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New HCAHPS Technical Assistance Email Address (hcahps@hsag.com)

HCAHPS 2023 Training Registration Now Open (1/27/2023)

The Centers for Medicare & Medicaid Services (CMS) will offer Introduction to HCAHPS and HCAHPS Update Training sessions the week of February 27, 2023. These training sessions are intended for hospitals self-administering the HCAHPS Survey, hospitals administering HCAHPS for multiple sites (multi-sites), and survey vendors participating in HCAHPS, as well as other interested individuals and organizations. Please see the list of required organizations for each training session below.  

Training Registration will close by 5:00 PM EST (COB) on Friday, February 17, 2023.

Introduction to HCAHPS Training

When:  Monday, February 27 through Thursday, March 2, 2023 (via a self-training module)

Who is Required to Participate in Introduction to HCAHPS Training:

  • Required: Hospitals interested in applying to become approved to self-administer the HCAHPS Survey
  • Required: Organizations interested in applying to become approved HCAHPS Survey vendors, as well as subcontractor(s)/partner(s) and other organizations with responsibility for major survey administration functions
  • Required: New Project Managers for currently approved vendors and hospitals
  • Optional: Recommended as a training/refresher course for new staff members at organizations that are currently approved to administer the HCAHPS Survey

Participation Steps and Requirements to Request Approval to Administer the HCAHPS Survey

Organizations requesting consideration for approval to administer the HCAHPS Survey as an HCAHPS approved survey vendor or a self-administering hospital must:

  •      Meet all of the current “HCAHPS Minimum Survey Requirements to Administer the HCAHPS Survey (Minimum Business Requirements).” These requirements are available on the HCAHPS Web site, on the “Quality Assurance” page.
  •       Register now for Introduction to HCAHPS Training by clicking on the link below or visiting the “Training Registration” page of the HCAHPS Web site
  •      When Introduction to HCAHPS Training opens, review training slides, submit a Confirmation of Training Completion Form, and complete and submit an online quiz. Please see the "Accessing the Self-training Module" section below for details and the "Training and Participation Information" page of the HCAHPS website for deadlines. 
  • Complete and submit a Participation Form. Participation Forms will be available online following training, from Friday, March 3, 2023 through Friday March 24, 2023, 5:00 PM EST.

Accessing the Self-training Module:

A link to the “Introduction to HCAHPS Training” page will be sent to registered organizations the week prior to training. The training page will provide access to the slides, agenda and the Confirmation of Training Completion Form. The link and page will only be available Monday, February 27 through Thursday, March 2, 2023. Please refer to the deadlines for the Confirmation of Training Completion Form and quiz on the “Training and Participation Information” page of the HCAHPS Web site.

HCAHPS Update Training

When:

  • Self-administering hospitals: March 1, 2023, 1:00 pm – 3:45 pm EST  (via Webinar)
  • Survey vendors and multi-sites: March 2, 2023, 1:00 pm – 3:45 pm EST  (via Webinar)

Who is Required to Participate in HCAHPS Update Training:

  • Required: All hospitals, multi-sites and survey vendors currently approved to administer the HCAHPS Survey
  • Required: Subcontractor(s)/partner(s) or other organization(s) who are responsible for major functions of HCAHPS Survey administration (e.g., mail/telephone/IVR operations). Survey vendors (and/or hospitals, if applicable) must ensure that their subcontractor(s)/partner(s) participate in the appropriate HCAHPS Training, Introduction and/or Update.

Please click here for additional HCAHPS Training and Participation information.

Please click here to register for the 2023 HCAHPS Training sessions.


Updated Hospital/Survey Vendor HCAHPS Minimum Survey Requirements to Administer the HCAHPS Survey (Minimum Business Requirements) (1/27/2023)

To administer the HCAHPS Survey, organizations must meet all of the HCAHPS Minimum Business Requirements. A hospital self-administering the HCAHPS Survey must meet ALL of the Self-administering Hospital Minimum Survey Requirements, and an independent survey vendor or a hospital administering the HCAHPS Survey for multiple sites or their subcontractor(s) must meet ALL of the Survey Vendor Minimum Survey Requirements. In addition, subcontractor(s)/partner(s) or other organization(s) performing major HCAHPS Survey Administration functions (e.g., mail/telephone/IVR operations, XML file preparation) must also meet ALL of the HCAHPS Minimum Survey Requirements which pertain to that role. For more information regarding the HCAHPS Minimum Business Requirements, please click here or on the left-hand Quality Assurance navigation button. 

