Patient Experience of Care Data Collection...

DATA COLLECTION GUIDE

2016 Patient Experience of Care Measure

2016 PHYSICIAN CLINIC PATIENT EXPERIENCE OF CARE SURVEY

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Table of Contents

Introduction ........................................................................................................................................... 2

Background ............................................................................................................................................ 2

Measure Specifications ......................................................................................................................... 3

Survey Instrument ................................................................................................................................. 5

Survey Administration & Vendors ......................................................................................................... 6

Modes of Data Collection ...................................................................................................................... 7

Step-by-Step Guide to Survey Implementation .................................................................................... 9

First Stage: Pre-Survey (Now through July 15, 2016) ...................................................................... 10

Step 1. Learn about the Measure and Contract for Vendor Services ......................................... 10

Step 2. Designate Survey Contacts in the MNCM Data Portal .................................................... 11

Step 3. Submit Pre-Survey Validation Documentation in the MNCM Data Portal ..................... 11

Second Stage: Surveying (September 1, 2016 through February 17, 2017) ................................... 14

Step 1. Identify Eligible Patient Visits .......................................................................................... 14

Step 2. Select Sample of Patients to be Surveyed ...................................................................... 15

Step 3. Field the Survey ............................................................................................................... 16

Step 4. Collect Survey Responses ................................................................................................ 17

Third Stage: Post-Survey (February 17, 2017 through April 5, 2017) ............................................. 20

Step 1. Submit Post-Survey Documentation ............................................................................... 20

Public Reporting of Survey Results ...................................................................................................... 21

Things to Consider ............................................................................................................................... 23

Whom to Contact for Help .................................................................................................................. 22

Appendix 1. Measure Eligibility ………………………………………………………………………………………………….. 25

Appendix 2. Measure Specifications ................................................................................................... 23

Appendix 3. Timeline ........................................................................................................................... 30

Appendix 4. Identifying Eligible Patient Visits ..................................................................................... 32

Appendix 5. Sampling Procedure ........................................................................................................ 33

Appendix 6. Test Sample File Layout ................................................................................................... 36

Appendix 7. Data Submission File Layout............................................................................................ 37

Appendix 8. Post-Survey Documentation and Data Upload ….………………………………………………………76


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Introduction

This Patient Experience of Care Data Collection Guide is intended

for Minnesota physician clinics and Centers for Medicare &

Medicaid Services (CMS) approved survey vendors (i.e., companies

specialized in the administration of patient surveys on behalf of

medical group clients). The Data Collection Guide outlines the

steps to be followed to participate in the 2016 measure of patient

experience of care. Following the protocol described in the Data

Collection Guide will allow physician clinics to meet the

requirements for the Minnesota Department of Health’s

Minnesota Statewide Quality Reporting and Measurement System

(SQRMS) and Health Care Homes (HCH) program. As well,

standardized implementation of the patient experience survey is a

must for MN Community Measurement (MNCM) to publicly report

clinic results.

Background As early as 2007, MNCM led a community stakeholder workgroup

that designed a patient experience survey implementation

process for clinics. Volunteer “early adopter” medical groups

participated in survey pilots in 2008 and again in 2010 to test and

enhance the implementation for scalability.

Meanwhile, Minnesota’s 2008 Health Reform Law required the

Minnesota Department of Health (MDH) to establish a

standardized set of quality measures for health care providers

across the state. To implement the collection and reporting of

quality measurement data, MDH developed the SQRMS, created

through Minnesota Rules, Chapter 4654). MDH has contracted with MNCM to collect these data and assist

clinics in meeting the measure requirements.

Patient Experience of Care was a required measure for physician clinics beginning in 2012 and every other

year after. In the first cycle, the measure was implemented using the Consumer Assessment of Healthcare

Providers and Systems Clinician & Group Visit Survey (CAHPS Visit survey). The next cycle in 2014 utilized

the CAHPS® Clinician & Group 12-Month survey (CAHPS 12-Month survey). This current cycle will be

implemented with the CAHPS® Clinician & Group 3.0 survey (CAHPS 3.0 survey), which has a six-month

look back period.

Why is it Important to Measure

and Improve Patient Experiences

of Care?

Growing demand by patients

for enhanced service

experiences and greater

participation in their health

care Various initiatives exist to

build patient experience into

performance-based

compensation, certification

and licensing, and recognition

programs

Increasing evidence linking

patient experience to

important clinical and

business outcomes.

For more on why it is important

to measure patient experience,

see AHRQ’s CAHPS Ambulatory

Care Improvement Guide:

Practical Strategies for Improving

Patient Experience

https://cahps.ahrq.gov/surveys-guidance/cg/instructions/index.html



https://cahps.ahrq.gov/quality-improvement/improvement-guide/improvement-guide.html





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If clinics in your medical group are certified through the Health Care Home program, you are required to add

the Patient Centered Medical Home (PCMH) Supplemental Items questions to the CAHPS 3.0 Survey for both

adult and pediatric populations based on specific eligibility rules. Please note that the implementation of the

adult CG-CAHPS 3.0 survey with PCMH Supplemental Items survey fulfills both the SQRMS and Health Care

Home requirements for Minnesota clinics. Any primary care clinic may add the PCMH Supplemental Items to

the 3.0 core survey if it so chooses.

MNCM will be coordinating the submission of results from the 2016 Patient Experience of Care Survey to

MDH. Visit the Minnesota Department of Health’s website to learn more about this requirement.

Measure Specifications The 2016 Patient Experience of Care Survey will assess patient’s experiences on visits occurring in physician

clinics between September 1, 2016 and November 30, 2016. The unit of measurement is the clinic site. While

the survey will ask patients to report on their experience with a specific provider, the results of these surveys

will be combined to measure the clinic’s overall performance. Provider-level scores will not be used for the

purposes of this measure or publicly reported.

The survey will measure visits:

Made by adult English-speaking patients (i.e., patients 18 years and older)

Conducted face-to-face in the clinic (i.e., consultations taking place over the telephone or through e-

mail are not included).

To board-certified physicians in all specialties, excluding psychiatry-only practices.

All clinics in Minnesota seeing a specific threshold number of unique adult patients during an eligibility

period are required to take part in the survey. The threshold number of adult patients uses a scaling table

based on the count of providers at the clinic as a proxy for clinic size. Please see Appendix One for

information on the provider scaling table.

Non - Minnesota clinics registered with MNCM are not required but may participate to have their results

publicly reported on MNHealthScores.org.

Pediatric clinics will have to assess their adult patient population (18 years or older) towards eligibility for the

measure. Pediatric clinics that saw more than a threshold number of adult patients for face-to-face visits in a

eligibility period are required to take part in the adult survey. Those pediatric clinics that saw fewer than the

threshold number of adult patients in this same three-month period are exempt from the measure.

http://www.health.state.mn.us/healthreform/measurement/adoptedrule/index.html


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Additionally, HCH clinics may also have to survey their pediatric population (12 and under) based on survey

eligibility rules. If a HCH pediatric clinic is eligible (saw at least a threshold number of unique pediatric

patients for face-to-face visits during an eligibility period), it would utilize the Child CG-CAHPS® 3.0 survey

with PCMH Supplemental Items. Please see Appendix One to review the measure eligibility requirements for

non-Heath Care Home and Health Care Home clinics.

An outline of the full measure specifications as contained in the Minnesota Department of Health’s 2016

Administrative Rule can be found in Appendix Two.


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Survey Instrument

The survey instrument for the 2016 Patient Experience of Care Survey is

the adult CAHPS® Clinician & Group 3.0 survey (CG-CAHPS 3.0 Survey).

If your clinic is a Health Care Home site, you are required to implement

the CG-CAHPS® 3.0 Survey plus PCMH Supplemental Items, for both adult

and child populations (see Appendix One for eligibility). The

implementation of the Adult 3.0 survey with PCMH Items fulfills both the

SQRMS and HCH requirement for Minnesota clinics. Any primary care

clinic may add the adult PCMH Supplemental Items to the core survey.

The survey is available to the public for free from the Consumer

Assessment of Healthcare Providers and Systems (CAHPS) program.

CAHPS is a program of the Agency for Healthcare Research and Quality

(AHRQ), part of the U.S. Department of Health and Human Services.

The CG-CAHPS 3.0 Survey includes questions about patients’ experience

over the past six months. Additional questions may be added to the

survey as long as all CAHPS protocols for doing so are followed. Please

note that the data for any additional questions added to the core CG-

CAHPS survey will not be submitted to MNCM. Protocols for fielding

CAHPS surveys are available on the CAHPS website .

There are other CAHPS Clinician & Group survey versions available;

however these other survey versions are NOT APPLICABLE for this

measure. Only the CAHPS Clinician & Group 3.0 Survey can be used to

meet the Patient Experience of Care survey requirement for SQRMS and

HCH.

Why did the 2016 survey

requirement change from

the 12-Month survey to the

3.0 survey?

The 3.0 survey utilizes a six month look-back period which aligns with national surveys.

A CAHPS randomized study showed similar scores for both timeframes – thus allowing trending to continue.

The 3.0 survey is shorter: two composites were reduced to only the most reliable question items.

New Care Coordination composite added as an important aspect of patient care.

The 3.0 survey retains previous four domain composites.

“Proposed Changes to the

CAHPS Clinician & Group

Survey”, revised 1/19/15




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Navigating the CAHPS Website

The CAHPS website, located at www.ahrq.gov provides a wealth of information related to

the CG-CAHPS surveys as well as other resources. Links to the CAHPS website provided in this

guide primarily lead to the Surveys and Guidance tab , which allows you to download the

materials needed to implement the survey.

Survey Administration & Vendors

To ensure unbiased results, physician clinics are required to use an external survey vendor company to

administer the CG-CAHPS® 3.0 Survey (with or without PCMH Supplemental Items) on their behalf. This vendor

must be approved by the Centers for Medicare & Medicaid Services (CMS). As CMS does not currently have a

process to approve vendors to administer the CG-CAHPS surveys, physician clinics must choose a vendor from

among those approved to administer either the Hospital CAHPS (HCAHPS) or the Medicare Advantage and

Prescription Drug Plan (MA & PDP) CAHPS surveys. To view the list of approved vendors, see the list of

HCAHPS Approved Survey Vendors or the list of MA & PDP CAHPS Approved Survey Vendors.

Modes of Data Collection The CG-CAHPS® 3.0 Survey will be distributed to a random sample of patients drawn from a list of all patients

who are eligible for the survey at each clinic site. Physician clinics may choose to have their vendor send

surveys out at regular intervals throughout the three-month measurement period September 1 through

November 30, 2016 (i.e., weekly or monthly, called “continuous surveying”) or to conduct a one-time survey

at the end of the measurement period.

http://www.ahrq.gov/

https://www.cahps.ahrq.gov/surveys-guidance/cg/index.html

http://www.hcahpsonline.org/app_vendor.aspx

http://www.ma-pdpcahps.org/Content/ApprovedSurvey.aspx


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The survey may be distributed using any of the data collection modes currently approved by the CAHPS

Consortium. The Consortium is a body of public and private research organizations tasked with the

development of CAHPS survey instruments and implementation protocols. The current approved data

collection modes include:

Mail only

Telephone only

A mixed mode of mail with telephone follow-up

A mixed mode of e-mail with mail follow-up

A mixed mode of e-mail with telephone follow-up

Physician clinics and their survey vendors are advised to download a copy of Fielding the CAHPS® Clinician &

Group Surveys available among other tools on the CAHPS website. Detailed protocols for each of the data

collection modes are described beginning on page 10 of the Fielding Guide and should be followed as written.

There are only a few exceptions:

1. For the mail protocol, a two-wave mailing is expected (i.e., the survey is mailed to all sampled patients

and sent again a second time to those who have not responded to the first mailing). However, the use

of a reminder postcard is not required.

2. For the mail protocol, cover letters may be customized to include the clinic or medical group logo and

the signature of an appropriate clinic or medical group representative.

Using E-mail to Collect Data

The use of e-mail to distribute surveys is an increasingly attractive mode of data collection and

deserves special attention. The CAHPS Consortium does not recommend mailing a letter with a link

to a web-based survey, as research has shown this to be ineffective. Instead CAHPS guidance calls

for a survey invitation to be sent via e-mail with a link to the online survey. The recently released

guidelines for the 3.0 survey continue to dissuade an e-mail only protocol at this time. Clinics

intending to have their vendors use e-mail as part of their survey administration must also be

prepared to follow-up with either a full mail or full telephone protocol. This is especially necessary

because clinics are not likely to have e-mail addresses for all of their patients and those selected for

the survey without an e-mail address listed must still have an equal opportunity to complete the

survey.

