CMS-10500 OAS CAHPS (Telephone Script)

OMB No. 0938-1240
Expires 12/31/2021

ATTACHMENT B
TELEPHONE INTERVIEW SCRIPT
FOR THE OUTPATIENT AND AMBULATORY SURGERY CAHPS SURVEY
(OAS CAHPS®)
GO TO INTRO4 IF THIS IS A FOLLOW-UP CALL TO AN INTERVIEW THAT WAS
STARTED IN A PRECEDING CALL. OTHERWISE GO TO INTRO1.
INTRO1

Hello, may I please speak to [SAMPLED MEMBER’S NAME]?
IF ASKED WHO IS CALLING:
This is [INTERVIEWER NAME] calling from [VENDOR] on behalf of
[FACILITY NAME]. I’d like to speak to [SAMPLE MEMBER’S NAME] about
a health care survey.
1.
2.
3.
4.

INTRO2

YES [GO TO INTRO2]
NO, NOT AVAILABLE RIGHT NOW [SET CALLBACK]
NO [REFUSAL] [GO TO Q_REF SCREEN]
MENTALLY/PHYSICALLY INCAPABLE [GO TO Q_INELIGIBLE
SCREEN]

(Hello, this is [INTERVIEWER NAME] calling on behalf of [FACILITY
NAME].) [FACILITY NAME] is participating in a survey about patients’
experiences with outpatient surgeries and procedures. The results will be used to
help [FACILITY NAME] understand patient experiences in their facilities.
Your participation in this survey is completely voluntary and will not affect any
health care or benefits you receive. All information you provide is confidential
and is protected by the Privacy Act. The interview will take about 8 minutes to
complete. This call may be monitored or recorded for quality improvement
purposes.

[ADDRESS ANY QUESTIONS/CONCERNS THEN CONTINUE.]
NOTE: THE LENGTH OF THE INTERVIEW WILL DEPEND ON WHETHER THE
FACILITY ADDS SUPPLEMENTAL QUESTIONS TO THE SURVEY. IF
SUPPLEMENTAL ITEMS ARE ADDED, INCREASE THE STATED
NUMBER OF MINUTES IN INTRO2 ACCORDINGLY.

1

INTRO3

This survey asks about your experience at [FACILITY NAME]. For this survey,
we use the term “procedure” for diagnostic, surgical or other procedures. We refer
to “facility” as the place where you had your procedure. Please answer these
questions only for the procedure you had on [DATE]. Do not include any other
procedures in your answers.

[ADDRESS ANY QUESTIONS/CONCERNS THEN SELECT RESPONSE OPTION.]
1
2
3
4

BEGIN INTERVIEW [GO TO Q1_INTRO]
NO, NOT RIGHT NOW [SET CALLBACK]
DID NOT RECEIVE SURGERY/PROCEDURE FROM THIS FACILITY
DURING [MONTH] [GO TO Q_INELIGIBLE SCREEN]
NO [REFUSAL] [GO TO Q_REF SCREEN]

INEL ITEMS ARE OPTIONAL AND ASKED ONLY IF NEW TELEPHONE NUMBER
IDENTIFIED.
INEL1

Were you ever a patient at [FACILITY NAME]?
1
2

INEL2

YES [GO TO INEL2]
NO [GO TO INEL_END]

When was this?
NOTE: IF DATE IS WITHIN 2 WEEKS OF SURGERY DATE ON RECORD,
GO TO Q1_INTRO. IF NOT, GO TO INEL_END.

INEL_END

Thank you for your time. It looks like we made a mistake. Have a good
(day/evening).

INTRO4

USED ONLY IF CALLING SAMPLE PATIENT BACK TO COMPLETE A
SURVEY THAT WAS STARTED IN A PREVIOUS CALL. NOTE THAT THE
PATIENT MUST HAVE ANSWERED AT LEAST ONE QUESTION IN THE
SURVEY IN A PRECEDING CALL.
Hello, may I please speak to [SAMPLE MEMBER’S NAME]?
IF ASKED WHO IS CALLING:
This is [INTERVIEWER NAME] calling from [VENDOR] on behalf of
[FACILITY NAME]. I’d like to speak to [SAMPLE MEMBER’S NAME] about
a health care survey.

