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Reminder: Only One Week before the Data Submission Deadline for the 2020 ICH CAHPS Fall Survey
folder_openData Submissionscalendar_todayPosted January 20, 2021

The deadline for submitting data files from the 2020 ICH CAHPS Fall Survey to the Data Center is at 5:00 PM Eastern Time on Wednesday, January 27, 2021, which is 1 week from today. The Centers for Medicare & Medicaid Services (CMS) will not accept any data files after that date and time.

We strongly encourage vendors who have not submitted an XML file for any of their facility clients to begin submitting as soon as possible. Remember that vendors must submit their data files in time to correct and re-submit any files that do not pass the validation checks.

Please feel free to contact the ICH CAHPS Coordination Team via e-mail at ichcahps@rti.org or call 1-866-245-8083 if you have any questions or need help with data submissions.

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RTI International will be closed January 18, 2021
folder_openOther Announcementscalendar_todayPosted January 13, 2021

RTI International will be closed on January 18, 2021. The ICH CAHPS Coordination Team will respond to email and telephone inquiries that are received on that date after RTI re-opens on January 19, 2021.

Please contact the ICH CAHPS Coordination Team at 1-866-245-8083 or via email at ichcahps@rti.org if you have any questions.

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Reminder: Only 2 Weeks before the Data Submission Deadline for the 2020 ICH CAHPS Fall Survey
folder_openData Submissionscalendar_todayPosted January 13, 2021

The deadline for submitting data files from the 2020 ICH CAHPS Fall Survey to the Data Center is at 5:00 PM Eastern Time on Wednesday, January 27, 2021, which is only 2 weeks away. The Centers for Medicare & Medicaid Services (CMS) will not accept any data files after that date and time.

We strongly encourage vendors to begin submitting XML files as soon as possible following the end of data collection. Remember that vendors should submit their data files in time for them to correct and re-submit any files that do not pass the validation checks.

Please feel free to contact the ICH CAHPS Coordination Team via e-mail at ichcahps@rti.org or call 1-866-245-8083 if you have any questions or need help with data submissions.

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ICH CAHPS Coordination Team Semiannual Review (CTSAR) Newsletter - January 2021 Edition
folder_openOther Announcementscalendar_todayPosted January 12, 2021

The ICH CAHPS Team has published the January 2021 edition of the ICH CAHPS Coordination Team Semiannual Review (CTSAR). As a reminder, this newsletter is a way to provide in-center hemodialysis (ICH) facilities and survey vendors with helpful ICH CAHPS information.

The CTSAR is posted on the ICH CAHPS website and updated every January and July. You can navigate to the January 2021 newsletter located under the General Information tab on the ICH CAHPS website or click here to view it now.

The CTSAR does not replace any source of information currently on the ICH CAHPS website; instead, it highlights important information for readers prior to each survey period. We encourage you to visit the ICH CAHPS website for more information on the items mentioned in this newsletter. Please continue to monitor the ICH CAHPS website for updates and announcements.

Please contact the Coordination Team via e-mail at ichcahps@rti.org or call 1-866-245-8083 if you have any questions or need more information.

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ICH CAHPS Semiannual Data Quality Reminders
folder_openOther Announcementscalendar_todayPosted January 11, 2021

As we approach the deadline for submitting data from the 2020 ICH CAHPS Fall Survey and the beginning of the 2021 Spring Survey, we would like to remind vendors of the importance of implementing quality control measures on all aspects of the survey.

This announcement includes a list of some of the data quality issues that the Coordination Team detected in the limited data from the 2020 Spring Survey and the few issues we observed during virtual and offsite site visits with survey vendors during the 2020 Fall Survey. As you conduct final data cleaning and processing of the 2020 Fall Survey data and prepare the XML file that will be submitted, please apply appropriate quality control measures so that you can detect and avoid these errors and data problems in all upcoming survey periods.

As a reminder, the XML files containing data from the 2020 Fall Survey must be submitted to the Data Center by 5:00 PM EST on Wednesday, January 27, 2021. Please contact the Coordination Team via email at ichcahps@rti.org or call (866) 245-8083 if you have any questions about any of the information provided below.

Data Quality Reminders (based on 2020 Fall Site Visits and 2020 Spring Data Submission)

  1. Check Assigned Disposition Codes. Survey vendors should make sure that the correct final disposition codes are assigned to all sample cases. Within 2 to 3 weeks after the data collection period begins and then after data collection ends (at a minimum), survey vendors should generate and review the interim and final disposition codes assigned to a sample of cases. Once final disposition codes are assigned, vendors should have a staff member (other than the one who assigned the disposition codes) conduct quality control on the disposition codes assigned.

