hcahps update training february 2009. 2 hcahps update training february 2009 welcome! in the hcahps...
TRANSCRIPT
HCAHPS Update Training
February 2009
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February 2009
Welcome!In the HCAHPS Update Training sessions, we
will:
• Explain purpose and use of HCAHPS survey
• Provide instruction on managing the survey
• Discuss modes of survey administration
• Instruct on sampling, data preparation, data submission and public reporting
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HCAHPS Program Updates
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Overview of Presentation
HCAHPS Upcoming events
New for HCAHPS
Participation in HCAHPS
How to Join HCAHPS in 2009
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Upcoming for HCAHPSMarch 26, 2009 Fifth public reporting of HCAHPS results;
July 2007-June 2008 discharges; ~3,800 hospitals
April 8 Submission deadline for 4th quarter 2008 data
April 10 - May 9 Preview Period for June public reporting
~ June 18 Sixth public reporting of HCAHPS results
~ September 17 Seventh public reporting of HCAHPS results
~ December 17 Eighth public reporting of HCAHPS results
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New for HCAHPS• IPPS hospitals must report HCAHPS
results on Hospital Compare website
• Enhanced oversight
• New languages added for mail mode
• HCAHPS Mode Experiment Two– Testing feasibility of two new candidate
modes:• SE-IVR and Web-based
• New footnotes
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New for HCAHPS (cont’d)• HCAHPS Bulletins
• HCAHPS Executive Insight
• HCAHPS Version 3.1 effective for second quarter 2009 discharges
• Hospitals with 5 or fewer HCAHPS-eligible patients need not survey from January 2009– However, still must submit header data
• Congress considering HCAHPS in possible pay-for-performance program
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Public Reporting MARCH 2009
– QUARTERS INCLUDED: 3Q07, 4Q07, 1Q08, 2Q08
– PREVIEW PERIOD: January 19 – February 17
– PUBLIC REPORTING: March 26, 2009
– NOTE: First reporting of hospitals that joined HCAHPS in July 2007
– Data from 2Q07 has rolled off
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Survey Mode
Second quarter 2008 hospitals (3,866):
•Mail: 2,833 hospitals; 73%•Telephone: 990 hospitals; 26%•Mixed: 8 hospitals; 0.2%• IVR: 35 hospitals; 1%
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Participation in HCAHPS
Second quarter 2008:
• 50 Approved survey vendors • 93 Self-administering
hospitals• 5 Multi-site hospitals
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Oversight and Compliance
As HCAHPS plays a greater role in hospital payment,
The importance of oversight
and compliance increase
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Steps to Join HCAHPS in 2009
1. Submit HCAHPS Participation Form • For self-administering hospitals, hospitals
administering survey for multiple sites and survey vendors
• Form now available online
2. Do an HCAHPS Dry Run• Voluntary, but strongly suggested• Last month of calendar quarter • Contact HCAHPS Project Team for details
3. Collect and submit HCAHPS survey data on continuous basis
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More information on HCAHPS
• Registration, applications, background information,
reports, updates and HCAHPS Executive Insight :
www.hcahpsonline.org
• Submitting HCAHPS data:
www.qualitynet.org
• Publicly reported HCAHPS results:
www.hospitalcompare.hhs.gov
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Questions?
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HCAHPS Participation and
Program Requirements
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Participation Overview
• Quality Assurance Guidelines V4.0
• Quality Assurance Plans
• Exceptions Request/Discrepancy Report
• HCAHPS Website
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HCAHPS Quality Assurance Guidelines
V4.0• General updates:
– Terminology changes• Web site; My QualityNet; CMS Certification Number
– Updates to Introduction and Overview• Mode Experiment II information• Updated 2009 timeline
– Program Requirements• Reminder that the HCAHPS survey must be administered before
any other survey• Data submission for “zero case” and fewer than 5 eligible
discharges in a month• Maintain counts of ineligible patients and exclusions
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HCAHPS Quality Assurance Guidelines V4.0 (cont’d)
• General updates (cont’d):– Additional methodologies approved to
determine HCAHPS service line– Sample Frame must be maintained for 3
years– Two new mail survey translations– Updates to the Telephone and IVR scripts– XML File Layout 3.1– Appendices
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Quality Assurance Plan (QAP)
• QAP 2009 submission date March 23, 2009– Appendix N– Revisions must be clearly identified
(track changes)– Must include a discussion of the
results of quality control activities conducted during the prior year
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Quality Assurance Plan (QAP) (cont’d)
• QAP 2009 submission date March 23, 2009 (cont’d)
• Include sample(s) of survey and cover letter (Mail Only and Mixed modes)
• Include sample(s) of telephone script (screen shots Telephone Only and Mixed modes)
• Include sample(s) of IVR Script (Active IVR mode)
• All survey languages administered
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HCAHPS Exceptions Request
• Exceptions Request required to use a service line determination methodology other than:– V.26 or V.25 MS-DRG codes– V.24 CMS-DRG codes– Mix of V.26, V.25, V.24 codes based on payer
source– ICD-9 codes– Hospital unit– New York State DRGs
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HCAHPS Exceptions Request
• Exceptions Request must be submitted online via the HCAHPS Web site
• Survey Vendors must submit Exceptions Request on behalf of their contracted hospital
• Organization submitting the Exceptions Request will receive notification emails
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Discrepancy Report• Discrepancy Reports must be submitted
online via the HCAHPS Web site• Survey Vendors must submit Discrepancy
Report on behalf of their contracted hospital• Organization submitting the Discrepancy
Report will receive notification emails• Detailed information and hospital CCN
required• Reviewed each reporting period
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Discrepancy Report (cont’d)
• Reviewed each reporting period
• Timing of notification emails
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HCAHPS Web site• Regular update items
– HCAHPS Executive Insights
– PMA Tables
– Data Submission Due Date Announcements
– HCAHPS Bulletin
– Online Form Submission
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Questions?
