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Request for Measures of Family Assessment of Nursing Home Care

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Information about this document as published in the Federal Register.

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Agency for Healthcare Research and Quality (AHRQ), HHS.


Notice of request for measures.


The Agency for Healthcare Research and Quality (AHRQ) is soliciting a voluntary submission by researchers, survey firms, stakeholders and other interested parties of survey instruments, or items from survey instruments, measuring family assessments of nursing home care. The Centers for Medicare & Medicaid Services (CMS) established as a priority, support for the development of a standardized survey for measuring and publicly reporting family and residents' assessments of nursing home care that could be used nation wide, and asked AHRQ for assistance in the development and testing of the survey instruments. A resident survey has been developed that is the process of field testing. The next step is the development of a standardized instrument for investigation of family perspectives on residents' nursing home care. As part of the feasibility study, AHRQ is reviewing existing instruments that capture family members' assessments of resident's nursing home care. To conduct as inclusive a review as possible of successful or informative measures of care, the agency is requesting voluntary submission of such instruments or individual measures along with documentation for administration of the instruments or individual measures, and, if possible, critical evaluations of particular measures or related survey administration techniques. If selected for incorporation into a standardized CAHPS instrument for comparing family assessments of nursing home care, measure(s) will be made freely available to encourage their widespread use and the creation of uniform criteria by which nursing homes can be compared by consumers and other interested individuals and organizations. The final instrument will carry a CAHPS trademark to assure that if it is distributed or implemented as a CAHPS instrument, it will be used in accordance with CAHPS instructions and documentation. It should be noted that though the term “family” is used throughout, the term should be construed broadly to include all persons who periodically observe the care of a nursing home resident (e.g., a “significant other”) and, based on their contact, are able to provide the perspective and assessment of a concerned third party regarding the resident's care received in the nursing home.


Please submit instruments and supporting information on or before July 6, 2004, to Judith Sangl (see address below). AHRQ will inquire and determine whether each submitter wishes to be identified. Submitters will not respond individually to submitters, but will consider all submitted instruments and measures and publicly report the results of the review of the submissions in aggregate. Prior to releasing the names of submitters we will inquire and determine whether each submitter wishes to be identified. Submitters will not be identified with specific items in the final instrument.


Submissions should include a brief cover letter, a copy of the instrument or items for consideration and supporting information as specified under “Submission Criteria”, below. Submissions may be in the form of a letter or e-mail, preferably with an electronic file in a standard word processing format on a 31/2-inch floppy disk or as an e-mail attachment. Electronic submissions are encouraged. Please do not use any acronyms. Responses to this request should be submitted to: Judith Sangl, Agency for Healthcare Research and Quality, 540 Gaither Road, Rockville, MD 20850, Phone: (301) 427-1308, Fax: (301) 427-1341, E-mail:,

To facilitate handling of submissions, please include full information about the instrument developer or contact: (a) Name, (b) title, (c) organization, (d) Start Printed Page 25393mailing address, (e) telephone number, (f) fax number, and (g) e-mail address. Also, please submit a copy of the instrument or items to be considered. A copy or citation of relevant peer-reviewed journal articles is also desirable, but not required. For citations, please include the title of the article, author(s), publication year, journal name, volume, issue, and page numbers where the article appears and/or other applicable evidence.

All submissions must include a statement of willingness to grant to AHRQ the right to use and authorize others to use submitted measures and their documentation as part of a CAHPS®-trademarked instrument. This statement must be signed by an individual authorized to act for any holder of copyright on the measure(s) or instrument(s). Authority of signator should be indicated or included. Submitters' willingness to grant to AHRQ the right to use and authorize others to use their measures or instruments means that there can be free access to all measures in the CAHPS® instrument, and free access to the instrument's supportive/administrative information. It is the agency's intention that the CAHPS® instrument for nursing home resident's family member assessment of nursing home care will be made publicly available, free of charge.

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Judith Sangl, from the Center for Quality Improvement and Patient Safety, Agency for Healthcare Research and Quality, (please see contact information above).

Submission Criteria

Instruments submitted should be usable to measure a family member's assessment of a short- or a long-term stay of a nursing home resident, whichever is applicable.

