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In 2012, the Agency for Healthcare Research and Quality with its Consumer Assessment of Health Provider and Systems (CAHPS) Consortium began developing the Outpatient and Ambulatory Surgery CAHPS (OAS CAHPS). The survey is designed to measure patients’ experiences with care received from Medicare-certified hospital outpatient departments (HOPDs) and ambulatory surgery centers (ASCs).

Who participates?
Hospital Outpatient Departments (HOPDs) and Ambulatory Surgery Centers (ASCs) that care for 60 or more eligible patients annually will be required to administer the OAS CAHPS survey. Critical Access Hospitals are not required to participate, but may do so on a voluntary basis.

When does mandatory reporting begin?
In the CY 2018 Proposed Rule, CMS plans to continue voluntary implementation of the OAS CAHPS Survey throughout 2018. If approved, confirmation of these plans will be posted in the Final Rule (to be published in November 2017).

Is there an exemption for small practices?
Yes. If an HOPD/ASC served 59 or fewer survey eligible patients during the year preceding the data collection period, the facility can request an exemption. To request an exemption, HOPD/ASCs will need to submit a Participation Exemption Request (PER) form which can be found on the OAS CAHPS website. HOPDs and ASCs will need to submit a PER for every year for which they qualify and wish to seek an exemption.

What topics does the OAS CAHPS survey assess?
The OAS CAHPS survey contains 37 questions that cover topics such as access to care, communication, and experience of the facility and interactions with facility staff. There are two global items on the survey:

1. Patients are asked to rate the care provided by the HOPD or ASC.
2. Patients are asked about their willingness to recommend the HOPD or ASC to family and friends.

Like other CAHPS surveys, ‘About You’ questions are included that obtain basic demographic information and self-rated health status from patients.
– Questions 1-24: Core Survey Questions
– Questions 25-37: ‘About You’ Questions

Survey Periodicity?
Monthly data collection and quarterly submission of patient survey files to CMS.

How many patients are surveyed?
Per CMS guidelines, the agency has set a target of 300 completed surveys per year, per OAS CAHPS facility operating under its own provider number (CCN). This translates to about 25 completed surveys per month. Using a 30% response rate (CAHPS national average) as the initial base rate, you can expect that about roughly 83 patients per month will be included in the sample and sent a survey, or roughly 1,000 patients annually.

Do I need a vendor to administer OAS CAHPS?
Yes. Eligible organizations are required by CMS to contract with an independent, approved vendor in order to administer the OAS CAHPS survey. Novaetus, Inc. (a SurveyVitals company) is an approved vendor and ready to administer the survey on your organization’s behalf.

What modes of administration are offered?
SurveyVitals offers mail-mode administration for the OAS CAHPS survey as we have found it to be most cost-effective solution for clients.

How often are patients eligible to receive an OAS CAHPS survey?
To reduce respondent burden, outpatient surgical patients can only be sampled by OAS CAHPS once in a 6-month period.

What languages are available for OAS CAHPS administration?
The OAS CAHPS survey is currently available in English, Spanish and Chinese, for both mail and telephone survey administration. CMS has indicated they will provide additional translations over time based on language needs of patients. The use of additional languages come at no extra costs to clients and are included in your OAS CAHPS solution.

What is an eligible patient (OAS CAHPS)?
CMS has outlined the following criteria to determine if a patient is OAS CAHPS-survey eligible:
1. Patient had at least one outpatient surgery/procedure during the sample month (including outpatient surgeries and procedures when the patient had an overnight stay for observation but was not admitted to the hospital).
2. Patients who were at least 18 years of age when they received their outpatient surgery or procedure.
3. Patients regardless of insurance or method of payment.
4. Patients whose outpatient surgery or procedure was given an HOPD or ASC.
5. Patient surgery or procedure is included in the list of eligible procedure codes (found in the OAS CAHPS guidelines manual).
6. Patients who have a domestic U.S. mailing address.
7. Patients who are not deceased.
8. Patients who do not reside in nursing homes.
9. Patients who were not discharged to hospice care following their surgery.
10. Patients who are not identified as prisoners.

Will my organization’s OAS CAHPS data be publicly reported?
Yes. CMS has indicated that public reporting will begin in January 2018 for OAS CAHPS data voluntarily collected between July 2016 and June 2017. Facilities will be able to request their voluntary collected OAS CAHPS data be suppressed from public reporting during the preview report period. As more information becomes available for when mandatory reporting will begin, we will provide an update.

Why should I start measuring my ASC/HOPD’s performance now if OAS CAHPS is not mandatory?
Your organization’s OAS CAHPS scores will not only have a direct impact on your bottom line with CMS payment determinations, but also on your reputation with public reporting. Based on SurveyVitals experience with other CAHPS initiatives, we’ve found that early adopters consistently outperform those who wait until participation is mandatory. Get a headstart with SurveyVitals and get a pulse on your ASC’s performance today.

What is the source of the sample for OAS CAHPS administration?
A monthly patient file will be provided by your facility through manual upload using our secure portal or via a HIPAA-compliant data feed with your EHR system or billing company.

Do you have supplemental surveys?
Yes! SurveyVitals’ ASC 360° solution provides insights for every level of your organization. Get started with the full solution today to get patient feedback year-round with real-time analytics and trending to pinpoint areas needing improvement between CAHPS survey cycles.