Quick links: FY 2019 IPPS Proposed Rule Has Been Published | The Star Ratings Distributions Have Been Updated | CMS Will No Longer Report the HCAHPS Pain Management Composite Measure | July 2018 Public Report Preview Period Begins | Star Ratings: July 2018 Technical Notes Have Been Posted | Patient-Mix Coefficients for July 2018 Technical Notes Have Been Posted | Hospital Compare Has Been Refreshed | Summary Analyses Page Tables Have Been Updated | Extraordinary Circumstances Exceptions (ECE) | HCAHPS Quality Assurance Guidelines V13.0 Change Matrix: Updates and Emphasis Has Been Posted | NEW! HCAHPS Podcast Now Available – Improving Response Rates of HCAHPS Hospitals | HCAHPS Quality Assurance Guidelines V13.0 Now Available Online | 2018 QualityNet Maintenance and Downtime Schedule | V.35 MS-DRG Codes | HCAHPS Public Reporting Periods for April 2017 Through July 2019 Have Been Posted | HCAHPS Patient-Mix Adjustment for Service Line and Gender | CMS Hurricane Webpage and Open Door Forum | Updated XML File Specification Version 4.0 Now Available | New Communication About Pain Composite Measure Released | Mode Adjustment Table Has Been Posted | CMS Finalizing Removal of the Pain Management Dimension from Hospital Value-Based Purchasing in FY 2018
The FY 2019 IPPS Proposed Rule, establishing the Hospital Inpatient Prospective Payment System (IPPS), is now available on the Federal Register.
The Final Rule and related tables are available at the following URL: https://federalregister.gov/d/2018-08705.
The following tables have been added to the HCAHPS Web site Star Ratings page:
The survey questions comprising Pain Management Composite 4 were removed from the HCAHPS Survey in the FY 2018 IPPS/LTCH PPS Final Rule (81 FR 38342). Composite 4 is no longer needed and will no longer be reported on Hospital Compare. July 2018 Preview Reports and public reporting will display “N/A” and Footnote 5 for the Pain Management measure and will display “N/A” and Footnote 15 for the Pain Management star rating. In addition, Pain Management is no longer included in the calculation of the HCAHPS Summary Star Rating or the Hospital Compare Overall Hospital Quality Star Rating.
The July 2018 Public Report Preview Reports are now available on the QualityNet Secure Portal to participating providers and Quality Improvement Organizations (QIOs). The Preview Reports will be available from May 4, 2018 through June 3, 2018. (To access the report, you must be registered as a QualityNet Secure Portal user and have been assigned the QIO Clinical Data Warehouse Feedback Report role). The data that appear in the Preview Reports will be reported on Hospital Compare, the Centers for Medicare & Medicaid Services Web site for Medicare beneficiaries and the general public, in July 2018.
The Technical Notes for the July 2018 HCAHPS results are now available. The July 2018 HCAHPS Star Ratings are included in the hospital Preview Reports (available to hospitals from May 4, 2018 through June 3, 2018), and will be Publicly Reported on Hospital Compare in July 2018. Please click here to access the HCAHPS Star Ratings page.
The Patient-Mix Coefficients for the July 2018 HCAHPS results are now available. Please click here to access the Mode & Patient-Mix Adjustment page.
The April 2018 Hospital Compare Refresh includes HCAHPS scores from July 2016 through June 2017 data collections.
The following tables have been added to the HCAHPS Web site Summary Analyses Page:
For recent Extraordinary Circumstances Extensions (ECE) the key HCAHPS content is displayed below. Please review the entire notification for additional details.
To review the entire Quality Reporting Notifications for Hurricane Nate, Hurricane Irma, Hurricane Harvey, and the California Wildfires, please click below:
The National Support Team for the Hospital IQR Program is available to answer questions or supply any additional information you may need. Please contact the team at InpatientSupport@viqrc1.hcqis.org or call toll-free at (844) 472-4477.
The HCAHPS Quality Assurance Guidelines V13.0 Change Matrix: Updates and Emphasis is a reference tool that highlights the major changes from the HCAHPS Quality Assurance Guidelines V12.0 to V13.0. The reference tool is available on the Quality Assurance page.
Please click here to view the Improving Response Rates of HCAHPS Hospitals on the HCAHPS Survey Podcast page.
The HCAHPS Project Team is pleased to announce the release of the HCAHPS Quality Assurance Guidelines V13.0. This manual has been revised from V12.0 and includes additional updates and enhancements that provide a comprehensive resource for hospitals and survey vendors participating in the HCAHPS initiative. This updated version is now available online to view or download on the Quality Assurance page.
In addition, the HCAHPS Quality Assurance Guidelines V13.0 manual, on CD-ROM, is in the process of being distributed to each organization’s contact person registered for the upcoming Introduction to HCAHPS or HCAHPS Update Training sessions.