Therefore, to implement a mixed mode of data collection involving e-mail, a clinic must first start

with the list of all patient visits eligible for the survey regardless of whether or not the patient has

an e-mail address listed. The survey vendor will then select a sample of these patients to be

surveyed. For those with an e-mail address available, an e-mail invitation to complete the survey

online is sent. Patients without an e-mail address available are instead mailed the survey or

contacted to complete the survey over the telephone. The full mail or telephone protocol must be

followed in this case. Finally, patients who were sent the survey via e-mail originally, but did not

respond, must be followed up by conducting a full mail or telephone protocol as well.



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3. For the mixed mode of mail with telephone follow-up, a notification letter to respondents in advance

to let them know that you will be contacting them by telephone is not required.

Step-by-Step Guide to Survey Implementation

This section of the Data Collection Guide walks physician clinics and survey vendors through the steps to

follow in order to implement the 2016 Patient Experience of Care Survey. Physician clinics—especially those

new to the survey process—should look to their survey vendor as a source of guidance in completing these

steps. Survey vendors are experts in implementing the surveys and should share additional information with

their physician clinic clients on how to work together to achieve the measure results. This section is divided

into three stages: 1) Pre-Survey; 2) Surveying; and 3) Post Survey. The steps physician clinics need to carry out

are highlighted in purple, while the steps survey vendors will conduct are highlighted in orange. An overview

of the timeline can be found in Appendix Three.

MNCM will manage the 2016 Patient Experience of Care Survey through the MNCM Data Portal found at

https://data.mncm.org/login. All physician clinics in the state of Minnesota must register annually via the

MNCM Data Portal as required by SQRMS. The deadline for this year’s registration was February 10, 2016. If

you represent a clinic or medical group that has not yet registered, you can do so by visiting the MNCM Data

Portal site. Further information about the registration process can be found on MNCM.org, Submitting

Data/Training and Guidance tab. Following registration, physician clinics should have received their

assignment of measures to complete for 2016, including Patient Experience of Care for all clinics except

psychiatry.

Once medical groups have completed registration, the 2016 child and adult Patient Experience of Care

measures show as separate measures on a group’s home page in MNCM’s Data Portal.

https://data.mncm.org/login




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First Stage: Pre-Survey (Now through July 15, 2016)

Please note that while the unit of measurement for the Patient Experience of Care Survey is at the physician

clinic, the larger medical group may follow the steps below on behalf of all of its clinics.

Step 1. Learn About the Measure and Assess Eligibility

Both physician clinics and survey vendors are encouraged to read this Data Collection Guide in its entirety,

carefully noting those tasks which are the responsibility of the physician clinic and those tasks that will be

handled by the survey vendor. Physician clinics and survey vendors are also invited to attend an upcoming

webinar to learn more about the measure. The webinar will scheduled in early April and the date will be

communicated as soon as possible. The webinar will be recorded and archived for those not able to attend.

An email invite will be sent closer to the date.

PHYSICIAN CLINCS

Step 1 of the First Stage Begins: Now Medical groups will need to assess each of their clinic’s

eligibility (excluding Psychiatry specialty practices) towards the Patient Experience of Care 3.0

survey, which is outlined in Appendix One. Pediatric clinics have to assess their count of

adult patients (18 and over) towards eligibility.

Health Care Home clinics also have to assess their unique primary care patient counts to

determine if they are required to do the CAHPS 3.0 + PCMH Supplemental Items surveys for

adults and/or children.

Reminder: The pediatric Patient Experience of Care measure is a separate measure from the

Adult Patient Experience of Care measure and only required of HCH clinics.

Physician clinics required to do the CAHPS survey(s) should select a CAHPS-certified survey

vendor and contract directly with that vendor for the services needed to meet the measure

requirements. If your physician clinic is still in need of a survey vendor, see page six of this Data

Collection Guide for information on approved survey vendors


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SURVEY VENDORS

Step 1 of the First Stage Begins: Now

Survey vendors should contract with physician clinic clients and begin to orient them to the

measure. Vendors should provide physician clinics with additional and specific procedural

information beyond what is contained in this guide to ensure a successful working relationship.

Please note that if you have an existing contract with a Minnesota medical group/clinic client and

survey on their behalf over the course of the year, you may be required to halt that process during

the measurement period if it is different than what is described here. It is imperative that these

instructions are followed during the 2016 measurement period; failing to do so may jeopardize

your client’s compliance with the State mandate.

Step 2. Designate Survey Information in the MNCM Data Portal

The MNCM Data Portal will be used to communicate and coordinate all of the administrative steps of the 2016

Patient Experience of Care Survey; therefore, it is important for physician clinics to designate key contacts and

keep this information up-to-date. The MNCM Data Portal will open for this measure on April 18, 2016.

PHYSICIAN CLINCS

Step 2 of the First Stage Begins: April 18, 2016

Ends: July 15, 2016

Medical groups access the MNCM Data Portal to document Patient Experience of Care eligibility for each

clinic site. The eligibility process under Step 3 is outlined in Appendix One.

Eligibility questions will be answered for each clinic site and the required CAHPS surveys, based on these

answers, will be displayed for each clinic.


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Health Care Home clinics will be asked to also document their eligibility towards the CAHPS 3.0 + PCMH

Supplemental Items adult and child surveys to determine which survey versions are required.

Reminder: The Pediatric Patient Experience measure is listed as separate from the Adult Patient

Experience measure.

Groups will also designate the approved survey vendor they plan to use and the person at the clinic

responsible for managing the Patient Experience survey process in Step 4. Once survey vendors are

designated in the portal, physician clinics should instruct their survey vendor to contact MNCM in order

to request a MNCM Data Portal username and password.

SURVEY VENDORS


Ends: July 15, 2016

Once a physician clinic has designated a survey vendor company, that vendor may contact

MNCM to request a username and password to access the Data Portal, if needed. This new

request should be sent to [email protected] and include the name of the physician clinic

client(s) with whom the vendor will be working. Once logged in, vendors will be able to view

their profile to confirm the list of all their physician clinic clients for this survey.

Please note: If you are a returning survey vendor, your user name may still be valid, but the

password will have to be reset.

Step 3. Submit Pre-Survey Validation Documentation in the MNCM Data Portal

Physician clinics and their survey vendors will participate in a series of steps to test the process of sampling

patients for the survey. This practice round will allow physician clinics and survey vendors the opportunity to

work out the correct process of assembling the list of patient visits eligible for the survey and drawing a

random sample. MNCM will review documentation of this process as a means to ensure consistent adherence

to the survey specifications.

Documentation of this pre-survey validation process should be submitted to MNCM for review via the MNCM

Data Portal. This pre-survey validation process must be successfully passed before surveying is allowed to

begin. Physician clinics and vendors are encouraged to conduct this process well in advance of the final

deadline date of July 15, 2016, in order to have enough time to resolve any issues that may be detected.

mailto:[email protected]


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PHYSICIAN CLINICS


Ends: July 15, 2016

1. Create a test file of all eligible patient visits. For more instruction on how to correctly identify eligible

visits, see Appendix Four. The test file should include all eligible adult patient visits (18 years old and

older) that took place during the specified test period of February 1, 2016 through April 30, 2016:

If your physician clinic intends to conduct a continuous survey throughout the measurement

period, create a test file for the same interval of time that will be used during the actual

sampling (for example, if you will sample and survey bi-weekly, you could use the two-week

period of 2/15/2016—2/28/2016 as your test period).

If your physician clinic intends to conduct a one-time survey at the end of the measurement

period, create a test file of all eligible patient visits for the three-month test period (2/1/16-

4/30/16).

Please be careful when sampling the appropriate range of patients (adults only, or include

children if you are a Health Care Home clinic) and work with your survey vendor for the

acceptable file format. After assessing survey eligibility, the MNCM Data Portal can be used

to indicate which surveys, and therefore, which patient populations you should include in

your test file(s).

Note that in creating an adult test file, HCH adult primary care visits can be combined with

other adult provider visits. Only one adult test file should be sent to your survey vendor that

contains ALL eligible adult visits. HCH visits are flagged so that the vendor and separate visits

if necessary. See Appendix Five for the test file layout.

If you are a HCH clinic and are required to also field the child CG-CAHPS 3.0 + PCMH

Supplemental Items, you will generate a second file of all eligible pediatric primary care visits

and send this to your survey vendor.

2. Submit the test file(s) to your survey vendor. Your survey vendor will review this file(s) and notify you

of any concerns. Your survey vendor will go on to use this test file(s) for their random test file

submission to MNCM.


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3. Once you are confident your test file is accurate, correctly including all eligible patient visits,

document your process in the Pre-Survey Validation Document located in Step 5.

The Pre-Survey Validation document can be filled out manually or you can type text directly into it.

Answer the components providing information on contacts, sampling mode & interval,

birthdate ranges, service codes, and attestations.

Provide a copy of the data query you used to pull this test information electronically. The

query language can be copied and pasted or inserted as screen shots. If you are a HCH clinic

that is fielding the Child 3.0 + PCMH Supplemental Items survey, you need to provide a

second data query for this population.

4. Upload the completed Word document(s) to the MNCM data portal under Step 5.

SURVEY VENDORS


Ends: July 15, 2016

1. Survey vendors are expected to have an established quality control process to review test files

submitted to them by physician clinics. Vendors are asked to provide technical assistance as

needed to assist physician clinics in resolving any data issues detected during this review.

2. Once physician clinics upload their validation documentation and receive approval from MNCM,

their survey vendors may proceed in uploading their portion of the validation documentation.

3. Survey vendors should generate one test sample of 200 randomized adult patients for the entire

medical group (not by clinic), and a separate test sample of 200 randomized pediatric patients if

required to do the CAHPS 3.0 Child + PCMH survey. Upload the file(s) to the MNCM Data Portal.

See Appendix Five for more instructions on correct sampling procedure and Appendix Six for the


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layout format required for the test sample file(s).

4. Survey vendors should also upload sample survey materials for all CAHPS versions being fielded

for the medical group for review by MNCM. Survey materials should follow all applicable CAHPS

guidelines.

For a mailed survey, this includes a sample cover letter and the final formatted surveys

(Adult CAHPS 3.0, Adult CAHPS 3.0 + PCMH Items, Child CAHPS 3.0 + PCMH Items, as

applicable)

For a telephone survey, this includes the survey script.

For those using email as part of their data collection process, this includes the email

invitation text and a link to the online survey. Materials for the choice of follow-up

protocol (i.e., mail or telephone) should also be uploaded.

5. Survey vendors will be asked to provide the following information:

Data collection mode that will be used (i.e., mail, phone, or mixed mode)

Survey frequency (i.e., continuous weekly; continuous bi-weekly; monthly; one-time)

Second Stage: Surveying (September 2016 through February 20, 2017)

Physician clinics will provide to their survey vendor a data file of all patient visits eligible for the survey. After

that point, survey vendors will be responsible for the entire administration of the CG-CAHPS 3.0 survey on

behalf of their physician clinic clients. Physician clinics and their survey vendors should agree as to when and

how updates on the survey process and final results are communicated.

Step 1. Identify Eligible Patient Visits

PHYSICIAN CLINICS

Step 1 of the Second Stage Begins: September 2016

Ends: December 9, 2016

As was done in the test round, physician clinics will identify all eligible patient visits for the

survey, called the Sample Frame. For a review of how to correctly identify eligible visits, see

Appendix Four.

For physician clinics choosing to conduct a continuous survey, a file of all eligible adult

patient visits should be compiled and submitted at regular intervals (i.e., weekly or bi-

weekly, etc.) in the manner agreed upon with the survey vendor. All eligible visits that

occur during the measurement period of September 1, 2016—November 30, 2016 must

be included throughout these intermittent files. In order to ensure that surveys are

fielded in time to meet the final data submission deadline, physician clinics should


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provide their last patient visit file to their survey vendor no later than December 9,

2016.