    The Coordination Team conducts quality control on each vendor’s data files after they are submitted. The following are some of the issues/errors that were found:

    1. Some cases were coded a 130 (Completed Mail Survey – Eligibility Unknown) but the respondent reported in Q2 that they no longer receive care at the facility and skipped to Q45 as instructed. The cases should have been coded as 190 (Ineligible: No Longer Receiving Care at Sampled Facility).
    2. Some cases were coded a 130 (Completed Mail Survey – Eligibility Unknown) but the responses to Q1 and Q2 indicated the cases should have been coded a 160 (Ineligible – Does Not Meet Eligibility Criteria).
    3. Some telephone cases were coded as 240 (Wrong, Disconnected, or No Telephone Number) but these cases had data; 240s should have no data and another code should apply.
    4. Some mail cases were coded as 110 (Completed Mail Survey) but the response to Q62 indicated they were completed by a proxy. These cases should have been coded a 199 (Survey Completed by Proxy Respondent) as proxy respondents are not permitted on ICH CAHPS.
    5. Some telephone cases were coded as 210 (Breakoff) but the survey responses indicated that the cases should have been coded a 190 (Ineligible: No Longer Receiving Care at Sampled Facility). If the case is finalized by telephone and the response to Q1 or Q2 is DK/RE, a code 190 should be assigned to the case.
  2. Vendors must update their QAP and/or Vendor Application to reflect any major changes with personnel or to survey implementation protocols and procedures. In addition to the annual QAP update due May 31st each calendar year, vendors must update their QAP (and in some instances their Vendor Application) to reflect these changes as they occur throughout the year. If you are unsure whether a particular change warrants updating your QAP, please reach out to the Coordination Team.
  3. Vendors must ensure that they are implementing adequate QC on data prior to submission of their XML file to the Data Center. Vendors should consistently review their QC procedures throughout the data collection period to make sure they are still functioning as intended. Vendors that conduct a more manual QC of data may consider automating some of their processes to avoid human error. Vendors that conduct QC using mostly automated processes should also consider conducting a small manual QC of data on top of the automated QC, to ensure the formulas and/or programs are written correctly. For more information on Quality Control, please refer to the ICH CAHPS Administration and Specifications Manual.
  4. Vendors must continually review and update, to the extent possible, the precision of their scanning software. Vendors who utilize optical scanning software to capture survey responses should review the requirements in the ICH CAHPS Survey Administration and Specifications Manual (section 5.5.2 or 7.4.2) to ensure their software is capturing quality data. There were instances where scanning software did not pick up survey responses or inaccurately coded stray marks or smudges as a response.
  5. Telephone interviewers should be reading the telephone script verbatim. The site visit teams observed several instances of telephone interviewing staff not reading the script verbatim. Although the majority of deviations were minor (i.e., did not alter the meaning of the question), it is important that each sample patient be administered the exact same survey to ensure the highest quality data.

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Reminder of Upcoming Deadline for Submitting Facility-Specific Questions for the 2021 ICH CAHPS Spring Survey for Approval
folder_openOther Announcementscalendar_todayPosted January 7, 2021

This is a reminder that ICH CAHPS Survey vendors must submit all facility-specific questions that they plan to add to the 2021 ICH CAHPS Spring Survey to the Coordination Team for review and approval. If any of your ICH facility clients are planning to add any new facility-specific questions to the 2021 ICH CAHPS Spring Survey, please send those questions and their proposed placement to the Coordination Team via e-mail at ichcahps@rti.org before 5:00 PM Eastern Time (ET) on February 5, 2021.

Please note that facility-specific questions that were approved by the Coordination Team for use in previous survey periods do not need to be approved again unless the question wording or response options have changed.

The Coordination Team will accept facility-specific questions for review after the February 5, 2021 deadline; however, approval of those questions may not be granted in time for the questions to be included in the 2021 Spring Survey. Survey vendors should work with their client ICH facilities to decide on the use of new facility-specific questions and submit the questions to the Coordination Team as soon as possible to avoid a delay in approval.

Please contact the Coordination Team via e-mail at ichcahps@rti.org or by calling 1-888-245-8083 if you have any questions.

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Reminder: Only 3 Weeks before the Data Submission Deadline for the 2020 ICH CAHPS Fall Survey
folder_openData Submissionscalendar_todayPosted January 6, 2021

As a reminder, data collection for the 2020 ICH CAHPS Fall Survey ends on Friday, January 8, 2021. The deadline for submitting data files from the 2020 ICH CAHPS Fall Survey to the Data Center is at 5:00 PM Eastern Time on Wednesday, January 27, 2021, which is only 3 weeks away. The Centers for Medicare & Medicaid Services (CMS) will not accept any data files after that date and time.

