centro de cuidados paliativos lhe deu
informação confusa ou contraditória
sobre a condição ou cuidados do seu
familiar?
0 Nunca
2
0 Por vezes
3
0 Frequentemente
4
0 Sempre
1
0 Nunca
0 Por vezes
3
0 Frequentemente
4
0 Sempre
2
13. Enquanto o seu familiar esteve no
centro de cuidados paliativos, falou
com a equipa do centro de cuidados
paliativos sobre quaisquer problemas
com os cuidados paliativos prestados
ao seu familiar?
1
2
11. Enquanto o seu familiar esteve no
centro de cuidados paliativos, com que
frequência a equipa do centro de
cuidados paliativos tratou o seu
familiar com dignidade e respeito?
1
12. Enquanto o seu familiar esteve no
centro de cuidados paliativos, com que
frequência sentiu que a equipa do
centro de cuidados paliativos
realmente se importava com o seu
familiar?
0 Sim
0 Não
Se Não, passe para a Questão
15
14. Com que frequência a equipa do
centro de cuidados paliativos o
escutou atentamente quando lhe falou
sobre problemas com os cuidados
paliativos prestados ao seu familiar?
0 Nunca
0 Por vezes
3
0 Frequentemente
4
0 Sempre
1
2
15. Enquanto o seu familiar esteve no
centro de cuidados paliativos, ele(a)
sentiu qualquer dor?
0 Sim
2
0 Não
1
16
Se Não, passe para a Questão
17
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
16. O seu familiar recebeu a assistência
para as dores que necessitava?
0 Sim, sem dúvida
2
0 Sim, de certa forma
3
0 Não
1
17. Enquanto o seu familiar esteve no
centro de cuidados paliativos, ele(a)
tomou algum medicamento para as
dores?
1
2
0 Sim
0 Não
Se Não, passe para a Questão
21
18. Os efeitos secundários dos
medicamentos para as dores
incluem efeitos secundários, como
sonolência. Algum membro da
equipa do centro de cuidados
paliativos discutiu consigo, ou com o
seu familiar, os efeitos secundários
dos medicamentos para as dores?
0 Sim, sem dúvida
0 Sim, de certa forma
3
0 Não
1
2
19. A equipa do centro de cuidados
paliativos deu-lhe a formação
necessária sobre que efeitos
secundários dos medicamentos para
as dores deveria vigiar?
0 Sim, sem dúvida
0 Sim, de certa forma
3
0 Não
1
2
20. A equipa do centro de cuidados
paliativos deu-lhe a formação
necessária sobre se e quando deveria
dar mais medicamentos para as dores
ao seu familiar?
0 Sim, sem dúvida
2
0 Sim, de certa forma
3
0 Não
4
0 Não tive de dar medicamento para
1
as dores ao meu familiar
21. Enquanto o seu familiar esteve no
centro de cuidados paliativos, ele(a)
teve problemas a respirar ou recebeu
tratamento para a dificuldade em
respirar?
0 Sim
2
0 Não
1
Se Não, passe para a Questão
24
22. Com que frequência o seu familiar
obteve a assistência necessária para a
dificuldade em respirar?
0 Nunca
2
0 Por vezes
3
0 Frequentemente
4
0 Sempre
1
23. A equipa do centro de cuidados
paliativos deu-lhe a formação
necessária sobre como ajudar o seu
familiar caso ele(a) tivesse problemas
a respirar?
0 Sim, sem dúvida
0 Sim, de certa forma
3
0 Não
4
0 Não precisei de dar assistência ao
1
2
meu familiar para a dificuldade em
respirar
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
17
24. Enquanto o seu familiar esteve no
centro de cuidados paliativos, ele(a)
teve problemas de prisão de ventre?
1
2
0 Sim
0 Não
Se Não, passe para a Questão
26
25. Com que frequência o seu familiar
obteve a assistência necessária para
problemas de prisão de ventre?
0 Nunca
2
0 Por vezes
3
0 Frequentemente
4
0 Sempre
1
2
0 Sim
0 Não
2
0 Sim
0 Não
Se Não, passe para a Questão
30
29. A equipa do centro de cuidados
paliativos deu-lhe a formação
necessária sobre o que fazer se o seu
familiar ficasse inquieto ou agitado?
0 Sim, sem dúvida
2
0 Sim, de certa forma
3
0 Não
Se Não, passe para a Questão
28
27. Com que frequência o seu familiar
obteve a assistência necessária por
parte da equipa do centro de cuidados
paliativos para sentimentos de
ansiedade ou tristeza?
0 Nunca
2
0 Por vezes
3
0 Frequentemente
4
0 Sempre
1
1
26. Enquanto o seu familiar esteve no
centro de cuidados paliativos, ele(a)
mostrou sentimentos de ansiedade ou
tristeza?
1
28. Enquanto o seu familiar esteve no
centro de cuidados paliativos, ele(a)
alguma vez ficou inquieto(a) ou
agitado(a)?
30. Mover o seu familiar inclui atividades
como ajudá-lo a virar-se na cama, a ir
para a cama ou a sair da mesma ou a
levantar-se e sentar-se numa cadeira
de rodas. A equipa do centro de
cuidados paliativos deu-lhe a
formação necessária sobre como
mover o seu familiar de forma segura?
0 Sim, sem dúvida
0 Sim, de certa forma
3
0 Não
4
0 Não tive de mover o meu familiar
1
2
1
31. A equipa do centro de cuidados
paliativos deu-lhe a informação
desejada sobre o que esperar
enquanto o seu familiar estivesse a
morrer?
0 Sim, sem dúvida
2
0 Sim, de certa forma
3
0 Não
1
18
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
CUIDADOS PALIATIVOS
PRESTADOS EM CASA DE
REPOUSO
32. Algumas pessoas recebem cuidados
paliativos quando estão a viver numa
casa de repouso. O seu familiar
recebeu cuidados paliativos deste
centro quando ele(a) estava a viver
numa casa de repouso?
1
2
0 Sim
0 Não
Se Não, passe para a Questão
35
33. Enquanto o seu familiar esteve no
centro de cuidados paliativos, com
que frequência as equipas da casa de
repouso e do centro de cuidados
paliativos colaboraram eficientemente
nos cuidados prestados ao seu
familiar?
0 Nunca
0 Por vezes
3
0 Frequentemente
4
0 Sempre
1
2
34. Enquanto o seu familiar esteve no
centro de cuidados paliativos, com
que frequência a informação que
recebeu sobre o seu familiar da
equipa da casa de repouso diferiu da
informação que recebeu da equipa do
centro de cuidados paliativos?
A SUA PRÓPRIA EXPERIÊNCIA
COM O CENTRO DE CUIDADOS
PALIATIVOS
35. Enquanto o seu familiar esteve no
centro de cuidados paliativos, com que
frequência a equipa do centro de
cuidados paliativos o escutou
atentamente?
0 Nunca
2
0 Por vezes
3
0 Frequentemente
4
0 Sempre
1
36. O apoio às crenças espirituais ou
religiosas inclui falar, rezar, tempo de
reflexão, ou outras formas de atender
às suas necessidades espirituais ou
religiosas. Enquanto o seu familiar
esteve no centro de cuidados
paliativos, quanto apoio recebeu da
equipa do centro de cuidados
paliativos às suas crenças espirituais
ou religiosas?
0 Muito pouco
2
0 A quantidade certa
3
0 Demasiado
1
37. Enquanto o seu familiar esteve no
centro de cuidados paliativos, quanto
apoio emocional recebeu da equipa do
centro de cuidados paliativos?
0 Muito pouco
0 A quantidade certa
3
0 Demasiado
1
0 Nunca
2
0 Por vezes
3
0 Frequentemente
4
0 Sempre
1
2
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
19
38. Nas semanas após a morte do seu
familiar, quanto apoio emocional
recebeu da equipa do centro de
cuidados paliativos?
40. Recomendaria este centro de cuidados
paliativos aos seus amigos e
familiares?
0 Definitivamente não
0 Provavelmente não
3
0 Provavelmente sim
4
0 Definitivamente sim
1
0 Muito pouco
2
0 A quantidade certa
3
0 Demasiado
1
2
CLASSIFICAÇÃO GERAL DO
CENTRO DE CUIDADOS
PALIATIVOS
39. Responda às seguintes questões acerca
dos cuidados prestados ao seu familiar
pelo centro de cuidados paliativos
indicado na carta de apresentação do
inquérito. Não inclua nas suas
respostas cuidados prestados por
outros centros de cuidados paliativos.
Usando qualquer número de 0 a 10,
sendo 0 os piores cuidados paliativos
possíveis e 10 os melhores cuidados
paliativos possíveis, que número
selecionaria para classificar os
cuidados paliativos do seu familiar?
0
0
0
01
2
02
3
03
4
04
5
05
6
06
7
07
8
08
9
09
10
0 10
Os piores cuidados paliativos
possíveis
1
20
SOBRE O SEU FAMILIAR
41. Qual foi o nível de escolaridade mais
elevado que o seu familiar concluiu?
0 8o ano ou menos
2
0 Frequentou o liceu, mas não acabou
3
0 Acabou o liceu ou fez o exame de
1
Desenvolvimento Educativo Geral
(General Educational Development,
GED)
4
0 Frequentou o ensino universitário
ou completou um curso de 2 anos
0 Curso de 4 anos
6
0 Curso superior a 4 anos
7
0 Não sabe
5
42. O seu familiar era de origem ou
descendência Hispânica, Latina ou
Espanhola?
1
0 Não, não
Espanhol/Hispânico/Latino
2
0 Sim, Porto Riquenho
3
4
5
Os melhores cuidados
paliativos possíveis
0 Sim, Mexicano, Mexicano
Americano, Chicano
0 Sim, Cubano
0 Sim, Outro
Espanhol/Hispânico/Latino
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
43. Qual era a raça do seu familiar?
Selecione um ou mais.
46. Qual foi o nível de escolaridade mais
elevado que concluiu?
0 Branca
2
0 Negra ou Africano Americano
3
0 Asiática
4
0 Nativo do Havai ou outra Ilha do
0 8o ano ou menos
2
0 Frequentou o liceu, mas não acabou
3
0 Acabou o liceu ou fez o exame de
1
1
Desenvolvimento Educativo Geral
(General Educational Development,
GED)
Pacífico
5
0 Índio Americano ou Nativo do
Alasca
4
ou completou um curso de 2 anos
SOBRE SI
0 Curso de 4 anos
6
0 Curso superior a 4 anos
5
44. Qual a sua idade?
0 18 a 24
2
0 25 a 34
3
0 35 a 44
4
0 45 a 54
5
0 55 a 64
6
0 65 a 74
7
0 75 a 84
8
0 85 ou mais
0 Frequentou o ensino universitário
1
47. Que língua fala maioritariamente em
casa?
0 Inglês
0 Espanhol
3
0 Chinês
4
0 Russo
5
0 Português
6
0 Vietnamita
7
0 Polonesa
8
0 Coreano
9
0 Outra língua (escrever em letras de
1
2
45. Qual o seu sexo?
0 Masculino
2
0 Feminino
1
imprensa):
OBRIGADO.
Devolva o inquérito preenchido no envelope com portes pagos.
[NAME OF SURVEY VENDOR]
[RETURN ADDRESS OF SURVEY VENDOR]
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
21
22
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
Inquérito CAHPS® Sobre Centros de Cuidados Paliativos
Responda às questões do inquérito sobre os cuidados que o doente recebeu neste centro de
cuidados paliativos:
[NAME OF HOSPICE]
Todas as questões deste inquérito irão cobrir as experiências neste centro de cuidados
paliativos.
Se desejar obter mais informações sobre este inquérito, ligue para [TOLL FREE NUMBER].
Todas as chamadas para este número são grátis.
OMB# 0938-1257
Caduca a 31 de dezembro de 2020
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
23
Dê este inquérito à pessoa no seu agregado familiar que melhor conhece os cuidados
paliativos recebidos pela pessoa indicada na carta de apresentação do inquérito.
INSTRUÇÕES DO INQUÉRITO
♦
♦
Utilize uma caneta de cor escura para preencher o inquérito.
Coloque um X diretamente dentro do círculo indicando a resposta, como no exemplo a
seguir.
Sim
Não
♦
Por vezes, ser-lhe-á pedido que salte algumas questões neste inquérito. Quando tal acontecer,
verá uma seta com uma nota indicando que questão deve responder a seguir, como se mostra
a seguir:
Sim
Se Sim, passe para a Questão 1
Não
O DOENTE DO CENTRO DE
CUIDADOS PALIATIVOS
1. Qual a sua relação com a pessoa
indicada na carta de apresentação do
inquérito?
2. Neste inquérito, "familiar" refere-se à
pessoa indicada na carta de
apresentação do inquérito. Em que
locais o seu familiar recebeu cuidados
neste centro? Selecione um ou mais.
1
O Casa
O Unidades de residência assistida
3
O Casa de repouso
4
O Hospital
5
O Unidades de cuidados paliativos
6
O Outro (escrever em letras de
2
O Meu cônjugue ou parceiro
2
O Meu pai ou mãe
3
O Meu sogro ou sogra
4
O Meu avô ou avó
5
O Meu tio ou tia
6
O Meu irmão ou irmã
7
O Meu filho ou filha
8
O Meu amigo ou amiga
9
O Outro (escrever em letras de
1
imprensa):
_____________________________
imprensa):
____________________________
24
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
O SEU PAPEL
3. Enquanto o seu familiar esteve no
centro de cuidados paliativos, com que
frequência participou ou
supervisionou os cuidados prestados?
1
O Nunca
Se Nunca, passe para a
Questão 41
O Por vezes
O Frequentemente
4
O Sempre
2
3
OS CUIDADOS PALIATIVOS DO
SEU FAMILIAR
Ao responder às restantes questões deste
inquérito, pense na experiência do seu
familiar no centro de cuidados paliativos
indicado na carta de apresentação.
4. Neste inquérito, a equipa do centro de
cuidados paliativos inclui todos os
enfermeiros, médicos, assistentes
sociais, capelães e outras pessoas que
prestaram cuidados paliativos ao seu
familiar. Enquanto o seu familiar
esteve no centro de cuidados
paliativos, precisou de contactar a
equipa do centro durante a noite, fins
de semana ou feriados para tirar
dúvidas ou obter assistência com os
cuidados do seu familiar?
1
O Sim
2
O Não Se Não, passe para a Questão
6
6. Enquanto o seu familiar esteve no
centro de cuidados paliativos, com que
frequência a equipa do centro de
cuidados paliativos o manteve
informado sobre quando iria chegar
para prestar cuidados ao seu familiar?
O Nunca
O Por vezes
3
O Frequentemente
4
O Sempre
1
2
7. Enquanto o seu familiar esteve no
centro de cuidados paliativos, quando
pediu ou quando o seu familiar pediu
assistência da parte da equipa do
centro de cuidados paliativos, com que
frequência a obteve assim que
precisou dela?
O Nunca
2
O Por vezes
3
O Frequentemente
4
O Sempre
1
8. Enquanto o seu familiar esteve no
centro de cuidados paliativos, com que
frequência a equipa do centro de
cuidados paliativos explicou as coisas
de uma forma fácil de compreender?
O Nunca
O Por vezes
3
O Frequentemente
4
O Sempre
1
2
5. Com que frequência obteve a
assistência de que necessitou da parte
da equipa do centro de cuidados
paliativos durante a noite, fins de
semana ou feriados?
O Nunca
O Por vezes
3
O Frequentemente
4
O Sempre
1
2
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
25
9. Enquanto o seu familiar esteve no
centro de cuidados paliativos, com que
frequência a equipa do centro de
cuidados paliativos o manteve
informado sobre a condição do seu
familiar?
O Nunca
2
O Por vezes
3
O Frequentemente
4
O Sempre
O Nunca
O Por vezes
3
O Frequentemente
4
O Sempre
1
1
2
10. Enquanto o seu familiar esteve no
centro de cuidados paliativos, com que
frequência um membro da equipa do
centro de cuidados paliativos lhe deu
informação confusa ou contraditória
sobre a condição ou cuidados do seu
familiar?
O Nunca
2
O Por vezes
3
O Frequentemente
4
O Sempre
1
O Nunca
O Por vezes
3
O Frequentemente
4
O Sempre
2
13. Enquanto o seu familiar esteve no
centro de cuidados paliativos, falou
com a equipa do centro de cuidados
paliativos sobre quaisquer problemas
com os cuidados paliativos prestados
ao seu familiar?
1
2
11. Enquanto o seu familiar esteve no
centro de cuidados paliativos, com que
frequência a equipa do centro de
cuidados paliativos tratou o seu
familiar com dignidade e respeito?
1
12. Enquanto o seu familiar esteve no
centro de cuidados paliativos, com que
frequência sentiu que a equipa do
centro de cuidados paliativos
realmente se importava com o seu
familiar?
O Sim
O Não
Se Não, passe para a
Questão 15
14. Com que frequência a equipa do
centro de cuidados paliativos o
escutou atentamente quando lhe falou
sobre problemas com os cuidados
paliativos prestados ao seu familiar?
O Nunca
O Por vezes
3
O Frequentemente
4
O Sempre
1
2
15. Enquanto o seu familiar esteve no
centro de cuidados paliativos, ele(a)
sentiu qualquer dor?
O Sim
2
O Não
1
26
Se Não, passe para a
Questão 17
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
16. O seu familiar recebeu a assistência
para as dores que necessitava?
O Sim, sem dúvida
2
O Sim, de certa forma
3
O Não
1
17. Enquanto o seu familiar esteve no
centro de cuidados paliativos, ele(a)
tomou algum medicamento para as
dores?
1
2
O Sim
O Não
Se Não, passe para a
Questão 21
18. Os efeitos secundários dos
medicamentos para as dores
incluem efeitos secundários, como
sonolência. Algum membro da
equipa do centro de cuidados
paliativos discutiu consigo, ou com o
seu familiar, os efeitos secundários
dos medicamentos para as dores?
O Sim, sem dúvida
O Sim, de certa forma
3
O Não
1
2
19. A equipa do centro de cuidados
paliativos deu-lhe a formação
necessária sobre que efeitos
secundários dos medicamentos para
as dores deveria vigiar?
O Sim, sem dúvida
O Sim, de certa forma
3
O Não
1
2
20. A equipa do centro de cuidados
paliativos deu-lhe a formação
necessária sobre se e quando deveria
dar mais medicamentos para as dores
ao seu familiar?
O Sim, sem dúvida
2
O Sim, de certa forma
3
O Não
4
O Não tive de dar medicamento para
1
as dores ao meu familiar
21. Enquanto o seu familiar esteve no
centro de cuidados paliativos, ele(a)
teve problemas a respirar ou recebeu
tratamento para a dificuldade em
respirar?
O Sim
2
O Não
1
Se Não, passe para a
Questão 24
22. Com que frequência o seu familiar
obteve a assistência necessária para a
dificuldade em respirar?
O Nunca
2
O Por vezes
3
O Frequentemente
4
O Sempre
1
23. A equipa do centro de cuidados
paliativos deu-lhe a formação
necessária sobre como ajudar o seu
familiar caso ele(a) tivesse problemas
a respirar?
O Sim, sem dúvida
O Sim, de certa forma
3
O Não
4
O Não precisei de dar assistência ao
1
2
meu familiar para a dificuldade em
respirar
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
27
24. Enquanto o seu familiar esteve no
centro de cuidados paliativos, ele(a)
teve problemas de prisão de ventre?
1
2
O Sim
O Não
2
O Nunca
2
O Por vezes
3
O Frequentemente
4
O Sempre
1
26. Enquanto o seu familiar esteve no
centro de cuidados paliativos, ele(a)
mostrou sentimentos de ansiedade ou
tristeza?
2
O Sim
O Não
O Sim, sem dúvida
O Sim, de certa forma
3
O Não
1
Se Não, passe para a
Questão 26
25. Com que frequência o seu familiar
obteve a assistência necessária para
problemas de prisão de ventre?
1
29. A equipa do centro de cuidados
paliativos deu-lhe a formação
necessária sobre o que fazer se o seu
familiar ficasse inquieto ou agitado?
Se Não, passe para a
Questão 28
27. Com que frequência o seu familiar
obteve a assistência necessária por
parte da equipa do centro de cuidados
paliativos para sentimentos de
ansiedade ou tristeza?
O Nunca
2
O Por vezes
3
O Frequentemente
4
O Sempre
1
30. Mover o seu familiar inclui atividades
como ajudá-lo a virar-se na cama, a ir
para a cama ou a sair da mesma ou a
levantar-se e sentar-se numa cadeira
de rodas. A equipa do centro de
cuidados paliativos deu-lhe a
formação necessária sobre como
mover o seu familiar de forma segura?
O Sim, sem dúvida
2
O Sim, de certa forma
3
O Não
4
O Não tive de mover o meu familiar
1
31. A equipa do centro de cuidados
paliativos deu-lhe a informação
desejada sobre o que esperar
enquanto o seu familiar estivesse a
morrer?
O Sim, sem dúvida
O Sim, de certa forma
3
O Não
1
2
28. Enquanto o seu familiar esteve no
centro de cuidados paliativos, ele(a)
alguma vez ficou inquieto(a) ou
agitado(a)?
1
2
28
O Sim
O Não
Se Não, passe para a
Questão 30
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
CUIDADOS PALIATIVOS
PRESTADOS EM CASA DE
REPOUSO
32. Algumas pessoas recebem cuidados
paliativos quando estão a viver numa
casa de repouso. O seu familiar
recebeu cuidados paliativos deste
centro quando ele(a) estava a viver
numa casa de repouso?
O Sim
2
O Não
1
A SUA PRÓPRIA EXPERIÊNCIA
COM O CENTRO DE CUIDADOS
PALIATIVOS
35. Enquanto o seu familiar esteve no
centro de cuidados paliativos, com que
frequência a equipa do centro de
cuidados paliativos o escutou
atentamente?
O Nunca
O Por vezes
3
O Frequentemente
4
O Sempre
1
2
Se Não, passe para a
Questão 35
33. Enquanto o seu familiar esteve no
centro de cuidados paliativos, com
que frequência as equipas da casa de
repouso e do centro de cuidados
paliativos colaboraram eficientemente
nos cuidados prestados ao seu
familiar?
O Nunca
O Por vezes
3
O Frequentemente
4
O Sempre
1
2
34. Enquanto o seu familiar esteve no
centro de cuidados paliativos, com
que frequência a informação que
recebeu sobre o seu familiar da
equipa da casa de repouso diferiu da
informação que recebeu da equipa do
centro de cuidados paliativos?
36. O apoio às crenças espirituais ou
religiosas inclui falar, rezar, tempo de
reflexão, ou outras formas de atender
às suas necessidades espirituais ou
religiosas. Enquanto o seu familiar
esteve no centro de cuidados
paliativos, quanto apoio recebeu da
equipa do centro de cuidados
paliativos às suas crenças espirituais
ou religiosas?
O Muito pouco
2
O A quantidade certa
3
O Demasiado
1
37. Enquanto o seu familiar esteve no
centro de cuidados paliativos, quanto
apoio emocional recebeu da equipa do
centro de cuidados paliativos?
O Muito pouco
O A quantidade certa
3
O Demasiado
1
O Nunca
2
O Por vezes
3
O Frequentemente
4
O Sempre
1
2
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
29
38. Nas semanas após a morte do seu
familiar, quanto apoio emocional
recebeu da equipa do centro de
cuidados paliativos?
40. Recomendaria este centro de cuidados
paliativos aos seus amigos e
familiares?
O Definitivamente não
O Provavelmente não
3
O Provavelmente sim
4
O Definitivamente sim
1
O Muito pouco
2
O A quantidade certa
3
O Demasiado
1
2
CLASSIFICAÇÃO GERAL DO
CENTRO DE CUIDADOS
PALIATIVOS
39. Responda às seguintes questões acerca
dos cuidados prestados ao seu familiar
pelo centro de cuidados paliativos
indicado na carta de apresentação do
inquérito. Não inclua nas suas
respostas cuidados prestados por
outros centros de cuidados paliativos.
Usando qualquer número de 0 a 10,
sendo 0 os piores cuidados paliativos
possíveis e 10 os melhores cuidados
paliativos possíveis, que número
selecionaria para classificar os
cuidados paliativos do seu familiar?
0
O
0
O1
2
O2
3
O3
4
O4
5
O5
6
O6
7
O7
8
O8
9
O9
10
O 10
Os piores cuidados paliativos
possíveis
SOBRE O SEU FAMILIAR
41. Qual foi o nível de escolaridade mais
elevado que o seu familiar concluiu?
O 8o ano ou menos
2
O Frequentou o liceu, mas não
1
acabou
3
O Acabou o liceu ou fez o exame de
Desenvolvimento Educativo Geral
(General Educational
Development, GED)
4
O Frequentou o ensino universitário
ou completou um curso de 2 anos
O Curso de 4 anos
6
O Curso superior a 4 anos
7
O Não sabe
5
1
30
42. O seu familiar era de origem ou
descendência Hispânica, Latina ou
Espanhola?
1
O Não, não
Espanhol/Hispânico/Latino
2
O Sim, Porto Riquenho
3
4
Os melhores cuidados
paliativos possíveis
5
O Sim, Mexicano, Mexicano
Americano, Chicano
O Sim, Cubano
O Sim, Outro
Espanhol/Hispânico/Latino
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
43. Qual era a raça do seu familiar?
Selecione um ou mais.
46. Qual foi o nível de escolaridade mais
elevado que concluiu?
O Branca
2
O Negra ou Africano Americano
3
O Asiática
4
O Nativo do Havai ou outra Ilha do
O 8o ano ou menos
2
O Frequentou o liceu, mas não
1
1
acabou
3
Pacífico
5
O Índio Americano ou Nativo do
Alasca
Desenvolvimento Educativo Geral
(General Educational
Development, GED)
4
SOBRE SI
O Frequentou o ensino universitário
ou completou um curso de 2 anos
44. Qual a sua idade?
O 18 a 24
2
O 25 a 34
3
O 35 a 44
4
O 45 a 54
5
O 55 a 64
6
O 65 a 74
7
O 75 a 84
8
O 85 ou mais
O Acabou o liceu ou fez o exame de
O Curso de 4 anos
6
O Curso superior a 4 anos
5
1
47. Que língua fala maioritariamente em
casa?
O Inglês
2
O Espanhol
3
O Chinês
4
O Russo
5
O Português
6
O Vietnamita
7
O Polonesa
8
O Coreano
9
O Outra língua (escrever em letras de
1
45. Qual o seu sexo?
O Masculino
2
O Feminino
1
imprensa):
OBRIGADO.
Devolva o inquérito preenchido no envelope com portes pagos.
[NAME OF SURVEY VENDOR]
[RETURN ADDRESS OF SURVEY VENDOR]
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
31
32
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
Sample Initial Cover Letter for the CAHPS Hospice Survey
[HOSPICE OR VENDOR LETTERHEAD]
[SAMPLED CAREGIVER NAME]
[ADDRESS]
[CITY, STATE ZIP]
Caro(a) [SAMPLED CAREGIVER NAME]:
[HOSPICE NAME] está a conduzir um inquérito sobre os serviços prestados pelos centros de
cuidados paliativos aos doentes e suas famílias. Foi selecionado para este inquérito porque foi
identificado como sendo o cuidador de [DECEDENT NAME]. Reconhecemos que este possa ser
um período difícil para si, mas esperamos que possa ajudar-nos a compreender a qualidade dos
cuidados que recebeu, ou que o seu familiar ou amigo recebeu, no centro de cuidados paliativos.
As questões [NOTE THE QUESTION NUMBERS] no inquérito incluso são parte integrante de
uma iniciativa a nível nacional, promovida pelo Departamento da Saúde e Serviços Humanos
dos Estados Unidos (United States Department of Health and Human Services, HHS) para
medir a qualidade dos centros de cuidados paliativos. Os Centros para os Serviços Medicare &
Medicaid (Centers for Medicare & Medicaid Services, CMS), que fazem parte do HHS, estão a
conduzir este inquérito com o objetivo de melhorar os cuidados prestados nos centros de
cuidados paliativos. Os CMS cobrem a maior parte dos cuidados paliativos prestados nos
centros de cuidados paliativos nos EUA. É da responsabilidade dos CMS assegurar que os
doentes nos centros de cuidados paliativos e os seus familiares e amigos recebem cuidados da
melhor qualidade. Uma das formas de cumprirem a sua responsabilidade consiste em obter,
diretamente de si, informação sobre os cuidados paliativos que o seu familiar ou amigo recebeu
no centro. A sua participação é voluntária e não irá afetar quaisquer cuidados de saúde ou
benefícios que receba.
Esperamos que dedique algum tempo a completar este inquérito. Após completar este inquérito,
devolva-o no envelope com portes pagos. As suas respostas poderão ser partilhadas com o centro
de cuidados paliativos para fins de melhoria de qualidade. [OPTIONAL: Poderá reparar num
número no inquérito. Este número é usado para nos informar se devolveu o seu inquérito para que
não tenhamos de o lembrar.]
Caso tenha alguma questão sobre o inquérito incluso, ligue para o número grátis 1-800-xxxxxxx. Obrigado por ajudar a melhorar os centros de cuidados paliativos para todos os
consumidores.
Com os melhores cumprimentos,
[HOSPICE ADMINISTRATOR]
[HOSPICE NAME]
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
33
34
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
Sample Follow-up Cover Letter for the CAHPS Hospice
Survey
[HOSPICE OR VENDOR LETTERHEAD]
[SAMPLED CAREGIVER NAME]
[ADDRESS]
[CITY, STATE ZIP]
Caro(a) [SAMPLED CAREGIVER NAME]:
Os nossos registos mostram que atuou recentemente como cuidador de [HOSPICE NAME] em
[DECEDENT NAME]. Há cerca de três semanas, enviámos-lhe um inquérito relativo aos
cuidados que recebeu e que o seu familiar ou amigo recebeu neste centro. Se já nos devolveu o
inquérito, queira aceitar o nosso agradecimento e ignore esta carta. No entanto, se ainda não o
fez, agradecíamos que disponibilizasse algum tempo para completar este importante inquérito.
Esperamos que aproveite esta oportunidade para nos ajudar a compreender acerca da qualidade
dos cuidados que o seu familiar ou amigo recebeu. Os resultados deste inquérito serão usados de
modo a garantir que todos os americanos recebem cuidados paliativos da melhor qualidade.
As questões [NOTE THE QUESTION NUMBERS] no inquérito incluso são parte integrante de
uma iniciativa a nível nacional, promovida pelo Departamento da Saúde e Serviços Humanos
dos Estados Unidos (United States Department of Health and Human Services, HHS) para
medir a qualidade dos centros de cuidados paliativos. Os Centros para os Serviços Medicare &
Medicaid (Centers for Medicare & Medicaid Services, CMS), que fazem parte do HHS, estão a
conduzir este inquérito com o objetivo de melhorar os cuidados prestados nos centros de
cuidados paliativos. Os CMS cobrem a maior parte dos cuidados paliativos prestados nos
centros de cuidados paliativos nos EUA. É da responsabilidade dos CMS assegurar que os
doentes nos centros de cuidados paliativos e os seus familiares e amigos recebem cuidados da
melhor qualidade. Uma das formas de cumprirem a sua responsabilidade consiste em obter,
diretamente de si, informação sobre os cuidados paliativos que o seu familiar ou amigo recebeu
no centro. A sua participação é voluntária e não irá afetar quaisquer cuidados de saúde ou
benefícios que receba.
Por favor disponibilize alguns minutos para completar o inquérito incluído. Após completar este
inquérito, devolva-o no envelope com portes pagos. As suas respostas poderão ser partilhadas com
o centro de cuidados paliativos para fins de melhoria de qualidade. [OPTIONAL: Poderá reparar
num número no inquérito. Este número é usado para nos informar se devolveu o seu inquérito para
que não tenhamos de o lembrar.]
Caso tenha alguma questão sobre o inquérito incluso, ligue para o número grátis 1-800-xxxxxxx. Obrigado por ajudar a melhorar os centros de cuidados paliativos para todos os
consumidores.
Com os melhores cumprimentos,
[HOSPICE ADMINISTRATOR]
[HOSPICE NAME]
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
35
36
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
OMB Paperwork Reduction Act Language
The OMB Paperwork Reduction Act language must appear in the mailing, either on the cover
letter or on the front or back of the questionnaire. In addition, the OMB control number must
appear on the front page of the questionnaire. The following is the language that must be used:
Portuguese Version
“De acordo com a Lei de Redução da Burocracia de 1995, nenhuma pessoa é obrigada a responder
a uma recolha de informação a menos que exibe um número de controle OMB válido. O número
de controle OMB válido para esta recolha de informação é 0938-1257 (Caduca a 31 de dezembro
de 2020). O tempo necessário para completar esta informação recolhida é estimada a 11 minutos
para as perguntas 1 a 40 do inquérito, "Sobre o seu membro de família" e "Sobre Si", incluindo o
tempo para revisar as instruções, pesquisa dos recursos de dados existentes, reunir os dados
necessários, completar e revisar a recolha de informação. Se tiver algum comentário sobre a
exatidão da(s) estimativa(s) de tempo ou sugestões para melhorar este formulário, por favor
escreva para: Centers for Medicare & Medicaid Services, 7500 Security Boulevard, C1-25-05,
Baltimore, MD 21244-1850.”
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
37
38
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
Appendix T
Mail Survey Materials (Vietnamese)
KHẢO SÁT VỀ CAHPS® HOSPICE
**Hospice: Một loại dịch vụ chăm sóc cuối đời.
Vui lòng trả lời các câu hỏi khảo sát về việc chăm sóc bệnh nhân đã được nhận từ Hospice này:
[NAME OF HOSPICE]
Tất cả những câu hỏi trong cuộc khảo sát này sẽ hỏi về những trải nghiệm với Hospice.
Nếu bạn muốn biết thêm về cuộc khảo sát này, xin vui lòng gọi vào [TOLL FREE NUMBER].
Tất cả các cuộc gọi đến số điện thoại này là miễn phí.
OMB#0938-1257
Hết hạn vào ngày 31/12/2020
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
1
KHẢO SÁT VỀ CAHPS® HOSPICE
HƯỚNG DẪN KHẢO SÁT
♦
Xin vui lòng đưa cuộc khảo sát này cho người trong gia đình của bạn, người mà hiểu biết
nhiều nhất về việc Hospice care được nhận bởi người được liệt kê trên thư xin khảo sát.
♦
Sử dụng cây bút màu đen để điền vào bản khảo sát.
♦
Đánh một dấu X trực tiếp vào bên trong ô vuông để cho biết phản hồi của bạn, như mẫu dưới
đây:
Có
☐ Không
♦
Đôi khi bạn sẽ bỏ qua một số câu hỏi trong cuộc khảo sát này. Khi điều đó xảy ra, bạn sẽ
thấy một mũi tên với một lưu ý cho bạn biết những câu hỏi tiếp theo để bạn trả lời, như sau:
Có Nếu có, trả lời tiếp câu hỏi 1
☐ Không
________________________________________________________________________________________________________
_______
BỆNH NHÂN CỦA HOSPICE
1. Bạn có quan hệ như thế nào đối với
người đã được liệt kê trong thư khảo
sát?
Vợ hoặc chồng của tôi
Cha/ mẹ của tôi
3
Cha/ mẹ vợ của tôi hoặc cha/ mẹ
1
2
chồng của tôi
Ông bà nội/ngoại của tôi
5
Cô/chú của tôi
6
Anh/ chị/ em của tôi
7
Con của tôi
8
Bạn bè của tôi
9
Khác (vui lòng viết ra):
4
2. Đối với cuộc điều tra này, cụm từ
"thành viên gia đình" đề cập đến
những người có tên trong thư khảo
sát. Ở những địa điểm nào thành viên
gia đình bạn được chăm sóc từ
Hospice này? Vui lòng chọn một hoặc
nhiều.
1
Nhà
2
Trung tâm trợ sinh
3
Viện dưỡng lão
4
Bệnh viện
5
Cơ sở/ viện tế bần
6
Khác (vui lòng viết ra):
___________________________
____________________________
2
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
VAI TRÒ CỦA BẠN
3. Trong khi thành viên gia đình của bạn
đang được chăm sóc của Hospice care,
bạn có thường xuyên tham gia chăm
sóc hoặc quan sát người thân của bạn
hay không:
1
Không bao giờ Nếu không bao
giờ, trả lời tiếp
câu 41
Thỉnh thoảng
Thường thường
4
Luôn luôn
2
3
THÀNH VIÊN GIA ĐÌNH BẠN CỦA
HOSPICE CARE
Khi bạn trả lời các câu hỏi còn lại của
cuộc điều tra này, xin vui lòng chỉ nghĩ về
kinh nghiệm của thành viên gia đình bạn
với Hospice được đặt tên trên bìa khảo
sát.
4. Đối với khảo sát này, nhóm Hospice
bao gồm tất cả các y tá, bác sĩ, nhân
viên xã hội, giáo sĩ và những người
khác, người mà cung cấp dịch vụ
Hospice Care cho thành viên gia đình
của bạn. Trong thời gian thành viên
gia đình của bạn đang được Hospice
chăm sóc, bạn có cần gặp gỡ hay liên
lạc với nhóm Hospice trong thời gian
buổi tối, ngày nghỉ cuối tuần, hoặc
ngày lễ cho những vấn đề hoặc cần
giúp đỡ chăm sóc thành viên gia đình
của bạn?
1
2
Có
Không Nếu không, trả lời tiếp
câu 6
5. Bạn có thường xuyên nhận được sự
giúp đỡ mà bạn cần từ nhóm Hospice
vào buổi tối, cuối tuần hoặc là những
ngày nghỉ hay không?
Không bao giờ
Thỉnh thoảng
3
Thường thường
4
Luôn luôn
1
2
6. Trong khi thành viên gia đình bạn
đang được Hospice Care chăm sóc,
nhóm Hospice có thường xuyên thông
tin cho bạn biết về việc khi nào họ sẽ
đến để chăm sóc thành viên gia đình
của bạn?
Không bao giờ
Thỉnh thoảng
3
Thường thường
4
Luôn luôn
1
2
7. Trong thời gian thành viên gia đình
của bạn được Hospice Care chăm sóc,
khi bạn hay thành viên gia đình của
bạn yêu cầu sự giúp đỡ từ nhóm
Hospice, bạn có thường xuyên nhận
đươc sự giúp đỡ sớm nhất như bạn
cần không?
Không bao giờ
Thỉnh thoảng
3
Thường thường
4
Luôn luôn
1
2
8. Trong thời gian thành viên gia đình
của bạn được Hospice Care chăm sóc,
nhóm Hospice có thường xuyên giải
thích những vấn đề một cách dễ hiểu
không?
Không bao giờ
Thỉnh thoảng
3
Thường thường
4
Luôn luôn
1
2
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
3
9. Trong thời gian thành viên của gia
đình bạn được Hospice chăm sóc,
nhóm Hospice có thường xuyên thông
báo tình trạng của thành viên gia đình
bạn không?
Không bao giờ
2
Thỉnh thoảng
3
Thường thường
4
Luôn luôn
Có
2
Không Nếu không, trả lời tiếp
1
1
câu 15
10. Trong thời gian thành viên gia đình
của bạn được Hospice chăm sóc,
nhóm Hospice có thường xuyên cung
cấp cho bạn thông tin nhầm lẫn hoặc
mâu thuẫn về tình trạng hay sự chăm
sóc thành viên trong gia đình bạn hay
không?
Không bao giờ
Thỉnh thoảng
3
Thường thường
4
Luôn luôn
1
2
14. Nhóm Hospice có thường xuyên lắng
nghe cẩn thận khi bạn nói chuyện với
họ về các vấn đề về thành viên của
bạn khi đang ở Hospice care?
Không bao giờ
2
Thỉnh thoảng
3
Thường thường
4
Luôn luôn
1
15. Trong thời gian được Hospice chăm
sóc, người thân của bạn có bất kỳ cơn
đau nào không?
11. Trong thời gian thành viên gia đình
của bạn được Hospice chăm sóc,
nhóm Hospice có thường xuyên đối xử
tốt và tôn trọng với thành viên của gia
đình bạn?
Không bao giờ
Thỉnh thoảng
3
Thường thường
4
Luôn luôn
1
2
1
2
câu 17
16. Thành viên gia đình bạn có nhận được
nhiều sự giúp đỡ khi anh ấy/ cô ấy có
những cơn đau hay không?
Có, chắc chắn rồi
Có, một chút
3
Không
2
17. Trong thời gian thành viên gia đình
của bạn được Hospice chăm sóc, họ có
nhận bất kỳ thuốc giảm đau nào
không?
1
1
4
Có
Không Nếu không, trả lời tiếp
1
12. Trong thời gian thành viên của gia
đình bạn được Hospice chăm sóc, bạn
có thường cảm thấy rằng nhóm
Hospice thực sự quan tâm đến gia
đình của bạn?
