Translation Only CMS-approved translations of the OAS Survey are permitted. If facilities choose to add their own supplemental questions, vendors will be responsible for translating these questions. n/a Logo and other information about the HOPD or ASC The HOPD or ASC name or logo must appear on the survey or the cover letter. Note that survey vendors cannot include any promotional messages or materials on the OAS CAHPS cover letter, questionnaire, or outgoing or incoming mailing envelopes. This includes indications that either the facility or the survey vendor has been approved by the Better Business Bureau. n/a The vendor’s name and mailing address must be printed at the bottom of the last page of the OAS CAHPS Survey questionnaire, in case the respondent does not use the enclosed business reply envelope. n/a OMB Number The OMB number shown in Appendix G must be printed on the questionnaire cover. If there is no cover, then the OMB number must be printed on the first page of the questionnaire. n/a Cover Letter Requirements and Recommendations Examples of cover letters in English, Spanish, and Chinese are provided in the appendices with the survey instruments (see Appendices C–F). Vendors may choose to develop their own cover letters as well, provided that the following requirements are met: Requirement Recommendation Personalization Cover letters must be personalized with the name and address of the sample member. n/a Cover letters must contain the date of the surgery/procedure and the name of the location where the surgery was received. (The monthly patient information file must contain the date of surgery, facility name, and location name because the name recognized by the patient may differ from the facility’s official name.) n/a
Separate from Questionnaire Cover letters must be separate from the questionnaire, so that no personally identifiable information (PII) is returned with the questionnaire when the respondent sends it back to the vendor. n/a Content of letters The OMB disclosure notice (see Appendix G) must be printed either on the questionnaire or in the cover letters. n/a Vendors may not offer sample members the opportunity to complete the survey over the telephone. Telephone interviews may only be conducted as part of the nonresponse n/a Must contain language describing the purpose of the survey. n/a Must contain a statement that participation is voluntary and will not affect any benefits the sample member receives or expects to receive. n/a Must contain language indicating that responses from all the survey participants will be grouped together and these grouped data may be shared with the HOPD or ASC, for purposes of quality improvement. n/a Must contain language stating that if the respondent needs help in reading the questions or marking responses, a friend or family member can assist them. n/a Must contain a toll-free customer support telephone number, which will be staffed by the survey vendor. n/a Printing The HOPD or ASC name (or logo) must appear on the letters or the survey. Note that survey vendors cannot include any promotional messages or materials on the OAS CAHPS cover letter, questionnaire, or outgoing or incoming mailing envelopes. This includes indications that either the facility or the survey vendor has been approved by the Better Business Bureau. n/a
Signature on the letters A signature is required. We recommend that the signature of an appropriate official from the HOPD or ASC be printed on each cover letter If this is not possible, the signature from an appropriate official at the survey vendor is acceptable. Requests for Survey in Other Languages n/a Survey vendors offering an English, Spanish, and Chinese version of the questionnaire may add language to the English cover letter indicating that a version of the questionnaire is available in those languages. Mailing Requirements and recommendations are described below. Vendors are expected to follow these requirements to maximize response rates and ensure consistency in how the mail survey portion of the mixed-mode administration is implemented. Requirement Recommendation Questionnaire contents Each questionnaire mailing must contain a personalized cover letter, questionnaire, and postage-paid business reply envelope. n/a Envelopes Vendors are responsible for supplying both the outgoing envelopes for the questionnaire mailings and business-reply envelopes that sample members will use to return their completed surveys (i.e., they cannot be supplied by the HOPD or ASC). n/a Addresses Patients must have a U.S. domestic address to be eligible to participate in the OAS CAHPS Survey. n/a
When it is NOT Acceptable to Code a Response Example 1: In this example, the respondent has placed a check mark to the right of the response boxes. It is not clear which response was intended. Therefore, the correct procedure for a question presenting like Q10 is to code the response as “M” which stands for “missing.” Example 2: In this example, the respondent has placed a mark to the right of the response boxes. It is not clear which response was intended. Therefore, the correct procedure for a question presenting like Q9 is to code the response as “M.”
