CAHPS Hospice Survey Update Training. September 2017

Transcription

1 CAHPS Hspice Survey CAHPS Hspice Survey Update Training

2 Welcme 2

3 Training Presentatin Overview In tday s CAHPS Hspice Survey Update Training, we will: Present CAHPS Hspice Survey Prgram Updates Review Highlights and Updates t CAHPS Hspice Survey Discuss Additinal Data Quality Checks Discuss Data Adjustment and Public Reprting Present Mde Experiment Results Administer the Pst-training Quiz and Evaluatin 3

4 Online Questin Submissin Illustratin 1 4

5 Online Questin Submissin (cnt d) Illustratin 2 5

6 Online Questin Submissin (cnt d) Illustratin 3 6

7 CAHPS Hspice Survey Prgram Updates 7

8 Overview f CAHPS Hspice Survey Prgram Updates CAHPS Hspice Survey By the Numbers CAHPS Hspice Survey Prcess Public Reprting f CAHPS Hspice Survey Data Reminder: Data Submissin Timeline 8

9 CAHPS Hspice Survey By the Numbers Data submitted fr 9 quarters 3,670 hspices have submitted data 675,130 surveys cmpleted Endrsement f the 8 CAHPS Hspice Survey measures by the Natinal Quality Frum 9

10 CAHPS Hspice Survey Prcess Hspice A Survey Vendr B Cnducts Survey C Quality Checks D CMS Data Warehuse E Public Reprting 10

11 Everybdy Take Nte! CAHPS Hspice Survey cmpliance in CY 2018 Affects FY 2020 APU 11

12 CMS Hspice Quality Reprting Prgram (HQRP) CAHPS Hspice Survey is a cmpnent HQRP infrmatin Assessment-Instruments/Hspice-Quality-Reprting/ Impacts Medicare payments (FY 2020 annual payment update) Gals: Imprve transparency thrugh public reprting n Create incentives fr quality imprvement 12

13 CAHPS Hspice Survey Public Reprting Official CAHPS Hspice Survey scres will be reprted fur times a year Anticipate reprting will begin Winter f 2018 Results will be available fr preview by hspices via the Certificatin and Survey Prvider Enhanced Reprts (CASPER) system befre being publicly reprted 13

14 Mnth f Death Timeline fr Initial Cntact with Sampled Decedents/Caregivers Data Submissin t the CAHPS Hspice Survey Data Warehuse April 2017 July 1, 2017 May 2017 August 1, 2017 June 2017 September 1, 2017 July 2017 Octber 1, 2017 August 2017 Nvember 1, 2017 December 1, 2017 Octber 2017 January 1, 2018 Nvember 2017 February 1, 2018 December 2017 March 1, 2018 January 2018 April 1, 2018 February 2018 May 1, 2018 March 2018 June 1, 2018 Nvember 8, 2017 February 14, 2018 May 9, 2018 August 8,

15 Timeline fr (cnt d) Mnth f Death Initial Cntact with Sampled Decedents/Caregivers Data Submissin t the CAHPS Hspice Survey Data Warehuse April 2018 July 1, 2018 May 2018 August 1, 2018 June 2018 September 1, 2018 July 2018 Octber 1, 2018 August 2018 Nvember 1, 2018 September 2018 December 1, 2018 Octber 2018 January 1, 2019 Nvember 2018 February 1, 2019 December 2018 March 1, 2019 Nvember 14, 2018 February 13, 2019 May 8,

16 Imprtant Pints t Remember Review QAG V4.0 as it supersedes all previus materials Updates have been made based n questins and feedback Data that are submitted must fllw the XML File Specificatin r it will be rejected frm the CAHPS Hspice Survey Data Warehuse XML File Specificatin V3.1 will be used fr Q Q XML File Specificatin V4.0 will be used starting with Q Submit data t the CAHPS Hspice Survey Data Warehuse early 16

17 Key URL: Cpy f the questinnaire in all available translatins Cpy f the QAG V4.0 Technical infrmatin Pdcasts fr hspices, including: Participatin exemptin requirements Selecting a survey vendr Creating the decedents/caregivers list 17

18 The CAHPS Hspice Survey and the questins that cmprise it are in the public dmain Can be used fr nn-cahps Hspice Survey eligible decedents/caregivers, etc. When used in an unfficial capacity: Use f CAHPS Hspice Survey The OMB Paperwrk Reductin Act language must nt be used All references t CAHPS Hspice Survey and CMS must be remved 18

19 Use f CAHPS Hspice Survey (cnt d) CAHPS Hspice Survey results are nt intended t be used fr marketing r prmtinal activities Only the CAHPS Hspice Survey scres that will be published n Hspice Cmpare will be the fficial scres Scres derived frm any ther surce are unfficial and shuld be labeled as such 19

20 Technical Assistance and Cmmunicatin Fr additinal infrmatin and technical assistance: via at via telephne at Fr CAHPS Hspice Survey Data Warehuse r data submissin issues: via at cahpshspicetechsupprt@rand.rg via telephne at , extensin 5599 T cmmunicate with CMS: via at hspicesurvey@cms.hhs.gv 20