Không bao giờ
2
Thỉnh thoảng
3
Thưởng thường
4
Luôn luôn
13. Trong thời gian thành viên gia đình
của bạn đang ở Hospice care, bạn có
từng nói chuyện với nhóm Hospice
care về bất cứ vấn đề về thành viên
gia đình bạn với Hospice care?
2
Có
Không Nếu không, trả lời tiếp
câu hỏi 21
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
18. Tác dụng phụ của thuốc giảm đau
bao gồm những việc như gây buồn
ngủ. Đã bất kỳ thành viên nào của
nhóm Hospice thảo luận về tác dụng
phụ của thuốc giảm đau với bạn
hoặc thành viên gia đình của bạn?
Có, chắc chắn rồi
Có, một chút
3
Không
1
2
19. Nhóm Hospice có dạy hoặc hướng dẫn
cho bạn về những tác dụng phụ của
thuốc giảm đau không?
Có, chắc chắn rồi
2
Có, một chút
3
Không
1
20. Nhóm Hospice có hướng dẫn cho bạn
khi đưa nhiều hơn thuốc giảm đau cho
thành viên gia đình bạn hay không?
Có, chắc chắn rồi
Có, một chút
3
Không
4
Tôi đã không cần thuốc giảm đau
1
2
22. Thành viên gia đình của bạn có
thường xuyên nhận được sự giúp đỡ
khi họ cần lúc bị khó thở hay không?
Không bao giờ
2
Thỉnh thoảng
3
Thường thường
4
Luôn luôn
1
23. Nhóm Hospice có hướng dẫn hoặc dạy
cho bạn cách xử lý khi thành viên gia
đình của bạn gặp vấn đề khó thở hay
không?
Có, chắc chắn rồi
Có, một chút
3
Không
4
Tôi đã không cần trợ giúp thành
1
2
viên gia đình tôi khi gặp vấn đề
khó thở
24. Trong thời gian được Hospice chăm
sóc, có bao giờ thành viên gia đình
bạn gặp vấn đề táo bón?
1
2
cho thành viên gia đình tôi
21. Trong thời gian thành viên gia đình
của bạn được Hospice chăm sóc, họ có
từng bị khó thở hoặc nhận được sự
điều trị khi bị khó thở không?
Có
2
Không Nếu không, trả lời tiếp
1
câu hỏi 24
Có
Không Nếu không, trả lời tiếp
câu 26
25. Thành viên gia đình bạn có thường
xuyên nhận được sự trợ giúp hoặc họ
có cần sự trợ giúp khi gặp vấn đề táo
bón không?
Không bao giờ
Thỉnh thoảng
3
Thường thường
4
Luôn luôn
1
2
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
5
26. Trong thời gian thành viên gia đình
bạn đươc Hospice chăm sóc, họ có thể
hiện bất kỳ sự lo lắng hay buồn bã
nào không?
1
2
Có
Không Nếu không, trả lời tiếp
câu 28
30. Di chuyển thành viên gia đình bạn bao
gồm những việc như giúp anh ấy/cô ấy
lật người trên giường, hoặc lên xuống
giường hay xe lăn. Nhóm Hospice có
hướng dẫn cho bạn cách di chuyển
thành viên gia đình bạn một cách toàn
không?
Có, chắc chắn rồi
Có, một chút
3
Không
4
Tôi không cần dịch chuyển thành
1
27. Thành viên gia đình bạn có thường
xuyên nhận được sự giúp đỡ hay họ
cần sự giúp đỡ từ nhóm Hospice khi
họ lo lắng hay khi họ buồn hay
không?
Không bao giờ
2
Thỉnh thoảng
3
Thường thường
4
Luôn luôn
2
viên gia đình tôi
31. Nhóm Hospice có thông báo cho bạn
nhiều thông tin như bạn muốn về
những điều mong đợi khi thành viên
gia đình bạn đang hấp hối?
1
Có, chắc chắn rồi
Có, một chút
3
Không
1
28. Trong thời gian thành viên gia đình
bạn được Hospice chăm sóc, có bao
giờ anh ấy/cô ấy trở nên không ngủ
được hoặc bị kích động không?
Có
2
Không Nếu không, trả lời tiếp
1
2
NHẬN ĐƯỢC SỰ CHĂM SÓC CỦA
HOSPICE CARE TRONG VIỆN
DƯỠNG LÃO
câu 30
29. Nhóm Hospice có hướng dẫn cho bạn
cách xử lý nếu thành viên của gia đình
bạn trở nên không ngủ được hoặc bị
kích động không?
Có, chắc chắn rồi
2
Có, một chút
3
Không
1
6
32. Vài người nhận được sự chăm sóc từ
Hospice khi họ đang sống ở viện
dưỡng lão. Gia đình bạn có nhận đươc
chăm sóc từ Hospice này trong khi
anh ấy/cô ấy đang sống ở viện dưỡng
lão hay không?
1
2
Có
Không Nếu không, trả lời tiếp
câu 35
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
33. Trong thời gian thành viên gia đình
bạn được Hospice chăm sóc, nhân
viên viện dưỡng lão và nhóm Hospice
có thường xuyên làm việc chung để
chăm sóc tốt cho thành viên gia đình
bạn hay không?
Không bao giờ
Thỉnh thoảng
3
Thường thường
4
Luôn luôn
1
2
34. Trong thời gian thành viên gia đình
bạn được Hospice chăm sóc, có bao
giờ thông tin được cung cấp cho thành
viên gia đình bạn từ nhân viên của
viện dưỡng lão và nhóm Hospice là
khác nhau không?
Không bao giờ
Thỉnh thoảng
3
Thường thường
4
Luôn luôn
1
2
KINH NGHIỆM CỦA BẢN THÂN
BẠN
VỚI HOSPICE
35. Trong thời gian thành viên gia đình
bạn được Hospice chăm sóc, nhóm
Hospice có thường xuyên lắng nghe ý
kiến của bạn một cách cẩn thận
không?
36. Về việc hỗ trợ cho các hoạt động về
tôn giáo hay tín ngưỡng tâm linh bao
gồm việc trò chuyện, cầu nguyện, thời
gian yên tĩnh, hoặc các hoạt động hội
họp về tôn giáo và các nhu cầu tín
ngưỡng. Trong thời gian thành viên
gia đình bạn được Hospice chăm sóc,
nhóm Hospice có hỗ trợ các hoạt động
về tôn giáo hay tín ngưỡng tâm linh
cho bạn không?
Rất ít
Đúng mức, vừa phải
3
Rất nhiều
1
2
37. Trong thời gian thành viên gia đình
bạn được Hospice chăm sóc, mức độ
hỗ trợ nhiệt tình từ nhóm Hospice đối
với gia đình bạn như thế nào?
Rất ít
Đúng mức, vừa phải
3
Rất nhiều
1
2
38. Trong những tuần sau khi thành viên
của gia đình bạn qua đời, mức độ hỗ
trợ nhiệt tình từ nhóm Hospice đối với
gia đình bạn như thế nào?
Rất ít
Đúng mức, vừa phải
3
Rất nhiều
1
2
Không bao giờ
Thỉnh thoảng
3
Thường thường
4
Luôn luôn
1
2
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
7
ĐÁNh GIÁ TỔNG THỂ VỀ
HOSPICE CARE
THÔNG TIN THÀNH VIÊN GIA
39. Vui lòng trả lời các câu hỏi dưới đây
về sự chăm sóc thành viên gia đình
bạn từ Hospice được đặt tên trên bìa
khảo sát. Không bao gồm sự chăm sóc
từ các Hospice khác trong câu trả lời
của bạn.
41. Trình độ học vấn cao nhất của thành
viên gia đình bạn đã hoàn thành là gì?
Sử dụng số từ 0 đến 10, số 0 thể hiện
mức độ chăm sóc tệ nhất, 10 thể hiện
mức độ chăm sóc tốt nhất, con số nào
để bạn đánh giá mức độ chăm sóc từ
Hospice cho thành viên gia đình bạn?
0 Hospice chăm sóc tồi tệ nhất
có thể
1
1
2
2
3
3
4
4
5
5
6
6
7
7
8
8
9
9
10
10 Hospice chăm sóc tốt nhất có
thể
0
40. Bạn có đề xuất Hospice care này cho
bạn bè và gia đình bạn không?
Chắc chắn là không
2
Có thể không
3
Có thể có
4
Chắc chắn là có
1
ĐÌNH CỦA BẠN
Lớp 8 hoặc thấp hơn
2
Trung học phổ thông, nhưng chưa
1
tốt nghiệp phổ thông
3
Tốt nghiệp trung học phổ thông
hoặc tương đương GED
4
Cao đẳng hoặc Khoá học 2 năm
5
Tốt nghiệp cao đẳng hệ 4 năm
6
Tốt nghiệp cao đẳng trên 4 năm
học
7
Không biết
42. Thành viên gia đình bạn là người Tây
Ban Nha, La tinh/ hay có gốc Nam Mỹ
không?
1
Không, không phải người Tây Ban
Nha/ gốc Nam Mỹ/ người La Tinh
Phải, Puerto Rican
3
Phải, người Mễ Tây Cơ, người Mỹ
gốc Mễ Tây Cơ, người Chicano
(người gốc Mễ Tây Cơ sinh tại
Mỹ)
4
Phải, Cuba
5
Phải, người Tây Ban Nha, người
gốc Nam Mỹ/ La Tinh
2
43. Chủng tộc của thành viên gia đình
bạn là gì? Vui lòng chọn một hoặc
nhiều hơn.
1
2
Người da Trắng
Người da Đen hoặc người Mỹ gốc
Phi
3
4
5
8
Người Châu Á
Người có nguồn gốc đảo Hawaii
hay đảo khác ở Thái Bình Dương
Người có nguồn gốc từ bất cứ sắc
dân bản địa nào ở Bắc Mỹ và Nam
Mỹ
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
THÔNG TIN VỀ BẠN
44. Bạn bao nhiêu tuổi?
18 đến 24
25 đến 34
3
35 đến 44
4
45 đến 54
5
55 đến 64
6
65 đến 74
7
75 đến 84
8
85 hoặc trên 85
1
2
45. Bạn là nam hay nữ?
1
2
Nam
Nữ
46. Trình độ học vấn cao nhất mà bạn đã
hoàn thành là gì?
1
2
Lớp 8 hoặc thấp hơn
Trung học phổ thông, nhưng chưa
tốt nghiệp
Tốt nghiệp trung học phổ thông
hoặc GED
4
Cao đẳng hoặc khoá học 2 năm
5
Tốt nghiệp cao đẳng hệ 4 năm học
6
Tốt nghiệp cao đẳng hệ trên 4 năm
học
3
47. Ngôn ngữ bạn sử dụng chính để giao
tiếp ở nhà là gì?
Tiếng Anh
Tiếng Tây Ban Nha
3
Tiếng Trung Quốc
4
Tiếng Nga
5
Tiếng Bồ Đào Nha
6
Tiếng Việt
7
Tiếng Ba Lan
8
Tiếng Hàn Quốc
9
Ngôn ngữ khác (vui lòng viết ra):
1
2
________________________
CHÂN THÀNH CÁM ƠN QUÝ VỊ
Vui lòng dùng bao thư đính kèm có sẵn bưu phí và gửi trở lại bản thăm dò ý kiến sau khi
trả lời đầy đủ.
[NAME OF SURVEY VENDOR]
[RETURN ADDRESS OF SURVEY VENDOR]
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
9
10
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
KHẢO SÁT VỀ CAHPS® HOSPICE
**Hospice: Một loại dịch vụ chăm sóc cuối đời.
Vui lòng trả lời các câu hỏi khảo sát về việc chăm sóc bệnh nhân đã được nhận từ Hospice này:
[NAME OF HOSPICE]
Tất cả những câu hỏi trong cuộc khảo sát này sẽ hỏi về những trải nghiệm với Hospice.
Nếu bạn muốn biết thêm về cuộc khảo sát này, xin vui lòng gọi vào [TOLL FREE NUMBER].
Tất cả các cuộc gọi đến số điện thoại này là miễn phí.
OMB#0938-1257
Hết hạn vào ngày 31/12/2020
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
11
KHẢO SÁT VỀ CAHPS® HOSPICE
HƯỚNG DẪN KHẢO SÁT
♦
Xin vui lòng đưa cuộc khảo sát này cho người trong gia đình của bạn, người mà hiểu biết
nhiều nhất về việc Hospice care được nhận bởi người được liệt kê trên thư xin khảo sát.
♦
Sử dụng cây bút màu đen để điền vào bản khảo sát.
♦
Trả lời tất cả các câu hỏi bằng cách điền đầy đủ vào ô bầu dục ở phía trái câu trả lời của bạn.
Có
0 Không
♦
Đôi khi bạn sẽ bỏ qua một số câu hỏi trong cuộc khảo sát này. Khi điều đó xảy ra, bạn sẽ
thấy một mũi tên với một lưu ý cho bạn biết những câu hỏi tiếp theo để bạn trả lời, như sau:
Có Nếu có, trả lời tiếp câu hỏi 1
0 Không
_______________________________________________________________________________
_____
BỆNH NHÂN CỦA HOSPICE
1. Bạn có quan hệ như thế nào đối với
người đã được liệt kê trong thư khảo
sát?
0 Vợ hoặc chồng của tôi
0 Cha/ mẹ của tôi
3
0 Cha/ mẹ vợ của tôi hoặc cha/ mẹ
1
2
chồng của tôi
0 Ông bà nội/ngoại của tôi
5
0 Cô/chú của tôi
6
0 Anh/ chị/ em của tôi
7
0 Con của tôi
8
0 Bạn bè của tôi
9
0 Khác (vui lòng viết ra):
4
2. Đối với cuộc điều tra này, cụm từ
"thành viên gia đình" đề cập đến
những người có tên trong thư khảo
sát. Ở những địa điểm nào thành viên
gia đình bạn được chăm sóc từ
Hospice này? Vui lòng chọn một hoặc
nhiều.
1
0 Nhà
2
0 Trung tâm trợ sinh
3
0 Viện dưỡng lão
4
0 Bệnh viện
5
0 Cơ sở/ viện tế bần
6
0 Khác (vui lòng viết ra):
_____________________________
____________________________
12
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
VAI TRÒ CỦA BẠN
3. Trong khi thành viên gia đình của
bạn đang được chăm sóc của Hospice
care, bạn có thường xuyên tham gia
chăm sóc hoặc quan sát người thân
của bạn hay không:
1
0 Không bao giờ Nếu không bao
giờ, trả lời tiếp
câu 41
0 Thỉnh thoảng
3
0 Thường thường
4
0 Luôn luôn
2
THÀNH VIÊN GIA ĐÌNH BẠN CỦA
HOSPICE CARE
Khi bạn trả lời các câu hỏi còn lại của
cuộc điều tra này, xin vui lòng chỉ nghĩ về
kinh nghiệm của thành viên gia đình bạn
với Hospice được đặt tên trên bìa khảo
sát.
4. Đối với khảo sát này, nhóm Hospice
bao gồm tất cả các y tá, bác sĩ, nhân
viên xã hội, giáo sĩ và những người
khác, người mà cung cấp dịch vụ
Hospice Care cho thành viên gia đình
của bạn. Trong thời gian thành viên
gia đình của bạn đang được Hospice
chăm sóc, bạn có cần gặp gỡ hay liên
lạc với nhóm Hospice trong thời gian
buổi tối, ngày nghỉ cuối tuần, hoặc
ngày lễ cho những vấn đề hoặc cần
giúp đỡ chăm sóc thành viên gia đình
của bạn?
1
2
0 Có
0 Không Nếu không, trả lời tiếp
câu 6
5. Bạn có thường xuyên nhận được sự
giúp đỡ mà bạn cần từ nhóm Hospice
vào buổi tối, cuối tuần hoặc là những
ngày nghỉ hay không?
0 Không bao giờ
0 Thỉnh thoảng
3
0 Thường thường
4
0 Luôn luôn
1
2
6. Trong khi thành viên gia đình bạn
đang được Hospice Care chăm sóc,
nhóm Hospice có thường xuyên thông
tin cho bạn biết về việc khi nào họ sẽ
đến để chăm sóc thành viên gia đình
của bạn?
0 Không bao giờ
0 Thỉnh thoảng
3
0 Thường thường
4
0 Luôn luôn
1
2
7. Trong thời gian thành viên gia đình
của bạn được Hospice Care chăm sóc,
khi bạn hay thành viên gia đình của
bạn yêu cầu sự giúp đỡ từ nhóm
Hospice, bạn có thường xuyên nhận
đươc sự giúp đỡ sớm nhất như bạn
cần không?
0 Không bao giờ
0 Thỉnh thoảng
3
0 Thường thường
4
0 Luôn luôn
1
2
8. Trong thời gian thành viên gia đình
của bạn được Hospice Care chăm sóc,
nhóm Hospice có thường xuyên giải
thích những vấn đề một cách dễ hiểu
không?
0 Không bao giờ
0 Thỉnh thoảng
3
0 Thường thường
4
0 Luôn luôn
1
2
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
13
9. Trong thời gian thành viên của gia
đình bạn được Hospice chăm sóc,
nhóm Hospice có thường xuyên thông
báo tình trạng của thành viên gia
đình bạn không?
0 Không bao giờ
2
0 Thỉnh thoảng
3
0 Thường thường
4
0 Luôn luôn
1
1
2
0 Không bao giờ
0 Thỉnh thoảng
3
0 Thường thường
4
0 Luôn luôn
1
2
0 Không bao giờ
0 Thỉnh thoảng
3
0 Thường thường
4
0 Luôn luôn
1
2
0 Không bao giờ
0 Thỉnh thoảng
3
0 Thường thường
4
0 Luôn luôn
1
2
1
2
0 Có
0 Không Nếu không, trả lời tiếp
câu 17
16. Thành viên gia đình bạn có nhận
được nhiều sự giúp đỡ khi anh ấy/ cô
ấy có những cơn đau hay không?
0 Có, chắc chắn rồi
0 Có, một chút
3
0 Không
1
2
12. Trong thời gian thành viên của gia
đình bạn được Hospice chăm sóc, bạn
có thường cảm thấy rằng nhóm
Hospice thực sự quan tâm đến gia
đình của bạn?
14
14. Nhóm Hospice có thường xuyên lắng
nghe cẩn thận khi bạn nói chuyện với
họ về các vấn đề về thành viên của
bạn khi đang ở Hospice care?
15. Trong thời gian được Hospice chăm
sóc, người thân của bạn có bất kỳ cơn
đau nào không?
11. Trong thời gian thành viên gia đình
của bạn được Hospice chăm sóc,
nhóm Hospice có thường xuyên đối
xử tốt và tôn trọng với thành viên của
gia đình bạn?
0 Không bao giờ
2
0 Thỉnh thoảng
3
0 Thường thường
4
0 Luôn luôn
0 Có
0 Không Nếu không, trả lời tiếp
câu 15
10. Trong thời gian thành viên gia đình
của bạn được Hospice chăm sóc,
nhóm Hospice có thường xuyên cung
cấp cho bạn thông tin nhầm lẫn hoặc
mâu thuẫn về tình trạng hay sự chăm
sóc thành viên trong gia đình bạn hay
không?
1
13. Trong thời gian thành viên gia đình
của bạn đang ở Hospice care, bạn có
từng nói chuyện với nhóm Hospice
care về bất cứ vấn đề về thành viên
gia đình bạn với Hospice care?
17. Trong thời gian thành viên gia đình
của bạn được Hospice chăm sóc, họ
có nhận bất kỳ thuốc giảm đau nào
không?
1
2
0 Có
0 Không Nếu không, trả lời tiếp
câu 21
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
18. Tác dụng phụ của thuốc giảm đau
bao gồm những việc như gây buồn
ngủ. Đã bất kỳ thành viên nào của
nhóm Hospice thảo luận về tác
dụng phụ của thuốc giảm đau với
bạn hoặc thành viên gia đình của
bạn?
0 Có, chắc chắn rồi
0 Có, một chút
3
0 Không
1
2
19. Nhóm Hospice có dạy hoặc hướng
dẫn cho bạn về những tác dụng phụ
của thuốc giảm đau không?
0 Có, chắc chắn rồi
2
0 Có, một chút
3
0 Không
1
20. Nhóm Hospice có hướng dẫn cho bạn
khi đưa nhiều hơn thuốc giảm đau
cho thành viên gia đình bạn hay
không?
0 Có, chắc chắn rồi
2
0 Có, một chút
3
0 Không
4
0 Tôi đã không cần thuốc giảm đau
1
cho thành viên gia đình tôi
21. Trong thời gian thành viên gia đình
của bạn được Hospice chăm sóc, họ
có từng bị khó thở hoặc nhận được sự
điều trị khi bị khó thở không?
1
2
0 Có
0 Không Nếu không, trả lời tiếp
câu 24
22. Thành viên gia đình của bạn có
thường xuyên nhận được sự giúp đỡ
khi họ cần lúc bị khó thở hay không?
0 Không bao giờ
0 Thỉnh thoảng
3
0 Thường thường
4
0 Luôn luôn
23. Nhóm Hospice có hướng dẫn hoặc
dạy cho bạn cách xử lý khi thành viên
gia đình của bạn gặp vấn đề khó thở
hay không?
0 Có, chắc chắn rồi
0 Có, một chút
3
0 Không
4
0 Tôi đã không cần trợ giúp thành
1
2
viên gia đình tôi khi gặp vấn đề khó
thở
24. Trong thời gian được Hospice chăm
sóc, có bao giờ thành viên gia đình
bạn gặp vấn đề táo bón?
1
2
0 Có
0 Không Nếu không, trả lời tiếp
câu 26
25. Thành viên gia đình bạn có thường
xuyên nhận được sự trợ giúp hoặc họ
có cần sự trợ giúp khi gặp vấn đề táo
bón không?
0 Không bao giờ
0 Thỉnh thoảng
3
0 Thường thường
4
0 Luôn luôn
1
2
26. Trong thời gian thành viên gia đình
bạn đươc Hospice chăm sóc, họ có
thể hiện bất kỳ sự lo lắng hay buồn
bã nào không?
1
2
0 Có
0 Không Nếu không, trả lời tiếp
câu 28
27. Thành viên gia đình bạn có thường
xuyên nhận được sự giúp đỡ hay họ
cần sự giúp đỡ từ nhóm Hospice khi
họ lo lắng hay khi họ buồn hay
không?
1
1
2
2
0 Không bao giờ
0 Thỉnh thoảng
3
0 Thường thường
4
0 Luôn luôn
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
15
28. Trong thời gian thành viên gia đình
bạn được Hospice chăm sóc, có bao
giờ anh ấy/cô ấy trở nên không ngủ
được hoặc bị kích động không?
1
2
0 Có
0 Không Nếu không, trả lời tiếp
câu 30
29. Nhóm Hospice có hướng dẫn cho bạn
cách xử lý nếu thành viên của gia
đình bạn trở nên không ngủ được
hoặc bị kích động không?
NHẬN ĐƯỢC SỰ CHĂM SÓC
CỦA HOSPICE CARE TRONG
VIỆN DƯỠNG LÃO
32. Vài người nhận được sự chăm sóc từ
Hospice khi họ đang sống ở viện
dưỡng lão. Gia đình bạn có nhận
đươc chăm sóc từ Hospice này trong
khi anh ấy/cô ấy đang sống ở viện
dưỡng lão hay không?
1
2
câu 35
0 Có, chắc chắn rồi
2
0 Có, một chút
3
0 Không
1
30. Di chuyển thành viên gia đình bạn
bao gồm những việc như giúp anh
ấy/cô ấy lật người trên giường, hoặc
lên xuống giường hay xe lăn. Nhóm
Hospice có hướng dẫn cho bạn cách
di chuyển thành viên gia đình bạn
một cách toàn không?
0 Có, chắc chắn rồi
0 Có, một chút
3
0 Không
4
0 Tôi không cần dịch chuyển thành
1
2
viên gia đình tôi
31. Nhóm Hospice có thông báo cho bạn
nhiều thông tin như bạn muốn về
những điều mong đợi khi thành viên
gia đình bạn đang hấp hối?
0 Có, chắc chắn rồi
0 Có, một chút
3
0 Không
1
2
16
0 Có
0 Không Nếu không, trả lời tiếp
33. Trong thời gian thành viên gia đình
bạn được Hospice chăm sóc, nhân
viên viện dưỡng lão và nhóm Hospice
có thường xuyên làm việc chung để
chăm sóc tốt cho thành viên gia đình
bạn hay không?
0 Không bao giờ
0 Thỉnh thoảng
3
0 Thường thường
4
0 Luôn luôn
1
2
34. Trong thời gian thành viên gia đình
bạn được Hospice chăm sóc, có bao
giờ thông tin được cung cấp cho
thành viên gia đình bạn từ nhân viên
của viện dưỡng lão và nhóm Hospice
là khác nhau không?
0 Không bao giờ
0 Thỉnh thoảng
3
0 Thường thường
4
0 Luôn luôn
1
2
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
ĐÁNH GIÁ TỔNG THỂ VỀ
HOSPICE CARE
KINH NGHIỆM CỦA BẢN THÂN
BẠN
VỚI HOSPICE
35. Trong thời gian thành viên gia đình
bạn được Hospice chăm sóc, nhóm
Hospice có thường xuyên lắng nghe ý
kiến của bạn một cách cẩn thận
không?
0 Không bao giờ
2
0 Thỉnh thoảng
3
0 Thường thường
4
0 Luôn luôn
1
36. Về việc hỗ trợ cho các hoạt động về
tôn giáo hay tín ngưỡng tâm linh bao
gồm việc trò chuyện, cầu nguyện, thời
gian yên tĩnh, hoặc các hoạt động hội
họp về tôn giáo và các nhu cầu tín
ngưỡng. Trong thời gian thành viên
gia đình bạn được Hospice chăm sóc,
nhóm Hospice có hỗ trợ các hoạt động
về tôn giáo hay tín ngưỡng tâm linh
cho bạn không?
0 Rất ít
0 Đúng mức, vừa phải
3
0 Rất nhiều
1
2
37. Trong thời gian thành viên gia đình
bạn được Hospice chăm sóc, mức độ
hỗ trợ nhiệt tình từ nhóm Hospice đối
với gia đình bạn như thế nào?
39. Vui lòng trả lời các câu hỏi dưới đây
về sự chăm sóc thành viên gia đình
bạn từ Hospice được đặt tên trên bìa
khảo sát. Không bao gồm sự chăm sóc
từ các Hospice khác trong câu trả lời
của bạn.
Sử dụng số từ 0 đến 10, số 0 thể hiện
mức độ chăm sóc tệ nhất, 10 thể hiện
mức độ chăm sóc tốt nhất, con số nào
để bạn đánh giá mức độ chăm sóc từ
Hospice cho thành viên gia đình bạn?
0
0 0 Hospice chăm sóc tồi tệ nhất có
thể
1
0 1
0 2
3
0 3
4
0 4
5
0 5
6
0 6
7
0 7
8
0 8
9
0 9
10
0 10 Hospice chăm sóc tốt nhất có
2
thể
40. Bạn có đề xuất Hospice care này cho
bạn bè và gia đình bạn không?
0 Rất ít
0 Đúng mức, vừa phải
3
0 Rất nhiều
1
2
0 Chắc chắn là không
0 Có thể không
3
0 Có thể có
4
0 Chắc chắn là có
1
2
38. Trong những tuần sau khi thành viên
của gia đình bạn qua đời, mức độ hỗ
trợ nhiệt tình từ nhóm Hospice đối
với gia đình bạn như thế nào?
0 Rất ít
0 Đúng mức, vừa phải
3
0 Rất nhiều
1
2
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
17
THÔNG TIN THÀNH VIÊN GIA
ĐÌNH CỦA BẠN
41. Trình độ học vấn cao nhất của thành
viên gia đình bạn đã hoàn thành là
gì?
1
2
0 Lớp 8 hoặc thấp hơn
0 Trung học phổ thông, nhưng chưa
tốt nghiệp phổ thông
0 Tốt nghiệp trung học phổ thông
hoặc tương đương GED
4
0 Cao đẳng hoặc Khoá học 2 năm
5
0 Tốt nghiệp cao đẳng hệ 4 năm
6
0 Tốt nghiệp cao đẳng trên 4 năm học
7
0 Không biết
3
42. Thành viên gia đình bạn là người Tây
Ban Nha, La tinh/ hay có gốc Nam
Mỹ không?
1
0 Không, không phải người Tây Ban
Nha/ gốc Nam Mỹ/ người La Tinh
0 Phải, Puerto Rican
3
0 Phải, người Mễ Tây Cơ, người Mỹ
gốc Mễ Tây Cơ, người Chicano
(người gốc Mễ Tây Cơ sinh tại Mỹ)
4
0 Phải, Cuba
5
0 Phải, người Tây Ban Nha, người
gốc Nam Mỹ/ La Tinh
2
43. Chủng tộc của thành viên gia đình
bạn là gì? Vui lòng chọn một hoặc
nhiều hơn.
1
2
Phi
0 Người Châu Á
4
0 Người có nguồn gốc đảo Hawaii
hay đảo khác ở Thái Bình Dương
5
0 Người có nguồn gốc từ bất cứ sắc
dân bản địa nào ở Bắc Mỹ và Nam
Mỹ
3
THÔNG TIN VỀ BẠN
44. Bạn bao nhiêu tuổi?
0 18 đến 24
0 25 đến 34
3
0 35 đến 44
4
0 45 đến 54
5
0 55 đến 64
6
0 65 đến 74
7
0 75 đến 84
8
0 85 hoặc trên 85
1
2
45. Bạn là nam hay nữ?
1
2
18
0 Người da Trắng
0 Người da Đen hoặc người Mỹ gốc
0 Nam
0 Nữ
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
46. Trình độ học vấn cao nhất mà bạn đã
hoàn thành là gì?
0 Lớp 8 hoặc thấp hơn
2
0 Trung học phổ thông, nhưng chưa
1
tốt nghiệp phổ thông
0 Tốt nghiệp trung học phổ thông
hoặc tương đương GED
4
0 Cao đẳng hoặc Khoá học 2 năm
5
0 Tốt nghiệp cao đẳng hệ 4 năm
6
0 Tốt nghiệp cao đẳng trên 4 năm học
3
47. Ngôn ngữ bạn sử dụng chính để giao
tiếp ở nhà là gì?
0 Tiếng Anh
0 Tiếng Tây Ban Nha
3
0 Tiếng Trung Quốc
4
0 Tiếng Nga
5
0 Tiếng Bồ Đào Nha
6
0 Tiếng Việt
7
0 Tiếng Ba Lan
8
0 Tiếng Hàn Quốc
9
0 Ngôn ngữ khác (vui lòng viết ra):
1
2
____________________________
CHÂN THÀNH CÁM ƠN QUÝ VỊ
Vui lòng dùng bao thư đính kèm có sẵn bưu phí và gửi trở lại bản thăm dò ý kiến sau khi
trả lời đầy đủ.
[NAME OF SURVEY VENDOR]
[RETURN ADDRESS OF SURVEY VENDOR]
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
19
20
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
KHẢO SÁT VỀ CAHPS® HOSPICE
**Hospice: Một loại dịch vụ chăm sóc cuối đời.
Vui lòng trả lời các câu hỏi khảo sát về việc chăm sóc bệnh nhân đã được nhận từ Hospice này:
[NAME OF HOSPICE]
Tất cả những câu hỏi trong cuộc khảo sát này sẽ hỏi về những trải nghiệm với Hospice.
Nếu bạn muốn biết thêm về cuộc khảo sát này, xin vui lòng gọi vào [TOLL FREE NUMBER].
Tất cả các cuộc gọi đến số điện thoại này là miễn phí.
OMB#0938-1257
Hết hạn vào ngày 31/12/2020
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
21
KHẢO SÁT VỀ CAHPS® HOSPICE
HƯỚNG DẪN KHẢO SÁT
♦
Xin vui lòng đưa cuộc khảo sát này cho người trong gia đình của bạn, người mà hiểu biết
nhiều nhất về việc Hospice care được nhận bởi người được liệt kê trên thư xin khảo sát.
♦
Sử dụng cây bút màu đen để điền vào bản khảo sát.
♦
Trả lời tất cả các câu hỏi bằng cách điền đầy đủ vào hình tròn ở phía trái câu trả lời của bạn.
Có
O Không
♦
Đôi khi bạn sẽ bỏ qua một số câu hỏi trong cuộc khảo sát này. Khi điều đó xảy ra, bạn sẽ
thấy một mũi tên với một lưu ý cho bạn biết những câu hỏi tiếp theo để bạn trả lời, như sau:
Có Nếu có, trả lời tiếp câu hỏi 1
O Không
______________________________________________________________________________
BỆNH NHÂN CỦA HOSPICE
1. Bạn có quan hệ như thế nào đối với
người đã được liệt kê trong thư khảo
sát?
O Vợ hoặc chồng của tôi
2
O Cha/ mẹ của tôi
3
O Cha/ mẹ vợ của tôi hoặc cha/ mẹ
1
chồng của tôi
O Ông bà nội/ngoại của tôi
5
O Cô/chú của tôi
6
O Anh/ chị/ em của tôi
7
O Con của tôi
8
O Bạn bè của tôi
9
O Khác (vui lòng viết ra):
4
2. Đối với cuộc điều tra này, cụm từ
"thành viên gia đình" đề cập đến
những người có tên trong thư khảo
sát. Ở những địa điểm nào thành viên
gia đình bạn được chăm sóc từ
Hospice này? Vui lòng chọn một hoặc
nhiều.
1
O Nhà
2
O Trung tâm trợ sinh
3
O Viện dưỡng lão
4
O Bệnh viện
5
O Cơ sở/ viện tế bần
6
O Khác (vui lòng viết ra):
_____________________________
______________________________
22
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
VAI TRÒ CỦA BẠN
3. Trong khi thành viên gia đình của bạn
đang được chăm sóc của Hospice care,
bạn có thường xuyên tham gia chăm
sóc hoặc quan sát người thân của bạn
hay không:
1
O Không bao giờ Nếu không bao
giờ, trả lời tiếp
câu 41
O Thỉnh thoảng
3
O Thường thường
4
O Luôn luôn
2
THÀNH VIÊN GIA ĐÌNH BẠN CỦA
HOSPICE CARE
Khi bạn trả lời các câu hỏi còn lại của
cuộc điều tra này, xin vui lòng chỉ nghĩ về
kinh nghiệm của thành viên gia đình bạn
với Hospice được đặt tên trên bìa khảo
sát.
4. Đối với khảo sát này, nhóm Hospice
bao gồm tất cả các y tá, bác sĩ, nhân
viên xã hội, giáo sĩ và những người
khác, người mà cung cấp dịch vụ
Hospice Care cho thành viên gia đình
của bạn. Trong thời gian thành viên
gia đình của bạn đang được Hospice
chăm sóc, bạn có cần gặp gỡ hay liên
lạc với nhóm Hospice trong thời gian
buổi tối, ngày nghỉ cuối tuần, hoặc
ngày lễ cho những vấn đề hoặc cần
giúp đỡ chăm sóc thành viên gia đình
của bạn?
1
2
O Có
O Không Nếu không, trả lời tiếp
câu 6
5. Bạn có thường xuyên nhận được sự
giúp đỡ mà bạn cần từ nhóm Hospice
vào buổi tối, cuối tuần hoặc là những
ngày nghỉ hay không?
O Không bao giờ
O Thỉnh thoảng
3
O Thường thường
4
O Luôn luôn
1
2
6. Trong khi thành viên gia đình bạn
đang được Hospice Care chăm sóc,
nhóm Hospice có thường xuyên thông
tin cho bạn biết về việc khi nào họ sẽ
đến để chăm sóc thành viên gia đình
của bạn?
O Không bao giờ
O Thỉnh thoảng
3
O Thường thường
4
O Luôn luôn
1
2
7. Trong thời gian thành viên gia đình
của bạn được Hospice Care chăm sóc,
khi bạn hay thành viên gia đình của
bạn yêu cầu sự giúp đỡ từ nhóm
Hospice, bạn có thường xuyên nhận
đươc sự giúp đỡ sớm nhất như bạn
cần không?
O Không bao giờ
O Thỉnh thoảng
3
O Thường thường
4
O Luôn luôn
1
2
8. Trong thời gian thành viên gia đình
của bạn được Hospice Care chăm sóc,
nhóm Hospice có thường xuyên giải
thích những vấn đề một cách dễ hiểu
không?
O Không bao giờ
2
O Thỉnh thoảng
3
O Thường thường
4
O Luôn luôn
1
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
23
9. Trong thời gian thành viên của gia
đình bạn được Hospice chăm sóc,
nhóm Hospice có thường xuyên thông
báo tình trạng của thành viên gia đình
bạn không?
O Không bao giờ
2
O Thỉnh thoảng
3
O Thường thường
4
O Luôn luôn
O Có
2
O Không Nếu không, trả lời tiếp
1
1
câu 15
10. Trong thời gian thành viên gia đình
của bạn được Hospice chăm sóc,
nhóm Hospice có thường xuyên cung
cấp cho bạn thông tin nhầm lẫn hoặc
mâu thuẫn về tình trạng hay sự chăm
sóc thành viên trong gia đình bạn hay
không?
O Không bao giờ
O Thỉnh thoảng
3
O Thường thường
4
O Luôn luôn
1
2
O Không bao giờ
O Thỉnh thoảng
3
O Thường thường
4
O Luôn luôn
1
2
24
O Không bao giờ
O Thỉnh thoảng
3
O Thường thường
4
O Luôn luôn
1
2
1
2
O Có
O Không Nếu không, trả lời tiếp
câu 17
16. Thành viên gia đình bạn có nhận được
nhiều sự giúp đỡ khi anh ấy/ cô ấy có
những cơn đau hay không?
O Có, chắc chắn rồi
O Có, một chút
3
O Không
1
2
12. Trong thời gian thành viên của gia
đình bạn được Hospice chăm sóc, bạn
có thường cảm thấy rằng nhóm
Hospice thực sự quan tâm đến gia
đình của bạn?
O Không bao giờ
2
O Thỉnh thoảng
3
O Thường thường
4
O Luôn luôn
14. Nhóm Hospice có thường xuyên lắng
nghe cẩn thận khi bạn nói chuyện với
họ về các vấn đề về thành viên của
bạn khi đang ở Hospice care?
15. Trong thời gian được Hospice chăm
sóc, người thân của bạn có bất kỳ cơn
đau nào không?
11. Trong thời gian thành viên gia đình
của bạn được Hospice chăm sóc,
nhóm Hospice có thường xuyên đối xử
tốt và tôn trọng với thành viên của gia
đình bạn?
1
13. Trong thời gian thành viên gia đình
của bạn đang ở Hospice care, bạn có
từng nói chuyện với nhóm Hospice
care về bất cứ vấn đề về thành viên
gia đình bạn với Hospice care?
17. Trong thời gian thành viên gia đình
của bạn được Hospice chăm sóc, họ có
nhận bất kỳ thuốc giảm đau nào
không?
1
2
O Có
O Không Nếu không, trả lời tiếp
câu 21
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
18. Tác dụng phụ của thuốc giảm đau
bao gồm những việc như gây buồn
ngủ. Đã bất kỳ thành viên nào của
nhóm Hospice thảo luận về tác dụng
phụ của thuốc giảm đau với bạn
hoặc thành viên gia đình của bạn?
O Có, chắc chắn rồi
O Có, một chút
3
O Không
1
2
19. Nhóm Hospice có dạy hoặc hướng dẫn
cho bạn về những tác dụng phụ của
thuốc giảm đau không?
O Có, chắc chắn rồi
O Có, một chút
3
O Không
1
2
20. Nhóm Hospice có hướng dẫn cho bạn
khi đưa nhiều hơn thuốc giảm đau cho
thành viên gia đình bạn hay không?
O Có, chắc chắn rồi
O Có, một chút
3
O Không
4
O Tôi đã không cần thuốc giảm đau
1
2
cho thành viên gia đình tôi
21. Trong thời gian thành viên gia đình
của bạn được Hospice chăm sóc, họ có
từng bị khó thở hoặc nhận được sự
điều trị khi bị khó thở không?
1
2
O Có
O Không Nếu không, trả lời tiếp
câu 24
23. Nhóm Hospice có hướng dẫn hoặc dạy
cho bạn cách xử lý khi thành viên gia
đình của bạn gặp vấn đề khó thở hay
không?
O Có, chắc chắn rồi
O Có, một chút
3
O Không
4
O Tôi đã không cần trợ giúp thành
1
2
viên gia đình tôi khi gặp vấn đề
khó thở
24. Trong thời gian được Hospice chăm
sóc, có bao giờ thành viên gia đình
bạn gặp vấn đề táo bón?
1
2
O Có
O Không Nếu không, trả lời tiếp
câu 26
25. Thành viên gia đình bạn có thường
xuyên nhận được sự trợ giúp hoặc họ
có cần sự trợ giúp khi gặp vấn đề táo
bón không?
