2016 annual report for hospitals and related facilities (patient origin survey instructions only)

How do I Count “all other inpatient locations” on the hospital survey?

On the hospital survey, include these beds in the count for “All other inpatient locations”. In addition, counts from these locations should be included in the total facility patient days and admissions on the hospital survey.

How should users report the number of beds in a facility?

Users should report the number of beds that were used for the majority (six months or greater) of the previous calendar year in a facility. If the change occurred with an equal number of months captured in a year, then users should report the number of total beds that were in place at the end of the year.

Does public reporting improve quality of hospital care?

Second, public reporting of the survey results creates new incentives for hospitals to improve quality of care. Third, public reporting serves to enhance accountability in health care by increasing transparency of the quality of hospital care provided in return for the public investment.

How often do hospitals report HCAHPS results?

HCAHPS and Public Reporting Publicly reported HCAHPS results are based on four consecutive quarters of patient surveys. CMS publishes participating hospitals' HCAHPS results on the Hospital Compare website (www.hospitalcompare.hhs.gov) four times a year, with the oldest quarter of patient surveys rolling off as the most recent quarter rolls on.

What is the purpose of the Hcahps survey?

The HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) Survey, also known as the CAHPS® Hospital Survey or Hospital CAHPS®, is a standardized survey instrument and data collection methodology that has been in use since 2006 to measure patients' perspectives of hospital care.

How do you prepare for a hospital survey?

Coach and prepare your staff through in-services, regular rounding, and questions of the day during morning huddles. Be congenial and honest. Don't argue about findings; offer additional information or use the formal appeal process.

Is Press Ganey the same as Hcahps?

HCAHPS measures frequency, how often a service was performed (Never, Sometimes, Usually, Always). Press Ganey measures quality, how well we performed a service (Very Poor, Poor, Fair, Good, Very Good). HCAHPS is used for public reporting.

What are the 8 domains of Hcahps?

Eight HCAHPS measures, called “dimensions,” are included in Hospital VBP: six HCAHPS composites (Communication with Nurses, Communication with Doctors, Staff Responsiveness, Communication about Medicines, Discharge Information, and Care Transition); a composite that combines the Cleanliness and Quietness items; and one ...

What is a patient safety survey?

SOPS Surveys Each SOPS survey is designed to assess patient safety culture in a specific healthcare setting.

How often must a health care organization undergo an on site survey in order to maintain accreditation with the Joint Commission?

To earn and maintain The Joint Commission's Gold Seal of Approval... -an organization must undergo an on-site survey by a Joint Commission survey team at least every three years. (Laboratories must be surveyed every two years.)

Do hospitals still use Press Ganey?

Press Ganey partners with roughly 40% of hospitals in the United States – including more than 10,000 health care facilities – to measure and improve quality of care.

What is Press Ganey survey?

The Press Ganey survey is a list of questions that asks patients about their experience with their doctor. The questions ask about how patients feel about their doctor and what they think when they see their doctor.

How many hospitals use Hcahps?

Over 4,000 hospitals participate in HCAHPS and over 3.0 million patients complete the survey each year.

What are the three broad goals of the Hcahps survey?

The three goals of the survey include: creating incentives to improve the quality of care, producing comparable data on patient's perspectives, and increasing transparency within healthcare to make the public more accountable.

How do hospitals use Hcahps?

The HCAHPS survey is administered to a random sample of adult patients across medical conditions between 48 hours and six weeks after discharge; the survey is not restricted to Medicare beneficiaries. Hospitals may either use an approved survey vendor, or collect their own HCAHPS data (if approved by CMS to do so).

What questions are on the Hcahps survey?

What are the 27 HCAHPS Questions?During this hospital stay, how often did nurses treat you with courtesy and respect?During this hospital stay, how often did nurses listen carefully to you?During this hospital stay, how often did nurses explain things in a way you could understand?More items...

What is the rule for reporting surgery rooms?

Report only the surgery rooms in the CON-Approved operating room or surgical suite pursuant to Rule 111-2-2-.40 and 111-8-40-.28

What is LTCH utilization?

