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The HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) Survey is the first national, standardized, publicly reported survey of patients' perspectives of hospital care. HCAHPS (pronounced “H-caps”), also known as the CAHPS® Hospital Survey*, is a 27-item survey instrument and data collection methodology for measuring patients’ perceptions of their hospital experience. While many hospitals have collected information on patient satisfaction for their own internal use, until HCAHPS there were no common metrics and no national standards for collecting and publicly reporting information about patient experience of care. Since 2008, HCAHPS has allowed valid comparisons to be made across hospitals locally, regionally and nationally.
Three broad goals have shaped HCAHPS. First, the standardized survey and implementation protocol produce data that allow objective and meaningful comparisons of hospitals on topics that are important to consumers. Second, public reporting of HCAHPS results creates new incentives for hospitals to improve quality of care. Third, public reporting enhances accountability in health care by increasing transparency of the quality of hospital care provided in return for the public investment. With these goals in mind, the Centers for Medicare & Medicaid Services (CMS) and the HCAHPS Project Team have taken substantial steps to assure that the survey is credible, useful, and practical.
HCAHPS Development, Testing and Endorsement Beginning in 2002, CMS partnered with the Agency for Healthcare Research and Quality (AHRQ), another agency in the federal Department of Health and Human Services, to develop and test the HCAHPS Survey. AHRQ carried out a rigorous and multi-faceted scientific process, including a public call for measures; literature review; cognitive interviews; consumer focus groups; stakeholder input; a three-state pilot test; extensive psychometric analyses; consumer testing; and numerous small-scale field tests. In addition, CMS provided three separate opportunities for the public to comment on HCAHPS, and responded to well over one thousand comments.
In May 2005, the HCAHPS Survey was endorsed by the National Quality Forum, a national organization that represents the consensus of many healthcare providers, consumer groups, professional associations, purchasers, federal agencies, and research and quality organizations. In December 2005, the federal Office of Management and Budget gave its final approval for the national implementation of HCAHPS for public reporting purposes. CMS implemented the HCAHPS Survey in October 2006, and the first public reporting of HCAHPS results occurred in March 2008. The survey, its methodology and the results it produces are in the public domain.
Enactment of the Deficit Reduction Act of 2005 created an additional incentive for acute care hospitals to participate in HCAHPS. Since July 2007, hospitals subject to the Inpatient Prospective Payment System (IPPS) annual payment update provisions ("subsection (d) hospitals") must collect and submit HCAHPS data in order to receive their full annual payment update. IPPS hospitals that fail to publicly report the required quality measures, which include the HCAHPS Survey, may receive an annual payment update that is reduced by 2.0 percentage points. Non-IPPS hospitals, such as Critical Access Hospitals, may voluntarily participate in HCAHPS.
The incentive for IPPS hospitals to improve patient experience of care was further strengthened by the Patient Protection and Affordable Care Act of 2010 (P.L. 111-148), which specifically included HCAHPS performance in the calculation of the value-based incentive payment in the Hospital Value-Based Purchasing program, beginning with discharges in October 2012; see below for more information about HCAHPS in Hospital VBP.
HCAHPS Content and Survey Administration The HCAHPS Survey asks recently discharged patients about aspects of their hospital experience that they are uniquely suited to address. The core of the survey contains 18 items that ask “how often” or whether patients experienced a critical aspect of hospital care, rather than whether they were “satisfied” with the care. The survey also includes four items to direct patients to relevant questions, three items to adjust for the mix of patients across hospitals, and two items that support Congressionally-mandated reports.
HCAHPS is administered to a random sample of adult inpatients between 48 hours and six weeks after discharge. Patients admitted in the medical, surgical and maternity care service lines are eligible for the survey; the survey is not restricted to Medicare beneficiaries. Hospitals may use an approved survey vendor, or collect their own HCAHPS data (if approved by CMS to do so). To accommodate hospitals, HCAHPS can be implemented in four different survey modes: mail, telephone, mail with telephone follow-up, or active interactive voice recognition (IVR), each of which requires multiple attempts to contact patients.
Hospitals may use the HCAHPS Survey alone, or include additional questions after the core HCAHPS items. Hospitals must survey patients throughout each month of the year, and IPPS hospitals must achieve at least 300 completed surveys over four calendar quarters. HCAHPS is available in official English, Spanish, Chinese, Russian and Vietnamese versions. The survey itself and the protocols for sampling, data collection, coding and file submission can be found in the current HCAHPS Quality Assurance Guidelines manual, available on the official HCAHPS On-Line Web site, www.hcahpsonline.org.
HCAHPS Measures Ten HCAHPS measures (six summary measures, two individual items and two global items) are publicly reported on the Hospital Compare Web site (www.hospitalcompare.hhs.gov) for each participating hospital. Each of the six summary measures, or composites, is constructed from two or three survey questions. Combining related questions into composites allows consumers to quickly review patient experience of care data and increases the statistical reliability of these measures. The six composites summarize how well nurses and doctors communicate with patients, how responsive hospital staff are to patients’ needs, how well hospital staff help patients manage pain, how well the staff communicates with patients about medicines, and whether key information is provided at discharge. The two individual items address the cleanliness and quietness of patients’ rooms, while the two global items report patients’ overall rating of the hospital, and whether they would recommend the hospital to family and friends. Survey response rate and the number of completed surveys, in broad ranges, are also publicly reported.