O Không bao giờ
O Thỉnh thoảng
3
O Thường thường
4
O Luôn luôn
1
2
26. Trong thời gian thành viên gia đình
bạn đươc Hospice chăm sóc, họ có thể
hiện bất kỳ sự lo lắng hay buồn bã
nào không?
1
2
22. Thành viên gia đình của bạn có
thường xuyên nhận được sự giúp đỡ
khi họ cần lúc bị khó thở hay không?
O Có
O Không Nếu không, trả lời tiếp
câu 28
O Không bao giờ
2
O Thỉnh thoảng
3
O Thường thường
4
O Luôn luôn
1
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
25
27. Thành viên gia đình bạn có thường
xuyên nhận được sự giúp đỡ hay họ
cần sự giúp đỡ từ nhóm Hospice khi
họ lo lắng hay khi họ buồn hay
không?
O Không bao giờ
2
O Thỉnh thoảng
3
O Thường thường
4
O Luôn luôn
1
2
O Có, chắc chắn rồi
O Có, một chút
3
O Không
1
2
28. Trong thời gian thành viên gia đình
bạn được Hospice chăm sóc, có bao
giờ anh ấy/cô ấy trở nên không ngủ
được hoặc bị kích động không?
1
31. Nhóm Hospice có thông báo cho bạn
nhiều thông tin như bạn muốn về
những điều mong đợi khi thành viên
gia đình bạn đang hấp hối?
O Có
O Không Nếu không, trả lời tiếp
câu 30
29. Nhóm Hospice có hướng dẫn cho bạn
cách xử lý nếu thành viên của gia đình
bạn trở nên không ngủ được hoặc bị
kích động không?
O Có, chắc chắn rồi
O Có, một chút
3
O Không
1
2
30. Di chuyển thành viên gia đình bạn bao
gồm những việc như giúp anh ấy/cô ấy
lật người trên giường, hoặc lên xuống
giường hay xe lăn. Nhóm Hospice có
hướng dẫn cho bạn cách di chuyển
thành viên gia đình bạn một cách toàn
không?
NHẬN ĐƯỢC SỰ CHĂM SÓC CỦA
HOSPICE CARE TRONG VIỆN
DƯỠNG LÃO
32. Vài người nhận được sự chăm sóc từ
Hospice khi họ đang sống ở viện
dưỡng lão. Gia đình bạn có nhận đươc
chăm sóc từ Hospice này trong khi
anh ấy/cô ấy đang sống ở viện dưỡng
lão hay không?
1
2
O Có
O Không Nếu không, trả lời tiếp
câu 35
33. Trong thời gian thành viên gia đình
bạn được Hospice chăm sóc, nhân
viên viện dưỡng lão và nhóm Hospice
có thường xuyên làm việc chung để
chăm sóc tốt cho thành viên gia đình
bạn hay không?
O Không bao giờ
O Thỉnh thoảng
3
O Thường thường
4
O Luôn luôn
1
2
O Có, chắc chắn rồi
O Có, một chút
3
O Không
4
O Tôi không cần dịch chuyển thành
1
2
viên gia đình tôi
26
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
34. Trong thời gian thành viên gia đình
bạn được Hospice chăm sóc, có bao
giờ thông tin được cung cấp cho thành
viên gia đình bạn từ nhân viên của
viện dưỡng lão và nhóm Hospice là
khác nhau không?
O Không bao giờ
O Thỉnh thoảng
3
O Thường thường
4
O Luôn luôn
1
2
KINH NGHIỆM CỦA BẢN THÂN
BẠN
VỚI HOSPICE
35. Trong thời gian thành viên gia đình
bạn được Hospice chăm sóc, nhóm
Hospice có thường xuyên lắng nghe ý
kiến của bạn một cách cẩn thận
không?
O Không bao giờ
O Thỉnh thoảng
3
O Thường thường
4
O Luôn luôn
1
2
36. Về việc hỗ trợ cho các hoạt động về
tôn giáo hay tín ngưỡng tâm linh bao
gồm việc trò chuyện, cầu nguyện, thời
gian yên tĩnh, hoặc các hoạt động hội
họp về tôn giáo và các nhu cầu tín
ngưỡng. Trong thời gian thành viên
gia đình bạn được Hospice chăm sóc,
nhóm Hospice có hỗ trợ các hoạt động
về tôn giáo hay tín ngưỡng tâm linh
cho bạn không?
O Rất ít
2
O Đúng mức, vừa phải
3
O Rất nhiều
1
37. Trong thời gian thành viên gia đình
bạn được Hospice chăm sóc, mức độ
hỗ trợ nhiệt tình từ nhóm Hospice đối
với gia đình bạn như thế nào?
O Rất ít
O Đúng mức, vừa phải
3
O Rất nhiều
1
2
38. Trong những tuần sau khi thành viên
của gia đình bạn qua đời, mức độ hỗ
trợ nhiệt tình từ nhóm Hospice đối với
gia đình bạn như thế nào?
O Rất ít
2
O Đúng mức, vừa phải
3
O Rất nhiều
1
Centers for Medicare & Medicaid Services
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ĐÁNH GIÁ TỔNG THỂ VỀ
HOSPICE CARE
THÔNG TIN THÀNH VIÊN GIA
39. Vui lòng trả lời các câu hỏi dưới đây
về sự chăm sóc thành viên gia đình
bạn từ Hospice được đặt tên trên bìa
khảo sát. Không bao gồm sự chăm sóc
từ các Hospice khác trong câu trả lời
của bạn.
41. Trình độ học vấn cao nhất của thành
viên gia đình bạn đã hoàn thành là gì?
Sử dụng số từ 0 đến 10, số 0 thể hiện
mức độ chăm sóc tệ nhất, 10 thể hiện
mức độ chăm sóc tốt nhất, con số nào
để bạn đánh giá mức độ chăm sóc từ
Hospice cho thành viên gia đình bạn?
0 Hospice chăm sóc tồi tệ nhất có
thể
1
O1
2
O2
3
O3
4
O4
5
O5
6
O6
7
O7
8
O8
9
O9
10
O 10 Hospice chăm sóc tốt nhất có
thể
0
O
40. Bạn có đề xuất Hospice care này cho
bạn bè và gia đình bạn không?
O Chắc chắn là không
2
O Có thể không
3
O Có thể có
4
O Chắc chắn là có
1
ĐÌNH CỦA BẠN
1
2
O Lớp 8 hoặc thấp hơn
O Trung học phổ thông, nhưng chưa
tốt nghiệp phổ thông
O Tốt nghiệp trung học phổ thông
hoặc tương đương GED
4
O Cao đẳng hoặc Khoá học 2 năm
5
O Tốt nghiệp cao đẳng hệ 4 năm
6
O Tốt nghiệp cao đẳng trên 4 năm
học
7
O Không biết
3
42. Thành viên gia đình bạn là người Tây
Ban Nha, La tinh/ hay có gốc Nam Mỹ
không?
1
O Không, không phải người Tây Ban
Nha/ gốc Nam Mỹ/ người La Tinh
O Phải, Puerto Rican
3
O Phải, người Mễ Tây Cơ, người Mỹ
gốc Mễ Tây Cơ, người Chicano
(người gốc Mễ Tây Cơ sinh tại
Mỹ)
4
O Phải, Cuba
5
O Phải, người Tây Ban Nha, người
gốc Nam Mỹ/ La Tinh
2
43. Chủng tộc của thành viên gia đình
bạn là gì? Vui lòng chọn một hoặc
nhiều hơn.
1
2
O Người da Trắng
O Người da Đen hoặc người Mỹ gốc
Phi
O Người Châu Á
4
O Người có nguồn gốc đảo Hawaii
hay đảo khác ở Thái Bình Dương
5
O Người có nguồn gốc từ bất cứ sắc
dân bản địa nào ở Bắc Mỹ và Nam
Mỹ
3
28
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
THÔNG TIN VỀ BẠN
44. Bạn bao nhiêu tuổi?
O 18 đến 24
2
O 25 đến 34
3
O 35 đến 44
4
O 45 đến 54
5
O 55 đến 64
6
O 65 đến 74
7
O 75 đến 84
8
O 85 hoặc trên 85
1
45. Bạn là nam hay nữ?
O Nam
2
O Nữ
1
46. Trình độ học vấn cao nhất mà bạn đã
hoàn thành là gì?
1
2
O Lớp 8 hoặc thấp hơn
O Trung học phổ thông, nhưng chưa
tốt nghiệp phổ thông
O Tốt nghiệp trung học phổ thông
hoặc tương đương GED
4
O Cao đẳng hoặc Khoá học 2 năm
5
O Tốt nghiệp cao đẳng hệ 4 năm
6
O Tốt nghiệp cao đẳng trên 4 năm
học
3
47. Ngôn ngữ bạn sử dụng chính để giao
tiếp ở nhà là gì?
O Tiếng Anh
O Tiếng Tây Ban Nha
3
O Tiếng Trung Quốc
4
O Tiếng Nga
5
O Tiếng Bồ Đào Nha
6
O Tiếng Việt
7
O Tiếng Ba Lan
8
O Tiếng Hàn Quốc
9
O Ngôn ngữ khác (vui lòng viết ra):
1
2
____________________________
CHÂN THÀNH CÁM ƠN QUÝ VỊ
Vui lòng dùng bao thư đính kèm có sẵn bưu phí và gửi trở lại bản thăm dò ý kiến sau khi
trả lời đầy đủ.
[NAME OF SURVEY VENDOR]
[RETURN ADDRESS OF SURVEY VENDOR]
Centers for Medicare & Medicaid Services
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Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
Sample Initial Cover Letter for the CAHPS Hospice Survey
[HOSPICE OR VENDOR LETTERHEAD]
[SAMPLED CAREGIVER NAME]
[ADDRESS]
[CITY, STATE ZIP]
Kính thưa [SAMPLED CAREGIVER NAME]:
[HOSPICE NAME] đang tiến hành một cuộc khảo sát về dịch vụ hospice mà bệnh nhân và gia
đình họ nhận được. Bạn được chọn cho cuộc khảo sát này vì bạn được xác định là người đã chăm
sóc cho [DECEDENT NAME]. Chúng tôi nhận thấy điều này có thể là thời gian khó khăn đối với
bạn, nhưng chúng tôi hy vọng rằng, bạn sẽ giúp chúng tôi tìm hiểu về chất lượng mà bạn và thành
viên gia đình hay bạn bè của bạn nhận được sự chăm sóc.
Câu hỏi [NOTE THE QUESTION NUMBERS] trong cuộc khảo sát được đính kèm là một phần
sáng kiến quốc gia được tài trợ bởi Bộ Y tế và Dịch vụ Nhân sinh Hoa Kỳ (HHS) để đo lường chất
lượng chăm sóc của hospices. Dịch vụ Bảo hiểm Y tế Người già và Trợ giúp Bảo hiểm Y tế Người
nghèo (CMS) – một phần của HHS – đang tiến hành cuộc khảo sát này để nâng cao dịch vụ chăm
sóc. CMS chi cho hầu hết cho việc chăm sóc tại hospice care ở Hoa Kỳ. Đó là trach nhiêm của
CMS để đảm bảo rằng, bệnh nhân của hospice và người thân hay bạn bè của họ có được sự chăm
sóc với chất lượng cao nhất. Một trong những cách để họ có thể thực hiện trách nhiệm này là để
tìm hiểu trực tiếp từ bạn về dịch vụ chăm sóc hospice mà người thân hay gia đình bạn nhận được.
Sự tham gia của bạn là tình nguyện và sẽ không có bất kỳ ảnh hưởng nào đến vấn đề sức khỏe hay
quyền lợi mà bạn nhận được.
Chúng tôi hy vọng rằng, bạn sẽ dành thời gian để hoàn thành cuộc khảo sát này. Sau khi bạn hoàn
thành cuộc khảo sát, vui lòng gửi trả lại vào phong bì trả trước. Câu trả lời của bạn có thể được
chia sẻ với hospice với mục đích cải thiện chất lượng. [OPTIONAL: Bạn có thể chú ý đến con số
trong cuộc khảo sát của bạn. Con số này được sử dụng để cho chúng tôi biết nếu bạn hoàn trả bảng
khảo sát của bạn, vì vậy, chúng tôi không phải nhắc nhở bạn.]
Nếu bạn có bất kỳ câu hỏi gì về khảo sát đính kèm, vui lòng gọi miễn phí tới số điện thoại 1-800xxx-xxxx. Cảm ơn sự giúp đỡ của bạn để cải thiện dịch vụ chăm sóc của Hospice cho tất cả các
khách hàng.
Chân thành cảm ơn,
[HOSPICE ADMINISTRATOR]
[HOSPICE NAME]
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Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
Sample Follow-up Cover Letter for the CAHPS Hospice
Survey
[HOSPICE OR VENDOR LETTERHEAD]
[SAMPLED CAREGIVER NAME]
[ADDRESS]
[CITY, STATE ZIP]
Kính thưa [SAMPLED CAREGIVER NAME]:
Hồ sơ của chúng tôi cho thấy rằng, cách đây không lâu, bạn là người chăm sóc cho [DECEDENT
NAME] tại [NAME OF HOSPICE]. Khoảng ba tuần trước, chúng tôi đã gửi cho bạn một khảo sát
liên quan đến việc chăm sóc mà bạn và các thành viên gia đình hay bạn bè của bạn đã nhận từ hay
hospice của chúng tôi. Nếu bạn đã gửi trả lại khảo sát đó cho chúng tôi, xin hãy vui lòng đón nhận
lời cảm ơn và bỏ qua lá thư này. Tuy nhiên, nếu bạn chưa gửi trả bản khảo sát đó, chúng tôi thực
sự cảm kích nếu bạn dành thời gian để hoàn thành bảng câu hỏi quan trọng này.
Chúng tôi hy vọng, bạn sẽ tận dụng cơ hội này để giúp chúng tôi tìm hiểu về chất lượng chăm sóc
thành viên gia đình hay bạn bè của bạn đã nhận được. Kết quả từ cuộc khảo sát này sẽ được sử
dụng để đảm bảo rằng, tất cả người Mỹ có được sự chăm sóc với chất lượng cao nhất từ hospice
care.
Những câu hỏi [NOTE THE QUESTION NUMBERS] trong cuộc khảo sát được đính kèm là một
phần của một sáng kiến quốc gia được tài trợ bởi Bộ Y tế và Dịch vụ Nhân sinh Hoa Kỳ (HHS) để
đo lường chất lượng của việc chăm sóc tại hospices. Dịch vụ Bảo hiểm Y tế Người già và Trợ giúp
Bảo hiểm Y tế Người nghèo (CMS) – một phần của HHS – đang tiến hành cuộc khảo sát này để
nâng cao dịch vụ chăm sóc. CMS chi cho hầu hết cho việc chăm sóc tại hospice care ở Hoa Kỳ.
Đó là trach nhiêm của CMS để đảm bảo rằng, bệnh nhân của hospice và người thân hay bạn bè
của họ có được sự chăm sóc với chất lượng cao nhất. Một trong những cách để họ có thể thực hiện
trách nhiệm này là để tìm hiểu trực tiếp từ bạn về dịch vụ chăm sóc hospice care mà người thân
hay gia đình bạn nhận được.
Vui lòng dành một vài phút và hoàn thành khảo sát được đính kèm. Sau khi bạn hoàn thành bảng
khảo sát, vui lòng gửi trả lại vào trong phong bì trả trước. Câu trả lời của bạn có thể được chia sẻ
với các hospice với mục đích cải thiện chất lượng. [OPTIONAL: Bạn có thể chú ý đến con số
trong cuộc khảo sát của bạn. Con số này được sử dụng để cho chúng tôi biết nếu bạn hoàn trả bảng
khảo sát của bạn, vì vậy, chúng tôi không phải nhắc nhở bạn.]
Nếu bạn có bất kỳ câu hỏi gì về khảo sát đính kèm, vui lòng gọi miễn phí tới số điện thoại 1-800xxx-xxxx. Cảm ơn sự giúp đỡ của bạn để cải thiện dịch vụ chăm sóc của Hospice cho tất cả các
khách hàng.
Chân thành cảm ơn,
[HOSPICE ADMINISTRATOR]
[HOSPICE NAME]
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
33
34
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
OMB Paperwork Reduction Act Language
The OMB Paperwork Reduction Act language must appear in the mailing, either on the cover
letter or on the front or back of the questionnaire. In addition, the OMB control number must
appear on the front page of the questionnaire. The following is the language that must be used:
Vietnamese Version
“Thể theo Đạo luật Giảm thiểu Thủ tục Giấy tờ năm 1995, không một ai bị bắt buộc phải trả lời
và cung cấp thông tin trừ khi trên bản câu hỏi có ghi rõ số kiểm soát OMB có hiệu lực. Số kiểm
soát OMB có hiệu lực cho bản thu thập thông tin này là 0938-1257 (Hết hạn vào ngày 31/12/2020).
Thời gian cần thiết để hoàn thành bản thu thập thông tin này được ước tính trung bình 11 phút cho
các câu hỏi từ 1 – 40, những câu hỏi “Giới thiệu Thành viên Gia đình Bạn” và những câu hỏi
“Thông tin về Bạn” trong cuộc khảo sát, bao gồm thời gian để xem xét hướng dẫn, tìm kiếm các
nguồn dữ liệu hiện có, thu thập các dữ liệu cần thiết, hoàn thành và xem xét lại việc thu thập thông
tin. Nếu quý vị có ý kiến gì về mức chính xác của thời gian ước tính hoặc đề nghị gì trong việc
đơn giản hóa bản thăm dò ý kiến này, vui lòng gửi thư về: Centers for Medicare & Medicaid
Services, 7500 Security Boulevard, C1-25-05, Baltimore, MD 21244-1850.”
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
35
36
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
Appendix U
Mail Survey Materials (Polish)
CAHPS® Ankieta na temat usług hospicjum
Proszę odpowiedzieć na pytania ankiety dotyczące opieki, jaką pacjent uzyskał we
wskazanym poniżej hospicjum:
[NAME OF HOSPICE]
Wszystkie pytania tej ankiety będą dotyczyć doświadczeń związanych z wyżej
wymienionym hospicjum.
Aby dowiedzieć się więcej na temat tej ankiety, proszę zadzwonić pod [TOLL FREE
NUMBER]. Wszystkie połączenia z tym numerem są bezpłatne.
OMB#0938-1257
Traci ważność dnia 31.12.2020
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
1
CAHPS® Ankieta na temat usług hospicjum
WSKAZÓWKI DO ANKIETY
♦
Proszę przekazać tę ankietę domownikowi, który wie najwięcej o opiece hospicyjnej,
zapewnianej osobie wymienionej w liście przewodnim dołączonym do tej ankiety.
♦
Proszę wypełnić ankietę ciemnym długopisem.
♦
Proszę postawić X wewnątrz kratki przy wybranej odpowiedzi, jak w poniższym
przykładzie.
Tak
Nie
♦
Czasami prosimy o opuszczenie niektórych pytań ankiety. W takim przypadku
widoczna będzie strzałka z informacją, do którego pytania należy przejść, na przykład:
Tak Jeżeli Tak, proszę przejść do Pytania 1
Nie
PACJENT HOSPICJUM
1. Kim jest dla Pana/Pani osoba
wymieniona w liście
towarzyszącym tej ankiecie?
1
4
5
6
7
8
9
2
3
2
Mój współmałżonek/ka lub
partner/ka
Mój rodzic
Moja teściowa lub teść
Moja babcia lub dziadek
Moja ciotka lub wujek
Moja siostra lub brat
Moje dziecko
Moja przyjaciółka lub przyjaciel
Inne (proszę wpisać
drukowanymi literami):
2. W tej ankiecie zwrot „członek
rodziny” oznacza osobę
wymienioną w liście przewodnim
dołączonym do tej ankiety.
W jakich lokalizacjach członek
rodziny korzystał z opieki tego
hospicjum? Proszę wybrać jedną
lub więcej odpowiedzi:
1
2
3
5
6
4
Dom
Ośrodek opieki
z zamieszkaniem (Assisted
living facility)
Dom opieki pielęgniarskiej
(Nursing home)
Szpital
Ośrodek / dom hospicjum
Inne (proszę wpisać
drukowanymi literami):
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
PANA/PANI ROLA
3. Kiedy członek rodziny był pod
opieką hospicjum, jak często
uczestniczył/a Pan/Pani w tej
opiece lub nadzorował/a ją?
1
3
4
2
Nigdy Jeżeli Nigdy, proszę
przejść do Pytania 41
Czasami
Zazwyczaj
Zawsze
OPIEKA HOSPICJUM NAD
CZŁONKIEM RODZINY
Odpowiadając na pozostałe pytania
tej ankiety, prosimy wziąć pod uwagę
tylko doświadczenia członka rodziny
związane z hospicjum, którego nazwa
podana jest na stronie tytułowej
ankiety.
4. W tej ankiecie personel hospicjum
oznacza wszystkie pielęgniarki,
wszystkich lekarzy, pracowników
socjalnych, kapelanów i inne
osoby, które zapewniały opiekę
hospicyjną członkowi Pana/Pani
rodziny. Kiedy członek rodziny
był pod opieką hospicjum, czy
musiał/a Pan/Pani kontaktować
się z personelem hospicjum
wieczorami, w weekendy, albo w
święta w sprawie pytań lub
pomocy w opiece nad członkiem
rodziny?
1
2
Tak
Nie Jeżeli Nie, proszę
przejść do Pytania 6
5. Jak często uzyskiwał/a Pan/Pani
potrzebną pomoc personelu
hospicjum wieczorami,
w weekendy, albo w święta?
2
3
4
1
Nigdy
Czasami
Zazwyczaj
Zawsze
6. Kiedy członek rodziny był pod
opieką hospicjum, jak często
personel hospicjum informował
Pana/Panią, kiedy ktoś przyjdzie,
aby zaopiekować się członkiem
rodziny?
3
4
1
2
Nigdy
Czasami
Zazwyczaj
Zawsze
7. Kiedy członek rodziny był pod
opieką hospicjum i Pan/Pani albo
członek rodziny prosił personel
hospicjum o pomoc, jak często
zapewniana ona była tak szybko,
jak była potrzebna?
2
3
4
1
Nigdy
Czasami
Zazwyczaj
Zawsze
8. Kiedy członek rodziny był pod
opieką hospicjum, jak często
personel hospicjum wyjaśniał
różne informacje w przystępny
sposób?
2
3
4
1
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
Nigdy
Czasami
Zazwyczaj
Zawsze
3
9. Kiedy członek rodziny był pod
opieką hospicjum, jak często
personel hospicjum przekazywał
Panu/Pani informacje na temat
stanu członka rodziny?
2
3
4
1
3
4
1
Nigdy
Czasami
Zazwyczaj
Zawsze
2
10. Kiedy członek rodziny był pod
opieką hospicjum, jak często ktoś
z personelu hospicjum
przekazywał Panu/Pani mylące lub
sprzeczne informacje na temat
stanu członka rodziny lub opieki
nad nim?
3
4
1
2
Nigdy
Czasami
Zazwyczaj
Zawsze
11. Kiedy członek rodziny był pod
opieką hospicjum, jak często
personel hospicjum traktował
członka rodziny z szacunkiem
i godnością?
3
4
1
2
Nigdy
Czasami
Zazwyczaj
Zawsze
12. Kiedy członek rodziny był pod
opieką hospicjum, jak często
miał/a Pan/Pani wrażenie, że
zespół hospicjum naprawdę
troszczy się o członka rodziny?
13. Kiedy członek rodziny był pod
opieką hospicjum, czy
rozmawiał/a Pan/Pani z zespołem
hospicjum na temat problemów
związanych z opieką hospicjum
nad członkiem rodziny?
2
1
Tak
Nie Jeżeli Nie, proszę
przejść do Pytania 15
14. Jak często personel hospicjum
słuchał Pana/Pani uważnie, kiedy
mówił/a Pan/Pani o problemach
związanych z opieką hospicjum
nad członkiem rodziny?
3
4
1
2
Nigdy
Czasami
Zazwyczaj
Zawsze
15. Czy członek rodziny odczuwał
jakikolwiek ból, kiedy był pod
opieką hospicjum?
1
2
4
Nigdy
Czasami
Zazwyczaj
Zawsze
Tak
Nie Jeżeli Nie, proszę
przejść do Pytania 17
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
16. Czy członek rodziny otrzymywał
tyle pomocy w opanowaniu bólu,
ile potrzebował?
3
1
2
Zdecydowanie tak
W pewnym stopniu tak
Nie
17. Czy członek rodziny otrzymywał
jakiś lek przeciwbólowy, kiedy był
pod opieką hospicjum?
1
2
Tak
Nie Jeżeli Nie, proszę
przejść do Pytania 21
18. Skutki uboczne leków
przeciwbólowych obejmują np.
senność. Czy ktoś z personelu
hospicjum rozmawiał
z Panem/Panią lub członkiem
rodziny o skutkach ubocznych
leków przeciwbólowych?
3
1
2
Zdecydowanie tak
W pewnym stopniu tak
Nie
19. Czy personel hospicjum
przeszkolił Pana/Panią w zakresie
skutków ubocznych leków
przeciwbólowych, na które trzeba
uważać?
3
1
2
20. Czy personel hospicjum
przeszkolił Pana/Panią na temat
okoliczności, w których należy
podawać członkowi rodziny więcej
leków przeciwbólowych?
3
4
1
2
Zdecydowanie tak
W pewnym stopniu tak
Nie
Nie potrzebowałem/am
podawać leków
przeciwbólowych członkowi
rodziny
21. Czy członek rodziny miał
trudności z oddychaniem lub był
leczony z powodu trudności
z oddychaniem, kiedy był pod
opieką hospicjum?
2
1
Tak
Nie Jeżeli Nie, proszę
przejść do Pytania 24
22. Jak często członek rodziny
otrzymywał potrzebną pomoc
z powodu trudności
z oddychaniem?
2
3
4
1
Nigdy
Czasami
Zazwyczaj
Zawsze
Zdecydowanie tak
W pewnym stopniu tak
Nie
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
5
23. Czy personel hospicjum
przeszkolił Pana/Panią na temat
sposobów udzielania pomocy
członkowi rodziny w przypadku
trudności z oddychaniem?
2
3
4
1
Zdecydowanie tak
W pewnym stopniu tak
Nie
Nie potrzebowałem/am udzielać
pomocy członkowi rodziny z
powodu trudności
z oddychaniem
24. Czy członkowi rodziny dokuczały
kiedykolwiek zaparcia, kiedy był
pod opieką hospicjum?
2
1
Tak
Nie Jeżeli Nie, proszę
przejść do Pytania 26
25. Jak często członek rodziny
otrzymywał potrzebną pomoc w
związku z zaparciami?
3
4
1
2
Nigdy
Czasami
Zazwyczaj
Zawsze
27. Jak często członek rodziny
otrzymywał od personelu
hospicjum potrzebną pomoc w
związku z odczuwanym lękiem lub
smutkiem?
3
4
1
2
Nigdy
Czasami
Zazwyczaj
Zawsze
28. Czy członek rodziny wykazywał
kiedykolwiek niepokój ruchowy
lub pobudzenie, kiedy był pod
opieką hospicjum?
2
1
Tak
Nie Jeżeli Nie, proszę
przejść do Pytania 30
29. Czy personel hospicjum
przeszkolił Pana/Panią na temat
sposobów udzielania pomocy
członkowi rodziny w przypadku
niepokoju ruchowego lub
pobudzenia?
2
3
1
Zdecydowanie tak
W pewnym stopniu tak
Nie
26. Czy członek rodziny okazywał
kiedykolwiek lęk lub smutek,
kiedy był pod opieką hospicjum?
1
2
6
Tak
Nie Jeżeli Nie, proszę
przejść do Pytania 28
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
30. Pomoc członkowi rodziny w
poruszaniu się obejmuje takie
czynności jak pomoc przy
obracaniu się na łóżku, wstawaniu
z łóżka lub wózka inwalidzkiego.
Czy personel hospicjum zapewnił
Panu/Pani szkolenie na temat
tego, jak bezpiecznie pomagać
członkowi rodziny w poruszaniu
się?
2
3
4
1
Zdecydowanie tak
W pewnym stopniu tak
Nie
Nie potrzebowałem/am
pomagać członkowi rodziny
w poruszaniu się
31. Czy personel hospicjum przekazał
Panu/Pani wszystkie informacje,
jakie chciał/a Pan/Pani uzyskać na
temat tego, czego należy
oczekiwać w czasie, kiedy członek
rodziny umiera?
2
3
1
Zdecydowanie tak
W pewnym stopniu tak
Nie
OPIEKA HOSPICJUM
ŚWIADCZONA W DOMU OPIEKI
PIELĘGNIARSKIEJ
32. Niektórzy pacjenci mają
zapewnianą opiekę hospicyjną,
kiedy przebywają w domu opieki
pielęgniarskiej. Czy członek
rodziny miał zapewnioną opiekę
tego hospicjum, kiedy przebywał
w domu opieki pielęgniarskiej?
2
1
33. Kiedy członek rodziny był pod
opieką hospicjum, jak często
personel domu opieki
pielęgniarskiej współpracował
z personelem hospicjum
w zapewnianiu mu opieki?
2
3
4
1
Nigdy
Czasami
Zazwyczaj
Zawsze
34. Kiedy członek rodziny był pod
opieką hospicjum, jak często
informacje na temat członka
rodziny przekazywane przez
personel domu opieki
pielęgniarskiej różniły się od tych,
które przekazywał personel
hospicjum?
3
4
1
2
Nigdy
Czasami
Zazwyczaj
Zawsze
PANA/PANI WŁASNE
DOŚWIADCZENIA ZWIĄZANE
Z HOSPICJUM
35. Jak często personel hospicjum
słuchał Pana/Pani uważnie, kiedy
członek rodziny był pod opieką
hospicjum?
3
4
1
2
Nigdy
Czasami
Zazwyczaj
Zawsze
Tak
Nie Jeżeli Nie, proszę
przejść do Pytania 35
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
7
36. Wsparcie dla wierzeń religijnych
czy innych form duchowości
obejmuje rozmowy, modlitwę,
czas spędzany w ciszy i inne
sposoby zaspakajania potrzeb
religijnych lub duchowych. Kiedy
członek rodziny był pod opieką
hospicjum, jak wiele wsparcia dla
Pana/Pani wierzeń religijnych czy
innych form duchowości
otrzymał/a Pan/Pani od personelu
hospicjum?
3
1
2
Za mało
Wystarczająco
Za dużo
37. Jak wiele wsparcia
emocjonalnego dostarczał
Panu/Pani personel hospicjum,
kiedy członek rodziny był pod
opieką hospicjum?
3
1
2
Za mało
Wystarczająco
Za dużo
3
2
Za mało
Wystarczająco
Za dużo
39. Odpowiadając na kolejne pytania
ankiety, prosimy wziąć pod uwagę
opiekę, jaką członek rodziny
otrzymał ze strony hospicjum,
którego nazwa podana jest na
stronie tytułowej ankiety. Prosimy
nie uwzględniać w odpowiedziach
opieki świadczonej przez inne
hospicja.
Posługując się skalą od 0 do 10,
na której 0 oznacza najgorszą
możliwą opiekę hospicjum, a 10
oznacza najlepszą możliwą opiekę
hospicjum, jak ocenił/a/by
Pan/Pani opiekę hospicjum, jaką
otrzymał członek Pana/Pani
rodziny?
0
2
3
4
5
6
7
8
9
10
1
38. Jak wiele wsparcia
emocjonalnego otrzymała/a
Pan/Pani od personelu hospicjum
w tygodniach po śmierci członka
Pana/Pani rodziny?
1
OGÓLNA OCENA OPIEKI
HOSPICJUM
0 Najgorsza możliwa opieka
hospicjum
1
2
3
4
5
6
7
8
9
10 Najlepsza możliwa opieka
hospicjum
40. Czy polecił/a/by Pan/Pani to
hospicjum znajomym i rodzinie?
3
4
1
2
8
Na pewno nie
Chyba nie
Chyba tak
Na pewno tak
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
INFORMACJE O CZŁONKU
RODZINY
41. Jaki najwyższy poziom
wykształcenia lub ile klas szkoły
ukończył członek rodziny?
2
1
3
4
6
5
7
8 klas lub mniej
Rozpoczęta, ale nie ukończona
szkoła średnia
Ukończona szkoła średnia lub
zdany egzamin GED
Niepełne studia lub dyplom po
studium 2-letnim
Skończone studia 4-letnie
Więcej niż skończone studia 4letnie
Nie wiem
42. Czy członek Pana/Pani rodziny był
Latynosem/pochodzenia
iberyjskiego lub miał przodków
pochodzenia latynoskiego/
iberyjskiego?
1
3
2
4
5
Nie, nie był Latynosem/
pochodzenia iberyjskiego
Tak, Portorykańczyk
Tak, Meksykanin, Amerykanin
pochodzenia meksykańskiego
(Chicano)
Tak, Kubańczyk
Tak, innego pochodzenia
latynoskiego/ iberyjskiego
43. Jakiej rasy był członek Pana/Pani
rodziny? Proszę wybrać co
najmniej jedną odpowiedź.
3
4
1
2
5
Rasa biała
Rasa czarna - Afroamerykanin
Rasa azjatycka
Rodowity mieszkaniec Hawajów
lub innych wysp Pacyfiku
Rodowity Indianin lub
Alaskańczyk
INFORMACJE O PANU/PANI
44. Proszę podać swój wiek:
2
3
4
5
6
7
8
1
18 do 24 lat
25 do 34 lat
35 do 44 lat
45 do 54 lat
55 do 64 lat
65 do 74 lat
75 do 84 lat
85 lat lub więcej
45. Proszę podać swoją płeć:
2
1
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
Mężczyzna
Kobieta
9
46. Jaki jest najwyższy poziom
Pana/Pani wykształcenia lub
liczba ukończonych klas?
2
1
3
4
6
5
47. Jakim językiem głównie mówi
Pan/Pani w domu?
3
4
5
6
7
8
9
1
8 klas lub mniej
Rozpoczęta, ale nie ukończona
szkoła średnia
Ukończona szkoła średnia lub
zdany GED
Niepełne studia lub dyplom po
studium 2-letnim
Skończone studia 4-letnie
Więcej niż skończone studia 4letnie
2
Angielski
Hiszpański
Chiński
Rosyjski
Portugalski
Wietnamski
Polski
Koreański
Inny język (proszę wpisać
drukowanymi literami):
DZIĘKUJEMY
Prosimy odesłać wypełnioną ankietę w załączonej kopercie z opłaconymi
kosztami przesyłki zwrotnej.
[NAME OF SURVEY VENDOR]
[RETURN ADDRESS OF SURVEY VENDOR]
10
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
CAHPS® Ankieta na temat usług hospicjum
Proszę odpowiedzieć na pytania ankiety dotyczące opieki, jaką pacjent uzyskał we
wskazanym poniżej hospicjum:
[NAME OF HOSPICE]
Wszystkie pytania tej ankiety będą dotyczyć doświadczeń związanych z wyżej
wymienionym hospicjum.
Aby dowiedzieć się więcej na temat tej ankiety, proszę zadzwonić pod [TOLL FREE
NUMBER]. Wszystkie połączenia z tym numerem są bezpłatne.
OMB#0938-1257
Traci ważność dnia 31.12.2020
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
11
CAHPS® Ankieta na temat usług hospicjum
WSKAZÓWKI DO ANKIETY
♦
Proszę przekazać tę ankietę domownikowi, który wie najwięcej o opiece hospicyjnej,
zapewnianej osobie wymienionej w liście przewodnim dołączonym do tej ankiety.
♦
Proszę wypełnić ankietę ciemnym długopisem.
♦
Odpowiedz na wszystkie pytania, wypełniając całkowicie kółko znajdujące się z
lewej strony wybranej odpowiedzi.
0 Tak
Nie
♦
Czasami prosimy o opuszczenie niektórych pytań ankiety. W takim przypadku
widoczna będzie strzałka z informacją, do którego pytania należy przejść, na przykład:
Tak Jeżeli Tak, proszę przejść do Pytania 1
0
Nie
2. W tej ankiecie zwrot „członek
rodziny” oznacza osobę
wymienioną w liście przewodnim
dołączonym do tej ankiety.
W jakich lokalizacjach członek
rodziny korzystał z opieki tego
hospicjum? Proszę wybrać jedną
lub więcej odpowiedzi:
PACJENT HOSPICJUM
1. Kim jest dla Pana/Pani osoba
wymieniona w liście
towarzyszącym tej ankiecie?
0
1
0
30
40
50
60
70
80
90
2
12
Mój współmałżonek/ka lub
partner/ka
Mój rodzic
0
0
Moja teściowa lub teść
Moja babcia lub dziadek
1
Dom
2
Ośrodek opieki
z zamieszkaniem (Assisted
living facility)
Dom opieki pielęgniarskiej
(Nursing home)
Szpital
Moja ciotka lub wujek
Moja siostra lub brat
0
3
Moje dziecko
Moja przyjaciółka lub przyjaciel
4
Inne (proszę wpisać
drukowanymi literami):
5
0
0
60
Ośrodek / dom hospicjum
Inne (proszę wpisać
drukowanymi literami):
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
PANA/PANI ROLA
3. Kiedy członek rodziny był pod
opieką hospicjum, jak często
uczestniczył/a Pan/Pani w tej
opiece lub nadzorował/a ją?
0
1
0
30
40
2
Nigdy Jeżeli Nigdy, proszę
przejść do Pytania 41
Czasami
Zazwyczaj
Zawsze
OPIEKA HOSPICJUM NAD
CZŁONKIEM RODZINY
Odpowiadając na pozostałe pytania
tej ankiety, prosimy wziąć pod uwagę
tylko doświadczenia członka rodziny
związane z hospicjum, którego nazwa
podana jest na stronie tytułowej
ankiety.
4. W tej ankiecie personel hospicjum
oznacza wszystkie pielęgniarki,
wszystkich lekarzy, pracowników
socjalnych, kapelanów i inne
osoby, które zapewniały opiekę
hospicyjną członkowi Pana/Pani
rodziny. Kiedy członek rodziny
był pod opieką hospicjum, czy
musiał/a Pan/Pani kontaktować
się z personelem hospicjum
wieczorami, w weekendy, albo w
święta w sprawie pytań lub
pomocy w opiece nad członkiem
rodziny?
0
0
1
Tak
2
Nie Jeżeli Nie, proszę
przejść do Pytania 6
5. Jak często uzyskiwał/a Pan/Pani
potrzebną pomoc personelu
hospicjum wieczorami,
w weekendy, albo w święta?
0
0
30
40
1
Nigdy
2
Czasami
Zazwyczaj
Zawsze
6. Kiedy członek rodziny był pod
opieką hospicjum, jak często
personel hospicjum informował
Pana/Panią, kiedy ktoś przyjdzie,
aby zaopiekować się członkiem
rodziny?
0
0
30
40
1
Nigdy
2
Czasami
Zazwyczaj
Zawsze
7. Kiedy członek rodziny był pod
opieką hospicjum i Pan/Pani albo
członek rodziny prosił personel
hospicjum o pomoc, jak często
zapewniana ona była tak szybko,
jak była potrzebna?
0
0
30
40
1
Nigdy
2
Czasami
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
Zazwyczaj
Zawsze
13
8. Kiedy członek rodziny był pod
opieką hospicjum, jak często
personel hospicjum wyjaśniał
różne informacje w przystępny
sposób?
0
20
30
40
1
0
20
30
40
1
Nigdy
Czasami
Zazwyczaj
Zawsze
9. Kiedy członek rodziny był pod
opieką hospicjum, jak często
personel hospicjum przekazywał
Panu/Pani informacje na temat
stanu członka rodziny?
0
20
30
40
1
0
20
30
40
Czasami
Zazwyczaj
Zawsze
12. Kiedy członek rodziny był pod
opieką hospicjum, jak często
miał/a Pan/Pani wrażenie, że
zespół hospicjum naprawdę
troszczy się o członka rodziny?
0
0
30
40
1
Nigdy
Czasami
2
Czasami
Zazwyczaj
Zawsze
Nigdy
Zawsze
Zawsze
0
0
1
Tak
2
Nie Jeżeli Nie, proszę
przejść do Pytania 15
Czasami
Zazwyczaj
Zazwyczaj
13. Kiedy członek rodziny był pod
opieką hospicjum, czy
rozmawiał/a Pan/Pani z zespołem
hospicjum na temat problemów
związanych z opieką hospicjum
nad członkiem rodziny?
14. Jak często personel hospicjum
słuchał Pana/Pani uważnie, kiedy
mówił/a Pan/Pani o problemach
związanych z opieką hospicjum
nad członkiem rodziny?
0
20
30
40
1
14
Nigdy
Nigdy
10. Kiedy członek rodziny był pod
opieką hospicjum, jak często ktoś
z personelu hospicjum
przekazywał Panu/Pani mylące lub
sprzeczne informacje na temat
stanu członka rodziny lub opieki
nad nim?
