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[Federal Register: July 31, 2003 (Volume 68, Number 147)]
[Page 44951-44953]
From the Federal Register Online via GPO Access []



Agency for Healthcare Research and Quality

Request for Additional Hospital CAHPS[reg] (HCAHPS) Test Sites

AGENCY: Agency for Healthcare Research and Quality (AHRQ), HHS.

ACTION: Notice of Request.


SUMMARY: The Agency for Healthcare Research and Quality (AHRQ) in 
partnership with the Centers for Medicare and Medicaid Services (CMS) 
is soliciting volunteer sites for the additional testing of a draft 
Hospital CAHPS (HCAHPS) instrument. The mutual goals of AHRQ and CMS 
are to develop a standardized survey that is reliable and valid, that 
will reside in the public domain, and that will make comparative non-

[[Page 44952]]

information on hospital patients' perspectives on care widely 
available. While there are many good survey tools available to 
hospitals, there is currently no nationally used or universally 
accepted survey instrument that allows comparisons across all 
hospitals. To this end, at the request of CMS, AHRQ and the 
CAHPS[reg]II grantees developed a draft HCAHPS instrument with input 
from the various stakeholders in the industry. Initial testing of the 
survey is being done as part of a CMS three-State pilot by hospitals in 
Arizona, Maryland, and New York.
    On June 27th, 2003, CMS published a Federal Register Notice (vol. 
68, no. 124, pages 38346-38358) soliciting input into implementation 
options and the draft HCAHPS survey. To take advantage of the input 
received, AHRQ and CMS are interested in conducting additional testing 
of the HCAHPS instrument, sampling and data collection processes to 
assess issues involved in survey implementation. To accomplish these 
tasks we plan to conduct very quickly, additional testing at a limited 
number of hospitals that volunteer to work with AHRQ and CMS. This 
notice describes an opportunity for volunteering for additional testing 
for refining the HCAHPS survey and the nature of the implementation 
procedures. Most of this additional testing will occur between 
September and December 2003.
    This is a separate initiative from "The Quality Initiative: A 
Public Resource on Hospital Performance". (For more information about 
that initiative, please see the Supplemental Information section of 
this notice).

Types of Studies To Be Conducted During Additional Testing

A. Survey Method Issues

    The following are some examples of the type of Methodological 
studies that AHRQ and CMS would like to conduct. These will be 
finalized once we have received public input at the close of the 
comment period for the June 27th Federal Register Notice.
    1. Test of mode effects (mail versus telephone) within hospitals 
using randomly assigned split samples. Because HCAHPS, when finally 
implemented, may be fielded in by both mail and telephone it is 
important to test and revise the instrument so that there is 
comparability across these modes.
    2. Test the effect of intervening stays in other facilities. A 
proportion of patients will be discharged from the hospital in question 
to another facility before they go home. It is important to test the 
effect of intervening stays in other facilities on HCAHPS scores for 
the acute care hospital from which the patient was sampled.
    3. Psychometric analyses to evaluate the equivalence of English and 
the Spanish HCAHPS forms.
    4. Test the effect of lag time on HCAHPS scale scores. Due to 
logistical delays in obtaining up-to-date discharge lists, there will 
almost certainly be a lag between hospital discharge and survey 
administration. Long time lags between discharge and survey 
administration may bias survey responses. For example, time since 
discharge may affect the survey scores because respondents' memories of 
their experience degrade with time or because the composition of the 
respondent pool changes with time (the less healthy patients may be 
less likely to respond or can not respond because they are too ill or 
have expired).
    5. Test the effect on response rate of different survey materials, 
taking into account incremental changes in cost. There is some evidence 
in the survey research literature that response rate can be influenced 
by the type of survey materials that are sent out. In general 
impersonal materials from lower status sources will result in lower 
response rates than personalized materials sent out by higher status 
sources. However, personalized materials may cost more to produce.
    6. Evaluate the covariation of HCAHPS scores with clinical 
indicators of hospital performance, such as those required by CMS in 
the 7th scope of work for Quality Improvement Organizations (QIOs) 
i.e., see for more information on QIOs and the 7th scope of 
work statement. These analyses would constitute an expansion of the 
construct validity analyses for HCAHPS scores in the CMS Pilot.
    7. Evaluate HCAHPS instrument psychometrically including the 
following characteristics:
    [sbull] Quality of item responses (missing item rates, skip pattern 
    [sbull] Factors associated with item response rates;
    [sbull] Factors associated with survey response rates;
    [sbull] Construct validity of composites and ratings;
    [sbull] Internal consistency;
    [sbull] Hospital level reliability;
    [sbull] Components of variance; and
    [sbull] Case mix adjustment.