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Sampling Protocol
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Overview
• Steps of Sampling Process
• Population, Sample Frame and Sample
• Sampling Facts
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Steps of Sampling Process
1. Population (All Patient Discharges)2. Identify Eligible Patients3. Remove Exclusions4. De-Duplication Process5. HCAHPS Sample Frame6. Draw Sample
See Quality Assurance Guidelines V4.0, Flowchart of HCAHPS Sampling Protocol
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Step 1: Population(All Patient Discharges)
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Step 1: Population (cont’d)
• Patients of all payer types are eligible for sampling
• Hospitals contracting with survey vendors are strongly encouraged to provide entire patient discharge list (excluding no-publicity patients and patients excluded because of state regulations) to their survey vendor
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Step 2: Identify Eligible Patients
All Eligible Patients
• 18 years or older at the time of admission
• Admission includes at least one overnight stay in the hospital
• Non-psychiatric MS-DRG/principal diagnosis at discharge
• Alive at the time of discharge
Ineligible Patients
Record count of Ineligible patients
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Step 2: Identify Eligible Patients Eligibility Criteria
(cont’d)• V.26 MS-DRGs effective October 1, 2008
– To classify into Medical and Surgical service lines
• The Federal Register Notice – most recent August 19, 2008 (updated approximately twice per year)
– To classify into Maternity Care service line• Use MS-DRGs 765 – 768, 774, 775
• Current Service Line-MS-DRG Crosswalk Table– Quality Assurance Guidelines V4.0
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Step 2: Identify Eligible Patients Eligibility Criteria
(cont’d)• Effective with Version 3.1 2Q 2009 patient discharges - accepted methodologies for determination of service line (Exceptions Request not required)– V.26 or V.25 MS-DRG codes– V.24 CMS-DRG codes– Mix of V.26, V.25, V.24 codes based on payer source– ICD-9 codes– Hospital unit– New York State DRGs
Hospitals/Survey vendors must submit an Exceptions Request Form online for approval to use other means.
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Step 2: Identify Eligible Patients Eligibility Criteria
(cont’d)• Include patients unless have positive
evidence that a patient is ineligible– Missing or incomplete MS-DRG, address
and/or telephone number does not exclude patient from being sampled
– Nursing home patients must not be excluded
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Step 2: Identify Eligible Patients
Eligibility Criteria (cont’d)• Do not include patients with
discharge dates beyond the 42-day initial contact period in the sample frame– Discrepancy Report must be filed to
account for patient information received beyond the 42-day initial contact protocol
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Step 3: Remove Exclusions
All Eligible Patients
Ineligible Patients
Exclusions• “No-Publicity” patients• Court/Law enforcement patients
(i.e., prisoners)• Patients with a foreign home
address Patients discharged to hospice care
• Patients who are excluded because of state regulations
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Step 3: Remove Exclusions (cont’d)
• Record count of patients by each exclusions category
• Hospitals/Survey vendors must retain documentation that verifies all exclusions
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Step 4: De-Duplication Process
All Eligible Patients
Ineligible Patients
Exclusions
De-Duplication• Household• Multiple Discharges
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Step 4: De-Duplication Process
De-Duplication by Household• Sample only one patient per
household in a given calendar month– De-duplicate address and/or telephone
number from medical records and patient unique IDs within each month
– Do not de-duplicate address and/or telephone number for nursing homes, long-term care facilities, etc., unless residents are family members
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• Sample patient only once in a given calendar month– For continuous sampling, only use the
first discharge date– For weekly sampling, use the last
discharge during the week – For end of the month sampling, de-
duplicate across all discharges in the month and only use the last discharge
Patients are eligible to be included in the sample in consecutive months.
