The HCAHPS Frequently Asked Questions Document Has Been Revised (12/20/2024)

The HCAHPS Frequently Asked Questions document has been revised and is posted to the Facts and FAQs page. The update includes information pertaining to HCAHPS Survey Content and Administration, HCAHPS Measures, HCAHPS Public Reporting on Care Compare, HCAHPS Star Ratings, and HCAHPS and Hospital Value-Based Purchasing.

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New! HCAHPS Podcast Now Available - HCAHPS Program Updates: Changes to Survey Content and Survey Protocol (12/19/2024)

 

Please click here to view HCAHPS Program Updates: Changes to the Survey Content and Survey Protocol podcast on the Podcasts Page.

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Summary of Key Changes to Content of Updated HCAHPS Survey (12/17/2024)

• Updated HCAHPS Survey Includes 32 Questions (or items):
  • 8 new questions added to survey
  • 5 questions removed from survey
• 3 new measures of patient experience
  • Care Coordination (3 questions)
  • Restfulness of Hospital Environment (3 questions)
  • Information about Symptoms (1 question)
• 1 measure removed
  • Care Transition (3 questions)
• Responsiveness of Hospital Staff measure altered
  • "Help right away" question added to survey
  • "Call button" question removed from survey
• Changes to "About You" section:
  • "Hospital stay planned in advance" question added to survey
  • "Emergency room admission" question removed from survey
  • The order of several "About You" questions has been changed

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Summary of Key Changes to Administration of Updated HCAHPS Survey (12/17/2024)

• 3 new modes of survey administration available:
  • Web-Mail: E-mail survey with mail follow-up of non-respondents
  • Web-Phone: E-mail survey with telephone follow-up of non-respondents
  • Web-Mail-Phone: E-mail survey with mail and telephone follow-up of non-respondents
• Mail Only, Phone Only, and Mail-Phone (Mixed) modes remain available
  • The Interactive Voice Response (IVR) mode is discontinued
• Official Spanish translation must be administered to all Spanish-preferring patients
  • Applies to all modes of survey administration
• Maximum of 12 supplemental items may be added to the survey
  • Formerly unrestricted
• Proxy respondents not prohibited from answering survey for patient
  • Formerly prohibited

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Updates to HCAHPS Public Reporting on Care Compare (12/17/2024)

Because four quarters of data are required for public reporting, there will be changes to the roster of HCAHPS measures on Care Compare between October 2025 and October 2026. Please see the Technical Specifications page for a summary of these changes.

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HCAHPS Survey Changes and Hospital Value-Based Purchasing (12/17/2024)

Changes to the HCAHPS Survey coupled with the requirements of the Hospital VBP program will result in several sequential changes to the HCAHPS dimensions. Please see the HCAHPS and Hospital VBP page for a summary of these changes.

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FOLLOW-UP: January 2, 2025 HCAHPS Data Submission Deadline (12/12/2024)

January 2, 2025 is the data submission deadline for patients discharged in July, August, and September (3Q24). September 2024 Dry Run data must also be submitted by this date.

Due to the upcoming holiday season, please make sure to allow adequate time to submit data in case resubmissions are necessary. A successful submission to the QualityNet Secure Portal is defined as a file that has been accepted by the QualityNet Secure Portal, as indicated on the Data Submission Report. Be sure to check the HCAHPS Data Submission Reports (if your hospital uploaded data) or the HCAHPS Warehouse Feedback Reports (if your hospital has contracted with an approved survey vendor).

Should you encounter any data submission issues, be sure to open a ticket with the QualityNet Help Desk at qnetsupport@cms.hhs.gov, or by telephone at 866.288.8912. In addition, please forward the QualityNet Help Desk Ticket/Incident number to the HCAHPS Project Team via the HCAHPS Technical Assistance email (hcahps@hsag.com).