1
11. Kiedy członek rodziny był pod
opieką hospicjum, jak często
personel hospicjum traktował
członka rodziny z szacunkiem
i godnością?
Nigdy
Czasami
Zazwyczaj
Zawsze
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
15. Czy członek rodziny odczuwał
jakikolwiek ból, kiedy był pod
opieką hospicjum?
0
20
1
Tak
Nie Jeżeli Nie, proszę
przejść do Pytania 17
16. Czy członek rodziny otrzymywał
tyle pomocy w opanowaniu bólu,
ile potrzebował?
0
20
30
1
Zdecydowanie tak
W pewnym stopniu tak
Nie
17. Czy członek rodziny otrzymywał
jakiś lek przeciwbólowy, kiedy był
pod opieką hospicjum?
0
20
1
Tak
0
20
30
1
1
Zdecydowanie tak
2
W pewnym stopniu tak
Nie
Zdecydowanie tak
W pewnym stopniu tak
Nie
20. Czy personel hospicjum
przeszkolił Pana/Panią na temat
okoliczności, w których należy
podawać członkowi rodziny więcej
leków przeciwbólowych?
0
20
30
40
1
Nie Jeżeli Nie, proszę
przejść do Pytania 21
18. Skutki uboczne leków
przeciwbólowych obejmują np.
senność. Czy ktoś z personelu
hospicjum rozmawiał
z Panem/Panią lub członkiem
rodziny o skutkach ubocznych
leków przeciwbólowych?
0
0
30
19. Czy personel hospicjum
przeszkolił Pana/Panią w zakresie
skutków ubocznych leków
przeciwbólowych, na które trzeba
uważać?
Zdecydowanie tak
W pewnym stopniu tak
Nie
Nie potrzebowałem/am
podawać leków
przeciwbólowych członkowi
rodziny
21. Czy członek rodziny miał
trudności z oddychaniem lub był
leczony z powodu trudności
z oddychaniem, kiedy był pod
opieką hospicjum?
0
20
1
Tak
Nie Jeżeli Nie, proszę
przejść do Pytania 24
22. Jak często członek rodziny
otrzymywał potrzebną pomoc
z powodu trudności
z oddychaniem?
0
20
30
40
1
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
Nigdy
Czasami
Zazwyczaj
Zawsze
15
23. Czy personel hospicjum
przeszkolił Pana/Panią na temat
sposobów udzielania pomocy
członkowi rodziny w przypadku
trudności z oddychaniem?
10
Zdecydowanie tak
0
30
40
2
W pewnym stopniu tak
Nie
Nie potrzebowałem/am udzielać
pomocy członkowi rodziny z
powodu trudności
z oddychaniem
24. Czy członkowi rodziny dokuczały
kiedykolwiek zaparcia, kiedy był
pod opieką hospicjum?
0
20
1
Tak
Nie Jeżeli Nie, proszę
przejść do Pytania 26
25. Jak często członek rodziny
otrzymywał potrzebną pomoc w
związku z zaparciami?
0
0
30
40
1
Nigdy
2
Czasami
27. Jak często członek rodziny
otrzymywał od personelu
hospicjum potrzebną pomoc w
związku z odczuwanym lękiem lub
smutkiem?
0
20
30
40
1
0
20
1
Zazwyczaj
Zawsze
Tak
Nie Jeżeli Nie, proszę
przejść do Pytania 30
29. Czy personel hospicjum
przeszkolił Pana/Panią na temat
sposobów udzielania pomocy
członkowi rodziny w przypadku
niepokoju ruchowego lub
pobudzenia?
0
20
30
Zawsze
Czasami
28. Czy członek rodziny wykazywał
kiedykolwiek niepokój ruchowy
lub pobudzenie, kiedy był pod
opieką hospicjum?
1
Zazwyczaj
Nigdy
Zdecydowanie tak
W pewnym stopniu tak
Nie
26. Czy członek rodziny okazywał
kiedykolwiek lęk lub smutek,
kiedy był pod opieką hospicjum?
0
20
1
16
Tak
Nie Jeżeli Nie, proszę
przejść do Pytania 28
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
30. Pomoc członkowi rodziny w
poruszaniu się obejmuje takie
czynności jak pomoc przy
obracaniu się na łóżku, wstawaniu
z łóżka lub wózka inwalidzkiego.
Czy personel hospicjum zapewnił
Panu/Pani szkolenie na temat
tego, jak bezpiecznie pomagać
członkowi rodziny w poruszaniu
się?
0
20
30
40
1
Zdecydowanie tak
W pewnym stopniu tak
Nie
Nie potrzebowałem/am
pomagać członkowi rodziny
w poruszaniu się
31. Czy personel hospicjum przekazał
Panu/Pani wszystkie informacje,
jakie chciał/a Pan/Pani uzyskać na
temat tego, czego należy
oczekiwać w czasie, kiedy członek
rodziny umiera?
0
20
30
1
Zdecydowanie tak
W pewnym stopniu tak
Nie
OPIEKA HOSPICJUM
ŚWIADCZONA W DOMU OPIEKI
PIELĘGNIARSKIEJ
32. Niektórzy pacjenci mają
zapewnianą opiekę hospicyjną,
kiedy przebywają w domu opieki
pielęgniarskiej. Czy członek
rodziny miał zapewnioną opiekę
tego hospicjum, kiedy przebywał
w domu opieki pielęgniarskiej?
0
0
1
Tak
2
Nie Jeżeli Nie, proszę
przejść do Pytania 35
33. Kiedy członek rodziny był pod
opieką hospicjum, jak często
personel domu opieki
pielęgniarskiej współpracował
z personelem hospicjum
w zapewnianiu mu opieki?
0
20
30
40
1
Nigdy
Czasami
Zazwyczaj
Zawsze
34. Kiedy członek rodziny był pod
opieką hospicjum, jak często
informacje na temat członka
rodziny przekazywane przez
personel domu opieki
pielęgniarskiej różniły się od tych,
które przekazywał personel
hospicjum?
0
20
30
40
1
Nigdy
Czasami
Zazwyczaj
Zawsze
PANA/PANI WŁASNE
DOŚWIADCZENIA ZWIĄZANE
Z HOSPICJUM
35. Jak często personel hospicjum
słuchał Pana/Pani uważnie, kiedy
członek rodziny był pod opieką
hospicjum?
0
20
30
40
1
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
Nigdy
Czasami
Zazwyczaj
Zawsze
17
36. Wsparcie dla wierzeń religijnych
czy innych form duchowości
obejmuje rozmowy, modlitwę,
czas spędzany w ciszy i inne
sposoby zaspakajania potrzeb
religijnych lub duchowych. Kiedy
członek rodziny był pod opieką
hospicjum, jak wiele wsparcia dla
Pana/Pani wierzeń religijnych czy
innych form duchowości
otrzymał/a Pan/Pani od personelu
hospicjum?
0
20
30
1
Za mało
Wystarczająco
Za dużo
37. Jak wiele wsparcia
emocjonalnego dostarczał
Panu/Pani personel hospicjum,
kiedy członek rodziny był pod
opieką hospicjum?
0
20
30
1
Za mało
0
20
30
Wystarczająco
Za dużo
Posługując się skalą od 0 do 10,
na której 0 oznacza najgorszą
możliwą opiekę hospicjum, a 10
oznacza najlepszą możliwą opiekę
hospicjum, jak ocenił/a/by
Pan/Pani opiekę hospicjum, jaką
otrzymał członek Pana/Pani
rodziny?
0
0
0
0
30
40
50
60
70
80
90
100
2
Za dużo
Za mało
39. Odpowiadając na kolejne pytania
ankiety, prosimy wziąć pod uwagę
opiekę, jaką członek rodziny
otrzymał ze strony hospicjum,
którego nazwa podana jest na
stronie tytułowej ankiety. Prosimy
nie uwzględniać w odpowiedziach
opieki świadczonej przez inne
hospicja.
1
Wystarczająco
38. Jak wiele wsparcia
emocjonalnego otrzymała/a
Pan/Pani od personelu hospicjum
w tygodniach po śmierci członka
Pana/Pani rodziny?
1
OGÓLNA OCENA OPIEKI
HOSPICJUM
0 Najgorsza możliwa opieka
hospicjum
1
2
3
4
5
6
7
8
9
10 Najlepsza możliwa opieka
hospicjum
40. Czy polecił/a/by Pan/Pani to
hospicjum znajomym i rodzinie?
0
20
30
40
1
18
Na pewno nie
Chyba nie
Chyba tak
Na pewno tak
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
INFORMACJE O CZŁONKU
RODZINY
41. Jaki najwyższy poziom
wykształcenia lub ile klas szkoły
ukończył członek rodziny?
0
20
1
0
3
0
4
0
0
5
6
0
7
8 klas lub mniej
Rozpoczęta, ale nie ukończona
szkoła średnia
Ukończona szkoła średnia lub
zdany egzamin GED
Niepełne studia lub dyplom po
studium 2-letnim
Skończone studia 4-letnie
Więcej niż skończone studia 4letnie
Nie wiem
42. Czy członek Pana/Pani rodziny był
Latynosem/pochodzenia
iberyjskiego lub miał przodków
pochodzenia latynoskiego/
iberyjskiego?
0
1
0
30
2
0
50
4
Nie, nie był Latynosem/
pochodzenia iberyjskiego
Tak, Portorykańczyk
Tak, Meksykanin, Amerykanin
pochodzenia meksykańskiego
(Chicano)
Tak, Kubańczyk
43. Jakiej rasy był członek Pana/Pani
rodziny? Proszę wybrać co
najmniej jedną odpowiedź.
0
20
30
40
1
0
5
Rasa biała
Rasa czarna - Afroamerykanin
Rasa azjatycka
Rodowity mieszkaniec Hawajów
lub innych wysp Pacyfiku
Rodowity Indianin lub
Alaskańczyk
INFORMACJE O PANU/PANI
44. Proszę podać swój wiek:
0
20
30
40
50
60
70
80
1
18 do 24 lat
25 do 34 lat
35 do 44 lat
45 do 54 lat
55 do 64 lat
65 do 74 lat
75 do 84 lat
85 lat lub więcej
45. Proszę podać swoją płeć:
1
Mężczyzna
2
Kobieta
0
0
Tak, innego pochodzenia
latynoskiego/ iberyjskiego
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
19
46. Jaki jest najwyższy poziom
Pana/Pani wykształcenia lub
liczba ukończonych klas?
0
20
1
0
3
0
4
0
0
5
6
47. Jakim językiem głównie mówi
Pan/Pani w domu?
8 klas lub mniej
Rozpoczęta, ale nie ukończona
szkoła średnia
Ukończona szkoła średnia lub
zdany GED
Niepełne studia lub dyplom po
studium 2-letnim
Skończone studia 4-letnie
Więcej niż skończone studia 4letnie
0
0
30
40
50
60
70
80
90
1
Angielski
2
Hiszpański
Chiński
Rosyjski
Portugalski
Wietnamski
Polski
Koreański
Inny język (proszę wpisać
drukowanymi literami):
DZIĘKUJEMY
Prosimy odesłać wypełnioną ankietę w załączonej kopercie z opłaconymi
kosztami przesyłki zwrotnej.
[NAME OF SURVEY VENDOR]
[RETURN ADDRESS OF SURVEY VENDOR]
20
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
CAHPS® Ankieta na temat usług hospicjum
Proszę odpowiedzieć na pytania ankiety dotyczące opieki, jaką pacjent uzyskał we
wskazanym poniżej hospicjum:
[NAME OF HOSPICE]
Wszystkie pytania tej ankiety będą dotyczyć doświadczeń związanych z wyżej
wymienionym hospicjum.
Aby dowiedzieć się więcej na temat tej ankiety, proszę zadzwonić pod [TOLL FREE
NUMBER]. Wszystkie połączenia z tym numerem są bezpłatne.
OMB#0938-1257
Traci ważność dnia 31.12.2020
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
21
CAHPS® Ankieta na temat usług hospicjum
WSKAZÓWKI DO ANKIETY
♦
Proszę przekazać tę ankietę domownikowi, który wie najwięcej o opiece hospicyjnej,
zapewnianej osobie wymienionej w liście przewodnim dołączonym do tej ankiety.
♦
Proszę wypełnić ankietę ciemnym długopisem.
♦
Odpowiedz na wszystkie pytania, wypełniając całkowicie kółko znajdujące się z
lewej strony wybranej odpowiedzi.
Tak
♦
Nie
Czasami prosimy o opuszczenie niektórych pytań ankiety. W takim przypadku
widoczna będzie strzałka z informacją, do którego pytania należy przejść, na przykład:
Tak Jeżeli Tak, proszę przejść do Pytania 1
Nie
2. W tej ankiecie zwrot „członek
rodziny” oznacza osobę
wymienioną w liście przewodnim
dołączonym do tej ankiety.
W jakich lokalizacjach członek
rodziny korzystał z opieki tego
hospicjum? Proszę wybrać jedną
lub więcej odpowiedzi:
PACJENT HOSPICJUM
1. Kim jest dla Pana/Pani osoba
wymieniona w liście
towarzyszącym tej ankiecie?
O
1
O
O
4O
5O
6O
7O
8O
9O
2
3
22
Mój współmałżonek/ka lub
partner/ka
Mój rodzic
O
2O
1
Moja teściowa lub teść
Moja babcia lub dziadek
Moja ciotka lub wujek
Moja siostra lub brat
O
3
Moje dziecko
Moja przyjaciółka lub przyjaciel
Inne (proszę wpisać
drukowanymi literami):
O
5O
6O
4
Dom
Ośrodek opieki
z zamieszkaniem (Assisted
living facility)
Dom opieki pielęgniarskiej
(Nursing home)
Szpital
Ośrodek / dom hospicjum
Inne (proszę wpisać
drukowanymi literami):
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
PANA/PANI ROLA
3. Kiedy członek rodziny był pod
opieką hospicjum, jak często
uczestniczył/a Pan/Pani w tej
opiece lub nadzorował/a ją?
O
1
O
3O
4O
2
Nigdy Jeżeli Nigdy, proszę
przejść do Pytania 41
Czasami
Zazwyczaj
Zawsze
OPIEKA HOSPICJUM NAD
CZŁONKIEM RODZINY
Odpowiadając na pozostałe pytania
tej ankiety, prosimy wziąć pod uwagę
tylko doświadczenia członka rodziny
związane z hospicjum, którego nazwa
podana jest na stronie tytułowej
ankiety.
4. W tej ankiecie personel hospicjum
oznacza wszystkie pielęgniarki,
wszystkich lekarzy, pracowników
socjalnych, kapelanów i inne
osoby, które zapewniały opiekę
hospicyjną członkowi Pana/Pani
rodziny. Kiedy członek rodziny
był pod opieką hospicjum, czy
musiał/a Pan/Pani kontaktować
się z personelem hospicjum
wieczorami, w weekendy, albo w
święta w sprawie pytań lub
pomocy w opiece nad członkiem
rodziny?
O
O
1
Tak
2
Nie Jeżeli Nie, proszę
przejść do Pytania 6
5. Jak często uzyskiwał/a Pan/Pani
potrzebną pomoc personelu
hospicjum wieczorami,
w weekendy, albo w święta?
O
O
3O
4O
1
Nigdy
2
Czasami
Zazwyczaj
Zawsze
6. Kiedy członek rodziny był pod
opieką hospicjum, jak często
personel hospicjum informował
Pana/Panią, kiedy ktoś przyjdzie,
aby zaopiekować się członkiem
rodziny?
O
O
3O
4O
1
Nigdy
2
Czasami
Zazwyczaj
Zawsze
7. Kiedy członek rodziny był pod
opieką hospicjum i Pan/Pani albo
członek rodziny prosił personel
hospicjum o pomoc, jak często
zapewniana ona była tak szybko,
jak była potrzebna?
O
O
3O
4O
1
Nigdy
2
Czasami
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
Zazwyczaj
Zawsze
23
8. Kiedy członek rodziny był pod
opieką hospicjum, jak często
personel hospicjum wyjaśniał
różne informacje w przystępny
sposób?
O
2O
3O
4O
1
O
2O
3O
4O
1
Nigdy
Czasami
Zazwyczaj
Zawsze
9. Kiedy członek rodziny był pod
opieką hospicjum, jak często
personel hospicjum przekazywał
Panu/Pani informacje na temat
stanu członka rodziny?
O
2O
3O
4O
1
O
2O
3O
4O
Czasami
Zazwyczaj
Zawsze
12. Kiedy członek rodziny był pod
opieką hospicjum, jak często
miał/a Pan/Pani wrażenie, że
zespół hospicjum naprawdę
troszczy się o członka rodziny?
O
O
3O
4O
1
Nigdy
Czasami
2
Czasami
Zazwyczaj
Zawsze
Nigdy
Zawsze
Zawsze
O
O
1
Tak
2
Nie Jeżeli Nie, proszę
przejść do Pytania 15
Czasami
Zazwyczaj
Zazwyczaj
13. Kiedy członek rodziny był pod
opieką hospicjum, czy
rozmawiał/a Pan/Pani z zespołem
hospicjum na temat problemów
związanych z opieką hospicjum
nad członkiem rodziny?
14. Jak często personel hospicjum
słuchał Pana/Pani uważnie, kiedy
mówił/a Pan/Pani o problemach
związanych z opieką hospicjum
nad członkiem rodziny?
O
2O
3O
4O
1
24
Nigdy
Nigdy
10. Kiedy członek rodziny był pod
opieką hospicjum, jak często ktoś
z personelu hospicjum
przekazywał Panu/Pani mylące lub
sprzeczne informacje na temat
stanu członka rodziny lub opieki
nad nim?
1
11. Kiedy członek rodziny był pod
opieką hospicjum, jak często
personel hospicjum traktował
członka rodziny z szacunkiem
i godnością?
Nigdy
Czasami
Zazwyczaj
Zawsze
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
15. Czy członek rodziny odczuwał
jakikolwiek ból, kiedy był pod
opieką hospicjum?
O
2O
1
Tak
Nie Jeżeli Nie, proszę
przejść do Pytania 17
16. Czy członek rodziny otrzymywał
tyle pomocy w opanowaniu bólu,
ile potrzebował?
O
2O
3O
1
Zdecydowanie tak
W pewnym stopniu tak
Nie
17. Czy członek rodziny otrzymywał
jakiś lek przeciwbólowy, kiedy był
pod opieką hospicjum?
O
2O
1
Tak
O
2O
3O
1
1
Zdecydowanie tak
2
W pewnym stopniu tak
Nie
Zdecydowanie tak
W pewnym stopniu tak
Nie
20. Czy personel hospicjum
przeszkolił Pana/Panią na temat
okoliczności, w których należy
podawać członkowi rodziny więcej
leków przeciwbólowych?
O
2O
3O
4O
1
Nie Jeżeli Nie, proszę
przejść do Pytania 21
18. Skutki uboczne leków
przeciwbólowych obejmują np.
senność. Czy ktoś z personelu
hospicjum rozmawiał
z Panem/Panią lub członkiem
rodziny o skutkach ubocznych
leków przeciwbólowych?
O
O
3O
19. Czy personel hospicjum
przeszkolił Pana/Panią w zakresie
skutków ubocznych leków
przeciwbólowych, na które trzeba
uważać?
Zdecydowanie tak
W pewnym stopniu tak
Nie
Nie potrzebowałem/am
podawać leków
przeciwbólowych członkowi
rodziny
21. Czy członek rodziny miał
trudności z oddychaniem lub był
leczony z powodu trudności
z oddychaniem, kiedy był pod
opieką hospicjum?
O
2O
1
Tak
Nie Jeżeli Nie, proszę
przejść do Pytania 24
22. Jak często członek rodziny
otrzymywał potrzebną pomoc
z powodu trudności
z oddychaniem?
O
2O
3O
4O
1
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
Nigdy
Czasami
Zazwyczaj
Zawsze
25
23. Czy personel hospicjum
przeszkolił Pana/Panią na temat
sposobów udzielania pomocy
członkowi rodziny w przypadku
trudności z oddychaniem?
1O Zdecydowanie tak
O
3O
4O
2
W pewnym stopniu tak
Nie
Nie potrzebowałem/am udzielać
pomocy członkowi rodziny z
powodu trudności
z oddychaniem
24. Czy członkowi rodziny dokuczały
kiedykolwiek zaparcia, kiedy był
pod opieką hospicjum?
O
2O
1
Tak
Nie Jeżeli Nie, proszę
przejść do Pytania 26
25. Jak często członek rodziny
otrzymywał potrzebną pomoc w
związku z zaparciami?
1O Nigdy
O
3O
4O
2
27. Jak często członek rodziny
otrzymywał od personelu
hospicjum potrzebną pomoc w
związku z odczuwanym lękiem lub
smutkiem?
O
2O
3O
4O
1
O
2O
1
Zawsze
Zazwyczaj
Zawsze
Tak
Nie Jeżeli Nie, proszę
przejść do Pytania 30
29. Czy personel hospicjum
przeszkolił Pana/Panią na temat
sposobów udzielania pomocy
członkowi rodziny w przypadku
niepokoju ruchowego lub
pobudzenia?
1
Zazwyczaj
Czasami
28. Czy członek rodziny wykazywał
kiedykolwiek niepokój ruchowy
lub pobudzenie, kiedy był pod
opieką hospicjum?
O
2O
3O
Czasami
Nigdy
Zdecydowanie tak
W pewnym stopniu tak
Nie
26. Czy członek rodziny okazywał
kiedykolwiek lęk lub smutek,
kiedy był pod opieką hospicjum?
O
2O
1
26
Tak
Nie Jeżeli Nie, proszę
przejść do Pytania 28
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
30. Pomoc członkowi rodziny w
poruszaniu się obejmuje takie
czynności jak pomoc przy
obracaniu się na łóżku, wstawaniu
z łóżka lub wózka inwalidzkiego.
Czy personel hospicjum zapewnił
Panu/Pani szkolenie na temat
tego, jak bezpiecznie pomagać
członkowi rodziny w poruszaniu
się?
O
2O
3O
4O
1
Zdecydowanie tak
W pewnym stopniu tak
Nie
Nie potrzebowałem/am
pomagać członkowi rodziny
w poruszaniu się
31. Czy personel hospicjum
przekazał Panu/Pani wszystkie
informacje, jakie chciał/a Pan/Pani
uzyskać na temat tego, czego
należy oczekiwać w czasie, kiedy
członek rodziny umiera?
O
2O
3O
1
Zdecydowanie tak
W pewnym stopniu tak
Nie
OPIEKA HOSPICJUM
ŚWIADCZONA W DOMU OPIEKI
PIELĘGNIARSKIEJ
32. Niektórzy pacjenci mają
zapewnianą opiekę hospicyjną,
kiedy przebywają w domu opieki
pielęgniarskiej. Czy członek
rodziny miał zapewnioną opiekę
tego hospicjum, kiedy przebywał
w domu opieki pielęgniarskiej?
O
O
1
Tak
2
Nie Jeżeli Nie, proszę
przejść do Pytania 35
33. Kiedy członek rodziny był pod
opieką hospicjum, jak często
personel domu opieki
pielęgniarskiej współpracował
z personelem hospicjum
w zapewnianiu mu opieki?
O
2O
3O
4O
1
Nigdy
Czasami
Zazwyczaj
Zawsze
34. Kiedy członek rodziny był pod
opieką hospicjum, jak często
informacje na temat członka
rodziny przekazywane przez
personel domu opieki
pielęgniarskiej różniły się od tych,
które przekazywał personel
hospicjum?
O
2O
3O
4O
1
Nigdy
Czasami
Zazwyczaj
Zawsze
PANA/PANI WŁASNE
DOŚWIADCZENIA ZWIĄZANE
Z HOSPICJUM
35. Jak często personel hospicjum
słuchał Pana/Pani uważnie, kiedy
członek rodziny był pod opieką
hospicjum?
O
2O
3O
4O
1
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
Nigdy
Czasami
Zazwyczaj
Zawsze
27
36. Wsparcie dla wierzeń religijnych
czy innych form duchowości
obejmuje rozmowy, modlitwę,
czas spędzany w ciszy i inne
sposoby zaspakajania potrzeb
religijnych lub duchowych. Kiedy
członek rodziny był pod opieką
hospicjum, jak wiele wsparcia dla
Pana/Pani wierzeń religijnych czy
innych form duchowości
otrzymał/a Pan/Pani od personelu
hospicjum?
O
2O
3O
1
Za mało
Wystarczająco
Za dużo
37. Jak wiele wsparcia
emocjonalnego dostarczał
Panu/Pani personel hospicjum,
kiedy członek rodziny był pod
opieką hospicjum?
O
2O
3O
1
Za mało
O
2O
3O
Wystarczająco
Za dużo
Posługując się skalą od 0 do 10,
na której 0 oznacza najgorszą
możliwą opiekę hospicjum, a 10
oznacza najlepszą możliwą opiekę
hospicjum, jak ocenił/a/by
Pan/Pani opiekę hospicjum, jaką
otrzymał członek Pana/Pani
rodziny?
O
0
0 Najgorsza możliwa opieka
hospicjum
1
O
O 2
3O 3
4O 4
5O 5
6O 6
7O 7
8O 8
9O 9
10O 10
2
Za dużo
Za mało
39. Odpowiadając na kolejne pytania
ankiety, prosimy wziąć pod uwagę
opiekę, jaką członek rodziny
otrzymał ze strony hospicjum,
którego nazwa podana jest na
stronie tytułowej ankiety. Prosimy
nie uwzględniać w odpowiedziach
opieki świadczonej przez inne
hospicja.
1
Wystarczająco
38. Jak wiele wsparcia
emocjonalnego otrzymała/a
Pan/Pani od personelu hospicjum
w tygodniach po śmierci członka
Pana/Pani rodziny?
1
OGÓLNA OCENA OPIEKI
HOSPICJUM
Najlepsza możliwa opieka
hospicjum
40. Czy polecił/a/by Pan/Pani to
hospicjum znajomym i rodzinie?
O
2O
3O
4O
1
28
Na pewno nie
Chyba nie
Chyba tak
Na pewno tak
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
INFORMACJE O CZŁONKU
RODZINY
41. Jaki najwyższy poziom
wykształcenia lub ile klas szkoły
ukończył członek rodziny?
O
2O
1
O
3
O
4
O
O
5
6
O
7
8 klas lub mniej
Rozpoczęta, ale nie ukończona
szkoła średnia
Ukończona szkoła średnia lub
zdany egzamin GED
Niepełne studia lub dyplom po
studium 2-letnim
Skończone studia 4-letnie
Więcej niż skończone studia 4letnie
Nie wiem
42. Czy członek Pana/Pani rodziny był
Latynosem/pochodzenia
iberyjskiego lub miał przodków
pochodzenia latynoskiego/
iberyjskiego?
O
1
O
3O
2
O
5O
4
Nie, nie był Latynosem/
pochodzenia iberyjskiego
Tak, Portorykańczyk
Tak, Meksykanin, Amerykanin
pochodzenia meksykańskiego
(Chicano)
Tak, Kubańczyk
43. Jakiej rasy był członek Pana/Pani
rodziny? Proszę wybrać co
najmniej jedną odpowiedź.
O
2O
3O
4O
1
O
5
Rasa biała
Rasa czarna - Afroamerykanin
Rasa azjatycka
Rodowity mieszkaniec Hawajów
lub innych wysp Pacyfiku
Rodowity Indianin lub
Alaskańczyk
INFORMACJE O PANU/PANI
44. Proszę podać swój wiek:
O
2O
3O
4O
5O
6O
7O
8O
1
18 do 24 lat
25 do 34 lat
35 do 44 lat
45 do 54 lat
55 do 64 lat
65 do 74 lat
75 do 84 lat
85 lat lub więcej
45. Proszę podać swoją płeć:
1
Mężczyzna
2
Kobieta
O
O
Tak, innego pochodzenia
latynoskiego/ iberyjskiego
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
29
46. Jaki jest najwyższy poziom
Pana/Pani wykształcenia lub
liczba ukończonych klas?
O
2O
1
O
3
O
4
O
O
5
6
47. Jakim językiem głównie mówi
Pan/Pani w domu?
8 klas lub mniej
Rozpoczęta, ale nie ukończona
szkoła średnia
Ukończona szkoła średnia lub
zdany GED
Niepełne studia lub dyplom po
studium 2-letnim
Skończone studia 4-letnie
Więcej niż skończone studia 4letnie
O
O
3O
4O
5O
6O
7O
8O
9O
1
Angielski
2
Hiszpański
Chiński
Rosyjski
Portugalski
Wietnamski
Polski
Koreański
Inny język (proszę wpisać
drukowanymi literami):
DZIĘKUJEMY
Prosimy odesłać wypełnioną ankietę w załączonej kopercie z opłaconymi
kosztami przesyłki zwrotnej.
[NAME OF SURVEY VENDOR]
[RETURN ADDRESS OF SURVEY VENDOR]
30
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
Sample Initial Cover Letter for the CAHPS Hospice Survey
[HOSPICE OR VENDOR LETTERHEAD]
[SAMPLED CAREGIVER NAME]
[ADDRESS]
[CITY, STATE ZIP]
Szanowny Panie/ Szanowna Pani,
[HOSPICE NAME] prowadzi ankietę na temat usług świadczonych przez hospicjum na rzecz
pacjentów i ich rodzin. Wybrano Pana/Panią do tej ankiety, ponieważ ustaliliśmy, że był/a
Pan/Pani opiekunem/opiekunką [DECEDENT NAME] Zdajemy sobie sprawę, że może to być dla
Pana/Pani trudny okres, mamy jednak nadzieję, że pomoże nam Pan/Pani uzyskać informacje na
temat jakości opieki, jaką członek Pana/Pani rodziny lub przyjaciel otrzymał ze strony hospicjum.
Pytania [NOTE THE QUESTION NUMBERS] w załączonej ankiecie są częścią ogólnokrajowej
inicjatywy sponsorowanej przez federalny Departament Zdrowia i Usług dla Ludności
(Department of Health and Human Services, HHS), którego celem jest określenie jakości opieki
świadczonej przez hospicja. Ośrodki Centers for Medicare & Medicaid Services (CMS), będące
częścią HHS, prowadzą tę ankietę w celu poprawy jakości opieki w hospicjach. CMS pokrywa
koszty większości opieki w hospicjach w USA. CMS ma również obowiązek zapewnić, że
pacjenci hospicjów, członkowie ich rodzin i przyjaciele otrzymują opiekę wysokiej jakości.
Jednym ze sposobów wywiązywania się z tego obowiązku jest uzyskanie informacji
bezpośrednio od Pana/Pani na temat opieki hospicyjnej, jaką otrzymał członek Pana/Pani rodziny
lub przyjaciel. Udział w ankiecie jest dobrowolny i nie będzie miał wpływu na Pana/Pani opiekę
zdrowotną ani świadczenia.
Mamy nadzieję, że znajdzie Pan/Pani czas na wypełnienie tej ankiety. Po wypełnieniu ankiety
prosimy zwrócić ją w dołączonej kopercie z opłaconymi kosztami przesyłki. Pana/Pani
odpowiedzi mogą być udostępnione hospicjum w celu poprawy jakości świadczonych usług.
[OPTIONAL: Być może zauważy Pan/Pani numer podany na ankiecie. Numer ten służy do
powiadomienia nas, że odesłał/a Pan/Pani swoją ankietę, co oznacza, że nie musimy wysyłać
upomnień].
W razie jakichkolwiek pytań na temat załączonej ankiety, prosimy zadzwonić pod bezpłatny
numer 1-800-xxx-xxxx. Dziękujemy za przyczynienie się do poprawy opieki hospicjów nad
wszystkimi pacjentami.
Z poważaniem,
[HOSPICE ADMINISTRATOR]
[HOSPICE NAME]
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
31
32
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
Sample Follow-up Cover Letter for the CAHPS Hospice
Survey
[HOSPICE OR VENDOR LETTERHEAD]
[SAMPLED CAREGIVER NAME]
[ADDRESS]
[CITY, STATE ZIP]
Szanowny Panie/ Szanowna Pani,
Nasze dane wskazują, że niedawno opiekował/a się Pan/Pani [DECEDENT NAME] w [NAME
OF HOSPICE]. Mniej więcej trzy tygodnie temu wysłaliśmy do Pana/Pani ankietę na temat jakości
opieki, jaką Pan/Pani i członek Pana/Pani rodziny lub przyjaciel otrzymał ze strony hospicjum.
Jeżeli już odesłał/a Pan/Pani do nas ankietę, bardzo za to dziękujemy i prosimy zignorować to
przypomnienie. Jeżeli jednak jeszcze Pan/Pani tego nie zrobił/a, bylibyśmy zobowiązani, gdyby
znalazł/a Pan/Pani chwilę na wypełnienie tej ważnej ankiety.
Mamy nadzieję, że skorzysta Pan/Pani z tej możliwości, aby pomóc nam uzyskać informacje na
temat jakości opieki, jaką otrzymał Pan/Pani i członek Pana/Pani rodziny lub przyjaciel. Wyniki
ankiety przyczynią się do zapewnienia najwyższej jakości opieki hospicyjnej wszystkim
Amerykanom.
Pytania [NOTE THE QUESTION NUMBERS] w załączonej ankiecie są częścią ogólnokrajowej
inicjatywy sponsorowanej przez federalny Departament Zdrowia i Usług dla Ludności
(Department of Health and Human Services, HHS), którego celem jest określenie jakości opieki
świadczonej przez hospicja. Ośrodki Centers for Medicare & Medicaid Services (CMS), będące
częścią HHS, prowadzą tę ankietę w celu poprawy jakości opieki w hospicjach. CMS pokrywa
koszty większości opieki w hospicjach w USA. CMS ma również obowiązek zapewnić, że
pacjenci hospicjów, członkowie ich rodzin i przyjaciele otrzymują opiekę wysokiej jakości.
Jednym ze sposobów wywiązywania się z tego obowiązku jest uzyskanie informacji bezpośrednio
od Pana/Pani na temat opieki hospicyjnej, jaką otrzymał członek Pana/Pani rodziny lub przyjaciel.
Udział w ankiecie jest dobrowolny i nie będzie miał wpływu na Pana/Pani opiekę zdrowotną ani
świadczenia.
Prosimy o znalezienie kilku minut na wypełnienie załączonej ankiety. Po wypełnieniu ankiety
prosimy zwrócić ją w dołączonej kopercie z opłaconymi kosztami przesyłki. Pana/Pani
odpowiedzi mogą być udostępnione hospicjum w celu poprawy jakości świadczonych usług.
[OPTIONAL: Być może zauważy Pan/Pani numer podany na tej ankiecie. Ten numer służy do
powiadomienia nas, że odesłał/a Pan/Pani swoją ankietę, co oznacza, że nie musimy wysyłać
upomnień].
W razie jakichkolwiek pytań na temat załączonej ankiety, prosimy zadzwonić pod bezpłatny
numer 1-800-xxx-xxxx. Dziękujemy za przyczynienie się do poprawy opieki hospicjów nad
wszystkimi pacjentami.
Z poważaniem,
[HOSPICE ADMINISTRATOR]
[HOSPICE NAME]
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
33
34
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
OMB Paperwork Reduction Act Language
The OMB Paperwork Reduction Act language must appear in the mailing, either on the cover
letter or on the front or back of the questionnaire. In addition, the OMB control number must
appear on the front page of the questionnaire. The following is the language that must be used:
Polish Version
Zgodnie z Ustawą o ograniczeniu dokumentacji z roku 1995, nie ma obowiązku odpowiadania na
wnioski o informacje, jeżeli wniosek nie zawiera ważnego numeru kontrolnego OMB. Ważny
numer kontrolny OMB dotyczący tego wniosku o informacje to 0938-1257 (traci ważność dnia
31.12.2020). Szacuje się, że czas wymagany do wypełnienia tego wniosku o informacje to ok. 11
minut dla pytań 1 – 40, pytań z części „Informacje o członku rodziny” i „Informacje o Panu/Pani”,
co obejmuje czas na zapoznanie się z instrukcją, przeszukanie istniejących źródeł danych,
zgromadzenie potrzebnych danych, wypełnienie i przegląd formularza użytego do gromadzenia
informacji. Wszelkie uwagi na temat dokładności wyznaczonego szacunkowo czasu wypełnienia
ankiety i sugestie odnośnie ulepszenia formularza należy kierować na adres: Centers for Medicare
& Medicaid Services, 7500 Security Boulevard, C1-25-05, Baltimore, MD 21244-1850.
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
35
36
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
Appendix V
Mail Survey Materials (Korean)
CAHPS® 호스피스 설문 조사
이 호스피스로부터 환자가 받은 케어에 관해서 설문지에 답변해 주시기 바랍니다.
[NAME OF HOSPICE]
이 설문지의 모든 질문들은 이 호스피스와의 경험에 관한 것입니다.
본 설문지에 관해서 더 자세히 알고 싶으시면, [TOLL FREE NUMBER] 로 연락을 주시기
바랍니다. 이 번호로의 통화는 무료로 이용하실 수 있습니다.
OMB#0938-1257
2020 년 12 월 31 일에 만료됨
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
1
CAHPS® 호스피스 설문 조사
설문 조사 지시 사항
♦
본 설문지는 설문지 커버레터에 적혀있는 사람이 받은 호스피스 케어에 관하여 가장
잘 알고 있는 귀하의 가족 구성원에게 주시기 바랍니다.
♦
설문지를 작성하실 때 어두운 색깔의 펜을 사용하여 주십시오.
♦
답변은 해당하는 네모 안에 X 를 직접 적어주세요, 밑에 견본이 있습니다.
예
아니요
♦
이 설문지에서 몇 개의 질문들은 건너 뛰라고 할 수도 있습니다. 이런 경우, 여기에
나온 것처럼 다음에 답변할 질문이 무엇인지를 말하는 안내와 함께 화살표가
표시되어 있습니다.
예 응답이 ‘예’면 1 번으로 가세오.
아니요
_____________________________________________________________________
호스피스 환자
1. 귀하는 설문지 커버 레터에 나와 있는
사람과 어떤 관계 입니까?
2
3
1
6
7
8
9
4
5
2
배우자나 파트너
부모
시어머니(장모) 또는
시아버지(장인)
조부모
고모(이모) 또는 삼촌(외삼촌)
자매 또는 형제
자녀
친구
이외(정자체로 써주세요).
2. 이 설문지에서, “가족”은 설문지
커버 레터에 나와 있는 사람을
말합니다. 귀하의 가족이 이
호스피스로부터 케어를 받은
장소가 어디입니까? 한가지 이상
선택하십시오.
3
4
5
6
1
2
집
노인 원호 생활 시설
양로원
병원
호스피스 시설/ 호스피스 집
이외(정자체로 써주세요).
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
귀하의 역할
3. 귀하의 가족이 호스피스 케어를 받는
동안, 얼마나 자주 케어 받는 가족을
돌보는 데 참여하고 감독을 했습니까?
1
4
2
3
전혀 응답이 ‘전혀’이면,
41 번으로 가세요.
때때로
보통
항상
가족의 호스피스 케어
이 설문지의 나머지 질문에 답변하실 때,
설문지 커버에 나와 있는 이름의
호스피스에 대한 귀하의 가족의 경험만을
생각해 주십시오.
4. 이 설문지에서, 호스피스 팀은 귀하의
가족에게 호스피스 케어를 제공했던
모든 간호사, 의사, 사회 복지사,
목사님 그리고 다른 사람들을
포함합니다. 귀하의 가족이 호스피스
케어를 받는 동안, 질문이 있거나
귀하의 가족을 케어하는 데 도움을
받기 위해 호스피스 팀에게 저녁, 주말,
휴일에 연락을 해야 했습니까?
2
1
예
아니요 응답이 ‘아니요’면,
6 번으로 가세요.
5. 귀하는 얼마나 자주 호스피스
팀으로부터 저녁, 주말, 휴일에 필요한
도움을 받으셨습니까?
3
4
1
2
전혀
때때로
보통
항상
6. 귀하의 가족이 호스피스의 케어를
받는 동안, 호스피스 팀은 귀하의
가족에게 케어를 위한 방문의 도착
시간을 얼마나 자주 알려 주었습니까?
2
3
4
1
전혀
때때로
보통
항상
7. 귀하의 가족이 호스피스 케어를 받는
동안, 귀하 또는 귀하의 가족이
호스피스 팀에게 도움을 요청 했을 때,
도움을 얼마나 즉시 자주 받았습니까?
3
4
1
2
전혀
때때로
보통
항상
8. 귀하의 가족이 호스피스 케어를 받는
동안, 얼마나 자주 호스피스 팀이
이해하기 쉽게 설명을 해 주었습니까?
2
3
4
1
전혀
때때로
보통
항상
9. 귀하의 가족이 호스피스 케어를 받는
동안, 얼마나 자주 호스피스 팀이
귀하의 가족의 상태에 관해서 알려
주었습니까?
