In-Center Hemodialysis CAHPS SurveySurvey Administration and Specifications ManualVersion 4.0
February 2016
Communications and Technical Support for the In-Center Hemodialysis CAHPS Survey
In-center hemodialysis (ICH) facilities and survey vendors may use the following resources to obtain information or technical support with any aspect of the In-Center Hemodialysis CAHPS (ICH CAHPS) Survey.
For general information, important news, updates, and all materials to support implementation of the ICH CAHPS Survey:
https://ichcahps.org
For technical assistance, contact the ICH CAHPS Coordination Team as noted below.
By e-mail:[email protected]
By telephone:1-866-245-8083
By FAX transmission:1-919-541-7400
Please provide the ICH facilitys name and six-digit CMS Certification Number (CCN) when contacting the ICH CAHPS Coordination Team for technical assistance.
[This page intentionally left blank.]
Centers for Medicare & Medicaid Services
ICH CAHPS Survey Administration and Specifications ManualPage 7
Centers for Medicare & Medicaid Services
Page 6ICH CAHPS Survey Administration and Specifications Manual
Centers for Medicare & Medicaid Services
ICH CAHPS Survey Administration and Specifications ManualPage 5
List of Abbreviations and Acronyms
In-Center Hemodialysis CAHPS Survey Administration and Specifications Manual
Abbreviation/Acronym
Term/Phrase
AAPOR
American Association for Public Opinion Research
AHRQ
Agency for Healthcare Research and Quality
AV
Arteriovenous
CAHPS
Consumer Assessment of Healthcare Providers and Systems
CATI
Computer-assisted telephone interview
CCN
CMS Certification Number (formerly known as the Medicare Provider Number)
CMS
Centers for Medicare & Medicaid Services
CROWNWeb
Consolidated Renal Operations in a Web-Enabled Network
CY
Calendar year
DFC
Dialysis Facility Compare
DUA
Data Use Agreement
ESRD
End-stage renal disease
FAQs
Frequently Asked Questions
HIPAA
Health Insurance Portability and Accountability Act of 1996
ICH
In-center hemodialysis
ICH CAHPS
In-Center Hemodialysis CAHPS Survey
IRB
Institutional Review Board
NCOA
National Change of Address
NDA
Nondisclosure agreement
NIH
National Institutes of Health
OHRP
Office for Human Research Protections
OMB
Office of Management and Budget
PHI
Protected health information
PII
Personally identifiable information
QAP
Quality Assurance Plan
SID
Sample identification (number)
XML
Extensible Markup Language
[This page intentionally left blank.]
In-Center Hemodialysis CAHPS SurveySurvey Administration and Specifications ManualTable of contents
Communications and Technical Support for the In-Center Hemodialysis CAHPS Surveyi
List of Abbreviations and Acronymsiii
I. Overview of the Contents of the In-Center Hemodialysis CAHPS Survey Administration and Specifications Manual1
Overview1
Introduction and Overview (ChapterII)1
In-Center Hemodialysis CAHPS Survey Participation Requirements (ChapterIII)1
Sample Selection and Distribution (ChapterIV)1
Mail-Only Administration Procedures (ChapterV)2
Telephone-Only Administration Procedures (ChapterVI)2
Mail With Telephone Follow-Up (Mixed-Mode) Survey Administration Procedures (ChapterVII)2
Confidentiality and Data Security (ChapterVIII)2
Data Processing and Coding (ChapterIX)2
The ICH CAHPS Website (ChapterX)2
Data File Preparation and Data Submission (ChapterXl)2
Quality Control (ChapterXII)3
Oversight Activities (ChapterXIIl)3
Exceptions Request Process and Discrepancy Notification Report (ChapterXIV)3
Public Reporting (ChapterXV)3
Appendices3
Whats New or Different?3
II. Introduction and Overview7
The ICH CAHPS Survey7
The ICH CAHPS Survey Questionnaire8
The ICH CAHPS Mode Experiment9
ICH CAHPS Survey Public Reporting9
Sources of Information About the ICH CAHPS Survey9
The ICH CAHPS Survey Website (https://ichcahps.org/)9
The Medicare Website (http://www.medicare.gov)11
III. In-Center Hemodialysis CAHPS Survey Participation Requirements13
Overview13
Communications With Patients About the ICH CAHPS Survey13
Roles and Responsibilities14
ICH Facilities Roles and Responsibilities14
Survey Vendor Roles and Responsibilities17