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HCAHPS Participation to Open for New Applicants and Mode Additions in Early January 2025 (12/11/2024)

 

Organizations that must go through the 2025 HCAHPS Participation process to administer the HCAHPS Survey beginning with July 1, 2025 discharges and forward:

• Currently approved HCAHPS Survey vendors and self-administering hospitals that seek to administer a mode for which they were not previously approved must go through the Participation process
• Organizations that are not currently approved HCAHPS Survey vendors that are interested in applying to become approved to administer the HCAHPS Survey must go through the Participation process
• Hospitals that are not currently approved to self-administer the HCAHPS Survey that are interested in applying to become approved to self-administer the HCAHPS Survey must go through the Participation process

Note: Survey vendors and self-administering hospitals who were approved in 2024 for a new mode(s) beginning with January 1, 2025 discharges and those who do not wish to add further modes are not required to go through the 2025 HCAHPS Participation process.

Steps for the 2025 HCAHPS Participation process:

• Meet all of the HCAHPS Minimum Business Requirements to administer the HCAHPS Survey which are now available on the HCAHPS Minimum Business Requirements page
• Complete and submit a Participation Form on the HCAHPS Website (www.hcahpsonline.org) during the open Participation period. The HCAHPS Participation period will open in early January 2025 and will remain open for a period of approximately three weeks. Please monitor the HCAHPS Website for specific dates.
• If conditionally approved to administer the HCAHPS Survey, participate in both Introduction to HCAHPS Training and Update Training in Spring 2025

For more information, please contact HCAHPS Technical Assistance at hcahps@hsag.com or 1-888-884-4007.

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HCAHPS Minimum Business Requirements to Administer the HCAHPS Survey (12/11/2024)

The Minimum Business Requirements for HCAHPS are now available on the HCAHPS Minimum Business Requirements page of the HCAHPS Website. Organizations must meet all of the HCAHPS Minimum Business Requirements in order to administer the HCAHPS Survey:

• Survey vendors and subcontractor(s) if applicable, must meet all of the Survey Vendor Minimum Business Requirementss
  • Subcontractor(s) and other organization(s) performing major HCAHPS Survey Administration functions (e.g., mail/phone/web operations, XML file preparation) must meet all HCAHPS Minimum Business Requirements that pertain to that role
• Hospitals that self-administer the HCAHPS Survey must meet all of the Self-administering Hospital Minimum Business Requirements

Applicants must demonstrate their recent survey experience and provide documentation of meeting survey experience requirements. When reviewing Participation Forms, CMS will 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.

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The HCAHPS Fact Sheet Has Been Revised (12/09/2024)

The HCAHPS Fact Sheet has been revised and is posted to the Facts and FAQs page. The update includes information pertaining to HCAHPS Survey Content and Administration, HCAHPS Measures, HCAHPS Public Reporting on Care Compare, HCAHPS Star Ratings, HCAHPS and Hospital Value-Based Purchasing, and a Review and Revision of HCAHPS.

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HCAHPS Response Rate by Survey Mode Table Added to the Summary Analyses Page (12/06/2024)

The HCAHPS Response Rate by Survey Mode Table has been added to the Summary Analyses page.

This table displays the response rate of hospitals that used the Mail Only, Telephone Only, or Mixed Mode (mail followed by telephone contact for non-respondents) in a recent four-quarter roll-up. Mode-specific response rates are shown at the 25^th, 50^th, 75^th, and 90^th percentiles. These percentiles allow a hospital to compare its own response rate, which can be found on the Care Compare Website (https://www.medicare.gov/care-compare/?providerType=Hospital) under “Patient Survey Rating,” to other hospitals that employ the same mode. 

Hospitals whose response rate falls below the 50^th percentile should consider taking steps to improve (see podcast: https://hcahpsonline.org/en/podcasts/#improve). We encourage all hospitals to examine how well their survey mode resonates with the patient population they serve (see podcast: https://hcahpsonline.org/en/podcasts/#ImprovingRepresentativeness).

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HCAHPS Quality Assurance Guidelines V19.0 Survey Instruments Have Been Updated to Include the OMB Expiration Date (12/03/24)

OMB approval has been received for the Updated HCAHPS Survey instruments. The OMB expiration date of November 30, 2027 must be used on all HCAHPS mail and web survey materials for patients discharged on January 1, 2025 and forward. The updated OMB expiration date and translations are available for use immediately, but must be implemented by January 1, 2025. For HCAHPS mail survey administration, the OMB expiration date must appear in the OMB Paperwork Reduction Act language and on the front page of the questionnaire. For HCAHPS web survey administration, the OMB expiration date must appear in the OMB Paperwork Reduction Act language.