2
3
4
1
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
전혀
때때로
보통
항상
3
10. 귀하의 가족이 호스피스 케어를 받는
동안, 얼마나 자주 호스피스 팀원이
귀하에게 귀하의 가족의 상태나
케어에 관해서 혼란스럽거나
모순되는 정보를 주었습니까?
2
3
4
1
전혀
때때로
보통
항상
11. 귀하의 가족이 호스피스 케어를 받는
동안, 얼마나 자주 호스피스 팀이
귀하의 가족을 존중하면서
대하였습니까?
3
4
1
2
전혀
때때로
보통
항상
3
4
2
2
4
전혀
때때로
보통
항상
15. 귀하의 가족이 호스피스 케어를 받는
동안 통증이 있었던 적이 있습니까?
1
2
2
3
1
전혀
때때로
보통
항상
예
아니요 응답이 ‘아니요’면,
17 번으로 가세요.
2
예
아니요 응답이 ‘아니요’면,
15 번으로 가세요.
예, 확실히
예, 다소
아니요
17. 귀하의 가족이 호스피스 케어를 받는
동안, 가족 분이 통증 약을
받으셨습니까?
1
13. 귀하의 가족이 호스피스 케어를 받는
동안, 귀하의 가족의 호스피스 케어에
관한 문제에 대해서 호스피스 팀과
이야기를 나누셨습니까?
1
2
3
4
1
16. 귀하의 가족이 통증에 따라 필요한
만큼 도움을 받았습니까?
12. 귀하의 가족이 호스피스 케어를 받는
동안, 얼마나 자주 호스피스 팀이
귀하의 가족을 보살핀다고
느끼셨습니까?
1
14. 귀하께서 귀하의 가족의 호스피스
케어에 대해서 호스피스 팀과 이야기
할 때 얼마나 자주 호스피스 팀이
주의 깊게 경청해 주었나요?
예
아니요 응답이 ‘아니요’면,
21 번으로 가세요.
18. 통증 약의 부작용엔 졸림 증상과 같은
것이 있습니다. 호스피스 팀 중
누군가가 귀하 또는 귀하의 가족에게
통증약의 부작용에 대해서
설명했습니까?
2
3
1
예, 확실히
예, 다소
아니
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
19. 호스피스팀이 귀하께 통증약의 주의
해야할 부작용에 관해서 필요한
안내를 해드렸습니까?
3
1
2
예, 확실히
예, 다소
아니요
20. 호스피스 팀이 귀하께 언제 귀하의
가족에게 통증 약을 더 드려야 되는지
여부와 시기에 관해서 필요한 안내를
해 드렸습니까?
2
3
4
1
예, 확실히
예, 다소
아니요
가족에게 통증 약을 줄 필요가
없었다
21. 귀하의 가족이 호스피스 케어를 받는
동안, 귀하의 가족께서 호흡곤란이
있었거나 호흡곤란에 대한 치료를
받으신 적이 있습니까?
1
2
예
아니요 응답이 ‘아니요’면,
24 번으로 가세요.
22. 귀하의 가족이 호흡 곤란에 관해서
얼마나 자주 필요한 도움을
받았습니까?
2
3
4
1
전혀
때때로
보통
항상
23. 호스피스 팀이 귀하께 귀하의 가족이
호흡 곤란을 느낄때 어떻게 도와야
하는지에 관한 필요한 안내를
해드렸습니까?
2
3
4
1
예, 확실히
예, 다소
아니요
가족의 호흡 곤란을 도울 필요가
없었다
24. 귀하의 가족이 호스피스 케어를 받는
동안, 귀하의 가족이 변비로 고생하신
적이 있습니까?
1
2
예
아니요 응답이 ‘아니요’면
26 번으로 가세요
25. 귀하의 가족이 변비에 관해 얼마나
자주 필요한 도움을 받았습니까?
2
3
4
1
전혀
때때로
보통
항상
26. 귀하의 가족이 호스피스 케어를 받는
중에, 불안이나 슬픔을 보인 적이
있습니까?
1
2
예
아니요 응답이 ‘아니요’면
28 번으로 가세요.
27. 얼마나 자주 귀하의 가족이 호스피스
팀으로부터 불안이나 슬픈 감정에
도움을 받은 적이 있습니까?
3
4
1
2
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
전혀
때때로
보통
항상
5
28. 귀하의 가족이 호스피스 케어를 받는
동안, 안절부절 하거나 불안해 한 적이
있으십니까?
2
1
예
아니요 응답이 ‘아니요’면
30 번으로 가세요.
29. 호스피스 팀이 귀하께 귀하의 가족이
안절부절 하거나 불안해 할 때 어떻게
해야 되는지에 관해 설명을 해
드렸습니까?
2
3
1
예, 확실히
예, 다소
아니요
호스피스 케어를 양로원에서
받은 경우
32. 어떤 분들은 양로원에 사시면서
호스피스 케어를 받으십니다. 귀하의
가족께서 양로원에 사시면서
호스피스 케어를 받으셨습니까?
2
1
33. 귀하의 가족이 호스피스 케어를 받는
동안, 양로원 직원과 호스피스 팀이
얼마나 자주 귀하의 가족을 보살피기
위해서 함께 잘 일했습니까?
2
3
4
1
30. 귀하의 가족을 움직이게 하는 것에는
침대에서 방향을 바꾸는 것 또는
휠체어에 앉거나 일어나는 것, 또는
침대에 눕거나 일어나는 것이
포함됩니다. 호스피스 팀이 귀하께
어떻게 가족을 안전하게 움직일 수
있는지 필요한 안내를 해 드렸습니까?
2
3
4
1
예, 확실히
예, 다소
아니요
가족을 움직일 필요가 없었다.
31. 귀하의 가족께서 돌아가실 떄,
호스피스팀이 귀하께서 무엇을
예상하셔야 되는지 원하시는 만큼의
정보를 드렸습니까?
2
3
1
6
예, 확실히
예, 다소
아니요
예
아니요 응답이 ‘아니요’면,
35 번으로 가세요.
전혀
때때로
보통
항상
34. 귀하의 가족이 호스피스 케어를 받는
동안, 얼마나 자주, 양로원
직원으로부터 귀하의 가족에 관해
받은 정보와 호스피스 팀으로부터
받은 정보가 달랐습니까?
2
3
4
1
전혀
때때로
보통
항상
호스피스에 관한 귀하의 경험
35. 귀하의 가족이 호스피스 케어를 받는
동안, 얼마나 자주 호스피스 팀이 주의
깊게 귀하께 경청 하였습니까?
2
3
4
1
전혀
때때로
보통
항상
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
36. 종교적이거나 영적인 믿음에 관한
지원은 대화, 기도, 묵상 또는 어떠한
방식으로든 종교적이거나 영적으로
필요한 것을 충족시키는 것을
포함합니다. 귀하의 가족이 호스피스
케어를 받는 동안, 귀하는 호스피스
팀으로부터 얼마나 종교적 그리고
영적인 믿음에 관한 지원을
받으셨습니까?
3
1
2
너무 적게
적당하게
너무 많이
37. 귀하의 가족이 호스피스 케어를 받는
동안, 귀하는 호스피스 팀으로부터
얼마나 정서적인 지원을 받았습니까?
3
1
2
너무 적게
적당하게
너무 많이
38. 귀하의 가족이 돌아가신 후 몇 주 동안,
귀하는 호스피스 팀으로부터 얼마나
정서적인 지원을 받으셨습니까?
3
1
2
너무 적게
적당하게
너무 많이
호스피스 케어의 전체적인 점수
39. 설문지 겉 표지에 나와 있는
호스피스에게 귀하의 가족이 받은
케어에 관해서 다음의 질문들에
답변해 주시기 바랍니다. 귀하의
답변에 다른 호스피스로부터 받은
케어는 포함시키지 마십시오.
0 은 최악의 호스피스 케어이고 10 이
최고의 호스피스 케어라고 할 때
0 부터 10 까지의 숫자를 사용해서,
귀하의 가족이 받은 호스피스 케어에
대해 몇 점을 주시겠습니까?
0
1
2 2
3 3
4 4
5 5
6 6
7 7
8 8
9 9
10 10
0
최악의 호스피스 케어
1
최고의 호스피스 케어
40. 이 호스피스를 귀하의 친구나
가족에게 추천 하시겠습니까?
2
3
4
1
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
절대 안 함
안 할 것 같음
할 것 같음
확실히 할 것임
7
귀하의 가족에 관해서
귀하에 관해서
41. 귀하의 가족의 최종 학력이 어떻게
되시나요?
2
3
4
5
6
7
1
중졸 이하
고교 중퇴
고졸 또는 검정고시(GED)
대학 중퇴 또는 2 년제 대학 학위
4 년제 대학 졸업
대학원 이상
모름
42. 귀하의 가족이 히스패닉, 라티노 또는
스페인계 출신인가요?
1
3
2
5
4
44. 귀하의 연세가 어떻게 되십니까?
2
3
4
5
6
7
8
1
45. 귀하는 남성입니까, 아니면
여성입니까?
아니요, 히스패닉, 라티노,
스페인계 아님
예, 푸에르토리칸
예, 멕시코 사람, 멕시코계
미국인, 치카노 사람
예, 쿠바 사람
예, 다른
스페인계/히스패닉/라티노
18 ~ 24 세
25 ~ 34 세
35 ~ 44 세
45 ~ 54 세
55 ~ 64 세
65 ~ 74 세
75 ~ 84 세
85 세 이상
1
2
남성
여성
43. 귀하의 가족의 인종이 무엇입니까? 한
개 또는 한 개 이상을 고를 수
있습니다.
3
4
1
2
5
8
백인
흑인 또는 아프리카계 미국인
아시아인
하와이 원주민 혹은 다른 태평양
제도인
미국 인디안 또는 알래스카
원주민
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
46. 귀하의 학력이 어떻게 되십니까?
3
4
5
6
1
2
중졸 이하
고교 중퇴
고졸 또는 검정고시(GED)
대학 중퇴 또는 2 년제 대학 학위
4 년제 대학 졸업
대학원 이상
47. 댁에서 사용하시는 주요 언어가
무엇입니까?
3
4
5
6
7
8
9
1
2
영어
스페인어
중국어
러시아어
포르투갈어
베트남어
폴란드어
한국어
다른 언어(정자체로 써주세요).
감사합니다
작성하신 설문지를 우편요금 선납 반송용 우편 봉투에 넣어서 보내주세요.
[NAME OF SURVEY VENDOR]
[RETURN ADDRESS OF SURVEY VENDOR]
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
9
10
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
CAHPS® 호스피스 설문 조사
이 호스피스로부터 환자가 받은 케어에 관해서 설문지에 답변해 주시기 바랍니다.
[NAME OF HOSPICE]
이 설문지의 모든 질문들은 이 호스피스와의 경험에 관한 것입니다.
본 설문지에 관해서 더 자세히 알고 싶으시면, [TOLL FREE NUMBER] 로 연락을 주시기
바랍니다. 이 번호로의 통화는 무료로 이용하실 수 있습니다.
OMB#0938-1257
2020 년 12 월 31 일에 만료됨
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
11
CAHPS® 호스피스 설문 조사
설문 조사 지시 사항
♦
본 설문지는 설문지 커버레터에 적혀있는 사람이 받은 호스피스 케어에 관하여 가장
잘 알고 있는 귀하의 가족 구성원에게 주시기 바랍니다.
♦
설문지를 작성하실 때 어두운 색깔의 펜을 사용하여 주십시오.
♦
질문의 왼쪽에 있는 원을 완전히 채워서 모든 질문에 답변을 해주십시오.
0
♦
예
아니요
이 설문지에서 몇 개의 질문들은 건너 뛰라고 할 수도 있습니다. 이런 경우, 여기에
나온 것처럼 다음에 답변할 질문이 무엇인지를 말하는 안내와 함께 화살표가
표시되어 있습니다.
예 응답이 ‘예’면 1 번으로 가세오.
0
아니요
_____________________________________________________________________
호스피스 환자
1. 귀하는 설문지 커버 레터에 나와 있는
사람과 어떤 관계 입니까?
0
0
30
1
배우자나 파트너
2
부모
1
집
시어머니(장모) 또는
시아버지(장인)
2
노인 원호 생활 시설
0
50
60
70
80
90
4
12
2. 이 설문지에서, “가족”은 설문지 커버
레터에 나와 있는 사람을 말합니다.
귀하의 가족이 이 호스피스로부터
케어를 받은 장소가 어디입니까?
한가지 이상 선택하십시오.
조부모
고모(이모) 또는 삼촌(외삼촌)
자매 또는 형제
자녀
0
0
30
40
50
60
양로원
병원
호스피스 시설/ 호스피스 집
이외(정자체로 써주세요).
친구
이외(정자체로 써주세요).
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
귀하의 역할
3. 귀하의 가족이 호스피스 케어를 받는
동안, 얼마나 자주 케어 받는 가족을
돌보는 데 참여하고 감독을 했습니까?
0
1
전혀 응답이 ‘전혀’이면,
41 번으로 가세요.
0
30
40
때때로
2
보통
항상
가족의 호스피스 케어
이 설문지의 나머지 질문에 답변하실 때,
설문지 커버에 나와 있는 이름의
호스피스에 대한 귀하의 가족의 경험만을
생각해 주십시오.
4. 이 설문지에서, 호스피스 팀은
귀하의 가족에게 호스피스 케어를
제공했던 모든 간호사, 의사, 사회
복지사, 목사님 그리고 다른
사람들을 포함합니다. 귀하의
가족이 호스피스 케어를 받는 동안,
질문이 있거나 귀하의 가족을
케어하는 데 도움을 받기 위해
호스피스 팀에게 저녁, 주말, 휴일에
연락을 해야 했습니까?
6. 귀하의 가족이 호스피스의 케어를
받는 동안, 호스피스 팀은 귀하의
가족에게 케어를 위한 방문의 도착
시간을 얼마나 자주 알려
주었습니까?
0 전혀
20 때때로
30 보통
40 항상
1
7. 귀하의 가족이 호스피스 케어를
받는 동안, 귀하 또는 귀하의 가족이
호스피스 팀에게 도움을 요청 했을
때, 도움을 얼마나 즉시 자주
받았습니까?
0 전혀
20 때때로
30 보통
40 항상
1
8. 귀하의 가족이 호스피스 케어를
받는 동안, 얼마나 자주 호스피스
팀이 이해하기 쉽게 설명을 해
주었습니까?
0 전혀
0 때때로
30 보통
40 항상
1
2
0예
0 아니요 응답이 ‘아니요’면,
1
2
6 번으로 가세요.
5. 귀하는 얼마나 자주 호스피스
팀으로부터 저녁, 주말, 휴일에
필요한 도움을 받으셨습니까?
0 전혀
20 때때로
30 보통
40 항상
1
9. 귀하의 가족이 호스피스 케어를
받는 동안, 얼마나 자주 호스피스
팀이 귀하의 가족의 상태에 관해서
알려 주었습니까?
0 전혀
0 때때로
30 보통
40 항상
1
2
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
13
10. 귀하의 가족이 호스피스 케어를 받는
동안, 얼마나 자주 호스피스 팀원이
귀하에게 귀하의 가족의 상태나
케어에 관해서 혼란스럽거나
모순되는 정보를 주었습니까?
0
0
30
40
1
전혀
2
때때로
보통
0
20
30
40
0
20
30
40
때때로
0
20
14
때때로
보통
항상
15. 귀하의 가족이 호스피스 케어를 받는
동안 통증이 있었던 적이 있습니까?
0
0
1
예
2
아니요 응답이 ‘아니요’면,
17 번으로 가세요.
16. 귀하의 가족이 통증에 따라 필요한
만큼 도움을 받았습니까?
보통
항상
0
20
30
1
전혀
예, 확실히
예, 다소
아니요
17. 귀하의 가족이 호스피스 케어를 받는
동안, 가족 분이 통증 약을
받으셨습니까?
때때로
1
보통
예
2
아니요 응답이 ‘아니요’면,
21 번으로 가세요.
0
0
항상
13. 귀하의 가족이 호스피스 케어를 받는
동안, 귀하의 가족의 호스피스 케어에
관한 문제에 대해서 호스피스 팀과
이야기를 나누셨습니까?
1
전혀
2
전혀
12. 귀하의 가족이 호스피스 케어를 받는
동안, 얼마나 자주 호스피스 팀이
귀하의 가족을 보살핀다고
느끼셨습니까?
1
0
0
30
40
1
항상
11. 귀하의 가족이 호스피스 케어를 받는
동안, 얼마나 자주 호스피스 팀이
귀하의 가족을 존중하면서
대하였습니까?
1
14. 귀하께서 귀하의 가족의 호스피스
케어에 대해서 호스피스 팀과 이야기
할 때 얼마나 자주 호스피스 팀이
주의 깊게 경청해 주었나요?
예
아니요 응답이 ‘아니요’면,
15 번으로 가세요.
18. 통증 약의 부작용엔 졸림 증상과 같은
것이 있습니다. 호스피스 팀 중
누군가가 귀하 또는 귀하의 가족에게
통증약의 부작용에 대해서
설명했습니까?
0
20
30
1
예, 확실히
예, 다소
아니
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
19. 호스피스팀이 귀하께 통증약의 주의
해야할 부작용에 관해서 필요한
안내를 해드렸습니까?
0
20
30
1
예, 확실히
예, 다소
아니요
20. 호스피스 팀이 귀하께 언제 귀하의
가족에게 통증 약을 더 드려야 되는지
여부와 시기에 관해서 필요한 안내를
해 드렸습니까?
0
0
30
40
1
예, 확실히
2
예, 다소
아니요
가족에게 통증 약을 줄 필요가
없었다
21. 귀하의 가족이 호스피스 케어를 받는
동안, 귀하의 가족께서 호흡곤란이
있었거나 호흡곤란에 대한 치료를
받으신 적이 있습니까?
0
20
1
예
아니요 응답이 ‘아니요’면,
24 번으로 가세요.
22. 귀하의 가족이 호흡 곤란에 관해서
얼마나 자주 필요한 도움을
받았습니까?
23. 호스피스 팀이 귀하께 귀하의 가족이
호흡 곤란을 느낄때 어떻게 도와야
하는지에 관한 필요한 안내를
해드렸습니까?
0
20
30
40
1
0
20
30
40
전혀
때때로
예, 다소
아니요
가족의 호흡 곤란을 도울 필요가
없었다
24. 귀하의 가족이 호스피스 케어를 받는
동안, 귀하의 가족이 변비로 고생하신
적이 있습니까?
0
20
1
예
아니요 응답이 ‘아니요’면
26 번으로 가세요
25. 귀하의 가족이 변비에 관해 얼마나
자주 필요한 도움을 받았습니까?
0
20
30
40
1
전혀
때때로
보통
항상
26. 귀하의 가족이 호스피스 케어를 받는
중에, 불안이나 슬픔을 보인 적이
있습니까?
0
20
1
1
예, 확실히
예
아니요 응답이 ‘아니요’면
28 번으로 가세요.
보통
항상
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
15
27. 얼마나 자주 귀하의 가족이 호스피스
팀으로부터 불안이나 슬픈 감정에
도움을 받은 적이 있습니까?
0
0
30
40
31. 귀하의 가족께서 돌아가실 떄,
호스피스팀이 귀하께서 무엇을
예상하셔야 되는지 원하시는 만큼의
정보를 드렸습니까?
1
전혀
2
때때로
1
예, 확실히
보통
2
예, 다소
0
0
30
항상
28. 귀하의 가족이 호스피스 케어를 받는
동안, 안절부절 하거나 불안해 한
적이 있으십니까?
0
0
1
예
2
아니요 응답이 ‘아니요’면
30 번으로 가세요.
29. 호스피스 팀이 귀하께 귀하의 가족이
안절부절 하거나 불안해 할 때 어떻게
해야 되는지에 관해 설명을 해
드렸습니까?
0
20
30
1
예, 확실히
예, 다소
아니요
호스피스 케어를 양로원에서
받은 경우
32. 어떤 분들은 양로원에 사시면서
호스피스 케어를 받으십니다. 귀하의
가족께서 양로원에 사시면서
호스피스 케어를 받으셨습니까?
0
0
1
예
2
아니요 응답이 ‘아니요’면,
35 번으로 가세요.
33. 귀하의 가족이 호스피스 케어를 받는
동안, 양로원 직원과 호스피스 팀이
얼마나 자주 귀하의 가족을 보살피기
위해서 함께 잘 일했습니까?
0
20
30
40
1
30. 귀하의 가족을 움직이게 하는 것에는
침대에서 방향을 바꾸는 것 또는
휠체어에 앉거나 일어나는 것, 또는
침대에 눕거나 일어나는 것이
포함됩니다. 호스피스 팀이 귀하께
어떻게 가족을 안전하게 움직일 수
있는지 필요한 안내를 해 드렸습니까?
0
20
30
40
1
16
예, 확실히
예, 다소
아니요
전혀
때때로
보통
항상
34. 귀하의 가족이 호스피스 케어를 받는
동안, 얼마나 자주, 양로원
직원으로부터 귀하의 가족에 관해
받은 정보와 호스피스 팀으로부터
받은 정보가 달랐습니까?
0
20
30
40
1
가족을 움직일 필요가 없었다.
아니요
전혀
때때로
보통
항상
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
호스피스에 관한 귀하의 경험
35. 귀하의 가족이 호스피스 케어를 받는
동안, 얼마나 자주 호스피스 팀이
주의 깊게 귀하께 경청 하였습니까?
38. 귀하의 가족이 돌아가신 후 몇 주
동안, 귀하는 호스피스 팀으로부터
얼마나 정서적인 지원을
받으셨습니까?
0
20
30
1
0
20
30
40
1
전혀
때때로
보통
항상
36. 종교적이거나 영적인 믿음에 관한
지원은 대화, 기도, 묵상 또는 어떠한
방식으로든 종교적이거나 영적으로
필요한 것을 충족시키는 것을
포함합니다. 귀하의 가족이 호스피스
케어를 받는 동안, 귀하는 호스피스
팀으로부터 얼마나 종교적 그리고
영적인 믿음에 관한 지원을
받으셨습니까?
0
20
30
1
너무 적게
적당하게
너무 많이
너무 적게
적당하게
너무 많이
호스피스 케어의 전체적인 점수
39. 설문지 겉 표지에 나와 있는
호스피스에게 귀하의 가족이 받은
케어에 관해서 다음의 질문들에
답변해 주시기 바랍니다. 귀하의
답변에 다른 호스피스로부터 받은
케어는 포함시키지 마십시오.
0 은 최악의 호스피스 케어이고 10 이
최고의 호스피스 케어라고 할 때
0 부터 10 까지의 숫자를 사용해서,
귀하의 가족이 받은 호스피스 케어에
대해 몇 점을 주시겠습니까?
0 0
0 1
20 2
30 3
40 4
50 5
60 6
70 7
80 8
90 9
100 10
0
최악의 호스피스 케어
1
37. 귀하의 가족이 호스피스 케어를 받는
동안, 귀하는 호스피스 팀으로부터
얼마나 정서적인 지원을 받았습니까?
0
0
30
1
너무 적게
2
적당하게
너무 많이
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
최고의 호스피스 케어
17
40. 이 호스피스를 귀하의 친구나
가족에게 추천 하시겠습니까?
0
0
30
40
43. 귀하의 가족의 인종이 무엇입니까?
한 개 또는 한 개 이상을 고를 수
있습니다.
1
절대 안 함
2
안 할 것 같음
1
백인
할 것 같음
2
흑인 또는 아프리카계 미국인
0
0
30
40
확실히 할 것임
귀하의 가족에 관해서
0
5
41. 귀하의 가족의 최종 학력이 어떻게
되시나요?
0
20
30
40
50
60
70
1
고졸 또는 검정고시(GED)
1
대학 중퇴 또는 2 년제 대학 학위
18 ~ 24 세
2
25 ~ 34 세
4 년제 대학 졸업
대학원 이상
모름
아니요, 히스패닉, 라티노,
스페인계 아님
0
30
예, 푸에르토리칸
0
50
예, 쿠바 사람
4
18
미국 인디안 또는 알래스카
원주민
44. 귀하의 연세가 어떻게 되십니까?
고교 중퇴
1
2
하와이 원주민 혹은 다른 태평양
제도인
귀하에 관해서
중졸 이하
42. 귀하의 가족이 히스패닉, 라티노 또는
스페인계 출신인가요?
0
아시아인
예, 멕시코 사람, 멕시코계
미국인, 치카노 사람
0
0
30
40
50
60
70
80
35 ~ 44 세
45 ~ 54 세
55 ~ 64 세
65 ~ 74 세
75 ~ 84 세
85 세 이상
45. 귀하는 남성입니까, 아니면
여성입니까?
0
20
1
남성
여성
예, 다른
스페인계/히스패닉/라티노
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
46. 귀하의 학력이 어떻게 되십니까?
0
20
30
40
50
60
1
47. 댁에서 사용하시는 주요 언어가
무엇입니까?
중졸 이하
0
20
30
40
50
60
70
80
90
1
고교 중퇴
고졸 또는 검정고시(GED)
대학 중퇴 또는 2 년제 대학 학위
4 년제 대학 졸업
대학원 이상
영어
스페인어
중국어
러시아어
포르투갈어
베트남어
폴란드어
한국어
다른 언어(정자체로 써주세요)
감사합니다
작성하신 설문지를 우편요금 선납 반송용 우편 봉투에 넣어서 보내주세요.
[NAME OF SURVEY VENDOR]
[RETURN ADDRESS OF SURVEY VENDOR]
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
19
20
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
CAHPS® 호스피스 설문 조사
이 호스피스로부터 환자가 받은 케어에 관해서 설문지에 답변해 주시기 바랍니다.
[NAME OF HOSPICE]
이 설문지의 모든 질문들은 이 호스피스와의 경험에 관한 것입니다.
본 설문지에 관해서 더 자세히 알고 싶으시면, [TOLL FREE NUMBER] 로 연락을 주시기
바랍니다. 이 번호로의 통화는 무료로 이용하실 수 있습니다.
OMB#0938-1257
2020 년 12 월 31 일에 만료됨
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
21
CAHPS® 호스피스 설문 조사
설문 조사 지시 사항
♦
본 설문지는 설문지 커버레터에 적혀있는 사람이 받은 호스피스 케어에 관하여 가장
잘 알고 있는 귀하의 가족 구성원에게 주시기 바랍니다.
♦
설문지를 작성하실 때 어두운 색깔의 펜을 사용하여 주십시오.
♦
질문의 왼쪽에 있는 원을 완전히 채워서 모든 질문에 답변을 해주십시오.
O
♦
예
아니요
이 설문지에서 몇 개의 질문들은 건너 뛰라고 할 수도 있습니다. 이런 경우, 여기에
나온 것처럼 다음에 답변할 질문이 무엇인지를 말하는 안내와 함께 화살표가
표시되어 있습니다.
예 응답이 ‘예’면 1 번으로 가세오.
O
아니요
_____________________________________________________________________
호스피스 환자
1. 귀하는 설문지 커버 레터에 나와 있는
사람과 어떤 관계 입니까?
O
2O
3O
1
O
5O
6O
7O
8O
9O
4
22
배우자나 파트너
부모
조부모
고모(이모) 또는 삼촌(외삼촌)
자녀
O
2O
3O
4O
5O
6O
1
시어머니(장모) 또는
시아버지(장인)
자매 또는 형제
2. 이 설문지에서, “가족”은 설문지 커버
레터에 나와 있는 사람을 말합니다.
귀하의 가족이 이 호스피스로부터
케어를 받은 장소가 어디입니까?
한가지 이상 선택하십시오.
집
노인 원호 생활 시설
양로원
병원
호스피스 시설/ 호스피스 집
이외(정자체로 써주세요).
친구
이외(정자체로 써주세요).
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
귀하의 역할
3. 귀하의 가족이 호스피스 케어를 받는
동안, 얼마나 자주 케어 받는 가족을
돌보는 데 참여하고 감독을 했습니까?
6. 귀하의 가족이 호스피스의 케어를
받는 동안, 호스피스 팀은 귀하의
가족에게 케어를 위한 방문의 도착
시간을 얼마나 자주 알려 주었습니까?
O
2O
3O
4O
1
O
1
O
3O
4O
2
전혀 응답이 ‘전혀’이면,
41 번으로 가세요.
때때로
보통
항상
가족의 호스피스 케어
이 설문지의 나머지 질문에 답변하실 때,
설문지 커버에 나와 있는 이름의
호스피스에 대한 귀하의 가족의 경험만을
생각해 주십시오.
4. 이 설문지에서, 호스피스 팀은 귀하의
가족에게 호스피스 케어를 제공했던
모든 간호사, 의사, 사회 복지사,
목사님 그리고 다른 사람들을
포함합니다. 귀하의 가족이 호스피스
케어를 받는 동안, 질문이 있거나
귀하의 가족을 케어하는 데 도움을
받기 위해 호스피스 팀에게 저녁, 주말,
휴일에 연락을 해야 했습니까?
O
2O
1
예
아니요 응답이 ‘아니요’면,
6 번으로 가세요.
5. 귀하는 얼마나 자주 호스피스
팀으로부터 저녁, 주말, 휴일에 필요한
도움을 받으셨습니까?
O
2O
3O
4O
1
전혀
때때로
보통
전혀
때때로
보통
항상
7. 귀하의 가족이 호스피스 케어를 받는
동안, 귀하 또는 귀하의 가족이
호스피스 팀에게 도움을 요청 했을 때,
도움을 얼마나 즉시 자주 받았습니까?
O
2O
3O
4O
1
전혀
때때로
보통
항상
8. 귀하의 가족이 호스피스 케어를 받는
동안, 얼마나 자주 호스피스 팀이
이해하기 쉽게 설명을 해 주었습니까?
O
2O
3O
4O
1
전혀
때때로
보통
항상
9. 귀하의 가족이 호스피스 케어를 받는
동안, 얼마나 자주 호스피스 팀이
귀하의 가족의 상태에 관해서 알려
주었습니까?
O
2O
3O
4O
1
전혀
때때로
보통
항상
항상
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
23
10. 귀하의 가족이 호스피스 케어를 받는
동안, 얼마나 자주 호스피스 팀원이
귀하에게 귀하의 가족의 상태나
케어에 관해서 혼란스럽거나
모순되는 정보를 주었습니까?
O
O
3O
4O
1
전혀
2
때때로
보통
O
2O
3O
4O
O
2O
3O
4O
때때로
O
2O
24
때때로
보통
항상
15. 귀하의 가족이 호스피스 케어를 받는
동안 통증이 있었던 적이 있습니까?
O
O
1
예
2
아니요 응답이 ‘아니요’면,
17 번으로 가세요.
16. 귀하의 가족이 통증에 따라 필요한
만큼 도움을 받았습니까?
보통
항상
O
2O
3O
1
전혀
예, 확실히
예, 다소
아니요
17. 귀하의 가족이 호스피스 케어를 받는
동안, 가족 분이 통증 약을
받으셨습니까?
때때로
1
보통
예
2
아니요 응답이 ‘아니요’면,
21 번으로 가세요.
O
O
항상
13. 귀하의 가족이 호스피스 케어를 받는
동안, 귀하의 가족의 호스피스 케어에
관한 문제에 대해서 호스피스 팀과
이야기를 나누셨습니까?
1
전혀
2
전혀
12. 귀하의 가족이 호스피스 케어를 받는
동안, 얼마나 자주 호스피스 팀이
귀하의 가족을 보살핀다고
느끼셨습니까?
1
O
O
3O
4O
1
항상
11. 귀하의 가족이 호스피스 케어를 받는
동안, 얼마나 자주 호스피스 팀이
귀하의 가족을 존중하면서
대하였습니까?
1
14. 귀하께서 귀하의 가족의 호스피스
케어에 대해서 호스피스 팀과 이야기
할 때 얼마나 자주 호스피스 팀이
주의 깊게 경청해 주었나요?
예
아니요 응답이 ‘아니요’면,
15 번으로 가세요.
18. 통증 약의 부작용엔 졸림 증상과 같은
것이 있습니다. 호스피스 팀 중
누군가가 귀하 또는 귀하의 가족에게
통증약의 부작용에 대해서
설명했습니까?
O
2O
3O
1
예, 확실히
예, 다소
아니
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
19. 호스피스팀이 귀하께 통증약의 주의
해야할 부작용에 관해서 필요한
안내를 해드렸습니까?
O
2O
3O
1
예, 확실히
예, 다소
아니요
20. 호스피스 팀이 귀하께 언제 귀하의
가족에게 통증 약을 더 드려야 되는지
여부와 시기에 관해서 필요한 안내를
해 드렸습니까?
O
O
3O
4O
1
예, 확실히
2
예, 다소
아니요
가족에게 통증 약을 줄 필요가
없었다.
21. 귀하의 가족이 호스피스 케어를 받는
동안, 귀하의 가족께서 호흡곤란이
있었거나 호흡곤란에 대한 치료를
받으신 적이 있습니까?
O
2O
1
예
아니요 응답이 ‘아니요’면,
24 번으로 가세요.
22. 귀하의 가족이 호흡 곤란에 관해서
얼마나 자주 필요한 도움을
받았습니까?
23. 호스피스 팀이 귀하께 귀하의 가족이
호흡 곤란을 느낄때 어떻게 도와야
하는지에 관한 필요한 안내를
해드렸습니까?
O
2O
3O
4O
1
O
2O
3O
4O
전혀
때때로
예, 다소
아니요
가족의 호흡 곤란을 도울 필요가
없었다.
24. 귀하의 가족이 호스피스 케어를 받는
동안, 귀하의 가족이 변비로 고생하신
적이 있습니까?
O
2O
1
예
아니요 응답이 ‘아니요’면
26 번으로 가세요
25. 귀하의 가족이 변비에 관해 얼마나
자주 필요한 도움을 받았습니까?
O
2O
3O
4O
1
전혀
때때로
보통
항상
26. 귀하의 가족이 호스피스 케어를 받는
중에, 불안이나 슬픔을 보인 적이
있습니까?
O
2O
1
1
예, 확실히
예
아니요 응답이 ‘아니요’면
28 번으로 가세요.
보통
항상
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
25
27. 얼마나 자주 귀하의 가족이 호스피스
팀으로부터 불안이나 슬픈 감정에
도움을 받은 적이 있습니까?
O
O
3O
4O
31. 귀하의 가족께서 돌아가실 떄,
호스피스팀이 귀하께서 무엇을
예상하셔야 되는지 원하시는 만큼의
정보를 드렸습니까?
1
전혀
2
때때로
1
예, 확실히
보통
2
예, 다소
O
O
3O
항상
28. 귀하의 가족이 호스피스 케어를 받는
동안, 안절부절 하거나 불안해 한
적이 있으십니까?
O
O
1
예
2
아니요 응답이 ‘아니요’면
30 번으로 가세요.
29. 호스피스 팀이 귀하께 귀하의 가족이
안절부절 하거나 불안해 할 때 어떻게
해야 되는지에 관해 설명을 해
드렸습니까?
O
2O
3O
1
예, 확실히
예, 다소
아니요
호스피스 케어를 양로원에서
받은 경우
32. 어떤 분들은 양로원에 사시면서
호스피스 케어를 받으십니다. 귀하의
가족께서 양로원에 사시면서
호스피스 케어를 받으셨습니까?
O
O
1
예
2
아니요 응답이 ‘아니요’면,
35 번으로 가세요.
33. 귀하의 가족이 호스피스 케어를 받는
동안, 양로원 직원과 호스피스 팀이
얼마나 자주 귀하의 가족을 보살피기
위해서 함께 잘 일했습니까?
O
2O
3O
4O
1
30. 귀하의 가족을 움직이게 하는 것에는
침대에서 방향을 바꾸는 것 또는
휠체어에 앉거나 일어나는 것, 또는
침대에 눕거나 일어나는 것이
포함됩니다. 호스피스 팀이 귀하께
어떻게 가족을 안전하게 움직일 수
있는지 필요한 안내를 해 드렸습니까?
O
2O
3O
4O
1
26
예, 확실히
예, 다소
아니요
전혀
때때로
보통
항상
34. 귀하의 가족이 호스피스 케어를 받는
동안, 얼마나 자주, 양로원
직원으로부터 귀하의 가족에 관해
받은 정보와 호스피스 팀으로부터
받은 정보가 달랐습니까?
O
2O
3O
4O
1
가족을 움직일 필요가 없었다.
아니요
전혀
때때로
보통
항상
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
호스피스에 관한 귀하의 경험
35. 귀하의 가족이 호스피스 케어를 받는
동안, 얼마나 자주 호스피스 팀이
주의 깊게 귀하께 경청 하였습니까?
38. 귀하의 가족이 돌아가신 후 몇 주
동안, 귀하는 호스피스 팀으로부터
얼마나 정서적인 지원을
받으셨습니까?
O
2O
3O
1
O
2O
3O
4O
1
전혀
때때로
보통
항상
36. 종교적이거나 영적인 믿음에 관한
지원은 대화, 기도, 묵상 또는 어떠한
방식으로든 종교적이거나 영적으로
필요한 것을 충족시키는 것을
포함합니다. 귀하의 가족이 호스피스
케어를 받는 동안, 귀하는 호스피스
팀으로부터 얼마나 종교적 그리고
영적인 믿음에 관한 지원을
받으셨습니까?
O
2O
3O
1
너무 적게
적당하게
너무 많이
너무 적게
적당하게
너무 많이
호스피스 케어의 전체적인 점수
39. 설문지 겉 표지에 나와 있는
호스피스에게 귀하의 가족이 받은
케어에 관해서 다음의 질문들에
답변해 주시기 바랍니다. 귀하의
답변에 다른 호스피스로부터 받은
케어는 포함시키지 마십시오.
0 은 최악의 호스피스 케어이고 10 이
최고의 호스피스 케어라고 할 때
0 부터 10 까지의 숫자를 사용해서,
귀하의 가족이 받은 호스피스 케어에
대해 몇 점을 주시겠습니까?
O0
O1
2O 2
3O 3
4O 4
5O 5
6O 6
7O 7
8O 8
9O 9
10O 10
0
최악의 호스피스 케어
1
37. 귀하의 가족이 호스피스 케어를 받는
동안, 귀하는 호스피스 팀으로부터
얼마나 정서적인 지원을 받았습니까?
O
O
3O
1
너무 적게
2
적당하게
너무 많이
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
최고의 호스피스 케어
27
40. 이 호스피스를 귀하의 친구나
가족에게 추천 하시겠습니까?
O
O
3O
4O
43. 귀하의 가족의 인종이 무엇입니까?
한 개 또는 한 개 이상을 고를 수
있습니다.
1
절대 안 함
2
안 할 것 같음
1
할 것 같음
2
O 백인
O 흑인 또는 아프리카계 미국인
3O 아시아인
4O 하와이 원주민 혹은 다른 태평양
확실히 할 것임
귀하의 가족에 관해서
제도인
41. 귀하의 가족의 최종 학력이 어떻게
되시나요?
O 중졸 이하
2O 고교 중퇴
3O 고졸 또는 검정고시(GED)
4O 대학 중퇴 또는 2 년제 대학 학위
5O 4 년제 대학 졸업
6O 대학원 이상
7O 모름
O
5
귀하에 관해서
1
42. 귀하의 가족이 히스패닉, 라티노 또는
스페인계 출신인가요?
O
1
아니요, 히스패닉, 라티노,
스페인계 아님
O
3O
예, 푸에르토리칸
2
O
5O
4
28
예, 멕시코 사람, 멕시코계
미국인, 치카노 사람
예, 쿠바 사람
미국 인디안 또는 알래스카
원주민
44. 귀하의 연세가 어떻게 되십니까?
O
O
3O
4O
5O
6O
7O
8O
1
18 ~ 24 세
2
25 ~ 34 세
35 ~ 44 세
45 ~ 54 세
55 ~ 64 세
65 ~ 74 세
75 ~ 84 세
85 세 이상
45. 귀하는 남성입니까, 아니면
여성입니까?
O
2O
1
남성
여성
예, 다른
스페인계/히스패닉/라티노
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
46. 귀하의 학력이 어떻게 되십니까?
O
2O
3O
4O
5O
6O
1
47. 댁에서 사용하시는 주요 언어가
무엇입니까?
중졸 이하
O
2O
3O
4O
5O
6O
7O
8O
9O
1
고교 중퇴
고졸 또는 검정고시(GED)
대학 중퇴 또는 2 년제 대학 학위
4 년제 대학 졸업
대학원 이상
영어
스페인어
중국어
러시아어
포르투갈어
베트남어
폴란드어
한국어
다른 언어(정자체로 써주세요)
감사합니다
작성하신 설문지를 우편요금 선납 반송용 우편 봉투에 넣어서 보내주세요.