Measures submitted must:

1. Capture the resident's family member's assessment of care in a short/and or long-stay nursing home setting; and,

2. Demonstrate a high degree of reliability and validity.

AHRQ, in collaboration with highly experienced CAHPS investigators, will evaluate all submitted measures and instruments and select one instrument or more likely, measures from various instruments, either in whole or in part, for testing and, if required or appropriate, additional modification. AHRQ will assume responsibility for the final measures set as well as any future modifications to its family assessment of nursing home care instrument. The CAHPS® trademark will be applied to the new instrument which will incorporate and combine the best features of all the submissions as well as any ideas that may develop from reviewing them, and any future modifications to the instrument. As a matter of quality control, there will be warnings that the CAHPS® identification may not be used if any changes are made to the instrument or final measures or if survey administration deviates from the prescribed methods without review and permission of the Agency.

Each submission should include the following information:

  • The name of the instrument;
  • domain(s);
  • language(s) the instrument is available in;
  • evidence of cultural/cross group comparability, if any;
  • cognitive screening or assessments used;
  • selection of most appropriate family member/significant other, if more than one available;
  • instrument reliability (internal consistency, test-retest, etc.);
  • validity (content, construct, criterion-related);
  • response rates;
  • cost estimates for data collection;
  • methods and results of cognitive testing and field-testing; and,
  • description of sampling strategies and data collection protocols, including such elements as mode of administration, informed consent materials, use of advance letters, timing and frequencies of contacts.

In addition, a list of nursing homes in which the instrument has been fielded or counts of the number of nursing homes by state or region, in which the survey has been and/or is being used should also be included in the submission materials. Measures that have been tested or implemented in just one or two research studies or nursing home settings would have more limited value than those tested or implemented more widely, but would be considered on a more individual basis when evaluating the measure for further testing with regard to their inclusion in the CAHPS tool.

Submission of copies of existing report formats developed to disclose findings to consumers and providers is desirable, but not required. Additionally, information about existing database(s) for the instrument(s) submitted is helpful, but not required for submission. Evidence of meeting the validity, reliability, and other criteria may be demonstrated through submission of peer-reviewed journal article(s) or through the best evidence available at the time of submission.

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AHRQ is a leader in developing and testing instruments for measuring consumer experience within the healthcare system of the United States as evidenced by the development of CAHPS®, formerly the Consumer Assessment of Health Plans, which provides information on health plan quality to consumers and purchasers alike. While CAHPS® is highly regarded within the industry and provides valuable information; it does not address family member perspectives on resident care within nursing home settings. Standardization of measures is essential for meaningful comparison of performance across nursing homes and other providers. Use of a standardized measure of family member assessment of nursing home settings provides several benefits including: Comparable information across nursing homes for the public about the quality of care from the family's perspective; data-based recommendations for quality improvement efforts and a data base to stimulate research in this area.

Family members are often the primary decision-makers with regard to nursing home placement and selection. They may also serve in the role of resident advocate after nursing home placement has occurred. Hence, the National Quality Forum (NQF) has cited the need for measures of resident and family satisfaction as a high priority for inclusion in the nursing home measure set. NQF specifically cited the need for rapid development of a freely available and accessible standardized instrument.

In an effort to address the concerns of the industry, the Centers for Medicare & Medicaid Services (CMS) established a priority to examine the feasibility of a standard instrument or measurement for public reporting of family assessments (broadly defined) of nursing home residents' care. Accordingly, AHRQ, through a collaborative process with CMS and other stakeholders, has initiated the process for this project. The steps to advance this initiative include:

  • Stakeholder Meetings: Public meetings will be held to identify the issues and concerns of interested stakeholders in the healthcare community. Summaries of all meetings will be posted on the AHRQ Web site (
  • Survey Development and Testing: The process by which measures will be defined and the most useful instruments or measures identified is as follows: Instruments submitted will be evaluated by the CAHPS team of experts in consultation with AHRQ staff to Start Printed Page 25394determine if they meet high priority or common measurement needs and to identify whether additional measure development is required. Until the trademarked version is available, access to and use of draft versions will be limited and subject to certain conditions, e.g., obtaining explicit written permission from AHRQ and in return, agreeing to provide assessments of testing experience with the measures.
  • Implementation Plan: A description of the final survey process as well as recommendations to implement the final standardized CAHPS® family assessment of nursing home care instrument will be made readily available e.g., on AHRQ and CMS Web sites and will include information related to data collection, analysis, and public reporting.
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Dated: April 26, 2004.

Carolyn M. Clancy,


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[FR Doc. 04-10284 Filed 5-5-04; 8:45 am]