CMS-10500 OAS CAHPS (Telephone Script)

OMB Control Number 0938-1240 (Expires: TBD)

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. YES [GO TO INTRO2]

2. NO, NOT AVAILABLE RIGHT NOW [SET CALLBACK]

3. NO [REFUSAL] [GO TO Q_REF SCREEN]

4. MENTALLY/PHYSICALLY INCAPABLE [GO TO Q_INELIGIBLE SCREEN]

INTRO2 (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.

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. BEGIN INTERVIEW [GO TO Q1_INTRO]

1. NO, NOT RIGHT NOW [SET CALLBACK]

2. DID NOT RECEIVE SURGERY/PROCEDURE FROM THIS FACILITY DURING [MONTH] [GO TO Q_INELIGIBLE SCREEN]

3. 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. YES [GO TO INEL2]

2. NO [GO TO INEL_END]

INEL2 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.

1. YES, SAMPLE PATIENT IS AVAILABLE AND ON PHONE NOW [GO TO INTRO5]

2. NO, NOT AVAILABLE RIGHT NOW [SET CALLBACK]

3. NO [REFUSAL] [GO TO Q_REF SCREEN]

4. MENTALLY/PHYSICALLY INCAPABLE [GO TO Q_INELIGIBLE SCREEN]

INTRO5 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. CONTINUE WITH INTERVIEW AT FIRST UNANSWERED QUESTION

2. NO, NOT RIGHT NOW [SET CALLBACK]

3. 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.

1. 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. Yes, definitely,

2. Yes, somewhat, or

3. No?

M MISSING/DK

2. 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. Yes, definitely,

2. Yes, somewhat, or

3. No?

M MISSING/DK

Q3_INTRO The next questions ask about the day of your procedure.

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

1. Yes, definitely,

2. Yes, somewhat, or

3. No?

M MISSING/DK

4. Was the facility clean? Would you say…

1. Yes, definitely,

2. Yes, somewhat, or

3. No?

M MISSING/DK

5. Were the clerks and receptionists at the facility as helpful as you thought they should be? Would you say…

1. Yes, definitely,

2. Yes, somewhat, or

3. No?

M MISSING/DK

6. Did the clerks and receptionists at the facility treat you with courtesy and respect? Would you say…

1. Yes, definitely,

2. Yes, somewhat, or

3. No?

M MISSING/DK

7. Did the doctors and nurses treat you with courtesy and respect? Would you say…

1. Yes, definitely,

2. Yes, somewhat, or

3. No?

M MISSING/DK

8. Did the doctors and nurses make sure you were as comfortable as possible? Would you say…

1. Yes, definitely,

2. Yes, somewhat, or

3. No?

M MISSING/DK

Q9_INTRO As a reminder, please include any information you received before and on the day of the procedure.

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

1. Yes, definitely,

2. Yes, somewhat, or

3. No?

M MISSING/DK

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

1. YES

2. NO [GO TO Q13]

M MISSING/DK [GO TO Q13]

11. 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. Yes, definitely,

2. Yes, somewhat, or

3. No?

M MISSING/DK

12. 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. Yes, definitely,

2. Yes, somewhat, or

3. No?

M MISSING/DK

13. 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. YES

2. NO

M MISSING/DK

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

1. Yes, definitely,

2. Yes, somewhat, or

3. No?

M MISSING/DK

15. 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. Yes, definitely,

2. Yes, somewhat, or

3. No?

M MISSING/DK

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

1. YES

2. NO

M MISSING/DK

17. 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. Yes, definitely,

2. Yes, somewhat, or

3. No?

M MISSING/DK

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

1. YES

2. NO

M MISSING/DK

19. 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. Yes, definitely,

2. Yes, somewhat, or

3. No?

M MISSING/DK

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

1. YES

2. NO

M MISSING/DK

21. 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. Yes, definitely,

2. Yes, somewhat, or

3. No?

M MISSING/DK

22. At any time after leaving the facility, did you have any signs of infection?

1. YES

2. NO

M MISSING/DK

Q23_INTRO The next two questions ask about your overall experience.

