Fields Healthcare Research is an Approved Primary Care First Vendor
PCF-PECS Sampling Rules
| Providers in Practice Site | Patients CMS will Sample | Target Number of Completed Surveys |
| 1 | 296 | 105 |
| 2 | 350 | 124 |
| 3 | 450 | 159 |
| 4–9 | 500 | 177 |
| 10–13 | 550 | 195 |
| 14–19 | 650 | 230 |
| 20 or more | 800 | 264 |
Practice Site Roles and Responsibilities
As stated in the PCF Practice site Onboarding materials, each performance year practice sites must contract with a CMS-approved PCF PECS vendor to administer the annual PCF PECS. Practice sites can find the list of approved survey vendors on PCF Connect and on the PCF PECS web portal. Practice sites are responsible for the costs of the survey administration.
In order for CMS to know which vendor should receive the sample and submit data for which practice site, it is necessary to have this relationship carefully documented. This documentation is done through vendor authorization.
Practice sites are required to follow the below steps for vendor authorization:
In order for CMS to know which vendor should receive the sample and submit data for which practice site, it is necessary to have this relationship carefully documented. This documentation is done through vendor authorization.
Practice sites are required to follow the below steps for vendor authorization:
- Register on the PCF PECS web portal. Practice sites will first need to register on the website and obtain their username and password. This will require designating one of their staff members as the PCF PECS Administrator. He or she will serve as the practice site’s main point of contact for the PCF PECS. If desired, it can be the same person serving as the practice site’s POC on the roster submission or on PCF in general. Also, this person can serve as the PCF PECS Survey Administrator for multiple practices if they wish to do so. This PCF PECS web portal affords the PCF PECS Survey Administrator the convenience of performing the necessary practice functions—such as Survey Vendor Authorization and Business Associate Agreement upload at one time for all practice sites for which they are responsible.
- Authorize vendor. The most key role of this point of contact is related to the vendor authorization process. Practice sites need to authorize a CMS-approved approved PCF PECS survey vendor. This is done by completing the survey vendor authorization tool on the PCF PECS web portal. Practice sites choose a survey vendor and the start date when they authorize that vendor to conduct the survey and submit data on their behalf.There is no authorization end date; CMS will assume that this Authorization Form reflects the wishes of the practice site. If a practice wants to change vendors, they must indicate a new vendor and new start date for that vendor. CMS will not select and provide a patient sample for the practice site unless the vendor authorization form is completed.
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Update authorization if needed. Once an authorization is submitted, it remains valid unless the practice site changes it. The practice site will need to do so if it switches vendors, withdraws from PCF, splits off from its practice to form another practice, or merges with another practice.
Below are instructions for updating the Vendor Authorization in those circumstances:
- Switch to a different vendor. If a practice site decides to switch vendors, they should edit Survey Vendor Authorization associated with the old vendor by selecting the new vendor’s name and entering the date this new vendor is authorized to collect and submit data for the practice site. Please note that CMS does not recommend switching survey vendors once data collection has begun. Practices who switch vendors during data collection will have a truncated data collection timeline compared to other practices in the PCF Model. A new vendor may not be able to meet established PECS deadlines with a truncated date collection timeline and the practice risks a 0 PECS score, failing the Quality Gateway, and negative implications to Performance-Based Adjustment (PBA) for the Performance Year. CMS recommends practices make all vendor selections before sample is released or after survey vendors have submitted data.
- Withdrawals. If a practice site withdraws from PCF, they should contact PCF Support for guidance regarding the timing of their PEC Survey requirement and the Quality Gateway, pursuant to the timing of their withdrawal. If the PEC Survey is required, the practice site must have an active and up-to-date survey vendor authorization and contract with a vendor to conduct the PCF PECS.
- Practice site splitting into two PCF practice sites. If a practice site splits and forms two PCF practice sites prior to the roster submission deadline, these practice sites are considered unique as far as the PCF PECS is concerned, and each practice site needs a Survey Vendor Authorization (in addition to a PECS roster that is submitted to CMS). If the split and formation occur after the roster submission deadline, the practice sites are considered a single practice site as far as the PCF PECS is concerned and must have only a single Survey Vendor Authorization and single PECS roster.
- Practice site mergers. If two or more practice sites merge prior to the roster submission deadline, one practice site is designated a receiving practice site and the other practice site (or sites) are designated as withdrawing sites. The withdrawing practice site(s) need(s) to end any formerly active Survey Vendor Authorizations and survey vendor contractual arrangements if needed. Going forward, only the receiving practice site should submit a single PECS roster to CMS and a Survey Vendor Authorization. If the merge takes place after the roster submission deadline, all practice sites continue to be treated as unique as far as PCF PECS is concerned and PECS rosters and Survey Vendor Authorization are required for each practice site.