For physician clinics choosing to conduct a one-time survey at the end of the

measurement period, one complete file of all eligible adult patient visits should be

compiled and submitted to the survey vendor. All eligible visits that occur during the

measurement period of September 1, 2016—November 30, 2016 must be included. In

order to ensure that surveys are fielded in time to meet the final data submission

deadline, physician clinics should aim to provide this file to their survey vendor no later

than Friday, December 9, 2016.

Physician clinics that do not have certified Health Care Home providers will generate a sample

frame with eligible adult patient (18 and older) records only.

Physician clinics that have HCH-certified providers may need to generate both an adult (18 and

older) and child (0-12 years) sample frame(s) dependent on previously determined survey

eligibility and agreement with the survey vendor.

Step 2. Select Random Sample of Patients to be Surveyed

SURVEY VENDORS


Ends: after December 9, 2016

Survey vendors should randomly sample an amount of records equal to the “Sample size” listed

in the provider scaling table below, with the goal of achieving a minimum of 150 survey

responses for smaller clinics and 300 for larger clinics. Vendors may sample more than this

number per clinic or instead survey the full patient population provided, if requested by the

physician clinic to guarantee the number of responses per clinic will be received. For a review

of how to correctly sample patients, see Appendix Five. Vendors conducting a continuous

survey for their physician clinic clients must sample patients evenly over the survey period

and across the multiple files provided by the clinic.

Clinic-level sampling based on number of providers at clinic

Total # Providers at Clinic:

# HCH Providers at Clinic:

Required # of Complete Surveys

Survey Sample Size

1-3 1-3 150 450

4-9 4-9 175 550

10-13 10-13 200 600

14+ 14+ 300 900


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Step 3. Field the Survey

SURVEY VENDORS


Ends: February 17, 2017

Survey vendors will field the CG-CAHPS 3.0 survey during this period. Vendors must ensure

that there are 10 weeks of response time from the first survey attempt (CAHPS protocol) but

also complete the survey cycle by February 17, 2017.

If a medical group client has some HCH-certified clinics, then the medical group may choose to

field the 3.0 survey + PCMH Supplemental Items for all of its clinics (HCH and non-HCH). This is

acceptable and will fulfill both the SQRMS and HCH requirements.

If the medical group instructs the vendor to send the CAHPS 3.0 + PCMH Supplemental Items

survey to only its HCH clinics, then vendors will need to work with additional data fields

supplied in the sample frame to send out the correct survey version. A field, called “HCH flag”,

has been added to the sample frame generated by the group. This field identifies a record from

one of its HCH clinics that requires a CAHPS 3.0 + PCMH survey to be sent. This flag field used

in conjunction with the age of the patient will determine whether the adult or child 3.0 + PCMH

survey is to be sent to the randomly selected patient.

Survey modes must use one of the approved data collection modes described beginning on

page six of this guide and follow the protocols defined in the Fielding the CAHPS® Clinician &

Group Surveys guide. In brief:

For mailed surveys, the vendor should send an initial mailing—including a cover

letter, the CG-CAHPS 3.0 Survey (or 3.0 + PCMH Supplemental Items), and postage-

paid return envelope—to all patients randomly selected for the survey. Twenty-one

(21) days after the first mailing, any patient who has not yet responded should be

sent a second mailing, including a reminder letter, the CG-CAHPS 3.0 Survey (or 3.0 +

PCMH Items), and postage-paid return envelope.

The survey vendor may be distributing more than one 3.0 survey version (Adult and

Child 3.0 + PCMH survey) for a clinic based on HCH eligibility status and survey

selection by the clinic/group.

For telephone surveys, the vendor should make at least six attempts to reach each

patient selected for the survey, unless the patient explicitly refuses to complete the

survey. These attempts must be made on different days of the week (both weekdays

and weekends), at different times of the day, and in different weeks.

For mailed surveys with telephone follow-up (mixed mode), the vendor should




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follow the process for mailed surveys above. Twenty-one (21) days after the second

mailing, any patient who has not yet responded should be contacted by telephone.

For e-mailed surveys with mail or telephone follow-up (mixed mode), the vendor

should send an e-mail invitation with a link to the online survey to patients selected

for the survey who have an email address available. At the same time, for those

patients selected for the survey who do not have an email address available, the

vendor should mail the survey or contact the patient to complete the survey over

the telephone, following the process for mailed or telephone surveys above. Seven

(7) days after the initial e-mail invitation is sent, vendors should send a reminder

email. Two (2) weeks after the initial e-mail invitation is sent, vendors should send a

second reminder email to those who still have not responded. Finally, vendors must

follow-up with any patient who was sent the survey via e-mail originally, but has not

yet responded 21 days after the original e-mail reminder was sent. Vendors must

follow-up with these non-responders by conducting either the full mail or the full

telephone protocol. This mode requires more response time than the other

protocols.

For additional details on protocols for fielding the survey, see the Fielding the CAHPS® Clinician

& Group Surveys guide. Sample cover (notification) letters and telephone scripts can also be

downloaded on the CAHPS website.

Step 4. Collect Survey Responses

SURVEY VENDORS


Ends: February 17, 2017

Survey vendors should track and collect survey responses. For mailed surveys, vendors should

allow at least 10 weeks from the first mailing for patients to respond. Vendors should aim to

close the survey process by February 17, 2017. However, for those using a mixed mode of e-

mail with mail follow-up, additional time may be required to ensure patients who were

originally sent an email invitation, but did not respond, have adequate time to respond to the

mailed survey (i.e., the full 10 weeks). However, the final data must be uploaded to MNCM no

later than April 5, 2017. Data collection should not be stopped if the target number of

completed questionnaires is achieved. The protocol is continued through the entire

measurement period.



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Third Stage: Post-Survey (February 17, 2017 through April 5, 2017)

Survey vendors will be responsible for submitting all final survey data for each clinic of their medical group

clients. These data will be uploaded by the survey vendor to the MNCM data portal along with additional post-

survey documentation; and data will also be separately uploaded to the National CAHPS database (NCDB).

Some clinic clients may have more than one survey upload based on the types of surveys fielded. Each survey

type: Adult 3.0 core survey, Adult 3.0 + PCMH Supplemental Items, and Child 3.0 + PCMH Supplemental Items

will be a separate file upload.

Step 1. Submit Post-Survey Documentation

SURVEY VENDORS

Step 1 of the Third Stage Begins: February 17, 2017

Ends: April 5, 2017

Survey vendors should upload the following information to the MNCM Data Portal no later than

April 5, 2017:

1. Final data files for each clinic for each survey fielded. See Appendix Seven for a

discussion on the layout for each data submission. Survey vendors must include a

record for each patient that was sampled for the survey, regardless of whether or not

the patient responded. Each of the three survey types has a record layout in Appendix

Seven.

2. Documentation of any patients excluded from the survey for each clinic. See the table in

Appendix Five for file layout instructions.

3. Enter into the MNCM Data Portal the following additional survey information for each

clinic by population (see Appendix Eight):

Total number of patient visits submitted by the medical group for each clinic

Total number of unique patients identified for the sample frame by clinic

Total number of excluded patients in random sample by clinic, if applicable

Total number of surveys sent/attempted for each clinic

Total number of surveys returned for each clinic

[Total number of surveys completed is calculated by the MNCM Data Portal

(completed surveys are surveys where more than 50 percent of the key

questions are answered)]

[Response rate and return rate are calculated by the MNCM Data Portal.]


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Step 2. Submit Final Data Files to the National CAHPS Benchmarking Database (NCBD)

SURVEY VENDORS

Step 2 of the Third Stage Begins: February 17, 2017

Ends: April 5, 2017

Survey vendors will upload final data files to the NCBD:

1. Specifications for submitting data files are available at CAHPS Database.

2. Vendors will complete all steps to ensure accurate data uploads to the NCBD.

Public Reporting of Survey Results

The unit of measurement for the 2016 Patient Experience of Care Survey is the physician clinic. Therefore, any

public reporting of survey results will be reported at the clinic level. There will be no reporting of provider

level results.

Clinics should be aware that results from the CG-CAHPS 3.0 Survey are typically reported as three composite

measures and a provider rating score, also called “domains”. New for the 3.0 version is an added composite

domain on Care Coordination. A composite measure is composed of two or more survey items (i.e.,

questions) that are highly related both conceptually and statistically. The reported measures are described

below.

1. Getting Timely Appointments, Care, and Information. This composite measure is composed of the following three survey items:

Q6 In the last 6 months, when you contacted this provider’s office to get an appointment for care you needed right away, how often did you get an appointment as soon as you needed?

Q8 In the last 6 months, when you made an appointment for a check-up or routine care with this provider, how often did you get an appointment as soon as you needed?

Q10 In the last 6 months, when you contacted this provider’s office during regular office hours, how often did you get an answer to your medical question that same day?

2. How Well Providers Communicate With Patients. This composite measure is composed of the

following four survey items:

Q11 In the last 6 months, how often did this provider explain things in a way that was easy to understand?

Q12 In the last 6 months, how often did this provider listen carefully to

https://cahps.ahrq.gov/cahps-database/submitting-data/cg-data/index.html


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you?

Q14 In the last 6 months, how often did this provider show respect for what you had to say?

Q15 In the last 6 months, how often did this provider spend enough time with you?

3. Helpful, Courteous, and Respectful Office Staff. This composite measure is composed of the following two survey items:

Q21 In the last 6 months, how often were clerks and receptionists at this provider’s office as helpful as you thought they should be?

Q22 In the last 6 months, how often did clerks and receptionists at this provider’s office treat you with courtesy and respect?

4. Patients’ Rating of the Provider. This is a measure based on the following survey item

Q18 Using any number from 0 to 10, where 0 is the worst provider possible and 10 is the best provider possible, what number would you use to rate this provider?

5. NEW: Providers’ Use of Information to Coordinate Care. This composite measure is composed of the

following three survey items:

Q13 In the last 6 months, how often did this provider seem to know the important information about your medical history?

Q17 In the last 6 months, when this provider ordered a blood test, x-ray, or other test for you, how often did someone from this provider’s office follow up to give you those results?

Q20 In the last 6 months, how often did you and someone from this provider’s office talk about all the prescription medicines you were taking?

Results are reported as “top box” scores for each measure. In other words, the reported score will be the

percentage of responses with the most positive response for the composite measure by clinic.

For survey items with a response scale ranging from Never/Sometimes/Usually/Always, the top box

score is the percentage of respondents answering “Always” to those questions in the composite.

For the provider rating survey item, the top box score is the percentage of respondents awarding a ‘9’

or ‘10’ rating to the provider.

For composite measures, top box scores are calculated by taking the average top box score across all of the

survey times belonging to a given composite. All reported scores are case mix adjusted for three respondent


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demographic characteristics from the survey that have been shown to affect patient reports and ratings of

experience: respondent age, education, and self-reported health status.

Things to Consider

Beyond meeting the requirements for this measure, physician clinics have some additional options they may

want to consider when fielding the CG-CAHPS 3.0 Survey.

1. Increase Sample Size - Physician clinics may voluntarily want to have their survey vendor sample more

than the quantity identified in the Provider Scaling Table (see Appendix One) to ensure that at least the

minimum number of completed responses are received for each clinic. Past response rates to the

Patient Experience of Care survey could help inform this decision. Physician clinics may also survey all

patients with an eligible visit during the measurement period instead of a random sample, if they

choose.

The sample size requirement was based on a response rate of 35 percent - which was reached in 2012.

(The response rate in 2014 fell slightly to 33 percent overall.) Physician clinics may know by experience

that they tend toward lower response rates than 35 percent when surveying. If this is the case, or if the

physician clinic has other reasons to believe it will be difficult to achieve at least 150 survey responses

per clinic, consider sampling a greater number of patients. Certain composite domain measures may

not be publicly reported for the clinic if less than 150 completed returns are received.

2. Add Survey Questions - Physician clinics may want to add additional questions to the CG-CAHPS 3.0

Survey. This is allowed as long as all CAHPS protocols for inserting additional items are followed.

Specialty clinics in particular may want to use specialty-specific CAHPS supplemental questions. CAHPS

supplemental items have a specific protocol for insertion within the survey. However physician clinic or

vendor-created questions must be added only to the end of the survey to avoid biasing the core survey

questions.

Users can adapt some supplemental items developed for the Adult 3.0 Survey that are available on the

CAHPS website. For more information on adding additional survey items, see “Preparing Your

Questionnaire” under Step 2. Administer A Survey, available for download on the CAHPS website. Any

additional questions are for the clinics own use and should not be submitted to MNCM in the final data

file.