Step 4: De-Duplication Process
De-Duplication by Multiple Discharges
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Step 5: HCAHPS Sample Frame
All HCAHPS Eligible Patients(Sample Frame)
Ineligible Patients
Exclusions
De-Duplication• Household• Multiple Discharges
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Step 5: HCAHPS Sample Frame Sample Frame
Creation1. Survey vendor generates sample frame (Recommended)
– Contracted hospital submits their entire patient discharge list, excluding no-publicity patients and patients excluded because of state regulations
– Survey vendor applies Eligible Population criteria and removes Exclusions and generates the sample frame before sampling
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Step 5: HCAHPS Sample Frame
Sample Frame Creation (cont’d)2. Hospital generates sample frame
– File contains all patients that meet Eligible Population criteria
– Hospital provides all required data file elements• Total count of ineligible patients• Total count of patients by each exclusions category
– Survey vendor validates the integrity of the sample frame before sampling
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Step 5: HCAHPS Sample Frame Sample Frame
Creation (cont’d)• Include all patients:
– Who meet eligible population criteria – Discharged between first and last days
of month• Include patients even if:
– Missing or incomplete address/telephone number
– Missing eligibility criteria
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Step 5: HCAHPS Sample Frame Sample Frame
Creation(cont’d)• Do not include patients if:
– Discharge dates beyond the 42-day initial contact period if known before sample drawn
• Discrepancy Report must be filed to account for patient information received beyond the 42-day initial contact protocol
• Include these patients towards the count in the Eligible Discharge field
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• Must maintain sample frame for a minimum of three years
• Updated sample frame layout (Appendix K)– File Content (i.e., All Patient Discharges or HCAHPS
Sample Frame)– Total Number of Ineligibles– Total Number of Exclusions and by Exclusions
Category– Total Number of Patient Discharges
Step 5: HCAHPS Sample Frame
HCAHPS Sample Frame
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Step 6: Draw SampleEligible Patients
Not Selected for Sample
Ineligible Patients
Exclusions
De-Duplication
Sample1. Simple Random Sample
(SRS)2. Proportionate Stratified
Random Sample (PSRS)3. Disproportionate Stratified
Random Sample (DSRS)
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Population, Sample Frame and Sample
A + B + C + D + E= Hospital Population (All Patient Discharges)
A + B = HCAHPS Sample Frame: generated by hospital/survey vendor. Contains entire Eligible Population
A = Sample: randomly selected
C
DE
A
B
A B C D E
Population (All Patient Discharges)
Sample Drawn
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Sampling Facts• Same sampling type must be
maintained throughout the quarter • Sample must include discharges from
each month in the 12-month reporting period
• HCAHPS random sample drawn first if multiple surveys administered
• Do not stop sampling/surveying if 300 completes attained
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Questions?
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Survey Administration
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Overview
• Survey Translations and Materials
• Survey Management
• Modes of Survey Administration
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Survey Translations and Materials
• Mail survey materials availability—questionnaires, alternative survey instructions (circle responses), cover letters, and OMB language – English language materials (Appendix A)– Spanish language materials (Appendix B)– Chinese language materials (Appendix C)– Russian language materials (Appendix D)– Vietnamese language materials (Appendix E)
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Survey Translations and Materials (cont’d)
• Telephone and IVR survey materials availability—scripts – English telephone script (Appendix F)– Spanish telephone script (Appendix G)– English IVR script (Appendix H)
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Survey Management • Personnel training and oversight
– Project staff and subcontractors• Training• Ongoing oversight • Performance evaluation
– Volunteer staff must not be used
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Modes of Administration • Data collection begins within 48 hours to 6 weeks
(42 days) after discharge from hospital– Lag time = the number of days between the patient’s
discharge from the hospital and the return of the mail survey, or the final disposition of the telephone or IVR survey
• If a patient is found to be ineligible, discontinue survey administration for that patient
• No changes are permitted to the order of the questions or answer categories for the Core or “About You” questions
• The “About You” questions must remain as one block of questions
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Mail Only Mode
• Questionnaire formatting requirement– Name and return address of
hospital/survey vendor must be printed on the questionnaire• Hospital/Survey vendor must add this
requirement to their survey templates as they update them
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Mail Only Mode (cont’d)
• Mail Out - Requirements– Addresses acquired from hospital record– Addresses updated using
commercial software– Mailings sent to patients by name
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Mail Only Mode (cont’d) • Quality control guidelines
– Hospitals/Survey vendors must:• Provide ongoing oversight of staff and
subcontractors
• Conduct seeded mailings to project staff for timeliness and accuracy of delivery
• Check for accuracy of mailing contents
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Telephone/IVR Mode• Protocol
– Initiate systematic telephone contact with sampledpatient(s) between 48 hours and 6 weeks (42 days) after discharge
– Complete telephone sequence within 42 days of initiation so that a total of 5 telephone calls are attempted• at different times of day• on different days of the week• and in more than one week
– Submit data to CMS via My QualityNet by the data submission deadline
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Telephone/IVR Mode (cont’d)
• Obtaining telephone numbers– Main source of telephone numbers is
hospital discharge records– Must attempt to update missing or
incorrect telephone numbers using • commercial software • internet directories• directory assistance • other tested methods
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Telephone/IVR ScriptINTRO1 Hello, may I please speak to [SAMPLED PATIENT NAME]? (Appendices F & G)
<1> YES [GO TO INTRO2]<2> NO [REFUSAL]<3> NO, NOT AVAILABLE RIGHT NOW [SET CALLBACK]
IF ASKED WHO IS CALLING: This is [INTERVIEWER NAME] calling from [DATA COLLECTION CONTRACTOR]. We are conducting a survey about healthcare. I am calling to talk to [SAMPLED PATIENT NAME] about a recent healthcare experience.