As XML files are uploaded to the ICH CAHPS Data Center a series of validation checks are made, one of which is a check to ensure that a patient-level record is included on the XML file for every case that was sampled for a CCN. Please note the following.

  • If the number of cases you include on an XML file does not match the number sampled, an error or warning message will appear on your data submission report.
  • If the error message appears for one or more of your CCNs, please make sure that you have entered information about each sampled case on the XML file.

Also be reminded that survey vendors:

  • should submit their files as soon as possible to allow adequate time to correct any problems identified and re-submit the files before the deadline; and
  • can submit a file for a CCN as many times as needed; however, keep in mind that each time a file for a CCN is re-submitted, it overwrites the file that was submitted previously.

Please feel free to contact the ICH CAHPS Coordination Team via e-mail at ichcahps@rti.org or call 1-866-245-8083 if you have any questions or need help with data submissions.

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Authorizing a Survey Vendor for the 2021 ICH CAHPS Spring Survey
folder_openFacility Participation Requirementscalendar_todayPosted January 5, 2021

All in-center hemodialysis (ICH) facilities that are administering the ICH CAHPS Survey for the first time or are switching to a different survey vendor to administer the 2021 ICH CAHPS Spring Survey must update their vendor authorization on the ICH CAHPS website by 5:00 PM Eastern Time on February 28, 2021.

If your organization will continue to use the same survey vendor that was used to administer the 2020 Fall Survey, you do not need to update the online vendor authorization form. However, you must update the online vendor authorization if any of the following apply:

  • Your facility is participating in the ICH CAHPS Survey for the first time during the 2021 Spring Survey; OR
  • Your facility is switching to a different survey vendor to administer the 2021 Spring Survey; OR
  • Your facility entered the 2020 Fall Survey as the last survey period for which the vendor would administer the survey when you originally submitted the authorization form.

If any of the above statements apply to your facility, you must update the online vendor authorization form for the 2021 ICH CAHPS Spring Survey on the ICH CAHPS website by the February 28, 2021 deadline. ICH facilities that served 30 or more survey-eligible patients in calendar year 2020 must administer both the 2021 Spring and Fall Surveys to be compliant with CMS’s quality reporting requirements. If the online vendor authorization form is not updated by the deadline, a sample will not be provided to a survey vendor, which means the 2021 Spring Survey cannot be administered.

The steps for authorizing a vendor on the ICH CAHPS website are as follows:

  • Log in to the ICH CAHPS website here.
  • From your personal dashboard, click “Authorize a Vendor.” The system will then take you to the Authorize a Vendor page.
  • From the “Select Action” drop-down list on the Authorize a Vendor page:
    • If authorizing a vendor for the first time: Select the “Select a vendor for the first time” option.
    • If changing/switching to a different vendor: Select the “Switch to a different vendor” option.
  • Select the name of your survey vendor from the vendor drop-down list.
  • Select the Beginning Survey Period for your new vendor. In this instance, you would select "2021 Spring Survey."
  • Do not enter an end date for your survey vendor unless you know that you will not be using this vendor for the 2021 Fall Survey.
  • Select the CCN(s) of the ICH facility (or facilities) to which the authorization applies.
  • Click the “Submit” button.

Please note:  No changes to vendor authorizations will be accepted for the 2021 Spring Survey after 5:00 PM Eastern Time on February 28, 2021.

Please contact the ICH CAHPS Survey Coordination Team at 1–866–245–8083 or via email at ichcahps@rti.org if you have any questions.

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The 2021 ICH CAHPS Survey Facility Non-Participation Form
folder_openFacility Participation Requirementscalendar_todayPosted January 5, 2021

Please note that the 2021 ICH CAHPS Survey Facility Non-Participation Form is now available on the ICH CAHPS website. To access this form, log in to the website using your user credentials and choose “Facility Non-Participation Form” under the For Facilities menu.

As noted in an e-mail message sent to in-center hemodialysis (ICH) facilities on January 5, 2021 and posted under the Quick Links menu on the ICH CAHPS website’s home page, all ICH facilities must determine whether they will be required to administer the ICH CAHPS Survey in calendar year (CY) 2021 by counting the number of survey-eligible patients they served in CY2020.

ICH facilities that determine that they are not required to administer the 2021 ICH CAHPS Survey and those that choose not to administer the survey must complete and submit the 2021 ICH CAHPS Facility Non-Participation Form on the website.

