Participation Form

CAHPS Hospice Survey Participation Form for Survey Vendors

The CAHPS Hospice Survey Participation Form for Survey Vendors is to be completed by organizations requesting consideration for approval to administer the CAHPS Hospice Survey for the first time and current vendors who wish to apply for approval to administer the survey in additional modes. All required fields are indicated with an asterisk (*).

The CAHPS Hospice Survey Participation Form for Survey Vendors is due by May 29, 2024. The CAHPS Hospice Survey Participation Form for Survey Vendors must be completed and submitted online on the CAHPS Hospice Survey Website (www.hospicecahpssurvey.org).

Note: No organization, firm, or business that owns, operates, or provides staffing for a hospice is permitted to administer its own CAHPS Hospice Survey or administer the survey on behalf of any other hospice in the capacity as a CAHPS Hospice Survey vendor. Such organizations will not be approved by CMS as CAHPS Hospice Survey vendors.

An entity must be approved by CMS in order to administer the CAHPS Hospice Survey and submit CAHPS Hospice Survey data to the CAHPS Hospice Survey Data Warehouse. A survey vendor must meet ALL of the Survey Vendor Minimum Business Requirements at the time the CAHPS Hospice Survey Participation Form is received (a subcontractor's or other organization's survey administration experience does not substitute for a survey vendor's). In addition, subcontractors and any other organizations that are responsible for performing major CAHPS Hospice Survey administration functions (e.g., mail/telephone/web operations, XML file preparation) must also meet all of the CAHPS Hospice Survey Minimum Business Requirements that pertain to that role.

CAHPS® Hospice Survey Participation Form for Survey Vendors

This participation form is to be completed by survey vendors conducting the CAHPS® Hospice Survey.

Submission Date 05/11/2024

I. General Participation Information

General Participation Information

This section is to be completed with general information for participation in CAHPS Hospice Survey data collection.

1. Applicant Organization

1a.Organization Name * The Name of the Organization is required.

1b. Mailing Address 1 * The Address is required.

1c. Mailing Address 2

1d. City * The City is required.

1e. State * The State is required.

1f. Zip Code * The Zip Code is required.

1g. Telephone * Telephone is required.

1h. Fax Number Fax must at least 10 digits.

1i. Website

2. Applicant Primary Contact Person

2a. First Name * First Name is required.

2b. Middle Initial

2c. Last Name * Last Name is required.

2d. Title * Title is required.

2e. Degree (e.g. RN, MD, PhD)

2f. Telephone * Telephone is required.

2g. Fax Number Fax must at least 10 digits.

2h. Email Address * Email is required.

3. Type(s) of Mode of Survey Administration Requested (Check all that apply)

Mail Only

Telephone Only

Mixed Mode (mail with telephone follow-up)

Web/Mail

II. CAHPS® Hospice Survey Minimum Business Requirements

A survey vendor must meet ALL of the Survey Vendor Minimum Business Requirements at the time the CAHPS Hospice Survey Participation Form is received (a subcontractor’s or other organization’s survey administration experience does not substitute for a survey vendor’s). In addition, subcontractors and any other organizations that are responsible for performing major CAHPS Hospice Survey administration functions (e.g., mail/telephone/web operations, XML file preparation) must also meet all of the CAHPS Hospice Survey Minimum Business Requirements that pertain to that role. The minimum business requirements for an organization to become approved to administer the CAHPS Hospice Survey are as follows:

1. Management Relationships

*Current/Future Relationships with Hospices

Survey vendor is not an:

organization or division within organizations that owns or operates a hospice or provide hospice services, even if the division is run as a separate entity to the hospice;
organization that provides telehealth, monitoring of hospice patients, or teleprompting services for the hospice; and
organization that provides staffing to hospices for providing care to hospice patients, whether personal care aides or skilled services staff.

Yes No Answer Required.

2. Relevant Survey Experience

*Number of Years in Business

Minimum four years

Yes No Answer Required.

*Number of Years Conducting Patient-Specific Surveys

Survey vendor has conducted complex, patient-specific health care surveys as an organization for a minimum of three consecutive years in Mail, and/or Telephone, and/or Mixed Mode (mail followed by telephone) within the most recent three-year time period

Yes No Answer Required.

Survey vendor requesting Web/Mail Mode has a minimum of two consecutive years conducting patient-specific surveys via web, in the most recent two-year time period

Yes No Not Requested Answer Required.

Survey vendor has prior experience in conducting surveys in English

Yes No Answer Required.