IF ASKED WHETHER PERSON CAN SERVE AS PROXY FOR SAMPLED PATIENT:For this survey, we need to speak directly to [SAMPLED PATIENT NAME]. Is [SAMPLED PATIENT NAME] available?
IF THE SAMPLED PATIENT IS NOT AVAILABLE:Can you tell me a convenient time to call back to speak with (him/her)?
IF THE SAMPLED PATIENT SAYS THIS IS NOT A GOOD TIME:If you don’t have the time now, when is a more convenient time to call you back?
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Telephone/IVR ScriptINTRO2 Hi, this is [INTERVIEWER NAME] calling on behalf of [HOSPITAL NAME].
[HOSPITAL NAME] is participating in a survey about the care people receive in the hospital. This survey is part of a national initiative to measure the quality of care in hospitals. Survey results can be used by people to choose a hospital. Your answers may be shared with the hospital for purposes of quality improvement.
Participation in the survey is completely voluntary and will not affect your health care or your benefits. It should take about 7 minutes to answer. NOTE: THE NUMBER OF MINUTES WILL DEPEND ON WHETHER HCAHPS IS INTEGRATED WITH HOSPITAL-SPECIFIC QUESTIONS.
This call may be monitored [recorded] for quality improvement purposes.
OPTIONAL QUESTION TO INCLUDE:I’d like to begin the survey now, is this a good time for us to
continue?
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Telephone/IVR Script• “About You” questions introduction
Q23_INTRO This last set of questions is about you. Please listen to all response choices before you answer the following questions.
Q23 In general, how would you rate your overall health? Would you say that it is…
<1> Excellent,<2> Very good,<3> Good,<4> Fair, or<5> Poor?<M> MISSING/DK
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Telephone/IVR Script (cont’d)
• Race questions instruction[FOR TELEPHONE INTERVIEWING THIS QUESTION IS BROKEN INTO PARTS A-E.]
READ ALL RACE CATEGORIES PAUSING AT EACH RACE CATEGORY TO ALLOW RESPONDENT TO REPLY TO EACH RACE CATEGORY.
Q26 When I read the following list, please tell me if the category describes your race. You may choose one or more.
Q26A Are you White?<1> YES/WHITE<0> NO/NOT WHITE<M> MISSING/DK
Q26B Are you Black or African-American?<1> YES/BLACK OR AFRICAN-AMERICAN<0> NO/NOT BLACK OR AFRICAN-AMERICAN <M> MISSING/DK
Read Questions A through E to capture multiple races. Do not stop reading the list when you get a Yes answer.
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Telephone Script
• Race questions probe
IF THE RESPONDENT REPLIES “I ALREADY TOLD YOU MY RACE”:
I understand, however the survey requires me to ask about all races so results can include people who are multiracial. If the race does not apply to you please answer no. Thanks for your patience.
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Telephone Only Mode (cont’d)
• Quality control guidelines
– Formal interviewer training to ensure standardized, non-directive interviews
– Telephone monitoring and oversight of staff and subcontractors
• At least 10% of interviews are monitored
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Questions?