Note: Practice sites should follow standard PCF protocol for notifying PCF Support of merges, splits or withdrawals. Practice sites do not need to notify pcfpecs@rti.org.
- Review Data Submission Summary. Practice sites should also review the Data Submission Summary on the dashboard to ensure that the survey vendor has submitted data on time and without data problems.
Note: A practice point of contact can update the Survey Vendor Authorization on behalf of multiple practices linked to the PCF PECS Survey Administrator (the linked practices are established in the Registration step).
Each year, practice sites must submit the all-patient roster of patients for the PCF PECS. This is submitted to PCF Support via the PCF Portal. CMS will communicate detailed roster-related instructions and schedules via First Edition and PCF Connect.
Practice sites should never submit their all-patient roster to their survey vendor.
Practice sites should never submit their all-patient roster to their survey vendor.
Patients residing in residential care facilities or assisted living facilities are eligible for PCF and therefore eligible for the PCF PECS. However, experience from the predecessor project, CPC+, teaches us that reaching these patients by mail and telephone for a survey is challenging and these challenges hamper patient response rates. Staff at these patients’ care facilities can experience significant burden from the telephone-follow-up survey. CMS has developed an evidence-based protocol to mitigate these barriers when surveying these patients, which is described below.
Practice sites must communicate to their vendor the names and addresses of residential care facilities and assisted living facilities where patients in their practice site reside. It is preferable if all such facilities can be identified, but at a minimum the practice site must identify all such facilities where 5 or more of their patients reside. To identify facilities, the practice site may scan through their patient’s addresses or may do a geographical search of nearby residential care/assisted living facilities
The vendor will be responsible for identifying these patients residing at these facilities if they are sampled. The vendor will treat these patients differently in the survey. They receive a special envelope which is designed to catch the attention of facility staff and solicit proxy respondents. They also do not receive telephone follow-up due to the burden this causes facility staff.
Practice sites must communicate to their vendor the names and addresses of residential care facilities and assisted living facilities where patients in their practice site reside. It is preferable if all such facilities can be identified, but at a minimum the practice site must identify all such facilities where 5 or more of their patients reside. To identify facilities, the practice site may scan through their patient’s addresses or may do a geographical search of nearby residential care/assisted living facilities
The vendor will be responsible for identifying these patients residing at these facilities if they are sampled. The vendor will treat these patients differently in the survey. They receive a special envelope which is designed to catch the attention of facility staff and solicit proxy respondents. They also do not receive telephone follow-up due to the burden this causes facility staff.
Practice sites should be well-informed about the survey, communicate their support of it, and answer patient questions about the survey with confidence. These are key tools for attaining good response rates.
Note: All patient-facing survey materials refer to the survey as the Patient Experience of Care Survey and do not mention Primary Care First. Explaining the program and the practice site’s participation is an unnecessary distraction for most patients.
Practice sites must adhere to the following specifications:
Note: All patient-facing survey materials refer to the survey as the Patient Experience of Care Survey and do not mention Primary Care First. Explaining the program and the practice site’s participation is an unnecessary distraction for most patients.
Practice sites must adhere to the following specifications:
- Hang the poster. A CMS-developed poster will be provided to practices. Practice sites must download the poster and hang at least one poster in a well-visible area of their practice site beginning 6 months before the survey’s first mailout.
- Print Waiting Room FAQs. CMS-developed Waiting Room FAQs will be given (in electronic format) to all vendors and posted on PCF Connect. Practice sites must print these and keep them in their waiting rooms beginning 6 months before the survey begins. They can be removed after the survey ends.
- Become familiar with Waiting Room FAQs. It is common for patients who are contacted by the survey to seek assurance from their providers that the survey is legitimate. Therefore, practice site staff should be aware of the survey basics so they can respond to questions with confidence.
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Respond to patient questions and comments about the survey. If a patient talks to practice staff about the survey, practice staff should adhere to the following rules regarding statements for patients.
The following are appropriate:- Answering any question according to the response given in the Waiting Room FAQs.
- Telling patients that they may be asked to participate in the Patient Experience of Care survey from your practice site.
- Telling patients that the survey is legitimate.
- Telling patients that their response, while voluntary, is valued and paid attention to.
- Most importantly, express your support of the survey with statements such as, “We are supportive of the survey and want to hear feedback from our patients” or “We think the survey is important.”
