Quality Assurance Guidelines CAHPS® Hospital Survey - HCAHPS

Reader’s Guide
Purpose of Quality Assurance Guidelines
The Quality Assurance Guidelines V6.0 manual has been developed by the Centers for Medicare
& Medicaid Services (CMS) to standardize the survey data collection process and to ensure
comparability of data reported through the CAHPS ®1 Hospital Survey (also known as Hospital
CAHPS or HCAHPS). The Hospital Consumer Assessment of Healthcare Providers and
Systems, or HCAHPS (pronounced “H-caps”) survey is part of a larger Consumer Assessment of
Healthcare Providers and Systems (CAHPS) initiative sponsored by the Agency for Healthcare
Research and Quality (AHRQ). This Reader’s Guide provides hospitals and survey vendors with
a high-level overview and reference for essential information presented in the Quality Assurance
Guidelines V6.0. Readers are directed to the related sections of the Quality Assurance Guidelines
V6.0 for more detail.
Quality Assurance Guidelines V6.0 Contents
The Quality Assurance Guidelines V6.0 contains sections that address HCAHPS survey
administration requirements. These include:
Introduction and Overview
This section includes a description of the HCAHPS initiative and the history of its development. It also
includes an overview of the HCAHPS development, data collection and public reporting timeline.
Program Requirements
This section presents the Program Requirements, including the purpose of the HCAHPS survey,
use of HCAHPS in conjunction with other hospital inpatient surveys, communicating with
patients about the HCAHPS survey, the roles and responsibilities for participating organizations
(i.e., CMS, hospitals and survey vendors), Rules of Participation, and Minimum Survey
Requirements to administer the HCAHPS survey.
Communications and Technical Support
This section includes information about communications and technical support available to
hospitals/survey vendors administering the HCAHPS survey.
Survey Management
Hospitals/Survey vendors must establish a survey management process to administer the
HCAHPS survey. This section reviews guidelines that pertain to system resources, location of
survey operations, customer support lines, personnel training, monitoring and quality oversight,
safeguarding patient confidentiality, data security, and data retention.
Sampling
This section describes the process and requirements for selecting a random sample of patients to
respond to the HCAHPS survey. Several illustrations and examples of the HCAHPS sampling
protocol are included in this section. Sampling can be done at one time after the end of the month
1 CAHPS ® is a registered trademark of the Agency for Healthcare Research and Quality, a U.S. Government agency.
Centers for Medicare & Medicaid Services 1
HCAHPS Quality Assurance Guidelines V6.0