Roles & Responsibilities
logo
513-821-6266
  • Register for CAHPS Hospice

GETTING STARTED WITH THE CAHPS Hospice® SURVEY:

 

The following content clarifies the roles and responsibilities of participating organizations. 

Hospice Roles and Responsibilities

It is the responsibility of the Medicare-certified hospice to participate every month in the CAHPS Hospice® Survey.

If a hospice is eligible to participate, it must:

  • Contract with an approved CAHPS Hospice® Survey vendor to administer the survey on behalf of the hospice
  • Authorize the contracted survey vendor to collect and submit CAHPS Hospice® Survey data to the CAHPS Hospice® Survey Data Warehouse on the hospice’s behalf by submitting a CAHPS Hospice® Survey Vendor Authorization Form (refer to Appendix B) 90 days prior to the data submission deadline
    • Once an organization authorizes a survey vendor, it is not necessary to provide additional notification unless the organization chooses to de-authorize its survey vendor and switch to a different survey vendor

      Note: If an organization chooses to de-authorize its survey vendor and switch to a different survey vendor, it must contact the CAHPS Hospice® Survey Project Team immediately to begin the transition process (refer to Appendix B). This change in survey vendor can only take effect at the beginning of a calendar quarter, and the timing of receipt of the request may affect when the change may be made.
        
  • Complete and submit a CAHPS Hospice® Survey Data Warehouse Access Form for Vendors and Hospices (refer to Appendix C) 90 days prior to the data submission deadline  Work with their approved survey vendor to determine a date each month by when to provide their survey vendor with the monthly decedents/caregivers list
  • Compile and deliver a complete and accurate decedents/caregivers list to the survey vendor by the agreed-upon date each month with the caregiver information that will enable the survey vendor to administer the survey
  • Use a secure method to transmit decedents/caregivers lists to the survey vendor
  • Review data submission reports in the CAHPS Hospice® Survey Data Warehouse to ensure that the survey vendor has submitted data on time and without data problems
  • Preview CAHPS Hospice® Survey results prior to public reporting
  • Avoid influencing caregivers in any way about whether to or how to answer the CAHPS Hospice® Survey. For example, a hospice may not suggest that caregivers decline to be contacted for the survey or provide any information to caregivers about how to answer the survey.

    Note: If a hospice wants to let caregivers know that they may receive a survey and encourage them to complete it, the hospice must inform all caregivers.
     
  • Understand the hospice’s responsibilities regarding participation in the HQRP, including key date ranges and deadline dates

Some hospices may be exempt from participation for a given APU period. The scenarios under which a Medicare-certified hospice provider can be exempted from participation in the CAHPS Hospice® Survey are described below:

  • The Participation Exemption for Size process has been created to provide hospices meeting the size criteria a means to request consideration for this exemption. For the calendar year (CY) 2020 data collection period, Medicare-certified hospices that have served fewer than 50 survey-eligible decedents/caregivers in the period from January 1, 2019 through December 31, 2019 can apply for an exemption from CAHPS Hospice® Survey CY 2020 data collection and reporting requirements. To qualify for the survey exemption for CY 2020, hospices must submit a Participation Exemption for Size Form online via the Participation Exemption for Size page of the CAHPS Hospice® Survey Web site (www.hospicecahpssurvey.org). For the CY 2020 data collection period, this form must be submitted no later than December 31, 2020. The form must be completed in its entirety and must be submitted each year the hospice intends to be considered for the Participation Exemption for Size. Hospices are not eligible to receive the Participation Exemption for Size if they do not submit a Participation Exemption for Size Form for the year. Hospices that are eligible to apply for an exemption are encouraged to apply, even if they are participating in CAHPS Hospice® Survey data collection. Please see Appendix K for specific information to be submitted on the Participation Exemption for Size Form.
    • Hospices will need to include the total number of decedents for CY 2019, the total number of patients discharged alive and the number of decedents who fall into each ineligibility category (i.e., under the age of 18, died within 48 hours of admission to hospice care, no caregiver of record [a decedent for whom no caregiver is listed in the medical record or administrative data], caregiver is a non-familial legal guardian, caregiver has a foreign home address, and no publicity decedents/caregivers).