The HCAHPS Project Team is alerting approved HCAHPS Survey vendors and self-administering hospitals of upcoming regular QualityNet maintenance weekends. During this time organizations will not be able to upload HCAHPS data to the HCAHPS Data Warehouse. This alert is provided so that survey vendors and self-administering hospitals can plan data submission as needed.
Please see the Technical Specifications page for a schedule of upcoming regular QualityNet maintenance weekends.
Click here to view the HCAHPS Public Reporting Periods document. This document indicates which calendar quarters of HCAHPS results will be publicly reported on the Hospital Compare Web site through July 2019.
Please Note: The dates of future preview periods and public reporting are estimates based on current timetables and are subject to change.
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The HCAHPS Patient-Mix Adjustment (PMA) model has been updated to incorporate more detailed information about patient Service Line and Gender.
The Mode & Patient-Mix Adjustment page can be found by clicking here.
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Open Door Forum
The Centers for Medicare & Medicaid Services (CMS) is granting exceptions under certain Medicare quality reporting and value-based purchasing programs to acute care hospitals, PPS-exempt cancer hospitals, inpatient psychiatric facilities, skilled nursing facilities, home health agencies, hospices, inpatient rehabilitation facilities, outpatient dialysis facilities, long-term care hospitals, and ambulatory surgical centers located in areas affected by Hurricane Harvey due to the devastating impact of the storm. These providers will be granted exceptions without having to submit an extraordinary circumstances exception request if they are located in one of the Texas counties or Louisiana parishes, all of which have been designated by the Federal Emergency Management Agency (FEMA) as a major disaster county.
The scope and duration of the exception under each Medicare quality reporting program is described in the memo posted on 8-31-17, however, all of the exceptions are being granted to assist these providers while they direct their resources toward caring for their patients and repairing structural damages to facilities.
If FEMA expands the current disaster declaration for Hurricane Harvey to include additional counties or parishes, CMS will update this memo to expand the list of providers eligible to receive an exception without submitting a request to include the hospitals, PPS-exempt cancer hospitals, inpatient psychiatric facilities, skilled nursing facilities, home health agencies, hospices, inpatient rehabilitation facilities, long-term care hospitals, and ambulatory surgical centers located in the additional counties and parishes.
In addition, CMS will continue to monitor the situation and adjust exempted reporting periods and submission deadlines accordingly.
Additional details and materials are available on the CMS Hurricane webpage. Please check back frequently for updates.
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The updated XML File Specifications Version 4.0, which includes the new Communication About Pain questions (Q12, Q13, Q14), is now available on the HCAHPS Technical Specifications page. The updated XML File Specifications Version 4.0 must be used for all patients discharged from January 1, 2018 and forward.
Please click here to access the Technical Specifications page.
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On August 2, 2017, in the FY 2018 IPPS Final Rule, CMS announced plans to replace the current Pain Management questions (items 12, 13 and 14 on the HCAHPS Survey) with three new questions that focus on communication about pain. The new pain items will be required on all surveys administered to patients discharged from January 1, 2018 and forward. The new Pain Management items will comprise a new composite measure, “Communication About Pain.” This change will affect all survey translations and all survey modes. The Mail Mode version of the new Pain Management items can be found below.
In the coming months, the HCAHPS Project Team will post official versions of the new Pain Management items for all survey modes and in all language translations on the HCAHPS Web site (www.hcahpsonline.org) on the “Survey Instruments” page. The HPT will also provide more information to approved HCAHPS Survey vendors and self-administering hospitals about the transition to the new Pain Management items.
Please note that the current pain questions must be used for all patients discharged before January 1, 2018
12. During this hospital stay, did you have any pain?
No -> If No, Go to Question 15
13. During this hospital stay, how often did hospital staff talk with you about how much pain you had?
14. During this hospital stay, how often did hospital staff talk with you about how to treat your pain?
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An updated Mode Adjustments of Top Box and Bottom Box Percentages (after PMA) table is now available. Please click here to access the Mode & Patient-Mix Adjustment page.
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The CY 2017 OPPS Final Rule has been published and is now available on the Federal Register.
The Final Rule is available at the following URL: https://federalregister.gov/d/2016-26515
CMS is finalizing the removal of the Pain Management dimension from the scoring formula used in the Hospital Value-Based Purchasing Program (Hospital VBP), beginning with the FY 2018 payment adjustments. The Pain Management dimension is derived from Questions 12, 13 and 14 on the HCAHPS Survey.
Please note that the Pain Management questions will remain on the HCAHPS Survey and the Pain Management measure will continue to be publicly reported on Hospital Compare.
Please monitor the HCAHPS Web site for future announcements about the Pain Management measure.
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This page was last modified on (5/10/18)