21 Highlights and Updates t CAHPS Hspice Survey 21

22 Highlights and Updates Overview Rles and Respnsibilities: CMS, Hspices and Survey Vendrs Sampling Prtcl Survey Administratin Questins & Answers File Specificatins Data Submissin Questins & Answers 22

23 Updated Rles and Respnsibilities: CMS Prvide calculatins and adjustments t CAHPS Hspice Survey data fr mde and case-mix effects prir t public reprting Create preview reprts cntaining CAHPS Hspice Survey results fr participating hspices prir t public reprting Prvide CAHPS Hspice Survey results that will be publicly reprted n the Hspice Cmpare Web site 23

24 Rles and Respnsibilities: Hspices Participate in the CAHPS Hspice Survey, if eligible Authrize a survey vendr Submit the CAHPS Hspice Survey Vendr Authrizatin Frm If the hspice is cntracting with a survey vendr fr the first time OR If the hspice is changing survey vendrs Review Data Submissin Reprts in the CAHPS Hspice Survey Data Warehuse Update: Preview CAHPS Hspice Survey results prir t public reprting 24

25 Participatin Exemptins Participatin Exemptin fr Size Hspices that served fewer than 50 survey-eligible decedents/caregivers in a calendar year can apply fr exemptin fr the fllwing year s data cllectin and submissin requirements The Participatin Exemptin fr Size Frm must be submitted every year Participatin Exemptin fr Newness The hspice must have received its CCN n r after the first day f the year Hspices that receive the exemptin fr newness are required t begin participating the first mnth f the fllwing calendar year Hspices that intend t be cnsidered fr the Participatin Exemptin fr Size may unfficially participate in the CAHPS Hspice Survey, hwever, data cllected must nt be submitted t the Data Warehuse 25

26 Rles and Respnsibilities: Survey Vendrs Fllw all CAHPS Hspice Survey guidelines Meet all CAHPS Hspice Survey due dates Cmplete and sign the CAHPS Hspice Survey Attestatin Statement by December 13, 2017 Update: Request client hspices review CAHPS Hspice Survey Data Submissin Reprts Maintain a tll-free custmer supprt line(s) n behalf f cntracted hspice client(s) Specify n vic recrding that the caller can leave a message abut the CAHPS Hspice Survey Dcument questins received and respnses prvided 26

27 Rles and Respnsibilities: Survey Vendrs (cnt d) Perfrm quality checks f all survey administratin prcesses and dcument the perfrmance f the quality check activities Perfrm checks f the decedents/caregivers lists and fllwup with hspices fr discrepancies/issues Cnfirm decedents/caregivers list has been received frm all cntracted hspices Cmpare cunt f ttal decedents minus n publicity cunt t number f decedent/caregiver cases submitted (these numbers shuld match) Review n publicity cunt fr reasnableness (shuld be infrequent) Review missing r inapprpriately assigned fields 27

28 Review f survey materials Only survey vendrs with cntracted hspice client(s) need t submit survey materials Due date f 11/01/2017 Oversight Activities English mail materials (questinnaires, cver letters and utging envelpes) English CATI screenshts (including skip pattern lgic) Review f Quality Assurance Plan (QAP) Fllws the QAP specificatins Due date f 12/13/2017 Submit via the CAHPS Hspice Survey Technical Assistance hspicecahpssurvey@hcqis.rg 28

29 Update: Survey Vendr Analysis f Data Cell sizes with less than 11 bservatins are n lnger prhibited Survey vendr scres are nt fficial CMS scres and shuld nly be used fr quality imprvement purpses Each page f the reprt prvided t hspices must cntain the fllwing statement: This reprt has been prduced by [Survey Vendr] and des nt represent fficial CAHPS Hspice Survey results. If hspices use survey vendr scres in any way, they must indicate that they are nt fficial CMS scres Any identifying respnses shuld nt be shared with direct care staff These results shuld be limited t management and/r quality imprvement persnnel 29

30 Each mnth, each hspice must submit t its cntracted survey vendr: Decedents/Caregivers List Decedents f all payer types are eligible Cunt f decedents served in the mnth This cunt includes requests fr n cntact ( n publicity ) cases Cunt f hspice ffices cvered under a single CCN This cunt is the number f administrative r practice ffices fr the CCN NOT individual facilities r settings in which hspice care is prvided (i.e., hmes, assisted living facilities, hspitals, hspice facilities, r hspice huses) Cunts f cases ineligible due t: Live discharges Requests fr n cntact n publicity (i.e., request directly and vluntarily at any time during their stay nt t be cntacted) 30