ICH facilities should note the following:

  • The Facility Non-Participation Form is an annual form that is valid only for the year in which it was submitted. ICH facilities that submitted the Facility Non-Participation Form in CY2020 must submit the 2021 Facility Non-Participation Form if they do not plan to administer the 2021 ICH CAHPS Spring and Fall Surveys.
  • Submission of the Facility Non-Participation Form only alerts the ICH CAHPS Coordination Team that the facility does not wish for a sample file to be provided to their authorized vendor for the current calendar year; it does not affect compliance, which is determined on an annual basis by the ESRD Quality Incentive Program (QIP) team.
  • Once the Facility Non-Participation Form is submitted, any existing vendor authorization for the submitted facility is removed from the ICH CAHPS website. This means that if at any point in the future the submitted facility wishes to participate in the ICH CAHPS Surveys, the designated ICH CAHPS Facility Survey Administrator will need to authorize a survey vendor for the facility.
  • Facilities certified after December 31, 2020 are not required to complete and submit the online Facility Non-Participation Form, unless they are registered with an authorized vendor on the ICH CAHPS website.

The deadline to submit the 2021 Facility Non-Participation Form is 5:00 PM Eastern Time on February 28, 2021.

Please contact the ICH CAHPS Coordination Team at 1-866-245-8083 or via e-mail at ichcahps@rti.org if you have any questions or need more information about the Facility Non-Participation Form.

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Participation in the 2021 ICH CAHPS Surveys
folder_openFacility Participation Requirementscalendar_todayPosted January 5, 2021

In-center hemodialysis (ICH) facilities that served 30 or more survey-eligible patients in calendar year (CY) 2020 must administer the In-center Hemodialysis CAHPS (ICH CAHPS) Survey in the spring and fall of CY2021 to comply with the Centers for Medicare & Medicaid Services’ (CMS) quality reporting requirements for the 2023 payment year.

All ICH facilities should read this announcement in its entirety to determine whether they are required to participate in the ICH CAHPS Survey in CY2021 and if so, review the steps that need to be taken.

 

Determining Whether Participation in the CY2021 ICH CAHPS Surveys is Required

To determine whether your ICH facility (CCN) is required to participate in the ICH CAHPS Survey in CY2021, count the number of survey-eligible patients your facility served in CY2020. Your count must include hemodialysis patients who:

  • were 18 years old or older as of December 31, 2020;
  • were alive as of December 31, 2020;
  • received hemodialysis on an outpatient basis from your facility for 3 consecutive months or longer at some point in CY2020;
  • are not currently receiving hospice care; and
  • were not living in a nursing home/skilled nursing facility or other long-term facility such as a prison or jail as of December 31, 2020.

Patients who receive home or peritoneal dialysis are not eligible to participate in the ICH CAHPS Survey; therefore, do not include those patients in your count of survey-eligible patients. In addition, ICH facilities that received Medicare certification after December 31, 2020 are not required to participate in the ICH CAHPS Survey in CY2021.

ICH facilities should note that the ICH CAHPS Coordination Team DOES NOT have information about the number of survey-eligible patients a facility served in CY2020. Therefore, each ICH facility is responsible for determining whether it is required to administer the 2021 ICH CAHPS semiannual surveys.

 

For Facilities That Are NOT Required To Participate

ICH facilities that served 29 or fewer survey-eligible patients in CY2020 are not required to participate in the ICH CAHPS semiannual surveys in CY2021. However, all such facilities can choose one of the following four options:

  • Option 1. Administer the surveys in 2021 following all of the ICH protocols and procedures described in the ICH CAHPS Survey Administration and Specifications Manual;
  • Option 2. Administer the survey using a third-party vendor but not following the ICH CAHPS protocols and procedures;
  • Option 3. Administer the survey themselves, instead of using a third-party vendor; however, if any changes are made to the survey, it cannot be referred to as a CAHPS Survey; or
  • Option 4. Choose not to administer the survey at all.

If a facility that served 29 or fewer survey-eligible patients in CY2020 chooses Option 1, the ICH facility must be registered on the ICH CAHPS website and a vendor must be authorized. CMS will provide a patient sample to the facility’s authorized ICH CAHPS Survey vendor for both the 2021 Spring and Fall Surveys. The surveys must be conducted according to all ICH CAHPS Survey protocols and procedures, which include the following:

  • Using a CMS-approved ICH CAHPS Survey vendor to administer the survey on its behalf;
  • Administering both the 2021 ICH CAHPS Spring and Fall Surveys;
  • Adhering to the ICH CAHPS survey administration procedures and protocols described in the ICH CAHPS Survey Administration and Specifications Manual when administering the survey; and
  • Submitting an ICH CAHPS Survey data file for each survey period to the ICH CAHPS Data Center.

