Statement of Work (SOW)

1. PROJECT TITLE: Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey.

2. BACKGROUND/PURPOSE: HCAHPS (Hospital Consumer Assessment of

Healthcare Providers and Systems) is a standardized, national survey that asks patients about their experiences during a recent hospital stay. Our hospital utilizes the CMS-mandated HCAHPS survey to measure patient perspectives on inpatient care, ensuring transparency in our performance on Care Compare, by listening to and learning from patient feedback via HCAHPS. This mandatory, standardized survey helps us ensure safe, high-quality care and directly impacts on our hospital’s reputation and financial stability.

3. SCOPE: HCAHPS (Hospital Consumer Assessment of Healthcare Providers and

Systems) is a standardized survey—comprising of patient perspective items and demographic items—that evaluates key services: communication with nurses/doctors, responsiveness of staff, pain management, medication communication, hospital cleanliness, quietness, and discharge information. The survey targets adult inpatients discharged 48 hours to 42 days prior, specifically covering Medical, Surgical, and Maternity care lines. It focuses on actionable, patient-centered care areas, such as whether nurses listened carefully or if pain was well-controlled.

4. APPLICABLE DOCUMENTS:

a) HCAHPS Quality Assurance Guidelines: https://hcahpsonline.org/en/technical-specifications/

b) Centers for Medicare and Medicaid: HCAHPS; Patients Perspectives of care survey. https://www.cms.gov/medicare/quality/initiatives/hospital-quality-initiative/hcahps-patients-perspectives-care-survey

5. TASKS: HCAHPS service providers must meet minimum requirements, including having at least two years of survey experience (or one year for self-administering hospitals), conducting all operations within the U.S., and adhering strictly to CMS-approved methodologies. Vendors must submit data quarterly, ensure no survey tasks are performed by volunteers, and pass security/operational audits.

a) Vendor and/or subcontractor must be a HCAHPS Approved Survey Vendor. If subcontracting is used, the subcontractor’s information must be provided for verification.

b) Survey Experience: Minimum of two years of experience (for vendors) in survey research.

c) Data Handling: Must use approved HIPAA-compliant methods for patient data transfer.

https://hcahpsonline.org/en/technical-specifications/ https://hcahpsonline.org/en/technical-specifications/ https://www.cms.gov/medicare/quality/initiatives/hospital-quality-initiative/hcahps-patients-perspectives-care-survey https://www.cms.gov/medicare/quality/initiatives/hospital-quality-initiative/hcahps-patients-perspectives-care-survey

d) Data Submission: Vendor must submit data to CMS in four quarterly submissions (within 45 days after the end of each quarter)

e) Operational Standards: Must follow official CMS procedures strictly.

f) Mode Requirements: Vendor must support approved modes (Mail, Telephone, Mixed, Web, or IVR), ensuring telephone interviews are not conducted from residences.

g) Timing: Surveys must be conducted between 48 hours and 42 days after discharge.

6. DELLVERABLES AND DELIVERY SCHEDULE: Vendors submit data quarterly on behalf of the hospital and provide near real-time dashboards for daily updates.

7. GOVERNMENT-FURNISHED EQUIPMENT AND INFORMATION: NONE

8. PLACE OF PERFORMANCE: Inpatient discharges surveys are sent to the vendor monthly.

9. PERIOD OF PERFORMANCE: Shall include a twelve (12) month base year and four twelve (12) month option periods. Option periods are contingent on funding availability.

Base Year: 06/01/2026 – 05/31/2027 Option Year 1: 06/01/2027 – 05/31/2028 Option Year 2: 06/01/2028 – 05/31/2029 Option Year 3: 06/01/2029 – 05/31/2030 Option Year 4: 06/01/2030 – 05/31/2031

10. SECURITY: NONE