At any time after leaving the facility, did you have pain as a result of your procedure? Yes No Before you left the facility, did your doctor or anyone from the facility give you information about what to do if you had nausea or vomiting? Yes, definitely Yes, somewhat No At any time leaving the facility, did you have nausea or vomiting as a result of either your procedure or the anesthesia? Yes No Before you left the facility, did your doctor or anyone from the facility give you information about what to do if you had bleeding as a result of your procedure? Yes, definitely Yes, somewhat No At any time after leaving the facility, did you have bleeding as a result of your procedure? Yes No Possible signs of infection include fever, swelling, heat, drainage or redness. Before you left the facility, did your doctor or anyone from the facility give you information about what to do if you had possible signs of infection? Yes, definitely Yes, somewhat No At any time leaving the facility, did you have any signs of infection? Yes No V. any number from 0 to 10, where 0 is the worst facility possible and 10 is the best facility possible, what number would you use to rate this facility? 0 Worst facility possible 1 2 3 4 5 6 7 8 9 10 Best facility possible
Would you recommend this facility to your friends and family? Definitely no Probably no Probably yes Definitely yes VI. In general, how would you rate your overall health? Excellent Very good Good Fair Poor In general, how would you rate your overall mental or emotional health? Excellent Very good Good Fair Poor What is your age? 18 to 24 25 to 34 35 to 44 45 to 54 55 to 64 65 to 74 75 to 79 80 to 84 85 or older Are you male or female? Male Female What is the highest or level of school that you have completed? 8th grade or less Some high school, but did not graduate High school graduate or GED Some college or 2-year degree 4-year college graduate More than 4-year college degree Are you of Hispanic, Latino/a, or Spanish origin? Yes, Hispanic, Latino/a, or Spanish No, not Hispanic, Latino/a, or Spanish If No, go to #32 Which group best describes you? Mexican, Mexican American, Chicano/a Puerto Rican Cuban Another Hispanic, Latino/a, or Spanish origin YOU
What is your race? You may select one or more categories. White or African American American Indian or Alaska Native Indian Chinese Filipino Japanese Korean Vietnamese Other Asian Native Hawaiian Guamanian or Chamorro Samoan Other Pacific Islander How well do you speak English? Very well Well Not well Not at all Do you speak a language other than English at home? Yes No If No, go to #36 What is that language? Spanish Other Language (PLEASE SPECIFY): (Please print.) Did someone help you complete this survey? Yes No If No, go to END. How did that person help you? all that apply. Read the questions to me Wrote down the answers I gave Answered the questions for me Translated the questions into my language Helped in some other way: (EXPLAIN): (Please print.) No one helped me complete this survey END
¿Le el personal administrativo y de recepción del centro ambulatorio tanto como usted pensaba que debían hacerlo? Sí, definitivamente Sí, algo No ¿Le trató el personal administrativo y de recepción del centro ambulatorio con cortesía y respeto? Sí, definitivamente Sí, algo No ¿Le trataron los doctores y enfermeras con cortesía y respeto? Sí, definitivamente Sí, algo No ¿Se aseguraron los doctores y enfermeras que usted estuviera tan cómodo como fuera posible? Sí, definitivamente Sí, algo No III. Le recordamos que por favor incluya cualquier información que haya recibido ya sea antes o en el día del procedimiento. ¿Le explicaron los doctores u enfermeras el procedimiento de tal manera que fue fácil de entender? Sí, definitivamente Sí, algo No anestesia es algo que le haría sentir sueño o dormir durante el procedimiento. ¿Le dieron anestesia? Sí No Si contestó “No”, pase a la pregunta 13 explicó el doctor o alguien del centro ambulatorio el proceso de dar anestesia de tal manera que fue de entender? Sí, definitivamente Sí, algo No explicó el doctor o alguien del centro ambulatorio los posibles efectos secundarios de la anestesia de tal manera que fácil de entender? Sí, definitivamente Sí, algo No instrucciones al ser dado de alta incluyen observar los síntomas después de su procedimiento, instrucciones sobre los medicamentos y cuidado en el hogar. Antes de salir del centro ambulatorio, ¿recibió instrucciones por escrito al darle de alta? Sí No
IV. preparó el doctor o alguien del personal del centro ambulatorio qué esperar durante su recuperación? Sí, definitivamente Sí, algo No maneras para controlar el dolor incluyen medicamentos recetados, medicamentos para el dolor de venta libre o bolsas de hielo. ¿Su doctor o alguien del centro ambulatorio le dio información sobre qué hacer si tenía dolor como resultado de su procedimiento? Sí, definitivamente Sí, algo No algún momento después de salir del centro ambulatorio, ¿tuvo dolor debido al procedimiento? Sí No de salir del centro ambulatorio, ¿su doctor o alguien del personal del centro ambulatorio le dio información sobre qué hacer si tenía náusea o vómitos? Sí, definitivamente Sí, algo No momento después de salir del centro ambulatorio, ¿tuvo náusea o vómitos como resultado del procedimiento o la anestesia? Sí No de salir del centro ambulatorio, ¿su doctor o alguien del personal del centro ambulatorio le dio información sobre qué hacer si sangraba como resultado del procedimiento? Sí, definitivamente Sí, algo No momento después de salir del centro ambulatorio, ¿tuvo sangrado como resultado del procedimiento? Sí No señales de infección incluyen fiebre, hinchazón, calor, secreción o enrojecimiento. Antes de salir del centro ambulatorio, ¿su doctor o alguien del personal del centro ambulatorio le dio información sobre qué hacer si tuviera señales de infección? Sí, definitivamente Sí, algo No algún momento después de salir del centro ambulatorio, ¿tuvo señales de infección? Sí No
V. un número del 0 al 10, en donde 0 es el peor centro ambulatorio posible y 10 es el mejor centro ambulatorio posible, ¿qué número usaría para calificar éste centro ambulatorio? 0 Peor centro ambulatorio posible 1 2 3 4 5 6 7 8 9 10 Mejor centro ambulatorio posible este centro ambulatorio a sus amistades y familia? Definitivamente no Probablemente no Probablemente sí Definitivamente sí VI. general, ¿cómo calificaría su salud general? Excelente Muy buena Buena Regular Mala general, ¿cómo calificaría su mental o emocional? Excelente Muy buena Buena Regular Mala edad tiene usted? 18 a 24 años 25 a 34 años 35 a 44 años 45 a 54 años 55 a 64 años 65 a 74 años 75 a 79 años 80 a 84 años 85 años o más usted hombre o mujer? Hombre Mujer es el nivel o año escolar más avanzado que usted ha completado? 8o años de escuela o menos 9-12 años de escuela, pero sin graduarse Graduado de la escuela secundaria, Diploma de escuela secundaria, preparatoria o su equivalente (o GED) Algunos cursos universitarios o un título universitario de un programa de 2 años Título universitario de 4 años Título universitario de más de 4 años