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The April 2023 Public Report Preview Period Begins January 26, 2023 (01/26/2023)

The April 2023 Public Report Preview Reports are now available on the Hospital Quality Reporting (HQR) System (https://hqr.cms.gov/), formerly the QualityNet Secure Portal, to participating providers and Quality Improvement Organizations (QIOs). The Preview Reports will be available from January 26, 2023 through February 24, 2023. (To access the report, you must be registered as a HQR system 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 Care Compare  for Medicare & Medicaid Services Web site for Medicare beneficiaries and the general public in April 2023.

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Patient-Mix Adjustments and National Means for April 2023 HCAHPS Results Have Been Posted (01/26/2023)

The Patient-Mix Adjustments and National Means for the April 2023 HCAHPS results are now available. Please click here to access the Mode & Patient-Mix Adjustment page.

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Star Ratings: April 2023 Technical Notes Have Been Posted (01/26/2023)

The Technical Notes for the April 2023 HCAHPS results are now available. The April 2023 HCAHPS Star Ratings are included in the hospital Preview Reports (available to hospitals from January 26, 2023 through February 24, 2023), and will be Publicly Reported on Care Compare in April 2023. Please click here to access the HCAHPS Star Ratings page.

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Care Compare Has Been Refreshed (01/25/2023)

The January 2023 Care Compare Refresh includes HCAHPS scores from April 2021 through March 2022 data collections.

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Summary Analyses Page Tables Have Been Updated (01/25/2023)

The following tables have been added to the HCAHPS Web site Summary Analyses page:

  • January 2023 Summary of HCAHPS Survey Results Table
  • January 2023 HCAHPS Percentiles Table
  • January 2023 HCAHPS Survey Individual Question Top-Box Scores

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The Star Ratings Distributions Have Been Updated (01/25/2023)

The following tables have been added to the HCAHPS Web site Star Ratings page:

  • January 2023 HCAHPS Stars Ratings Distributions
  • January 2023 HCAHPS Summary Star Distributions by US State

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HCAHPS Survey Individual Question Top-Box Scores Table Has Been Updated (01/25/2023)

The HCAHPS Survey Individual Question Top-Box Scores table has been added to the Summary Analyses  page:

·  January 2023 Public Report: April 2021 – March 2022 discharges

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CMS to Update HCAHPS Survey Mode Adjustments in January 2023 (12/20/22)

In 2021, CMS conducted a large-scale experiment that will serve a number of purposes. The experiment produced updated adjustments for current HCAHPS measures in the Mail Only, Telephone Only, and Mixed modes of the HCAHPS Survey, which will be applied beginning with patients discharged in January 2023.

To view HCAHPS survey mode adjustments for both the pre- and post-2023 periods, please click here to access the Mode and Patient-Mix Adjustment page.

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HCAHPS Public Reporting Periods for April 2022 Through October 2024 Have Been Updated (12/01/2022)

Click here to view the HCAHPS Public Reporting Periods document. This document indicates which calendar quarters HCAHPS results will be publicly reported on Care Compare on Medicare.gov (https://www.medicare.gov/care-compare) through October 2024.

Please Note: The dates of future preview periods and public reporting are estimates based on current timetables and are thus subject to change.

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Extraordinary Circumstances Extension/Exception (ECE) due to Hurricane Ian (10/25/2022)

To review the entire Quality Reporting Notification, please click here.

Key HCAHPS content is displayed below. Please review the entire notification for additional detail.

The Centers for Medicare & Medicaid Services (CMS) is granting exceptions under certain Medicare quality reporting and value-based purchasing programs located in areas affected by the Florida Hurricane Ian disaster to assist these providers while they direct their resources toward caring for patients and repairing structural damages to facilities.