B. Implementation Issues

    AHRQ and CMS also seek to study the processes for implementation of 
HCAHPS. Topics include:
    1. Sampling procedures that worked well or caused problems.
    2. Survey operations procedures that worked well or caused 
    3. How easily or readily can HCAHPS be integrated into a hospital's 
existing sampling and survey operations procedures.

Criteria for Additional Site Selection

    While AHRQ and CMS would like to provide wide access to the survey 
for testing, there are limited agency resources for coordinating the 
testing and analysis of data. Therefore, it is necessary to seek 
volunteer acute care sites that are able to provide the resources for 
data collection using the HCAHPS survey, and agree to submit the data 
to a central repository for analysis. Hospitals may volunteer to 
participate in the testing program individually or in a group in 
cooperation with a hospital association, chain or other coalition. 
Potential testing sites will be selected that best meet the analytic 
needs of the HCAHPS development effort. Thus, selection from among 
potential candidate sites will be made using the practical criteria set 
out below. Criteria for selection of the additional sites are designed 
to achieve additional diversity in the characteristics of test sites, 
obtain the most reliable and valid data possible, and to maximize the 
use of resources allotted for this work.
    The criteria for selection are as follows. The test site must:
    1. Be able to pay the full cost of data collection and database 
creation using specifications provided by AHRQ;
    2. Be able to field the survey within the timeframe specified by 
AHRQ to be determined at the time of selection (Most of the testing 
will occur between September and December 2003, but additional testing 
may be done in early 2004. Applicants should indicate their ability to 
carry out the work during those periods in response to Information Item 
12 below);
    3. Employ a survey vendor with an established record of hospital 
patient survey experience;
    4. Be able to provide an adequate sample size to meet the needs of 
    5. Be able to adapt survey implementation as requested by AHRQ, to 
meet the needs of the experimental design; and
    6. Be able to provide a person to coordinate the test site work 
with AHRQ.
    Selection of additional test sites will be determined at the sole 
discretion of the AHRQ and CMS.

[[Page 44953]]

    Information Requirements: To volunteer to participate as an 
additional testing site, please provide the following information:
    1. Volunteer site9s) name(s) and location(s).
    2. Contact person information including name and title, address, 
telephone number, fax number and e-mail address.
    3. Coordinator for site data collection information (if different 
from contact person) including name and title, address, telephone 
number, fax number and e-mail address.
    4. The following are examples of the types of studies that may be 
useful. Additional ones may be identified as a result of the June 27th 
Federal Register Notice. Please provide information about what types of 
studies you will or will not be willing to participate in.
    a. Test of mode effects (mail versus telephone).
    b. Test the effect of intervening stays in other facilities.
    c. Psychometric analyses to evaluate the equivalence of English and 
Spanish HCAHPS forms.
    d. Test the effect of lag time on HCAHPS scale scores.
    e. Test the effect on response rate of different survey materials 
(e.g., personalized cover letters), taking into account incremental 
changes in cost.
    f. Evaluate the covariation of HCAHPS scores with clinical 
indicators of hospital performance.
    g. Evaluate HCAHPS instrument psychometrically.
    h. Sampling procedures that worked well or caused problems.
    i. Survey operations procedures that worked well or caused 
    j. How easily or readily HCAHPS is integrated into a hospital's 
existing sampling and survey operations procedures.
    5. Number of hospitals proposed for inclusion in the testing.
    6. Evidence that hospital(s) is/are willing to participate (i.e., 
acknowledgement or confirmation from CEO).
    7. Average number of discharges per month from participating 
hospitals, and the average number of discharges for each of the 
following services: medical, surgical, and obstetrics.
    8. Name of current surveys being used in the site and modes of 
administration of each survey used.
    9. Name of current survey vendors working with the site(s).
    10. Name of survey vendor who has the largest share of the hospital 
market in which the volunteer facility, organization or association 
    11. Statement or affidavit indicating authorization to commit the 
organization(s) to pay the specific estimated cost of sample selection, 
data collection, database preparation and coordination with AHRQ.
    12. Current schedule for data collection of patient survey data, if 
you have one.
    13. Process and schedule for selecting a vendor for the proposed 
testing or name of vendor already selected.