      Note: “No publicity” status is a rare and unusual request. “No publicity” decedents/caregivers are those who initiate or voluntarily request at any time during their hospice stay that the hospice: 1) not reveal the patient’s identity; and/or 2) not survey him or her.

      Note: For multiple hospice programs sharing one CMS Certification Number (CCN), the survey-eligible decedents/caregivers count is the total from all programs sharing that CCN.
       
  • The Participation Exemption for Newness is based on how recently the hospice received its CCN (formerly known as the Medicare Provider Number). The criterion for this exemption is that the hospice must have received its CCN on or after the first day of the performance year for the CAHPS Hospice® Survey. For example, a hospice must receive its CCN on or after January 1, 2020 to be eligible for the Participation Exemption for Newness for CY 2020. CMS will identify hospices eligible for this exemption. There is no form for hospices to submit.

    Note: The Participation Exemption for Newness is only applicable for the CY that the hospice is assigned its CCN. Hospices that become eligible to participate in the CAHPS Hospice® Survey should begin participating during January of the year after they become eligible. For example, if a hospice received its CCN any time in 2020, whether it is in January 2020 or December 2020, it is exempt from survey administration for the remainder of 2020. A hospice that receives its CCN any time in 2020 is required to start participating in the CAHPS Hospice® Survey beginning with January 2021 decedents.
     

 

Hospice Communication with Patients and/or Their Caregivers

The sections below are intended to provide survey vendors and hospices with guidance when conducting quality improvement activities in conjunction with the CAHPS Hospice® Survey.

Communicating with Patients and/or Their Caregivers about the CAHPS Hospice® Survey

CAHPS Hospice® Survey guidelines allow hospices to communicate about the CAHPS Hospice® Survey with patients and/or their caregivers prior to administration of the survey. For example, hospices may inform caregivers during the hospice admission process that they may receive the CAHPS Hospice® Survey. If a hospice wants to let caregivers know that they may receive a survey and encourage them to complete it, the hospice must inform all caregivers. Certain types of communications are not permitted because they may introduce bias in the survey results. For instance, hospices/survey vendors are not allowed to:

  • ask any CAHPS Hospice® Survey or CAHPS Hospice® Survey-like questions of caregivers prior to administration of the survey
  • attempt to influence or encourage caregivers to answer CAHPS Hospice® Survey questions in a particular way
  • imply that the hospice, its personnel or agents will be rewarded or gain benefits for positive feedback from caregivers by asking caregivers to choose certain responses, or indicate that the hospice is hoping for a given response, such as a “10,” “Definitely yes” or an “Always”
  • indicate that the hospice’s goal is for all caregivers to rate them as a “10,” “Definitely yes” or an “Always”
  • offer incentives of any kind for participation in the survey
  • invite or ask the caregiver if they want to participate in a survey or suggest they can “opt out” of the survey
  • show or provide the CAHPS Hospice® Survey or cover letters to caregivers while they are in the hospice or at any time prior to the administration of the survey
  • mail or distribute any pre-notification letters or postcards after patient death to inform caregivers about the CAHPS Hospice® Survey

    Note: Hospices may not contact caregivers directly regarding survey responses. 
     

Use of Other Hospice Surveys

In this section, CMS provides guidelines to employ when asking caregivers questions regarding their family members’ or friends’ hospice care. CMS’ intent is to minimize the burden on caregivers, prevent the introduction of bias to CAHPS Hospice® Survey responses and not decrease the likelihood that caregivers will complete the CAHPS Hospice® Survey.

In general, activities and encounters that are intended to provide or assess clinical care or promote patient/family well-being are permissible. However, activities and encounters that are primarily intended to influence how caregivers, or which caregivers, respond to CAHPS Hospice® Survey items must be avoided. If patients or their caregivers are asked questions during their hospice care, we suggest that such questions be worded in a neutral tone and not slanted toward a particular outcome. Questions must not resemble CAHPS Hospice® Survey items or their response categories. In addition, references to CMS must not be included on any surveys that are not the official CAHPS Hospice® Survey. Hospices should focus on overall quality of care rather than the measures reported to CMS.

