Digital Debut
Start on OAS CAHPS Survey Implementation Now
This patient experience evaluation becomes mandatory in 2025
BY KARA NEWBURY | MARCH 22, 2024
The Outpatient and Ambulatory Surgery Consumer Assessment of Healthcare Providers and Systems (OAS CAHPS) Survey will become a mandatory component of the Centers for Medicare & Medicaid Services’ (CMS) ASC Quality Reporting (ASCQR) Program on January 1, 2025. As of March 13, 2024, 1,618 ASCs had registered with OAS CAHPS, and 1,208 of those had authorized a vendor to administer the survey on their behalf. This represents only a quarter of the CMS-certified ASCs.
Facilities should start the process of selecting a vendor now to ensure they are able to begin surveying by 2025. Read an interview with an early user in which she describes why it is important to get a head start on the survey.
Survey Contents
The OAS CAHPS mail survey contains 34 items, including questions about the patient’s overall rating of the outpatient surgery facility, experience with the check-in process, facility environment, communication with administrative staff and clinical providers, attention to comfort, pain control, provision of pre- and postsurgery care information, overall experience and patient characteristics. The phone survey includes only 32 questions, because two of the questions in the mail survey ask if anyone helped the patient complete the survey.
The survey includes three composite survey-based measures, which consist of six or more questions. Those measures are
- ASC-15a: OAS CAHPS—About Facilities and Staff;
- ASC-15b: OAS CAHPS—Communication About Procedure; and
- ASC-15c: OAS CAHPS—Preparation for Discharge and Recovery.
The survey also includes two global survey-based measures, which include a single question each and ask the patient to rate the care provided by the surgery center and their willingness to recommend the ASC to family and friends.
- ASC-15d: OAS CAHPS—Overall Rating of Facility; and
- ASC-15e: OAS CAHPS—Recommendation of Facility.
The same measures also are included in the Hospital Outpatient Quality Reporting Program as OP-37a-e. The survey became mandatory for hospital outpatient departments (HOPD) this year.
Survey Modes
The current data collection modes are mail-only; telephone-only; mail survey with telephone follow-up of nonrespondents; web with mail follow-up of nonrespondents; and web with telephone follow-up of nonrespondents. There is not a web-only mode, although ASCA continues to advocate for one to reduce the cost burden on facilities.
Approved Vendors
CMS must approve survey vendors prior to them administering the survey. The OAS CAHPS website lists 16 vendors. ASCA’s OAS CAHPS Survey page also includes vendor contact information and the modes each vendor has been approved to administer. Many vendors offer only select survey modes.
CMS-approved vendors collect survey data monthly for eligible patients at ASCs and report that data to CMS on the ASCs' behalf by the quarterly deadlines established for each data collection period. If a facility has an electronic health record (EHR) vendor, it will need to involve the vendor in the process, which can take time. Even if a facility does not use EHR technology, it takes time to determine the best way to get the required data elements to the vendor.
Sampling Requirement and Low-Volume Accommodations
ASCs will be required to collect at least 200 completed surveys over a 12-month reporting period. Originally, CMS planned to require 300 completed surveys, but ASCA advocated strongly for a lower number and CMS obliged in its 2022 rulemaking.
Smaller ASCs that cannot collect 200 completed surveys over a 12-month reporting period will be required to survey all eligible patients, meaning, no sampling. As a reminder, for all measures in the ASCQR Program, facilities are exempt from participation if they bill fewer than 240 Medicare primary and secondary claims in a year.
Measure Calculations
As noted above, CMS is proposing to adopt three composite OAS CAHPS-based measures—ASC-15a, ASC-15b and ASC-15c—and two global survey-based measures—ASC-15d and ASC-15e. As with all other ASCQR measures, an ASC’s performance for a given payment determination year will be based upon the successful submission of all required data, not on the information the data contains. This data will become public and available to potential patients to use to determine how individual facilities compare.
Composite Survey-Based Measures
ASC rates on each composite OAS CAHPS-based measure will be calculated by determining the proportion of “top-box” responses, i.e., only counting the “yes” or “yes definitely” answers for each question and averaging these numbers over all the questions the measure contains.
Global Survey-Based Measures
The two global measures are based on one question each. ASC-15d asks the patient to rate the care provided by the ASC on a scale of 0 to 10, and ASC-15e asks about the patient’s willingness to recommend the ASC to family and friends on a scale of “definitely no” to “definitely yes.” ASC performance on each of the global OAS CAHPS-based measures will be calculated by the proportion of respondents providing high-value responses—that is, a 9 or 10 rating or “definitely yes”—to the survey questions over the total number of respondents.
Additional Resources
ASCA mailed a postcard to every CMS-certified ASC in February, encouraging facilities to get started to ensure they are ready to go once the mandate kicks in next year. Additional resources, available on ASCA’s and CMS’ websites, can help with implementation.
ASCA’s OAS CAHPS Survey page includes information on all the survey modes available from the approved vendors, as well as additional resources to help you get started.
The inaugural session in ASCA’s new Regulatory Series, titled: “OAS CAHPS: Getting Started,” provides insights from two ASC administrators who have already selected vendors.
The OAS CAHPS website is the official source for news, trainings and updates to the OAS CAHPS Survey.
Write Kara Newbury at knewbury@ascassociation.org with questions.