LTCH Utilization by Race – Report LTCH admissions and inpatient days by race/ethnicity according to the indicated categories. Total LTCH admissions and days of care should balance to LTCH admissions and days of care reported elsewhere in the LTCH Addendum. The United States Census Bureau uses the following racial and ethnicity definitions: American Indian or Alaska Native: A person having origins in any of the original peoples of North and South America (including Central America), and who maintains tribal affiliation or community attachment.

What is an emergency department visit?

Emergency Department Visits - Report the total number of visits by patients who presented in the emergency department for true emergency purposes only. Include only those patients who presented in the Emergency Department and who had true emergencies.

What is an HMO?

Health Maintenance Organization (HMO) - An organization that has management responsibility for providing comprehensive health care services on a prepayment basis to voluntarily enrolled persons within a designated population.

What is the signature page?

The Signature Page is where the facility’s chief executive or administrator electronically authorizes the survey for release to the Department of Community Health. The facility's chief executive officer or administrator must sign to certify that the responses are complete and accurate for the report period specified. An electronic manually entered version of the signature is being accepted as an original signature pursuant to the Georgia Electronic Records and Signature Act.

Why is the Georgia Minority Health Advisory Council working with the Department of Community Health?

Because of Georgia’s racial and ethnic diversity, and a dramatic increase in segments of the population withLimited English Proficiency, the Georgia Minority Health Advisory Council is working with the Department ofCommunity Health to assess our health systems’ ability to provide Culturally and Linguistically AppropriateServices (CLAS) to all segments of our population. We appreciate your willingness to provide information onthe following questions:

What is Part C Question 1(A&B)?

If the owner or owner parent at Part C, Question 1(A&B) is an entity based in another state pleasereport the location in which the entity is based. (City and State)

Annual Hospital Survey: Teaching Status

Q1: Which designation of teaching status should I indicate on the annual hospital survey?

Annual Hospital Survey: units designated as Inpatient Rehabilitation Facilities (IRFs)

Q2: My acute care hospital includes a CMS-certified Rehab Unit mapped as a location within the hospital (specifically, the CCN for the Rehab unit includes an ‘R’ or ‘T’ in the 3rd position). Do I include the number of rehab beds, patient days and admissions from this unit on the annual hospital survey the Survey for CMS-IRF unit or both?

Annual Hospital Survey: units designated as Inpatient Psychiatric Facilities (IPFs) and Skilled Nursing Facilities (SNFs)

Q4: My hospital has an IPF and/or SNF unit located within the hospital. Do I include counts from these units on the annual hospital survey for patient days, admissions, and total bed size?

Annual Survey bed size for all facility types

Q5: During the previous calendar year my facility’s number of beds changed during the year. What number should I report for the total number of beds on the annual survey?

Annual Surveys for newly enrolled facilities

Q6: My facility just opened last month and we are currently enrolling in NHSN. Do I need to complete an annual survey?

Annual surveys for HCP Influenza Vaccination Summary Module

Q7: Which surveys are required to be completed for the HCP Influenza Vaccination Summary Module?

Annual Hospital Survey: Neonatal Admissions

Q11: Who in my facility should I to contact that collects admission data by birthweight?

When was the HCAHPS survey endorsed?

In May 2005, the HCAHPS survey was endorsed by the National Quality Forum, a national organization that represents the consensus of many healthcare providers, consumer groups, professional associations, purchasers, federal agencies, and research and quality organizations. In December 2005, the federal Office of Management ...

What is HCAHPS survey?

HCAHPS (pronounced "H-caps"), also known as the CAHPS Hospital Survey, is a survey instrument and data collection methodology for measuring patients' perceptions of their hospital experience. While many hospitals have collected information on patient satisfaction for their own internal use, until HCAHPS there was no national standard for collecting and publicly reporting information about patient experience of care that allowed valid comparisons to be made across hospitals locally, regionally and nationally.

How long does it take to get HCAHPS?

The HCAHPS survey is administered to a random sample of adult patients across medical conditions between 48 hours and six weeks after discharge; the survey is not restricted to Medicare beneficiaries. Hospitals may either use an approved survey vendor, or collect their own HCAHPS data (if approved by CMS to do so).

Is there a national standard for collecting and publicly reporting information about patient experience of care?

While many hospitals have collected information on patient satisfaction for their own internal use, until HCAHPS there was no national standard for collecting and publicly reporting information about patient experience of care that allowed valid comparisons to be made across hospitals locally, regionally and nationally.