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Data Coding, Preparation and
Submission
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Overview
• File Specifications Version 3.1• File Layout Version 3.1
– Header Record– Patient Administrative Data Record– Patient Response/Survey Results Record
• Preparing the Data File• Data Submission Timeline
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File Specifications Version 3.1
• Effective with patient discharges beginning 2Q 2009– Appendix L – Data File Structure Version
3.1– Appendix M – XML File Layout Version 3.1
• XML Filenames increased to 50 characters
• Anticipated release of File Specifications 3.1 in early April 2009
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File Specifications Version 3.1 (cont’d)
• Do not submit April 2009 and forward discharge data until HCAHPS Version 3.1 release is announced
• Monitor HCAHPS Web site for notification of release
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Header Record Version 3.1
Field Name Description
Provider Name Name of the hospital
Provider ID CMS Certification Number (CCN), formerly known as the Medicare Provider Number
NPI National Provider Identifier (optional)
Discharge Year Year of discharge
Discharge Month Month of discharge
Survey Mode Mode of survey administration
Determination of Service Line
Methodology used by a facility to determine whether a patient falls into one of the three service line categories eligible for HCAHPS survey
Eligible Discharges Number of eligible discharges in sample frame in the month
Sample Size Number of sampled discharges in the month
Type of Sampling Type of sampling utilized
DSRS Strata Name If sampling type is DSRS, the name of strata
DSRS Eligible If sampling type is DSRS, the number of eligible patients within the stratum
DSRS Sample Size If sampling type is DSRS, the number of sampled patients within the stratum
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File Layout Version 3.1
1. Header Record (Updated Version 3.1)– Complete once per monthly file per CCN
2. Patient Administrative Data Record (Updated Version 3.1)− Complete for every patient in the sample
3. Patient Response/Survey Results Record– Complete for patients who responded to the
survey• “Final Survey Status” of “1 - Completed Survey” or
“6 – Non-response: Break-off”– Enter missing responses as “M - Missing/Don’t
Know” or “8 - Not Applicable”
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Header Record Version 3.1 (cont’d)
• All fields in the Header Record must have a valid value
• Exceptions:– NPI (optional)– DSRS Strata Name (required only if DSRS)– DSRS Eligible (required only if DSRS)– DSRS Sample Size (required only if DSRS)
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Header Record Version 3.1 (cont’d)
• CMS Certification Number (CCN)– Valid 6 digit CCN (formerly known as
Medicare Provider Number)– Sample per unique CCN– Hospitals that share a common CCN
must obtain a combined total of at least 300 completes per CCN per 12-month reporting period
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Header Record Version 3.1 (cont’d)
• Discharge Year and Month– Use of Version 3.1 requires April 2009 or greater
• Survey Mode– Code with the approved survey mode for the hospital
• If the hospital is using IVR survey mode and have patients who opt to complete the survey by telephone, the “Survey Mode” field must still be coded as “4 – IVR”
• If the hospital is using Mixed survey mode and have patients who complete the survey by telephone, the “Survey Mode” field must still be coded as “3 – Mixed Mode”
– Must be the same for all three months within a quarter– Cannot be coded as “5 - Exception” as it is an invalid
value
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Header Record Version 3.1 (cont’d)
• Methodology for Determination of Service Line1. V.26 MS-DRG codes or V.25 MS-DRG codes2. V.24 CMS-DRG codes3. Mix of V.26, V.25, V.24 codes based on payer
source4. ICD-9 codes5. Hospital unit6. New York State DRGs7. Other - Approved Exceptions Request only
• Note: Hospitals/Survey vendors must submit an Exceptions Request Form online for approval to use other means
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Header Record Version 3.1 (cont’d)
• Eligible Discharges– Number of eligible discharges in the
sample frame• All eligible discharges are included even if the
patient’s information is received from the hospital with discharge dates that are beyond the 42-day initial contact period
– Note: A Discrepancy Report must be filed to account for patient information received beyond the 42-day initial contact protocol
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Header Record Version 3.1 (cont’d)
• Eligible Discharges (cont’d)– Hospitals with 5 or few eligible HCAHPS
patient discharges in a month may choose to not survey those patients for that given month, beginning with January 2009 patient discharges
• If patients are not surveyed, an HCAHPS Header Record (Survey Month Data) must still be submitted online via My QualityNet
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Header Record Version 3.1 (cont’d)
• Eligible Discharges (cont’d)– In calculating the “Eligible Discharges”
field, do not include patients later determined to be ineligible or excluded, regardless of whether they are selected for the survey sample
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Header Record Version 3.1 (cont’d)
• Eligible Discharges (cont’d)– If a patient was selected for the survey sample and later
determined to be ineligible (i.e., “Final Survey Status” code of “3 – Ineligible: Not in eligible population”), the patient must be subtracted when reporting the “Eligible Discharges” field (number of eligible discharges in sample in the month)
– Does NOT apply to “Final Survey Status” codes of “2 – Ineligible: Deceased,” “4 – Ineligible: Language barrier,” or “5 – Ineligible: Mental/Physical incapacity.”