Appropriate answers with respect to assuring patients of confidentiality:- This survey is public health research. HIPAA allows the release of patient contact information for the purpose of public health research.
- This practice site has no way of knowing who responded to the survey. Patients’ answers on the survey, whether negative or positive, are valued.
- Their survey responses will never be reported with their name or other identifying information.
- All respondents’ survey responses will be reported in aggregate.
- They can skip or refuse to answer any question they do not feel comfortable with.
- Their participation in the study will not affect their care at this practice site or Medicare benefits that they currently receive or expect to receive in the future.
Practice sites must take care not to influence patients’ answers on the survey. Therefore, practice site staff may not do any of the following:- Provide a copy of the PCF PECS questionnaire or survey materials to their patients.
- Attempt to determine which patients were sampled. Vendors are strictly prohibited from sharing this information with practice sites both before and after the survey administration.
- Ask their patients if they would like to be included in the survey.
- Tell patients that the practice site or provider hopes or expects their patients will give them the best or highest rating.
- Imply that the practice site, its personnel or its agents will be rewarded or gain benefits for positive feedback.
- Offer incentives of any kind to patients for participating (or not) in the PCF PECS.
- Include any messages or materials promoting the practice site in PCF PECS materials, including mail survey cover letters, questionnaires, and telephone interview scripts.
- Use the PCF PECS to identify or ask about other patients who are looking for a primary care practice site
- Translate the survey into the patient’s language. (A translation provided by the patient’s family member or friend is appropriate.)
Some practice sites may wish to conduct other patient experience of care or satisfaction surveys to support internal quality improvement activities. A formal survey, regardless of the data collection mode employed, is one in which the primary goal is to ask standardized questions of the practice site’s patient population. In contrast, contacting patients to assess their care at any time or calling a patient to check on services received are both considered to be routine patient contacts, not surveys.
To avoid imposing on patients, CMS strongly encourages practice sites to refrain from conducting other patient surveys from 4 weeks prior to and during the period when the PCF PECS is actively surveying. CMS-sponsored surveys are exempt from this guidance.
In addition, CMS strongly encourages practice sites to refrain from conducting census surveys. Census surveys ensure that some respondents are surveyed at least twice and will increase survey burden on respondents, thereby lowering response rates on PCF PECS as well as on the practice site’s other survey(s).
When conducting other surveys, practice sites must follow these rules:
Other surveys can include questions that ask for more in-depth information as long as the questions are different from those included in the PCF PECS.
To avoid imposing on patients, CMS strongly encourages practice sites to refrain from conducting other patient surveys from 4 weeks prior to and during the period when the PCF PECS is actively surveying. CMS-sponsored surveys are exempt from this guidance.
In addition, CMS strongly encourages practice sites to refrain from conducting census surveys. Census surveys ensure that some respondents are surveyed at least twice and will increase survey burden on respondents, thereby lowering response rates on PCF PECS as well as on the practice site’s other survey(s).
When conducting other surveys, practice sites must follow these rules:
- Do not ask patients any additional survey questions that are the same as or similar to those included in the PCF PECS questionnaire. (This guidance does not apply to other CMS-sponsored surveys).
Other surveys can include questions that ask for more in-depth information as long as the questions are different from those included in the PCF PECS.
HIPAA allows practices to release patient contact information to their agents for the purpose of public health research.
Survey vendors will be acting as agents of PCF practices. When a vendor is a Business Associate of a practice site, vendors inherit all of a practice’s HIPAA requirements with regard to data use and safeguarding. Therefore, each practice site must execute a BAA with their survey vendor. More information about Business Associates can be found here: https://www.hhs.gov/hipaa/for-professionals/privacy/guidance/business-associates/index.html. An example BAA can be downloaded from here: https://www.hhs.gov/hipaa/for-professionals/covered-entities/sample-business-associate-agreement-provisions/index.html.
Survey vendors will be acting as agents of PCF practices. When a vendor is a Business Associate of a practice site, vendors inherit all of a practice’s HIPAA requirements with regard to data use and safeguarding. Therefore, each practice site must execute a BAA with their survey vendor. More information about Business Associates can be found here: https://www.hhs.gov/hipaa/for-professionals/privacy/guidance/business-associates/index.html. An example BAA can be downloaded from here: https://www.hhs.gov/hipaa/for-professionals/covered-entities/sample-business-associate-agreement-provisions/index.html.
CMS Roles and Responsibilities
CMS (through its contractor, RTI International) will provide Introduction to the PCF PECS Training, via webinar. Successful completion of training and passing training certification are necessary steps in attaining status as a Fully Approved vendor.