31 Cnfirming Accuracy f Hspice Sample Files Survey vendrs shuld cntact their hspice clients befre data cllectin begins if there are missing r incrrectly frmatted data in the file prvided by the hspice r if sample cunts d nt add-up If a hspice des nt submit a mnthly sample file t its survey vendr, the survey vendr must nt assume that there are zer survey-eligible decedents/caregivers fr the mnth Update: The hspice must cnfirm in writing that there are zer survey-eligible decedents/caregivers fr the mnth If zer survey-eligible decedents/caregivers is cnfirmed, survey vendrs shuld submit a Hspice Recrd t the CAHPS Hspice Survey Data Warehuse, including the sample size, the cunt f ineligibles due t n publicity and live discharge If there is nt cnfirmatin f zer survey-eligible decedents/caregivers, then a Hspice Recrd must nt be upladed. A Discrepancy Reprt fr this hspice must be submitted. 31

32 Sample File Layut New Element Data Element Length Value Labels and Use Required fr Data Submissin Caregiver Language 1 1 = English 2 = Spanish 3 = Chinese 4 = Russian 5 = Prtuguese 6 = Vietnamese 7 = Plish 8 = Krean M = Missing N Update: The Caregiver Language element has been added t aid in determining the apprpriate language in which t administer the CAHPS Hspice Survey 32

33 Survey vendrs must: Include recrds with missing r incmplete decedent r caregiver names, addresses and/r telephne numbers Include cases in the sample frame if the eligibility status is uncertain Exceptin: If any part (i.e., day, mnth r year) f the decedent s date f death is missing, the case must nt be included in the sample frame Calculate additinal cunts Sample Frame Creatin Ttal number f cases available t be sampled, thse actually drawn int the sample and thse determined t be ineligible preand pst-sample 33

34 Survey vendrs shuld: Cnfirm that all decedent/caregiver cases submitted by hspice were imprted int survey management database Generate reprts that trend cunts ver time (e.g., ttal decedents, n publicity, ineligible pre-sample, sample size, ineligible pstsample, etc.) Quality Assurance: Survey Sample Develp threshld fr variance and fllw-up with hspice regarding any utliers Review eligible and ineligible cases fr apprpriate classificatin Cnfirm that all hspices have been sampled and pushed t prductin fr the mnth Designate a secnd staff member t review sample fr accuracy Dcument all quality assurance checks cmpleted 34

35 Mail Only Mde Cver letter requirements Update: The text CMS pays fr mst f the hspice care in the U.S. It is CMS respnsibility t ensure that hspice patients and their family members and friends get high quality care. One f the ways CMS can fulfill this respnsibility is t find ut directly frm yu abut the hspice care yur family member r friend received. must be included n bth initial and fllw-up cver letters Cver letters must nt include: Dates (e.g., print date, mail date) Update: Any prmtinal r marketing text 35

36 OMB Paperwrk Reductin Act language must appear in the mailing In the future, OMB expiratin date may be required Watch fr updates n Questinnaire guidelines and frmatting requirements May incrprate either circle, val r square respnse ptins Dates are nt permitted t be included n the questinnaire (e.g., print date, mail date) Update: Language such as ne f the fllwing may be added t the bttm f the page: Mail Only Mde (cnt d) Cntinue n next page Cntinue n reverse side Turn ver t cntinue 36

37 Mail Only Mde (cnt d) Guidelines fr utging survey envelpes Update: CMS lg is nt permitted n utging survey envelpe Caregivers withut valid mailing addresses Survey vendrs must make every reasnable attempt t btain a caregiver s address including re-cntacting the hspice t inquire abut an address update fr caregivers with n/incmplete mailing address 37

38 Mail receipt Blank questinnaire If first survey mailing is returned with all missing respnses (i.e., n questins are answered) and n written cmments (such as Refused ), send a secnd survey mailing t the caregiver if the data cllectin time perid has nt expired Mail Only Mde (cnt d) If secnd survey mailing is returned with all missing respnses, then cde the Final Survey Status as 8 Nn-respnse: Refusal If the secnd mailing is nt returned, then cde the Final Survey Status as 9 Nn-respnse: Nn-respnse after Maximum Attempts 38

39 Data receipt and entry Key-entry r scanning allwed fr data capture Mail Only Mde (cnt d) Key-entered data are entered a secnd time by different staff and any discrepancies between the tw entries are identified; discrepancies shuld be recnciled Review all surveys that cntain blank respnses, stray marks and multiple respnses using the decisin rules Scanning sftware shuld be set t identify these items fr manual review Train data entry staff t crrectly use the decisin rules Prvide cpies f these decisin rules t staff Review key-entered r scanned data t cnfirm the crrect applicatin f these guidelines 39

40 Survey vendrs must: Cnduct seeded (embedded) mailings t designated hspice r survey vendr CAHPS Hspice Survey prject staff n a minimum f a quarterly basis Mail Only Mde (cnt d) Update: Keep a lg dcumenting the quality checks perfrmed n the seeded mailings 40

41 During mail prductin, survey vendrs must: Check quality f printed materials Smearing, fading, flded edges, and misalignment Check a sample f mailings fr inclusin f all materials Quality Assurance: Mail Review mail packets fr questinnaire, cver letter and BRE Check that entire sample has been printed fr each hspice client 41

