CAHPS Hospice Survey Participation Form for Survey Vendors

The CAHPS Hospice Survey Participation Form for Survey Vendors is to be completed by survey vendors requesting consideration for approval to administer the CAHPS Hospice Survey. All required fields are indicated with an asterisk (*). The CAHPS Hospice Survey Participation Form for Survey Vendors is due by June 5, 2017. The CAHPS Hospice Survey Participation Form for Survey Vendors must be completed and submitted online on the CAHPS Hospice Survey Web site (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 operations) must also meet all of the CAHPS Hospice Survey Minimum Business Requirements that pertain to that role.

DATE SUBMITTED

4/20/2018

I. General Participation Information

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

1. APPLICANT
1a. SURVEY VENDOR NAME*
1b. MAILING ADDRESS 1*
1c. MAILING ADDRESS 2
1d. CITY*		1e. STATE*	1f. ZIP CODE*
1g. TELEPHONE AND FAX (area code, number and extension)			1h. WEBSITE
TEL*	EXT	FAX
2. SURVEY VENDOR CONTACT PERSON
2a. PRIMARY CONTACT PERSON
FIRST NAME*	MIDDLE INITIAL	LAST NAME*
2b. TITLE*		2c. DEGREE (e.g., RN, MD, PhD)
2d. TELEPHONE AND FAX (area code, number and extension)			2e. EMAIL ADDRESS*
TEL*	EXT	FAX
3. SELECT MODE OF SURVEY ADMINISTRATION REQUESTED (Check all that apply):*
Mail Only Telephone Only Mixed Mode (mail with telephone follow-up)

II. CAHPS Hospice Survey Minimum Business Requirements

1. Management Relationships
*Current/Future Relationships with Hospices: Survey vendor is not an: organization or division within an organization that owns or operates a hospice or provides 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
2. Relevant Survey Experience
*Number of Years in Business: Survey vendor has been in business a minimum of four years	Yes No
*Number of Years Conducting Surveys in the Requested Mode: Survey vendor has conducted surveys in the requested mode(s) of survey administration for a minimum of three years	Yes No
*Number of Years Conducting Patient-Specific Surveys: Survey vendor has conducted patient-specific surveys as an organization for a minimum of two years	Yes No
*Sampling Experience: Survey vendor has two years prior experience selecting a random sample based on specific eligibility criteria: 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
3. Organizational Survey Capacity
*Personnel: Survey vendor has designated CAHPS Hospice Survey personnel: Project Director with minimum two years prior experience conducting patient-specific surveys in the requested mode(s) Staff with minimum one year prior experience in sample frame development and sample selection 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 Call Center/Mail Center Supervisor (subcontractor designee, if applicable) with minimum one year prior experience in role	Yes No
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
*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 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
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 patient/primary informal caregiver (i.e., family member or friend of the hospice patient)	Yes No
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
All System Resources are subject to oversight activities, including site visits to physical locations	Yes No
*Sample Frame Creation: Survey vendor has two years prior experience selecting a random sample based on specific eligibility criteria: 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
*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. Survey vendor has the capability and capacity to: 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 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
*Telephone Only Mode of Survey Administration (if applicable): Telephone interviews are not to be conducted from a residence, nor from a virtual office. Survey vendor has the capability and capacity to: 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 screen shots 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 results of attempts to obtain a completed interview with each sampled record	Yes No Not Requested
*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. Survey vendor has the capability and capacity to: 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
*Data Submission: Survey vendors are responsible for conducting data submission and must not subcontract this process. Survey vendor has two years prior experience transmitting data via secure methods (HIPAA-compliant). Survey vendor has the capability and capacity to: 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
*Data Security: 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	Yes No
*Data Retention and Storage: Survey vendor has the capability and capacity to securely store all data related to survey administration taking the following actions: Store CAHPS Hospice Survey-related data files, including decedents/caregivers lists and de-identified electronic data files, 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.	Yes No
*Technical Assistance/Customer Support: Survey vendor has two years prior experience providing telephone customer support and capacity to provide a toll-free customer support line. Survey vendor has the capability and capacity to: Offer customer support in all languages that the survey vendor administers the survey in Return calls within 24-28 hours	Yes No
*Organizational Confidentiality Requirements: Survey vendor has the capability and capacity to: 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 Associates 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
4. Participation in Quality Control Activities and Documentation Requirements
*Demonstrated Quality Control Procedures: Survey vendor has incorporated 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 Telephone administration of survey Coding and verifying of survey data and survey-related materials 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
Survey vendor must 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, and file construction documentation	Yes No
*Documentation Requirements: Survey vendor has the capability and capacity to: 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, 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
*Survey Training: Survey vendor has the capability and capacity to: Attend the Introduction to CAHPS Hospice Survey Training session and all CAHPS Hospice Survey Update Training sessions (at a minimum, survey vendor’s Project Manager and subcontractors or other organizations involved in survey administration assigned key roles must attend training) Complete the post-training quiz measuring comprehension of CAHPS Hospice Survey protocols	Yes No
*Administer the Survey According to all Survey Specifications: Survey vendor has the capability and capacity to: 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
Fully comply with the CAHPS Hospice Survey oversight activities 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 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.	Yes No

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
*Survey	*Average Sample Size Per Data collection period	Data Collection Period (Start and End Dates – Month/Year*)	*Number of Contracted Clients	Mode of Survey Administration (Mixed-Mode, Mail Only, Telephone Only, etc.)*	*Language(s) in which Survey is Administered

IV. List of Key Project Staff

List of key project staff
Project Staff Name*	Role	Email*	Telephone*
	Project Director
	Project Manager
	Sampling Manager
	Programmer
	Call Center/Mail Center Supervisor

V. List of Subcontractors

Check here if you do not use subcontractors. Go to Section VI.

LIST OF SUBCONTRACTORS (include additional subcontractors as a separate attachment, if necessary). Note: Survey vendors should promptly update the List of Subcontractors as subcontractors are added or deleted.

Subcontractor 1 Name*	Role*
Subcontractor 2 Name*	Role*
Subcontractor 3 Name*	Role*
Subcontractor 4 Name*	Role*
Subcontractor 5 Name*	Role*

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 the Introduction to CAHPS Hospice Survey Training session and all CAHPS Hospice Survey Update Training sessions. At a minimum, the survey vendor’s Project Manager must attend training as a representative of the organization. The survey vendor’s subcontractors and any other organizations who are responsible for major functions of CAHPS Hospice Survey administration (e.g., mail/telephone operations) must also attend all CAHPS Hospice Survey Training sessions. It is strongly recommended that the Mail Survey Supervisor and Telephone Survey Supervisor attend the training as well.
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.

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 Web site

AUTHORIZED REPRESENTATIVE:

Name:*
Title:*
Organization:*
Date:

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CAHPS® Hospice Survey