Affected counties designated by the Federal Emergency Management Agency (FEMA) under the Florida Hurricane Ian (DR-4673) disaster declaration are located at Designated Areas: Disaster 4673 under sections Public Assistance PA-A and PA-B of the FEMA website.

If FEMA expands the current emergency disaster declarations to include additional counties, sections PA-A and PA-B will be updated to reflect the newly designated counties.

Providers located outside the counties listed in the FEMA disaster declaration are not covered by this communication, but they may request an exception to the reporting requirements under one or more Medicare quality reporting or value-based purchasing programs they participate in using the applicable ECE procedure for the respective program(s). In addition, providers located within a county listed in the FEMA disaster declaration who seek an exception for a reporting requirement not covered by this communication may request an individual exception using the applicable ECE procedure for the respective program(s). CMS will assess and decide upon each extraordinary circumstances exception request on a case-by-case basis.

Hospitals should be aware of the potential impact to reporting requirements and payment programs when deciding whether or not to report data included in the exceptions. If data are submitted, it may be publicly reported or used in scoring.

Please refer to the ECE request process and form specific to the program for additional information.

CMS is granting an exception for the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) Survey for the following quarters:

§  April 1, 2022 – June 30, 2022 (2nd Quarter 2022)

o   Submission Deadline – 10/5/22

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V.40 MS-DRG Codes Effective October 1, 2022 (09/26/2022)

CMS has adopted V.40 MS-DRG Codes effective October 1, 2022. Please click here for the Table of V.40 MS-DRG Codes and HCAHPS Service Line Categories.

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FY 2023 IPPS Final Rule Has Been Published (08/10/22)

The Final Rule and related tables are now available on the Federal Register at the following URL: https://www.federalregister.gov/d/2022-16472

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HCAHPS XML File Specifications V4.5 Have Been Posted (08/01/2022)

The HCAHPS XML File Specifications Version 4.5 have been added to the HCAHPS Web site Technical Specifications page. The HCAHPS Technical File Specifications V4.5 are to be used starting with July 1, 2022 patient discharges.

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NEW! HCAHPS Podcast Now Available - Improving Representativeness of the HCAHPS Survey (07/22/2022)

Please click here to view the Improving Representativeness of the HCAHPS Survey on the Podcasts Page.


Update on Progress of the 2021 HCAHPS Mode Experiment Has Been Posted (07/14/2022)

Information on the 2021 HCAHPS Mode Experiment was presented during the 2022 HCAHPS Update Trainiing. Please click here to view the Update on Progress of the 2021 HCAHPS Mode Experiment document.

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The HCAHPS Fact Sheet Has Been Revised (04/14/2022)

The HCAHPS Fact Sheet has been revised and is posted to the Facts page. The update includes information pertaining to HCAHPS Survey Content and Administration, HCAHPS measures, HCAHPS Public Reporting on Care Compare, HCAHPS Star Ratings, HCAHPS Hospital and Value-Based Purchasing, and a Review of Revisions of HCAHPS. Click here to access the Facts page.

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Update: HCAHPS 2021 Mode Experiment (06/21/2021)

The 2021 CMS HCAHPS mode experiment includes a test of new survey modes as well as new and revised survey items. CMS and its HCAHPS Project Team are testing an expanded HCAHPS Survey instrument using six different survey administration protocols: 3 standard modes (Mail Only, Telephone Only, and Mixed Mode (mail followed by telephone), and three new mixed mode protocols that begin with a web-based survey followed by a standard mode:  Web-Mail, Web-Telephone, and Web-Mail-Telephone.

 

In addition to testing web-based survey administration, the mode experiment also tests new and revised survey content. The mode experiment survey contains 43 items. The core of the survey includes 26 items that generally duplicate the current HCAHPS Survey, though with one deletion and some minor revisions to item wording and sequence. This core is followed by 17 test items that include new patient experience topics, new items on existing topics, and proxy help items. A copy of the survey is available for informational purposes.

 

Please note: The HCAHPS mode experiment survey instrument is for testing purposes only. It is not intended to represent the future survey and is not approved for use.

