Quality Assurance Guidelines CAHPS® Hospital Survey - HCAHPS

March 2011
Introduction and Overview
HSAG assembles a team comprised of the National Committee for Quality Assurance
(NCQA), RAND, Westat, and expert consultants from Harvard Medical School to
support the National Implementation.
‣ October 2003 – Six consumer focus groups are conducted in California and Maryland to
obtain consumer feedback on the HCAHPS survey content and domains
‣ November 2003 – HCAHPS Stakeholders Meeting is held to provide an update on the
development process and to discuss implementation issues
‣ December 2003 – CMS publishes the draft 32-item HCAHPS instrument in the Federal
Register
‣ December 2003 – The Three State Pilot Final Report is issued
2004
‣ January 2004 – AHRQ begins additional HCAHPS testing at five sites
‣ February 2004 – AHRQ announces Pre-National Implementation Testing in the Federal
Register
‣ March 2004 – Additional consumer focus groups are held in Arizona and Florida to
address issues raised in comments to the initial National Implementation of HCAHPS
Federal Register Notice
‣ June 2004 – AHRQ Pre-National Implementation Testing begins
‣ November 2004 – CMS issues second 60-day Federal Register Notice announcing the
National Implementation of HCAHPS (25-item HCAHPS instrument)
‣ November 2004 – CMS submits HCAHPS to the NQF’s Consensus Development process
for its endorsement
‣ December 2004 – The NQF Review Committee recommends adding the ‘doctors and
nurses showing courtesy and respect’ items back into the HCAHPS survey, which
increases the number of survey items from 25 to 27
2005
‣ January 2005 − The second Federal Register Notice closes; CMS proceeds to respond to
the public comments received through the Federal Register
‣ March 2005 − NQF public comment period
‣ May 2005 – The four NQF Member Councils and Executive Board formally endorse
HCAHPS
‣ November 2005 – The final Federal Register Notice, a 30-day notice, is published
‣ December 2005 − HCAHPS receives final clearance from OMB
2006
‣ February 2006 – The first HCAHPS Quality Assurance Guidelines manual is released
‣ February 2006 – The first HCAHPS Hospital/Survey Vendor Training sessions are held
at the CMS Central Office in Baltimore, and also via Webinar
‣ April-June 2006 – The first HCAHPS Dry Run is conducted, which allows hospitals to
test the survey and data submission process without public reporting
‣ April 2006 – The second HCAHPS Hospital/Survey Vendor Training is conducted, via
Webinar
‣ October 2006 – Data collection for the National Implementation of HCAHPS for Public
Reporting commences
Centers for Medicare & Medicaid Services 13
HCAHPS Quality Assurance Guidelines V6.0