[NAME OF SURVEY VENDOR]
[RETURN ADDRESS OF SURVEY VENDOR]
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
29
30
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
Sample Initial Cover Letter for the CAHPS Hospice Survey
[HOSPICE OR VENDOR LETTERHEAD]
[SAMPLED CAREGIVER NAME]
[ADDRESS]
[CITY, STATE ZIP]
[SAMPLED CAREGIVER NAME] 께:
[HOSPICE NAME]은(는) 환자와 가족이 받은 호스피스 서비스에 관해서 설문조사를
실시하고 있습니다. 귀하는 [DECEDENT NAME]의 간병인으로 확인되었기 때문이 이
설문조사 참여에 선택 되셨습니다. 귀하께서 힘든 시간을 보내고 계실 것이란 것을 알고
있지만, 귀하 그리고 귀하의 가족 또는 친구가 받은 호스피스 케어의 수준에 관해서 알 수
있도록 도와 주시기 바랍니다.
동봉된 설문지에 들어 있는 질문[NOTE THE QUESTION NUMBERS]들은 호스피스의
서비스 수준을 측정하기 위해 미국 보건사회복지부(HHS)에서 후원하는 국가적인
이니셔티브(계획)의 한 부분입니다. HHS 의 한 부분인 ‘메디케어 및 메디케이드 서비스
센터’(CMS)가 호스피스 케어를 증진하기 위해서 이 설문 조사를 진행하고 있습니다.
CMS 는 미국내 대부분의 호스피스 케어를 재정적으로 지원하고 있습니다. 호스피스
환자와 그의 가족 그리고 친구들이 수준 높은 케어를 받는 것을 보장할 책임이 CMS 에
있습니다. 이러한 책임을 이행하기 위한 방법으로 귀하의 가족과 친구들이 받은
호스피스 케어에 관해서 알고자 하는 것입니다. 귀하의 참여는 본인의 선택에 따라
자발적으로 이루어지는 것이며 귀하께서 받으시는 건강 관리와 혜택에는 영향을 미치지
않습니다.
귀하께서 시간을 내셔서 이 설문지를 작성해 주시기 바랍니다. 설문지 작성을
완료하시고 나서 제공된 우편 요금 선납 반송용 우편 봉투로 보내 주시기 바랍니다.
귀하의 답변은 품질 개선의 목적으로 호스피스에 공유 될 수 있습니다.
[OPTIONAL:설문지에 나와 있는 번호를 보셨을 것입니다. 이 번호는 귀하께서 설문지를
돌려 보내 주셨는지 확인해서 추가로 후속 편지를 보내지 않도록 확인하기 위한
것입니다.]
동봉된 설문지에 관한 궁금증이 있으시면 무료 전화 번호 1-800-xxx-xxxx 번으로 연락해
주시기 바랍니다. 모든 고객을 위한 호스피스 케어의 품질을 향상시키는 데 도움을
주셔서 감사합니다.
감사합니다.
[HOSPICE ADMINISTRATOR]
[HOSPICE NAME]
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Sample Follow-up Cover Letter for the CAHPS Hospice
Survey
[HOSPICE OR VENDOR LETTERHEAD]
[SAMPLED CAREGIVER NAME]
[ADDRESS]
[CITY, STATE ZIP]
[SAMPLED CAREGIVER NAME]께:
기록에 따르면 귀하께서는 최근에 [DECEDENT NAME]에서 [NAME OF
HOSPICE]의 간병인이셨습니다. 대략 3주 전에, 저희가 귀하께 귀하와 귀하의 가족
또는 친구가 이 호스피스로부터 받은 케어에 관한 설문지를 보냈습니다. 이미
설문지를 돌려 보내 주셨으면 감사드리고요, 이 편지를 무시하셔도 됩니다. 그러나,
아직 안 보내 주셨으면, 시간을 내주셔서 이 중요한 질문서를 작성해 주시면 대단히
감사하겠습니다.
저희는 귀하가 이번을 기회 삼아 귀하의 가족과 친구들이 받은 케어의 수준에 관해서
저희가 알 수 있도록 도와주시기 바랍니다. 이 설문지의 결과는 모든 미국인들이 최고의
호스피스 케어 받을 수 있도록 보장하는 데 도움을 주기 위해 사용될 것입니다.
동봉한 설문지의 질문[NOTE THE QUESTION NUMBERS]들은 호스피스 케어의 수준을
측정하기 위해서 미국 보건사회복지부(HHS)에서 지원하는 국가 계획의 한 부분입니다.
HHS 의 한 부분인 ‘메디케어 및 메디케이드 서비스 센터’(CMS)가 호스피스 케어를
증진하기 위해서 이 설문 조사를 진행하고 있습니다. CMS 는 미국내 대부분의 호스피스
케어를 재정적으로 지원하고 있습니다. 호스피스 환자와 그의 가족 그리고 친구들이
수준 높은 케어를 받는 것을 보장할 책임이 CMS 에 있습니다. 이러한 책임을 이행하기
위한 방법으로 귀하의 가족과 친구들이 받은 호스피스 케어에 관해서 알고자 하는
것입니다. 귀하의 참여는 본인의 선택에 따라 자발적으로 이루어지는 것이며 귀하께서
받으시는 건강 관리와 혜택에는 영향을 미치지 않습니다.
시간을 내주셔서 동봉한 설문지를 작성해 주시기 바랍니다. 설문지 작성을 마치신 후에
우편 요금 선납 반송 봉투에 넣어서 돌려 보내 주시기 바랍니다. 귀하의 답변은 품질
향상을 위해 호스피스와 공유 될 수 있습니다. [OPTIONAL: 설문지에 나와 있는 번호를
보셨을 것입니다. 이 번호는 귀하께서 설문지를 돌려 보내 주셨는지 확인해서 귀하께
추가로 편지를 보내지 않도록 하기 위한 것입니다.]
동봉된 설문지에 관한 궁금증이나 질문이 있으시면, 무료 전화 1-800-xxx-xxxx번으로
전화해 주시기 바랍니다. 모든 고객을 위한 호스피스 케어 품질 향상을 위해 도움을
주셔서 감사합니다.
감사합니다.
[HOSPICE ADMINISTRATOR]
[HOSPICE NAME]
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OMB Paperwork Reduction Act Language
The OMB Paperwork Reduction Act language must appear in the mailing, either on the cover
letter or on the front or back of the questionnaire. In addition, the OMB control number must
appear on the front page of the questionnaire. The following is the language that must be used:
Korean Version
1995 년의 종이 삭감법에 따르면, 어느 누구도 유효한 OMB 규제 번호가 없다면 정보
수집에 답변해야할 책임이 없습니다. 이 정보 수집에 유효한 OMB 규제 번호는 0938- 1257
입니다 (2020 년 12 월 31 일에 만료됨). 이 정보 수집을 완료하는 데 요구되는 시간은
지시사항을 검토하고, 존재하는 자료의 출처를 찾고, 필요한 자료를 모으고, 정보 수집을
작성하고 검토하는 것을 포함해서, 1-40 번 문제들(이 설문지의 “가족에 관해서” 질문
그리고 “귀하에 관해서” 질문)에 평균 11 분이 걸릴 것으로 예상됩니다. 귀하께서 예상된
시간의 정확성에 관해서 하실 말씀이 있으시거나 이 양식을 개선하는 데 조언을 주고자
하신다면 편지를 보내주시기 바랍니다. 주소: Centers for Medicare & Medicaid Services,
7500 Security Boulevard, C1-25-05, Baltimore, MD 21244-1850.
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Appendix W
Telephone Script (English)
CAHPS Hospice Survey
Telephone Script (English)
Overview
This telephone interview script is provided to assist interviewers while attempting to reach the
caregiver of the sampled decedent. The script explains the purpose of the survey and confirms
necessary information about the caregiver and decedent.
General Interviewing Conventions and Instructions
The telephone introduction script must be read verbatim
All text that appears in lowercase letters must be read out loud
Text in UPPERCASE letters must not be read out loud
• YES and NO response options are only to be read if necessary
Note: It is not permissible to capitalize underlined content, as text that appears in
uppercase letters throughout the CATI script must not be read out loud. Survey vendors
are permitted to emphasis underlined content in a different manner if underlining is not a
viable option, such as placing quotes (“”) or asterisks (**) around the text to be
emphasized or italicizing the emphasized words.
All questions and all answer categories must be read exactly as they are worded
• During the course of the survey, use of neutral acknowledgment words such as the
following is permitted:
o Thank you
o Alright
o Okay
o I understand, or I see
o Yes, Ma’am
o Yes, Sir
The script must be read from the interviewer screens (reciting the survey from memory
can lead to unnecessary errors and missed updates to the scripts)
The pace of the CAHPS Hospice Survey interview should be adjusted to be conducive to
the needs of the respondent
No changes are permitted to the order of the question and answer categories for the
“Core,” “About Your Family Member” and “About You” CAHPS Hospice Survey
questions
• The first forty “Core” questions must remain together
• The three “About Your Family Member” questions must remain together
• The four “About You” questions must remain together
All transitional statements must be read
Text that is underlined must be emphasized
Characters in < > must not be read
[Square brackets] are used to show programming instructions that must not actually
appear on electronic telephone interviewing system screens
Only one language (i.e., English or Spanish) can appear on the electronic
interviewing system screen
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MISSING/DON’T KNOW (DK) is a valid response option for each item in the electronic
telephone interviewing system scripts. This allows the telephone interviewer to go to the
next question if a caregiver is unable to provide a response for a given question (or
refuses to provide a response). In the survey file layouts, a value of “MISSING/DK” is
coded as “M – Missing/Don't Know.”
Skip patterns should be programmed into the electronic telephone interviewing system
• Appropriately skipped questions should be coded as “88 – Not Applicable.” For
example, if a caregiver answers “No” to Question 4 of the CAHPS Hospice Survey, the
program should skip Question 5, and go to Question 6. Question 5 must then be coded
as “88 – Not Applicable.” Coding may be done automatically by the telephone
interviewing system or later during data preparation.
• When a response to a screener question is not obtained, the screener question and any
questions in the skip pattern should be coded as “M – Missing/Don't Know.” For
example, if the caregiver does not provide an answer to Question 4 of the CAHPS
Hospice Survey and the interviewer selects “MISSING/DK” to Question 4, then the
telephone interviewing system should be programmed to skip Question 5, and go to
Question 6. Question 5 must then be coded as “M – Missing/Don't Know.” Coding may
be done automatically by the telephone interviewing system or later during data
preparation.
INITIATING CONTACT
START:
Hello, this is [INTERVIEWER NAME]. May I please speak with [SAMPLED
CAREGIVER NAME]?
<1> YES [GO TO INTRO]
<2> YES, RESPONDENT IS ANOTHER MEMBER OF THE HOUSEHOLD
[GO TO CONFIRMATION]
<3> PROXY IDENTIFIED [COLLECT PROXY INFORMATION THEN
RETURN TO INTRO]
<4> NO, REFUSAL [GO TO REFUSAL]
<5> NO, NOT AVAILABLE RIGHT NOW [SET CALLBACK]
<6> ALREADY RETURNED SURVEY BY MAIL [GO TO MAILED]
<7> PATIENT DIDN’T RECEIVE CARE AT NAMED HOSPICE [GO TO
DISAVOWAL]
IF ASKED WHO IS CALLING:
This is [INTERVIEWER NAME] calling from [VENDOR NAME]. We are
working with [HOSPICE NAME] and the U.S. Department of Health and
Human Services to conduct a survey about hospice care.
IF THE SAMPLED CAREGIVER IS NOT AVAILABLE:
Can you tell me a convenient time to call back?
IF THE SAMPLED CAREGIVER SAYS THIS IS NOT A GOOD TIME:
Can you tell me a convenient time to call back?
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CONFIRMATION:
Am I speaking with [SAMPLED CAREGIVER]?
<1> YES [GO TO INTRO]
<2> NO [GO TO START]
******
INITIATING CONTACT WITH A PROXY RESPONDENT
START:
Hello, may I please speak to [PROXY CAREGIVER NAME]?
<1> YES [GO TO INTRO]
<2> NO [GO TO REFUSAL]
<3> NO, NOT AVAILABLE RIGHT NOW [SET CALLBACK]
IF ASKED WHO IS CALLING:
This is [INTERVIEWER NAME] calling from [VENDOR NAME]. We are
working with [HOSPICE NAME] and the U.S. Department of Health and
Human Services to conduct a survey about hospice care.
IF THE PROXY CAREGIVER IS NOT AVAILABLE:
Can you tell me a convenient time to call back to speak with (him/her)?
IF THE PROXY CAREGIVER SAYS THIS IS NOT A GOOD TIME:
If you don’t have the time now, when is a more convenient time to call you
back?
IF SOMEONE OTHER THAN THE PROXY CAREGIVER ANSWERS THE
PHONE, RECONFIRM THAT YOU ARE SPEAKING WITH THE PROXY
CAREGIVER WHEN HE OR SHE PICKS UP.
******
CALL BACK TO COMPLETE A PREVIOUSLY STARTED SURVEY
START:
Hello, may I please speak to [SAMPLED CAREGIVER NAME/PROXY
CAREGIVER NAME]?
<1> YES [GO TO CONFIRM RESPONDENT]
<2> NO [REFUSAL]
<3> NO, NOT AVAILABLE RIGHT NOW [SET CALLBACK]
IF NEEDED TO CONFIRM SPEAKING TO RESPONDENT: This is
[INTERVIEWER NAME] calling from [SURVEY VENDOR]. I am calling to
complete a survey that you started at an earlier date. Before we continue with the
survey, I would like to confirm that I am speaking with [CAREGIVER NAME]?
CONTINUE SURVEY WHERE PREVIOUSLY LEFT OFF.
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SPEAKING WITH CAREGIVER
INTRO:
Hi, my name is [INTERVIEWER NAME] and I’m calling from [VENDOR
NAME].
[HOSPICE NAME] is conducting a survey about the hospice services that patients
and their families receive. It is part of a national initiative sponsored by the United
States Department of Health and Human Services to measure the quality of care in
hospices. We realize this may be a difficult time for you, but we hope that you will
take a few minutes to help us learn about the quality of hospice care that you and
your loved one received.
Your participation is voluntary and will not affect any health care or benefits you
receive. The interview will take [FILL: approximately 11 minutes/SURVEY
VENDOR SPECIFY]. Your answers may be shared with the hospice for purposes
of quality improvement.
IF ASKED WHETHER SOMEONE ELSE CAN SERVE AS PROXY FOR
SAMPLED CAREGIVER:
For this survey, we need to speak to the person in your household who is the
most knowledgeable about the hospice care received by [DECEDENT NAME].
Are you or is another household member most knowledgeable?
IF OTHER HOUSEHOLD MEMBER: And may I please have that person’s
name?
AFTER RECORDING NAME: May I please speak to this person?
IF NEEDED AND SPEAKING WITH THE SAMPLED CAREGIVER:
We received your name from [HOSPICE NAME] because you were listed as
the caregiver for [DECEDENT NAME].
IF NEEDED AND SPEAKING WITH PROXY FOR SAMPLED
CAREGIVER: We received your name from [SAMPLED CAREGIVER]
because he/she indicated that you were knowledgeable about the hospice care
received by [DECEDENT NAME].
<1> YES [GO TO CONTINUE]
<2> PROXY IDENTIFIED [COLLECT PROXY INFORMATION, THEN
RETURN TO PROXY INTRO]
<3> NO, WILL RETURN COMPLETED MAILED SURVEY [GO TO
CALLBACK]
<4> NO, CALL BACK [GO TO CALLBACK]
<5> NO, OR UNAVAILABLE DURING FIELD PERIOD [GO TO ITEM TO
CODE INELIGIBLE, ETC.,]
<6> REFUSE [GO TO REFUSAL]
<7> ALREADY RETURNED SURVEY BY MAIL [GO TO MAILED]
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<8> NOT INVOLVED IN CARE AND NO PROXY IDENTIFIED [GO TO
INELIGIBLE]
<9> PATIENT DIDN’T RECEIVE CARE AT NAMED HOSPICE [GO TO
DISAVOWAL]
*******
CONTINUE
This call may be monitored [OPTIONAL: and/or recorded] for quality
improvement purposes. May we begin?
<1> YES [BEGIN SURVEY]
<2> NO, CALL BACK [GO TO CALLBACK]
<3> REFUSE [GO TO REFUSAL]
*******
MAILED
Thank you so much for completing the survey by mail. Perhaps we still have not
gotten it but we’ll check our records again. We may need to contact you again in
case we still have not received it. [END CALL]
*******
INELIGIBLE
I’m sorry, for this project we are only speaking with family members or friends
who took part in or oversaw hospice care for their family members. Thank you for
your time. Have a good (day/evening). [END CALL]
*******
DISAVOWAL
Perhaps there was an error in our records. Thank you for your time. Have a good
(day/evening). [END CALL]
*******
BEGIN CAHPS HOSPICE SURVEY QUESTIONS
Q1_INTRO
Please answer all questions in this survey about the care the patient received at
[HOSPICE NAME]. When thinking about your answers, do not include any other
hospice stays.
BE PREPARED TO PROBE IF THE CAREGIVER ANSWERS OUTSIDE OF
THE ANSWER CATEGORIES PROVIDED. PROBE BY REPEATING THE
ANSWER CATEGORIES ONLY; DO NOT INTERPRET FOR THE
CAREGIVER.
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Q1
How are you related to [DECEDENT NAME]?
READ ANSWER CHOICES ONLY IF NECESSARY
Q1A
<1> MY SPOUSE OR PARTNER
<2> MY PARENT
<3> MY MOTHER-IN-LAW
OR FATHER-IN-LAW
<4> MY GRANDPARENT
<5> MY AUNT OR UNCLE
<6> MY SISTER OR BROTHER
<7> MY CHILD
<8> MY FRIEND
<9> OTHER (PLEASE SPECIFY)
[GO TO Q2]
[GO TO Q2]
[GO TO Q2]
[GO TO Q2]
[GO TO Q2]
[GO TO Q2]
[GO TO Q2]
[GO TO Q2]
[GO TO Q1A]
MISSING/DK
[GO TO Q2]
How are you related to [DECEDENT NAME]?
NOTE: PLEASE DOCUMENT THE RELATIONSHIP AND MAINTAIN IN
YOUR INTERNAL RECORDS.
[NOTE: FOR TELEPHONE INTERVIEWING, Q2 IS BROKEN INTO PARTS A – G.]
Q2
For this survey, the phrase “family member” refers to [DECEDENT NAME].
Please answer yes or no to each of the categories. I am required to read all six
categories. In what locations did your family member receive care from [HOSPICE
NAME]?
READ YES/NO RESPONSE CHOICES ONLY IF NECESSARY
Q2A
At home?
<1> YES
<0> NO
MISSING/DK
Q2B
At an assisted living facility?
<1> YES
<0> NO
MISSING/DK
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Q2C
At a nursing home?
<1> YES
<0> NO
MISSING/DK
Q2D
At a hospital?
<1> YES
<0> NO
MISSING/DK
Q2E
At a hospice facility or hospice house?
<1> YES
<0> NO
MISSING/DK
Q2F
Q2G
At some other place?
<1> YES
<0> NO
[GO TO Q2G]
[GO TO Q3]
MISSING/DK
[GO TO Q3]
Where did your family member receive care?
NOTE: PLEASE DOCUMENT THE OTHER PLACE AND MAINTAIN IN
YOUR INTERNAL RECORDS.
Q3
While your family member was in hospice care, how often did you take part in or
oversee care for him or her? Would you say…
<1>
<2>
<3>
<4>
Never,
Sometimes,
Usually, or
Always?
[GO TO Q41_INTRO]
MISSING/DK
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Q4_INTRO
As you answer the rest of the questions in this survey, please think only about your
family member's experience with [HOSPICE NAME].
Q4
For this survey, the hospice team includes all the nurses, doctors, social workers,
chaplains and other people who provided hospice care to your family member.
While your family member was in hospice care, did you need to contact the hospice
team during evenings, weekends, or holidays for questions or help with your family
member’s care?
READ YES/NO RESPONSE CHOICES ONLY IF NECESSARY
Q5
<1> YES
<2> NO
[GO TO Q6]
[<88> NOT APPLICABLE]
MISSING/DK
[GO TO Q6]
How often did you get the help you needed from the hospice team during
evenings, weekends, or holidays? Would you say…
<1>
<2>
<3>
<4>
Never,
Sometimes,
Usually, or
Always?
[<88> NOT APPLICABLE]
MISSING/DK
Q6
While your family member was in hospice care, how often did the hospice team
keep you informed about when they would arrive to care for your family member?
Would you say…
<1>
<2>
<3>
<4>
Never,
Sometimes,
Usually, or
Always?
[<88> NOT APPLICABLE]
MISSING/DK
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Q7
While your family member was in hospice care, when you or your family member
asked for help from the hospice team, how often did you get help as soon as you
needed it? Would you say…
<1>
<2>
<3>
<4>
Never,
Sometimes,
Usually, or
Always?
[<88> NOT APPLICABLE]
MISSING/DK
Q8
While your family member was in hospice care, how often did the hospice team
explain things in a way that was easy to understand? Would you say…
<1>
<2>
<3>
<4>
Never,
Sometimes,
Usually, or
Always?
[<88> NOT APPLICABLE]
MISSING/DK
Q9
While your family member was in hospice care, how often did the hospice team
keep you informed about your family member’s condition? Would you say…
<1>
<2>
<3>
<4>
Never,
Sometimes,
Usually, or
Always?
[<88> NOT APPLICABLE]
MISSING/DK
Q10
While your family member was in hospice care, how often did anyone from the
hospice team give you confusing or contradictory information about your family
member’s condition or care? Would you say…
<1>
<2>
<3>
<4>
Never,
Sometimes,
Usually, or
Always?
[<88> NOT APPLICABLE]
MISSING/DK
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Q11
While your family member was in hospice care, how often did the hospice team
treat your family member with dignity and respect? Would you say…
<1>
<2>
<3>
<4>
Never,
Sometimes,
Usually, or
Always?
[<88> NOT APPLICABLE]
MISSING/DK
Q12
While your family member was in hospice care, how often did you feel that the
hospice team really cared about your family member? Would you say…
<1>
<2>
<3>
<4>
Never,
Sometimes,
Usually, or
Always?
[<88> NOT APPLICABLE]
MISSING/DK
Q13
While your family member was in hospice care, did you talk with the hospice team
about any problems with your family member’s hospice care?
READ YES/NO RESPONSE CHOICES ONLY IF NECESSARY
NOTE: IF THE RESPONDENT REPLIES, “I DIDN’T HAVE ANY
PROBLEMS,” CODE RESPONSE AS “NO.”
Q14
<1> YES
<2> NO
[GO TO Q15]
[<88> NOT APPLICABLE]
MISSING/DK
[GO TO Q15]
How often did the hospice team listen carefully to you when you talked with them
about problems with your family member’s hospice care? Would you say…
<1>
<2>
<3>
<4>
Never,
Sometimes,
Usually, or
Always?
[<88> NOT APPLICABLE]
MISSING/DK
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Q15
While your family member was in hospice care, did he or she have any pain?
READ YES/NO RESPONSE CHOICES ONLY IF NECESSARY
Q16
<1> YES
<2> NO
[GO TO Q17]
[<88> NOT APPLICABLE]
MISSING/DK
[GO TO Q17]
Did your family member get as much help with pain as he or she needed? Would
you say…
<1> Yes, definitely,
<2> Yes, somewhat, or
<3> No?
[<88> NOT APPLICABLE]
MISSING/DK
Q17
While your family member was in hospice care, did he or she receive any pain
medicine?
READ YES/NO RESPONSE CHOICES ONLY IF NECESSARY
Q18
<1> YES
<2> NO
[GO TO Q21]
[<88> NOT APPLICABLE]
MISSING/DK
[GO TO Q21]
Side effects of pain medicine include things like sleepiness. Did any member of
the hospice team discuss side effects of pain medicine with you or your family
member? Would you say…
<1> Yes, definitely,
<2> Yes, somewhat, or
<3> No?
[<88> NOT APPLICABLE]
MISSING/DK
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Q19
Did the hospice team give you the training you needed about what side effects to
watch for from pain medicine? Would you say…
<1> Yes, definitely,
<2> Yes, somewhat, or
<3> No?
[<88> NOT APPLICABLE]
MISSING/DK
Q20
Did the hospice team give you the training you needed about if and when to give
more pain medicine to your family member? Would you say…
<1>
<2>
<3>
<4>
Yes, definitely,
Yes, somewhat,
No, or
I did not need to give pain medicine to my family member.
[<88> NOT APPLICABLE]
MISSING/DK
Q21
While your family member was in hospice care, did your family member ever have
trouble breathing or receive treatment for trouble breathing?
READ YES/NO RESPONSE CHOICES ONLY IF NECESSARY
Q22
<1> YES
<2> NO
[GO TO Q24]
[<88> NOT APPLICABLE]
MISSING/DK
[GO TO Q24]
How often did your family member get the help he or she needed for trouble
breathing? Would you say…
<1>
<2>
<3>
<4>
Never,
Sometimes,
Usually, or
Always?
[<88> NOT APPLICABLE]
MISSING/DK
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Q23
Did the hospice team give you the training you needed about how to help your
family member if he or she had trouble breathing? Would you say…
<1>
<2>
<3>
<4>
Yes, definitely,
Yes, somewhat,
No, or
I did not need to help my family member with trouble breathing.
[<88> NOT APPLICABLE]
MISSING/DK
Q24
While your family member was in hospice care, did your family member ever have
trouble with constipation?
READ YES/NO RESPONSE CHOICES ONLY IF NECESSARY
Q25
<1> YES
<2> NO
[GO TO Q26]
[<88> NOT APPLICABLE]
MISSING/DK
[GO TO Q26]
How often did your family member get the help he or she needed for trouble with
constipation? Would you say...
<1>
<2>
<3>
<4>
Never,
Sometimes,
Usually, or
Always?
[<88> NOT APPLICABLE]
MISSING/DK
Q26
While your family member was in hospice care, did he or she show any feelings of
anxiety or sadness?
READ YES/NO RESPONSE CHOICES ONLY IF NECESSARY
<1> YES
<2> NO
[GO TO Q28]
[<88> NOT APPLICABLE]
MISSING/DK
[GO TO Q28]
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Q27
How often did your family member get the help he or she needed from the hospice
team for feelings of anxiety or sadness? Would you say…
<1>
<2>
<3>
<4>
Never,
Sometimes,
Usually, or
Always?
[<88> NOT APPLICABLE]
MISSING/DK
Q28
While your family member was in hospice care, did he or she ever become restless
or agitated?
READ YES/NO RESPONSE CHOICES ONLY IF NECESSARY
Q29
<1> YES
<2> NO
[GO TO Q30]
[<88> NOT APPLICABLE]
MISSING/DK
[GO TO Q30]
Did the hospice team give you the training you needed about what to do if your
family member became restless or agitated? Would you say…
<1> Yes, definitely,
<2> Yes, somewhat, or
<3> No?
[<88> NOT APPLICABLE]
MISSING/DK
Q30
Moving your family member includes things like helping him or her turn over in
bed, or get in and out of bed or a wheelchair. Did the hospice team give you the
training you needed about how to safely move your family member? Would you
say…
<1>
<2>
<3>
<4>
Yes, definitely,
Yes, somewhat,
No, or
I did not need to move my family member.
[<88> NOT APPLICABLE]
MISSING/DK
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Q31
Did the hospice team give you as much information as you wanted about what to
expect while your family member was dying? Would you say…
<1> Yes, definitely,
<2> Yes, somewhat, or
<3> No?
[<88> NOT APPLICABLE]
MISSING/DK
Q32
Some people receive hospice care while they are living in a nursing home. Did your
family member receive care from this hospice while he or she was living in a
nursing home?
READ YES/NO RESPONSE CHOICES ONLY IF NECESSARY
Q33
<1> YES
<2> NO
[GO TO Q35_INTRO]
[<88> NOT APPLICABLE]
MISSING/DK
[GO TO Q35_INTRO]
While your family member was in hospice care, how often did the nursing home
staff and hospice team work well together to care for your family member? Would
you say…
<1>
<2>
<3>
<4>
Never,
Sometimes,
Usually, or
Always?
[<88> NOT APPLICABLE]
MISSING/DK
Q34
While your family member was in hospice care, how often was the information you
were given about your family member by the nursing home staff different from the
information you were given by the hospice team? Would you say…
<1>
<2>
<3>
<4>
Never,
Sometimes,
Usually, or
Always?
[<88> NOT APPLICABLE]
MISSING/DK
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15
Q35_INTRO The next set of questions is about you.
Q35
While your family member was in hospice care, how often did the hospice team
listen carefully to you? Would you say…
<1>
<2>
<3>
<4>
Never,
Sometimes,
Usually, or
Always?
[<88> NOT APPLICABLE]
MISSING/DK
Q36
Support for religious or spiritual beliefs includes talking, praying, quiet time, or
other ways of meeting your religious or spiritual needs. While your family member
was in hospice care, how much support for your religious and spiritual beliefs did
you get from the hospice team? Would you say…
<1> Too little,
<2> The right amount, or
<3> Too much?
[<88> NOT APPLICABLE]
MISSING/DK
Q37
While your family member was in hospice care, how much emotional support did
you get from the hospice team? Would you say…
<1> Too little,
<2> The right amount, or
<3> Too much?
[<88> NOT APPLICABLE]
MISSING/DK
Q38
In the weeks after your family member died, how much emotional support did you
get from the hospice team? Would you say…
<1> Too little,
<2> The right amount, or
<3> Too much?
[<88> NOT APPLICABLE]
MISSING/DK
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Q39
Please answer the following questions about your family member’s care from
[HOSPICE NAME]. Do not include care from other hospices in your answers.
Using any number from 0 to 10, where 0 is the worst hospice care possible and 10
is the best hospice care possible, what number would you use to rate your family
member’s hospice care?
IF THE RESPONDENT DOES NOT PROVIDE AN APPROPRIATE
RESPONSE, PROBE BY REPEATING: Using any number from 0 to 10, where 0
is the worst hospice care possible and 10 is the best hospice care possible, what
number would you use to rate your family member’s hospice care?
READ ANSWER CHOICES ONLY IF NECESSARY
<0> 0
<1> 1
<2> 2
<3> 3
<4> 4
<5> 5
<6> 6
<7> 7
<8> 8
<9> 9
<10> 10
[<88> NOT APPLICABLE]
MISSING/DK
Q40
Would you recommend this hospice to your friends and family? Would you say…
<1>
<2>
<3>
<4>
Definitely no,
Probably no,
Probably yes, or
Definitely yes?
[<88> NOT APPLICABLE]
MISSING/DK
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Q41_INTRO The next questions are about your family member.
Q41
What is the highest grade or level of school that your family member completed?
[OPTIONAL: Did he or she…]
READ ANSWER CHOICES ONLY IF NECESSARY
<1>
<2>
<3>
<4>
<5>
<6>
<7>
Complete 8th grade or less,
Complete some high school, but did not graduate,
Graduate from high school or earn a GED,
Complete some college or earn a 2-year degree,
Graduate from a 4-year college, or
Complete more than a 4-year college degree?
RESPONDENT INDICATES THAT HE OR SHE DOES NOT
KNOW FAMILY MEMBER’S LEVEL OF EDUCATION
MISSING
ACADEMIC TRAINING BEYOND A HIGH SCHOOL DIPLOMA THAT DOES
NOT LEAD TO A BACHELORS DEGREE SHOULD BE CODED AS 4. IF THE
RESPONDENT DESCRIBES NON-ACADEMIC TRAINING, SUCH AS
TRADE SCHOOL, PROBE TO FIND OUT IF THE FAMILY MEMBER HAS A
HIGH SCHOOL DIPLOMA AND CODE 2 OR 3, AS APPROPRIATE.
Q42
Was your family member of Hispanic, Latino, or Spanish origin or descent?
READ YES/NO RESPONSE CHOICES ONLY IF NECESSARY
YES
<1> NO
MISSING/DK
IF YES: Would you say your family member was (READ ALL RESPONSE
CHOICES)
<2>
<3>
<4>
<5>
Puerto Rican,
Mexican, Mexican American, Chicano/a,
Cuban, or
Other Spanish/Hispanic/Latino?
MISSING/DK
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[NOTE: FOR TELEPHONE INTERVIEWING, QUESTION 43 IS BROKEN INTO PARTS
A – E.]
Q43
When I read the following, please tell me if the category describes your family
member’s race. I am required to read all five categories. Please answer yes or no to
each of the categories.
READ ALL RACE CATEGORIES PAUSING AT EACH RACE CATEGORY
TO ALLOW CAREGIVER TO REPLY TO EACH RACE CATEGORY.
IF THE RESPONDENT REPLIES, “WHY ARE YOU ASKING ABOUT MY
FAMILY MEMBER’S RACE?:” We ask about your family member’s race for
demographic purposes. We want to make sure that the people we include accurately
represent the racial diversity in this country.
IF THE RESPONDENT REPLIES, “I ALREADY TOLD YOU ABOUT MY
FAMILY MEMBER’S RACE:” I understand, however the survey requires me to
ask about all races so results can include people who are multiracial. If the race
does not apply to your family member please answer no. Thanks for your patience.
READ YES/NO RESPONSE CHOICES ONLY IF NECESSARY
Q43A
Was your family member White?
<1> YES/WHITE
<0> NO/NOT WHITE
MISSING/DK
Q43B
Was your family member Black or African American?
<1> YES/BLACK OR AFRICAN AMERICAN
<0> NO/NOT BLACK OR AFRICAN AMERICAN
MISSING/DK
Q43C
Was your family member Asian?
<1> YES/ASIAN
<0> NO/NOT ASIAN
MISSING/DK
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Q43D
Was your family member Native Hawaiian or other Pacific Islander?
<1> YES/NATIVE HAWAIIAN OR OTHER PACIFIC ISLANDER
<0> NO/NOT NATIVE HAWAIIAN OR OTHER PACIFIC ISLANDER
MISSING/DK
Q43E
Was your family member American Indian or Alaska Native?
<1> YES/AMERICAN INDIAN OR ALASKA NATIVE
<0> NO/NOT AMERICAN INDIAN OR ALASKA NATIVE
MISSING/DK
Q44_INTRO The next questions are about you.
Q44
What is your age?
READ ANSWER CHOICES ONLY IF NECESSARY
<1>
<2>
<3>
<4>
<5>
<6>
<7>
<8>
18 to 24
25 to 34
35 to 44
45 to 54
55 to 64
65 to 74
75 to 84
85 or older
MISSING/DK
Q45
INTERVIEWER ASK ONLY IF NEEDED: Are you male or female?
<1> MALE
<2> FEMALE
MISSING/DK
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Q46
What is the highest grade or level of school that you have completed?
[OPTIONAL: Did you…]
READ ANSWER CHOICES ONLY IF NECESSARY
<1>
<2>
<3>
<4>
<5>
<6>
Complete 8th grade or less,
Complete some high school, but did not graduate,
Graduate from high school or earn a GED,
Complete some college or earn a 2-year degree,
Graduate from a 4-year college, or
Complete more than a 4-year college degree?
MISSING/DK
ACADEMIC TRAINING BEYOND A HIGH SCHOOL DIPLOMA THAT DOES
NOT LEAD TO A BACHELORS DEGREE SHOULD BE CODED AS 4. IF THE
RESPONDENT DESCRIBES NON-ACADEMIC TRAINING, SUCH AS
TRADE SCHOOL, PROBE TO FIND OUT IF SHE/HE HAS A HIGH SCHOOL
DIPLOMA AND CODE 2 OR 3, AS APPROPRIATE.
Q47
What language do you mainly speak at home? Please listen to all response choices
before you answer. Would you say that you mainly speak…
<1>
<2>
<3>
<4>
<5>
<6>
<7>
<8>
<9>
English,
Spanish,
Chinese,
Russian,
Portuguese,
Vietnamese,
Polish,
Korean, or
Some other language?
MISSING/DK
[GO TO END]
[GO TO END]
[GO TO END]
[GO TO END]
[GO TO END]
[GO TO END]
[GO TO END]
[GO TO END]
[GO TO Q47A]
[GO TO END]
IF THE CAREGIVER REPLIES WITH MULTIPLE LANGUAGES, PROBE:
Would you say that you mainly speak [LANGUAGE A] or [LANGUAGE B]?
NOTE: IF THE CAREGIVER REPLIES THAT THEY SPEAK AMERICAN,
PLEASE CODE AS 1 – ENGLISH.
Q47A
What other language do you mainly speak at home?
NOTE: PLEASE DOCUMENT THE OTHER LANGUAGE AND MAINTAIN IN
YOUR INTERNAL RECORDS
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END
Those are all the questions I have. [OPTIONAL: Should you like the number for
bereavement support at [HOSPICE NAME], I can provide that to you now.]
INTERVIEWER: PROVIDE CONTACT INFORMATION AS NEEDED.
Thank you for your time.
READ ONLY IF APPROPRIATE
Have a good (day/evening). [END CALL]
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Appendix X
Telephone Script (Spanish)
CAHPS Hospice Survey
Telephone Script (Spanish)
Overview
This telephone interview script is provided to assist interviewers while attempting to reach the
caregiver of the sampled decedent. The script explains the purpose of the survey and confirms
necessary information about the caregiver and decedent.
General Interviewing Conventions and Instructions
The telephone introduction script must be read verbatim
All text that appears in lowercase letters must be read out loud
Text in UPPERCASE letters must not be read out loud
• YES and NO response options are only to be read if necessary
Note: It is not permissible to capitalize underlined content, as text that appears in
uppercase letters throughout the CATI script must not be read out loud. Survey vendors
are permitted to emphasis underlined content in a different manner if underlining is not a
viable option, such as placing quotes (“”) or asterisks (**) around the text to be
emphasized or italicizing the emphasized words.
All questions and all answer categories must be read exactly as they are worded
• During the course of the survey, use of neutral acknowledgment words such as the
following is permitted:
o Thank you
o Alright
o Okay
o I understand, or I see
o Yes, Ma’am
o Yes, Sir
The script must be read from the interviewer screens (reciting the survey from memory
can lead to unnecessary errors and missed updates to the scripts)
The pace of the CAHPS Hospice Survey interview should be adjusted to be conducive to
the needs of the respondent
No changes are permitted to the order of the question and answer categories for the
“Core”, “About Your Family Member” and “About You” CAHPS Hospice Survey
questions
• The first forty “Core” questions must remain together
• The three “About Your Family Member” questions must remain together
• The four “About You” questions must remain together
All transitional statements must be read
Text that is underlined must be emphasized
Characters in < > must not be read
[Square brackets] are used to show programming instructions that must not actually
appear on electronic telephone interviewing system screens
Only one language (i.e., English or Spanish) can appear on the electronic
interviewing system screen
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1
MISSING/DON’T KNOW (DK) is a valid response option for each item in the electronic
telephone interviewing system scripts. This allows the telephone interviewer to go to the
next question if a caregiver is unable to provide a response for a given question (or
refuses to provide a response). In the survey file layouts, a value of “MISSING/DK” is
coded as “M – Missing/Don't Know.”
Skip patterns should be programmed into the electronic telephone interviewing system
• Appropriately skipped questions should be coded as “88 – Not Applicable.” For
example, if a caregiver answers “No” to Question 4 of the CAHPS Hospice Survey, the
program should skip Question 5, and go to Question 6. Question 5 must then be coded
as “88 – Not Applicable.” Coding may be done automatically by the telephone
interviewing system or later during data preparation.
• When a response to a screener question is not obtained, the screener question and any
questions in the skip pattern should be coded as “M – Missing/Don't Know.” For
example, if the caregiver does not provide an answer to Question 4 of the CAHPS
Hospice Survey and the interviewer selects “MISSING/DK” to Question 4, then the
telephone interviewing system should be programmed to skip Question 5, and go to
Question 6. Question 5 must then be coded as “M – Missing/Don't Know.” Coding may
be done automatically by the telephone interviewing system or later during data
preparation.
INITIATING CONTACT - INICIANDO CONTACTO
START:
Buenos(as) días(tardes/noches), Soy [INTERVIEWER NAME]. ¿Podría hablar
con [SAMPLED CAREGIVER NAME]?
<1> SÍ [GO TO INTRO]
<2> SÍ, PERSONA ES OTRO MIEMBRO DEL HOGAR [GO TO
CONFIRMATION]
<3> PROXY IDENTIFICADO [COLLECT PROXY INFORMATION THEN
RETURN TO INTRO]
<4> NO, NEGATIVA [GO TO REFUSAL]
<5> NO, NO ESTÁ DISPONIBLE EN ESTE MOMENTO [SET CALLBACK]
<6> YA ENVIÓ LA ENCUESTA POR CORREO [GO TO MAILED]
<7> PACIENTE NO RECIBIÓ ATENCIÓN EN EL HOSPICIO NOMBRADO
[GO TO DISAVOWAL]
SI LE PREGUNTAN QUIÉN LLAMA:
Soy [INTERVIEWER NAME] de [VENDOR NAME].Estamos trabajando
con [HOSPICE NAME] y con el Departamento de Salud y Servicios
Humanos de los Estados Unidos para realizar un estudio sobre los cuidados de
hospicio.