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Expires 12/31/2021

1
2
3
4

INTRO5

YES, SAMPLE PATIENT IS AVAILABLE AND ON PHONE NOW [GO
TO INTRO5]
NO, NOT AVAILABLE RIGHT NOW [SET CALLBACK]
NO [REFUSAL] [GO TO Q_REF SCREEN]
MENTALLY/PHYSICALLY INCAPABLE [GO TO Q_INELIGIBLE
SCREEN]

Hello, this is [INTERVIEWER NAME] calling from [VENDOR]. I am calling to
continue the survey that we started in a previous call, regarding your experience at
[FACILITY NAME]. I’d like to continue with that survey now.
1
2
3

CONTINUE WITH INTERVIEW AT FIRST UNANSWERED QUESTION
NO, NOT RIGHT NOW [SET CALLBACK]
NO [REFUSAL] [GO TO Q_REF SCREEN]

Q1_INTRO

The first few questions are about getting ready for your procedure. Include any
information you received before and on the day of your procedure.

Q1.

Before your procedure, did your doctor or anyone from the facility give you all
the information you needed about your procedure? Would you say…
1
2
3

Yes, definitely,
Yes, somewhat, or
No?

M MISSING/DK
Q2.

Before your procedure, did your doctor or anyone from the facility give you easy
to understand instructions about getting ready for your procedure? Would you
say…
1
2
3

Yes, definitely,
Yes, somewhat, or
No?

M MISSING/DK
Q3_INTRO

The next questions ask about the day of your procedure.

3

Q3.

Did the check-in process run smoothly? Would you say…
1
2
3

Yes, definitely,
Yes, somewhat, or
No?

M MISSING/DK
Q4.

Was the facility clean? Would you say…
1
2
3

Yes, definitely,
Yes, somewhat, or
No?

M MISSING/DK
Q5.

Were the clerks and receptionists at the facility as helpful as you thought they
should be? Would you say…
1
2
3

Yes, definitely,
Yes, somewhat, or
No?

M MISSING/DK
Q6.

Did the clerks and receptionists at the facility treat you with courtesy and respect?
Would you say…
1
2
3

Yes, definitely,
Yes, somewhat, or
No?

M MISSING/DK
Q7.

Did the doctors and nurses treat you with courtesy and respect? Would you say…
1
2
3

Yes, definitely,
Yes, somewhat, or
No?

M MISSING/DK

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Expires 12/31/2021

Q8.

Did the doctors and nurses make sure you were as comfortable as possible?
Would you say…
1
2
3

Yes, definitely,
Yes, somewhat, or
No?

M MISSING/DK
Q9_INTRO

As a reminder, please include any information you received before and on the day
of the procedure.

Q9.

Did the doctors and nurses explain your procedure in a way that was easy to
understand? Would you say…
1
2
3

Yes, definitely,
Yes, somewhat, or
No?

M MISSING/DK
Q10.

Anesthesia is something that would make you feel sleepy or go to sleep during
your procedure. Were you given anesthesia?
1
2

YES
NO [GO TO Q13]

M MISSING/DK
Q11.

[GO TO Q13]

Did your doctor or anyone from the facility explain the process of giving
anesthesia in a way that was easy to understand? Would you say…
1
2
3

Yes, definitely,
Yes, somewhat, or
No?

M MISSING/DK

5

Q12.

Did your doctor or anyone from the facility explain the possible side effects of the
anesthesia in a way that was easy to understand? Would you say…
1
2
3

Yes, definitely,
Yes, somewhat, or
No?

M MISSING/DK
Q13.

Discharge instructions include things like symptoms you should watch for after
your procedure, instructions about medicines, and home care. Before you left the
facility, did you receive written discharge instructions?
1
2

YES
NO

M MISSING/DK
Q14.

Did your doctor or anyone from the facility prepare you for what to expect during
your recovery? Would you say…
1
2
3

Yes, definitely,
Yes, somewhat, or
No?

M MISSING/DK
Q15.

The next questions are about possible outcomes you could have during recovery.
Some procedures do not require that you get this information. Please answer
based on what you remember.
Some ways to control pain include prescription medicine, over-the-counter pain
relievers or ice packs. Did your doctor or anyone from the facility give you
information about what to do if you had pain as a result of your procedure?
Would you say…
1
2

Yes
No

M MISSING/DK

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Q16.

At any time after leaving the facility, did you have pain as a result of your
procedure?
1
2

YES
NO

M MISSING/DK
Q17.

Before you left the facility, did your doctor or anyone from the facility give you
information about what to do if you had nausea or vomiting? Would you say…
1
2

Yes
No

M MISSING/DK
Q18.

At any time after leaving the facility, did you have nausea or vomiting as a result
of either your procedure or the anesthesia?
1
2

YES
NO

M MISSING/DK
Q19.

Before you left the facility, did your doctor or anyone from the facility give you
information about what to do if you had bleeding as a result of your procedure?
Would you say…
1
2

Yes
No

M MISSING/DK
Q20.

At any time after leaving the facility, did you have bleeding as a result of your
procedure?
1
2

YES
NO

M MISSING/DK

7

Q21.