Caregivers should not be given any formal, CAHPS Hospice® Survey-like, patient experience/satisfaction survey before they receive the official CAHPS Hospice® Survey. A formal survey, regardless of the mode employed, is one in which the primary goal is to ask standardized questions of a significant portion of a hospice’s patient/caregiver population.

  • When asking non-CAHPS Hospice® Survey questions, do not use CAHPS Hospice® Survey-like response categories (for instance, “Always,” “Usually,” “Sometimes,” or “Never”)
  • The following are examples of the types of questions that are not permissible:
    • “On a scale of 0 to 10, how would you rate your family member’s hospice care?”
    • “Is there a way we could always….?”
    • “Did the hospice team explain things in a way you could understand?”
    • “Overall, how would you rate the care you received from the hospice?”

Note: It is permissible for hospices to ask patients and/or their caregivers questions about their care during their hospice stay or during bereavement calls when this is a normal part of quality improvement activities, as long as the questions and/or response categories do not resemble the CAHPS Hospice® Survey.

The CAHPS Hospice® Survey should be administered prior to administering any other survey after the patient’s death. As noted above, it is permissible for patients and their caregivers to be asked questions during their hospice stay when the focus is on the clinical care of the individual patient. The hospice or its agents must not seek to influence which caregivers receive the CAHPS Hospice® Survey or how caregivers answer CAHPS Hospice® Survey items.

Other Communications with Patients and/or Their Caregivers

When communicating with patients and/or their caregivers while in hospice care regarding their healthcare, hospices should take care to avoid introducing bias in the way caregivers may answer questions on the CAHPS Hospice® Survey. Many of the guidelines above in the Communicating with Patients and/or Their Caregivers about the CAHPS Hospice® Survey and Use of Other Hospice Surveys apply to general communications with patients and/or their caregivers.

  • Examples of statements that comply with CAHPS Hospice® Survey protocols include:
    • “We are looking for ways to improve your family member’s stay. Please share your comments with us.”
    • “What can we do to improve your family member’s care?” 
    • “We want to hear from you, please share your experience with us.”
    • “Please let us know if you have any questions about your family member’s treatment plan.”
    • “Let us know if your family member’s room is not comfortable.”
  • Hospices should not:
    • permit staff to wear buttons, stickers, etc. that state “Always” or “10”
    • emphasize CAHPS Hospice® Survey response options in posters, white boards, rounding questions, in-room televisions, or other media accessible to patients and/or their caregivers. Examples of statements that do not comply with CAHPS Hospice® Survey protocols include:
      • “We expect to be the best hospice possible.”
      • “Our goal is to always address your needs.”
      • “Let us know if we are not listening carefully to you.”
      • “We treat our patients with dignity and respect.”
      • “In order to provide the best possible care, please tell us how we can always…”
      • “Our doctors and nurses always listen carefully to you.”
      • “We want to always explain things to you in a way you can understand.”
      • “We want you to recommend us to family and friends.”

 

CAHPS Hospice® Survey Hospice-specific Frequently Asked Questions (FAQs)

Does my hospice need to participate?

In general, all Medicare-certified hospices (identified by CMS Certification Number [CCN]) must participate in the CAHPS Hospice® Survey in order to receive their full Annual Payment Update (APU). However, certain exemptions are granted by CMS for size or newness.

Exemption for Size

  • If your hospice has served fewer than 50 survey-eligible decedents/caregivers during the “reference period” (see table below) you can apply for an exemption from the CAHPS Hospice® Survey
  • Exemptions on the basis of size are active for one year only. If your hospice remains eligible for this exemption in subsequent years, your organization will need to request this exemption on an annual basis.