– “Sample Size” can therefore be larger than the number of “Eligible Discharges”
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Header Record Version 3.1 (cont’d)
• Eligible Discharges (cont’d)– If a patient was not selected for the
survey sample and later determined to be ineligible (i.e., received an update with an ineligible MS-DRG code for the patient), the patient must be subtracted when reporting the “Eligible Discharges” field
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Patient Administrative Data Record Version 3.1
Field Name Description
Provider ID CMS Certification Number (CCN), formerly known as the Medicare Provider Number
Discharge Year Year of discharge
Discharge Month Month of discharge
Patient ID Random, unique, de-identified, assigned patient ID by hospital/survey vendor
Point of Origin for Admission or Visit
Source of inpatient admission for the patient (same as UB-04 field location 15)
Reason Admission Service line
Discharge Status Patient’s discharge status (same as UB-04 field location 17)
Strata Name If sampling type is DSRS, name of the stratum the patient belongs to
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Patient AdministrativeData Record Version 3.1
(cont’d)Field Name Description
Final Survey Status Disposition of survey
Survey Language Identify whether survey was completed in English Spanish, Chinese, Russian or Vietnamese
Lag Time Number of days between the patient’s discharge from the hospital and the return of the mail survey, or the final disposition of the telephone or IVR survey.
Gender Patient’s gender (same as UB-04 field location 11)
Age at Admission Patient’s age at hospital admission
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Patient AdministrativeData Record Version 3.1
(cont’d)• All fields in the Patient Administrative Data
Record must have a valid value • Use code “M - Missing/Don’t Know” for all
missing fields, with the following exceptions:– “Point of Origin for Admission or Visit”—code as
“9 - Information not available”– “Survey Language”—code as “8 – Not applicable”– “Lag Time”—code as “888 – Not applicable”
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Patient AdministrativeData Record Version 3.1
(cont’d)• Service Line (Reason Admission)
– Based on one of the accepted methodologies for Determination of Service Line in Header Record
• Discharge Status– Updated code “5 – Discharge/transfer to a
designated cancer center or children’s hospital”– Added code “70 - Discharge/transfer to a health
care institution not defined elsewhere in the code list”
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Patient AdministrativeData Record Version 3.1
(cont’d)• Survey Language
– Based on the language survey was completed and not the patient’s language
– Added Russian and Vietnamese languages for Mail only
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Patient AdministrativeData Record Version 3.1
(cont’d)• Lag Time
– Number of days between the patient’s discharge from the hospital and the return of the mail survey, or the final disposition of the telephone or IVR survey
– “Final Survey Status” code of 1 – Completed survey” or “6 – Non-response: Break-off” must contain the actual lag time
• These surveys should NOT be coded “888 – Not Applicable” for lag time
– “Final Survey Status” code of 2, 3, 4, 5, 7, 8, 9, 10, or M (that is, any “Final Survey Status” code OTHER THAN 1 or 6) need not contain the actual lag time
• Such surveys MAY use either the actual lag time or “888 – Not Applicable”
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Patient AdministrativeData Record Version 3.1
(cont’d)• Patient administrative information must be
submitted for all patients selected in the survey sample
• If a patient is later found to be ineligible or excluded, the patient administrative information must be submitted and the patient should be assigned a “Final Survey Status” code of “3-Ineligible: Not in eligible population”
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Patient Response/Survey Results Record Version
3.1• Required when “Final Survey Status”
in the Patient Administrative Data Record is coded as “1 - Completed Survey” or “6 – Non-response: Break-off”
• All fields must have a valid value, including “M - Missing/Don’t Know” or “8 - Not Applicable”
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File Layout Structure• Header Record completed once per
monthly file• Patient Administrative Data Record
completed for every patient in the sample• Patient Response/Survey Results Record
completed for patients who responded to the survey – “Final Survey Status” codes of “1 - Completed
Survey” or “6 – Non-response: Break-off”– Enter missing responses as “M - Missing/Don’t
Know” or “8 - Not Applicable”
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Preparing the Data File• Check data file
– Check for (no) out of range values– Check for consistency
• Male patients should not be reported in the “Maternity Care” service line
• Patients with a “Discharge Status” of “Expired” (codes 20 or 41) must not have “Final Survey Status” coded as “1 - Completed Survey” or “6 – Non-response: Break-off”
– Check frequency distributions of values• Survey responses coded as all “M – Missing”
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Data Submission Timeline
Data Submission Deadline
Month of Patient DischargesFile
Specifications Version
April 8, 2009 October, November and December 2008
Version 3.0
July 8, 2009 January, February and March 2009 Version 3.0
October 14, 2009 April, May and June 2009 Version 3.1
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Questions?