The stages of vendor approval on PCF PECS are as follows:
CMS will also provide PCF PECS Update Training, via webinar, on an annual basis.
The stages of vendor approval on PCF PECS are as follows:
- Conditional approval. In January 2022, CMS will invite vendors who are on the approved list of other CAHPS mixed-mode surveys as of December 1, 2020 to submit an application to PCF PECS. All vendors whose PCF PECS applications have been received by CMS (through their contractor RTI) on or before February 1, 2022 and have been found to be satisfactory will receive Conditional Approval.
- Full approval. Vendors will receive Full Approval upon completion of two steps. First, survey vendors must successfully complete the Introduction to PCF PECS training and pass the training certification. Second, a vendor must submit a Quality Assurance Plan (QAP) for review by CMS (through their contractor RTI). Once the QAP has been deemed satisfactory, vendors will receive Full Approval.
CMS will also provide PCF PECS Update Training, via webinar, on an annual basis.
CMS (through its contractor, RTI International) will provide all survey administration materials and instructions. All updates will be provided promptly on the PCF PECS web portal. This web portal—to which all vendors will receive credentials—is the main communication channel through which vendors will access materials, updates, schedules, and transact files with CMS. Although CMS will send email notifications to survey vendors alerting them to updates, CMS recommends survey vendors accustom themselves to regularly checking the PCF PECS web portal for updates.
Additionally, on an annual basis, CMS will publish (1) an updated version of these Quality Assurance Guidelines comprehensive of any mid-year changes, and (2) a description of changes from the prior version. CMS will publish this document before the annual PCF PECS Update Training.
Throughout PCF PECS, CMS will also:
Additionally, on an annual basis, CMS will publish (1) an updated version of these Quality Assurance Guidelines comprehensive of any mid-year changes, and (2) a description of changes from the prior version. CMS will publish this document before the annual PCF PECS Update Training.
Throughout PCF PECS, CMS will also:
- provide technical assistance to survey vendors via a toll-free telephone number, emails, and the PCF PECS web portal and,
- conduct oversight and quality assurance of survey vendors
PCF outreach and onboarding materials communicated to practice sites that they are required to contract with a CMS-approved survey vendor to conduct the PCF PECS. CMS supports practices in their requirement by assembling and maintaining an up-to-date list of PCF PECS vendors who have Full Approval. CMS is also responsible for making this list available to practice sites at least 120 days in advance of when PCF practice sites must begin conducting PECS, which is in May of each year. CMS will refresh the list annually in approximately May, and more frequently to account for any changes in vendor status. CMS will publicize this list, together with vendor contact information, on the communication portal specific to PCF practice sites and partners. The list will also be posted on the PCF PECS web portal.
With respect to CMS’ maintenance of the list of Approved Vendors, please note the following reasons a vendor could lose their approval status and be removed from the list:
Vendors without clients: Conditionally Approved and Fully Approved Vendors that
Vendor withdrawals: Any PCF PECS vendor, regardless of status, who wishes to be removed from the list should contact pcfpecs@rti.org with this request.
CMS may also revoke vendors approval if they do not maintain their minimum business requirements, if appropriate members of their staff and subcontractors do not attend required training sessions, and if they do not submit an up-to-date QAP annually.
With respect to CMS’ maintenance of the list of Approved Vendors, please note the following reasons a vendor could lose their approval status and be removed from the list:
Vendors without clients: Conditionally Approved and Fully Approved Vendors that
- have never had any PCF practice site clients after 2 years from the date approval as a PCF PECS vendor was granted, OR
- that have not had any clients for two years since submitting data for a PCF practice site
Vendor withdrawals: Any PCF PECS vendor, regardless of status, who wishes to be removed from the list should contact pcfpecs@rti.org with this request.
- If they have no active practice sites CMS will remove them from the list of approved vendors as soon as their request is received.
- If they have active practice sites CMS expects them to finish data collection activities of the current survey period for each client, process the data collected, and submit an XML data file for each practice site to CMS. RTI will continue to consider them an active vendor until the data submission period for the current performance year ends. As such, they will continue to receive emails sent to all survey vendors, and are expected to check the website on a regular basis to review new posted announcements. This vendor’s access to the private links on the website will remain in effect until after the data submission period deadline for the performance year ends. Consistent with the vendor’s desire to no longer participate as a vendor in PCF PECS, the vendor must inform their client practice site(s) of their decision in a timely manner so the client(s) can select and contract with another vendor for the upcoming performance years. CMS will remove withdrawing vendors from the list when the list is next updated.
