CAHPS Hospice Survey Summary of Updates and Emphasis

CAHPS Hospice Survey Quality Assurance Guidelines Version 6.0
Summary of Updates and Emphasis
This document is a reference tool that highlights the major changes from the CAHPS Hospice Survey Quality Assurance Guidelines Version 5.0 to 6.0. This
document is not a substitute for reviewing the CAHPS Hospice Survey Quality Assurance Guidelines V6.0 in its entirety. The CAHPS Hospice Survey Quality
Assurance Guidelines V6.0 manual is effective upon its release in September 2019. General formatting and minor wording revisions have occurred throughout the
manual and are not included in this change matrix. Please contact the CAHPS Hospice Survey Project Team for any specific questions.
QAG Section
Chapters
Miscellaneous

Summary of Key Changes in V6.0
•

Updates:

o Revised V5.0 to V6.0
o Revised dates as necessary (e.g., 2018 to 2019)
o Minor formatting and wording revisions throughout the manual
o Updated references to appendices as needed
o References to XML File Specification V5.0 have been updated to XML File Specification V6.0
o Changed the CAHPS Hospice Survey Technical Assistance email address throughout the manual to
[email protected]
o Added references to the CAHPS Hospice Survey Telephone Script (Russian)
o Update references to include the Telephone script (Russian) as needed
II. Introduction and
Overview

•

III. Program
Requirements

•

September 2019

Updates:

o Updated section regarding the public reporting of CAHPS Hospice Survey results
o Updated Hospice Compare Refresh Date Timeline table
o Updated CAHPS Hospice Survey Development and National Implementation Timeline
o Updated Data Collection and Submission Timeline
Updates:

o Clarified that hospices may not contact caregivers directly regarding survey responses
o Clarified Customer Support Line requirement to support calls from the deaf or hearing impaired
o Clarified that a Consent to Share question is not required by CMS in order to share identifiable caregiver
responses with hospices
o Clarified that any responses that would identify a particular decedent/caregiver must not be shared with direct
care staff
o Clarified that a 24-month wait period is required for survey vendors that do not re-apply, when approval status
is withdrawn due to having no clients within the initial 24-month approval period, before the survey vendor is
eligible to apply again

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CAHPS Hospice Survey Quality Assurance Guidelines Version 6.0
Summary of Updates and Emphasis
QAG Section
V. Sampling Protocol

Summary of Key Changes in V6.0
•
•

Updates:

o Clarified that contracted caregivers should not be considered primary informal caregivers
Emphasis:

o Clarified that a caregiver relationship of “8-No caregiver of record” should be used to identify decedents who
have no caregiver of record
o Clarified that decedents/caregivers are eligible for inclusion in the sample frame if they meet all the eligibility
criteria
VI. Mail Only Survey
Administration

•

VII. Telephone Only
Survey
Administration

•

VIII. Mixed Mode
Survey
Administration

•

IX. Data Coding and
Data File Preparation

•

Updates:

o Added the requirement for the OMB expiration date to be printed on the front page of the questionnaire
o Clarified the Customer Support Line requirement to support calls from the deaf or hearing impaired
Updates:

o Added references to the Telephone script (Russian)
o Clarified requirement that telephone monitoring not be conducted from a residence
o Clarified the Customer Support Line requirement to support calls from the deaf or hearing impaired
Updates:

o Added references to the Telephone script (Russian)
o Added the requirement for the OMB expiration date to be printed on the front page of the questionnaire
o Clarified requirement that telephone monitoring not be conducted from a residence
o Clarified the Customer Support Line requirement to support calls from the deaf or hearing impaired

•

Updates:

o Clarified that for a survey vendor’s final submission(s) each quarter, a separate file for each month of data is not
permitted
Emphasis:

o Clarified that “zero cases” submissions must not be used when survey vendors do not confirm in writing that the
hospice had zero eligible decedents/caregivers in a month

September 2019

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CAHPS Hospice Survey Quality Assurance Guidelines Version 6.0
Summary of Updates and Emphasis
QAG Section
X. Data Submission

Summary of Key Changes in V6.0
•

•

Updates:

o Updated the instructions for completing the CAHPS Hospice Survey Vendor Authorization Form
o Clarified that 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.
o Updated the CAHPS Hospice Survey Data Warehouse new password creation requirement to 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
o Update the instructions for accessing the CAHPS Hospice Survey Data Warehouse
Emphasis:

o Clarified that for vendors, the “Upload” button within their organization’s “Hospice” folder will allow the user
to upload their organization’s files
XI. Oversight
Activities

No revisions

XII. Data Reporting

•

XIII. Exception
Request Process

No revisions

XIV. Discrepancy
Report Process

•

XV. Data Quality
Checks

No revisions

September 2019

Updates:
o Updated the Provider Preview Period and Hospice Compare Refresh dates
o Added a table illustrating the Response Scales related to Top-Box, Middle-Box, and Bottom-Box scoring
o Updated the text regarding the Response Scales related to Top-Box, Middle-Box, and Bottom-Box scoring

Updates:

o Clarified that a Discrepancy Report must be submitted when a sampled eligible decedent/caregiver is found to
be ineligible
o Added recommendation that hospices contact their survey vendors to inquire about the outcome of the review of
submitted Discrepancy Report(s)