The HCAHPS Survey instruments (for mail and web) have been updated to include the OMB expiration date and are available on the Survey Instruments page.

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HCAHPS FINAL Quality Assurance Guidelines V19.0 (HCAHPS FINAL QAG V19.0) Now Available (10/31/24)

The HCAHPS Project Team is pleased to announce the release of the HCAHPS FINAL Quality Assurance Guidelines V19.0 (HCAHPS FINAL QAG V19.0). This manual has been revised from the DRAFT HCAHPS Quality Assurance Guidelines V19.0 and includes additional updates and enhancements that provide a comprehensive resource for survey vendors and hospitals participating in the HCAHPS initiative. This updated version is now available online to view or download on the Quality Assurance page. Please use the HCAHPS FINAL QAG V19.0 for January 1, 2025 patient discharges and forward.

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HCAHPS FINAL Quality Assurance Guidelines V19.0 Summary of Changes Now Available (10/31/24)

The HCAHPS Quality Assurance Guidelines V19.0 Summary of Changes is a reference tool that highlights the major changes from the HCAHPS DRAFT Quality Assurance Guidelines V19.0 to the HCAHPS FINAL Quality Assurance Guidelines V19.0. The reference tool is available on the Quality Assurance page.

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Foreign Language Survey Material Submission (10/31/24)

HCAHPS Survey vendors and self-administering hospitals that plan to administer the survey in languages other than English and Spanish beginning with January 1, 2025 patient discharges must submit survey materials in those languages to the HCAHPS Project Team for review. Please submit these survey materials at your earliest convenience, no later than November 27, 2024.

Survey Materials for the HCAHPS Survey include:

• HCAHPS Mail Survey Packet (questionnaires, cover letters, outgoing and return envelopes)
• HCAHPS Phone Interviewer Screen Shots and/or Scripts
• HCAHPS Web Survey Packet (survey screen shots, email invitations and web survey testing links)

Documents may be submitted either via HCAHPS Technical Assistance (hcahps@hsag.com) or via the HCAHPS Secure Access File Exchange (SAFE) application.

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Care Compare Has Been Refreshed (10/30/2024)

The October 2024 Care Compare Refresh includes HCAHPS scores from January 2023 through December 2023 data collections.

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Summary Analyses Page Tables Have Been Updated (10/30/2024)

The following tables have been added to the HCAHPS Website Summary Analyses page:

• October 2024 Summary of HCAHPS Survey Results Table
• October 2024 HCAHPS Percentiles Table
• October 2024 HCAHPS Survey Individual Question Top-Box Score

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The Star Ratings Distributions Have Been Updated (10/30/2024)

The following tables have been added to the HCAHPS Website Star Ratings page:

• October 2024 HCAHPS Star Rating Distributions
• October 2024 HCAHPS Summary Star Distributions by US State

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HCAHPS Survey Individual Question Top-Box Scores Table Has Been Updated (10/30/2024)

The HCAHPS Survey Individual Question Top-Box Scores table has been added to the Summary Analyses page: 

• October 2024 Public Report: January 2023 – December 2023 discharges

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Patient-Mix Adjustments and National Means for January 2025 HCAHPS Results Have Been Posted (10/28/2024)

The Patient-Mix Adjustments and National Means for the January 2025 HCAHPS results are now available. Please click here to access the Mode & Patient-Mix Adjustment page.

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Star Ratings: January 2025 Technical Notes Have Been Posted (10/28/2024)

The Technical Notes for the January 2025 HCAHPS results are now available. The January 2025 HCAHPS Star Ratings are included in the hospital Preview Reports (available to hospitals from October 28, 2024 through November 23, 2024), and will be Publicly Reported on Care Compare in January 2025. Please click here to access the HCAHPS Star Ratings page.

