Quality Assurance Guidelines CAHPS® Hospital Survey - HCAHPS

March 2011
Introduction and Overview
HCAHPS and the Hospital Inpatient Quality Reporting Program, (Formerly known
as Reporting Hospital Quality Data for Annual Payment Update [RHQDAPU]
Program)
The Deficit Reduction Act of 2005 required the Secretary of the Department of Health and
Human Services to expand the set of measures that the Secretary determines to be appropriate for
the measurement of the quality of care furnished by hospitals in the inpatient setting. The statute
further specified that the payment update for FY 2007 and each subsequent fiscal year will be
reduced by 2.0 percentage points for any “subsection (d) hospital” that does not submit certain
quality data in a form and manner, and at a time, specified by the Secretary.
In expanding the set of measures for the Hospital Inpatient Quality Reporting Program, CMS
began to adopt the baseline set of performance measures as set forth in the 2005 report
Performance Measurement: Accelerating Improvement, issued by the Institute of Medicine
(IOM) of the National Academy of Sciences, effective for payments beginning in FY 2007. For
FY 2007, participating hospitals were required to collect and submit 21 clinical quality measures
for payment purposes. For FY 2008 and subsequent fiscal years, the set of measures was
expanded to include HCAHPS.
HCAHPS and Hospital Value Based Purchasing
HCAHPS is named in Section 3001 of the Patient Protection and Affordable Care Act of 2010 as
one measure that will be included in the Hospital Value Based Purchasing (HVBP) program
payments made with respect to discharges occurring during Fiscal Year 2013. CMS will propose
how HVBP will be implemented and the formula that will be used to determine future hospital
payments through the formal rule-making process.
HCAHPS Mode Experiment I
In order to achieve the goal of fair comparisons across all hospitals that participate in HCAHPS,
it is necessary to adjust for factors that are not directly related to hospital performance but do
affect how patients answer HCAHPS survey items. To ensure that publicly reported HCAHPS
scores allow fair and accurate comparisons of hospitals, in 2006 CMS undertook Mode
Experiment I to examine whether mode of survey administration, the mix of patients in
participating hospitals, or survey non-response systematically affect HCAHPS survey results and
then developed necessary statistical adjustments.
Mode Experiment I addressed three important sources of potential bias in hospital-level
HCAHPS results. First, hospitals participating in the HCAHPS survey have the option of
choosing among four different modes of data collection: Mail, Telephone, Mail combined with
Telephone follow-up (also known as Mixed mode), and Active Interactive Voice Response
(IVR). If patient responses differ systematically by mode of survey administration, it is necessary
to adjust for survey mode.
Second, certain patient characteristics that are not under the control of the hospital, such as age
and education, may be related to the patient's survey responses. For example, several studies
have found that younger and more educated patients provide less positive evaluations of
healthcare. If such differences occur in HCAHPS data, it is necessary to adjust for such
respondent characteristics before comparing hospitals' HCAHPS results. Third, we examined
Centers for Medicare & Medicaid Services 9
HCAHPS Quality Assurance Guidelines V6.0