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Self-administering Participation Form
CAHPS® Hospital Survey Participation Form for Hospitals Self-administering Survey
This Participation Form is to be completed only by hospitals requesting to become approved to self-administer the CAHPS® Hospital Survey (HCAHPS) (without using a survey vendor) or by hospitals self-administering the HCAHPS Survey that have significant changes to administration processes (e.g., adding an administration mode).

Indicate whether this report is a New Participation Form or an Updated Participation Form.
01/20/2025
I. General Participation Information

This section is to be completed with general information for participation in HCAHPS Data Collection and Public Reporting.

1. Applicant Organization
The Name of the Organization is required.
The Medicare Provider Number is required.
The Address is required.
The City is required.
The State is required.
The Zip Code is required.
Telephone is required.
2. Applicant Primary Contact Person
First Name is required.
Last Name is required.
Title is required.
City is required.
State is required.
Zip Code is required.
Telephone is required.
Email is required.
3. Type(s) of Mode of Survey Administration Fielding for the CAHPS® Hospital Survey (Check all that apply)1
1No alternative modes of survey administration will be permitted for use other than those prescribed for the survey (Mail Only, Phone Only, Mail-Phone, Web-Mail, Web-Phone, and Web-Mail-Phone).
At least one Type(s) of mode of Survey Administration Fielding is required.
II. CAHPS® Hospital Survey Minimum Business Requirements

A hospital must be approved by CMS in order to self-administer the HCAHPS Survey and submit HCAHPS data to the HCAHPS Data Warehouse. Hospitals self-administering the HCAHPS Survey must meet all of the following Minimum Business Requirements.

Please note, subcontractor(s)/partner(s), and any other organization(s) performing major HCAHPS Survey administration functions for Self-administering Hospitals must meet the Minimum Business Requirements for Survey Vendors. Please see the Minimum Business Requirements for Survey Vendors column, beginning on page 3.

To become approved to self-administer the HCAHPS Survey, hospitals must submit this HCAHPS Participation Form and agree to the Rules of Participation (See section V). In Reviewing Participation Forms, CMS will also consider any prior experience and past performance the applicant organization and/or subcontractor(s) may have with administering CMS surveys or other patient experience surveys. Applicants must demonstrate recent survey experience (i.e., provide documentation of meeting survey experience requirements). HCAHPS approval status is based on the information provided at the time of application. If changes are made to the major HCAHPS Survey administration functions, including changes to HCAHPS subcontractors, the HCAHPS Project Team must be notified immediately. These changes may be subject to review and evaluation by the HCAHPS Project Team.

In addition, approved HCAHPS self-administering hospitals must fully comply with the HCAHPS oversight activities. The FY 2014 IPPS Final Rule states: “Approved HCAHPS self-administering hospitals must fully comply with all HCAHPS oversight activities, including allowing CMS and its HCAHPS Project Team to perform site visits at the hospitals’ and survey vendors’ company locations.” Federal Register/Vol. 78, No. 160/Monday, August 19, 2013/Rules and Regulations, Section. 412.140. In order for the HCAHPS Project Team to perform the required oversight activities, organizations that are approved to administer the HCAHPS Survey must conduct all business operations within the United States. This requirement applies to all staff and subcontractors.

Please check Yes or No for each item below to indicate that the organization has read and meets the following Minimum Business Requirements, as applicable for requested mode(s).

1. Relevant Survey Experience

Demonstrated recent (eg., 2022 - 2024) continuous experience in fielding patient-specific surveys in the requested mode(s) (i.e., Mail, Phone, Mail-Phone, or Web).
  • Minimum of two continuous years Mail, Phone, or Mail-Phone patient-specific survey experience for the most recent two-year time period
  • Minimum of one year continuous web patient-specific survey experience for the most recent one-year time period
Answer Required.
  • Capacity to conduct surveys in both English and Spanish
Answer Required.
  • Minimum of three years
Answer Required.
  • One year prior experience selecting random sample based on specific eligibility criteria within the most recent one-year time period
  • Adequately document sampling process

Note: Hospitals are responsible for conducting the sampling process and must not subcontract this activity.
Answer Required.
2. Organizational Survey Capacity

Capability and capacity to handle a required volume of mail questionnaires, conduct standardized phone interviewing, and/or conduct web survey administration in specified time frame.