3. Translate Survey - The 2016 Patient Experience of Care Survey is only required to be used among

English-speaking patients. However, the use of translated materials is allowed and encouraged. A

version of survey materials in Spanish is already available on the CAHPS website. Other languages may

be available at the time of survey implementation. Contact MNCM at [email protected] if you are

interested in fielding a translated survey.

https://www.cahps.ahrq.gov/surveys-guidance/item-sets/index.html

https://www.cahps.ahrq.gov/surveys-guidance/cg/instructions/index.html

https://www.cahps.ahrq.gov/surveys-guidance/cg/instructions/surveysummary.html



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Whom to Contact for Help

The following resources are available to both physician clinics and survey vendors with questions about the

2016 Patient Experience of Care Survey.

If your questions is about: Contact:

The rule requiring this measure or the

measure specifications

Minnesota Department of Health at

[email protected]

How to implement the measure,

including clarifications on information

provided in this guide

MN Community Measurement at

[email protected] or 612 746-4522

CAHPS Consortium protocols for

fielding the CG-CAHPS 3.0 Survey

The CAHPS Help Line at

[email protected] or 1-800-492-9261

In addition, please visit the MNCM Data Portal and refer to the RESOURCE tab located along the top of the

page for regular updates to Frequently Asked Questions (FAQ) or webinar materials.





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Appendix 1. Measure Eligibility

Eligibility for the Patient Experience of Care survey is based on the table below, whether assessing the Adult or

Child population, for SQRMS or HCH requirements.

Clinic-level eligibility and sample sizes based on number of providers

SQRMS Requirements for non-HCH Clinics: HCH Clinic Requirements:


Threshold for unique patient count


HCH threshold for unique primary care patient count (adult or child)

1-3 450 1-3 450

4-9 550 4-9 550

10-13 600 10-13 600

14+ 900 14+ 900

Step 1. Assess the overall eligible adult population for non-HCH clinics

All clinics (including pediatrics but excluding Psychiatry specialty clinics) should pull a count of all unique adult

patients, 18 and older, who saw any provider specialty (defined as MD, DO, adv NP, PA) for a face-to-face visit

in the clinic during the eligibility period of February 1, 2016 through April 30, 2016.

If that unique adult patient count is equal to or above the “threshold” based on the number of all providers in

that clinic (MD, DO, Adv NP, PA) from the chart above, the clinic is required to field the adult CAHPS 3.0 survey

on adult patients towards the SQRMS requirements.

If the clinic’s unique adult patient count does not hit the threshold, the clinic is not required to do the 3.0

Adult survey. Assessment is completed.

Step 2. Assess the Health Care Home adult population for HCH clinics

As above, for clinics that are Health Care Home certified, the clinic generates a list of all unique adult patients,

18 and older, who were in the clinic for primary care visit during the eligibility period of February 1, 2016

through April 30, 2016.

If that unique adult patient count is equal to or above the threshold based on the number of HCH providers in

the clinic from the chart above, the clinic is required to field the adult 3.0 + PCHM Supplemental Items survey

for its primary care patients towards the HCH requirements. However, if there also are non-HCH certified

providers in the same clinic, then there are the following considerations:

1) The clinic can decide to field the adult core 3.0 survey for non-HCH patients and the adult 3.0 survey +

PCMH Supplemental Items for the HCH patients selected in the sample,

2) or alternatively, the clinic can decide to field the adult 3.0 + PCMH Supplemental Items survey on all

patients randomly selected.


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If the HCH clinic’s unique adult patient count does not hit the patient count threshold, the clinic should

contact the HCH program at [email protected] as a Patient Experience of Care survey is

required under this program.

Step 3. Assess the Health Care Home Child Population for HCH Clinics

Implementing the child CAHPS survey is only a requirement of the Health Care Home program. Therefore, if a

pediatric clinic is HCH certified or has any practicing HCH providers at the site, then the clinic will also have to

assess the count of pediatric patients towards the Child 3.0 + PCMH Supplemental Items survey.

Pediatric HCH clinics should pull a count of all unique pediatric patients, 0-12 years old, who were in the clinic

for a primary care visit only during the eligibility period of February 1, 2016 through April 30, 2016.

If that unique pediatric patient count is equal to or above the threshold based on the number of HCH

providers in the clinic from the chart above, the clinic is required to field the Child 3.0 + PCMH Supplemental

Items survey towards the HCH requirements.

If the clinic’s unique pediatric patient count does not hit the threshold, the clinic should contact the HCH

program at [email protected] as a patient experience survey is required.

Step 4. Register for Patient Experience in the Data Portal

On April 18, 2016, clinics will be instructed to register for Patient Experience in the MNCM Data Portal.


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Step 3 allows groups to indicate if any of their clinics are psychiatry specialty clinics and are therefore

exempted from the measure.

If a clinic is psychiatry-only, the box is checked and that clinic is removed from further measure activity. The

boxes are left unchecked for all other clinics.

This screen incorporates a behind-the-scenes analysis of the total number of providers (by count and HCH

status) to build the eligibility questions for the adult and child populations.

The first set of eligibility questions (by column) relate to the SQRMS requirements for each clinic. The group

answers “yes” or “no” based on the unique patient count from the test file generated in Step 1 above. The

clinic answers these questions and that information is used to assess the adult survey requirements.

The second column builds eligibility questions for a clinic that is flagged as a HCH clinic. The question is

answered based on the results of the unique patient count generated from the test file in Step 2 above. The

clinic answers these questions and that information is used to assess the adult HCH survey requirements.


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All HCH clinics will have to log into the pediatric Patient Experience of Care measure, separate from the adult

measure, and complete the eligibility question based on the results of the unique pediatric patient count

generated from the test file in Step 3 above. The clinic answers these questions and that information is used

to assess pediatric HCH survey requirements.

The MNCM Data Portal will list all survey versions (under each measure) that a clinic is required to do based

on the eligibility questions and display that information.


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Appendix 2. Measure Specifications

Patient Experience of Care Survey Specifications as required under the Minnesota Statewide Quality Reporting

and Measurement System (SQRMS; Minnesota Rules, Chapter 4654)

Patient Experience of Care Specifications 2016 Report Year

Summary of Changes The survey version changed to the adult 3.0 version as recommended by the CAHPS Consortium

Description The CAHPS® Clinician & Group Survey (CG-CAHPS) reports adult patients’ experiences in four domains: access to care, provider communication, courteous & helpful office staff, and a provider rating

Measurement Period September 1, 2016 through November 30, 2016; occurs every other year

Eligible Population Eligible Specialties

Board-certified physicians in all specialties excluding psychiatry-only practices

Eligible Providers Medical Doctor (MD), Doctor of Osteopathy (DO), Physician Assistant (PA), Advanced Practice Registered Nurses (APRN)

Eligible Clinics Clinics with a threshold number of unique patients during the measurement period

Ages English-speaking patients 18 years of age or older as of September 1 of the measurement period

Event At least one face-to-face visit with an eligible provider in an eligible specialty at an eligible clinic during the measurement period

Denominator A random sample of the eligible patient population at each eligible clinic whose experiences were assessed using the CG-CAHPS Adult Survey 3.0 (Six-Month version).

Numerator For each domain, the percentage of respondent patients in the denominator who rated their experiences with the most positive response (“top box”). Each domain is calculated as an individual measure of: access to care, provider communication, courteous & helpful office staff, and a provider rating.

Calculated Exclusions The following exclusions are calculated and applied after data submission:

Patient did not respond to the survey after specified number of attempts

Patient was reported as deceased during the measurement period

Patient reported not seeing the provider indicated

Measure Scoring Rate/Proportion

Interpretation of Score Higher score indicates better quality

Measure Type Survey

For purposes of fulfilling state requirements under Minnesota Rules, Chapter 4654, physician clinics must use a vendor certif ied by CMS to administer

HCAHPS, MA and PDP CAHPS, or CG-CAHPS

http://www.hcahpsonline.org/app_vendor.aspx

http://www.ma-pdpcahps.org/Content/ApprovedSurvey.aspx


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Appendix 3. Timeline

Key Tasks/Milestones Who is Responsible Timelines

First Stage: Pre-Survey (Now through July 15, 2016)

Read this guide, assess eligibility, and

contract for vendor services

Physician clinics and

Survey Vendors

February through

March 2016

Attend Webinar: The 2016 Patient

Experience of Care Survey


Survey Vendors

Early April 2016

MNCM Data Portal opens MN Community

Measurement

April 18, 2016

Designate Survey Contacts in the MNCM Data

Portal


Survey Vendors

April 18, 2016

through July 15, 2016

Submit Pre-Survey Validation Documentation

in the MNCM Data Portal


Survey Vendors

April 18, 2016

through July 15, 2016

Second Stage: Surveying (September 1, 2016 through February 17, 2016)

Identify Eligible Patient Visits and send file to

survey vendor

Physician clinics September 1, 2016

through December 9,

2016

Select Sample of Patients to be Surveyed Survey Vendors September 1, 2016

through December 9,

2016

Field the Survey

Survey Vendors September 1, 2016

through February 17,

2016

Collect Survey Responses Survey Vendors September 1, 2016

through February 17,

2016


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Key Tasks/Milestones Who is Responsible Timelines

Third Stage: Post-Survey (February 17, 2016 through April 5, 2017)

Submit Post-Survey Documentation Survey Vendors February 17, 2016

through April 5, 2017

Aggregation of data and analysis of results MN Community

Measurement

April through May

2017

Public reporting of results by MNCM MN Community

Measurement

August 2017


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Appendix 4. Identifying Eligible Patient Visits

Instructions for Medical Groups

Your survey vendor should provide you with specific instructions on:

The correct format to use when assembling your data file of eligible patient visits;

All of the data elements you will need to include in the file;

How to flag any patient visit that should be excluded from the survey; and

How to securely submit this file to your vendor.

The unit of measurement for the 2016 Patient Experience of Care Survey is the clinic site. Medical groups are

required to identify all eligible patient visits for each clinic that is required to take part in the measure. The

definition of a clinic site follows the definition established during registration in the MNCM Data Portal

required under the SQRMS. Medical groups must identify their clinic sites in the data file by using the MNCM

CLINIC ID as listed in the MNCM Data Portal. Vendors will submit final survey results to MNCM using this same

MNCM CLINIC ID, so it is important that this data element is used consistently throughout the survey process.

If you have any questions about your MNCM Clinic ID, please contact MNCM at [email protected]

What is an eligible patient visit - Eligible patient visits are those visits that meet the measurement

specifications and are therefore eligible to be included in the survey. Any patient visit meeting the following

criteria must be included in your data file. Include each visit that:

Was made to the clinic in-person (i.e., exclude e-mail or telephone consultations),

Was by an English-speaking1 adult patient (i.e., the patient was 18 or older at the time of the visit),

Saw a provider (defined as a physician, advanced practice nurse, or physician assistant) between

o TEST FILE PERIOD: February 1, 2016 – April 30, 2016

o MEASUREMENT PERIOD: September 1, 2016 -November 30, 2016 (inclusive of these dates).

For Health Care Home clinics required to do the CAHPS 3.0 + PCMH Supplemental Items survey for the adult

and/or child populations, identify primary care patient visits that meet the following criteria:

Was made to the clinic in-person (i.e., exclude e-mail or telephone consultations),

Was by an English-speaking2 adult or pediatric patient (i.e., the adult patient was 18 or older at the

time of the visit and the pediatric patient was 12 or younger at the time of the visit),

1 Contact MNCM at [email protected] if you would like to include non-English speakers using a translated survey.

2 Contact MNCM at [email protected] if you would like to include non-English speakers using a translated survey.





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Saw a provider (defined as a physician, advanced practice nurse, or physician assistant)

Was considered a primary care visit (i.e. internal medicine, family practice, pediatrics) between

o TEST FILE PERIOD: February 1, 2016 – April 30, 2016

o MEASUREMENT PERIOD: September 1, 2016 -November 30, 2016 (inclusive of these dates).

Every visit that meets the above criteria must be included in the file regardless of how many times a patient

may have been to the clinic during that period, the reason for the visit, the provider relationship, the patient’s

insurance coverage or lack thereof, the patient’s demographic characteristics, etc. Include all scheduled and

non-scheduled visits.