Exemption for Newness

  • The exemption for newness is based on how recently the hospice received its CCN, also known as the Medicare Provider Number. The criterion for this exemption is that the hospice must have received its CCN on or after the first day of the performance year for the CAHPS Hospice® Survey.
    • For the calendar year (CY) 2020 data collection period, hospices who received their CCN on or after January 1, 2020 are eligible for a one-time exemption for newness. For example, if a hospice receives its CCN any time in 2020, whether it is in January 2020 or December 2020, it is exempt from survey administration for the remainder of 2020. A hospice that receives its CCN any time in 2020 is required to start participating in the CAHPS Hospice® Survey beginning with January 2021 decedents.
  • This is a one-time exemption for each hospice as identified by CCN
  • Hospices eligible for this exemption will be identified by CMS, as this exemption is based on when the hospice’s CCN is assigned. There is no form for hospices to submit.

Does my hospice need to have a contract with a survey vendor? 

  • If your hospice is exempt from participation because of size or newness, you will not need to contract with a survey vendor
  • If your hospice does not meet the exemptions for size or newness, then your hospice will need to select a survey vendor, negotiate a contract with the survey vendor, and authorize the survey vendor to collect and submit data on your hospice’s behalf. The approved survey vendor list is located under the left hand Approved Vendor List navigation button on the CAHPS Hospice® Survey Web site.

How does my organization authorize our survey vendor?

  • Your hospice needs to fill out the CAHPS Hospice® Survey Vendor Authorization Form which can be found on the Technical Specifications page of the CAHPS Hospice® Survey Web site. This form will authorize the survey vendor you have chosen to collect and submit data on your hospice’s behalf. This serves as your notification to CMS of the survey vendor with whom your hospice has contracted.
  • This form must be submitted to the RAND Corporation one calendar quarter (90 days) prior to the data submission deadline. If you have questions, contact the CAHPS Hospice® Survey Data Coordination Team via email at: This email address is being protected from spambots. You need JavaScript enabled to view it..

How does my organization submit a sample file to the survey vendor? 

  • Your hospice will work with its contracted survey vendor to determine a date each month to submit the monthly decedents/caregivers list and counts of cases ineligible due to live discharges and voluntary requests for no contact (“no publicity”)
  • There is specific information that the hospice will need to provide to its survey vendor. This information can be found in Appendix D of the CAHPS Hospice® Survey Quality Assurance Guidelines V6.0. This manual is available on the CAHPS Hospice® Survey Web site, under the left hand Quality Assurance Guidelines navigation button.

How is the “primary informal caregiver” identified?

  • The hospice is responsible for identifying the primary informal caregiver that may be eligible to receive and respond to the CAHPS Hospice® Survey. Please note, hospices should not necessarily prioritize a primary informal caregiver that is a family member over a friend, as one caregiver category does not automatically have preference over another. The CAHPS Hospice® Survey is designed to be administered to the person most knowledgeable about the care the decedent received at the hospice. Staff members or employees of the hospice or care setting in which the patient received care should not be considered primary informal caregivers.

How will my hospice access the CAHPS Hospice® Survey Data Warehouse?

  • Your hospice will need user accounts to access and review the data submitted by your survey vendor via the CAHPS Hospice® Survey Data Warehouse. This gives your hospice an opportunity to check the quality of the work of your survey vendor.
  • Your hospice will need to complete the CAHPS Hospice® Survey Data Warehouse Form, which is located on the Technical Specifications page of the CAHPS Hospice® Survey Web site. Your hospice will not be required to install any special software or pay a licensing fee to access the Data Warehouse.
  • It is important to designate two people from your hospice to have access to the CAHPS Hospice® Survey Data Warehouse in order to be able to review quarterly data submission reports. Make sure to notify the CAHPS Hospice® Survey Data Coordination Team of any staff changes by sending an updated CAHPS Hospice® Survey Data Warehouse Form to This email address is being protected from spambots. You need JavaScript enabled to view it..
  • The CAHPS Hospice® Survey Data Warehouse can be found online at: https://kiteworks.rand.org  
  • Your form must be received one calendar quarter (90 days) prior to the first time data will be submitted to the CAHPS Hospice® Survey Data Warehouse. If you have questions, contact the CAHPS Hospice® Survey Data Coordination Team via email at: This email address is being protected from spambots. You need JavaScript enabled to view it..

