Quality Assurance Guidelines CAHPS® Hospital Survey - HCAHPS

March 2011
Introduction and Overview
HCAHPS Public Reporting
Official HCAHPS scores are publicly reported four times each year on the Hospital Compare Web
site. Public reporting of HCAHPS results is comprised of a rolling four quarters of survey data, with
hospitals/survey vendors submitting data on a monthly or quarterly basis through My QualityNet.
The HCAHPS data submitted by each hospital/survey vendor is reviewed, cleaned, scored, and
adjusted (including adjustments for patient-mix and mode). Then, HCAHPS results can be
previewed by the submitting hospital before public reporting on the Hospital Compare Web site.
The first public reporting of HCAHPS results on Hospital Compare occurred in March 2008 with
2,521 hospitals voluntarily reporting their HCAHPS scores, based on 1.1 million completed surveys
from patients discharged between October 2006 and June 2007. Most recently, the December 2010
public reporting of HCAHPS results included the scores of 3,798 hospitals based on 2.6 million
completed surveys from patients discharged between April 2009 and March 2010. Hospital Compare
(www.hospitalcompare.hhs.gov). The schedule of public reporting for 2011 can be found in the Data
Reporting section.
CMS regularly publishes supplemental information about survey results on the HCAHPS Summary
Analyses page of the HCAHPS Web site (www.hcahpsonline.org), including a summary table of
state and national “top-box” scores for each HCAHPS measure, HCAHPS “top-box” and “bottombox”
percentile scores, a table of patient level Pearson “top-box” correlations among HCAHPS
measures, and HCAHPS Hospital Characteristics Comparison Charts.
CMS and its HCAHPS partners continually review and analyze HCAHPS data. A bibliography
of published articles based on the HCAHPS Team’s HCAHPS research can be found on the
HCAHPS Web site (www.hcahpsonline.org).
HCAHPS Results Beyond Hospital Compare
Since CMS began publicly reporting HCAHPS results in March 2008, HCAHPS scores have
appeared in a wide variety of publications and have been incorporated in a number of hospital
rating tools. Please note, however, that the full, complete and official HCAHPS results are those
publicly reported on Hospital Compare.
HCAHPS Bulletins
To quickly and directly communicate with hospitals and survey vendors participating in HCAHPS,
in 2008 CMS began to issue HCAHPS Bulletins. HCAHPS Bulletins are released, when needed, to
provide uniform guidance or clarification to all hospitals and survey vendors on HCAHPS protocols.
It is incumbent upon all approved HCAHPS survey vendors, self-administering hospitals, and multisite
hospitals to promptly read all HCAHPS Bulletins, review their procedures for handling the
matters addressed, and where necessary institute changes to comply with HCAHPS protocols. The
HCAHPS Bulletins supplement training; their instructions and clarifications are subsequently
incorporated into the published HCAHPS Quality Assurance Guidelines.
Centers for Medicare & Medicaid Services 11
HCAHPS Quality Assurance Guidelines V6.0