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V.42 MS-DRG Codes Effective October 1, 2024 (10/09/2024)

CMS has adopted V.42 MS-DRG Codes effective October 1, 2024. Please click here for the Table of V.42 MS-DRG Codes and HCAHPS Service Line Categories.

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FY 2025 IPPS Final Rule Has Been Published (08/29/2024)

The Final Rule and related tables are now available on the Federal Register at the following URL: 2024-17021.pdf (federalregister.gov)

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HCAHPS Public Reporting Periods for October 2023 Through October 2025 Have Been Updated (08/29/2024)

Click here to view the HCAHPS Public Reporting Periods document. This document indicates which calendar quarters HCAHPS results will be publicly reported on the Care Compare Website through October 2025.

Please Note: The dates of future preview periods and public reporting are estimates based on current timetables and are thus subject to change.

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In 2021, CMS conducted a large-scale, randomized HCAHPS mode experiment. The experiment allowed calculation of survey mode adjustments applicable to all modes, both the legacy modes (Mail Only, Phone Only, and Mixed Mode) and the new Web-First modes (Web-Mail, Web-Phone, and Web-Mail-Phone).

The new Web-First adjustments will be applied when the new Web-First modes are launched in January 2025. Patients discharged in January 2025 will receive the updated HCAHPS Survey. To view HCAHPS Survey mode adjustments beginning with January 2025 discharges, please click here to access the 2021 Mode Experiment on the Patient-Mix Adjustment page.

*Pending final approval of the proposed HCAHPS Survey changes included in the FY 2025 proposed Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals Rule (CMS-1808-P)

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OMB Expiration Date Now Available for the Current HCAHPS Survey Instruments (05/02/2024)

The HCAHPS Survey OMB expiration date of September 30, 2024 has been extended to January 31, 2025. This can be found on the front page of the questionnaire in the OMB control number (OMB #0938-0981) text box and in the OMB Paperwork Reduction Act Language.

 

 

For HCAHPS Survey administration, the OMB Paperwork Reduction Act language must appear in the mailing, either on the front or back of the questionnaire (preferred) or cover letter.

The HCAHPS Survey extended OMB expiration date and translations are available for use immediately, but must be implemented by September 2024.

Please note: The HCAHPS Project Team is not requiring re-submission of current HCAHPS Survey materials, unless otherwise requested.

Please see the translations for the extended OMB expiration date, as shown below:

Language	OMB DATE
English	OMB #0938-0981 (Expires January 31, 2025)
Spanish	OMB #0938-0981 (Fecha de vencimiento: 31 de enero de 2025)
Chinese	OMB #0938-0981 (到期日2025年1月31日)
Russian	OMB №0938-0981 (срок истекает 31 января 2025 г.)
Vietnamese	OMB #0938-0981 (Hết hạn ngày 31 tháng 1 năm 2025)
Portuguese	OMB #0938-0981 (Vence a 31 de janeiro de 2025)
German	OMB #0938-0981 (Frist: 31. Januar 2025)
Tagalog	OMB #0938-0981 (Mag-e-expire sa ika-31 ng Enero, 2025)
Arabic	رقم ضبط مكتب الإدارة والميزانية ‎0938-0981 (تنتهي صلاحيته في 31 يناير 2025)

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NEW! Updated HCAHPS Survey Page Now Available (04/11/2024)

Please click here to view the Updated HCAHPS Survey Page. The page provides several documents about the Updated HCAHPS Survey, which will be administered beginning with patients discharged on January 1, 2025 and forward.

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Updated HCAHPS Survey (12/11/2023)

As you know, a number of important changes will be made to the HCAHPS Survey administered to patients discharged on January 1, 2025 and forward, pending rulemaking.

Until now, the HCAHPS Project Team has referred to this survey as "HCAHPS 2.0."

However, to emphasize continuity with the current survey, going forward we will refer to the survey administered to patients discharged on January 1, 2025 and forward as the "updated HCAHPS Survey."

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HCAHPS XML File Specifications V4.6 Have Been Posted (06/30/2023)

The HCAHPS XML File Specifications Version 4.6 have been added to the HCAHPS Web site Technical Specifications page. The HCAHPS Technical File Specifications V4.6 are to be used starting with July 1, 2023 patient discharges.