Survey vendor has prior experience in conducting surveys in Spanish

Yes No Answer Required.

*Sampling Experience

Two years prior experience selecting a random sample based on specific eligibility criteria within the most recent two-year time period
Work with contracted client(s) to obtain patient data for sampling via Health Insurance Portability and Accountability Act - (HIPAA) compliant electronic data transfer processes
Adequately document sampling process
Survey vendors are responsible for conducting the sampling process and must not subcontract this activity

Yes No Answer Required.

3. Organizational Survey Capacity

*Personnel

Designated CAHPS Hospice Survey personnel:

Project Director with minimum two years prior experience conducting patient-specific surveys in the requested mode(s)

Yes No Answer Required.

For web/mail administration: Subject Matter Expert (SME) in web survey administration (subcontractor designee, if applicable) with a minimum of two years prior experience for web surveys

Yes No Not Requested Answer Required.

Staff with minimum one year prior experience in sample frame development and sample selection

Yes No Answer Required.

Programmer (subcontractor designee, if applicable) with minimum one year prior experience receiving large, encrypted data files in different formats/software packages electronically from an external organization; processing survey data needed for survey administration and survey response data; preparing data files for electronic submission; and submitting data files to an external organization

Yes No Answer Required.

For web/mail administration: Web Programmer (subcontractor designee, if applicable) with a minimum of one year prior experience programming, testing, and collecting data via web survey instruments

Yes No Not Requested Answer Required.

Call Center/Mail Center Supervisor (subcontractor designee, if applicable) with minimum one year prior experience in role

Yes No Answer Required.

Have appropriate organizational back-up staff for coverage of key staff

(Volunteers are not permitted to be involved in any aspect of the CAHPS Hospice Survey administration process)

Yes No Answer Required.

*Physical Plant and System Resources

Physical plant resources available to handle the volume of surveys being administered, including computer and technical equipment:

A secure commercial work environment
Home-based or virtual interviewers cannot be used to administer the CAHPS Hospice Survey, nor may they conduct any survey administration processes unless an Exception Request has been submitted and approved by CMS
Physical facilities and electronic equipment and software to collect, process and report data securely
If offering telephone surveys, must have the equipment, software and facilities to conduct computer-assisted telephone interviewing (CATI) and to monitor interviewers

Yes No Answer Required.

Electronic or alternative survey management system to:

Track fielded surveys throughout the protocol, avoiding respondent burden and losing respondents
Assign random, unique, de-identified identification number (Tracking ID) to track each sampled decedent/primary informal caregiver (i.e., family member or friend of the hospice patient)

Yes No Answer Required.

For web/mail administration: Computer software for implementing web survey instruments that are accessible in mobile and computer versions that are 508 compliant, present similarly on different browser applications, browser sizes and platforms (mobile, tablet, computer)

Yes No Not Requested Answer Required.

Organizations that are approved to administer the CAHPS Hospice Survey must conduct all of their business operations within the United States. This requirement applies to all staff and subcontractors or other organizations involved in survey administration.

Yes No Answer Required.

All System Resources are subject to oversight activities, including site visits to physical locations

Yes No Answer Required.

*Sample Frame Creation

A minimum of two years prior experience selecting a random sample based on specific eligibility criteria in the most recent two-year time period
Generate the sample frame data file that contains all individuals who meet the eligible population criteria
Draw random sample of individuals for the survey who meet the eligible population criteria

Yes No Answer Required.

*Mail Only Mode of Survey Administration (if applicable)

Mail survey administration activities are not to be conducted from a residence, nor from a virtual office unless an Exception Request has been submitted and approved by CMS
Obtain and update addresses of sampled caregivers of hospice decedents
Produce and print professional quality survey instruments and materials according to guidelines; a sample of all mailing materials must be submitted for review
Merge and print sample name and address on personalized mail prenotification letters, survey cover letters and print unique Tracking ID on the survey questionnaire
Mail out survey materials
Receive and process (key-enter or scan) completed questionnaires
Track and identify non-respondents for follow-up mailing
Assign final survey status codes to describe the final result of work on each sampled record

Yes No Not Requested Answer Required.