 

The 2021 HCAHPS mode experiment is being conducted on a random sample of HCAHPS-eligible patients discharged from April through September 2021 from more than 40 hospitals. The hospitals were randomly selected and are broadly representative of all hospitals participating in HCAHPS. Within each hospital, sampled patients are randomly assigned to the six survey administration protocols. Patients assigned to the three web-based administration protocols receive invitations to the web survey via email. The mode experiment will assess different data collection windows for the web-based survey: 6, 8, and 10 days. The mode experiment will allow up to 49 days for initial contact of patients, and 49 days for completion of the survey after the initial contact. The table below provides an overview of the schedule of contacts for the mode experiment.

 

Schedule of HCAHPS Mode Experiment Contact Attempts

Day

Standard Mail Only

Standard Phone Only

Standard Mixed Mode

Web-Mail

Web-Phone

Web-Mail- Phone

1

Mail out first survey

Phone calls begin

Mail out survey

Email first survey invitation

Email first survey invitation

Email first survey invitation

2

 

 

 

 

 

 

 

 

3

 

 

 

Email second survey invitation

 

 

4

 

 

 

 

Email second survey invitation

Email second survey invitation

5

 

 

 

 

 

 

 

 

6

 

 

 

Email third survey invitation

 

Mail out survey

7

 

 

 

 

Email third survey invitation

 

8

 

 

 

Mail out first survey

 

 

9

 

 

 

 

 

 

 

 

10

 

 

 

 

Phone calls begin

 

 

21

Mail out second survey

 

 

 

 

 

28

 

 

Phone calls begin

 

 

 

Phone calls begin

30

 

 

 

Mail out second survey

 

 

49

End data collection

 

End data collection

End data collection

End data collection

End data collection

End data collection

 

The additional email invitations and the secondary modes are enacted only for patients who do not respond to the initial contact. Patients randomly assigned to a web-based mode who lack a valid email address receive their first contact when the secondary mode begins.

After the completion of mode experiment data collection in late 2021, CMS will analyze the data and use the results to inform decisions about HCAHPS modes of survey administration, survey content, proxies, schedule and timing of contacts, and length of survey administration. Any changes to current HCAHPS Survey content or administration procedures will be proposed through the CMS rulemaking process.

 

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CMS Clarifies Policy Regarding Requirement of 300 Completed HCAHPS Surveys in Periods Affected by the COVID-19 ECE (10/05/2020)      

The 300 completed HCAHPS Surveys standard applies to every 4-quarter roll-up period in which HCAHPS data collection and submission were required in all four quarters.  However, the 300 competes standard does NOT apply to any 4-quarter roll-up period in which HCAHPS data collection was not required for one or more quarter.  Due to the COVID-19 ECE for Q1 and Q2 2020, the 300 completes standard does NOT apply to the following 4-quarter roll-up periods:

 

  • Q2 2019/Q3 2019/Q4 2019/Q1 2020
  • Q3 2019/Q4 2019/Q1 2020/Q2 2020
  • Q4 2019/Q1 2020/Q2 2020/Q3 2020
  • Q1 2020/Q2 2020/Q3 2020/Q4 2020
  • Q2 2020/Q3 2020/Q4 2020/Q1 2021

Please refer to the CMS Exceptions and Extension for Quality Reporting Requirements memorandum dated March 27, 2020, for Q1 and Q2 2020 information.

 

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NEW! Care Compare Web Site Now Available (09/03/2020)

 

CMS Care Compare Empowers Patients when Making Important Health Care Decisions

 

The Centers for Medicare & Medicaid Services (CMS) launched Care Compare, which contains HCAHPS survey results and many other measures, and is a streamlined redesign of eight existing CMS healthcare compare tools available on Medicare.gov.