Roles and Responsibilities of the CMS ICH CAHPS Coordination Team19
Survey Vendor Participation Requirements20
Survey Vendor Eligibility and Minimum Business Requirements21
Survey Vendor Eligibility22
Minimum Business Requirements22
Survey Vendor Analysis of ICH CAHPS Survey Data24
IV. Sample Selection and Distribution27
Overview27
Patient Survey Eligibility Criteria27
Sample Selection27
Sample Distribution29
Sample File Variables and Format31
Sample Identification Number33
V. Mail-Only Administration Procedures35
Overview35
Mail Survey Activities and Schedule35
Production of Letters, Envelopes, and Questionnaires36
Prenotification Letter37
Mail Survey Cover Letters (First and Second Questionnaire Mailings)38
ICH CAHPS Survey Questionnaire39
Adding Supplemental Questions to the ICH CAHPS Survey42
Definitions43
Mailing Survey Questionnaire Packages44
Mail Survey Envelopes44
Mailing Requirements44
Mailing Recommendations45
Data Receipt and Data Capture Requirements45
Data Receipt Requirements45
Optical Scanning Requirements46
Data Entry Requirements47
Staff Training48
Other Mail-Only Administration Protocols49
Conducting the ICH CAHPS Survey With Other ICH Facility Surveys50
VI. Telephone-Only Administration Procedures51
Overview51
Telephone-Only Survey Activities and Schedule51
Prenotification Letters52
Telephone Interview Development Process54
Telephone Interviewing Systems54
Telephone Interview Script55
Definitions55
Adding Supplemental Questions to the ICH CAHPS Survey57
Telephone Interviewing Requirements58
Telephone Contact58
Contacting Difficult-to-Reach Sample Patients60
Telephone Interviewer Training61
Distressed Respondent Procedures62
Telephone Data Processing Procedures63
Telephone Data Processing Requirements63
Conducting the ICH CAHPS Survey With Other ICH Facility Surveys64
VII. Mail with Telephone Follow-Up (Mixed-Mode) Survey Administration Procedures65
Overview65
Mixed-Mode Activities and Schedule65
Use of Other Languages in the Mixed-Mode Data Collection66
Production of Letters, Envelopes, and Questionnaires67
Prenotification Letters67
Mail Survey Cover Letters69
ICH CAHPS Survey Questionnaire70
Adding Supplemental Questions to the ICH CAHPS Survey73
Definitions74
Mailing Survey Questionnaire Packages75
Mail Survey Envelopes75
Mailing Requirements75
Mailing Recommendations76
Data Receipt and Data Capture Requirements76
Data Receipt Requirements76
Optical Scanning Requirements77
Data Entry Requirements78
Staff Training79
Other Mail Administration Protocols80
Telephone Interview Development Process80
Telephone Interviewing Systems81
Telephone Interview Script81
Adding Supplemental Questions to the ICH CAHPS Survey83
Telephone Interviewing Requirements84
Telephone Contact84
Contacting Difficult-to-Reach Sample Patients87
Telephone Interviewer Training88
Distressed Respondent Procedures88
Telephone Data Processing Procedures89
Telephone Data Processing Requirements89
Conducting the ICH CAHPS Survey With Other ICH Facility Surveys90
VIII. Confidentiality and Data Security91
Overview91
Assuring Sample Patients of Confidentiality91
Safeguarding Patient Data92
Confidential Data Must Be Kept Secure92
Limit Access to Confidential Data to Authorized Staff93
Patient Identifying Information Must Be Kept Confidential93
Develop Procedures for Identifying and Handling Breaches of Confidential Data93
Provide Only De-identified Data Files to the ICH CAHPS Survey Data Center93
Confidentiality Agreements94
Physical and Electronic Data Security94
IX. Data Coding and Processing95
Overview95
Data Processing Coding Guidelines and Decision Rules95
Skip Patterns95
Decision Rules for Coding Screening Questions (Qs. 1, 2, 20, 23, 37, 41, 42, and 60)96
Decision Rules for Coding Follow-up Questions (Qs. 21, 24, 38, 4244, 57a*, 58a*, 59a*, 59b*, 61, and 62).96
Decision Rules for Coding Open-Ended Questions (Qs. 57, 61, and 62)97
Decision Rules for Coding Survey Responses Marked Outside of the Response Box97
Survey Disposition Codes100
Differentiating Between Disposition Codes 130, 140, 160, and 190102
Differentiating Between Disposition Codes 230 (Nonresponse: Bad Address), 240 (Bad/No Telepho