*Web-Mail Survey Administration (if applicable)

Web/mail survey administration is not to be conducted from a residence, nor from a virtual office unless an Exception Request has been submitted and approved by CMS
Obtain and update patient email addresses provided by client hospice(s)
Collect web survey data
Identify non-respondents for follow-up mail administration
Submit a sample of survey materials for review (as applicable):·
- Invitation and reminder emails
- Web survey screenshots that display what the respondent will see and will present similarly on different browser applications, browser sizes and platforms (mobile, tablet, computer) and a web survey testing link
- Hard copy letter(s) and questionnaire
Capacity to disseminate survey invitation emails that include an embedded hyperlink that the caregiver can click on to directly connect to the web survey
Adhere to all Mail Only survey administration requirements (described above)

Yes No Not Requested Answer Required.

*Telephone Only Mode of Survey Administration (if applicable)

Telephone interviews are not to be conducted from a residence, nor from a virtual office unless an Exception Request has been submitted and approved by CMS
Obtain and update addresses of sampled caregivers of hospice decedents
Produce and print prenotification letters; a sample of all mailing materials must be submitted for review
Mail out prenotification letters
Obtain, verify, and update telephone numbers
Develop CATI system
Collect telephone interview data for the survey using CATI system; a sample of the telephone script and interviewer screenshots in all languages must be submitted for review
Identify non-respondents for follow-up telephone calls
Schedule and conduct callbacks to non-respondents at varying times of the day and different days of the week
Assign final survey status codes to reflect the final result of attempts to obtain a completed interview with each sampled record

Yes No Not Requested Answer Required.

*Mixed Mode of Survey Administration (if applicable)

Mail survey administration and telephone interviews are not to be conducted from a residence, nor from a virtual office unless an Exception Request has been submitted and approved by CMS
Adhere to all Mail Only and Telephone Only survey administration requirements (described above)
Track cases from mail survey through telephone follow-up activities

Yes No Not Requested Answer Required.

*Data Submission

Survey vendors are responsible for conducting data submission and must not subcontract this process

Yes No Answer Required.

Two years prior experience transmitting data via secure methods (HIPAA-compliant)

Yes No Answer Required.

Survey vendor has the capability and capacity to do the following actions to submit quarterly data files:

Register as a user of the CAHPS Hospice Survey Data Warehouse
Confirm contracted hospices have authorized survey vendor to submit data on behalf of the hospice
Import scanned or key-entered data from completed mail surveys into a data file, if applicable
Import (as necessary) data from CATI system into a data file, if applicable
Develop data files and edit and clean data according to standard protocols
Follow all data cleaning and data submission rules, including verifying that data files are de-identified and contain no duplicate cases
Export data from the electronic data collection system to the required format for data submission, confirm that the data are exported correctly and that the data submission files are formatted correctly and contain the correct data headers and data records
Encrypt and submit data electronically in the specified format to the CAHPS Hospice Survey Data Warehouse
Work with CMS’ contractors to resolve data problems and data submission issues

Yes No Answer Required.

For web/mail administration: Import data from web survey system into a data file, if applicable

Yes No Not Requested Answer Required.

*Data Security

For web/mail administration: Administer web surveys with a secure hyperlink that is unique to each sampled caregiver, the data transmitted over a secure connection over HTTPS using transport layer security (TLS), and respondent information must be securely stored, if applicable

Yes No Not Requested Answer Required.

Survey vendor has the capability and capacity to secure electronic data taking the following actions:

Use a firewall and/or other mechanisms for preventing unauthorized access to electronic files
Implement access levels and security passwords so that only authorized users have access to sensitive data
Implement daily data back-up procedures that adequately safeguard system data
Test back-up files on a quarterly basis, at a minimum, to make sure the files are easily retrievable and working
Perform frequent saves to media to minimize data losses in the event of power interruption
Develop procedures for identifying and handling breaches of confidential data
Develop a disaster recovery plan for conducting ongoing business operations in the event of a disaster

Yes No Answer Required.

*Data Retention and Storage

Survey vendors must have the capacity to do the following actions to securely store all data related to survey administration:

Store CAHPS Hospice Survey-related data files, including decedents/caregivers lists and de-identified electronic data files (e.g., sample frame, survey responses, XML files, etc.), for all applicable survey modes for a minimum of three years. Archived electronic data files must be easily retrievable.
Store de-identified returned mail questionnaires in a secure and environmentally safe location (e.g., locked file cabinet, locked closet or room), if applicable. Paper copies or optically scanned images of the questionnaires must be retained for a minimum of three years and be easily retrievable.
Destroy CAHPS Hospice Survey related data files, including paper copies or scanned images of the questionnaires and electronic data files in a secure and environmentally safe location. Obtain a certificate of the destruction of data.

Yes No Answer Required.

