Executive Insight

2018 HCAHPS Executive Insight Letter


Welcome to the HCAHPS Executive Insight, the gold button on the HCAHPS On-Line Web site, www.hcahpsonline.org.

In December 2017, the Centers for Medicare & Medicaid Services (CMS) refreshed the HCAHPS results on the Hospital Compare Web site, www.medicare.gov/hospitalcompare/. The new HCAHPS scores are based on patients discharged between April 1, 2016 and March 30, 2017.


  • The December 2017 HCAHPS results on Hospital Compare scores are based on more than 3.1 million completed surveys from approximately 4,355 hospitals
  • The “Summary of HCAHPS Results" and “HCAHPS Percentiles” tables on the Summary Analyses page have been updated to include the newest HCAHPS scores

News and Notes from the HCAHPS Project Team

There have been a number of important developments in the HCAHPS world since we last updated HCAHPS Executive Insight:

– CMS has replaced the three Pain Management items currently in the HCAHPS Survey (questions 12, 13 and 14) with three items that are focused on communication about pain.  The three new Pain Management items added to the HCAHPS Survey will be effective with January 1, 2018 patient discharges and forward.

–  The HCAHPS Fact Sheet was updated in October 2019.

–  CMS would like to reiterate that HCAHPS scores are designed and intended for use at the hospital level. That is, the comparison of hospitals to each other (designated by their CMS Certification Number). CMS does not review or endorse the use of HCAHPS scores for comparisons within hospitals, such as comparison of HCAHPS scores among wards, floors or individual staff members. Such comparisons are unreliable unless large sample sizes are collected at the ward, floor or individual staff member level.

–  CMS conducted a new HCAHPS mode experiment in early 2016.

HCAHPS Star Ratings

As part of a new initiative to add five-star quality ratings to its Compare Web sites, CMS added HCAHPS Star Ratings to the Hospital Compare Web site in April 2015. Star ratings make it easier for consumers to use the information on the Compare Web sites and spotlight excellence in healthcare quality. Twelve HCAHPS Star Ratings will appear on Hospital Compare: one for each of the 11 publicly reported HCAHPS measures, plus a Summary Star Rating that combines (“rolls-up”) all of the HCAHPS Star Ratings. HCAHPS Star Ratings are derived from the same data used to create the HCAHPS measures on Hospital Compare. CMS plans to update the HCAHPS Star Ratings each quarter.

To receive HCAHPS Star Ratings, hospitals must have at least 100 completed HCAHPS Surveys over a given four-quarter period. In addition, hospitals must be eligible for public reporting of HCAHPS measures. Hospitals with fewer than 100 completed HCAHPS surveys will not receive Star Ratings. If the hospital obtains more than 25 and fewer than 100 completed surveys, the hospital’s HCAHPS scores will still be publicly reported. Hospitals can see their HCAHPS Star Ratings in their CMS Preview Report for each reporting period.

More information about HCAHPS Star Ratings, including Frequently Asked Questions and HCAHPS Star Rating Technical Notes, can be found under the maroon button on HCAHPS On-Line Web site, http://hcahpsonline.org/en/hcahps-star-ratings/. More information about HCAHPS Star Ratings can be found on the Hospital Compare Web site at “Survey of patients’ experiences,” http://www.medicare.gov/hospitalcompare/search.html.

“What's New”

We encourage hospitals and their survey vendors to frequently check our “What’s New” button to find the latest information on HCAHPS, such as upcoming data submission deadlines. We also invite you to share the material presented on HCAHPS Executive Insight, but when you share or reproduce this material, please include the following citation:

Thanks for visiting HCAHPS Executive Insight. Comments or suggestions for HCAHPS Executive Insight should be directed to us, by email, at hcahps@HCQIS.org.

Bill Lehrman and Liz Goldstein, Editors

Division of Consumer Assessment & Plan Performance, Medicare Drug Benefit Group Centers for Medicare & Medicaid Services (CMS)

CAHPS® is a registered trademark of the Agency for Healthcare Research and Quality, a U.S. Government agency.

Previous HCAHPS Executive Insight Letters Have Been Posted


This page was last modified on (10/1/19)