SI EL CUIDADOR/PERSONA ENCARGADA DEL CUIDADO DEL
PACIENTE NO ESTÁ O NO PUEDE ATENDER LA LLAMADA:
¿Puede decirme a qué hora es conveniente llamar?
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SI EL CUIDADOR MUESTRA O DICE QUE NO ES UN BUEN MOMENTO:
¿Puede decirme a qué hora es conveniente volver a llamar?
CONFIRMATION:
¿Estoy hablando con [SAMPLED CAREGIVER]?
<1> SÍ [GO TO INTRO]
<2> NO [GO TO START]
******
INITIATING CONTACT WITH A PROXY RESPONDENT INICIANDO CONTACTO CON UN ENTREVISTADO PROXY
START:
Buenos(as) días (tardes/noches), ¿podría hablar con [PROXY CAREGIVER
NAME]?
<1> SÍ [GO TO INTRO]
<2> NO [GO TO REFUSAL]
<3> NO, NO ESTÁ DISPONIBLE EN ESTE MOMENTO [SET CALLBACK]
SI LE PREGUNTAN QUIÉN LLAMA:
Soy [INTERVIEWER NAME] de [VENDOR NAME]. Estamos trabajando
con [HOSPICE NAME] y con el Departamento de Salud y Servicios
Humanos de los Estados Unidos para realizar un estudio sobre los cuidados de
hospicio.
SI EL CUIDADOR PROXY NO ESTÁ O NO PUEDE ATENDER LA
LLAMADA:
¿Puede decirme a qué hora es conveniente llamar para hablar con él(ella)?
SI EL CUIDADOR PROXY DICE QUE NO ES UN BUEN MOMENTO:
Si usted no tiene tiempo ahora, ¿cuándo es más conveniente que vuelva a
llamarle?
SI CONTESTA EL TELÉFONO ALGUIEN QUE NO SEA EL CUIDADOR
PROXY, CUANDO ÉSTE TOME LA LLAMADA, CONFIRME QUE
EFECTIVAMENTE USTED ESTÁ HABLANDO CON EL CUIDADOR
PROXY.
******
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CALL BACK TO COMPLETE A PREVIOUSLY STARTED SURVEY NUEVA LLAMADA PARA TERMINAR LA ENCUESTA INICIADA
ANTERIORMENTE
START:
Buenos(as) días(tardes/noches), ¿podría hablar con [SAMPLED CAREGIVER
NAME/PROXY CAREGIVER NAME]?
<1> SÍ [GO TO CONFIRM RESPONDENT]
<2> NO [REFUSAL]
<3> NO, NO ESTÁ DISPONIBLE EN ESTE MOMENTO [SET CALLBACK]
PARA CONFIRMAR QUE ESTÁN HABLANDO CON EL RESPONDENT::
Soy [INTERVIEWER NAME], y llamo de [VENDOR NAME]. Le estoy
hablando para completar una encuesta que usted comenzó hace días atrás.
Antes de continuar con la encuesta, me gustaría confirmar que estoy hablando
con [CAREGIVER NAME].
CONFIRMAR QUE ES EL ENTREVISTADO: Antes de continuar con la
encuesta, quisiera confirmar que efectivamente estoy hablando con [SAMPLED
CAREGIVER NAME/PROXY CAREGIVER NAME].
CONTINUAR CON LA ENCUESTA DONDE SE DEJÓ.
******
SPEAKING WITH CAREGIVER - HABLANDO CON EL CUIDADOR
INTRO: Buenos(as) días(tardes/noches); soy [INTERVIEWER NAME], y llamo de [VENDOR
NAME].
[HOSPICE NAME] está llevando a cabo una encuesta sobre los servicios que
reciben los pacientes y sus familias en el hospicio. Esta encuesta es parte de una
iniciativa nacional patrocinada por el Departamento de Salud y Servicios Humanos
de los Estados Unidos para evaluar la calidad de la atención en los hospicios.
Estamos conscientes de que éste debe de ser un momento difícil para usted, pero
esperamos que nos dedique unos minutos para ayudarnos a conocer la calidad de la
atención que usted y su familiar o amigo recibieron en el hospicio.
Su participación es voluntaria y no afectará los beneficios o la atención médica que
usted recibe. La entrevista durará [FILL: aproximadamente 11 minutos/SURVEY
VENDOR SPECIFY]. Es posible que sus respuestas se envíen al hospicio a fin de
que éste emprenda tareas de mejoramiento de calidad..
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SI LE PREGUNTAN SI OTRA PERSONA PUEDE SERVIR DE PROXY DEL
CUIDADOR MUESTRA:
Para esta encuesta, tenemos que hablar con la persona de su hogar que esté más
enterada sobre el cuidado de hospicio recibido por [DECEDENT NAME].
UNA VEZ QUE LE DEN EL NOMBRE DE LA PERSONA QUE ESTÁ MÁS
AL TANTO: ¿Puede decirme si usted u otra persona del hogar está más
enterada del cuidado recibido por él/ella?
IF OTHER HOUSEHOLD MEMBER: ¿Me podría decir el nombre de esa persona?
AFTER RECORDING NAME: ¿Puedo hablar con esa persona?
SI ES NECESARIO, Y HABLA CON EL CUIDADOR MUESTRA:
Nos dieron su nombre en el [HOSPICE NAME] porque usted aparecía en sus
registros como la persona encargada del cuidado de [DECEDENT NAME].
SI ES NECESARIO, Y HABLA CON EL PROXY DEL CUIDADOR
MUESTRA:
Nos dió su nombre [SAMPLED CAREGIVER] porque nos dijo que usted está
al tanto de los cuidados paliativos/de hospicio que recibió [DECEDENT
NAME].
<1> SÍ [GO TO CONTINUE]
<2> PROXY IDENTIFICADO [COLLECT PROXY INFORMATION, THEN
RETURN TO PROXY INTRO]
<3> NO, VA A ENVIAR LA ENCUESTA LLENADA POR CORREO [GO TO
CALLBACK]
<4> NO, VOLVER A LLAMAR [GO TO CALLBACK]
<5> NO, NO ESTÁ DISPONIBLE DURANTE PERÍODO DE CAMPO [GO
TO ITEM TO CODE INELIGIBLE, ETC.,]
<6> NEGATIVA [GO TO REFUSAL]
<7> YA ENVIÓ LA ENCUESTA POR CORREO [GO TO MAILED]
<8> NO PARTICIPÓ EN EL CUIDADO Y NO SE IDENTIFICÓ AL PROXY
[GO TO INELIGIBLE]
<9> EL PACIENTE NO RECIBIÓ CUIDADOS EN EL HOSPICIO
MENCIONADO [GO TO DISAVOWAL]
******
CONTINUE - CONTINUAR
Esta llamada puede ser monitoreada [OPTIONAL: y/o grabada] con fines de
control de calidad. ¿Podemos empezar?
<1> SÍ [BEGIN SURVEY]
<2> NO, VOLVER A LLAMAR [GO TO CALLBACK]
<3> REHUSA [GO TO REFUSAL]
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
5
******
MAILED - ENCUESTA ENVIADA POR CORREO
Muchas gracias por contestar la encuesta por correo. Quizá no la hayamos recibido
todavía, pero voy a revisar nuestros registros de nuevo. Es posible que tengamos
que comunicarnos de nuevo con usted en caso de que aún no lo hayamos recibido.
[FINALICE LA LLAMADA/END CALL]
******
INELIGIBLE - INELEGIBLE
Lo siento, para este proyecto, sólo hablamos con los familiares o amigos que
supervisaron o participaron en los cuidados de hospicio de su familiar. Gracias por
su tiempo. Que tenga un(una/-) buen(buena/buenas) día(tarde/noches). [FINALICE
LA LLAMADA/END CALL]
******
DISAVOWAL - DESCONOCIDO
Debe de haber un error en nuestros registros. Gracias por su tiempo. Que tenga
un(una/-)
buen(buena/buenas)
día(tarde/noches).
[FINALICE
LA
LLAMADA/END CALL]
******
BEGIN CAHPS HOSPICE SURVEY QUESTIONS EMPIECE CON LAS PREGUNTAS CAHPS SOBRE EL HOSPICIO
Q1_INTRO
Responda a todas las preguntas de esta encuesta sobre la atención recibida por el
paciente en [HOSPICE NAME]. Cuando piense en sus respuestas, no incluya
ninguna estancia en ningún otro hospicio.
ESTÉ PREPARADO/A PARA TANTEAR EN CASO DE QUE EL
ENTREVISTADO DÉ UNA RESPUESTA FUERA DE LAS CATEGORÍAS DE
RESPUESTA PROVISTAS. TANTEE REPITIENDO SÓLO
LAS
CATEGORÍAS DE RESPUESTA; NO TRATE DE INTERPRETAR LO QUE
DIGA EL ENTREVISTADO.
6
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
Q1
¿Cuál es su parentesco o relación con [DECEDENT NAME]?
LEA LAS OPCIONES DE RESPUESTA SÓLO SI ES NECESARIO
<1>
<2>
<3>
<4>
<5>
<6>
<7>
<8>
<9>
MI CÓNYUGE O PAREJA
MI MADRE O PADRE
MI SUEGRA O SUEGRO
MI ABUELA O ABUELO
MI TÍA O TÍO
MI HERMANA O HERMANO
MI HIJA O HIJO
AMIGA O AMIGO
OTRO (POR FAVOR, ESPECIFIQUE)
MISSING/DK
Q1A
[GO TO Q2]
[GO TO Q2]
[GO TO Q2]
[GO TO Q2]
[GO TO Q2]
[GO TO Q2]
[GO TO Q2]
[GO TO Q2]
[GO TO Q1A]
[GO TO Q2]
¿Cuál es su relación con [DECEDENT NAME]?
NOTA: POR FAVOR DOCUMENTE EL DATO DE PARENTESCO O
RELACIÓN Y CONSÉRVELO EN SU ARCHIVO.
[NOTA: PARA LA ENTREVISTA TELEFÓNICA, LA PREGUNTA 2 SE DIVIDE EN
PARTES, DE LA “A” A LA “G.”]
Q2
Para este estudio, la palabra “familiar” se refiere a [DECEDENT NAME]. Por
favor, responda sí o no para cada una de las categorías. Estoy obligado a leer las
seis categorías. ¿En qué lugar o lugares recibió cuidados de [HOSPICE NAME]
su familiar?
LEA LAS OPCIONES DE RESPUESTA SÍ/NO SÓLO SI ES NECESARIO
Q2A
¿En casa?
<1> SÍ
<0> NO
MISSING/DK
Q2B
¿En un hogar de asistencia parcial?
<1> SÍ
<0> NO
MISSING/DK
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
7
Q2C
¿En un hogar de ancianos?
<1> SÍ
<0> NO
MISSING/DK
Q2D
¿En un hospital?
<1> SÍ
<0> NO
MISSING/DK
Q2E
¿En un hospicio o casa hospicio?
<1> SÍ
<0> NO
MISSING/DK
Q2F
Q2G
¿En algún otro lugar?
<1> SÍ
<0> NO
[GO TO Q2G]
[GO TO Q3]
MISSING/DK
[GO TO Q3]
¿Dónde recibió cuidados su familiar?
NOTA: POR FAVOR DOCUMENTE EL DATO DEL OTRO LUGAR Y
CONSÉRVELO EN SU ARCHIVO.
Q3
Mientras su familiar estaba bajo los cuidados del hospicio, ¿con qué frecuencia
participó usted en dichos cuidados o los supervisó? ¿Diría usted que...
<1> Nunca,
<2> A veces,
<3> La mayoría de las veces, o
<4> Siempre?
[GO TO Q41_INTRO]
MISSING/DK
8
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
Q4_INTRO
Mientras conteste el resto de las preguntas de esta encuesta, por favor piense
únicamente en la experiencia de su familiar con [HOSPICE NAME].
Q4
Para este estudio, el equipo del hospicio incluye a todas las enfermeras, médicos,
trabajadores sociales, sacerdotes y otras personas que le proporcionaron cuidados
paliativos/de hospicio a su familiar.
Mientras su familiar estaba bajo los cuidados del hospicio, ¿necesitó usted
ponerse en contacto con el equipo del hospicio durante la noche, en fin de semana
o en día festivo porque tenía alguna duda o necesitaba ayuda para el cuidado de su
familiar?
LEA LAS OPCIONES DE RESPUESTA SÍ/NO SÓLO SI ES NECESARIO
Q5
<1> SÍ
<2> NO
[GO TO Q6]
[<88> NOT APLICABLE]
MISSING/DK
[GO TO Q6]
¿Con qué frecuencia obtuvo la ayuda que necesitaba del equipo del hospicio
durante la noche, en fin de semana o en día festivo? ¿Diría usted que...
<1> Nunca,
<2> A veces,
<3> La mayoría de las veces, o
<4> Siempre?
[<88> NOT APLICABLE]
MISSING/DK
Q6
Mientras su familiar estaba bajo los cuidados del hospicio, ¿con qué frecuencia el
equipo del hospicio lo(a) mantuvo a usted informado(a) de cuando iban a llegar a
cuidar a su familiar? ¿Diría usted que...
<1> Nunca,
<2> A veces,
<3> La mayoría de las veces, o
<4> Siempre?
[<88> NOT APPLICABLE]
MISSING/DK
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
9
Q7
Mientras su familiar estaba bajo los cuidados del hospicio, cuando usted o alguno
de sus familiares le pedían ayuda al equipo del hospicio, ¿con qué frecuencia
obtenían la ayuda tan pronto como la necesitaban? ¿Diría usted que...
<1> Nunca,
<2> A veces,
<3> La mayoría de las veces, o
<4> Siempre?
[<88> NOT APPLICABLE]
MISSING/DK
Q8
Mientras su familiar estaba bajo los cuidados del hospicio, ¿con qué frecuencia el
equipo del hospicio explicaba las cosas de un modo fácil de entender? ¿Diría
usted que...
<1> Nunca,
<2> A veces,
<3> La mayoría de las veces, o
<4> Siempre?
[<88> NOT APPLICABLE]
MISSING/DK
Q9
Mientras su familiar estaba bajo los cuidados del hospicio, ¿con qué frecuencia el
equipo del hospicio lo(a) mantenía a usted informado(a) sobre el estado de su
familiar? ¿Diría usted que...
<1> Nunca,
<2> A veces,
<3> La mayoría de las veces, o
<4> Siempre?
[<88> NOT APPLICABLE]
MISSING/DK
10
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
Q10
Mientras su familiar estaba bajo los cuidados del hospicio, ¿con qué frecuencia
alguien del equipo del hospicio le dio a usted informes contradictorios o confusos
sobre el estado o los cuidados de su familiar? ¿Diría usted que...
<1> Nunca,
<2> A veces,
<3> La mayoría de las veces, o
<4> Siempre?
[<88> NOT APPLICABLE]
MISSING/DK
Q11
Mientras su familiar estaba bajo los cuidados del hospicio, ¿con qué frecuencia el
equipo del hospicio trataba a su familiar con dignidad y respeto? ¿Diría usted
que...
<1> Nunca,
<2> A veces,
<3> La mayoría de las veces, o
<4> Siempre?
[<88> NOT APPLICABLE]
MISSING/DK
Q12
Mientras su familiar estaba bajo los cuidados del hospicio, ¿con qué frecuencia
sintió usted que al equipo del hospicio le importaba realmente su familiar? ¿Diría
usted que...
<1> Nunca,
<2> A veces,
<3> La mayoría de las veces, o
<4> Siempre?
[<88> NOT APPLICABLE]
MISSING/DK
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
11
Q13
Mientras su familiar estaba bajo los cuidados del hospicio, ¿habló usted con el
equipo del hospicio sobre algún problema relacionado con la atención o el
cuidado de su familiar?
LEA LAS OPCIONES DE RESPUESTA SÍ/NO SÓLO SI ES NECESARIO
NOTA: SI LA PERSONA QUE CONTESTA DICE, "NO TUVE NINGÚN
PROBLEMA,” MARQUE “NO.”
Q14
<1> SÍ
<2> NO
[GO TO Q15]
[<88> NOT APPLICABLE]
MISSING/DK
[GO TO Q15]
¿Con qué frecuencia el equipo del hospicio lo(a) escuchó con atención cuando
usted les habló sobre algún problema relacionado con la atención o el cuidado de
su familiar? ¿Diría usted que...
<1> Nunca,
<2> A veces,
<3> La mayoría de las veces, o
<4> Siempre?
[<88> NOT APPLICABLE]
MISSING/DK
Q15
Mientras su familiar estaba bajo los cuidados del hospicio, ¿tuvo él(ella) algún
tipo de dolor?
LEA LAS OPCIONES DE RESPUESTA SÍ/NO SÓLO SI ES NECESARIO
12
<1> SÍ
<2> NO
[GO TO Q17]
[<88> NOT APPLICABLE]
MISSING/DK
[GO TO Q17]
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
Q16
¿Recibió su familiar toda la ayuda que necesitaba para aliviar el dolor? ¿Diría
usted que...
<1> Sí, definitivamente,
<2> Sí, más o menos, o
<3> No?
[<88> NOT APPLICABLE]
MISSING/DK
Q17
Mientras su familiar estaba bajo los cuidados del hospicio, ¿le dieron a él(ella)
algún medicamento contra el dolor?
LEA LAS OPCIONES DE RESPUESTA SÍ/NO SÓLO SI ES NECESARIO
Q18
<1> SÍ
<2> NO
[GO TO Q21]
[<88> NOT APPLICABLE]
MISSING/DK
[GO TO Q21]
Entre los efectos secundarios de la medicina contra el dolor está la somnolencia.
¿El equipo del hospicio habló con usted o con su familiar sobre los efectos
secundarios del medicamento contra el dolor? ¿Diría usted que...
<1> Sí, definitivamente,
<2> Sí, más o menos, o
<3> No?
[<88> NOT APPLICABLE]
MISSING/DK
Q19
¿El equipo del hospicio le dio la capacitación o información que usted necesitaba
para saber de qué efectos secundarios del medicamento contra el dolor tenía usted
que estar pendiente? ¿Diría usted que...
<1> Sí, definitivamente,
<2> Sí, más o menos, o
<3> No?
[<88> NOT APPLICABLE]
MISSING/DK
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
13
Q20
¿El equipo del hospicio le dio a usted la capacitación o información que usted
necesitaba para saber si tenía que darle más medicamento contra el dolor a su
familiar y, si sí, cuándo dárselo? ¿Diría usted que...
<1> Sí, definitivamente,
<2> Sí, más o menos,
<3> No, o
<4> No tuve necesidad de darle a mi familiar medicina para el dolor.
[<88> NOT APPLICABLE]
MISSING/DK
Q21
Mientras su familiar estaba bajo los cuidados del hospicio, ¿en algún momento
tuvo él(ella) dificultad para respirar o recibió tratamiento para su dificultad para
respirar?
LEA LAS OPCIONES DE RESPUESTA SÍ/NO SÓLO SI ES NECESARIO
Q22
<1> SÍ
<2> NO
[GO TO Q24]
[<88> NOT APPLICABLE]
MISSING/DK
[GO TO Q24]
¿Con qué frecuencia su familiar recibió la ayuda que necesitaba para su dificultad
para respirar? ¿Diría usted que...
<1> Nunca,
<2> A veces,
<3> La mayoría de las veces, o
<4> Siempre?
[<88> NOT APPLICABLE]
MISSING/DK
14
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
Q23
¿El equipo del hospicio le dio a usted la capacitación que usted necesitaba para
saber cómo ayudar a su familiar si él(ella) tenía problemas para respirar? ¿Diría
usted que...
<1> Sí, definitivamente,
<2> Sí, más o menos,
<3> No, o
<4> No tuve necesidad de ayudar a mi familiar con alguna dificultad para
respirar.
[<88> NOT APPLICABLE]
MISSING/DK
Q24
Mientras su familiar estaba bajo los cuidados del hospicio, ¿en algún momento
tuvo él(ella) problemas de estreñimiento?
LEA LAS OPCIONES DE RESPUESTA SÍ/NO SÓLO SI ES NECESARIO
Q25
<1> SÍ
<2> NO
[GO TO Q26]
[<88> NOT APPLICABLE]
MISSING/DK
[GO TO Q26]
¿Con qué frecuencia su familiar recibió la ayuda que necesitaba para sus
problemas de estreñimiento? ¿Diría usted que...
<1> Nunca,
<2> A veces,
<3> La mayoría de las veces, o
<4> Siempre?
[<88> NOT APPLICABLE]
MISSING/DK
Q26
Mientras su familiar estaba bajo los cuidados del hospicio, ¿en algún momento
él(ella) mostró ansiedad o tristeza?
LEA LAS OPCIONES DE RESPUESTA SÍ/NO SÓLO SI ES NECESARIO
<1> SÍ
<2> NO
[GO TO Q28]
[<88> NOT APPLICABLE]
MISSING/DK
[GO TO Q28]
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
15
Q27
¿Con qué frecuencia su familiar recibió del equipo del hospicio la ayuda que
necesitaba para su ansiedad o tristeza? ¿Diría usted que...
<1> Nunca,
<2> A veces,
<3> La mayoría de las veces, o
<4> Siempre?
[<88> NOT APPLICABLE]
MISSING/DK
Q28
Mientras su familiar estaba bajo los cuidados del hospicio, ¿en algún momento
estuvo su familiar inquieto o agitado?
LEA LAS OPCIONES DE RESPUESTA SÍ/NO SÓLO SI ES NECESARIO
Q29
<1> SÍ
<2> NO
[GO TO Q30]
[<88> NOT APPLICABLE]
MISSING/DK
[GO TO Q30]
¿El equipo del hospicio le dio a usted la capacitación que usted necesitaba para
saber qué hacer si su familiar estaba inquieto o agitado? ¿Diría usted que...
<1> Sí, definitivamente,
<2> Sí, más o menos, o
<3> No?
[<88> NOT APPLICABLE]
MISSING/DK
Q30
Mover a su familiar incluye acciones como ayudarlo(a) a darse la vuelta en la
cama, o meterse y salir de la cama o sentarse y levantarse de una silla de ruedas.
¿El equipo del hospicio le dio a usted la capacitación que usted necesitaba para
saber cómo mover a su familiar de manera segura? ¿Diría usted que...
<1> Sí, definitivamente,
<2> Sí, más o menos,
<3> No, o
<4> No tuve necesidad de mover a mi familiar.
[<88> NOT APPLICABLE]
MISSING/DK
16
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
Q31
¿El equipo del hospicio le dio a usted tanta información como usted quería sobre
qué acontecimientos esperar mientras su familiar estuviera muriéndose? ¿Diría
usted que...
<1> Sí, definitivamente,
<2> Sí, más o menos, o
<3> No?
[<88> NOT APPLICABLE]
MISSING/DK
Q32
Algunas personas reciben cuidados paliativos/de hospicio mientras viven en un
hogar de ancianos. ¿Su familiar recibió cuidados de este hospicio mientras él(ella)
estaba viviendo en un hogar de ancianos?
LEA LAS OPCIONES DE RESPUESTA SÍ/NO SÓLO SI ES NECESARIO
Q33
<1> SÍ
<2> NO
[GO TO Q35_INTRO]
[<88> NOT APPLICABLE]
MISSING/DK
[GO TO Q35_INTRO]
Mientras su familiar estaba bajo los cuidados del hospicio, ¿con qué frecuencia el
personal del hogar de ancianos y el equipo del hospicio se pusieron de acuerdo y
acoplaron bien para proporcionarle los cuidados a su familiar? ¿Diría usted que...
<1> Nunca,
<2> A veces,
<3> La mayoría de las veces, o
<4> Siempre?
[<88> NOT APPLICABLE]
MISSING/DK
Q34
Mientras su familiar estaba bajo los cuidados del hospicio, ¿con qué frecuencia
los informes que el personal del hogar de ancianos le daba sobre su familiar eran
diferentes de los informes que le daba el equipo del hospicio? ¿Diría usted que...
<1> Nunca,
<2> A veces,
<3> La mayoría de las veces, o
<4> Siempre?
[<88> NOT APPLICABLE]
MISSING/DK
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
17
Q35_INTRO El siguiente grupo de preguntas es sobre usted.
Q35
Mientras su familiar estaba bajo los cuidados del hospicio, ¿con qué frecuencia el
equipo del hospicio le escuchó a usted atentamente? ¿Diría usted que...
<1> Nunca,
<2> A veces,
<3> La mayoría de las veces, o
<4> Siempre?
[<88> NOT APPLICABLE]
MISSING/DK
Q36
El apoyo respecto a sus creencias religiosas o espirituales incluye hablar, rezar,
tener momentos de recogimiento, u otras maneras de satisfacer sus necesidades
religiosas o espirituales.
Mientras su familiar estaba bajo los cuidados del hospicio, ¿cuánto apoyo recibió
usted respecto a sus creencias religiosas y espirituales por parte del equipo del
hospicio? ¿Diría usted que...
<1> Demasiado poco,
<2> Justo el necesario, o
<3> Demasiado?
[<88> NOT APPLICABLE]
MISSING/DK
Q37
Mientras su familiar estaba bajo los cuidados del hospicio, ¿cuánto apoyo
emocional recibió usted del equipo del hospicio? ¿Diría usted que...
<1> Demasiado poco,
<2> Justo el necesario, o
<3> Demasiado?
[<88> NOT APPLICABLE]
MISSING/DK
18
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
Q38
Durante las semanas posteriores a la muerte de su familiar, ¿recibió usted todo el
apoyo emocional que usted quería por parte del equipo del hospicio? ¿Diría usted
que...
<1> Demasiado poco,
<2> Justo el necesario, o
<3> Demasiado?
[<88> NOT APPLICABLE]
MISSING/DK
Q39
Por favor conteste las siguientes preguntas sobre los cuidados paliativos/de
hospicio que su familiar recibió de [HOSPICE NAME]. No incluya ningún
cuidado proporcionado por otros hospicios.
Utilizando un número del 0 al 10, siendo 0 los peores cuidados paliativos/de
hospicio posibles y 10 los mejores cuidados paliativos/de hospicio posibles, ¿qué
número usaría para calificar los cuidados paliativos/de hospicio que recibió su
familiar?
SI EL ENTREVISTADO NO DA UNA RESPUESTA ADECUADA, INTENTE
DE NUEVO Y REPITA LA PREGUNTA: Utilizando un número del 0 al 10,
siendo 0 los peores cuidados paliativos/de hospicio posibles y 10 los mejores
cuidados paliativos/de hospicio posibles, ¿qué número usaría para calificar los
cuidados paliativos/de hospicio que recibió su familiar?
LEA LAS OPCIONES DE RESPUESTA SÓLO SI ES NECESARIO
<0> 0
<1> 1
<2> 2
<3> 3
<4> 4
<5> 5
<6> 6
<7> 7
<8> 8
<9> 9
<10> 10
[<88> NOT APPLICABLE]
MISSING/DK
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
19
Q40
¿Le recomendaría este hospicio a sus amigos y familiares? ¿Diría usted que...
<1> Definitivamente no,
<2> Probablemente no,
<3> Probablemente sí, o
<4> Definitivamente sí?
[<88> NOT APPLICABLE]
MISSING/DK
Q41_INTRO Las siguientes preguntas son sobre su familiar.
Q41
¿Cuál es el grado o nivel escolar más alto que terminó su familiar? [OPTIONAL:
¿Él(ella)...]
LEA LAS OPCIONES DE RESPUESTA SÓLO SI ES NECESARIO
<1> Terminó ocho años de escuela o menos,
<2> Terminó el bachillerato o la preparatoria, pero sin graduarse,
<3> Obtuvo el diploma de bachillerato, preparatoria, o su equivalente (o GED),
<4> Terminó algunos cursos universitarios u obtuvo un título universitario de un
programa de 2 años,
<5> Obtuvo un título universitario de 4 años, o
<6> Terminó estudios universitarios o superiores de más de 4 años
<7> EL ENTREVISTADO INDICA QUE NO SABE EL NIVEL ESCOLAR DE
SU FAMILIAR
MISSING/DK
CUALQUIER FORMACIÓN ACADÉMICA MÁS ALLÁ DE UN DIPLOMA
DE BACHILLERATO, PREPARATORIA O HIGH SCHOOL, QUE NO SEA
UNA LICENCIATURA DEBERÁ CODIFICARSE COMO 4. SI EL
ENTREVISTADO MENCIONA UNA FORMACIÓN NO ACADÉMICA,
COMO UNA ESCUELA DE COMERCIO, TRATE DE AVERIGUAR SI SU
FAMILIAR TIENE UN DIPLOMA DE BACHILLERATO, PREPARATORIA O
HIGH SCHOOL Y ASIGNE EL CÓDIGO 2 O EL 3, SEGÚN CORRESPONDA.
20
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
Q42
¿Su familiar era de ascendencia u origen hispano, latino o español?
LEA LAS OPCIONES DE RESPUESTA SÍ/NO SÓLO SI ES NECESARIO
SÍ
<1> NO
MISSING/DK
SI LA RESPUESTA ES SÍ: ¿Diría usted que su familiar era... (LEA TODAS
OPCIONES DE RESPUESTA)
<2> Puertorriqueño(a),
<3> Mexicano(a), estadounidense de origen mexicano, chicano(a),
<4> Cubano(a), o
<5> De otro origen, hispano, latino,o español?
MISSING/DK
[NOTA: PARA LA ENTREVISTA TELEFÓNICA, LA PREGUNTA 43 SE DIVIDE EN
PARTES, DE LA “A” A LA “E.”]
LEER TODAS CATEGORÍAS DE RAZA HACIENDO UNA PAUSA EN
CADA CATEGORÍA RACIAL PARA PERMITIRLE AL ENTREVISTADO
RESPONDER A CADA CATEGORÍA RACIAL.
SI EL ENTREVISTADO PREGUNTA: “¿POR QUÉ ME PREGUNTA LA
RAZA DE MI FAMILIAR?:” Le preguntamos la raza de su familiar para fines
demográficos. Queremos estar seguros de que las personas a las que incluimos en
el estudio representan efectivamente la diversidad racial de este país.
SI EL ENTREVISTADO RESPONDE: “YA LE DIJE LA RAZA DE MI
FAMILIAR:” Sí, ya lo sé; sin embargo, el estudio me obliga a preguntar sobre
todas las razas para que en los resultados se pueda incluir a personas que son
multirraciales. Si la raza que yo mencione no corresponde al miembro de su
familia por favor conteste NO. Gracias por su paciencia.
Q43
Cuando le lea lo siguiente, por favor, dígame si la categoría describe la raza de su
familiar. Estoy obligado a leer las cinco categorías. Por favor, responda SÍ o NO a
cada una de las categorías.
LEA LAS OPCIONES DE RESPUESTA SÍ/NO SÓLO SI ES NECESARIO
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Q43A
¿Su familiar era blanco(a)?
<1> SÍ/ ERA BLANCO(A)
<0> NO/NO ERA BLANCO(A)
MISSING/DK
Q43B
¿Su familiar era negro(a) o afro-americano(a)?
<1> SÍ/ ERA NEGRO(A)/AFRO AMERICANO(A)
<0> NO/NO ERA NEGRO(A) NI AFROAMTERICANO(A)
MISSING/DK
Q43C
¿Su familiar era asiático(a)?
<1> SÍ/ ERA ASIÁTICO(A)
<0> NO/NO ERA ASIÁTICO(A)
MISSING/DK
Q43D
¿Su familiar era nativo(a) de Hawáii o de otras islas del Pacífico?
<1> SÍ/ERA NATIVO(A) DE HAWAII/DE OTRAS ISLAS DEL PACÍFICO
<0> NO/NO ERA NATIVO(A) DE HAWAII NI DE OTRAS ISLAS DEL
PACÍFICO
MISSING/DK
Q43E
¿Su familiar era Indio(a) Americano(a) o nativo(a) de Alaska?
<1> SÍ/ERA INDIO(A) AMERICANO(A)/NATIVO(A) DE ALASKA
<0> NO/NO ERA INDIO(A) AMERICANO(A) NI NATIVO(A) DE ALASKA
MISSING/DK
Q44_INTRO Las siguientes preguntas son sobre usted.
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Q44
¿Qué edad tiene usted?
LEA LAS OPCIONES DE RESPUESTA SÓLO SI ES NECESARIO
<1> de 18 a 24 años
<2> de 25 a 34 años
<3> de 35 a 44 años
<4> de 45 a 54 años
<5> de 55 a 64 años
<6> de 65 a 74 años
<7> de 75 a 84 años
<8> 85 años o más
MISSING/DK
Q45
ENTREVISTADOR, PREGUNTE SÓLO SI ES NECESARIO: ¿Es usted
hombre o mujer?
<1> HOMBRE
<2> MUJER
MISSING/DK
Q46
¿Cuál es el grado o nivel escolar más alto que terminó? [OPTIONAL: ¿Usted...]
LEA LAS OPCIONES DE RESPUESTA SÓLO SI ES NECESARIO
<1> Terminó ocho años de escuela o menos,
<2> Terminó el bachillerato o la preparatoria, pero sin graduarse,
<3> Obtuvo el diploma de bachillerato, preparatoria, o su equivalente (o GED),
<4> Terminó algunos cursos universitarios u obtuvo un título universitario de un
programa de 2 años,
<5> Obtuvo un título universitario de 4 años, o
<6> Terminó estudios universitarios o superiores de más de 4 años
MISSING/DK
CUALQUIER FORMACIÓN ACADÉMICA MÁS ALLÁ DE UN DIPLOMA
DE BACHILLERATO, PREPARATORIA O HIGH SCHOOL, QUE NO SEA
UNA LICENCIATURA DEBERÁ CODIFICASE COMO 4. SI EL
ENTREVISTADO MENCIONA UNA FORMACIÓN NO ACADÉMICA,
COMO UNA ESCUELA DE COMERCIO, TRATE DE AVERIGUAR SI SU
FAMILIAR TIENE UN DIPLOMA DE BACHILLERATO, PREPARATORIA O
HIGH SCHOOL Y ASIGNE EL CÓDIGO 2 O EL 3, SEGÚN CORRESPONDA.
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Q47
¿Qué idioma habla usted principalmente en su casa? Por favor, escuche las
opciones de respuesta antes de contestar. ¿Diría usted que usted habla
principalmente...
<1> Inglés,
<2> Español,
<3> Chino,
<4> Ruso,
<5> Portugués,
<6> Vietnamita,
<7> Polaco,
<8> Coreano, o
<9> Algún otro idioma?
[GO TO END]
[GO TO END]
[GO TO END]
[GO TO END]
[GO TO END]
[GO TO END]
[GO TO END]
[GO TO END]
[GO TO Q47A]
MISSING/DK
[GO TO END]
SI LA RESPUESTA DEL ENTREVISTADO COMPRENDE VARIOS
IDIOMAS, INTENTE PREGUNTÁNDOLE:
¿Diría usted que usted habla principalmente (IDIOMA A) o (IDIOMA B)?
SI EL ENTREVISTADO CONTESTA QUE HABLA AMERICANO, POR
FAVOR ASIGNE EL CÓDIGO 1-INGLÉS.
Q47A
¿Qué otro idioma habla usted principalmente en su casa?
NOTA: POR FAVOR DOCUMENTE EL DATO DEL OTRO IDIOMA Y
CONSÉRVELO EN SU ARCHIVO.
END
Esas son todas las preguntas que tengo. [OPCIONAL: Si quiere ayuda para
sobrellevar su duelo puedo darle ahora el número de apoyo en el [HOSPICE
NAME].]
ENTREVISTADOR: PROPORCIONE LA INFORMACIÓN DE CONTACTO
SEGÚN SEA NECESARIO
Gracias por su tiempo.
LEER SOLO SI ES LO APROPIADO
Que tenga un buen día (una buena tarde/ unas buenas noches).
[FINALICE LA LLAMADA/END CALL]
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Appendix Y
Telephone Script (Russian)
CAHPS Hospice Survey
Telephone Script (Russian)
Overview
This telephone interview script is provided to assist interviewers while attempting to reach the
caregiver of the sampled decedent. The script explains the purpose of the survey and confirms
necessary information about the caregiver and decedent.
General Interviewing Conventions and Instructions
The telephone introduction script must be read verbatim
All text that appears in lowercase letters must be read out loud
Text in UPPERCASE letters must not be read out loud
• YES and NO response options are only to be read if necessary
Note: It is not permissible to capitalize underlined content, as text that appears in
uppercase letters throughout the CATI script must not be read out loud. Survey vendors
are permitted to emphasis underlined content in a different manner if underlining is not a
viable option, such as placing quotes (“”) or asterisks (**) around the text to be
emphasized or italicizing the emphasized words.
All questions and all answer categories must be read exactly as they are worded
• During the course of the survey, use of neutral acknowledgment words such as the
following is permitted:
o Thank you
o Alright
o Okay
o I understand, or I see
o Yes, Ma’am
o Yes, Sir
The script must be read from the interviewer screens (reciting the survey from memory
can lead to unnecessary errors and missed updates to the scripts)
The pace of the CAHPS Hospice Survey interview should be adjusted to be conducive to
the needs of the respondent
No changes are permitted to the order of the question and answer categories for the
“Core,” “About Your Family Member” and “About You” CAHPS Hospice Survey
questions
• The first forty “Core” questions must remain together
• The three “About Your Family Member” questions must remain together
• The four “About You” questions must remain together
All transitional statements must be read
Text that is underlined must be emphasized
Characters in < > must not be read
[Square brackets] are used to show programming instructions that must not actually
appear on electronic telephone interviewing system screens
Only one language (i.e., English, Spanish, or Russian) can appear on the electronic
interviewing system screen
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MISSING/DON’T KNOW (DK) is a valid response option for each item in the electronic
telephone interviewing system scripts. This allows the telephone interviewer to go to the
next question if a caregiver is unable to provide a response for a given question (or
refuses to provide a response). In the survey file layouts, a value of “MISSING/DK” is
coded as “M – Missing/Don't Know.”
Skip patterns should be programmed into the electronic telephone interviewing system
• Appropriately skipped questions should be coded as “88 – Not Applicable.” For
example, if a caregiver answers “No” to Question 4 of the CAHPS Hospice Survey, the
program should skip Question 5, and go to Question 6. Question 5 must then be coded
as “88 – Not Applicable.” Coding may be done automatically by the telephone
interviewing system or later during data preparation.
• When a response to a screener question is not obtained, the screener question and any
questions in the skip pattern should be coded as “M – Missing/Don't Know.” For
example, if the caregiver does not provide an answer to Question 4 of the CAHPS
Hospice Survey and the interviewer selects “MISSING/DK” to Question 4, then the
telephone interviewing system should be programmed to skip Question 5, and go to
Question 6. Question 5 must then be coded as “M – Missing/Don't Know.” Coding may
be done automatically by the telephone interviewing system or later during data
preparation.
INITIATING CONTACT - НАЧАЛО КОНТАКТА
START (НАЧАЛО): Алло, меня зовут [INTERVIEWER NAME]. могу ли я поговорить с
[SAMPLED CAREGIVER NAME]?
<1> ДА [GO TO INTRO]
<2> ДА, респондент является другим членом семьи [GO TO
CONFIRMATION]
<3> ВЫЯВЛЕНИЕ ЛИЧНОСТИ ЛИЦА, ЗАМЕЩАЮЩЕГО РАБОТНИКА
ПО УХОДУ [COLLECT PROXY INFORMATION THEN RETURN TO
INTRO]
<4> НЕТ, ОТКАЗ [GO TO REFUSAL]
<5> НЕТ, ЕГО/ЕЁ СЕЙЧАС НЕТ [SET CALLBACK]
<6> УЖЕ ОТПРАВИЛ ЗАПОЛНЕННУЮ АНКЕТУ ПО ПОЧТЕ [GO TO
MAILED]
<7> ПАЦИЕНТ НЕ ПОЛУЧАЛ УХОД В УПОМЯНУТОМ ХОСПИСЕ [GO
TO DISAVOWAL]
ЕСЛИ СПРОСЯТ, КТО ЗВОНИТ:
Это [INTERVIEWER NAME] звонит из [VENDOR NAME]. Мы работаем
с [HOSPICE NAME] и с Министерством здравоохранения и социальных
служб США над проведением опроса о качестве хосписного ухода.
ЕСЛИ ВЫБРАННЫЙ ДЛЯ ОПРОСА РАБОТНИК ПО УХОДУ
НЕДОСТУПЕН:
Когда вам удобно перезвонить?
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ЕСЛИ ВЫБРАННЫЙ ДЛЯ ОПРОСА РАБОТНИК ПО УХОДУ НА ДОМУ
СКАЖЕТ, ЧТО СЕЙЧАС У НЕГО НЕТ ВРЕМЕНИ РАЗГОВАРИВАТЬ:
Когда вам удобно перезвонить?
CONFIRMATION (ПОДТВЕРЖДЕНИЕ):
Я разговариваю с [SAMPLED CAREGIVER]?