 

Full Press Release can be found here: https://www.cms.gov/newsroom/press-releases/cms-care-compare-empowers-patients-when-making-important-health-care-decisions

 

Direct links to the tools & additional resources

 

Care Compare on Medicare.gov - https://www.medicare.gov/care-compare/

 

Care Compare resources for consumers and partners – Medicare blog, Promotional video, Conference card

 

Provider Data Catalog on CMS.gov - https://data.cms.gov/provider-data/

 

Provider Data Catalog and Medicare Care Compare

Webinar Recordings Now Available

 

Go to the “Videos” Section on the CMS National Training Program page here. Direct links below:

Provider Data Catalog (PDC) Webinar (Recorded August 10, 2020)

eMedicare: Improving Compare Tools (Recorded August 24, 2020)

 

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Impact of COVID-19 on HCAHPS Survey Operations for HCAHPS Survey Vendors and Self-administering Hospitals (04/13/2020)

 

CMS recognizes that the COVID-19 outbreak may impact your survey operations.  If you intend to request approval to conduct survey operations from a remote location (other than your place of business), please complete and submit an Exception Request Form online via the HCAHPS Web site (www.hcahpsonline.org).  Please remember, survey vendors and self-administering hospitals should take necessary steps to protect staff’s personal health and safety.

Please contact HCAHPS Technical Assistance at hcahps@hsag.com should you have questions regarding this information.

 

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Important Information for HCAHPS Survey Vendors and Self-administering Hospitals: Impact of COVID-19 on HCAHPS Survey Operations (03/23/2020)

In light of the 2019 Novel Coronavirus (COVID-19) outbreak, CMS is providing new guidance. Please see the attached documents, which can be accessed by clicking here and here.

 

Please contact HCAHPS Technical Assistance at hcahps@hsag.com should you have questions regarding this information.

 

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The National Quality Forum (NQF) Has Renewed its Endorsement of the HCAHPS Survey (11/21/2019)

On October 25, 2019, the National Quality Forum (NQF) announced its re-endorsement of the HCAHPS Survey. The NQF is a voluntary consensus and standard-setting organization established to standardize healthcare quality measurement and reporting. The NQF originally reviewed and endorsed the HCAHPS Survey in May 2005 and since then has reviewed and re-endorsed HCAHPS in 2010, 2015, and 2019.

For more information about NQF endorsement renewal, please click here.

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CMS to Review HCAHPS Content with Patients and Feasibility of Mixed Mode that Includes a Web Survey (06/21/2019)

CMS has begun to take steps to obtain feedback directly from patients about topics that are most important to them in the current HCAHPS Survey, as well as additional topics that might be added in the future.  This is part of a broader effort that CMS is undertaking to evaluate the items currently included in HCAHPS.  CMS also plans to investigate the feasibility of a new Mixed Mode that would include a Web survey.  Pending approval from the Office of Management and Budget, CMS will test a web mode of administration for several patient experience surveys, including HCAHPS.  Please continue to monitor the HCAHPS Web site for important updates on these topics.

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HCAHPS Pain Management Composite Measure Information

  • May 23, 2018 update: The Centers for Medicare & Medicaid Services (CMS) has suppressed the HCAHPS Pain Management composite scores on Hospital Compare and in the downloadable databases. In July, CMS is planning to remove the Pain Management composite from Hospital Compare and downloadable databases, and exclude it from the calculation of the HCAHPS Summary Star Rating and the Hospital Compare Overall Hospital Quality Star Rating. 

          As a result, HCAHPS Online is making the corresponding updates to all documents pertaining to the April 2018 public report period that are posted on this web site. 

  • 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.

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Extraordinary Circumstances Extension (ECE) (04/26/2022)

For recent Extraordinary Circumstances Extensions (ECE) the key HCAHPS content is displayed below.  To review the entire Quality Reporting Notifications please click below:

  • Hurricane Ida (Q2-Q3 2021) please click here
  • Texas Winter Storms (Q1 2021) please click here
  • Hurricane Laura (Q3 2020) please click here
  • California and Oregon Wildfires (Q3 2020) please click here
  • Hurricane Dorian (Q3 2019) please click here
  • Tropical Storm Barry (Q3 2019) please click here
  • California Wildfires (Q3 2018) please click here
  • Hurricane Michael (Q3 2018) please click here
  • Hurricane Florence (Q2-Q3 2018) please click here
  • California Wildfires (Q3-Q4 2017) please click here
  • Hurricane Nate (Q2-Q3 2017) please click here
  • Hurricane Irma (Q2-Q3 2017) please click here
  • Hurricane Harvey (Q2-Q3 2017) please click here

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.

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This page was last modified on (01/27/23)