The only patient visits that do not need to be included in this file are those that were made to the following

specialties:

Psychiatry

Otherwise, all patient visits must be included in the file regardless of the provider’s specialty. Do not exclude

visits to any one provider for any reason. For example, even if the provider only works one day a week at the

clinic or only sees female patients, all visits must be included.

Create a list of all eligible patient visits for any clinic that met the eligibility assessment. These include:

Primary care clinics,

Multispecialty clinics, and

Specialty clinics (i.e., clinics that are composed only of a group of specialists without primary care).

If you will be identifying patient visits using a practice management/billing system, the following CPT codes

may be used but are not all inclusive. Or if your clinic has home-grown codes, these may be used as well. The

critical logic is to use whatever method will guarantee that all eligible visits are identified. You will be asked to

provide the logic for this process in the Pre-Survey Validation document that is loaded to the MNCM Data

Portal.

Description CPT Codes

E & M Codes

Preventive Care Codes

Office Consultation

Individual Counseling

Group Counseling

Other Preventive Medicine Services

Unlisted E & M Codes

99201 – 99205, 99211 – 99215

99381 – 99387, 99391 – 99397

99241 – 99245

99401 – 99404

99411 – 99412

99420, 99429

99499


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Which patients may be flagged for exclusion from the survey - Only survey vendors are allowed to exclude

eligible patient records from the random sample. Medical groups must include all eligible patient visit records

to ensure standardized survey sampling across all participating clinics in the state.

Medical groups and vendors should agree to a method of flagging patients in the sample frame file who

should not receive a survey. Your vendor will likely already have specific instructions on how to do this.

Medical groups must still include all visits by these patients in the data file they supply to their vendor. You

may flag patient visits in the data file for exclusion if the patient:

Was previously surveyed using a CAHPS Clinician & Group tool in the three months prior to the start of

the measurement period (i.e., those who were surveyed with this tool June 1, 2016-August 31, 2016)

as part of a regular, ongoing survey protocol;

Has requested not to receive surveys; or

Is deceased.

Note: Patients who were previously surveyed using any patient survey tool other than the CG-CAHPS tool (i.e.,

the Hospital CAHPS survey, a proprietary vendor survey, a medical group’s own survey) may not be excluded

from the 2016 Patient Experience of Care Survey.


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Appendix 5. Sampling Procedure

Instructions for Survey Vendors

Depending on the requirements of the physician clinic, survey vendors may be sampling continuously

throughout the survey measurement period (i.e., weekly or bi-weekly) or will sample only once at the close of

the measurement period (after November 30, 2016).

Step 1. Create the sample frame. The survey vendor will receive from the physician clinic a data file of all

adult eligible patient visits for each clinic required to take part in the measure. If the clinic is a HCH and

required to field the Child 3.0 + PCMH survey, then the survey vendor will receive a second data file from the

clinic; one for all eligible adult visits and a second for all eligible pediatric visits. From this file(s), the vendor

should generate a list of unique patients for each clinic for each file. For patients who had multiple visits to

the clinic, the most recent visit record should be the one retained for the sample frame. Patients correctly

flagged for exclusion should be removed. This is the sample frame.

Step 2. Draw the survey sample. The unit of measurement for this survey is the clinic. Therefore draw one

random sample for each clinic for each file. The following should guide the development of your sampling

logic:

A random sample equal to the “Sample Size” from the provider scaling table below should be

drawn for each clinic for each file. This “Sample Size” information is retained in the MNCM Data

Portal for each clinic client. Physician clinics and their vendors may decide if it is better to sample

more than this number of patients in order to ensure that at least the number of completed

surveys will be received for the clinic per population. It is also possible to survey the clinic’s entire

sample frame instead of drawing a random sample.

Clinic-level sampling based on number of providers



Required # of Complete Surveys

Sample Size

1-3 1-3 150 450

4-9 4-9 175 550

10-13 10-13 200 600

14+ 14+ 300 900

*For continuous sampling (weekly, biweekly or monthly files), the minimum total number of

surveys to send out over the measurement period should be the “Sample size” count. This may

mean that less than the “Sample size” number of surveys are sent with each sample file over time.

It does not matter if a patient sampled for the survey lives in the same household as another

patient sampled for the survey. Both should be surveyed.


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For continuous surveying, patients previously sampled for the 2016 Patient Experience of Care

Survey early in the measurement period may be excluded if they are sampled again later in the

measurement period for the same clinic.

OVERSAMPLING: For physician clinics that would like to voluntarily oversample in order to achieve a certain

number of completed surveys per provider, specialty, or department, vendors will need to first draw the

random sample from the clinic sample frame for this protocol and from there may go back to oversample at a

particular level. Here is an example:

i. The vendor has created the sample frame for the 12-physician Purple Clinic. A random sample of 715

patients is drawn at the clinic level from this sample frame for the 2016 Patient Experience of Care

Survey. THIS BECOMES THE SAMPLE SUBMITTED FOR THE 2016 PATIENT EXPERIENCE OF CARE SURVEY

AND SHOULD BE TRACKED AS SUCH BY THE VENDOR.

ii. The Purple Clinic wants to make sure all 12 of its physicians have enough surveys returned so it can

report comparisons internally. However, due to random sampling at the clinic level, some of its

physicians had more of their patients selected during the initial sampling for the 2016 Patient

Experience of Care Survey compared to other physicians.

iii. The vendor may now go back to the sample frame and sample additional patients for the physicians

who had fewer patients included in the original sample. THESE SURVEYS ARE NOT CONSIDERED PART

OF THE SAMPLE FOR THE 2016 PATIENT EXPERIENCE AND SHOULD NOT BE SUBMITTED to MNCM.

Step 3. Document exclusions. In only a few cases, randomly selected patients may be excluded from the

survey. It is the survey vendors’ responsibility to track their reason for exclusion and submit documentation of

the exclusion to MNCM. Be prepared to submit the following documentation for any patient that was

removed from the random sample after selection but prior to survey distribution. This does not include

records removed during the de-duplication process. Create an Excel document and use this file layout:

Column Description Format

Medical group ID MNCM medical group ID Text field

Ex: 23

Clinic site ID Medical group’s clinic site ID Text field

Ex: 1515

Patient ID De-identified patient ID – keep a crosswalk for

potential validation

Text field

Ex: 555666777

Number of visits Number of visits the patient had during the time

period

Number

Ex: 2

Date of most

recent visit

Date of the most recent visit within the survey

measurement period of September 1, 2016 –

November 30, 2016

Date field (xx/xx/xxxx)

Ex:10/01/2016


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Provider ID

associated with

most recent visit

Can be an NPI or other physician identified Text field

Ex: 123456858

Exclusion reason Code as follows:

1 = Patient flagged by medical group as previously

surveyed using CG-CAHPS tool (June 1, 2016-

August 31, 2016)

2 = Patient flagged by medical group as

requesting not to receive surveys

3 = Patient flagged by medical group as deceased

4 = Patient previously sampled for the 2016

Patient Experience of Care Survey for this clinic or

surveyed as part of an oversampling methodology

for this survey period

5 = Patient sampled in error

6 = Patient disqualified for survey by vendor (i.e.,

patient information, such as address or telephone

number, that is required to field the survey is

missing or unusable). Note: This exclusion may

only be used after every reasonable attempt is

made to resolve the problem.

Number

Ex: 5


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Appendix 6. Test Sample File Layout


Survey vendors should generate one test sample of 200 randomized patients (for the entire medical group,

not by clinic) for each population (adult or child) and upload the files to the MNCM Data Portal. Each test

sample should contain the following columns:

Patient ID Text field (can be de-identified or randomly assigned)

MNCM Medical Group ID Text field

MNCM Clinic ID Text field

Patient DOB Date format xx/xx/xxxx Example: 02/21/1980

Date of visit Dates between February 1, 2016 – April 30, 2016

Date format xx/xx/xxxx Example: 02/22/2016

Visit service code (CPT code or

EMR visit code)

Text field (structured) xxxxx Example: 99212

Provider ID or NPI Text field

HCH Flag Text field Example: “0” or “1”, or “yes” or “no”

All dates of service should be between February 1, 2016 and April 30, 2016. Provide a code crosswalk for the

EMR visit codes if clinic uses a homegrown system, if applicable.


Page 37 of 82

Appendix 7. MNCM Data Submission File Layouts


The following data submission file layouts are based on the CAHPS Clinician & Group Data File specifications.

Vendors will submit three files for each survey type: Group, Site, and Sample to the National CAHPS Database

(NCBD). Specifications for submitting data files to the NCDB are available at: CAHPS website.

The Sample File will also be submitted to MNCM. For this reason, it is critical the MNCM MEDICAL GROUP ID

and the MNCM CLINIC ID are used consistently. Group, Site, and Sample level data files must be in ascii/flat

format.

The files must contain one record for each member in the sample.

The data files must conform to the layout specifications below.

The files must be in ascii/flat format, not delimited.

A header row cannot be included in the upload.

Do not assign any ID values with leading zeros (0).

CG- CAHPS 3.0 Adult Survey

Variable Description Field

Position Value Labels Details/Comments

Survey Type 1-2 19 = 3.0 Survey Adult Indicates which

instrument was used to

administer the survey.

Unique Record ID 3-12 10 characters Unique ID for each

record in the

Sample file.

MNCM Clinic ID 13-22 10 characters Used to match the

records in this

Sample Level data

file to the Practice

Site data file and

the Group/System

data file.

https://www.cahps.ahrq.gov/cahps-database/submitting-data/index.html


Page 38 of 82




MNCM Medical Group ID 23-32 10 characters Used to match the

records in this

Sample Level data

file to the

Group/System data

file and the

Practice Site data

file.

Physician NPI or ID 33-42 10 characters National Provider

Identifier or a

Unique ID for each

physician.

Physician First Name 43-62 20 characters

Physician Last Name 63-82 20 characters

Provider Type 83-85 101 = Anesthesiologist Assistant 102 = Audiologist 103 = Certified Nurse Midwife 104 = Certified Registered Nurse Anesthetist 105 = Clinical Nurse Specialist 106 = Clinical Psychologist 107 = Clinical Social Worker 108 = Doctor of Osteopathic Medicine (DO) 109 = Doctor of Medicine (MD) 110 = Nurse Practitioner 111 = Occupational Therapist 112 = Physical Therapist 113 = Physician Assistant 114 = Registered Dietitian / Nutrition Professional 115 = Registered Nurse 116 = Speech

Select one provider

type that best

describes the

provider

Physician Specialty 86-88 001 = Allergy/Immunology

002 = Anesthesiology

003 = Cardiology

004 = Child & Adolescent

Psychiatry

005 = Dermatology

What one specialty

category best

describes the

provider


Page 39 of 82




006 = Diagnostic Radiology

007 = Emergency Medicine

008 =

Endocrinology/Metabolism

009 = Family Practice/Family

010 = Forensic Pathology

011 = Gastroenterology

012 = General Practice

013 = General Preventive

Medicine

014 = General Surgery

015 = Geriatrics

016 = Hematology/Oncology

017 = Internal Medicine

018 = Medical Genetics

019 = Nephrology

020 = Neurology

021 = Nuclear Medicine

022 = OB/GYN or GYN

023 = Ophthalmology

024 = Orthopedics

025 = Pathology

026 = Pediatrics

027 = Physical Medicine &

Rehabilitation

028 = Podiatry

029 = Psychiatry

030 = Public Health &

Rehabilitation

031 = Pulmonary Medicine

032 = Radiology

033 = Rheumatology

034 = Surgery

035 = Urology

036 = Vascular Medicine


Pediatrics

998 = Other

M = Missing


Page 40 of 82




Date of Last Visit 89-96 mmddyyyy

M = Missing

8 digit date field

(do not include

dashes or slashes)

Survey Disposition Code 97 1 = Complete

2 = Partial Complete

3= Incomplete

4 = Survey returned – “No” to

Q1

5 = Refused to complete survey

6 = deceased

7 = Ineligible, mentally or

physically incapacitated –

not able to complete

8 = Unable to contact (bad

number, bad address,

language barrier)

9 = Did not respond after

maximum attempts

Disposition that

best represents

final disposition for

this record.

* Complete = Responses are available for at least half of the key survey items and at least one reportable item. * Partial Complete = Responses are available for at least one reportable item, but less than half of the key items. * Incomplete = Individual did not answer at least one reportable item. ** Please refer to

the CAHPS Survey

and Reporting Kit

documents for

additional

information on

complete rules.

