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The intent of the HCAHPS initiative is to provide a standardized survey instrument and data collection methodology for measuring patients’ perspectives on hospital care. While many hospitals have collected information on patient satisfaction, prior to HCAHPS there was no national standard for collecting or publicly reporting patients’ perspectives of care information that would enable valid comparisons to be made across all hospitals. In order to make “apples to apples” comparisons to support consumer choice, it was necessary to introduce a standard measurement approach: the HCAHPS Survey, which is also known as the CAHPS® Hospital Survey, or Hospital CAHPS. HCAHPS is a core set of questions that can be combined with a broader, customized set of hospital-specific items. HCAHPS Survey items complement the data hospitals currently collect to support improvements in internal customer services and quality related activities.
Three broad goals have shaped the HCAHPS Survey. First, the survey is designed to produce comparable data on the patient’s perspective on care that allows objective and meaningful comparisons between hospitals on domains that are important to consumers. Second, public reporting of the survey results is designed to create incentives for hospitals to improve their quality of care. Third, public reporting will serve to enhance public accountability in health care by increasing the transparency of the quality of hospital care provided in return for the public investment. With these goals in mind, the HCAHPS project has taken substantial steps to assure that the survey is credible, useful, and practical. This methodology and the information it generates are available to the public.
In May 2005, the National Quality Forum (NQF), an organization established to standardize health care quality measurement and reporting, formally endorsed the CAHPS® Hospital Survey. The NQF endorsement represents the consensus of many health care providers, consumer groups, professional associations, purchasers, federal agencies, and research and quality organizations.
The HCAHPS Survey is composed of 29 items: 19 items that encompass critical aspects of the hospital experience (communication with nurses, communication with doctors, responsiveness of hospital staff, communication about medicines, discharge information, care transition, cleanliness of the hospital environment, quietness of the hospital environment, overall rating of hospital, and recommendation of hospital); three items to skip patients to appropriate questions; five items to adjust for the mix of patients across hospitals; and two items to support congressionally-mandated reports.
There are four approved modes of administration for the CAHPS® Hospital Survey: 1) Mail Only; 2) Telephone Only; 3) Mixed (mail followed by telephone); and 4) Active Interactive Voice Response (IVR).
A commentary on the proper use of the HCAHPS Survey and its alleged association with opioid misuse was published recently, “Measurement of the Patient Experience Clarifying Facts, Myths, and Approaches.” This article can be accessed via the following link. http://jama.jamanetwork.com/article.aspx?articleid=2503222
CMS and the HCAHPS Project Team continually analyze HCAHPS data. To make locating our HCAHPS research easier, we have added a bibliography of publications from the HCAHPS Project Team.
To participate in HCAHPS Data Collection and Public Reporting, all hospitals self-administering the survey, hospitals administering the survey for multiple sites, and survey vendors must meet certain Program Requirements and must be in compliance with the requirements in the HCAHPS Quality Assurance Guidelines, V17.0. In addition, hospitals/survey vendors must submit a Participation Form to the HCAHPS Project Team for approval prior to the administration of the HCAHPS Survey.
Please note: At a minimum, the hospital's/survey vendor's Project Manager is required to participate in the HCAHPS Training. Hospitals that have contracted with a survey vendor to collect HCAHPS Survey data are not required to attend training. CMS strongly recommends that hospitals newly joining HCAHPS participate in a dry run, if feasible, prior to beginning to collect HCAHPS data on an ongoing basis to meet the Hospital Inpatient Quality Reporting program requirements.
Please click here to view the previous Executive Insight letters.
To learn more about the HCAHPS Survey, please see the HCAHPS Fact Sheet found at the “Facts” button on this website.
The FY 2020 IPPS Final Rule, establishing the Hospital Inpatient Prospective Payment Systems (IPPS), is now available on the Federal Register.
Please use the following citation when referencing material on this website:
https://www.hcahpsonline.org Centers for Medicare & Medicaid Services, Baltimore, MD. Month, Date, Year the page was accessed.
For information about the availability of auxiliary aids and services, please visit: http://www.medicare.gov/about-us/nondiscrimination/nondiscrimination-notice.html.
This page was last modified on (09/28/22)