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Tuesday, February 3rd 2004

Melissa Musotto
Centers for Medicare and Medicaid Services
Office of Strategic Operations and Regulatory Affairs
Division of Regulations Development and Issuances
Room C5-14-03
7500 Security Boulevard
Baltimore, MD 21244-1850

Dear Ms. Musotto:

The American Hospital Association (AHA), on behalf of its nearly 5,000 member hospitals, health systems, networks, and other providers of care, is pleased to comment on the HCAHPS survey and proposed administration instructions promulgated by CMS in the Federal Register on December 5, 2003.

The AHA and its member hospitals and health systems are committed to providing the public with valid and reliable information on which to assess the quality of health care being received by hospitalized patients.  This is the fundamental reason that we, along with the Federation of American Hospitals and the Association of American Medical Colleges, began The Quality Initiative in collaboration with government, consumer, and purchaser groups.  We believe that a critical component of this public information on quality is patients’ perceptions of their care.  We strongly support the concept of a standardized set of questions to collect comparable information from hospitalized patients, so that the data can be shared with the public.

America’s hospitals have worked with several patient survey firms for many years to measure patient satisfaction and identify opportunities to improve patients’ experiences.  One of the aspects of these relationships that hospitals value most is the ability to trend data over time so that they can identify changes in how patients feel about services.  These trends are critical to focusing quality improvement efforts and determining how changes have actually affected patients’ experiences.

Survey Must Meet Consumers Information Needs, Not Jeopardize Quality Improvement  
Standardized information must be collected in a way that informs the public, particularly people who are about to be hospitalized for treatment and who can choose among several hospitals that could meet their needs.  The collection of this information must not impede the quality improvement work already underway in America’s hospitals, nor should it be too costly, duplicative or cumbersome to implement.

Our view is that the only effective way to accomplish these two goals is to ensure that the standardized questions can be embedded at the beginning of the surveys already conducted by most hospitals through their survey firms.  This requires a balance between a number of standardized questions large enough to provide useful, reliable information to the public, and small enough to embed at the beginning of the survey without destroying the integrity of the rest of the survey questions.  We are not yet sure what number of questions achieves that balance.

CMS and the researchers who developed the HCAHPS survey have proposed a set of 24 substantive and eight demographic questions, most of which are aimed at providing critical information that helps attain the best possible results for patients.  On January 29, we met with representatives of the key patient survey firms who work with a majority of our member hospitals and health systems.  They felt strongly that the length of the proposed HCAHPS survey and the design of the questions and responses would preclude them from embedding these standardized questions in their current surveys and, if they did, that it would damage their ability to provide data and trend information to support the quality improvement work in hospitals.  This would clearly not be in the best interest of hospitals and the communities they serve and surely is not a result CMS intended. 

More Work is Needed
Further, in our conversations with hospitals, health systems and vendors, many concerns have been raised about the survey questions, the methodology proposed for collecting and analyzing the data, and how the information would be most usefully portrayed to the public.  These questions range from very practical issues of necessary sample sizes to whether multiple waves of mailing or telephoning are needed to ensure that the survey results are based on a reasonably representative group of patients who were hospitalized at any given hospital.  And many wonder whether these questions will actually achieve the goal of accurately providing the information patients want when choosing a hospital, and that communities want in order to feel that hospitals are forthcoming about the quality of care they provide.  The answers to these questions will, in many cases, remain elusive until we start providing some of this information broadly to the public and assess the results. 

We Can Get Started Now
Recognizing the urgent need to get standardized, useful information to the public, we believe that all interests would be best served if we begin collecting data as soon as possible using standardized questions and under standardized guidelines.  The data should then be analyzed and shared with the public; and representatives of the public, patients, hospitals, surveyors and other interested parties should be brought together to assess what is working well, what is not, and how the effort can be improved.  Improvement might mean adding questions, changing the questions or the survey methodology, altering the way in which the information is portrayed and shared with the public, or other changes to accomplish the goal of useful public information.

The survey vendors have agreed to work together to identify 10 standardized questions that could be embedded at the beginning of all of their surveys and data collection started within the next few months.  This would provide a solid basis for understanding what is truly valued by the public.  That understanding would serve as a platform for improving the standardized data collection over time.  Starting with 10 questions will allow us to test the usefulness of questions that ask patients for their overall assessments of care, as well as more detailed questions in specific areas.  We are delighted with the willingness of the survey firms to bring their expertise and experience to this process, and we urge CMS to consider taking advantage of this option. 

Survey Instructions Need to be Refocused
We are concerned about the implementation strategies CMS has outlined in the Federal Register.  For example, requiring surveys of 1,000 patients would be difficult for smaller hospitals, and may not result in an adequate sample.  And asking hospitals and their vendors to make multiple attempts to survey patients who do not respond to the first mailing or phone call imposes burdens that may not add value to the outcome of the survey.  Rather than instructing vendors and hospitals on how to achieve an adequate response, CMS should focus its attention on defining which patients are to be included in the population from which the sample is drawn, and articulating criteria for determining an appropriately representative sample.  This would allow those conducting the survey to choose among a variety of strategies to ensure that a representative sample has been achieved.

If you have questions concerning our comments, please contact Nancy Foster, senior associate director of policy, at (202) 626-2337.


Rick Pollack
Executive Vice President


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