1 / 144

HCAHPS Update Training February 2009

HCAHPS Update Training February 2009. Welcome!. In the HCAHPS Update Training sessions, we will: Explain purpose and use of HCAHPS survey Provide instruction on managing the survey Discuss modes of survey administration

halla-baker
Download Presentation

HCAHPS Update Training February 2009

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. HCAHPS Update TrainingFebruary 2009

  2. Welcome! In the HCAHPS Update Training sessions, we will: • Explain purpose and use of HCAHPS survey • Provide instruction on managing the survey • Discuss modes of survey administration • Instruct on sampling, data preparation, data submission and public reporting

  3. HCAHPS Program Updates

  4. Overview of Presentation • HCAHPS Upcoming events • New for HCAHPS • Participation in HCAHPS • How to Join HCAHPS in 2009

  5. Upcoming for HCAHPS March 26, 2009 Fifth public reporting of HCAHPS results; July 2007-June 2008 discharges; ~3,800 hospitals April 8Submission deadline for 4th quarter 2008 data April 10 - May 9Preview Period for June public reporting ~ June 18 Sixth public reporting of HCAHPS results ~ September 17 Seventh public reporting of HCAHPS results ~ December 17 Eighth public reporting of HCAHPS results

  6. New for HCAHPS • IPPS hospitals must report HCAHPS results on Hospital Compare website • Enhanced oversight • New languages added for mail mode • HCAHPS Mode Experiment Two • Testing feasibility of two new candidate modes: • SE-IVR and Web-based • New footnotes

  7. New for HCAHPS(cont’d) • HCAHPS Bulletins • HCAHPSExecutive Insight • HCAHPS Version 3.1 effective for second quarter 2009 discharges • Hospitals with 5 or fewer HCAHPS-eligible patients need not survey from January 2009 • However, still must submit header data • Congress considering HCAHPS in possible pay-for-performance program

  8. Public Reporting MARCH 2009 • QUARTERS INCLUDED: 3Q07, 4Q07, 1Q08, 2Q08 • PREVIEW PERIOD: January 19 – February 17 • PUBLIC REPORTING: March 26, 2009 • NOTE: First reporting of hospitals that joined HCAHPS in July 2007 • Data from 2Q07 has rolled off

  9. Survey Mode Second quarter 2008 hospitals (3,866): • Mail: 2,833 hospitals; 73% • Telephone: 990 hospitals; 26% • Mixed: 8 hospitals; 0.2% • IVR: 35 hospitals; 1%

  10. Participation in HCAHPS Second quarter 2008: • 50 Approved survey vendors • 93 Self-administering hospitals • 5 Multi-site hospitals

  11. Oversight and Compliance As HCAHPS plays a greater role in hospital payment, The importance of oversight and compliance increase

  12. Steps to Join HCAHPS in 2009 • Submit HCAHPS Participation Form • For self-administering hospitals, hospitals administering survey for multiple sites and survey vendors • Form now available online • Do an HCAHPS Dry Run • Voluntary, but strongly suggested • Last month of calendar quarter • Contact HCAHPS Project Team for details • HCAHPS@azqio.sdps.org • Collect and submit HCAHPS survey data on continuous basis

  13. More information on HCAHPS • Registration, applications, background information, reports, updates and HCAHPSExecutive Insight: www.hcahpsonline.org • Submitting HCAHPS data: www.qualitynet.org • Publicly reported HCAHPS results: www.hospitalcompare.hhs.gov

  14. Questions?

  15. HCAHPS Participation and Program Requirements

  16. Participation Overview • Quality Assurance Guidelines V4.0 • Quality Assurance Plans • Exceptions Request/Discrepancy Report • HCAHPS Website

  17. HCAHPS Quality Assurance Guidelines V4.0 • General updates: • Terminology changes • Web site; My QualityNet; CMS Certification Number • Updates to Introduction and Overview • Mode Experiment II information • Updated 2009 timeline • Program Requirements • Reminder that the HCAHPS survey must be administered before any other survey • Data submission for “zero case” and fewer than 5 eligible discharges in a month • Maintain counts of ineligible patients and exclusions