42 Telephne Only Mde Prgramming telephne scripts All punctuatin fr the questin and answer categries must be prgrammed (e.g., cmmas, questin marks) Transitinal statements and all prbes must be prgrammed and read verbatim Default respnse ptins may nt be prgrammed Peridically review skip pattern lgic and internal dispsitin cdes fr accuracy Missing/Incrrect telephne numbers Survey vendrs must fllw-up with the hspice and attempt t update missing r incrrect telephne numbers 42

43 Telephne Only Mde (cnt d) Scheduling calls Update: If a call back is scheduled t cntact a caregiver at a specific time, then an attempt t reach the caregiver must be made at the scheduled time If n the fifth attempt the caregiver requests a call back, it is permissible t schedule an appintment and cnduct the interview n the sixth attempt Definitin f a telephne attempt Busy signal At the discretin f the survey vendr, a single telephne attempt can cnsist f three cnsecutive busy signals btained at apprximately 20-minute intervals 43

44 Telephne Only Mde (cnt d) Cnducting telephne attempts Survey vendrs must fllw state regulatins when mnitring and recrding telephne calls Interviewers must cnfirm the identity f the caregiver using the full name prir t disclsing any identifiable infrmatin Update: If the interviewer reaches a healthcare facility staff member, the interviewer must request t get in tuch with the sampled caregiver 44

45 During fielding perid, survey vendrs must: Mnitr and prvide versight f staff, subcntractrs and ther rganizatins, if applicable Telephne Only Mde (cnt d) At least 10 percent f the CAHPS Hspice Survey interviews, interviewer survey respnse cding, dispsitins, and attempts must be mnitred in all applicable languages All interviewers cnducting the CAHPS Hspice Survey must be mnitred 45

46 Interviewers shuld be prficient with the fllwing: FAQs fr guidance n respnding t questins Reading script verbatim, including intrductin Telephne Only Mde (cnt d) Script shuld be read frm the telephne screens Use f neutral acknwledgement wrds (e.g., thank yu, kay, I understand, etc.) is permitted Update: Adjust the pace f the interview t be cnducive t the needs f the caregiver End the survey by thanking the caregiver fr his r her time D nt add extra infrmatin such as Have a gd day r It was a pleasure talking t yu 46

47 Interviewers shuld be prficient with the fllwing (cnt d): Prbing Telephne Only Mde (cnt d) Repeat questin and answer categries, adjusting pace and enunciatin if necessary Interviewer shuld use phrases such as: Take a minute t think abut it S wuld yu say Which wuld yu say is clser t the answer? Never interpret answers fr caregivers Instead, ask s did yu mean Cde MISSING/DON T KNOW when caregiver cannt/des nt prvide cmplete answer after prbing 47

48 Quality Assurance: Telephne During telephne attempts, survey vendrs must: Update telephne infrmatin Check that entire sample has received telephne attempts fr each hspice client Review call attempts t cnfirm first attempt within first seven days f fielding perid and that all applicable cases receive five attempts Mnitr scheduled call backs t ensure attempt is made at requested time Mnitr interviewers fr accuracy Check that data are being captured crrectly 48

49 Mixed Mde Survey vendrs must keep track f the mde and attempt in which each survey was cmpleted (i.e., mail r telephne) Mailings returned as undeliverable where n updated address is available must be sent t the telephne prtin 49

50 Supplemental Questins Use apprpriate phrasing t transitin frm the CAHPS Hspice Survey t the supplemental questin(s) Avid questins that ask the caregiver t explain why he r she chse a specific respnse Hspices cannt use any cmments, even if they are annymus, as testimnials r fr marketing purpses 50

51 Questins? Prgram Updates Rles and Respnsibilities Sampling Prtcl Survey Administratin 51

52 File Specificatins Must use XML file frmat t submit survey data files May submit multiple XML files as lng as the final file submitted fr each CCN every quarter cntains all three mnths f data fr the CCN Only the mst recent accepted file cntaining each CCN will be retained N substitutins fr valid Data Element values are acceptable 52

53 File Specificatins (cnt d) Each XML file will cnsist f fur parts Vendr Recrd Cntains infrmatin n the date and number f submissins Applicable t every recrd in the XML file Must appear nce per file The year, mnth and day f submissin must crrespnd t the date the file is submitted 53

54 Hspice Recrd All hspices shuld have a Hspice Recrd fr every decedent mnth (three per quarter) File Specificatins (cnt d) Survey vendrs must submit mnthly Hspice Recrds fr all hspices, even thse with zer survey-eligible decedents/caregivers in a mnth Survey vendrs must cnfirm that a hspice has zer survey-eligible decedents/caregivers If n cnfirmatin f zer survey-eligible decedents/caregivers is received frm the hspice, a Discrepancy Reprt must be submitted and n Hspice Recrd shuld be submitted 54