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Data Submission via My QualityNet
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Data Submission Deadlines
• Hospitals and survey vendors may revise their files up to the data submission deadline Revised XML files completely overwrite previous file Final submission of each file must contain all
records for that month
• Recommend submitting final data, including corrections, no later than 48 hours prior to deadline
• Review HCAHPS Reports
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Feedback Reports• Feedback reports available to
Vendors and Healthcare Systems– Report Authorization– Feedback reports roles
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Notifications• Submission Deadline reminder• APU submission reminders
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QualityNet Training and Users Guides
• Web-Ex available to the public– www.qualtynet.org
• Training – QualityNet Training
• QualityNet users guides available on the secure pages of MyQualityNet “Help” link– QualityNet– QualityNet Reports
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QualityNet Exchange Resources
• Website: www.qualitynet.org
• QualityNet Help Desk:Phone: (866) 288-8912Email: [email protected]: 8 a.m. – 8 p.m. ET Monday - Friday
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Questions?
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February 2009
Data Adjustmentand Public Reporting
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Overview• Reporting HCAHPS Results• Hospitals with 5 or fewer HCAHPS
Eligible Patients• Footnotes• Forms for Public Reporting• Hospital Preview Reports• Suppression of Results
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Reporting HCAHPS Results
• Results reported for the six composites, two individual items, two global items
• Number of completed surveys and response rate also reported
• The user is able to drill down for more detailed results
• Results aggregated into rolling four quarters (12 months) by hospital
• Footnotes are applied as applicable
• Each hospital’s results is displayed with national and state averages
• Results are updated quarterly
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Reporting HCAHPS Results (cont’d)
• On Hospital Compare website at www.hospitalcompare.hhs.gov
• Hospitals will be able to view a preview report of their results
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Hospital Preview Reports
• Preview Report data will encompass:-Aggregate of rolling 4 quarters (12
months)– All information that will be publicly
reported for each hospital
• Preview period is 30 days via My QualityNet
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Hospital Compare Screenshot
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Hospital Compare Screenshot
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Hospital Compare Screenshot
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Hospitals with 5 or Fewer HCAHPS Eligible Patients in a
Given Month• Starting with January 2009 discharges,
these hospitals are no longer required to collect and submit HCAHPS data for that month– A header record must be submitted to My
QualityNet through the on-line tool or XML file submission
• These hospitals can voluntarily collect and submit data for these months
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Public Reporting: Footnote 6
• Fewer than 100 patients completed the HCAHPS survey. Use these rates with caution, as the number of surveys may be too low to reliably assess hospital performance.
The number of completed surveys the hospital or its vendor provided to CMS is less than 100.
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March 2009 Public Reporting: Footnote 7
• Survey results are based on less than 12 months of data, or there were discrepancies in the data collection process.
Footnote 7 is applied when HCAHPS results are based on less than 12 months of survey data, or when there have been deviations from HCAHPS data collection protocols. CMS is working with survey vendors and/or hospitals to correct any discrepancies.
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Public Reporting: Footnote 8
• Survey results are not available for this period.
This footnote is applied when a hospital did not participate in HCAHPS, or chose to suppress their HCAHPS results.
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Public Reporting: Footnote 9
• No patients were eligible for the HCAHPS Survey.
This footnote is applied when a hospital has no patients eligible to participate in the HCAHPS survey.
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Changes in Footnotes for June 2009 Public Reporting:
Footnote 7• Survey results are based on less than 12
months of data.
Footnote 7 is applied when HCAHPS results are based on less than 12 months of survey data.
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Changes in Footnotes for June 2009 Public Reporting:
Footnote 11• There were discrepancies in the data
collection process.
Footnote 11 is applied when there have been deviations from HCAHPS data collection protocols. CMS is working with survey vendors and/or hospitals to correct any discrepancies.
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Forms for Public Reporting
• Hospitals must have either a Hospital Quality Alliance (HQA) Pledge or a RHDQAPU Notice of Participation Form submitted to have their data displayed on www.Hospitalcompare.hhs.gov
• Forms are accessible on My QualityNet (www.qualitynet.org)
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Suppression of Results: IPPS Hospitals
• IPPS hospitals can not suppress their results for 2009 public reporting periods
– Must withdraw from RHQDAPU program to suppress
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Suppression of Results: CAHs
• CAHs may suppress their results– Must suppress complete set of HCAHPS results
• Will receive footnote 8
• To suppress, the CAH must complete the HQA Request for Withholding Data from Public Reporting Form (found on the My QualityNet www.qualitynet.org) and submit it to the QIO
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Questions?