23. 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 WORST FACILITY POSSIBLE

1

2

3

4

5

6

7

8

9

10 BEST FACILITY POSSIBLE

M MISSING/DK

24. Would you recommend this facility to your friends and family? Would you say…

1. Definitely no,

2. Probably no,

3. Probably yes, or

4. Definitely yes?

M MISSING/DK

25. In general, how would you rate your overall health? Would you say …

1. Excellent,

2. Very good,

3. Good,

4. Fair, or

5. Poor?

M MISSING/DK

26. In general, how would you rate your overall mental or emotional health? Would you say …

1. Excellent,

2. Very good,

3. Good,

4. Fair, or

5. Poor?

M MISSING/DK

27. What is your age?

1. 18 TO 24

2. 25 TO 34

3. 35 TO 44

4. 45 TO 54

5. 55 TO 64

6. 65 TO 74

7. 75 TO 79

8. 80 TO 84

9. 85 OR OLDER

M MISSING/DK

28. Are you male or female?

1. MALE

2. FEMALE

M MISSING/DK

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

1. 8th grade or less,

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, or

6. More than 4-year college degree?

M MISSING/DK

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

1. YES

2. NO [GO TO Q32]

M MISSING/DK [GO TO Q32]

31. Which group best describes you…

1. Mexican, Mexican American, Chicano,

2. Puerto Rican,

3. Cuban, or

4. Another Hispanic, Latino, or Spanish origin?

M MISSING/DK

32. What is your race? You may select one or more categories. Are you…

1. White,

2. Black or African American,

3. American Indian or Alaska Native,

4. Asian, or

5. Native Hawaiian or Pacific Islander?

6. 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 Q33.

IF ASIAN ONLY, GO TO Q32A. IF WHITE, BLACK/AFRICAN AMERICAN, AND/OR AMERICAN INDIAN/ALASKA NATIVE AND ASIAN ARE CHOSEN, GO TO Q32A. IF NATIVE HAWAIIAN/PACIFIC ISLANDER IS ALSO CHOSEN, SEE INSTRUCTION AFTER Q32A.

IF NATIVE HAWAIIAN/PACIFIC ISLANDER ONLY, GO TO Q32B. IF WHITE, BLACK/AFRICAN AMERICAN, AND/OR AMERICAN INDIAN/ALASKA NATIVE AND NATIVE HAWAIIAN/PACIFIC ISLANDER ARE CHOSEN, GO TO Q32B.

Q32a. Which groups best describe you? You may select one or more categories. Are you…

1. Asian Indian,

2. Chinese,

3. Filipino,

4. Japanese,

5. Korean,

6. Vietnamese, or

7. Other Asian?

8. NONE OF THE ABOVE

M MISSING/DK

IF NATIVE HAWAIIAN/PACIFIC ISLANDER WAS ALSO CHOSEN IN Q32, GO TO Q32B. ELSE, GO TO Q33.

Q32b. Which groups best describe you? You may select one or more categories. Are you…

1. Native Hawaiian,

2. Guamanian or Chamorro,

3. Samoan, or

4. Other Pacific Islander?

5. NONE OF THE ABOVE

M MISSING/DK

33. How well do you speak English? Would you say…

1. Very well,

2. Well,

3. Not well, or

4. Not at all?

M MISSING/DK

34. Do you speak a language other than English at home? Would you say…

1. Yes, I speak a language other than English, or

2. No, I speak English at home? [GO TO Q_END]

M MISSING/DK [GO TO Q_END]

35. What is that language?

1. SPANISH [GO TO Q_END]

2. OTHER LANGUAGE [GO TO Q35a]

M MISSING/DK [GO TO Q_END]

Q35a. What is that language? [ENTER RESPONSE BELOW. ALLOW UP TO 50 CHARACTERS]

M MISSING/DK

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).

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