dates: Please submit requested information on or before September 2, 

addresses: Submissions should include a brief cover letter and the 
requested information about the potential site(s). They may be in the 
form of an e-mail with attachments, or a letter, preferably with an 
electronic file in a standard word processing format, (e.g., Microsoft 
Word or Word Perfect) on a 3\1/2\ inch diskette. E-mail submissions are 
preferred and will be acknowledged upon receipt.
    E-mail Responses to this request should be submitted to: hospital- Written or faxed responses should be submitted to:
    Charles Darby, Agency for Healthcare Research and Quality, Center 
for Quality Improvement @ Patient Safety, 540 Gaither Road, Rockville, 
MD 20850. Phone: (301) 427-1324; Fax: (301) 427-1341.
    In order to facilitate handling of submissions, please include all 
requested information about the candidate facilities. Please do not use 
acronyms. Electronic submissions are strongly encouraged.

for further information contact: Charles Darby, Center for Quality 
Improvement and Patient Safety, Agency for Healthcare Research and 
Quality; Phone: (301) 427-1324; Fax: (301) 427-1341; E-mail
supplementary information: The Agency for Healthcare Research and 
Quality (AHRQ) has been a leading proponent and supporter of the 
development of instruments for measuring patient experiences within the 
healthcare system of the United States. Through prior CAHPS[reg] patient 
survey development efforts, AHRQ has been able to provide valuable 
information to consumers and purchasers alike. The CAHPS survey for 
health plans is widely accepted as an industry standard. Therefore, as 
the research partner of CMS, AHRQ is charged with the development of a 
hospital patient experience of care instrument as well as the 
development of reporting strategies to maximize the utility of the 
survey results. In an effort to provide a firm foundation of evidence-
based research for the HCAHPS instrument, the AHRQ is requesting 
voluntary participation from acute care facilities as potential sites 
for additional field-testing of the draft HCAHPS survey instrument to 
provide analytic data that will complement the results of the pilot 
testing done by QIOs for CMS.
    Once HCAHPS is finalized, it will be made available to "The 
Quality Initiative: A Public Resource on Hospital Performance", which 
is a public/private partnership that includes the major hospital 
associations, government, consumer groups, measurement and accrediting 
bodies, and other stakeholders interested in reporting on hospital 
quality. In the first phase of the partnership (which has already 
begun), hospitals are voluntarily reporting the results of their 
performance on ten clinical quality measures for three medical 
conditions: acute myocardial infarction, heart failure, and pneumonia. 
HCAHPS reporting will comprise the second phase of the effort.
    For more information or to participate in the Quality Initiative 
please visit under "Quality and Patient Safety, 
Quality Initiative," or at, under "Issues/
Advisories," or at by going to "Government 
Affairs," "Teaching Hospitals" and then "Quality."

    Dated: July 24, 2003.
Carolyn M. Clancy,
[FR Doc. 03-19462 Filed 7-30-03; 8:45 am]


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