Survey Completion Mode 98 1 = Mail 2 = Telephone 3 = IVR - Speech enabled 4 = IVR - Touch tone enabled 5 = Web 6 = Other 7 = Not applicable

NEW: Select the survey completion mode that was used to collect the data. Use “7=Not

applicable” for

respondents with a

Survey Disposition

Code NOT equal to

1, 2, 3, or 4.


Page 41 of 82




Survey Completion Date 99-106 mmddyyyy

M = Missing

8 digit date field

(do not include

dashes or slashes)

Survey Complete Round 107-108 01 = 1st survey completed or

returned

02 = 2nd survey completed or

returned

03 = 3rd survey completed or

returned

04 = 4th survey completed or

returned


returned


returned

NC = Not completed or partial

(Disposition not equal to 11,

12, or 14)

Indicates which

mail, phone, or

web yielded a

completed survey.

If completed or

returned survey

after 6th attempt,

indicate survey

round (01 – 99 are

acceptable values)

Survey Language 109 1 = English

2 = Spanish

3 = Other/Not applicable

M = Missing

Use “Other/Not

applicable” for

respondents with

Survey Disposition

Code NOT equal to

1, 2, 3.

Patient Birth Year 110-113 yyyy

M = Missing

Patient’s year of

birth

Submission fails if all data are blank for this field AND Q25.

Patient Gender 114 1 = Male

2 = Female

M = Missing

Patient zip code 115-119 xxxxx

M= Missing

5 digit zip code


Page 42 of 82




Q1. Our records show that

you got care from the

provider named below in the

last 6 months. Is that right?

120 1 = Yes

2 = No

H = Multiple mark

M = Missing

Q2. Is this the provider you

usually see if you need a

check-up, want advice about

a health problem, or get sick

or hurt?

121 1 = Yes

2 = No

S = Appropriately skipped

H = Multiple mark

M = Missing

Q3. How long have you been

going to this provider?

122 1 = Less than 6 months

2 = At least 6 months but less

than 1 year

3 = At least 1 year but less than

3 years

4 = At least 3 years but less than

5 years

5 = 5 years or more


H = Multiple mark

M = Missing

Q4. In the last 6 months, how

many times did you visit this

provider to get care for

yourself?

123 1 = None

2 = 1 time

3 = 2

4 = 3

5 = 4

6 = 5 to 9

7 = 10 or more times


H = Multiple mark

M = Missing

Q5. In the last 6 months, did

you contact this provider’s

office to get an appointment

for an illness, injury or

condition that needed care

right away?

124 1 = Yes

2 = No


H = Multiple mark

M = Missing


Page 43 of 82




Q6. In the last 6 months,

when you contacted this

provider’s office to get an

appointment for care you

needed right away, how

often did you get an

appointment as soon as you

needed?

125 1 = Never

2 = Sometimes

3 = Usually

4 = Always


H = Multiple mark

M = Missing


you make any appointments

for a check-up or routine care

with this provider?

126 1 = Yes

2 = No


H = Multiple mark

M = Missing


when you made an

appointment for a check-up

or routine care with this

provider, how often did you

get an appointment as soon

as you needed?

127 1 = Never

2 = Sometimes

3 = Usually

4 = Always


H = Multiple mark

M = Missing



office with a medical question

during regular office hours?

128 1 = Yes

2 = No


H = Multiple Mark

M = Missing



provider’s office during

regular office hours, how

often did you get an answer

to your medical question that

same day?

129 1 = Never

2 = Sometimes

3 = Usually

4 = Always


H = Multiple mark

M = Missing


Page 44 of 82





how often did this provider

explain things in a way that

was easy to understand?

130 1 = Never

2 = Sometimes

3 = Usually

4 = Always


H = Multiple mark

M = Missing


when you phoned this

provider’s office after regular

office hours, how often did

you get an answer to your

medical question as soon as

you needed?

131 1 = Never

2 = Sometimes

3 = Usually

4 = Always


H = Multiple mark

M = Missing



seem to know the important

information about your

medical history?

132 1 = Never

2 = Sometimes

3 = Usually

4 = Always


H = Multiple mark

M = Missing



show respect for what you

had to say?

133 1 = Never

2 = Sometimes

3 = Usually

4 = Always


H = Multiple mark

M = Missing



spend enough time with you?

134 1 = Never

2 = Sometimes

3 = Usually

4 = Always


H = Multiple mark

M = Missing


Page 45 of 82





this provider order a blood

test, x-ray, or other test for

you?

135 1 = Yes

2 = No


H = Multiple mark

M = Missing


when this provider ordered a

blood test, x-ray, or other test

for you, how often did

someone from this provider’s

office follow up to give you

those results?

136 1 = Never

2 = Sometimes

3 = Usually

4 = Always


H = Multiple mark

M = Missing

Q18. Using any number from

0 to 10, where 0 is the worst

provider possible and 10 is

the best provider possible,

what number would you use

to rate this provider?

137-138 00 = 0 Worst provider possible

01 = 1

02 = 2

03 = 3

04 = 4

05 = 5

06 = 6

07 = 7

08 = 8

09 = 9

10 = 10 Best provider possible


H = Multiple Mark

M = Missing


you take any prescription

medicine?

139 1 = Yes

2 = No


H = Multiple mark

M = Missing


how often did you and


office talk about all the

prescription medicines you

were taking?

140 1 = Never

2 = Sometimes

3 = Usually

4 = Always


H = Multiple mark

M = Missing


Page 46 of 82





how often were clerks and

receptionists at this

provider’s office as helpful as

you thought they should be?

141 1 = Never

2 = Sometimes

3 = Usually

4 = Always


H = Multiple mark

M = Missing


how often did clerks and

receptionists at this

provider’s office treat you

with courtesy and respect?

142 1 = Never

2 = Sometimes

3 = Usually

4 = Always


H = Multiple mark

M = Missing

Q23. In general, how would

you rate your overall health?

143 1 = Excellent

2 = Very good

3 = Good

4 = Fair

5 = Poor

H = Multiple Mark

M = Missing


you rate your overall mental

or emotional health?

144 1 = Excellent

2 = Very good

3 = Good

4 = Fair

5 = Poor

H = Multiple Mark

M = Missing

Q25. What is your age? 145 1 = 18 to 24

2 = 25 to 34

3 = 35 to 44

4 = 45 to 54

5 = 55 to 64

6 = 65 to 74

7 = 75 or order

H = Multiple mark

M = Missing


Page 47 of 82




Q26. Are you male or female? 146 1 = Male

2 = Female

H = Multiple Mark

M = Missing

Q27. What is the highest

grade or level of school that

you have completed?

147 1 = 8th grade or less

2 = Some high school, but did

not graduate

3 = High school graduate or GED

4 = Some college or 2-year

degree

5 = 4-year college graduate

6 = More than 4-year college

degree

H = Multiple Mark

M = Missing

Q28. Are you of Hispanic or

Latino decent?

148 1 = Yes, Hispanic or Latino

2 = No, not Hispanic or Latino

H = Multiple Mark

M = Missing

Q29a. What is your race?

Mark one or more. White

149 0 = Not Selected

1 = Selected

Q29b. What is your race?

Black or African American


1 = Selected

Q29c. What is your race?

Asian


1 = Selected

Q29d. What is your race?

Native Hawaiian or other

Pacific Islander


1 = Selected

Q29e. What is your race?

(Please check one or more.)

American Indian or Alaska

Native


1 = Selected


Page 48 of 82




Q29f. What is your race?


Other


1 = Selected

Q30. Did someone help you

complete this survey?

155 1 = Yes

2 = No

H = Multiple mark

M = Missing

Q31a. How did that person

help you? Mark one or more.

Read the questions to me.


1 = Selected


Q31b. How did that person


Wrote down the answers I

gave


1 = Selected


Q31c. Answered the

questions for me


1 = Selected


Q31d. How did that person

help you? Mark all that apply.

Translated the questions into

my language


1 = Selected


Q31e. How did that person


Helped in some other way


1 = Selected

S= Appropriately skipped


Page 49 of 82

Data Layout for the CG-CAHPS Adult 3.0 + PCMH Supplemental

Items survey These data layouts are preliminary and will be finalized in early 2017 when the

final CAHPS layouts are released by the CAHPS Consortium. The files must contain one record for each member in the sample.




CG-CAHPS Adult 3.0 + PCMH Supplemental Items


Position

Value Labels Details/Comments

Survey Type 1-2 20= Adult 3.0 + PCMH Survey Indicates which

instrument was

used to administer

the survey.


record in the

Sample file.


records in this

Sample Level data


Site data file and

the Group/System

data file.


records in this

Sample Level data

file to the

Group/System data

file and the Practice

Site data file.


Identifier or a

Unique ID for each

physician.



Page 50 of 82




003 = Cardiology


Psychiatry

005 = Dermatology



008 =







Medicine


015 = Geriatrics




019 = Nephrology

020 = Neurology


022 = OB/GYN or GYN

023 = Ophthalmology

024 = Orthopedics

025 = Pathology

026 = Pediatrics


Rehabilitation

028 = Psychiatry


Rehabilitation


031 = Radiology

032 = Rheumatology

033 = Surgery

034 = Urology



Pediatrics

What one specialty

category best

describes the

physician.


Page 51 of 82

998 = Other

999 = Missing

Physician Gender 86 1 = Male

2 = Female

9 = Missing


99999999 = Missing

8 digit date field

(do not include

dashes or slashes)

Survey Disposition Code 95-96 11 = Mail Complete

12 = Phone Complete

13= IVR Complete

14 = Web/Internet Complete

21 = Mail Partial Complete

22 = Phone Partial Complete

23 = IVR Partial Complete

24 = Web/Internet Partial

Complete

31 = Deceased

32 = Survey returned -“No” to

Question 1

33 = Language barrier

34 = Unable to contact – Bad

address


phone number

36 = Ineligible; mentally or

physically

incapacitated – not able to

complete survey.

37 = Refused to complete

survey


maximum attempts

Disposition that

best represents final

disposition for this

record.


99999999 = Missing

8 digit date field

(do not include

dashes or slashes)


Page 52 of 82


returned


returned


returned


returned


returned


returned



12, or 14)

Indicates which

mail, phone, or web

yielded a completed

survey.

If completed or

returned survey

after 6th attempt,

indicate survey


acceptable values)


2 = Spanish


9 = Missing

Other/Not

applicable (use for

members with

Survey Disposition

Code NOT equal to

11 – 26)


9999 = Missing

Patient’s year of

birth


2 = Female

9 = Missing


99999 = Missing

5 digit zip code

Q1. Our records show that you

got care from the provider

named below in the last 6

months. Is that right?

118 1 = Yes

2 = No

8 = Multiple mark

9 = Missing


usually see if you need a check-

up, want advice about a health

problem, or get sick or hurt?

119 1 = Yes

2 = No

7 = Appropriately skipped

8 = Multiple mark

9 = Missing


Page 53 of 82

Q3. How long have you been

going to this provider?



than 1 year

3 = At least 1 year but less than

3 years

4 = At least 3 years but less

than 5 years

5 = 5 years or more


8 = Multiple mark

9 = Missing


many times did you visit this

provider to get care for

yourself?

121-122 1 = None

2 = 1 time

3 = 2

4 = 3

5 = 4

6 = 5 to 9



88 = Multiple mark

99 = Missing




for an illness, injury or

condition that needed care

right away?

123 1 = Yes

2 = No


8 = Multiple mark

9 = Missing

Q6. In the last 6 months, when

you phoned this provider’s


for care you needed right

away, how often did you get

an appointment as soon as you

needed?

124 1 = Never

2 = Sometimes

3 = Usually

4 = Always


8 = Multiple mark

9 = Missing




with this provider?

125 1 = Yes

2 = No


8 = Multiple mark

9 = Missing


Page 54 of 82

Q8. In the last 6 months, when

you made an appointment for

a check-up or routine care

with this provider, how often

did you get an appointment as

soon as you needed?

126 1 = Never

2 = Sometimes

3 = Usually

4 = Always


8 = Multiple mark

9 = Missing

Q9. Did this provider’s office

give you information about

what to do if you needed care

during evenings, weekends, or

holidays?

127 1 = Yes

2 = No


8 = Multiple Mark

9 = Missing

PCMH

supplemental item




during regular office hours?