*Technical Assistance / Customer Support

Two years prior experience providing telephone customer support
Provide toll-free customer support line:

Accommodate inquiries that are submitted by phone and/or email, if applicable
Offering customer support in all languages that the survey vendor administers the survey in
Returning calls/emails within 24-48 hours

Conduct accurate monitoring of the customer support line and customer support email inbox, if applicable, in all languages in which the survey is administered to ensure accurate responses are provided

Yes No Answer Required.

*Organizational Confidentiality Requirements

Survey vendors must have the capacity to do all of the following actions:

Develop confidentiality agreements which include language related to HIPAA regulations and the protection of personal identifying information (PII) and obtain signatures from all personnel with access to survey information, including staff and all subcontractors or other organizations involved in survey administration and data collection. Confidentiality agreements must be reviewed and re-signed periodically, at the discretion of the survey vendor, but not to exceed more than a three-year period.
Execute Business Associate Agreement(s) (BAA) in accordance with HIPAA regulations
Confirm that staff and subcontractors or other organizations involved in survey administration are compliant with HIPAA regulations in regard to decedent/caregiver protected health information (PHI) and PII
Establish protocols for secure file transmission. Emailing of PHI or PII via unsecure email is prohibited.

Yes No Answer Required.

4. Participation in Quality Control Activities and Documentation Requirements

*Demonstrated Quality Control Procedures

Incorporate well-documented quality control procedures (as applicable) for:

Training of in-house staff and subcontractors or other organizations involved in survey operations
Printing, mailing, and recording receipt of survey questionnaires, if applicable
Telephone administration and monitoring of survey (electronic telephone interviewing system) in all languages in which the survey is administered, if applicable
Overseeing transition between initial mode and follow-up mode (e.g., Mail-Phone, Web-Mail)
Coding and verifying of survey data and survey-related materials
Monitoring the performance of all subcontractor(s)/partner(s) or other organization(s) performing major CAHPS Hospice Survey administration functions
Web administration of survey, if applicable
Scanning or keying-in survey data
Preparation of final person-level data files for submission
Submitting Discrepancy Reports immediately upon discovering a discrepancy in following CAHPS Hospice Survey protocols
All other functions and processes that affect the administration of the CAHPS Hospice Survey

Yes No Answer Required.

Participate in any conference calls and site visits as part of overall quality monitoring activities:

Provide documentation as requested for site visits and conference calls, including but not limited to: staff training records, telephone interviewer monitoring records, web administration monitoring records, and file construction documentation

Yes No Answer Required.

*Documentation Requirements

Keep electronic or hard copy files of staff training and training dates
Maintain electronic documentation of telephone monitoring, if applicable
Maintain documentation of mail production quality checks
Maintain documentation of email and web administration quality checks, if applicable
Maintain documentation of all survey administration activities and related quality checks for review during site visits
Develop a Quality Assurance Plan (QAP) for survey administration in accordance with CAHPS Hospice Survey Quality Assurance Guidelines and update the QAP at the time of process and/or key personnel changes as part of retaining participation status

Yes No Answer Required.

*Survey Training

Attend all CAHPS Hospice Survey Training sessions (at a minimum, survey vendor’s Project Manager, SME in web survey administration (if applicable), Mail Survey Supervisor, and Telephone Survey Supervisor (if applicable), and subcontractors or other organizations involved in survey administration assigned key roles must attend training)
Successfully complete the post-training quiz measuring comprehension of CAHPS Hospice Survey protocols

Yes No Answer Required.

*Administer the Survey According to all Survey Specifications

Review and follow all procedures described in the CAHPS Hospice Survey Quality Assurance Guidelines that are applicable to the selected survey data collection mode(s)

Yes No Answer Required.

Fully comply with the CAHPS Hospice Survey oversight activities

Yes No Answer Required.

*Approved survey vendors are expected to maintain active contract(s) for CAHPS Hospice Survey administration with client hospice(s). An “active contract” is one in which the CAHPS Hospice Survey vendor is authorized by hospice client(s) to collect and submit CAHPS Hospice Survey data to the CAHPS Hospice Survey Data Warehouse.

If a CAHPS Hospice Survey vendor does not have any contracted hospice clients within two years (a consecutive 24 months) of the date they received approval to administer the CAHPS Hospice Survey, then that survey vendor’s “Approved” status for CAHPS Hospice Survey administration will be withdrawn
If approval status is withdrawn, the organization must once again follow the steps to apply for reconsideration for approval to administer the CAHPS Hospice Survey
- If a survey vendor chooses not to re-apply at this time, then a 24-month wait period will be required before the organization is eligible to apply again
- If a CAHPS Hospice Survey vendor is approved for a second term and does not have any contracted hospice clients by the end of the second 24-month approved period, a 24-month wait period will be required before the organization is eligible to apply again

Yes No Answer Required.