  18. HCAHPS Quality Assurance Guidelines V4.0(cont’d) • General updates (cont’d): • Additional methodologies approved to determine HCAHPS service line • Sample Frame must be maintained for 3 years • Two new mail survey translations • Updates to the Telephone and IVR scripts • XML File Layout 3.1 • Appendices

  19. Quality Assurance Plan (QAP) • QAP 2009 submission date March 23, 2009 • Appendix N • Revisions must be clearly identified (track changes) • Must include a discussion of the results of quality control activities conducted during the prior year

  20. Quality Assurance Plan (QAP) (cont’d) • QAP 2009 submission date March 23, 2009 (cont’d) • Include sample(s) of survey and cover letter (Mail Only and Mixed modes) • Include sample(s) of telephone script (screen shots Telephone Only and Mixed modes) • Include sample(s) of IVR Script (Active IVR mode) • All survey languages administered

  21. HCAHPS Exceptions Request • Exceptions Request required to use a service line determination methodology other than: • V.26 or V.25 MS-DRG codes • V.24 CMS-DRG codes • Mix of V.26, V.25, V.24 codes based on payer source • ICD-9 codes • Hospital unit • New York State DRGs

  22. HCAHPS Exceptions Request • Exceptions Request must be submitted online via the HCAHPS Web site • Survey Vendors must submit Exceptions Request on behalf of their contracted hospital • Organization submitting the Exceptions Request will receive notification emails

  23. Discrepancy Report • Discrepancy Reports must be submitted online via the HCAHPS Web site • Survey Vendors must submit Discrepancy Report on behalf of their contracted hospital • Organization submitting the Discrepancy Report will receive notification emails • Detailed information and hospital CCN required • Reviewed each reporting period

  24. Discrepancy Report (cont’d) • Reviewed each reporting period • Timing of notification emails

  25. HCAHPS Web site • Regular update items • HCAHPS Executive Insights • PMA Tables • Data Submission Due Date Announcements • HCAHPS Bulletin • Online Form Submission

  26. Questions?

  27. Sampling Protocol

  28. Overview • Steps of Sampling Process • Population, Sample Frame and Sample • Sampling Facts

  29. Steps of Sampling Process • Population (All Patient Discharges) • Identify Eligible Patients • Remove Exclusions • De-Duplication Process • HCAHPS Sample Frame • Draw Sample See Quality Assurance Guidelines V4.0, Flowchart of HCAHPS Sampling Protocol

  30. Step 1: Population(All Patient Discharges)

  31. Step 1: Population (cont’d) • Patients of all payer types are eligible for sampling • Hospitals contracting with survey vendors are strongly encouraged to provide entire patient discharge list (excluding no-publicity patients and patients excluded because of state regulations) to their survey vendor

  32. Step 2: Identify Eligible Patients Ineligible Patients Record count of Ineligible patients • All Eligible • Patients • 18 years or older at the time of admission • Admission includes at least one overnight stay in the hospital • Non-psychiatric MS-DRG/principal diagnosis at discharge • Alive at the time of discharge

  33. Step 2: Identify Eligible Patients Eligibility Criteria(cont’d) • V.26 MS-DRGs effective October 1, 2008 • To classify into Medical and Surgical service lines • The Federal Register Notice – most recent August 19, 2008 (updated approximately twice per year) • To classify into Maternity Care service line • Use MS-DRGs 765 – 768, 774, 775 • Current Service Line-MS-DRG Crosswalk Table • Quality Assurance Guidelines V4.0

  34. Step 2: Identify Eligible Patients Eligibility Criteria (cont’d) • Effective with Version 3.1 2Q 2009 patient discharges - accepted methodologies for determination of service line (Exceptions Request not required) • V.26 orV.25 MS-DRG codes • V.24 CMS-DRG codes • Mix of V.26, V.25, V.24 codes based on payer source • ICD-9 codes • Hospital unit • New York State DRGs Hospitals/Survey vendors must submit an Exceptions Request Form online for approval to use other means.

