What is HCAHPS, and what does it stand for?

HCAHPS (also known as Hospital CAHPS) stands for Hospital Consumer Assessment of Healthcare Providers and Systems and is a standardized survey of hospital patients that will capture patients’ unique perspectives on hospital care for the purpose of providing the public with comparable information on hospital quality.

HCAHPS consists of a standardized survey instrument and a set of data collection and reporting procedures. These will be used by hospitals (or their survey vendors) to gather information about patients’ perspectives on care in hospital. The core set of HCAHPS questions can either be added to a hospitals current patient survey, or used as a stand-alone instrument. HCAHPS is part of a public/private partnership dedicated to publicly reporting valid and comparable information on hospital care quality. This information will serve the goal of increasing consumers knowledge of hospital care. It will also provide hospitals with data and benchmarks to gauge their performance relative to others.
 

Why should my hospital partake in HCAHPS?

HCAHPS will serve the publics interest in improving the quality of care in Americas hospitals by providing consumers, healthcare professionals and individual hospitals with standardized and comparable information on how patients view their quality of care experience. HCAHPS will furnish valid and reliable information on several critical aspects of the hospital experience and will do so on a continuous basis. In addition to gaining valuable information about their own care processes, participating hospitals will be able to compare themselves to other hospitals and the industry as a whole on exactly the same indicators. This information could be fed directly into the hospitals assessment and improvement program. The ongoing and standardized nature of the survey will also allow hospitals to track changes in patient perspectives on care over time.

The concept of developing a core instrument to capture patients’ perspectives on care in hospital and reporting comparable data to the public has been endorsed by the major hospital associations and is strongly supported by leading health care and consumer organizations. The HCAHPS survey will become part of the Hospital Quality Alliance.

Beginning in July 2007, reporting of HCAHPS results will be tied to payment in the Annual Performance Update from CMS.  Hospitals that choose not to participate will see a reduction of 2.0% of their market basket update.
 

How will implementation of HCAHPS affect ongoing hospital survey efforts?

There are multiple survey vendors who are able to administer HCAHPS by following specific survey, sampling and administration specifications. HCAHPS can be seen as a core survey to which hospitals and survey vendors will be able to add a broader set of questions. HCAHPS is designed to gather only the necessary data that CMS needs for comparative pubic reporting. HCAHPS should complement, not replace, the data that hospitals are currently collecting to support improvement in internal hospital customer services and related activities. We expect that most hospitals will combine the HCAHPS module with items they currently use for internal improvement purposes. However, hospitals also have the flexibility to use the HCAHPS questionnaire as a stand-alone questionnaire if they choose.
 

What roles will hospitals or their survey vendors and the federal government play in the national implementation of HCAHPS?

There will be distinct roles for hospitals or their survey vendors and the federal government in the national implementation of HCAHPS. Hospitals or their vendors will be responsible for data collection, including: developing a sampling frame of relevant discharges, drawing the sample of discharges to be surveyed, collecting survey data from sampled discharges, and submitting HCAHPS data to CMS in a standard format.

The government will be responsible for support and public reporting, including: conducting training on data collection and submission procedures, providing on-going technical assistance, ensuring the integrity of data collection, accumulating HCAHPS data from individual hospitals, producing case mix-adjusted hospital-level estimates, conducting research on the presentation of data for public reporting, and publicly reporting the comparative hospital data.
 

Will the survey be conducted using mail or telephone?

In order to accommodate the different survey modes used by hospitals/vendors in their current surveys, HCAHPS will permit flexibility in mode of survey administration. Hospitals or their vendors will be able to choose among four different modes of administration: mail only, telephone only, IVR, and a mixed mode of mail with telephone follow-up. Hospital or their vendors that currently conduct their internal quality improvement surveys by mail can continue to do so, as can those who use telephone. To assure the comparability of all data collected in the HCAHPS initiative, we have created a recommended protocol within each mode of administration. We will allow exceptions to the recommended mail, telephone, IVR, and mixed mode protocols if the hospital/vendor can demonstrate that it can achieve a response rate standard.

Allowing different modes of survey administration can introduce bias in comparative reporting. Patient perspectives data collected through personal interaction (e.g., by telephone) often produces higher ratings on average than data collected without personal interaction (e.g., by mail). To control for such effects, CMS has released mode adjustment information. Visit HCAHPS Online (http://www.hcahpsonline.com) for detailed information about the HCAHPS Mode Experiment. You can also download a copy of the updated Mode and Patient-mix Adjustment abstract here.