What reports are available to my hospice on the CAHPS Hospice® Survey Data Warehouse?

Below is a brief overview of what is presented in your hospice’s reports. These reports will be posted to your hospice’s data warehouse folder no later than 5:00 PM Eastern Time on the business day following an upload by your survey vendor. The four reports are:

  • Data Submission Detail Report (Part I): This report indicates whether or not the data submitted by your survey vendor was accepted and processed. If the uploaded file fails to meet the required standards, the file will not be processed and the remainder of the reports will not be generated. A corrected file will need to be resubmitted prior to the deadline.
  • Data Submission Detail Report (Part II): This report indicates if the submitted data passed data quality checks. If any values are out of range, “Data Value Checks Status” will show as “Rejected,” the report will list all of the errors in the file, and the survey vendor must submit a new file. If all data values pass the data quality checks, “Data Value Checks Status” will show as “Accepted,” and no further action is needed.
  • Survey Status Summary Report: This report lists whether a Hospice Record was accepted, the sample size, the number of decedent/caregiver administrative records, the number of valid survey status codes, and the number of completed surveys within the file. These are listed separately by month of death, and overall.
  • Review and Correction Report: This report lists the number of valid and invalid responses to each variable in the file.

When does the survey take place? 

Hospices are now required to participate in the CAHPS Hospice® Survey on an ongoing monthly basis.

  • Data collection for sampled decedents/caregivers must be initiated two months following the month of patient death
    • For example, if a patient dies in January 2020, a hospice may begin surveying that patient’s primary caregiver starting April 1, 2020
  • For more information on the survey administration timeline, refer to the left hand FAQs navigation button on the CAHPS Hospice® Survey Web site

Can our hospice discuss the CAHPS Hospice® Survey with decedents/caregivers?

  • If your hospice wants to let caregivers know that they may receive a survey and to encourage them to complete it, you must tell all caregivers. However, your hospice must not attempt to influence the caregivers to answer the CAHPS Hospice® Survey questions in any particular way.

Are there guidelines for conducting quality improvement activities in conjunction with the CAHPS Hospice® Survey?

It is permissible for patients and/or their caregivers to be asked questions about their care during their hospice stay or during bereavement calls where this is a normal part of quality improvement activities.

Activities and encounters that are intended to provide or assess clinical care or promote patient/family well-being are permissible. If patients or their caregivers are asked questions during their hospice care, we suggest that such questions be worded in a neutral tone and not slanted toward a particular outcome. In addition, questions must not resemble CAHPS Hospice® Survey items or their response categories. Hospices should focus on overall quality of care rather than the measures reported to CMS.

Caregivers should not be given any formal, CAHPS Hospice® Survey-like, patient experience/satisfaction survey during their family member’s hospice stay or after the death of the patient. A formal survey, regardless of the mode employed, is one in which the primary goal is to ask standardized questions of a significant portion of a hospice’s patient/caregiver population.

  • When asking non-CAHPS Hospice® Survey questions, do not use CAHPS Hospice® Survey-like response categories (for instance, “Always,” “Usually,” “Sometimes,” or “Never”)
  • The following are examples of the types of questions that are not permissible:
    • “On a scale of 0 to 10, how would you rate your family member’s hospice care?”
    • “Is there a way we could always….?”
    • “Did the hospice team explain things in a way you could understand?”
    • “Overall, how would you rate the care you received from the hospice?”

Activities and encounters that are primarily intended to influence how caregivers, or which caregivers, respond to CAHPS Hospice® Survey items must be avoided.

  

CANCELLATION POLICY

We do not believe in long contracts, which is why you are free to cancel at any time.  We simply ask that you visit the link below and review the cancellation instructions.

Cancellation Instructions