  35. Step 2: Identify Eligible Patients Eligibility Criteria (cont’d) • Include patients unless have positive evidence that a patient is ineligible • Missing or incomplete MS-DRG, address and/or telephone number does not exclude patient from being sampled • Nursing home patients must not be excluded

  36. Step 2: Identify Eligible Patients Eligibility Criteria (cont’d) • Do not include patients with discharge dates beyond the 42-day initial contact period in the sample frame • Discrepancy Report must be filed to account for patient information received beyond the 42-day initial contact protocol

  37. Step 3: Remove Exclusions Ineligible Patients • Exclusions • “No-Publicity” patients • Court/Law enforcement patients (i.e., prisoners) • Patients with a foreign home address Patients discharged to hospice care • Patients who are excluded because of state regulations All Eligible Patients

  38. Step 3: Remove Exclusions(cont’d) • Record count of patients by each exclusions category • Hospitals/Survey vendors must retain documentation that verifies all exclusions

  39. Step 4: De-Duplication Process Ineligible Patients Exclusions All Eligible Patients • De-Duplication • Household • Multiple Discharges

  40. Step 4: De-Duplication ProcessDe-Duplication by Household • Sample only one patient per household in a given calendar month • De-duplicate address and/or telephone number from medical records and patient unique IDs within each month • Do not de-duplicate address and/or telephone number for nursing homes, long-term care facilities, etc., unless residents are family members

  41. Step 4: De-Duplication ProcessDe-Duplication by Multiple Discharges • Sample patient only once in a given calendar month • For continuous sampling, only use the first discharge date • For weekly sampling, use the last discharge during the week • For end of the month sampling, de-duplicate across all discharges in the month and only use the last discharge Patients are eligible to be included in the sample in consecutive months.

  42. Step 5: HCAHPS Sample Frame Ineligible Patients Exclusions All HCAHPS Eligible Patients (Sample Frame) • De-Duplication • Household • Multiple Discharges

  43. Step 5: HCAHPS Sample Frame Sample Frame Creation • Survey vendor generates sample frame (Recommended) • Contracted hospital submits their entire patient discharge list, excluding no-publicity patients and patients excluded because of state regulations • Survey vendor applies Eligible Population criteria and removes Exclusions and generates the sample frame before sampling

  44. Step 5: HCAHPS Sample FrameSample Frame Creation(cont’d) • Hospital generates sample frame • File contains all patients that meet Eligible Population criteria • Hospital provides all required data file elements • Total count of ineligible patients • Total count of patients by each exclusions category • Survey vendor validates the integrity of the sample frame before sampling

  45. Step 5: HCAHPS Sample Frame Sample Frame Creation(cont’d) • Include all patients: • Who meet eligible population criteria • Discharged between first and last days of month • Include patients even if: • Missing or incomplete address/telephone number • Missing eligibility criteria

  46. Step 5: HCAHPS Sample Frame Sample Frame Creation(cont’d) • Do not include patients if: • Discharge dates beyond the 42-day initial contact period if known before sample drawn • Discrepancy Report must be filed to account for patient information received beyond the 42-day initial contact protocol • Include these patients towards the count in the Eligible Discharge field

  47. Step 5: HCAHPS Sample FrameHCAHPS Sample Frame • Must maintain sample frame for a minimum of three years • Updated sample frame layout (Appendix K) • File Content (i.e., All Patient Discharges or HCAHPS Sample Frame) • Total Number of Ineligibles • Total Number of Exclusions and by Exclusions Category • Total Number of Patient Discharges

  48. Step 6: Draw Sample Eligible Patients Not Selected for Sample Ineligible Patients Exclusions De-Duplication • Sample • Simple Random Sample (SRS) • Proportionate Stratified Random Sample (PSRS) • Disproportionate Stratified Random Sample (DSRS)

  49. Population, Sample Frame and Sample Population (All Patient Discharges) A + B + C + D + E= Hospital Population (All Patient Discharges) A + B = HCAHPS Sample Frame: generated by hospital/survey vendor. Contains entire Eligible Population A = Sample: randomly selected A B C D E Sample Drawn

  50. Sampling Facts • Same sampling type must be maintained throughout the quarter • Sample must include discharges from each month in the 12-month reporting period • HCAHPS random sample drawn first if multiple surveys administered • Do not stop sampling/surveying if 300 completes attained

More Related