Hospitals/Survey vendors are responsible for the quality of work performed by any staff and subcontractor(s). Hospitals/Survey vendors should employ the following guidelines to ensure proper interviewer training, monitoring, and oversight regardless of whether they are using organizational staff or subcontractor(s) to perform this work.
Note: Hospitals/Survey vendors must retain a record of quality control activities and document such in the hospital’s/survey vendor’s Quality Assurance Plan. All materials relevant to survey administration are subject to review.
Interviewer Training
Consistent monitoring of interviewers’ work is essential to assure standardized and accurate results. Properly trained and supervised interviewers ensure that standardized, non-directive interviews are conducted. Interviewers conducting the telephone survey must be trained prior to interviewing. Training must ensure that interviewers are reading questions exactly as worded in the script, using non-directive probes, and are maintaining a neutral and professional relationship with the respondent.
If the hospital/survey vendor uses a subcontractor to conduct telephone interviewing, then the hospital/survey vendor is responsible for attending/participating in the subcontractor’s telephone interviewer training to ensure compliance with HCAHPS protocols and guidelines.
Telephone Monitoring and Oversight
Each hospital/survey vendor employing the mixed mode of survey administration must institute a telephone monitoring and evaluation program, during the telephone phase of the protocol. The monitoring and evaluation program must include, but is not limited to, the following oversight activities:
¾ Hospitals/Survey vendors must monitor at least 10 percent of all interviews through silent monitoring of interviewers using the electronic telephone interviewing system software or an alternative system.
¾ For hospitals using manual data collection, supervisors must observe at least 10 percent of all interviews where silent monitoring is not an option.
¾ Hospitals/Survey vendors utilizing a subcontractor must periodically conduct silent
monitoring of the quality of the subcontractor’s telephone interviews, provide feedback to subcontractor’s interviewers about their performance, and ensure that the subcontractor’s interviewers correct any areas that need improvement. Feedback must be provided to interviewers as soon as possible following a monitoring session.
• Staff who are found to be consistently unable to follow the script verbatim, employ proper probes, remain objective and courteous, be clearly understood, or operate the computer competently must be identified and retrained or, if necessary, replaced
A
CTIVEI
NTERACTIVEV
OICER
ESPONSE(IVR)
S
URVEYA
DMINISTRATIONOverview
This section describes guidelines for the Active Interactive Voice Response (IVR) mode of survey administration.
Data collection for sampled discharged patients must be initiated between 48 hours and six weeks (42 days) after discharge. Hospitals/Survey vendors must wait 48 hours to make the first attempt to contact discharged patients. This will allow enough time to pass for the patient to return home and feel settled after his or her hospital stay. A total of five IVR attempts must be made to contact non-respondents.
Note: If the hospital/survey vendor learns that a patient is ineligible for HCAHPS, the hospital/survey vendor must not make further attempts to contact that patient. After the sample
has been drawn, any patients who are found to be ineligible must not be removed or replaced in the sample. Instead, these patients are assigned a “Final Survey Status” code of ineligible. An administrative record must be submitted for these patients.
Data collection must be closed out for a sampled patient by six weeks (42 days) following the first IVR attempt. IVR attempts are to be made between the hours of 9 AM and 9 PM, respondent time. A live operator must be available to introduce the patient to the purpose of the call, get his or her permission for IVR survey administration, and orient the patient to the IVR system. Patients who respond to the HCAHPS survey must not be offered incentives of any kind. Patients who do not respond to the survey are assigned a “Final Survey Status” code of non- response.
Hospitals/Survey vendors must make every reasonable effort to ensure optimal survey response rates and to pursue contacts with potential respondents until the data collection protocol is completed.
No proxy respondents are permitted in the administration of the HCAHPS survey, not even for patients who are critically ill, elderly, physically or mentally impaired, do not speak the language the survey is being administered in (i.e., English), or are coming to the hospital from other institutions, such as nursing homes. As stated above, a proxy must not answer the survey questions for the respondent, however an individual may assist the patient by repeating the questions, but only the patient may provide answers to the survey.
The basic tasks and timing for conducting the HCAHPS survey using the IVR mode of survey administration are summarized below.
IVR Survey Administration
Initiate systematic IVR contact to sampled patient(s) between 48 hours and six weeks (42 days) after discharge.
Complete IVR sequence so that a total of five IVR calls are attempted at different times of day, on different days of the week, and in different weeks within six weeks (42 days) after initiation of the survey. The five IVR call attempts must span more than one week to account for patients who are temporarily unavailable.
IVR Survey Administration
Submit final data files to CMS via My QualityNet by the data submission deadline. No files will be accepted after the submission deadline date.
To reiterate, the first IVR attempt must occur between 48 hours and six weeks (42 days) after discharge. Data collection must then be completed no later than six weeks (42 days) after the initial IVR attempt. To illustrate, examples are provided of two patients who were discharged from a hospital on January 1 (not a leap year).
Patient 1:
¾ The first IVR attempt is made on January 4 (three days after discharge)
¾ Data collection must be closed out by February 15 for this patient (42 days from the January 4 initial contact date)
¾ If an IVR telephone interview is completed on February 15, which is the last day of survey administration for this patient, then the survey is included in the final survey data file and the Lag Time (See Data Specifications and Coding section) for this patient is calculated as 45 days
¾ If the survey was completed on the fifth and final IVR attempt, which was made later than February 15, or after the end of the survey administration time period for this patient, then the survey is not included in the final survey data file (however, and
administrative record is submitted for this patient) and a “Final Survey Status” code of “8 – Non-response: Non-response after maximum attempts” is assigned. Lag Time for this patient is entered as “888 – Not Applicable.”
Patient 2:
¾ The first IVR attempt is made on February 12 (42 days after discharge)
¾ Data collection must be closed out by March 26 for this patient , which is six weeks (42 days) from the February 12 initial contact date
¾ If an IVR telephone interview is completed on March 26, which is the last day of survey administration for this patient, then the survey is included in the final survey data file and the Lag Time for this patient is calculated as 84 days
¾ If the survey is completed on the fifth and final IVR attempt, which was made later than March 26, or after the end of the survey administration time period for this patient, then the survey is not included in the final survey data file (however, and administrative
record is submitted for this patient) and a “Final Survey Status” code of “8 – Non- response: Non-response after maximum attempts” is assigned. Lag Time for this patient is entered as “888 – Not Applicable.”
Hospitals/Survey vendors must make every reasonable effort to ensure optimal survey response rates, such as thoroughly familiarizing IVR operators with the study purpose, carefully supervising operators, retraining those operators having difficulty enlisting cooperation, and re- contacting reluctant respondents with different operators at different times until the data collection protocol is completed.