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February 2009
Oversight Activities and
Compliance
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Overview
• Purpose of Oversight
• Description of Oversight activities
• Quality Assurance Plan (QAP) requirements
• On-Site visits and Conference calls
• Oversight and Compliance
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Purpose of Oversight
• Ensure compliance with HCAHPS protocols
• Ensure that survey data collected and submitted are complete, valid and timely
• Ensure standardization and transparency of publicly reported HCAHPS results
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Description of Oversight Activities
The HCAHPS Project Team:
• Reviews Quality Assurance Plans
• Reviews survey materials
• Analyzes submitted data
• Conducts on-site visits & conference calls
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Quality Assurance Plan• Provides documentation of
understanding, application and compliance with HCAHPS protocols
– Sufficient detail to administer survey without prior knowledge of the survey process
– See “Tips” in QAG v4.0, Appendix N
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Quality Assurance Plan (cont’d)
• Serves as organization-specific guide for administering and training project staff to conduct HCAHPS surveys
• Must reflect actual survey processes and practices
• Provides a guide for the on-site visit
• Ensures high quality data collection and continuity in survey processes
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Quality Assurance Plan (cont’d)
• New QAP submitted after participation approval by CMS as self-administering hospital, hospital administering multiple sites, or survey vendor– New QAP submissions due on March 23
• QAP must be updated annually and when changes in key events or key project staff occur – Annual QAP update due by March 23
• HCAHPS Project Team “accepts” QAP– Acceptance does not imply approval of data collection
processes
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Quality Assurance Plan (cont’d)
• To produce the QAP– Follow the outline and specifications in
Appendix N, QAG v4.0
• Submit to HCAHPS Project Team through the HCAHPS Technical Assistance email ([email protected])
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Quality Assurance Plan (cont’d)
• Submitted QAP documentation includes:
– Organizational background and structure for the project
– Work plan for survey administration
– Survey and data management system and quality controls
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Quality Assurance Plan (cont’d)
• QAP documentation includes:
– Confidentiality/privacy and security procedures in accordance with HIPAA
– QAP Annual Update: discussion of recent quality control activities
• Including resolution of any issues identified by HCAHPS Project Team
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Analysis of Submitted Data
• Examine survey data submitted to the HCAHPS data warehouse –Outliers, anomalies, unusual patterns, etc.
• Contact hospitals/survey vendors regarding submitted data, as needed
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On-Site Visits/Conference Calls
• Purpose: ensure compliance with survey protocols
• Review of survey systems
• Discussions with project staff, including subcontractors
• All materials related to survey administration are subject to review
– Includes survey forms, letters, scripts, etc.
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On-Site Visits/Conference Calls (cont’d)
• On-site visit feedback report will include HCAHPS Project Team’s observations of the visit
– Survey administration– Customer support – Data preparation, specifications, coding & submission– Action items for follow-up
• Documentation of corrections will be required
• Further review and conference calls may occur
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On-Site Visits/Conference Calls (cont’d)
• Conference calls– Held with survey vendors, self-
administering hospitals, and multi-site hospitals
– May cover same topics as on-site visits
– Conference calls may also be conducted as a follow-up to on-site visits
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Oversight and Compliance
As HCAHPS results play a greater role in
hospital payment,
the importance of oversight and compliance increase
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HCAHPS Compliance (cont’d)
A participating hospital should:
• Work closely with its survey vendor (if using one)• Regularly monitor QualityNet Exchange
Feedback Reports• Read Quality Assurance Guidelines V4.0 and
monitor HCAHPS website for updates and announcements
• Comply with all HCAHPS oversight activities, as requested
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Non-Compliance with Program Requirements
• If hospital (or its survey vendor) fails to adhere to HCAHPS protocols, it must develop and implement corrective actions– Footnotes may be applied to publicly reported
results, as appropriate
• If problems persist, hospital may not qualify as meeting the APU requirements for HCAHPS
• Hospital’s APU may be jeopardized
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Non-Compliance with Program Requirements
(cont’d)If a survey vendor or self-
administering hospital does not fix persistent problems, it may lose its “approved” status for conducting HCAHPS
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Communicating with Patients about the HCAHPS
Survey• Hospital/Survey vendors are not allowed to:
– Attempt to influence or encourage patients to answer HCAHPS questions a particular way
– Ask patients to explain why they didn’t rate a hospital with most favorable rating possible
– Indicate the hospital’s goal is for all patients to rate them as an “Always” or other top response
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Advertising Guidelines• The Hospital Compare website is the
official source of HCAHPS results
• CMS does not endorse hospitals or survey vendors
• Hospital Compare is designed to provide objective information to help consumers make informed decisions about health care providers
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Contact Us
HCAHPS Information and Technical Support
• Website: www.hcahpsonline.org• E-mail: [email protected]• Telephone: 1-888-884-4007
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Questions?