55 File Specificatins (cnt d) Hspice Recrd (cnt d) The Available Sample field shuld equal the ttal number f decedents in the mnth, minus the number f n publicity decedents/caregivers, the number f decedents missing date f death, and the number f decedents/caregivers fund ineligible prir t sampling Available Sample = Ttal Decedents (N Publicity + Missing DOD + Ineligible Presample) The Sampled Cases field shuld equal the ttal number f decedents/caregivers drawn int the sample fr the mnth. Fr CCNs using census sampling, the Sampled Cases field shuld equal the Available Sample field. Sampled Cases = Available Sample Any cases nt drawn int the sample 55

56 File Specificatins (cnt d) Hspice Recrd (cnt d) In calculating the Sample Size field, the number f survey-eligible decedents/caregivers in the sample frame in the mnth must nt include decedents/caregivers wh are determined t be ineligible r excluded, either pre- r pst-sampling Sample Size = Sampled Cases (Any cases with an ineligible Survey Status cde (2, 3, 4, 5, 6, and/r 14)) 56

57 Example File Specificatins (cnt d) Hspice Recrd (cnt d) Calculating decedent/caregiver cunts Sample Type Live Discharges* Ttal Decedents N Publicity Missing Date f Death Ineligible Pre-sample Available Sample Sampled Cases Ineligible Pstsample A Census Sample Size B Census C D Simple Randm Sample Simple Randm Sample *Nte: Live Discharges are never included when calculating decedent cunt variables. 57

58 Decedent/Caregiver Administrative Recrd Cntains infrmatin n each sampled decedent/caregiver in the file (e.g., all cases included in the Sampled Cases cunt) File Specificatins (cnt d) Include the supplemental questin cunt Assign apprpriate cde (e.g., M Missing/Dn t Knw, 8888 ) fr all missing fields except Language Calculate Lag Time The end f the fielding perid (i.e., 42 calendar days after initial cntact) shuld be the date used t calculate a survey that is nt returned ( 9 Nn-respnse: Nn-respnse after Maximum Attempts ) 58

59 File Specificatins (cnt d) Example: Lag Time Calculatin Mail Mde f Survey Administratin Mail Only Decedent Date f Death March 16 Date f First Mail Attempt Date f Fllw-up Mail Attempt Date Data Cllectin Activities Ended fr this Decedent/Caregiver CAHPS Hspice Survey Final Survey Status Lag Time June 1 (77 days after death) June 22 (21 days after first mail attempt) July 13 (42 days after first mail attempt) Caregiver never returned the CAHPS Hspice Survey Cde as 9 Nn-respnse: Nn-respnse after Maximum Attempts The data cllectin prtcl f 42 days has been reached and the caregiver has nt returned the CAHPS Hspice Survey Calculated as 119 days (number f days between the patient s death [March 16] and the date data cllectin activities ended [July 13]) 59

60 File Specificatins (cnt d) Example: Lag Time Calculatin Telephne Mde f Survey Administratin Telephne Decedent Date f Death March 16 Date f First Call Attempt June 1 (77 days after death) Date Interview Cnducted June 14 (attempt 3) CAHPS Hspice Survey Final Survey Status Lag Time Cde as 1 Cmpleted Survey Calculated as 90 days (number f days between the patient s death [March 16] and the date interview was cnducted [June 14]) 60

61 File Specificatins (cnt d) Survey Results Recrd Survey vendrs MUST submit a Survey Results Recrd fr every decedent/caregiver wh has a final dispsitin f: 1 Cmpleted Survey, 6 Ineligible: Never Invlved in Decedent Care r 7 Nn-respnse: Break-ff Survey vendrs may mit survey data sectin fr all ther dispsitins Each field requires a valid value fr submissin May include M Missing/Dn t Knw and 88 Nt Applicable 61

62 File Specificatins (cnt d) Survey Results Recrd (cnt d) Caregivers may select mre than ne respnse categry in: Questin 2, In what lcatins did yur family member receive care frm this hspice? Please chse ne r mre. and Questin 43, What was yur family member s race? Please chse ne r mre. Fr bth Questins 2 and 43, enter all f the categries that the caregiver has selected Peridically review cding (in survey management system and scanning sftware, if applicable) f these tw questins, as the respnse categries are different frm the ther questins 62

63 Decisin Rules and Cding Decisin rules fr screener and dependent questins Dependent questins that are apprpriately skipped shuld be cded as 88 Nt Applicable Screener questins that are nt answered r left blank shuld be cded as M Missing Mail surveys Dependent questins shuld be cded as M Missing Update: Telephne surveys Dependent questins shuld be cded as M Missing/Dn t Knw D nt impute a respnse based n caregiver s answers t dependent questins 63

64 Survey Dispsitin Cdes 2 Ineligible: Deceased shuld be used when a cmment clearly indicates that the caregiver is deceased 6 Ineligible: Never Invlved in Decedent Care When the answer t Questin 3, While yur family member was in hspice care, hw ften did yu take part in r versee care fr him r her? is Never r When calling the husehld the sampled caregiver indicates that he/she was nt invlved in the patient s hspice care and n alternative caregiver resides in the husehld Cnfirm prir t data submissin that there are survey results fr all applicable cases assigned this cde 64

