Current/Future Relationships with Hospices

The following types of organizations are not eligible to administer the CAHPS Hospice Survey (as an approved CAHPS Hospice Survey vendor):

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

Number of Years in Business

Minimum four years

Number of Years Conducting Patient-Specific Surveys

Minimum of three consecutive years Mail, and/or Telephone, and or Mixed Mode (mail followed by telephone) administering of complex, patient-specific health care surveys within the most recent three-year time period

Prior experience in conducting surveys in English (required) and Spanish (preferred)

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

Personnel

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

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

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

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)

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.

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

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

Mail Administration

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 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

Telephone Administration

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, 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 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

Mixed Mode Administration (Mail with Telephone Follow-up)

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

Data Submission

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

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

Survey vendors must have the 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’ contractor to resolve data problems and data submission issues

Data Security

Survey vendors must have the capacity to do the following actions to secure electronic data:

• 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

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, 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 destruction of data.

Technical Assistance/Customer Support

Two years prior experience providing telephone customer support

Provide toll-free customer support line:

• Offering customer support in all languages that the survey vendor administers the survey in
• Returning calls within 24-48 hours

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.

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 of survey, if applicable
• 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

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

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, 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

Survey Training

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)

Successfully complete the post-training quiz measuring comprehension of CAHPS Hospice Survey protocols

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)

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 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