CMS may also revoke vendors approval if they do not maintain their minimum business requirements, if appropriate members of their staff and subcontractors do not attend required training sessions, and if they do not submit an up-to-date QAP annually.
CMS will select the sample for each practice site. To do so, there is an annual requirement that practice sites submit to CMS a patient roster. After receiving rosters, CMS is responsible for quality control, deduplication, confirming patient eligibility, and selecting the sample for each practice site.
The sample file for each PCF practice site will be available for download via a secure link on the PCF PECS web portal. The sample file will be available for download to only the practice site’s authorized vendor. When vendors are authorized for multiple practice sites, CMS will combine the appropriate practices’ samples in a single file for survey vendor download.
The sample file for each PCF practice site will be available for download via a secure link on the PCF PECS web portal. The sample file will be available for download to only the practice site’s authorized vendor. When vendors are authorized for multiple practice sites, CMS will combine the appropriate practices’ samples in a single file for survey vendor download.
CMS will review all survey data submitted by vendors to identify discrepancies between data and status codes and locate inconsistent data. Vendors may be consulted to explain, resolve, or repair problems.
CMS will calculate summary scores as the average of the 5 domain-specific measures and apply case-mix adjustments.
After scoring is complete, CMS will prepare and disseminate to each practice site a personalized score report showing their results on all questions, compared to results of practice sites overall on PCF. This score report will include raw data as well as risk-adjusted, final performance scores, in a user-friendly format. This report will be disseminated via the PCF PECS web portal in the Spring after each survey.
CMS will calculate summary scores as the average of the 5 domain-specific measures and apply case-mix adjustments.
After scoring is complete, CMS will prepare and disseminate to each practice site a personalized score report showing their results on all questions, compared to results of practice sites overall on PCF. This score report will include raw data as well as risk-adjusted, final performance scores, in a user-friendly format. This report will be disseminated via the PCF PECS web portal in the Spring after each survey.
Vendor Roles and Responsibilities
Survey vendors seeking approval as a PCF PECS vendor must have the capability and capacity to collect and process all survey-related data on the PCF PECS following standardized procedures and guidelines. Survey vendors must adhere to all minimum business requirements throughout PCF PECS, or their approval status may be revoked by CMS.
- Potential survey vendors will first need to register on the PCF PECS web portal, which is done by completing the Vendor Registration Form. This allows vendors to obtain their username and password.
- Potential survey vendors must then designate a staff member as the PCF PEC Survey Administrator who will serve as the vendor’s main point of contact for the PCF PECS.
- Potential survey vendors will then complete and submit the Vendor Application which is available on the PCF PECS web portal. The submission deadline will be announced on the web portal and disseminated via email to all registered vendors.
After their applications have been reviewed by CMS, potential vendors will receive notification informing them if their application is acceptable. Vendors with acceptable applications receive Conditional Approval and may proceed with training and the balance of the steps to receive Full Approval.
Each year there will be a period when potential survey vendors not currently approved for PCF PECS but who meet the minimum business requirements are invited to apply. Approved survey vendors do not re-apply unless they lose their approved status.
- Survey vendors must enter into a formal contract with each client PCF practice site; CMS requires that each survey vendor have a written contract with each of its facility clients.
- CMS will verify that each client PCF practice site has authorized the vendor to submit data on the practice site’s behalf.
- When practice sites merge with another practice site, split off from a practice site, or withdraw from PCF it impacts survey vendors. CMS learns about these practice-site driven changes through regular PCF communication channels, and will endeavor to notify the impacted survey vendors. Should survey vendors hear of such changes, CMS requests that survey vendors send email notification to pcfpecs@rti.org as well.
- Practice sites are required to update their Survey Vendor Authorization to account for switches to different survey vendors, mergers, splits and withdrawals. Vendors are responsible for understanding the details of those practice-facing requirements.
- CMS provides survey vendors a convenient report, the Vendor Authorization Status Report, which can be used to confirm that all of a vendor’s PCF practice site clients have completed or updated their Vendor Authorization forms. Survey vendors should check their Vendor Authorization Status Report weekly in the weeks leading up to the deadline for vendor authorization to make sure that all of their PCF practice site clients, especially any new or ending clients, have completed or updated the online Vendor Authorization Form. When reviewing the Vendor Authorization Status Report, please make sure all the practice site IDs, practice site names and practice site addresses match your written contract with the practice site, and ensure that the Vendor Authorization “authorization through” date encompasses upcoming current survey administration. The Vendor Authorization Status Report is available on the Vendor Dashboard.
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When coordinating with practice sites, pay very close attention to Practice site Address because PCF defines a practice site as a physical location where care is delivered. CMS will ensure that every practice site who joins PCF has a unique address and receives a unique Practice site ID.