Possible signs of infection include fever, swelling, heat, drainage or redness.
Before you left the facility, did your doctor or anyone from the facility give you
information about what to do if you had possible signs of infection? Would you
say…
1
2

Yes
No

M MISSING/DK
Q22.

At any time after leaving the facility, did you have any signs of infection?
1
2

YES
NO

M MISSING/DK
Q23_INTRO The next two questions ask about your overall experience.
Q23.

Using any number from 0 to 10, where 0 is the worst facility possible and 10 is
the best facility possible, what number would you use to rate this facility?
0
1
2
3
4
5
6
7
8
9
10

WORST FACILITY POSSIBLE

BEST FACILITY POSSIBLE

M MISSING/DK
Q24.

Would you recommend this facility to your friends and family? Would you say…
1
2
3
4

Definitely no,
Probably no,
Probably yes, or
Definitely yes?

M MISSING/DK

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Q25.

In general, how would you rate your overall health? Would you say …
1
2
3
4
5

Excellent,
Very good,
Good,
Fair, or
Poor?

M MISSING/DK
Q26.

In general, how would you rate your overall mental or emotional health? Would
you say …
1
2
3
4
5

Excellent,
Very good,
Good,
Fair, or
Poor?

M MISSING/DK
Q27.

What is the highest grade or level of school that you have completed? Would you
say…
1
2
3
4
5
6

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, or
More than 4-year college degree?

M MISSING/DK
Q28.

Are you of Hispanic, Latino, or Spanish origin?
1
2

YES
NO [GO TO Q30]

M MISSING/DK

[GO TO Q30]

9

Q29.

Which group best describes you…
1
2
3
4

Mexican, Mexican American, Chicano,
Puerto Rican,
Cuban, or
Another Hispanic, Latino, or Spanish origin?

M MISSING/DK
Q30.

What is your race? You may select one or more categories. Are you…
1
2
3
4
5
6

White,
Black or African American,
American Indian or Alaska Native,
Asian, or
Native Hawaiian or Pacific Islander?
NONE OF THE ABOVE

M MISSING/DK
PROGRAMMER INSTRUCTIONS: IF WHITE ONLY, BLACK/AFRICAN AMERICAN
ONLY, OR AMERICAN INDIAN/ALASKA NATIVE ONLY, OR ANY COMBINATION OF
THESE THREE OPTIONS, NONE OF THE ABOVE OR MISSING/DK, GO TO Q31.
IF ASIAN ONLY, GO TO Q30A. IF WHITE, BLACK/AFRICAN AMERICAN, AND/OR
AMERICAN INDIAN/ALASKA NATIVE AND ASIAN ARE CHOSEN, GO TO Q30A. IF
NATIVE HAWAIIAN/PACIFIC ISLANDER IS ALSO CHOSEN, SEE INSTRUCTION
AFTER Q32A.
IF NATIVE HAWAIIAN/PACIFIC ISLANDER ONLY, GO TO Q30B. IF WHITE,
BLACK/AFRICAN AMERICAN, AND/OR AMERICAN INDIAN/ALASKA NATIVE AND
NATIVE HAWAIIAN/PACIFIC ISLANDER ARE CHOSEN, GO TO Q30B.

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Expires 12/31/2021

Q30a.

Which groups best describe you? You may select one or more categories. Are
you…
1
2
3
4
5
6
7
8

Asian Indian,
Chinese,
Filipino,
Japanese,
Korean,
Vietnamese, or
Other Asian?
NONE OF THE ABOVE

M MISSING/DK
IF NATIVE HAWAIIAN/PACIFIC ISLANDER WAS ALSO CHOSEN IN Q30, GO TO Q30B.
ELSE, GO TO Q31.
Q30b.

Which groups best describe you? You may select one or more categories. Are
you…
1
2
3
4
5

Native Hawaiian,
Guamanian or Chamorro,
Samoan, or
Other Pacific Islander?
NONE OF THE ABOVE

M MISSING/DK
Q31.

How well do you speak English? Would you say…
1
2
3
4

Very well,
Well,
Not well, or
Not at all?

M MISSING/DK

11

Q32.

What language do you mainly speak at home? Would you say…
1
2
3
4
5
6
7
9

English
Spanish
Chinese
Russian
Vietnamese
Portuguese
German
Some other language

M MISSING/DK
Q_END

[GO TO Q_END]

These are all the questions I have for you. Thank you for your time. Have a good
(day/evening).

INELIGIBLE SCREEN:
Q_INELIG

Thank you for your time. Have a good (day/evening).

REFUSAL SCREEN:
Q_REF

Thank you for your time. Have a good (day/evening).

12