65 Survey Dispsitin Cdes (cnt d) Assigning missing r incmplete caregiver name dispsitin cdes Respndents with n caregiver name r an incmplete caregiver name are nt remved frm the sample frame Survey vendrs must first make every reasnable attempt t btain a caregiver s cmplete name including re-cntacting the hspice t inquire abut a name update fr decedents/caregivers with incmplete names 65

66 Survey Dispsitin Cdes (cnt d) Assigning missing r incmplete caregiver name dispsitin cdes (cnt d) If the caregiver name infrmatin is cmpletely missing after every reasnable attempt has been made t btain it, then: Decedent/Caregiver case is cnsidered Decedent has n caregiver f recrd and cded 3 Ineligible: Nt In Eligible Ppulatin If caregiver name infrmatin is partially missing after every reasnable attempt has been made t btain it, then: Update: Survey vendrs must nt administer the survey The decedent/caregiver case must be cded with Final Survey Status f 12 Nn-respnse: Incmplete Caregiver Name 66

67 Assigning missing r incmplete decedent name dispsitin cde Decedent/Caregiver cases with n decedent name r an incmplete decedent name 1) are nt remved frm the sample frame 2) must nt be administered the survey Survey vendrs must make every reasnable attempt t btain a decedent s full name, including re-cntacting the hspice t inquire abut an update Survey Dispsitin Cdes (cnt d) Assign a Final Survey Status cde f 13 Nn-respnse: Incmplete Decedent Name when there is evidence that the full decedent name is unavailable 67

68 Data Validatin Checks CAHPS Hspice Survey Data Crdinatin Team will audit data files as they are submitted fr cmpliance with file layut specificatins If the file des nt cmply t the naming cnventins r file frmat requirements, the file will nt be prcessed and will need t be resubmitted The data validatin prcess includes: Checks fr presence f required data fields Range and cding checks n all fields Verificatin f cding f survey dispsitin cdes Check fr authrizatin f survey vendr 68

69 Data Submissin Ntificatin After data auditing and validatin checks are cmplete, survey vendrs and hspices Data Administratrs will receive an ntificatin indicating CAHPS Hspice Survey Data Submissin Reprts are available fr viewing in their respective flders Fully crrected data file(s) must be submitted by 11:59 PM Eastern Time n the required submissin date Reprts will be psted by 5:00 PM Eastern Time n the next business day after submissin 69

70 Data Submissin Ntificatin (cnt d) If the file fails any edit checks, the Data Submissin Reprts will indicate the file has failed; survey vendrs must crrect and submit the data file again The Data Submissin Reprts will prvide a summary f file cntents Survey vendrs will need t review their CAHPS Hspice Survey Data Submissin Reprts t determine what errrs were fund in the file If the file passes checks: The Data Submissin Reprts will prvide a summary f file cntents Survey vendrs shuld review recrd cunts and values in the reprt Survey vendrs shuld review reprts t see the status f submissin Survey vendrs must retain cpies f Data Submissin Reprts fr a minimum f three year 70

71 Data Submissin Reprts Fur CAHPS Hspice Survey Data Submissin Reprts are accessible by hspices and survey vendrs Data Submissin Detail Reprt (Part I) Data Submissin Detail Reprt (Part II) Review and Crrectin Reprt Survey Status Summary Reprt Survey vendrs shuld review the values in the reprts against expected values 71

72 Data Submissin Reprts (cnt d) Data Submissin Detail Reprt (Part I) 72

73 Data Submissin Reprts (cnt d) Data Submissin Detail Reprt (Part II) Lk here was the file accepted r rejected? 73

74 Data Submissin Reprts (cnt d) Review and Crrectin Reprt 74

75 Data Submissin Reprts (cnt d) Survey Status Summary Reprt Hspice Recrd Accepted Decedent/ Caregiver Administrative -Level Recrds Valid Survey Status Cdes (1-15) Mnth f Death CCN Sample Size 01/ yes yes Mnth Ttal / n yes Mnth Ttal / yes yes Mnth Ttal FILE TOTAL Cmpleted Surveys 75

76 Discrepancy Reprt Required fr any discrepancy r variatin in fllwing standard prtcls during survey administratin Cmplete and submit nline reprt immediately upn discvery f issue at Prvide sufficient detail Unknwn is an acceptable value nly in the initial reprt Examples f Discrepancy Reprts include: Survey administratin utside f fielding perid (early r late) Eligible cases excluded r ineligible cases included in survey administratin Inaccurate cunts r inability t btain missing r crrect data frm hspice Include date(s) f cmmunicatin with hspice t btain this infrmatin 76