<1> ДА [GO TO INTRO]
<2> НЕТ [GO TO START]
******
INITIATING CONTACT WITH A PROXY RESPONDENT НАЧАЛО РАЗГОВОРА С ЛИЦОМ, ЗАМЕНЯЮЩИМ РАБОТНИКА ПО УХОДУ
START (НАЧАЛО):
Алло, могу ли я поговорить с [PROXY CAREGIVER NAME]?
<1> ДА [GO TO INTRO]
<2> НЕТ [GO TO REFUSAL]
<3> НЕТ, ЕГО/ЕЁ СЕЙЧАС НЕТ [SET CALLBACK]
ЕСЛИ СПРОСЯТ, КТО ЗВОНИТ:
Это [INTERVIEWER NAME] звонит из [VENDOR NAME]. Мы работаем
с [HOSPICE NAME] и с Министерством здравоохранения и социальных
служб США над проведением опроса о качестве хосписного ухода.
ЕСЛИ ЛИЦО, ЗАМЕЩАЮЩЕЕ РАБОТНИКА ПО УХОДУ НЕДОСТУПНО:
Скажите, пожалуйста, в какое время мне будет удобнее перезвонить,
чтобы поговорить (с ним/с ней)?
ЕСЛИ ЛИЦО, ЗАМЕЩАЮЩЕЕ РАБОТНИКА ПО УХОДУ НА ДОМУ,
СКАЖЕТ, ЧТО СЕЙЧАС У НЕГО НЕТ ВРЕМЕНИ РАЗГОВАРИВАТЬ:
Если у Вас нет времени сейчас, то когда мне удобнее Вам перезвонить?
ЕСЛИ НА ЗВОНОК ВМЕСТО ЛИЦА, ЗАМЕЩАЮЩЕГО РАБОТНИКА ПО
УХОДУ, ОТВЕТИТ КТО-ЛИБО ДРУГОЙ, ТО ЕЩЁ РАЗ ПОДТВЕРДИТЕ,
ЧТО ЧТО ВЫ БУДЕТЕ РАЗГОВАРИВАТЬ С ВЫБРАННЫМ ДЛЯ ОПРОСА
РАБОТНИКОМ ПО УХОДУ, КОГДА ОН ИЛИ ОНА ПОДНИМЕТ ТРУБКУ.
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******
CALL BACK TO COMPLETE A PREVIOUSLY STARTED SURVEY ОБРАТНЫЙ ЗВОНОК С ЦЕЛЬЮ ЗАВЕРШЕНИЯ ПРОХОЖДЕНИЯ
НАЧАТОГО ОПРОСА
START (НАЧАЛО):
Алло, могу ли я поговорить с [SAMPLED CAREGIVER
NAME/PROXY CAREGIVER NAME]?
<1> ДА [GO TO CONFIRM RESPONDENT]
<2> НЕТ [REFUSAL]
<3> НЕТ, ЕГО/ЕЁ СЕЙЧАС НЕТ [SET CALLBACK]
ЕСЛИ НУЖНО ПОДТВЕРДИТЬ ЧТО
РАЗГОВАРИВАЕШЬ С РЕСПОНДЕНТОМ:
Я [INTERVIEWER NAME], звоню из [SURVEY VENDOR]. Я звоню чтобы
завершить опрос который вы начали недавно. Прежде чем мы перейдем к
опросу, я хотел(а) бы убедиться, что разговариваю с [CAREGIVER NAME]?
ПРОДОЛЖАЙТЕ ОПРОС С ТОГО МЕСТА, НА КОТОРОМ ВЫ
ОСТАНОВИЛИСЬ В ПРОШЛЫЙ РАЗ
******
SPEAKING WITH CAREGIVER РАЗГОВОР С ЛИЦОМ, ОСУЩЕСТВЛЯЮЩИМ УХОД
INTRO (ВВЕДЕНИЕ):
Здравствуйте, меня зовут [INTERVIEWER NAME], я звоню от
[VENDOR NAME].
[HOSPICE NAME] проводит опрос о хосписном уходе, который получают
пациенты и члены их семей. Данный опрос проводится в рамках
государственной программы Департамента здравоохранения и социальных
служб США для оценки качества медицинской помощи в хосписах. Мы
понимаем, что сейчас для Вас может быть трудное время, но надеемся, что
Вы найдете несколько минут, чтобы ответить на вопросы о качестве помощи
в хосписе, которую получаете Вы и близкий для Вас человек.
Ваше участие является добровольным и не повлияет на какое-либо
медицинское обслуживание или пособия, которые Вы получаете. Опрос
займет примерно [FILL: около 11 минут/УКАЗЫВАЕТСЯ ПОСТАВЩИКОМ
ОПРОСА]. Ваши ответы могут быть переданы хоспису для улучшения
качества обслуживания.
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ЕСЛИ СПРАШИВАЮТ, МОЖЕТ ЛИ КТО-ТО ЕЩЕ ВЫСТУПИТЬ В
КАЧЕСТВЕ ДОВЕРЕННОГО ЛИЦА ОПЕКУНА:
Для этого опроса нам нужно поговорить с членом Вашей семьи, который
больше всех осведомлен о хосписном уходе, получаемом [DECEDENT
NAME]. Вы или кто то из вашей семьи более осведомлен?
ЕСЛИ ДРУГОЙ ЧЛЕН СЕМЬИ: Скажите пожалуйста как
зовут этого члена вашей семьи?
ПОСЛЕ ЗАПИСИ ИМЕНИ: Могу ли я поговорить с этим членом вашей
семьи?
В СЛУЧАЕ НЕОБХОДИМОСТИ И ПРИ РАЗГОВОРЕ С ОПЕКУНОМ:
Нам дали ваши данные в [HOSPICE NAME], так как Вы числитесь там
как опекун [DECEDENT NAME].
В СЛУЧАЕ НЕОБХОДИМОСТИ И ПРИ РАЗГОВОРЕ С ДОВЕРЕННЫМ
ЛИЦОМ ОПЕКУНА: Мы получили Ваши данные от [SAMPLED
CAREGIVER], так как он/она указали Вас как лицо, осведомленное о
хосписном уходе, который получает [DECEDENT NAME].
<1> ДА [GO TO CONTINUE]
<2> ИДЕНТИФИКАЦИЯ ДОВЕРЕННОГО ЛИЦА [COLLECT PROXY
INFORMATION, THEN RETURN TO PROXY INTRO]
<3> НЕТ, ПРИШЛЮ ОТВЕТЫ ПОЧТОЙ [GO TO CALLBACK]
<4> НЕТ, ПЕРЕЗВОНИТЕ [GO TO CALLBACK]
<5> НЕТ ИЛИ СЕЙЧАС ОТСУТСТВУЕТ НА МЕСТЕ [GO TO ITEM TO
CODE INELIGIBLE, ETC.,]
<6> ОТКАЗ [GO TO REFUSAL]
<7> УЖЕ ПРИСЛАЛ ОТВЕТЫ НА ВОПРОСЫ ПО ПОЧТЕ [GO TO
MAILED]
<8> НЕ УЧАСТВУЕТ В УХОДЕ И НЕ ИМЕЕТ ДОВЕРЕННОГО ЛИЦА [GO
TO INELIGIBLE]
<9> ПАЦИЕНТ НЕ ПОЛУЧАЕТ УХОД В ДАННОМ ХОСПИСЕ [GO TO
DISAVOWAL]
******
CONTINUE - ПРОДОЛЖЕНИЕ
В целях улучшения обслуживания этот звонок может записываться
[ОПЦИОНАЛЬНО: и/или записываться]. Мы можем начинать?
<1> ДА [BEGIN SURVEY]
<2> НЕТ, ПЕРЕЗВОНИТЕ [GO TO CALLBACK]
<3> ОТКАЗ [GO TO REFUSAL]
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******
MAILED - ВЫСЛАНО ПО ПОЧТЕ
Благодарим Вас за то, что Вы заполнили анкету и отправили ее по почте.
Возможно, мы ещё не получили Ваши ответы, но я ещё раз проверю нашу
учётную документацию. Возможно, нам придётся повторно связаться с Вами
- в том случае, если мы всё-таки не получим Ваше письмо в ближайшее время.
[END CALL]
******
INELIGIBLE - НЕ ОТВЕЧАЕТ ТРЕБОВАНИЯМ
Извините, но в рамках этой программы мы говорим только с членами семьи
или друзьями, которые принимали участие в хосписном уходе за членами их
семей или наблюдали за ним. Спасибо, что уделили время. Всего доброго.
[END CALL]
******
DISAVOWAL - ОТРИЦАНИЕ
Возможно, в наших записях была допущена ошибка. Благодарим Вас за
уделенное нам время. Всего Вам доброго. [END CALL]
******
BEGIN CAHPS HOSPICE SURVEY QUESTIONS НАЧАТЬ ОПРОС О ПРЕБЫВАНИИ В ХОСПИСЕ CAHPS
Q1_INTRO
Пожалуйста, ответьте на все вопросы анкеты о хосписном уходе за пациентом
в [HOSPICE NAME]. Отвечая на вопросы, не включайте в них информацию
об уходе в каком-либо другом хосписе.
БУДЬТЕ ГОТОВЫ К ТОМУ, ЧТОБЫ ПОПРАВИТЬ РЕСПОНДЕНТА, ЕСЛИ
ЕГО ОТВЕТЫ БУДУТ ВЫХОДИТЬ ЗА РАМКИ ПРЕДЛОЖЕННЫХ
ВАРИАНТОВ. В ЭТОМ СЛУЧАЕ ПРОСТО ПОВТОРИТЕ ВАРИАНТЫ
ОТВЕТА, НО НЕ ИНТЕРПРЕТИРУЙТЕ ИХ ДЛЯ РЕСПОНДЕНТА.
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Q1
Какова степень Вашего родства с [DECEDENT NAME]?
ЗАЧИТАЙТЕ ОТВЕТЫ, ТОЛЬКО ЕСЛИ ЭТО НЕОБХОДИМО
<1> МОЙ/МОЯ СУПРУГ/А ИЛИ ПАРТНЕР/ША
<2> МОЙ РОДИТЕЛЬ
<3> МОЯ/МОЙ ТЕЩА/СВЕКРОВЬ ИЛИ ТЕСТЬ/СВЕКР
<4> МОЙ/МОЯ ДЕДУШКА/БАБУШКА
<5> МОЯ/МОЙ ТЕТЯ ИЛИ ДЯДЯ
<6> МОЯ/МОЙ СЕСТРА ИЛИ БРАТ
<7> МОЙ РЕБЕНОК
<8> МОЙ ДРУГ
<9> ДРУГОЕ (УКАЖИТЕ)
MISSING/DK
Q1A
[GO TO Q2]
[GO TO Q2]
[GO TO Q2]
[GO TO Q2]
[GO TO Q2]
[GO TO Q2]
[GO TO Q2]
[GO TO Q2]
[GO TO Q1A]
[GO TO Q2]
Какова Ваша степень родства с [DECEDENT NAME]?
ПРИМЕЧАНИЕ: ВНЕСИТЕ ДАННЫЕ О СТЕПЕНИ РОДСТВА В СВОИ
ВНУТРЕННИЕ ЗАПИСИ.
[ПРИМЕЧАНИЕ: ДЛЯ ОПРОСА ПО ТЕЛЕФОН ВОПРОС Q2 РАЗБИТ НА ЧАСТИ A – G.]
Q2
В данной анкете фраза «член семьи» относится к [DECEDENT NAME].
Пожалуйста, отвечайте "да" или "нет" на каждый из вариантов ответа. Я
зачитаю Вам все шесть вариантов. Где именно (в каких местах) член Вашей
семьи получал помощь хосписа [HOSPICE NAME]?
ЗАЧИТАЙТЕ ОТВЕТЫ "ДА" И "НЕТ", ТОЛЬКО ЕСЛИ ЭТО
НЕОБХОДИМО
Q2A
Дома?
<1> ДА
<0> НЕТ
MISSING/DK
Q2B
В доме престарелых?
<1> YES
<0> NO
MISSING/DK
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
7
Q2C
В центре сестринского ухода?
<1> ДА
<0> НЕТ
MISSING/DK
Q2D
В больнице?
<1> ДА
<0> НЕТ
MISSING/DK
Q2E
В хосписе?
<1> ДА
<0> НЕТ
MISSING/DK
Q2F
Q2G
В каком-либо другом месте?
<1> ДА
<0> НЕТ
[GO TO Q2G]
[GO TO Q3]
MISSING/DK
[GO TO Q3]
Где член Вашей семьи получал уход?
ПРИМЕЧАНИЕ: ПОЖАЛУЙСТА, ЗАФИКСИРУЙТЕ В СВОИХ ЗАПИСЯХ
ДАННЫЕ О ПРЕБЫВАНИИ В ДРУГИХ УЧРЕЖДЕНИЯХ И ХРАНИТЕ
ЭТУ ИНФОРМАЦИЮ В СВОЕЙ УЧЁТНОЙ ДОКУМЕНТАЦИИ,
ПРЕДНАЗНАЧЕННОЙ ДЛЯ ВНУТРЕННЕГО ПОЛЬЗОВАНИЯ.
Q3
Пока член Вашей семьи получал хосписную помощь, как часто Вы
принимали в ней участие либо наблюдали? Можно ли сказать, что…
<1> Ни разу,
<2> Иногда,
<3> Как правило, или
<4> Постоянно?
[GO TO Q41_INTRO]
MISSING/DK
8
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
Q4_INTRO
При ответах на все остальные вопросы в данной анкете просим Вас учитывать
исключительно опыт члена Вашей семьи с хосписом [HOSPICE NAME].
Q4
Для данной анкеты хосписная команда включает весь средний медицинский
персонал, докторов, социальных работников, священников и других людей,
обеспечивающих хосписный уход за членом Вашей семьи. Когда член Вашей
семьи получал хосписный уход, приходилось ли Вам обращаться к хосписной
команде с вопросами или за помощью по поводу ухода за ним по вечерам, в
выходные или праздничные дни?
ЗАЧИТАЙТЕ ОТВЕТЫ "ДА" И "НЕТ", ТОЛЬКО ЕСЛИ ЭТО
НЕОБХОДИМО
Q5
<1> ДА
<2> НЕТ
[GO TO Q6]
[<88> NOT APPLICABLE]
MISSING/DK
[GO TO Q6]
Как часто Вы получали необходимую помощь от хосписной команды по
вечерам, в выходные или праздничные дни? Можно ли сказать, что…
<1>
<2>
<3>
<4>
Ни разу,
Иногда,
Как правило, или
Всегда?
[<88> NOT APPLICABLE]
MISSING/DK
Q6
Когда член Вашей семьи получал хосписный уход, как часто хосписная
команда информировала Вас о времени своего прибытия для оказания ему
помощи? Можно ли сказать, что…
<1>
<2>
<3>
<4>
Ни разу,
Иногда,
Как правило, или
Всегда?
[<88> NOT APPLICABLE]
MISSING/DK
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
9
Q7
Когда член Вашей семьи получал хосписный уход, и он или Вы обращались
к хосписной команде за помощью, как часто вы получали ее своевременно?
Можно ли сказать, что...
<1>
<2>
<3>
<4>
Ни разу,
Иногда,
Как правило, или
Всегда?
[<88> NOT APPLICABLE]
MISSING/DK
Q8
Когда член Вашей семьи получал хосписный уход, как часто хосписная
команда давала пояснения в простой и доступной форме? Можно ли сказать,
что...
<1>
<2>
<3>
<4>
Ни разу,
Иногда,
Как правило, или
Всегда?
[<88> NOT APPLICABLE]
MISSING/DK
Q9
Когда член Вашей семьи получал хосписный уход, как часто хосписная
команда информировала Вас о его состоянии? Можно ли сказать, что...
<1>
<2>
<3>
<4>
Ни разу,
Иногда,
Как правило, или
Всегда?
[<88> NOT APPLICABLE]
MISSING/DK
Q10
Когда член Вашей семьи получал хосписный уход, как часто кто-либо из
хосписной команды предоставлял Вам невнятную или противоречивую
информацию о состоянии здоровья члена Вашей семьи или уходе за ним?
Можно ли сказать, что…
<1>
<2>
<3>
<4>
Ни разу,
Иногда,
Как правило, или
Всегда?
[<88> NOT APPLICABLE]
MISSING/DK
10
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
Q11
Когда член Вашей семьи получал хосписный уход, как часто хосписная
команда относилась к нему с достоинством и уважением? Можно ли сказать,
что…
<1>
<2>
<3>
<4>
Ни разу,
Иногда,
Как правило, или
Всегда?
[<88> NOT APPLICABLE]
MISSING/DK
Q12
Когда член Вашей семьи получал хосписный уход, как часто Вы испытывали
ощущение, что хосписная команда действительно заботится о нем? Можно
ли сказать, что…
<1>
<2>
<3>
<4>
Ни разу,
Иногда,
Как правило, или
Всегда?
[<88> NOT APPLICABLE]
MISSING/DK
Q13
Когда член Вашей семьи получал хосписный уход, обсуждали ли Вы с
хосписной командой проблемы, которые возникали у Вас во время ухода за
ним?
ЗАЧИТАЙТЕ ОТВЕТЫ "ДА" И "НЕТ", ТОЛЬКО ЕСЛИ ЭТО
НЕОБХОДИМО
ПРИМЕЧАНИЕ: ЕСЛИ РЕСПОНДЕНТ ОТВЕЧАЕТ "У МЕНЯ НЕ БЫЛО
НИКАКИХ ПРОБЛЕМ", ОТВЕТ РАСЦЕНИВАЕТСЯ КАК "НЕТ".
<1> ДА
<2> НЕТ
[GO TO Q15]
[<88> NOT APPLICABLE]
MISSING/DK
[GO TO Q15]
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
11
Q14
Как часто хосписная команда внимательно Вас выслушивала, когда Вы
рассказывали о проблемах, возникавших во время ухода за членом Вашей
семьи? Можно ли сказать, что…
<1>
<2>
<3>
<4>
Ни разу,
Иногда,
Как правило, или
Всегда?
[<88> NOT APPLICABLE]
MISSING/DK
Q15
Когда член Вашей семьи получал хосписный уход, испытывал ли он боль?
ЗАЧИТАЙТЕ ОТВЕТЫ "ДА" И "НЕТ", ТОЛЬКО ЕСЛИ ЭТО
НЕОБХОДИМО
Q16
<1> ДА
<2> НЕТ
[GO TO Q17]
[<88> NOT APPLICABLE]
MISSING/DK
[GO TO Q17]
Получал член Вашей семьи всю возможную необходимую ему помощь,
когда испытывал боль? Можно ли сказать, что…
<1> Да, несомненно,
<2> Да, можно так сказать, или
<3> Нет?
[<88> NOT APPLICABLE]
MISSING/DK
Q17
Когда член Вашей семьи получал хосписный уход, получал ли он какие-то
обезболивающие препараты?
ЗАЧИТАЙТЕ ОТВЕТЫ "ДА" И "НЕТ", ТОЛЬКО ЕСЛИ ЭТО
НЕОБХОДИМО
12
<1> ДА
<2> НЕТ
[GO TO Q21]
[<88> NOT APPLICABLE]
MISSING/DK
[GO TO Q21]
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
Q18
Побочные эффекты обезболивающих препаратов включают, например,
сонливость. Обсуждал ли кто-либо из хосписной команды с Вами или
членом Вашей семьи побочные эффекты обезболивающих препаратов?
Можно ли сказать, что…
<1> Да, несомненно,
<2> Да, можно так сказать, или
<3> Нет?
[<88> NOT APPLICABLE]
MISSING/DK
Q19
Проводила ли с Вами хосписная команда необходимое обучение на тему
побочных эффектов, за которыми необходимо следить при приеме
обезболивающих препаратов? Можно ли сказать, что…
<1> Да, несомненно,
<2> Да, можно так сказать, или
<3> Нет?
[<88> NOT APPLICABLE]
MISSING/DK
Q20
Проводила ли с Вами хосписная команда необходимое обучение
относительно того, в каких случаях и когда необходимо увеличивать дозу
обезболивающего препарата члену Вашей семьи? Можно ли сказать, что…
<1> Да, несомненно,
<2> Да, можно так сказать,
<3> Нет, или
<4> У меня не было необходимости давать обезболивающие препараты
члену моей семьи.
[<88> NOT APPLICABLE]
MISSING/DK
Q21
Когда член Вашей семьи получал хосписный уход, были ли у него проблемы
с дыханием или получал ли он лечение в связи с затруднением дыхания?
ЗАЧИТАЙТЕ ОТВЕТЫ "ДА" И "НЕТ", ТОЛЬКО ЕСЛИ ЭТО
НЕОБХОДИМО
<1> ДА
<2> НЕТ
[GO TO Q24]
[<88> NOT APPLICABLE]
MISSING/DK
[GO TO Q24]
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
13
Q22
Как часто член Вашей семьи получал всю необходимую помощь вследствие
затрудненного дыхания? Можно ли сказать, что…
<1>
<2>
<3>
<4>
Ни разу,
Иногда,
Как правило, или
Всегда?
[<88> NOT APPLICABLE]
MISSING/DK
Q23
Проводила ли с Вами хосписная команда обучение по предоставлению
помощи члену Вашей семьи, когда он испытывает проблемы с дыханием?
Можно ли сказать, что…
<1> Да, несомненно,
<2> Да, можно так сказать,
<3> Нет, или
<4> У меня не было необходимости оказывать помощь члену моей семьи изза затрудненного дыхания.
[<88> NOT APPLICABLE]
MISSING/DK
Q24
Когда член Вашей семьи получал хосписный уход, были ли у него запоры?
ЗАЧИТАЙТЕ ОТВЕТЫ "ДА" И "НЕТ", ТОЛЬКО ЕСЛИ ЭТО
НЕОБХОДИМО
Q25
<1> ДА
<2> НЕТ
[GO TO Q26]
[<88> NOT APPLICABLE]
MISSING/DK
[GO TO Q26]
Как часто член Вашей семьи получал необходимую помощь вследствие
запоров? Можно ли сказать, что…
<1>
<2>
<3>
<4>
Ни разу,
Иногда,
Как правило, или
Всегда?
[<88> NOT APPLICABLE]
MISSING/DK
14
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
Q26
Когда член Вашей семьи получал хосписный уход, испытывал ли он чувства
тревоги или грусти?
ЗАЧИТАЙТЕ ОТВЕТЫ "ДА" И "НЕТ", ТОЛЬКО ЕСЛИ ЭТО
НЕОБХОДИМО
Q27
<1> ДА
<2> НЕТ
[GO TO Q28]
[<88> NOT APPLICABLE]
MISSING/DK
[GO TO Q28]
Как часто персонал хосписа проявлял к члену Вашей семьи необходимое
соучастие в моменты тревоги или грусти? Можно ли сказать, что…
<1>
<2>
<3>
<4>
Ни разу,
Иногда,
Как правило, или
Всегда?
[<88> NOT APPLICABLE]
MISSING/DK
Q28
Когда член Вашей семьи получал хосписный уход, испытывал ли он
ощущение беспокойства и нервного возбуждения?
ЗАЧИТАЙТЕ ОТВЕТЫ "ДА" И "НЕТ", ТОЛЬКО ЕСЛИ ЭТО
НЕОБХОДИМО
Q29
<1> ДА
<2> НЕТ
[GO TO Q30]
[<88> NOT APPLICABLE]
MISSING/DK
[GO TO Q30]
Проводила ли С Вами хосписная команда обучение на тему того, что делать
в случае, если член Вашей семьи испытывает ощущение беспокойства или
возбуждения? Можно ли сказать, что…
<1> Да, несомненно,
<2> Да, можно так сказать, или
<3> Нет?
[<88> NOT APPLICABLE]
MISSING/DK
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
15
Q30
Передвигать члена Вашей семьи означает помочь ему перевернуться в
кровати, подняться/лечь в кровать или пересесть в инвалидную коляску.
Проводила ли с Вами хосписная команда необходимое обучение на тему
того, каким образом Вы можете безопасно передвигать члена Вашей семьи?
Можно ли сказать, что…
<1> Да, несомненно,
<2> Да, можно так сказать,
<3> Нет, или
<4> У меня не было необходимости передвигать члена моей семьи.
[<88> NOT APPLICABLE]
MISSING/DK
Q31
Предоставляла ли Вам хосписная команда всю необходимую информацию
относительно того, чего ожидать, когда умирал член Вашей семьи? Можно
ли сказать, что…
<1> Да, несомненно,
<2> Да, можно так сказать, или
<3> Нет?
[<88> NOT APPLICABLE]
MISSING/DK
Q32
Некоторые люди получают хосписный уход, проживая в центре сестринского
ухода. Получал ли член Вашей семьи уход от данного хосписа, проживая в
центре сестринского ухода?
ЗАЧИТАЙТЕ ОТВЕТЫ "ДА" И "НЕТ", ТОЛЬКО ЕСЛИ ЭТО
НЕОБХОДИМО
16
<1> ДА
<2> НЕТ
[GO TO Q35_INTRO]
[<88> NOT APPLICABLE]
MISSING/DK
[GO TO Q35_INTRO]
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
Q33
Пока член Вашей семьи получал хосписный уход, как часто сотрудники
центра сестринского ухода эффективно сотрудничали с хосписной командой,
чтобы вместе заботиться о члене Вашей семьи? Можно ли сказать, что…
<1>
<2>
<3>
<4>
Ни разу,
Иногда,
Как правило, или
Всегда?
[<88> NOT APPLICABLE]
MISSING/DK
Q34
Пока член Вашей семьи получал хосписный уход, как часто информация о
члене Вашей семьи, которую Вы получали от сотрудников центра
сестринского ухода, отличалась от данных, предоставленных хосписной
командой? Можно ли сказать, что…
<1>
<2>
<3>
<4>
Ни разу,
Иногда,
Как правило, или
Всегда?
[<88> NOT APPLICABLE]
MISSING/DK
Q35_INTRO Следующая серия вопросов касается Вас.
Q35
Когда член Вашей семьи получал хосписный уход, как часто хосписная
команда внимательно выслушивала Вас? Можно ли сказать, что…
<1>
<2>
<3>
<4>
Ни разу,
Иногда,
Как правило, или
Всегда?
[<88> NOT APPLICABLE]
MISSING/DK
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
17
Q36
Поддержка религиозных или духовных убеждений подразумевает беседы,
молитвы, уединение или другие способы удовлетворения религиозных или
духовных потребностей. Когда член Вашей семьи получал хосписный уход,
насколько велика была поддержка Ваших религиозных или духовных
убеждений со стороны хосписной команды? Можно ли сказать, что…
<1> Слишком мала,
<2> Достаточная, или
<3> Чрезмерная?
[<88> NOT APPLICABLE]
MISSING/DK
Q37
Когда член Вашей семьи получал хосписный уход, насколько велика была
эмоциональная поддержка со стороны хосписной команды? Можно ли
сказать, что…
<1> Слишком мала,
<2> Достаточная, или
<3> Чрезмерная?
[<88> NOT APPLICABLE]
MISSING/DK
Q38
В ближайшие недели после смерти члена Вашей семьи, насколько велика
была эмоциональная поддержка со стороны хосписной команды? Можно ли
сказать, что…
<1> Слишком мала,
<2> Достаточная, или
<3> Чрезмерная?
[<88> NOT APPLICABLE]
MISSING/DK
18
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
Q39
Ответьте, пожалуйста, на следующие вопросы относительно ухода за членом
Вашей семьи в хосписе [HOSPICE NAME]. Просим в своих ответах не
упоминать об уходе, полученном в других хосписах.
Используя шкалу от 0 до 10, где 0 означает наихудшее качество хосписного
ухода, а 10 - наилучшее качество хосписного ухода, которое только можно
представить, оцените хосписный уход за членом Вашей семьи.
ЕСЛИ РЕСПОНДЕНТ НЕ ДАСТ ЧЕТКОГО ОТВЕТА, ПОВТОРИТЕ
ВОПРОС: Используя шкалу от 0 до 10, где 0 - это наихудшее, а 10 - наилучшее
качество хосписного ухода, какое только можно представить, оцените
уровень хосписного ухода за членом Вашей семьи?
ЗАЧИТАЙТЕ ОТВЕТЫ, ТОЛЬКО ЕСЛИ ЭТО НЕОБХОДИМО
<0> 0
<1> 1
<2> 2
<3> 3
<4> 4
<5> 5
<6> 6
<7> 7
<8> 8
<9> 9
<10> 10
[<88> NOT APPLICABLE]
MISSING/DK
Q40
Порекомендовали ли бы Вы данный хоспис своим друзьям и семье? Можно
ли сказать, что…
<1> Точно нет,
<2> Скорее всего, нет,
<3> Скорее всего, да, или
<4> Да, несомненно?
[<88> NOT APPLICABLE]
MISSING/DK
Q41_INTRO Следующие вопросы касаются члена Вашей семьи.
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
19
Q41
Какое образование получил член Вашей семьи?
[ОПЦИОНАЛЬНО: Он или она…]
ЗАЧИТАЙТЕ ОТВЕТЫ, ТОЛЬКО ЕСЛИ ЭТО НЕОБХОДИМО
<1>
<2>
<3>
<4>
<5>
<6>
<7>
8 классов и меньше,
Учился в старших классах, но не окончил школу,
Окончил среднюю школу,
Колледж или диплом о двухгодичном обучении,
Четырехгодичное законченное высшее образование, или
Обучение свыше четырех лет высшего образования?
РЕСПОНДЕНТ
СООБЩАЕТ,
ЧТО
НЕ
ЗНАЕТ,
ОБРАЗОВАНИЕ ПОЛУЧИЛ ЧЛЕН ЕГО СЕМЬИ
КАКОЕ
MISSING
ОБРАЗОВАНИЕ ВЫШЕ СРЕДНЕЙ ШКОЛЫ, НО БЕЗ ПОЛУЧЕНИЯ
ДИПЛОМА БАКАЛАВРА, ОТНОСИТСЯ К ВАРИАНТУ 4. ЕСЛИ
РЕСПОНДЕНТ
УКАЗЫВАЕТ
НА
ПРОХОЖДЕНИЕ
ПРОФЕССИОНАЛЬНО-ТЕХНИЧЕСКОЙ ПОДГОТОВКИ В ТАКИХ
УЧРЕЖДЕНИЯХ, КАК ПРОФЕССИОНАЛЬНОЕ УЧИЛИЩЕ, ТО
УТОЧНИТЕ, ПОЛУЧИЛ ЛИ ЧЛЕН ЕГО СЕМЬИ АТТЕСТАТ ЗРЕЛОСТИ И
ВЫБЕРИТЕ ВАРИАНТ 2 ИЛИ 3 В ЗАВИСИМОСТИ ОТ СИТУАЦИИ.
Q42
Был ли член Вашей семьи испанского либо латино-американского
происхождения?
ЗАЧИТАЙТЕ ОТВЕТЫ "ДА" И "НЕТ", ТОЛЬКО ЕСЛИ ЭТО
НЕОБХОДИМО
ДА
<1> НЕТ
MISSING/DK
ЕСЛИ "ДА": Можно ли сказать, что член Вашей семьи был (ПРОЧТИТЕ
ВСЕ ВАРИАНТЫ ОТВЕТА)
<1> Нет, он не испанского/латино-американского происхождения,
<2> Да, он пуэрториканец,
<3> Да, он мексиканец, мексикано-американец, американец мексиканского
происхождения,
<4> Да, он кубинец, или
<5> Да, другого испанского/латино-американского происхождения?
MISSING/DK
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CAHPS Hospice Survey Quality Assurance Guidelines V6.0
[ПРИМЕЧАНИЕ: В СЛУЧАЕ ТЕЛЕФОННОГО ОПРОСА ВОПРОС 43 РАЗБИТ НА
ЧАСТИ A – E.]
Q43
К какой расовой группе принадлежал член Вашей семьи? Я перечислю все
пять вариантов. Пожалуйста, ответьте "да" или "нет" по каждому из них.
ПРОЧИТАЙТЕ ВСЕ ВАРИАНТЫ, СДЕЛАВ ПАУЗУ ПОСЛЕ КАЖДОГО ИЗ
НИХ, ЧТОБЫ РЕСПОНДЕНТ МОГ ДАТЬ ОТВЕТ ПО КАЖДОМУ
ВАРИАНТУ.
ЕСЛИ РЕСПОНДЕНТ ИНТЕРЕСУЕТСЯ, ПОЧЕМУ ВЫ СПРАШИВАЕТЕ О
РАСОВОЙ ПРИНАДЛЕЖНОСТИ ЧЛЕНА ЕГО СЕМЬИ: Мы спрашиваем о
расовой принадлежности для демографической статистики. Мы хотим, чтобы
участие в опросе принимали представители всех рас, проживающих в стране.
ЕСЛИ РЕСПОНДЕНТ СООБЩАЕТ, ЧТО УЖЕ ОТВЕЧАЛ НА ВОПРОС О
РАСОВОЙ ПРИНАДЛЕЖНОСТИ ЧЛЕНА СЕМЬИ: Я Вас понимаю, но
условия опроса требуют спросить о расовой принадлежности, чтобы
результаты опроса включали в себя ответы от участников разных рас. Если
данный вопрос не относится к члену Вашей семьи, ответьте "нет". Благодарю
Вас за понимание и за терпение.
ЗАЧИТАЙТЕ ОТВЕТЫ "ДА" И "НЕТ", ТОЛЬКО ЕСЛИ ЭТО
НЕОБХОДИМО
Q43A
Был ли член Вашей семьи представителем/ представительницей белой расы?
<1> ДА/БЕЛЫЙ/БЕЛАЯ
<0> НЕТ/НЕ БЕЛЫЙ/НЕ БЕЛАЯ
MISSING/DK
Q43B
Был ли член Вашей семьи чернокожим/чернокожей или
афроамериканцем/афроамериканкой?
<1> ДА/АФРИКАНЕЦ/АФРИКАНКА ИЛИ
АФРОАМЕРИКАНЕЦ/АФРОАМЕРИКАНКА
<0> НЕТ/НЕ АФРИКАНЕЦ/ НЕ АФРИКАНКА И НЕ
АФРОАМЕРИКАНЕЦ/АФРОАМЕРИКАНКА
MISSING/DK
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
21
Q43C
Был ли член Вашей семьи азиатского происхождения?
<1> ДА/AЗИАТСКОГО ПРОИСХОЖДЕНИЯ
<0> НЕТ/НЕ АЗИАТСКОГО ПРОИСХОЖДЕНИЯ
MISSING/DK
Q43D
Был ли член Вашей семьи коренным жителем/коренной жительницей
Гавайских островов или других тихоокеанских островов?
<1> ДА/КОРЕННОЙ ЖИТЕЛЬ/КОРЕННАЯ ЖИТЕЛЬНИЦА ГАВАЙСКИХ
ОСТРОВОВ ИЛИ ДРУГИХ ТИХООКЕАНСКИХ ОСТРОВОВ
<0> НЕТ/НЕ БЫЛ КОРЕННЫМ ЖИТЕЛЕМ /КОРЕННОЙ ЖИТЕЛЬНИЦЕЙ
ГАВАЙСКИХ ОСТРОВОВ ИЛИ ДРУГИХ ТИХООКЕАНСКИХ
ОСТРОВОВ
MISSING/DK
Q43E
Был ли член Вашей семьи американским индейцем/американской
индианкой или коренным жителем/коренной жительницей Аляски?
<1> ДА/АМЕРИКАНСКИЙ ИНДЕЕЦ/АМЕРИКАНСКАЯ ИНДИАНКА
ИЛИ КОРЕННОЙ ЖИТЕЛЬ/КОРЕННАЯ ЖИТЕЛЬНИЦА АЛЯСКИ
<0> НЕТ/НЕ АМЕРИКАНСКИЙ ИНДЕЕЦ/НЕ АМЕРИКАНСКАЯ
ИНДИАНКА И НЕ КОРЕННОЙ ЖИТЕЛЬ/КОРЕННАЯ
ЖИТЕЛЬНИЦА АЛЯСКИ
MISSING/DK
Q44_INTRO Следующие вопросы касаются Вас.
Q44
Сколько Вам лет?
ЗАЧИТАЙТЕ ОТВЕТЫ, ТОЛЬКО ЕСЛИ ЭТО НЕОБХОДИМО
<1> от 18 до 24 лет
<2> от 25 до 34 лет
<3> от 35 до 44 лет
<4> от 45 до 54 лет
<5> от 55 до 64 лет
<6> от 65 до 74 лет
<7> от 75 до 84 лет
<8> 85 лет и старше
MISSING/DK
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Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
Q45
ИНТЕРВЬЮЕР ЗАДАЕТ ВОПРОС ТОЛЬКО В СЛУЧАЕ
НЕОБХОДИМОСТИ: Ваш пол?
<1> МУЖСКОЙ
<2> ЖЕНСКИЙ
MISSING/DK
Q46
Какое образование Вы получили? [ОПЦИОНАЛЬНО: Ваше образование…]
ЗАЧИТАЙТЕ ОТВЕТЫ ТОЛЬКО В СЛУЧАЕ НЕОБХОДИМОСТИ
<1> 8 классов и меньше,
<2> Учился в старших классах, но не окончил школу,
<3> Окончил среднюю школу,
<4> Колледж или диплом о двухгодичном обучении,
<5> Четырехгодичное законченное высшее образование, или
<6> Обучение свыше четырех лет высшего образования?
MISSING/DK
ОБРАЗОВАНИЕ ВЫШЕ СРЕДНЕЙ ШКОЛЫ, НО БЕЗ ПОЛУЧЕНИЯ
ДИПЛОМА БАКАЛАВРА, ОТНОСИТСЯ К ВАРИАНТУ 4. ЕСЛИ
РЕСПОНДЕНТ
УКАЗЫВАЕТ
НА
ПРОХОЖДЕНИЕ
ПРОФЕССИОНАЛЬНО-ТЕХНИЧЕСКОЙ ПОДГОТОВКИ В ТАКИХ
УЧРЕЖДЕНИЯХ, КАК ПРОФЕССИОНАЛЬНОЕ УЧИЛИЩЕ, УТОЧНИТЕ,
ПОЛУЧИЛ ЛИ ОН АТТЕСТАТ ЗРЕЛОСТИ И ВЫБЕРИТЕ ВАРИАНТ 2 ИЛИ
3 В ЗАВИСИМОСТИ ОТ СИТУАЦИИ.
Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
23
Q47
На каком языке Вы в основном общаетесь дома? Пожалуйста, перед ответом
прослушайте все варианты ответа. Можно ли сказать, что в основном Вы
говорите на…
<1> Английском,
<2> Испанском,
<3> Китайском,
<4> Русском,
<5> Португальском,
<6> Вьетнамском,
<7> Польском,
<8> Корейском, или
<9> Другом языке?
[GO TO END]
[GO TO END]
[GO TO END]
[GO TO END]
[GO TO END]
[GO TO END]
[GO TO END]
[GO TO END]
[GO TO Q47A]
MISSING/DK
[GO TO END]
ЕСЛИ РЕСПОНДЕНТ НАЗЫВАЕТ НЕСКОЛЬКО ЯЗЫКОВ, СПРОСИТЕ:
Можно ли сказать, что в основном Вы говорите на [LANGUAGE A] или
[LANGUAGE B]?
ПРИМЕЧАНИЕ: ЕСЛИ РЕСПОНДЕНТ ГОВОРИТ, ЧТО В ОСНОВНОМ
ГОВОРИТ НА АМЕРИКАНСКОМ, ТО ВЫБЕРИТЕ ВАРИАНТ 1 АНГЛИЙСКИЙ
Q47A
На каких еще языках Вы в основном общаетесь дома?
ПРИМЕЧАНИЕ: УКАЖИТЕ ДРУГОЙ ЯЗЫК И ВНЕСИТЕ ЕГО В СВОИ
ВНУТРЕННИЕ ЗАПИСИ
END (КОНЕЦ)
Это все вопросы. [ОПЦИОНАЛЬНО: Если вам нужен номер для
поддержки скорбящих в [HOSPICE NAME], я могу сейчас его вам
предоставить]
ВЕДУЩИЙ ОПРОСА: ОСТАВЬТЕ КОНТАКТНУЮ ИНФОРМАЦИЮ,
ЕСЛИ ЭТО НЕОБХОДИМО.
Благодарим Вас за уделенное нам время.
ПРОЧИТАТЬ, ТОЛЬКО ЕСЛИ НУЖНО
Желаем приятного (дня/вечера). [END CALL]
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Centers for Medicare & Medicaid Services
CAHPS Hospice Survey Quality Assurance Guidelines V6.0
| File Type | application/pdf |
| File Title | CAHPS Hospice Survey Quality Assurance Guideline V6.0 September 2019 |
| Subject | CAHPS Hospice Survey Quality Assurance Guideline V6.0 September 2019 |
| Author | CMS |
| File Modified | 2019-09-19 |
| File Created | 2019-09-13 |