- It is common for multiple practice sites who share a system affiliation to join a model like PCF as a group. Their practice site names may be very similar to each other or even indistinguishable from one another, and often their physicians work in multiple locations. In some systems or physician groups, the only differentiating feature is the address.
- From a client relations perspective, vendors may find it convenient to consolidate all contact with one person for all affiliated practice sites in a system or group. When doing so, vendors must bear in mind that each practice site address makes it a unique practice site, and therefore, Practice site ID. Practice site ID will carry through all aspects of the survey, starting from the practice site’s roster to its sample which the vendor downloads, to the vendor’s conduct of the survey, to the vendor’s submission of survey results, and CMS’ scoring of the practice site.
Training dates and registration deadlines will be announced on the PCF PECS web portal and disseminated via email to all registered vendors. The first performance year of a survey vendor’s participation in PCF, the survey vendor must, participate in and successfully complete the Introduction to the PCF PECS Webinar training session. Participating in training includes:
After the survey vendor’s first year of participation in PCF PECS, survey vendors will need to attend a PCF PECS Update Training Webinar training session. Attending the full Introduction to the PCF PECS Webinar training session is not required unless the survey vendor has a new staff person serving as their Survey Administrator who has not previously attended Introduction to the PCF PECS Webinar training. Failure to attend any required training—either Introduction to the PCF PECS, or PCF PECS Update Training—may lead to CMS’ revocation of the vendor’s approval status.
- The survey vendor’s designated PCF PECS Survey Administrator must also complete a Training Certification Form after participating in the Introduction to the PCF PECS Webinar training session.
- If the survey vendor is using a subcontractor and the subcontractor will be conducting a substantial component of the work on the PCF PECS, the subcontractor’s lead PCF PECS staff member must participate in the Introduction to the PCF PECS Webinar training session and all vendor update training sessions.
- Ensure that all survey vendor staff and any subcontractors who work on the PCF PECS are trained and follow the standard PCF PECS protocols and guidelines.
- If update or refresher trainings are required, the survey vendor’s designated PCF PECS Survey Administrator must also attend those and complete their Training Certification Forms.
After the survey vendor’s first year of participation in PCF PECS, survey vendors will need to attend a PCF PECS Update Training Webinar training session. Attending the full Introduction to the PCF PECS Webinar training session is not required unless the survey vendor has a new staff person serving as their Survey Administrator who has not previously attended Introduction to the PCF PECS Webinar training. Failure to attend any required training—either Introduction to the PCF PECS, or PCF PECS Update Training—may lead to CMS’ revocation of the vendor’s approval status.
CMS requires PCF practice sites to execute a Business Associate Agreement (BAA) with their contracted survey vendor.
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Survey vendors must sign the Business Associate Agreements of each client practice site. The BAA permits survey vendors access to PII, in sample files and any other practice files they receive. Survey vendors must ensure that:
- Contacts on the BAA are correct and that all contact information is accurate.
- Current BAAs are extended before their expiration date as needed.
- Submit a BAA Addendum for each subcontractor that views patient-level data (e.g., name, address, telephone number).
- Survey vendors (and their subcontractors with PII access) must use systems, processes, and procedures to safeguard and protect the security of PCF PECS data.
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Note that the only electronic transactions containing personally identifiable (PII) data shall be encrypted and be for the purpose of:
- Obtaining the practice site’s sample file from RTI
- Printing the survey mailing materials
- Conducting the telephone non-response follow-up
- Survey vendors (and their subcontractors with PII access) may not share information that could identify sample patients and their survey response data with anyone. The sample file cannot be shared with practice sites, even after the survey is complete.
- Survey vendors’ QAPs will need to include information regarding how data containing PII or protected health information (PHI) are transferred within the survey vendor’s organization and between the survey vendor and any subcontractors.
- Survey vendors (and their subcontractors with PII access) must have a disaster recovery plan in place.
- Survey vendors will access a personalized link to the PCF PECS web portal.
- Survey vendors must complete the attestation form at link and receive sample files to conduct the survey for client PCF practice sites.
- Survey vendors must administer the PCF PECS in accordance with the protocols specified and oversee the quality of work performed by staff and any subcontractors, if applicable.
- Survey vendors must prepare and submit data files to CMS (through their contractor, RTI) following the guidelines specified.
- Survey vendors must review all data submission reports for PCF PECS clients to ensure that data have been successfully uploaded and received by CMS.
- Survey vendors must follow guidelines when preparing reports for client practice sites.