77 File Specificatins Data Submissin Questins? 77

78 Break 78

79 Additinal Data Quality Checks 79

80 Objectives Overview Create Traceable Data File Trail Review f Data Files Validate Change t Cde r Prcesses Verify Accuracy f Data Prcessing Activities Data Quality Checks Perfrm Additinal XML File Quality Checks 80

81 Overview Survey vendrs must implement quality assurance prcesses t verify the integrity f the cllected and submitted CAHPS Hspice Survey data Quality check activities must be perfrmed by a different staff member than the individual wh riginally perfrmed the specific prject task(s) D NOT rely n prgramming alne t cmplete tasks Have staff cmplete manual review f samples and XML files Must be peratinalized fr all f the key cmpnents r steps f survey administratin and data prcessing 81

82 Create Traceable Data File Trail Guidelines fr survey vendrs: Preserve a cpy f every file received in riginal frm and leave unchanged Recrd general summary infrmatin such as ttal number f decedent/caregiver cases, survey-eligible size, decedent mnth, etc. Institute versin cntrls fr datasets, reprts, sftware cde, and prgrams 82

83 Review f Data Files Survey vendrs shuld examine their wn data files and all clients data files fr any unusual r unexpected changes Investigate data fr ntable changes in the cunts f ttal decedents/caregivers and eligible decedents/caregivers Investigate data when cunts fr ttal decedents, n publicity and sample size d nt recncile Prir t preparing data files fr submissin t the Data Warehuse, run frequency/percentage tables fr all survey variables stred fr a given hspice and mnth Verify that required data elements fr all decedents/caregivers in the sample frame are submitted t the Data Warehuse Verify that data are assciated with the crrect CCN 83

84 Validate Changes t Cde r Prcesses Survey vendrs must have prcedures in place t review any changes t cde r prcessing steps Save riginal cde/dcuments fr reference Dcument changes thrughly (e.g., what, when, why, wh, hw) Have at least ne ther different team member verify the new cde Verify that n errrs r unintended changes have been made Cnduct cmparisn f ld and new data, reviewing even elements that were nt expected t change 84

85 Verify Accuracy f Data Prcessing Activities Survey vendrs shuld implement data quality checks t verify prtcls have been fllwed, including: Verify that every decedent/caregiver has equal chance f being sampled Evaluate frequency f break-ff surveys and/r unanswered questins, and investigate pssible causes Review CAHPS Hspice Survey Data Submissin Reprts t cnfirm data submissin activity (verify results are as expected) Review quarterly submissin results frm the Review and Crrectin Reprt t cnfirm a match with frequency tables cmpleted during previus quality check activities 85

86 Data Quality Checks Maintain mnthly and quarterly dcumentatin fr all hspices, including but nt limited t: Ttal cunts frm hspices, number f eligible and ineligible (pre- and pst-sample) cases, sample size, numbers f each Final Survey Status cde, and respnse rate Create frequency and distributin tables fr all decedent/caregiver administrative and survey respnse variables Cmpare cunts acrss mnths and quarters fr trends Investigate any unexpected variatins, unusual cunts r percentages 86

87 Data Quality Check Examples Hspice ID Sex Decedent Hispanic Decedent Race Caregiver Relatinship Primary Payer GHI 5% 3% 60% 80% 0% Fllw-up shuld ccur during and/r after Quarter t discuss missing values (emphasize decedent race and caregiver relatinship) Hspice ID Sex Decedent Hispanic Decedent Race Caregiver Relatinship Primary Payer GHI 4% 3% 5% 75% 0% Cntinue fllw-up t btain caregiver relatinship (submit Discrepancy Reprt[s] if hspice cntinues t nt prvide required infrmatin) 87

88 Data Quality Check Examples (cnt d) Hspice ID Questin 3 Never Questin 3 Smetimes Questin 3 Usually Questin 3 Always Questin 3 Missing ABC 80% 10% 0% 5% 5% Q3 Oversee r take part in care: Did the hspice send the decedents/caregivers list with caregiver mismatched infrmatin? Was there a data prcessing errr? 88

89 Data Quality Check Examples (cnt d) Hspice ID Questin 7 Never Questin 7 Smetimes Questin 7 Usually Questin 7 Always Questin 7 Missing JKL 65% 10% 12% 9% 4% Hspice ID Questin 7 Never Questin 7 Smetimes Questin 7 Usually Questin 7 Always Questin 7 Missing JKL 30% 5% 25% 34% 6% Q7 Help as sn as needed: Did the hspice implement a quality imprvement initiative? Des this change appear reasnable? 89

90 Perfrm Additinal XML File Quality Checks Prir t submitting XML files t the Data Warehuse, survey vendrs shuld minimally: Cnfirm Hspice Recrd fr each applicable mnth fr each hspice Verify crrect calculatin f sample size, ineligible pre- and pst-sample Check reasnability f cunts frm hspices and submissin f all elements such as NPI Review a subset f administrative data in XML file t the riginal decedents/caregivers list Validate survey vendr-assigned decedent/caregiver administrative fields, such as: Final Survey Status cdes, lag time and supplemental questin cunt Review survey respnse results against riginal returned survey r recrded interview/database Check skip pattern cding 90