128 1 = Yes

2 = No


8 = Multiple Mark

9 = Missing



provider’s office during regular

office hours, how often did you

get an answer to your medical

question that same day?

129 1 = Never

2 = Sometimes

3 = Usually

4 = Always


8 = Multiple mark

9 = Missing


often did this provider explain

things in a way that was easy

to understand?

130 1 = Never

2 = Sometimes

3 = Usually

4 = Always


8 = Multiple mark

9 = Missing


often did this provider listen

carefully to you?

131 1 = Never

2 = Sometimes

3 = Usually

4 = Always


8 = Multiple mark

9 = Missing


Page 55 of 82


often did this provider seem to

know the important

information about your

medical history?

132

1 = Never

2 = Sometimes

3 = Usually

4 = Always


8 = Multiple mark

9 = Missing


often did this provider show

respect for what you had to

say?

133 1 = Never

2 = Sometimes

3 = Usually

4 = Always


8 = Multiple mark

9 = Missing


often did this provider spend

enough time with you?

134 1 = Never

2 = Sometimes

3 = Usually

4 = Always


8 = Multiple mark

9 = Missing




you?

135 1 = Yes

2 = No


8 = Multiple Mark

9 = Missing




for you, how often did



those results??

136 1 = Never

2 = Sometimes

3 = Usually

4 = Always


8 = Multiple mark

9 = Missing


Page 56 of 82

Q19. Using any number from 0

to 10, where 0 is the worst

provider possible and 10 is the

best provider possible, what

number would you use to rate

this provider?


1 = 1

2 = 2

3 = 3

4 = 4

5 = 5

6 = 6

7 = 7

8 = 8

9 = 9



88 = Multiple Mark

99 = Missing

Q20. Specialists are doctors

like surgeons, heart doctors,

allergy doctors, skin doctors,

and other doctors, who

specialize in one area of health

care. In the last 12 months, did

you see a specialist for a

particular health problem?

139 1 = Yes

2 = No


8 = Multiple mark

9 = Missing

PCMH

Supplemental Item


how often did the provider in

Question 1 seem informed and

up-to-date about the care you

got from specialists?

140 1 = Never

2 = Sometimes

3 = Usually

4 = Always


8 = Multiple mark

9 = Missing

PCMH

Supplemental Item



office talk with you about

specific goals for your health?

141 1 = Yes

2 = No


8 = Multiple mark

9 = Missing

PCMH

Supplemental Item


anyone in this provider’s office

ask you if there are things that

make it hard for you to take

care of your health?

142 1 = Yes

2 = No


8 = Multiple mark

9 = Missing

PCMH

Supplemental Item


Page 57 of 82


you and someone from this

provider’s office talk about

things in your life that worry

you or cause you stress?

143 1 = Yes

2 = No


8 = Multiple mark

9 = Missing

PCMH

Supplemental

Items


you take any prescription

medicine?

144 1 = Yes

2 = No


8 = Multiple mark

9 = Missing


how often did you and


office talk about all the

prescription medicines you

were taking?

145 1 = Never

2 = Sometimes

3 = Usually

4 = Always


8 = Multiple mark

9 = Missing


how often were clerks and

receptionists at this provider’s

office as helpful as you thought

they should be?

146 1 = Never

2 = Sometimes

3 = Usually

4 = Always


8 = Multiple mark

9 = Missing


often did clerks and


office treat you with courtesy

and respect?

147 1 = Never

2 = Sometimes

3 = Usually

4 = Always


8 = Multiple mark

9 = Missing


you rate your overall health?

148 1 = Excellent

2 = Very good

3 = Good

4 = Fair

5 = Poor

8 = Multiple Mark

9 = Missing


Page 58 of 82


you rate your overall mental or

emotional health?

149 1 = Excellent

2 = Very good

3 = Good

4 = Fair

5 = Poor

8 = Multiple Mark

9 = Missing

Q31. What is your age? 150 1 = 18 to 24

2 = 25 to 34

3 = 35 to 44

4 = 45 to 54

5 = 55 to 64

6 = 65 to 74

7 = 75 or order

8 = Multiple mark

9 = Missing


2 = Female

8 = Multiple Mark

9 = Missing

Q33. What is the highest grade

or level of school that you have

completed?


2 = Some high school, but did

not graduate

3 = High school graduate or

GED

4 = Some college or 2-year

degree



degree

8 = Multiple Mark

9 = Missing

Q34. Are you of Hispanic or

Latino decent?



8 = Multiple Mark

9 = Missing

Q35a. What is your race?

Mark one or more. White


1 = Selected


Page 59 of 82

Q35b. What is your race?

Black or African American


1 = Selected

Q35c. What is your race?

Asian


1 = Selected

Q35d. What is your race?


Pacific Islander


1 = Selected




Native


1 = Selected



Other


1 = Selected



160 1 = Yes

2 = No

8 = Multiple mark

9 = Missing



Read the questions to me.


1 = Selected




Wrote down the answers I

gave


1 = Selected


Q37c. How did that person


Answered the questions for me


1 = Selected





my language


1 = Selected



Page 60 of 82





1 = Selected



Page 61 of 82

Data Layout for the CG-CAHPS Child 3.0 + PCMH Supplemental Items survey

These data layouts are preliminary and will be finalized in early 2017 when the

final CAHPS layouts are released by the CAHPS Consortium.

The files must contain one record for each member in the sample.




CG-CAHPS Child 3.0 + PCMH Supplemental Items


Position

Value Labels Details/Comments

Survey Type 1-2 22 = Child 3.0 + PCMH Survey Indicates which

instrument was

used to administer

the survey.


record in the

Sample file.


records in this

Sample Level data


Site data file and

the Group/System

data file.


records in this

Sample Level data

file to the

Group/System data

file and the Practice

Site data file.


Identifier or a

Unique ID for each

physician.




Page 62 of 82



003 = Cardiology


Psychiatry

005 = Dermatology



008 =







Medicine


015 = Geriatrics




019 = Nephrology

020 = Neurology


022 = OB/GYN or GYN

023 = Ophthalmology

024 = Orthopedics

025 = Pathology

026 = Pediatrics


Rehabilitation

028 = Psychiatry


Rehabilitation


031 = Radiology

032 = Rheumatology

033 = Surgery

034 = Urology



Pediatrics

998 = Other

What one specialty

category best

describes the

physician.


Page 63 of 82

999 = Missing

Physician Gender 86 1 = Male

2 = Female

9 = Missing


99999999 = Missing

8 digit date field

(do not include

dashes or slashes)

Survey Disposition Code 95-96 11 = Mail Complete

12 = Phone Complete

13= IVR Complete

14 = Web/Internet Complete

21 = Mail Partial Complete

22 = Phone Partial Complete

23 = IVR Partial Complete

24 = Web/Internet Partial

Complete

31 = Deceased

32 = Survey returned -“No” to

Question 1

33 = Language barrier


address


phone number

36 = Ineligible; mentally or

physically

incapacitated – not able to

complete survey.

37 = Refused to complete survey


maximum attempts

Disposition that

best represents final

disposition for this

record.


99999999 = Missing

8 digit date field

(do not include

dashes or slashes)


Page 64 of 82


returned


returned


returned


returned


returned


returned



12, or 14)

Indicates which

mail, phone, or web

yielded a completed

survey.

If completed or

returned survey

after 6th attempt,

indicate survey


acceptable values)


2 = Spanish


9 = Missing

Other/Not

applicable (use for

members with

Survey Disposition

Code NOT equal to

11 – 26)


9999 = Missing

Patient’s year of

birth


2 = Female

9 = Missing


99999 = Missing

5 digit zip code

Q1. Our records show that your

child got care from the

provider named below in the

last 6 months. Is that right?

118 1 = Yes

2 = No

8 = Multiple mark

9 = Missing


usually see if your child needs a

check-up, or gets sick or hurt?

119 1 = Yes

2 = No


8 = Multiple mark

9 = Missing


Page 65 of 82

Q3. How long has your child

been going to this provider?



than 1 year

3 = At least 1 year but less than 3

years

4 = At least 3 years but less than 5

years

5 = 5 years or more


8 = Multiple mark

9 = Missing


many times did your child visit

this provider for care?

121-122 1 = None

2 = 1 time

3 = 2

4 = 3

5 = 4

6 = 5 to 9



88 = Multiple mark

99 = Missing


you ever stay in the exam room

with your child during a visit to

this provider?

123 1 = Yes

2 = No


8 = Multiple mark

9 = Missing

Q6. Did this provider give you

enough information about

what was discussed during the

visit when you were not there?

124 1 = Yes

2 = No


8 = Multiple mark

9 = Missing

Q7. Is your child able to talk

with providers about his or her

health care?

125 1 = Yes

2 = No


8 = Multiple mark

9 = Missing


Page 66 of 82



things in a way that was easy

for your child to understand?

126 1 = Never

2 = Sometimes

3 = Usually

4 = Always


8 = Multiple mark

9 = Missing


often did this provider listen

carefully to your child?

127 1 = Never

2 = Sometimes

3 = Usually

4 = Always


8 = Multiple mark

9 = Missing

Q10. Did this provider tell you

that you needed to do anything

to follow up on the care your

child got during the visit?

128 1 = Yes

2 = No


8 = Multiple Mark

9 = Missing

Q11. Did this provider give you

enough information about

what you needed to do follow

up on your child’s care?

129 1 = Yes

2 = No


8 = Multiple Mark

9 = Missing




for your child for an illness,

injury, or condition that

needed care right away?

130 1 = Yes

2 = No


8 = Multiple Mark

9 = Missing



provider’s office to get an

appointment for care your

child needed right away, how

often did you get an

appointment as soon as your

child needed?

131 1 = Never

2 = Sometimes

3 = Usually

4 = Always


8 = Multiple mark

9 = Missing


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for your child with this

provider?

132 1 = Yes

2 = No


8 = Multiple Mark

9 = Missing


when you made an

appointment for a check-up or

routine care for your child with

this provider, how often did

you get an appointment as

soon as your child needed?

133 1 = Never

2 = Sometimes

3 = Usually

4 = Always


8 = Multiple mark

9 = Missing

Q16. Did this provider’s office

give you information about

what to do if your child needed

care during evenings,

weekends, or holidays?

134 1 = Yes

2 = No


8 = Multiple Mark

9 = Missing

PCMH

Supplemental

Item




about your child during regular

office hours?

135 1 = Yes

2 = No


8 = Multiple Mark

9 = Missing



provider’s office during regular

office hours, how often did you

get an answer to your medical

question that same day?

136 1 = Never

2 = Sometimes

3 = Usually

4 = Always


8 = Multiple mark

9 = Missing



things about your child’s health

in a way that was easy to

understand?

137 1 = Never

2 = Sometimes

3 = Usually

4 = Always


8 = Multiple mark

9 = Missing


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listen carefully to you?

138 1 = Never

2 = Sometimes

3 = Usually

4 = Always


8 = Multiple mark

9 = Missing


often did this provider seem to

know the important

information about your child’s

medical history?

139 1 = Never

2 = Sometimes

3 = Usually

4 = Always


8 = Multiple mark

9 = Missing



show respect for what you had

to say?

140 1 = Never

2 = Sometimes

3 = Usually

4 = Always


8 = Multiple mark

9 = Missing

Q23. In the past 6 months,


spend enough time with your

child?

141 1 = Never

2 = Sometimes

3 = Usually

4 = Always


8 = Multiple mark

9 = Missing

Q24. In the past 6 months, did



your child?

142 1 = Yes

2 = No


8 = Multiple mark

9 = Missing




for your child, how often did



those results?

143 1 = Never

2 = Sometimes

3 = Usually

4 = Always


8 = Multiple mark

9 = Missing


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Q26. Using any number from 0

to 10, where 0 is the worst

provider possible and 10 is the

best provider possible, what

number would you use to rate

this provider?


1 = 1

2 = 2

3 = 3

4 = 4

5 = 5

6 = 6

7 = 7

8 = 8

9 = 9



88 = Multiple Mark

99 = Missing

Q27. Specialists are doctors like

surgeons, heart doctors, allergy

doctors, skin doctors, and

other doctors who specialize in

one area of health care. In the

last 6 months, did your child

see a specialist for a particular

health problem?

146 1 = Yes

2 = No


8 = Multiple Mark

9 = Missing

PCMH

Supplemental Item


often did the provider named

in Question 1 seem informed

and up-to-date about the care

your child got from specialists?