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CAHPS Hospice Survey Quality Assurance Guidelines Version 6.0
Summary of Updates and Emphasis
QAG Section

Summary of Key Changes in V6.0

Appendices
Appendix A
Minimum Business
Requirements

•

Appendix B
Survey Vendor
Authorization Form

•

Appendix C
Data Warehouse
Access Form for
Vendors and Hospices
Appendix D
Sample File Layout

•

Updates:

o Clarified that a 24-month wait period is required for survey vendors that do not re-apply, when approval status
is withdrawn due to having no clients within the initial 24-month approval period, before the survey vendor is
eligible to apply again
Updates:

o Updated Survey Vendor Authorization Form
o Updated address, contact name, and phone number in the mailing and FedEx instructions
o Added additional guidance for determining start date for vendor authorization
Updates:

o Updated address and contact name in the mailing and FedEx instructions
•
•

Updates:

o Clarified the Decedent Last Location/Setting of Care
o Removed the “Decedent Primary Diagnosis Code Format” field
Emphasis:

o Clarified “Caregiver Relationship to the Decedent” should be “8-No caregiver of record” to identify decedents
who have no caregiver of record
Appendix E
XML File Layout
Version 6.0

•

Appendix F
Interviewing Guidelines
for Telephone Surveys

No Revisions

Appendix G
Frequently Asked
Questions for Customer
Support

No Revisions

September 2019

Updates:

o Revised dates as necessary (e.g., 2018 to 2019)
o Removed the “diagnosis-code-format” field

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CAHPS Hospice Survey Quality Assurance Guidelines Version 6.0
Summary of Updates and Emphasis
QAG Section
Appendix H
Model Quality
Assurance Plan

Summary of Key Changes in V6.0
•

Updates:

o Added additional survey vendor contact information to be provided in the Organizational Background and
Structure section
o Added “Note” emphasizing the importance that the CAHPS Hospice Survey Project Team be able to reach a
survey vendor organization in case of problems with the data or other operational issues
o Clarified that survey vendors must update and resubmit their QAP at the time of process and/or key personnel
changes as part of retaining participation status

Appendix I
Exception Request
Form

•

Updates:
o Added Captcha requirement for form submission

Appendix J
Discrepancy Report
Form
Appendix K
Participation
Exemption for Size
Form

•

Updates:
o Added Captcha requirement for form submission

•

Updates:

o Added Captcha requirement for form submission

Appendix L
Attestation Statement
Appendix M
Examples of Additional
Supplemental
Questions for Survey
Vendor Use
Appendix N
Mail Survey Materials
(English)

No revisions

Appendix O
Mail Survey Materials
(Spanish)

•

September 2019

No revisions

•

Updates:

o Added OMB Expiration Date on the front page of the questionnaire
o Added OMB Expiration Date to the OMB Paperwork Reduction Act Language
Updates:

o Added OMB Expiration Date on the front page of the questionnaire
o Added OMB Expiration Date to the OMB Paperwork Reduction Act Language

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CAHPS Hospice Survey Quality Assurance Guidelines Version 6.0
Summary of Updates and Emphasis
QAG Section
Appendix P
Mail Survey Materials
(Traditional Chinese)

Summary of Key Changes in V6.0
•

o Added OMB Expiration Date on the front page of the questionnaire
o Added OMB Expiration Date to the OMB Paperwork Reduction Act Language

Appendix Q
Mail Survey Materials
(Simplified Chinese)
Appendix R
Mail Survey Materials
(Russian)
Appendix S
Mail Survey Materials
(Portuguese)

•

Appendix T
Mail Survey Materials
(Vietnamese)
Appendix U
Mail Survey Materials
(Polish)
Appendix V
Mail Survey Materials
(Korean)
Appendix W
Telephone Script
(English)

•

Appendix X
Telephone Script
(Spanish)

•

Appendix Y
Telephone Script
(Russian)

•

September 2019

Updates:

Updates:

o Added OMB Expiration Date on the front page of the questionnaire
o Added OMB Expiration Date to the OMB Paperwork Reduction Act Language
•

Updates:

o Added OMB Expiration Date on the front page of the questionnaire
o Added OMB Expiration Date to the OMB Paperwork Reduction Act Language
•

Updates:

o Added OMB Expiration Date on the front page of the questionnaire
o Updated the Survey Instructions
o Added OMB Expiration Date to the OMB Paperwork Reduction Act Language
Updates:

o Added OMB Expiration Date on the front page of the questionnaire
o Added OMB Expiration Date to the OMB Paperwork Reduction Act Language
•

Updates:

o Added OMB Expiration Date on the front page of the questionnaire
o Added OMB Expiration Date to the OMB Paperwork Reduction Act Language
•

Updates:

o Added OMB Expiration Date on the front page of the questionnaire
o Added OMB Expiration Date to the OMB Paperwork Reduction Act Language
•

Updates:

o Updated Initiating Contact instructions
o Updating Call Back to Complete a Previously Started Survey instruction
o Updated If Asked Whether Someone Else Can Serve as A Proxy For Sampled Caregiver instructions
Updates:

o Updated Initiating Contact instructions
o Updating Call Back to Complete a Previously Started Survey instruction
o Updated If Asked Whether Someone Else Can Serve as A Proxy For Sampled Caregiver instructions
Updates:
o New script

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