If a facility chooses Option 2 or Option 3, CMS will not provide patient samples to the facility, nor will it accept submission of any data files to the Data Center. The ICH facility will be responsible for either working with a survey vendor (if choosing Option 2) or within their own organization (if choosing Option 3) to select the samples for the survey that will be conducted and for conducting all other aspects of the survey.

Please note: Because facilities implementing Option 2 or Option 3 will not submit an ICH CAHPS Survey data file to the Data Center, their collected survey data will not be analyzed for official ICH CAHPS public reporting purposes, nor will the administration of these surveys be used to determine ESRD Quality Incentive Program (QIP) compliance.

 

Facility Non-Participation Form

If an ICH facility chooses Option 2, Option 3, or Option 4, the facility must complete and submit a 2021 ICH CAHPS Facility Non-Participation Form, which is an online form that is available on the ICH CAHPS website (available under the For Facilities tab once the user logs in to the website). ICH facilities should note the following:

  • The Facility Non-Participation Form is an annual form that is valid only for the year in which it was submitted. ICH facilities that submitted the Facility Non-Participation Form in CY2020 must submit the 2021 Facility Non-Participation Form if they do not plan to administer the 2021 ICH CAHPS Spring and Fall Surveys.
  • Submission of the Facility Non-Participation Form only alerts the ICH CAHPS Coordination Team that the facility does not wish for a sample file to be provided to their authorized vendor for the current calendar year; it does not affect compliance, which is determined on an annual basis by the ESRD Quality Incentive Program (QIP) team.
  • Once the Facility Non-Participation Form is submitted, any existing vendor authorization for the submitted facility is removed from the ICH CAHPS website. This means that if at any point in the future the submitted facility wishes to participate in the ICH CAHPS Surveys, the designated ICH CAHPS Facility Survey Administrator will need to authorize a survey vendor for the facility.
  • Facilities certified after December 31, 2020 are not required to complete and submit the online Facility Non-Participation Form, unless they are registered with an authorized vendor on the ICH CAHPS website.

If your organization does not plan to administer the ICH CAHPS Survey in 2021, you must complete and submit the 2021 Facility Non-Participation Form by 5:00 PM Eastern Time on February 28, 2021.

 

For Facilities That ARE Required To Participate

ICH facilities that served 30 or more survey-eligible patients in calendar year CY2020 must administer the 2021 ICH CAHPS Spring and Fall Surveys to comply with quality reporting requirements for the 2023 payment year.

For Facilities that Administered the ICH CAHPS Survey in CY2020

Unless a 2021 Facility Non-Participation Form is submitted, the Coordination Team will provide a sample file to the survey vendor that is currently authorized on the ICH CAHPS website. If an ICH facility plans to use a different ICH CAHPS Survey vendor than was used in 2020, the facility must update its vendor authorization on the ICH CAHPS website before 5:00 PM Eastern Time on February 28, 2021. Click here for instructions on how to change the online vendor authorization.

For Facilities that have Never Administered the ICH CAHPS Survey

To participate in the survey for the first time, ICH facilities must do the following, if they have not already done so.

  1. Select and contract with one of the ICH CAHPS Survey vendors that have been approved by CMS. The list of CMS-approved ICH CAHPS Survey vendors is available on the ICH CAHPS website: https://ichcahps.org/GeneralInformation/ApprovedSurveyVendors.aspx.
  2. Designate a staff member to be the facility’s ICH CAHPS Survey Administrator (SA). For more information about the role of the ICH CAHPS SA, see information provided in Chapter III of the ICH CAHPS Survey Administration and Specifications Manual, which is available on the ICH CAHPS website: https://ichcahps.org/SurveyandProtocols.aspx
  3. Register on the ICH CAHPS website: https://ichcahps.org/ForFacilities/FacilityUserRegistration.aspx. When registering, your facility’s designated SA will create user credentials (username and password) that will allow him or her to access the private links on the ICH CAHPS website.
  4. Complete the online “Authorize a Vendor” form on the ICH CAHPS website by February 28, 2021 to authorize your survey vendor to collect and submit ICH CAHPS Survey data on your facility’s behalf.

Please contact the ICH CAHPS Coordination Team at 1-866-245-8083 or via email at ichcahps@rti.org if you have any questions or need more information about the 2021 ICH CAHPS Surveys.

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