147 1 = Never

2 = Sometimes

3 = Usually

4 = Always


8 = Multiple mark

9 = Missing

PCMH

Supplemental Item



provider’s office talk about the

kinds of behaviors that are

normal for your child at this

age?

148 1 = Yes

2 = No


8 = Multiple Mark

9 = Missing

PCMH

Supplemental Item




how your child’s body is

growing?

149 1 = Yes

2 = No


8 = Multiple Mark

9 = Missing

PCMH

Supplemental Item


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you and anyone in this


your child’s moods and

emotions?

150 1 = Yes

2 = No


8 = Multiple mark

9 = Missing

PCMH

Supplemental Item




things you can do to keep your

child from getting injured?

151 1 = Yes

2 = No


8 = Multiple mark

9 = Missing

PCMH

Supplemental Item




how much or what kind of food

your child eats?

152 1 = Yes

2 = No


8 = Multiple mark

9 = Missing

PCMH

Supplemental Item


you and anyone in this


how much or what kind of

exercise your child gets?

153 1 = Yes

2 = No


8 = Multiple mark

9 = Missing

PCMH

Supplemental Item




how your child gets along with

others?

154 1 = Yes

2 = No


8 = Multiple mark

9 = Missing

PCMH

Supplemental Item


often were clerks and


office as helpful as you thought

they should be?

155 1 = Never

2 = Sometimes

3 = Usually

4 = Always


8 = Multiple mark

9 = Missing


often did clerks and


office treat you with courtesy

and respect?

156 1 = Never

2 = Sometimes

3 = Usually

4 = Always


8 = Multiple mark

9 = Missing


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you rate your child’s overall

health?

157 1 = Excellent

2 = Very good

3 = Good

4 = Fair

5 = Poor

8 = Multiple mark

9 = Missing


you rate your child’s overall

mental or emotional health?

158 1 = Excellent

2 = Very good

3 = Good

4 = Fair

5 = Poor

8 = Multiple mark

9 = Missing

Q40. What is your child’s age? 159-160 0 = Less than 1 year old

Enter reported age if one year or

older

88 = Multiple mark

99 = Missing

Q41. Is your child male or

female?

161 1 = Male

2 = Female

8 = Multiple mark

9 = Missing

Q42. Is your child of Hispanic

or Latino origin or descent?



8 = Multiple mark

9 = Missing

Q43a. What is your child’s race? White


1 = Selected

Q43b. What is your child’s race? Black or African American


1 = Selected

Q43c. What is your child’s race? Asian


1 = Selected


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Q43d What is your race?


Pacific Islander


1 = Selected



Native


1 = Selected


Other


1 = Selected

Q44. What is your age? 169 0 = Under 18

1 = 18 to 24

2 = 25 to 34

3 = 35 to 44

4 = 45 to 54

5 = 55 to 64

6 = 65 to 74

7 = 75 or order

8 = Multiple mark

9 = Missing


2 = Female

8 = Multiple Mark

9 = Missing

Q46. What is the highest grade

or level of school that you have

completed?


2 = Some high school, but did not

graduate

3 = High school graduate or GED

4 = Some college or 2-year degree



degree

8 = Multiple Mark

9 = Missing


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Q47. How are you related to

the child?

172 1 = Mother or Father

2 = Grandparent

3 = Aunt or Uncle

4 = Older brother or sister

5 = Other relative

6 = Legal guardian

7 = Someone else

8 = Multiple mark

9 = Missing



173 1 = Yes

2 = No


8 = Multiple mark

9 = Missing


help you? Read the questions

to me.


1 = Selected



help you? Wrote down the

answers I gave


1 = Selected


Q49c. How did that person

help you? Answered the

questions for me


1 = Selected



help you?


my language


1 = Selected



help you?



1 = Selected



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Appendix 8. Post-Survey Documentation & Data Upload


Vendors are required to upload the final survey data file(s) to the MNCM Data Portal no later than April 5,

2017. In addition, MNCM expects each vendor to work with their clients to also be abke to upload data files to

the National CAHPS Benchmarking Database (NCBD). Each survey type fielded requires a separate data upload

(Adult CAHPS 3.0, Adult CAHPS 3.0 + PCMH Supplemental Items, Child 3.0 + PCMH Supplemental Items). In

conjunction with the upload(s), there are “Post-Survey” steps that are required to be completed by vendors

before the data submission can be accepted by MNCM.

On your vendor homepage, this area is displayed for each medical group contracted with the vendor and the

“Post-Survey Documentation and Data Upload” section shows red for incomplete status. This area refers to

the adult CAHPS survey.

Any clinic within the vendor’s assigned medical groups that was a Health Care Home (HCH) at the beginning of

the Patient Experience of Care measure process, will have two separate areas that display to account for the

potential of two survey versions: adult 3.0 core survey, and 3.0 + PCMH Supplemental Items survey.

(Note: these screen shots are from the 2014 cycle and have not been updated yet to reflect the 3.0 survey

name.)


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Step 1. Enter Summary Statistics for Adult Survey(s)

Each medical group for which you fielded adult surveys requires summary statistics entered under step 1:

“Enter Summary Statistics” from the Post-Survey Documentation and Data Upload area.

It is critical you enter summary statistics for each clinic in the medical group under the correct survey

version area based on what survey type was fielded. The counts entered under each section are directly

connected to internal review of the data file(s) that are uploaded. Incorrect record counts entered in this

area will cause the data file upload(s) to fail.

Survey Scenarios

If your medical group client does not have any HCH clinics, your display will only include “Adult 3.0 CAHPS

Survey” to indicate that only the 3.0 core survey was fielded.

If your medical group client has some or all HCH clinics, your display will also include “Adult 3.0 + PCMH Survey

(HCH)”. For any clinic (whether HCH or not) in the medical group that had the adult CAHPS 3.0 + PCMH Survey

fielded, the summary statistics should only be entered under “Enter Summary Statistics” on the right side of

the display. Any other clinics under the same medical group who had the Adult 3.0 core survey fielded should

have their statistics entered under “Enter Summary Statistics” on the left side of the screen.


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Click on “Enter Summary Statistics” on left or right section to open the entry page.

On the “Enter Summary Statistics” screen, each clinic under your medical group client will be listed. In the

image above, “Test Clinic 1” with ID=2274 is listed as an example.

It is possible that not all eligible clinics went on to surveying; that decision is made by the medical group. If

your live files from the medical group did not contain any records for a particular clinic that is displaying, check

“Not Reporting” on the far right side of the screen. This will indicate no data in the final data file exists for this

clinic ID.

Conversely, if the “Not Reporting” checkbox is marked but you did survey for that clinic, simply uncheck the

box and enter the summary statistics.

If there is survey data in the final file for a clinic whose clinic ID does not show on this screen, please contact

MNCM as the data file submission will fail until all clinic IDs in the data file are accurately reflected in the

MNCM Data Portal.

Reminder: If you fielded both adult survey versions for a clinic (3.0 core and 3.0 + PCMH), this process has to

be completed in both survey areas. You will enter summary statistics for the same clinic ID in two areas.


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Field Descriptors

Field Can it be blank? Must be >0? Other conditions/comments

No. of Patient Visits Submitted by Medical Group

No - required Yes

This is the total number of visit records sent to you by the group for the three-month measurement period, per clinic ID.

No. of Unique Patients Identified for Sample Frame

No - required Yes

This is the total number of unique (de-duped) patient records from the files for the three-month measurement period, per clinic ID. Note: Count prior to sampling process.

No. of Excluded Patients

Yes No This is the total number of excluded records before sampling for the three-month measurement period, per clinic ID. If there is a numeric entry here, the total submission will not be complete until there is an exclusions file uploaded in Step 1.

No. of Surveys Sent/Attempted

No - required Yes This is the total number of surveys distributed, per clinic ID. This field is compared to the number of records in the data file for successful upload.

No. of Surveys Returned

No - required Yes This is the total number of surveys returned, per clinic ID. Note: This number cannot be > “No. of Surveys Sent/Attempted.”

Not Reporting checkbox

Yes n/a This should be checked if the clinic was not included in the files sent to you by the group or if no surveys of this type were sent for this clinic ID.

Complete Entry

Complete entry of one or both Summary Statistics, based on the survey version fielded, for every clinic listed.

Ensure the statistics are entered correctly; particularly, check that any clinics showing on the Summary

Statistics screen that you did not field surveys for has the corresponding “Not Reporting” checkbox marked.

Medical groups with HCH clinics have both survey sections showing, and if you fielded only one survey type;

the Not Reporting” checkbox should be marked for that clinic on the other survey section. For example, if you

fielded only the 3.0 core survey for a HCH clinic, you enter summary statistics in the section on the left side of

the screen and you check the “Not Reporting” box for that clinic in the section on the right side of the screen.

If field descriptor entry rules are not kept, the file upload will fail and error messages will generate that

require file correction and re-upload.


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After all clinic-level summary statistic entries are accepted, a medical group summary line will be generated.

Verify that the Number of Surveys Sent/Attempted count is equal to the total number of lines in the final data

file. The number of records for each clinic ID within the file must match the Number of Surveys

Sent/Attempted total at the clinic level.

If changes are needed, click “Edit.” If you have verified that the counts match, click “Verify” and the counts

entered will be accepted.

Step 2. Exclusions File

Any patient record in the de-duped random sample that was later flagged by the clinic/medical group and

subsequently removed from the random sample by the vendor must be documented in an Exclusions File.

Additionally, the vendor may learn of an accepted exclusion reason (e.g., death) after surveying begins.

The record layout for this file can be found on page 31 of the Data Collection Guide and should be created as

an Excel file. The Exclusion File is uploaded under Step 2 and saved to the MNCM Data Portal.

If no records were excluded during sampling and surveying, a file is not required and this step can be skipped.

Step 3. Upload Detailed Data File

The final survey data file for each survey fielded should be uploaded and attached. Acceptable file layouts are

in Appendix Seven of the Data Collection Guide. All files must be a flat ASCII file, either .txt or .dat format and

each medical group requires a separate file upload.


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The final survey data file must be uploaded under the appropriate survey section: either “Adult 3.0 CAHPS

Survey” or “Adult 3.0 + PCMH Survey (HCH),” based on which survey was fielded. The MNCM Data Portal

recognizes these surveys as unique and distinct. If you fielded both surveys for one clinic, you must separate

the results into separate data files.

Once a file is attached, click “Submit.” The following status screen will display while the MNCM Data Portal

checks the file.

Warnings do not prevent a successful file upload; however, warning messages should be reviewed for

potential data integrity issues.

Errors must be corrected for a successful upload. Error descriptions can be reviewed by clicking “View Errors &

Warnings.” If your file submission has errors, the only option offered will be “Re-Upload Data File.”


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If the quality checks pass the file and/or only “warnings” are displayed, or after you’ve corrected the errors

and re-uploaded the file so it passes the quality check, click “Continue” on the far right.

Complete this process for both post-survey areas if you fielded both survey types for a medical group.

Once a file has passed the quality check and “Continue” is selected, an attestation screen summarizing the file

will display. This screen provides preliminary return and response rates based on the initial data. These rates

should be checked against your own response rate calculations.

The response rate is generated based on the CAHPS definition of response - where the equation is (total # of

“completes”/ # sent – (deceased + ineligible)) – both per clinic and by medical group. Ineligibles are removed

from the denominator for records that answered “none” to Q4 (“In the last six months, how many times did you

visit this provider to get care for yourself?”). The return rate is calculated by MNCM. The equation is (total #

returned / total # sent) both per clinic and by medical group.

If the displayed rates do not match your internal rates, corrections can be made by clicking “Re-Upload Data

File” button. Otherwise, select “Submit Data to MNCM.”

Once submitted, a final status screen will appear confirming the successful upload.


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Your Homepage for this medical group will be updated after a successful upload to:

Note: This example does not have an exclusions. Your submission may have exclusions.

MNCM will review the submission and either approve or contact you for clarification.

Step 4. Complete all Steps for Child 3.0 + PCMH Survey

Follow the same Steps 1, 2 and 3 if you fielded the child survey for any of your clients. This is listed as a

separate measure on your homepage; however, all steps are the same as the adult survey process. Note:

There is only one survey version, one set of Summary Statistics, and one data file to upload under the child

survey.

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