91 Data Adjustment and Public Reprting 91

92 Objectives Overview Measures t be Reprted Data Adjustment Adjust fr Mde f Survey Administratin Adjust fr Case Mix 92

93 Overview Public reprting f CAHPS Hspice Survey data is anticipated t begin in early 2018 CMS will publish fficial CAHPS Hspice Survey scres n Hspice Cmpare: Dwnladable database cntaining de-identified CAHPS Hspice Survey results by CCN Results t be updated quarterly, reprting: Six cmpsites and tw glbal measures Tp-bx scres 93

94 Measures t be Reprted Cmpsite Measures Hspice Team Cmmunicatin (Q6, 8, 9, 10, 14, and 35) Getting Timely Care (Q5 and 7) Treating Family Member with Respect (Q11 and 12) Getting Emtinal and Religius Supprt (Q36, 37 and 38) Getting Help fr Symptms (Q16, 22, 25, and 27) Getting Hspice Care Training (Q18, 19, 20, 23, and 29) Glbal Measures Rating f Hspice (Q39) Willingness t Recmmend (Q40) 94

95 Data Adjustment Purpse Differences in hspice ratings shuld reflect differences in quality nly Adjustments permit valid cmparisn f all hspices Will adjust the results t level the playing field That is, adjust fr factrs nt directly related t hspice perfrmance 95

96 Adjust fr Mde Purpse Caregiver respnses are affected by mde f survey administratin (mail, telephne) Mde experiment cnducted in 2015 Summary dcument f mde experiment results and adjustments is available n CAHPS Hspice Survey Web site 96

97 Adjust fr Case Mix Purpse Certain decedent/caregiver characteristics affect hw smene might respnd t the survey Case-Mix Adjuster Variables Decedent age / Respndent age Payer fr hspice care Primary diagnsis Length f final episde f hspice care Respndent educatin Relatinship f decedent t caregiver Language Respnse percentile (calculated by ranking lag time) Adjustments updated quarterly and published n CAHPS Hspice Survey Web site ( /en/scring-and-analysis) 97

98 Presentatin f Research: Mde Experiment Results 98

99 2015 Mde Experiment Design 17,121 hspice deaths frm 57 hspice prgrams between February and June 2015 were sampled and fielded between May 1, 2015 and Octber 17, hspice prgrams were selected such that hspice characteristics including prfit status and gegraphic regin were balanced acrss the hspices Eligible decedents/caregivers were randmized within each hspice t ne f the 3 mdes in equal prprtin Single vendr 99

100 Overall Respnse Rate 44.7 Percent, Highest fr Mixed Mde Respnse Rate Telephne Only 38% Mail Only 43% Mixed Mde 53% 0% 10% 20% 30% 40% 50% 60% 100

101 Odds f Respnding Varied Odds were higher when the caregiver was the decedent s parent r spuse/partner (OR=2.63, p<0.001; OR=1.79 p<0.001; respectively, cmpared with decedent s child r step-child) Odds varied by the decedent s primary diagnsis 101

102 Mde Experiment Demnstrated Substantial Mde Effects Randmized mde experiment demnstrated: Substantial mde effects n respnse rates and respnse tendencies fr quality measures derived frm the CAHPS Hspice survey Lwer respnse rates by Telephne Only when cmpared t Mail Only and Mixed Mde Mre negative respnse tendencies when caregivers respnded by telephne Withut mde adjustments, these mde effects are large enugh t substantially bias cmparisns amng hspices that chse different mdes 102

103 Why Mre Negative by Telephne? Different frm previus studies that have shwn mre psitive evaluatins by telephne Auditry recency bias Scial desirability bias Hypthesis: Grief may be playing an imprtant rle in hw caregivers respnd Earlier cmpletin by telephne cmpared t mail Telephne may be felt as mre invasive and nt at a time f the caregiver s chsing 103

104 Questins? Additinal Data Quality Checks Data Adjustment and Public Reprting Mde Experiment Results 104

105 Wrap Up and Next Steps Upcming deadlines fr survey vendrs Samples f CAHPS Hspice Survey materials due by 11/01/2017 Quarter decedent data due by 11:59 PM Eastern Time 11/08/2017 CAHPS Hspice Survey Quality Assurance Plan due by 12/13/2017 CAHPS Hspice Survey Attestatin Statement due by 12/13/

106 Wrap Up and Next Steps (cnt d) Pst-training Survey Vendr Quiz Immediately upn cnclusin f training Accessible via Webinar fr 20 minutes Feedback n training Fllws pst-training quiz Accessible via Webinar fr 10 minutes Survey vendr ntificatin CMS fllw-up regarding survey vendr quiz by 10/04/

107 Cntact Us CAHPS Hspice Survey Infrmatin and Technical Assistance Web site: Telephne:

108 Quiz and Evaluatin 108