To ensure that publicly reported HCAHPS scores allow fair and accurate comparisons across hospitals, it is necessary to adjust for factors that are not directly related to hospital performance but which affect how patients answer HCAHPS Survey items. CMS and the HCAHPS Project Team apply adjustments that are intended to eliminate any advantage or disadvantage in scores that might result from the survey mode employed or from characteristics of patients that are beyond a hospital’s control. In addition, the HCAHPS Project Team undertakes a series of quality oversight activities, including inspection of survey administration procedures, statistical analyses of submitted data, and site visits of HCAHPS survey vendors, to assure that the HCAHPS Survey is being administered according to protocols.
HCAHPS and Public Reporting on Hospital Compare Publicly reported HCAHPS results are based on four consecutive quarters of patient surveys. CMS publishes HCAHPS results on the Hospital Compare Web site (www.hospitalcompare.hhs.gov) four times a year, rolling the oldest quarter of patient surveys off and the newest quarter on each time. A downloadable version of HCAHPS results is also available on this Web site. The first public reporting of HCAHPS results in March 2008 included 2,521 hospitals and 1.1 million completed surveys; the Spring 2012 public reporting entailed 3,851 hospitals and 2.8 million completed surveys.
Summary analyses of HCAHPS scores are available on the HCAHPS On-Line Web site, www.hcahpsonline.org. This Web site houses tables that summarize current state and national HCAHPS results (and an archive of past results), “top-box” and “bottom-box” (which represent the most and least positive survey responses) percentiles for each HCAHPS measure, inter-correlations of the measures, charts that compare HCAHPS results by key hospital characteristics, and a bibliography of related research publications from the HCAHPS Project Team. HCAHPS On-Line, the official source of information for the HCAHPS program, also includes current news and upcoming events, training materials and survey instruments and implementation protocols.
HCAHPS and Hospital Value-Based Purchasing The Hospital Value-Based Purchasing (Hospital VBP) program links a portion of IPPS hospitals' payment from CMS to performance on a set of quality measures. The Hospital VBP Total Performance Score (TPS) for FY 2013 has two components: the Clinical Process of Care Domain, which accounts for 70% of the TPS; and the Patient Experience of Care Domain, 30% of the TPS. The HCAHPS Survey is the basis of the Patient Experience of Care Domain.
HCAHPS and Hospital VBP Scoring Eight HCAHPS measures are employed in Hospital VBP (these are termed “dimensions” in Hospital VBP): the six HCAHPS composites (Communication with Nurses, Communication with Doctors, Staff Responsiveness, Pain Management, Communication about Medicines, and Discharge Information); one new composite that combines the hospital Cleanliness and Quietness survey items; and one Global item (Overall Rating of Hospital). The percentage of a hospital’s patients who chose the most positive, or “top-box,” survey response in these HCAHPS dimensions is used to calculate the Patient Experience of Care Domain score.
Hospital VBP utilizes HCAHPS scores from two time periods: a Baseline and a Performance Period. For FY 2013, the Baseline Period covers patients discharged from July 1, 2009 through March 31, 2010, and the Performance Period from July 1, 2011 through March 31, 2012.
The Patient Experience of Care Domain score is comprised of two parts: the HCAHPS Base Score (maximum of 80 points) and the HCAHPS Consistency Points score (maximum of 20 points). Each of the eight HCAHPS dimensions contributes to the HCAHPS Base Score through either an Improvement or Achievement score. “Improvement” is the amount of change in an HCAHPS dimension from the earlier Baseline Period to the later Performance Period. “Achievement” is the comparison of each dimension in the Performance Period to the national median for that dimension during the Baseline Period. The larger of the Improvement or Achievement score for each dimension is used to calculate a hospital’s HCAHPS Base Score.
The second part of the Patient Experience of Care Domain is the Consistency Points score, which ranges from 0 to 20 points. Consistency Points are designed to target and further incentivize improvement in a hospital's lowest performing HCAHPS dimension.
The Patient Experience of Care Domain Score is the sum of the HCAHPS Base Score (0 – 80 points) and HCAHPS Consistency Points score (0 – 20 points), thus ranges from 0 to 100 points, and comprises 30% of the Hospital VBP Total Performance Score.
For More Information For more information about Hospital VBP, please visit CMS' dedicated Web site, http://www.cms.gov/Hospital-Value-Based-Purchasing/. A slide set that describes the Hospital VBP program and its scoring in more detail can be found at http://www.cms.gov/Hospital-Value-Based-Purchasing/Downloads/HospVBP_ODF_072711.pdf. In particular, slides 35 to 61 explain in detail the scoring of the Patient Experience of Care Domain (HCAHPS).
To learn more about HCAHPS, including background information, policy updates, survey administration procedures, patient-mix and survey mode adjustments, training opportunities, and how to participate in the survey, please visit HCAHPS On-Line, at www.hcahpsonline.org.
To Provide Comments or Ask Questions • To communicate with CMS staff about HCAHPS: Hospitalcahps@cms.hhs.gov • For technical assistance, contact the HCAHPS Project Team: hcahps@azqio.sdps.org or
1-888-884-4007
- CAHPS® is a registered trademark of the Agency for Healthcare Research and Quality, a U.S. Government agency.