III. CMS - Sponsored and CAHPS® Survey Experience

*Have you been approved as a survey vendor to implement other CMS or CAHPS® Surveys in the past five years? If Yes, please provide the name of the survey(s) for which you have been approved as a survey vendor.

Yes No Answer Required.

Name of Survey * Name of Survey is required.

Average Sample Size Per Data Collection Period * Average Sample Size is required. Not a valid number.

Hours * Minutes * Seconds * Data Collection Period Start Date (Month/Year) * Data Collection Start Period is required.

Data Collection Period End Date (Month/Year) * Data Collection End Period is required.

Number of Contracted Clients * Number of Contracted Clients is required. Not a valid number.

Language(s) in which Survey is Administered * Language(s) is required.

Type(s) of Mode of Survey Administration *

Mail Only

Web/Mail

Telephone Only

Mixed Mode

At least one Survey Mode is Required.

Add

Edit

Cancel

At least one contracted hospital is required.

(click on a row in the grid to edit it)

IV. List of Key Project Staff

Name

Role

Phone

Project Director is required.

Project Director

A valid Email is required.

Telephone is required.

Project Manager

A valid Email is required.

Telephone is required.

SME in Web Survey Administration is required.

SME in Web Survey Administration

A valid Email is required.

Telephone is required.

Sampling Manager

A valid Email is required.

Telephone is required.

Programmer

A valid Email is required.

Telephone is required.

Web Programmer is required.

Web Programmer

A valid Email is required.

Telephone is required.

Mail Center Supervisor is required.

Mail Center Supervisor

A valid Email is required.

Telephone is required.

Call Center Supervisor is required.

Call Center Supervisor

A valid Email is required.

Telephone is required.

V. List of Subcontractors

Do you currently use subcontractors?

Yes No Answer Required.

LIST OF SUBCONTRACTORS AND ANY OTHER ORGANIZATION(S) that are responsible for major functions of CAHPS Survey administration.

Survey Vendors should promptly update the List of Subcontractors as subcontractors are added or deleted.

Subcontractor Name * Name of Subcontractor is required.

Role * Role is required.

Add

Please add all additional subcontractors before submitting the form.

Edit

Cancel

At least one subcontractor is required.

(click on a row in the grid to edit it)

VI. Rules of Participation

Any survey vendor participating in the CAHPS Hospice Survey must adhere to the following Rules of Participation. To be eligible, the organization must:

Participate in all CAHPS Hospice Survey Training sessions. At a minimum, the survey vendor’s Project Manager, SME in web survey administration, Mail Survey Supervisor, and Telephone Survey Supervisor must attend training as representatives of the organization. The survey vendor’s subcontractor(s) who are responsible for major functions of CAHPS Hospice Survey administration (e.g., mail/telephone/web operations) must also attend all CAHPS Hospice Survey Training sessions.
Review and follow all procedures described in the most current version of the CAHPS Hospice Survey Quality Assurance Guidelines manual that are applicable to the selected survey data collection mode(s).
Train employees to be compliant with HIPAA regulations.
Execute BAAs in accordance with HIPAA regulations.
Complete an attestation document annually.
Develop CAHPS Hospice Survey QAP.
Participate and cooperate (including subcontractors and any other organizations) in all oversight activities conducted by the CAHPS Hospice Survey Project Team.
Become a registered user of the CAHPS Hospice Survey Data Warehouse.
Approved survey vendors are expected to maintain active contract(s) for CAHPS Hospice Survey administration with client hospice(s). If a CAHPS Hospice Survey vendor does not have any contracted hospice clients for the CAHPS Hospice Survey within two years (a consecutive 24 months) of the date it received approval to administer the survey, then that survey vendor’s “Approved” status for CAHPS Hospice Survey administration will be withdrawn.

VII. Applicant Organization Qualification and Acceptance

I agree to comply with the CAHPS Hospice Survey Quality Assurance Guidelines, as well as following all policy updates posted on the CAHPS Hospice Survey Website.

AUTHORIZED REPRESENTATIVE

Name * The Representative's Name is required.

Title * The Representative's Title is required.

Organization * The Representative's Organization is required.

Date 05/11/2024

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