Exceptions Request Process:

The exceptions request process is designed to allow for as much flexibility as possible, while still maintaining the integrity of the data for standardized public reporting. Hospitals/Survey vendors proposing a variation from the standard HCAHPS protocol must request an exception prior to survey administration. To request an exception, hospitals/survey vendors are required to complete and submit an Exceptions Request Form (see the current HCAHPS Quality Assurance Guidelines,) that must be submitted online (www.hcahpsonline.org). The form will collect information on the proposed alternative to the standard protocols. Survey vendor must submit an Exceptions Request Form on behalf of their client hospital(s). Survey vendors may submit one Exceptions Request Form on behalf of multiple hospitals with the same exceptions request. Survey vendors must include a list of contracted hospitals on whose behalf they are submitting the exceptions request. This list should be updated as hospitals are added or deleted.

Allowable Exceptions The HCAHPS Project Team has identified acceptable variations from established methodologies. Requested exceptions may fall into categories Disproportionate Stratified Random Sampling - The file layout must include the following additional data elements: Name of each stratum Number of eligible patients for each stratum Number of sampled patients for each stratum (minimum of 10 sampled discharges) Determination of Service Line Categories - MS-DRGs are the preferred means to establish the service line category (Maternity Care, Medical, or Surgical). Hospitals/Survey vendors will need to request an exception for alternative strategies not identified in the Quality Assurance Guidelines manual. No alternative modes of survey administration will be permitted other than those prescribed for the survey (mail only, telephone only, mixed mode, and IVR).

Review Process The exceptions request will be reviewed by the HCAHPS Project Team who will assess the methodological soundness of the proposed alternative and the potential for introducing bias. Depending on the type of exception, a review of procedures and/or conference call or site visit may also be required. The HCAHPS Project Team will notify hospitals/survey vendors whether or not their exception has been approved. If it has not been approved, the HCAHPS Project Team will send the hospital/survey vendor an explanation. Hospitals/Survey vendors then have the option of appealing the decision. Hospitals/Survey vendors have five business days to submit an appeal. In such cases, hospitals/survey vendors will resubmit the Exceptions Request Form (checking the box marked "Appeal of Exception Denial") and update it to provide further information about the nature of the exception. The appeal is then returned to the HCAHPS Project Team for re-review. The second review will take approximately 10 business days.

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Discrepancy Report Process:

From time to time a hospital/survey vendor may identify inadvertent and temporary discrepancies from HCAHPS protocols that require corrections to procedures and/or electronic processing to realign the activity to HCAHPS protocols. Hospitals/Survey vendors are required to notify CMS of these discrepancies. (Examples of temporary discrepancies may include, but are not limited to, missing eligible discharges from a particular date, or computer programming that caused an otherwise eligible MS-DRG to be excluded from the sample frame.) To formally notify CMS of discrepancies such as these, hospitals/survey vendors are required to complete and submit a Discrepancy Report as soon as possible. See the current HCAHPS Quality Assurance Guidelines for the form that must be submitted online (www.hcahpsonline.org). This report notifies the HCAHPS Project Team of the nature, timing, cause, and extent of the discrepancy, as well as the proposed correction and timeline to correct the discrepancy. Survey vendor must submit a Discrepancy Report on behalf of their client hospital(s). The Discrepancy Report must be completed and submitted immediately upon discovery of the discrepancy from HCAHPS Protocol

Review Process The Discrepancy Report will be reviewed by the HCAHPS Project Team, who will assess the actual or potential impact of the noted discrepancy on publicly reported HCAHPS results Depending on the nature and extent of the discrepancy, a formal review of the hospital's/survey vendor's procedures, and/or conference call or on-site visit, may be undertaken. The HCAHPS Project Team will notify hospitals/survey vendors whether additional information is required to document and correct the issue.

Directions for Completing the Discrepancy Report Form General Instructions Please be sure to complete the Discrepancy Report in its entirety. Section 1: Must contain information for the organization submitting the Discrepancy Report. Section 2: Must contain the name of the individual to contact regarding the Discrepancy Report. Section 3: Provide information about the discrepancy, including: a detailed description of the discrepancy; how it was identified; the corrective actions taken to prevent the identified issue from reoccurring; and any other information that might assist the HCAHPS team to determine an outcome. Section 4: Submit information for each hospital that was affected by the discrepancy. All fields are required and at least one hospital must be listed in order to submit the online Discrepancy Report. To enter data for a minimum of one hospital: Complete all items in Section 4 and select the “Add Affected Hospital Information” button. Select the “Submit Form” button and the Discrepancy Request will be submitted to the HCAHPS team for review. To enter data for multiple hospitals: After entering the data for one hospital, select the “Add Affected Hospital Information” button. A notice will appear at the top of the page indicating that the “Affected hospital information has been added successfully.” This action will result in listing the previously entered information in the “onscreen” table and blank out the data fields so that information regarding an additional hospital may be entered. Repeat this process until all hospitals have been entered. Next step is to select the “Submit Form” button and the Discrepancy Request will be submitted to the HCAHPS team for review. A notice will appear at the top of the page indicating that “You have successfully submitted your completed Discrepancy Report Form.” If the Discrepancy Report affects more than 20 hospitals, download the Discrepancy Report Hospital Information Form, input the information regarding each hospital, and email the completed spreadsheet via HCAHPS Technical Assistance at hcahps@azqio.sdps.org.

Click here to begin the Discrepancy Report