- In submitting their QAP, survey vendors must attest to the accuracy of their organization’s data collection processes and that data collection processes conform to the requirements outlined in this document.
- Survey vendors are prohibited from subcontracting the data submission task.
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Data collected in a manner that does not adhere to the PCF PECS procedures or timeline may result in data which CMS cannot use in calculating and reporting the practice site’s scores for the impacted performance period.
- The Exceptions Request and Discrepancy Report processes exist to give survey vendors a way to document data collection that cannot adhere to procedures for extenuating circumstances. Prompt communication of these circumstances can prevent problems.
In the first year that a vendor is participating in PCF PECS, before data collection begins and while they are considered conditionally approved, survey vendors must submit a Quality Assurance Plan (QAP) after training (see timeline in Exhibit 5-1). Submission deadlines for the QAP will be announced on the PCF PECS web portal and disseminated via email to all conditionally approved vendors.
The main purposes of the QAP are to provide documentation of survey vendors’ understanding, application and compliance with the Quality Assurance Guidelines and to serve as the organization-specific guide for administering the PCF PECS, training project staff to conduct the survey, and conducting quality control and oversight activities.
CMS will distribute an Outline for a Model QAP which survey vendors must follow. As shown in the outline, the QAP submission is divided into two parts, with the first submission requiring organizational information and a workplan, and the second submission several months later requiring examples of mail and telephone materials CMS deems key to survey quality.
CMS reviews all QAPs and may follow up with survey vendors for clarification, resubmission and re-review as needed. Upon CMS’ approval of the first submission of the QAP, the vendor is fully approved. This approval endures, unless the vendor loses their approval status.
In subsequent years of the project, vendors must submit QAPs annually to maintain their Full Approval status. Survey vendors are also required to update and resubmit the QAP anytime there are key personnel or protocol changes. When submitting a revised or updated QAP, vendors should highlight any changes to their QAP from the prior submission. Updated QAPs must also address any corrections made by the vendor based on feedback during the oversight process.
The main purposes of the QAP are to provide documentation of survey vendors’ understanding, application and compliance with the Quality Assurance Guidelines and to serve as the organization-specific guide for administering the PCF PECS, training project staff to conduct the survey, and conducting quality control and oversight activities.
CMS will distribute an Outline for a Model QAP which survey vendors must follow. As shown in the outline, the QAP submission is divided into two parts, with the first submission requiring organizational information and a workplan, and the second submission several months later requiring examples of mail and telephone materials CMS deems key to survey quality.
CMS reviews all QAPs and may follow up with survey vendors for clarification, resubmission and re-review as needed. Upon CMS’ approval of the first submission of the QAP, the vendor is fully approved. This approval endures, unless the vendor loses their approval status.
In subsequent years of the project, vendors must submit QAPs annually to maintain their Full Approval status. Survey vendors are also required to update and resubmit the QAP anytime there are key personnel or protocol changes. When submitting a revised or updated QAP, vendors should highlight any changes to their QAP from the prior submission. Updated QAPs must also address any corrections made by the vendor based on feedback during the oversight process.
Fully approved survey vendors, including their subcontractors, must be prepared to participate in all oversight activities, such as remote site visits and/or teleconference calls, as requested by CMS or RTI, to make sure correct survey protocols are followed. All materials relevant to survey administration are subject to review. Maintaining status as a Fully Approved vendor is contingent upon receiving satisfactory reports during oversight activities.
Note that the Vendor Application lists the participation requirements of oversight activities as well. All vendors who submitted their Vendor Application have already agreed to these requirements.
Note that the Vendor Application lists the participation requirements of oversight activities as well. All vendors who submitted their Vendor Application have already agreed to these requirements.
Primary Care First (PCF) Patient Experience of Care Survey (PECS) Survey Overview
| Activity | Date(s) |
|---|---|
|
Vendor Application, Approval and Authorization
|
|
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Practices authorize a vendor for the PY22 PEC Survey*
*Only PCF Practice Sites that will be switching to a different survey vendor and those that will be participating in PCF for the first time will need to complete the online Vendor Authorization form
|
03/21/23 – 06/30/23
|
|
Patient Data Collection by Survey Vendors
|
|
|
Sample files are posted to PCF PEC Survey website for vendors
|
09/11/23 – 09/14/23
|
|
Help Desk open
|
09/26/23 – 12/17/23
|
|
Teaser postcard mailing
|
09/25/23
|
|
1st Questionnaire mailing
|
10/02/23
|
|
Reminder/Thank you postcard mailing
|
10/09/23
|
|
2nd Questionnaire mailing
|
10/30/23
|
|
CATI non-response follow up
|
11/20/23 – 12/17/23
|
|
Data Submission
|
|
|
1st interim data submission due from vendors
|
10/23/23
|
|
2nd interim data submission due from vendors
|
11/28/23
|
|
Final data submission due from vendors
|
01/16/24
|
The Primary Care First (PCF) Patient Experience of Care Survey (PECS) (CAHPS® with PCF supplemental items) is designed to measure the experiences of people receiving care from Practice Sites participating in the Primary Care First (PCF) model. Beginning in 2022, the PCF PECS is conducted for PCF Practice Sites by survey vendors approved by the Centers for Medicare & Medicaid Services (CMS).