Designated personnel:

  • HCAHPS Project Manager with minimum one year prior experience conducting patient-specific mail and/or phone surveys
  • Subject Matter Expert (SME) in web survey administration (subcontractor designee, if applicable) with a minimum of one-year prior experience for web surveys
  • Web Programmer (subcontractor designee, if applicable) with a minimum of one-year prior experience programming, testing, and collecting data via web survey instruments
  • Have appropriate organizational back-up staff for coverage of key staff

Note: Hospitals must not use volunteers in any capacity for HCAHPS Survey administration.
Answer Required.
  • Physical plant resources available to handle the volume of surveys being administered
  • A systematic process to:
    • track fielded surveys through the protocol, avoiding respondent burden and losing respondents
    • assign random, unique, de-identified patient identification number (Patient ID) to track each sampled patient
  • Computer programs for implementing web survey instruments that are accessible in mobile and computer versions that are 508 compliant, present similarly on different browser applications, browser sizes and platforms (mobile, tablet, computer)

Note: All System Resources are subject to oversight activities including on-site visits to physical locations.
Answer Required.
  • Generate the sample frame data file that contains all discharged patients who meet the eligible population criteria
  • Draw the sample of discharges for the survey, who meet the eligible population criteria

Note: Hospitals are responsible for conducting the sampling process and must not subcontract this activity.
Answer Required.
  • Obtain and update addresses
  • Produce and print survey instruments and materials; a sample of all mailing materials must be submitted for review
  • Mail out of survey materials
  • Process survey data (including key-entry or scanning)
  • Identify non-respondents for follow-up mailing

Note: Mail survey administration activities must not be conducted from a residence or non-business location unless an approved Exception Request is in place.
Answer Required.
  • Obtain and update all phone numbers
  • Collect phone interview data for the survey; a sample of the phone script and interviewer screen shots must be submitted for review
  • Identify non-respondents for follow-up phone calls
  • Schedule and conduct callback appointments

Note: Phone interviews/monitoring must not be conducted from a residence or non-business location unless an approved Exception Request is in place. Phone interviews/monitoring cannot be conducted by staff that provide direct patient care.
Answer Required.

See both of the above referenced Mail Mode of Survey Administration and Phone Mode of Survey Administration requirements.
Answer Required.
  • Disseminate survey invitation and follow-up emails to non-respondents that include an embedded hyperlink unique to each sampled patient that the patient can click on to directly connect to the web survey
  • Obtain and validate patient email addresses
  • Collect web survey data
  • Identify non-respondents for follow-up mail and/or phone administration
    • See above referenced Mail Administration and Phone Administration requirements
  • Submit a sample of survey materials for review, if applicable:
    • Invitation and reminder emails
    • Web survey screenshots that display what the respondent will see and will present similarly on different browser applications, browser sizes and platforms (mobile, tablet, computer) and a web survey testing link
    • Hard copy letter(s) and questionnaire
    • Phone script and interviewer screenshots

Note: Web survey administration activities must not be conducted from a residence or non-business location unless an approved Exception Request is in place.
Answer Required.
  • One year prior experience transmitting data via secure methods (HIPAA-compliant)
  • Registered user of the Hospital Quality Reporting (HQR) system (https://hqr.cms.gov/)
  • Prepare final patient-level data files for submission
  • Access and submit data electronically via the HQR system

Note: Hospitals are responsible for data submission and must not subcontract this process.
Answer Required.

Take the following actions to secure electronic data:

  • Administer web surveys with a secure hyperlink that is unique to each sampled patient, the data transmitted over a secure connection over HTTPS using transport layer security (TLS), and respondent information must be securely stored
  • Use a firewall and/or other mechanisms for preventing unauthorized access to the electronic files
  • Implement access levels and security passwords so that only authorized users have access to sensitive data
  • Implement daily backup procedures that adequately safeguard system data
  • Test backup files at a minimum on a quarterly basis to make sure the files are easily retrievable and working
  • Perform frequent saves to media to minimize data losses in the event of power interruption
  • Develop a disaster recovery plan for conducting ongoing business operations in the event of a disaster
Answer Required.

Take the following actions to securely store all survey administration related data for all survey modes:

  • Store HCAHPS-related data files, including patient discharge files and de-identified electronic data files (e.g., HCAHPS Sample Frame, survey responses, XML files, etc.), for a minimum of three years. Archived electronic data files must be easily retrievable.
  • Store returned mail questionnaires in a secure and environmentally safe location. Paper copies or optically scanned images of the questionnaires must be retained for a minimum of three years and be easily retrievable, when needed.
  • Destroy HCAHPS-related data files, including paper copies or scanned images of the questionnaires and electronic data files in a secure and environmentally safe location; obtain a certificate of the destruction of data
Answer Required.
  • One year prior experience providing phone customer support
  • Provide a customer support line in all languages administered
Answer Required.
  • Develop confidentiality agreements which include language related to HIPAA regulations and the protection of patient information, and obtain signatures from all personnel with access to survey information, including staff and all subcontractors involved in survey administration and data collection
  • Execute Business Associate Agreement(s) in accordance with HIPAA regulations
  • Confirm that staff and subcontractors are compliant with HIPAA regulations in regard to patient protected health information (PHI)
  • Establish protocols for secure file transmission. Emailing of PHI via unsecure email is prohibited.
Answer Required.
3. Quality Control Procedures

Personnel Training and quality control mechanisms employed to collect valid, reliable survey data and achieve at least 300 completed HCAHPS Surveys in a rolling four-quarter period.

