This blog post is taken from a recent RE-CAHPS Webinar featuring Karen Sorensen, HealthStream Associate Vice President, National Initiatives.
The countdown to mandatory OAS CAHPS participation has begun, and CMS has announced that it will become mandatory in January of 2018. Hospitals that have not participated in the program during the initial voluntary phase will need to begin making plans to do so very soon.
Who Should Participate? (You Are Probably Not Exempt!)
The first two categories are Hospital Outpatient Surgery Departments (HOPDs) and Ambulatory Surgery Centers (ASCs).
HOPDs and ASCs are eligible to participate if: (1) one or more of its departments perform outpatient surgeries and procedures, (2) those surgeries and procedures fall within the specified range of CPT-4 surgical billing codes, (3) the facility is Medicare-certified, and (4) the procedures are not performed in a physician’s office or emergency department.
The final category is Critical Access Hospitals (CAHs). CAHs that perform outpatient procedures and surgeries may participate on a voluntary basis. For more information on specific types of patients and procedures that are eligible for inclusion, you can consult your HealthStream team or the CMS documentation that can be found on the OAS CAHPS website.
There are relatively few exemptions. Facilities treating fewer than 60 eligible patients per year may request an exemption. If the patient volume in 2017 was 59 or below, the facility must fill out an exemption form on the OAS CAHPS website. Similarly, if your facility is exempt from the ASC payment program, the facility is also exempt from participating in OAS CAHPS. ASC-exempt facilities need not fill out any paperwork in order to qualify for the exemption.
Prepare For Success – Now!
While mandatory participation is still some months away, it is now time to begin preparing for OAS CAHPS.
HealthStream has assisted well over 1,000 hospitals with the seven CMS CAHPS surveys and has some key recommendations for HOPDs and ASCs as they plan for the OAS CAHPS implementation deadline.
- Build a smart sample plan to insure that you are able to sort your data by service, department and key demographic groups. For some facilities, this will mean a larger sample size than is required by CMS. Your HealthStream team can help you identity the sample plan that will meet the CMS requirements and provide optimal data segmentation for the purposes of accountability and improvement.
- If your organization is sufficiently nimble to begin in October rather than the mandated January start date, start in October. There are several tasks that need to be accomplished prior to actual implementation. You will need to decide on a methodology and a sample plan. Your organization will also need to designate someone on your staff as the OAS CAHPS survey administrator and authorize HealthStream as your survey partner to insure timely data submission. In addition, as with other CAHPS surveys, CMS requires a long list of patient variables be included in patient file uploads. Updating patient files to meet the new requirements is fairly cumbersome and it worthwhile to start in advance to insure that your organization can meet these requirements.
- Start “teaching to the test.” While it may feel somewhat counterintuitive, the fact is that CAHPS surveys are open-book tests. We know what will be on this test and it is perfectly acceptable to begin the process of preparing your staff now. HealthStream’s high-performers are very intentional in their training processes. Start by helping staff understand what is on the 37-item survey by sharing the survey with them and be sure to educate physicians about their role as well.
- Plan for how to share results. Establish a regular and frequent process for sharing results and addressing opportunities for celebration and improvement.
- Understand the survey differences. Other CAHPS surveys address physician, nursing and other staff behaviors with questions specific to each discipline. OAS CAHPS questions combine doctors, nurses and other staff, for example; “Did the doctors, nurses and other staff make sure you were as comfortable as possible?” Your HealthStream team can help you to think through strategies to address these combined questions.
Lastly, HealthStream has some great resources to support you and your organization’s compliance with these evolving mandates. Don’t miss the PX Advisor Magazine. It is completely free and now there is a new magazine, Provider Advisor, devoted to the physician office practice patient experience. HealthStream’s website also includes eBooks, White Papers and the CAHPS brief to help you stay current on all CAHPS topics.
Learn more here.