Primary Care First (PCF) is a 5-year model aiming to improve quality, improve patient experience of care, and reduce expenditures. Clinical quality, utilization, and patient experience measures are used to assess quality of care delivered at the practice and PCF practice sites must meet standards that reflect quality care and model requirements in order to be eligible for a positive performance-based adjustment (PBA). The measures were selected to be actionable, clinically meaningful, and aligned with CMS’s broader quality measurement strategy.
The Patient Experience of Care Survey (PECS), which is based on the Consumer Assessment of Healthcare Providers and Systems (CAHPS) Clinician and Groups Survey (CG), is also required for all practice sites. Positive patient experience reflects high-quality care. Positive patient experience is also associated with higher levels of patient adherence, improved clinical outcomes, and lower utilization of inpatient and emergency department services. The designers of the PCF questionnaire specifically included CAHPS questions that measure whether patients observe providers and practice sites engaging in behaviors connected to PCF objectives, such as use of a care team with 24/7 access to the patient’s EHR and educating patients about how to get emergency care outside of practice hours.
CMS asks that providers display PECS posters between April-December. This will allow time for patients to see the poster and become familiar with the PECS. Rostering for PECS takes place in early summer. The rosters that practices provide are submitted online through the PCF portal using a template. Health IT vendors can support practices in the creation of their patient rosters. More information about roster submissions will be distributed to practices and health IT vendors closer to the roster submission period. The CMS contractor will select the survey sample. The PECS data collection begins in September and ends in December. Patient responses to the survey determine the practice score. This score is used to evaluate the practice's strengths and needs in providing patient centered care. Practice scores will be available in the PCF Portal in Spring. The survey vendor will be able to give survey results faster, before CMS’ PEC score report is available.
Participation
The general Primary Care First payment model option is designed for primary care practices with advanced primary care capabilities that are prepared to accept increased financial risk in exchange for flexibility and potential rewards based on practice performance. Eligible applicants are primary care practices that:
- Include primary care practitioners (MD, DO, CNS, NP, and PA), certified in internal medicine, general medicine, geriatric medicine, family medicine, and hospice and palliative medicine.
- Provide primary care health services to a minimum of 125 attributed Medicare beneficiaries at a particular location
- Have primary care services account for at least 70% of the practices’ collective billing based on revenue. In the case of a multi-specialty practice, 70% of the practice’s eligible primary care practitioners’ combined revenue must come from primary care services.
- Have experience with value-based payment arrangements or payments based on cost, quality, and/or utilization performance such as shared savings, performance-based incentive payments, and episode-based payments, and/or alternative to fee-for-service payments such as full or partial capitation.
- Use 2015 Edition Certified Electronic Health Record Technology (CEHRT), support data exchange with other providers and health systems via Application Programming Interface (API), and connect to their regional health information exchange (HIE).
- Attest via questions in the Practice Application to a limited set of advanced primary care delivery capabilities, such as 24/7 access to a practitioner or nurse call line and empanelment of patients to a practitioner or care team.
- Can meet the requirements of the Primary Care First Participation Agreement
Eligible practitioners (that each practice applicant must identify by NPI in its application) are those in internal medicine, general medicine, geriatric medicine, family medicine, and/or hospice and palliative medicine. CMS may reject an application on the basis of the results of a program integrity screening.
CMS will also encourage other payers – including Medicare Advantage Plans, commercial health insurers, Medicaid managed care plans, and State Medicaid agencies – to align payment, quality measurement, and data sharing with CMS in support of Primary Care First practices.
For more information about PCF-PECS and Fields Healthcare Research, please call Ken Fields at 800-748-0830, or email Ken@FieldsResearch.com.
PCF-PECS, Official Site: pcfpecs.org
For direct Email communications with CMS regarding the PCF-PECS survey: pcfpecs@rti.org
For PCF-PECS Training Slides and Videos: pcfpecs.org/Training/Training-Materials