Established systems for conducting and documenting quality control activities including:

  • In-house training of staff and subcontractors involved in survey operations
  • Oversee transition between initial mode and follow-up mode(s) (e.g., Mail-Phone, Web-Mail, Web-Phone, Web-Mail-Phone)
  • Monitoring the performance of all subcontractor(s)/partner(s) or other organization(s) performing major HCAHPS Survey administration functions
  • Printing, mailing and recording of receipt of survey information, if applicable
  • Phone administration of survey, if applicable
  • Web administration of survey, if applicable
  • Coding and editing or keying in survey data
  • Preparing of final patient-level data files for submission
  • All other functions and processes that affect the administration of the HCAHPS Survey
  • Compliance with HCAHPS Project Team's oversight activities
Answer Required.
  • Develop and maintain a QAP for survey administration in accordance with the HCAHPS Quality Assurance Guidelines and update the QAP on an annual basis and at the time of process and/or key personnel changes as part of retaining participation status, following approval
Answer Required.

The HCAHPS Project Team will review performance on CMS surveys or other patient experience surveys, including:

  • Occurance of substantive errors within or across projects
  • Compliance with required protocols
  • Receipt of corrective action memo from CMS
  • CMS requests for quality improvement plans
  • Timeliness and completion of required documentation (e.g., QAP, survey materials, etc.)

Note: In determining approval, CMS will take into consideration any prior experience the applicant organization may have administering CMS or other patient experience surveys, including as a subcontractor.
Answer Required.
4. Survey Experience

Provide a brief description of you organization's experience in conducting patient-specific surveys in each of the requested mode(s) of survey administration. Please limit to patient-specific surveys conducted within the most recent time period (e.g., 2022-2024).
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III. List of Key Project Staff
Project Director is required. A valid Email is required. Telephone is required.
A valid Email is required. Telephone is required.
A valid Email is required. Telephone is required.
A valid Email is required. Telephone is required.
IV. List of Subcontractors
Answer Required.
LIST OF SUBCONTRACTORS AND ANY OTHER ORGANIZATION(S) that are responsible for major functions of HCAHPS Survey administration.
Note: HCAHPS approval status is based on the information provided at the time of application. If changes are made to the major HCAHPS Survey administration functions, including changes to HCAHPS subcontractors, the HCAHPS Project Team must be notified immediately.
Name of Subcontractor is required.
Role is required.
Organization Address is required.
Contact Name is required.
Contact Email Address is required.

Add
Please add all additional subcontractors before submitting the form.
Edit
Cancel
At least one subcontractor is required.
(click on a row in the grid to edit it)
V. Rules of Participation

Any organization participating in the CAHPS Hospital Survey (HCAHPS) must adhere to the following Rules of Participation. To be eligible, the organization must:

  1. Participate in HCAHPS training and all subsequent HCAHPS trainings. At a minimum, the organization’s Project Manager must participate in training as a representative of the organization. The organization’s subcontractors/partners and any other organizations that are responsible for major functions of HCAHPS Survey administration (e.g., mail/phone/web operations) must also participate in HCAHPS training.
  2. Participate in teleconference call(s) with the HCAHPS Project Team to discuss relevant survey experience, organizational survey capability and capacity, and quality control procedures.
  3. Review and adhere to the HCAHPS Quality Assurance Guidelines and policy updates.
  4. Attest to the accuracy of the organization's data collection activities in accordance with HCAHPS protocols; the accuracy of data submission(s) and that data quality checks will be conducted.
  5. Develop and maintain an HCAHPS Quality Assurance Plan (QAP) by due date. In addition, submit materials relevant to HCAHPS Survey administration (as determined by CMS), including mailing materials (e.g., cover letters, questionnaires and outgoing/return envelopes), phone scripts, and/or web materials (e.g., invitation and reminder emails and web survey screenshots).
  6. Create a HARP (HCQIS Access Roles and Profile) account or ensure that the account is active by logging into the Hospital Quality Reporting (HQR) system at https://hqr.cms.gov/.
  7. Become a registered user of the Hospital Quality Reporting (HQR) system (https://hqr.cms.gov/) for Data Collection.
  8. Participate and cooperate (including subcontractors/partners and any other organization(s) that are responsible for major functions of HCAHPS Survey administration) in all oversight activities conducted by the HCAHPS Project Team.
  9. Comply with all requirements of the HIPAA Security and Privacy Rules in conducting all survey administration and data collection processes
  10. Meet all HCAHPS due dates including data submission.
  11. Acknowledge that review of and agreement with the Rules of Participation is necessary for participation and public reporting of results through the Centers for Medicare & Medicaid Services Care Compare on Medicare.gov (https://www.medicare.gov/care-compare/).
VI. Applicant Organization Certification and Acceptance

I certify that:

  • I have reviewed and agree to meet the Rules of Participation for participating in the CAHPS Hospital Survey (HCAHPS).

  • The statements herein are true, complete and accurate to the best of my knowledge, and I accept the obligation to comply with the CAHPS Hospital Survey (HCAHPS) Minimum Business Requirements.
AUTHORIZED REPRESENTATIVE
The Representative's Name is required.
The Representative's Title is required.
The Representative's Organization is required.
01/20/2025
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