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Update on Progress of the 2021 HCAHPS Mode Experiment Has Been Posted (07/14/2022)

Information on the 2021 HCAHPS Mode Experiment was presented during the 2022 HCAHPS Update Trainiing. Please click here to view the Update on Progress of the 2021 HCAHPS Mode Experiment document.

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Update: HCAHPS 2021 Mode Experiment (06/21/2021)

The 2021 CMS HCAHPS mode experiment includes a test of new survey modes as well as new and revised survey items. CMS and its HCAHPS Project Team are testing an expanded HCAHPS Survey instrument using six different survey administration protocols: 3 standard modes (Mail Only, Telephone Only, and Mixed Mode (mail followed by telephone), and three new mixed mode protocols that begin with a web-based survey followed by a standard mode:  Web-Mail, Web-Telephone, and Web-Mail-Telephone.

 

In addition to testing web-based survey administration, the mode experiment also tests new and revised survey content. The mode experiment survey contains 43 items. The core of the survey includes 26 items that generally duplicate the current HCAHPS Survey, though with one deletion and some minor revisions to item wording and sequence. This core is followed by 17 test items that include new patient experience topics, new items on existing topics, and proxy help items. A copy of the survey is available for informational purposes.

 

Please note: The HCAHPS mode experiment survey instrument is for testing purposes only. It is not intended to represent the future survey and is not approved for use.

 

The 2021 HCAHPS mode experiment is being conducted on a random sample of HCAHPS-eligible patients discharged from April through September 2021 from more than 40 hospitals. The hospitals were randomly selected and are broadly representative of all hospitals participating in HCAHPS. Within each hospital, sampled patients are randomly assigned to the six survey administration protocols. Patients assigned to the three web-based administration protocols receive invitations to the web survey via email. The mode experiment will assess different data collection windows for the web-based survey: 6, 8, and 10 days. The mode experiment will allow up to 49 days for initial contact of patients, and 49 days for completion of the survey after the initial contact. The table below provides an overview of the schedule of contacts for the mode experiment.

 

Schedule of HCAHPS Mode Experiment Contact Attempts

Day	Standard Mail Only	Standard Phone Only	Standard Mixed Mode	Web-Mail	Web-Phone	Web-Mail- Phone
1	Mail out first survey	Phone calls begin	Mail out survey	Email first survey invitation	Email first survey invitation	Email first survey invitation
2
3				Email second survey invitation
4					Email second survey invitation	Email second survey invitation
5
6				Email third survey invitation		Mail out survey
7					Email third survey invitation
8				Mail out first survey
9
10					Phone calls begin
21	Mail out second survey
28			Phone calls begin			Phone calls begin
30				Mail out second survey
49	End data collection	End data collection	End data collection	End data collection	End data collection	End data collection

 

The additional email invitations and the secondary modes are enacted only for patients who do not respond to the initial contact. Patients randomly assigned to a web-based mode who lack a valid email address receive their first contact when the secondary mode begins.

After the completion of mode experiment data collection in late 2021, CMS will analyze the data and use the results to inform decisions about HCAHPS modes of survey administration, survey content, proxies, schedule and timing of contacts, and length of survey administration. Any changes to current HCAHPS Survey content or administration procedures will be proposed through the CMS rulemaking process.

 

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Care Compare Web Site Now Available (09/03/2020)

 

CMS Care Compare Empowers Patients when Making Important Health Care Decisions

 

The Centers for Medicare & Medicaid Services (CMS) launched Care Compare, which contains HCAHPS survey results and many other measures, and is a streamlined redesign of eight existing CMS healthcare compare tools available on Medicare.gov.

 

Full Press Release can be found here: https://www.cms.gov/newsroom/press-releases/cms-care-compare-empowers-patients-when-making-important-health-care-decisions

 

Direct links to the tools & additional resources

 

Care Compare on Medicare.gov - https://www.medicare.gov/care-compare/

 

Care Compare resources for consumers and partners – Medicare blog, Promotional video, Conference card

 

Provider Data Catalog on CMS.gov - https://data.cms.gov/provider-data/

 

Provider Data Catalog and Medicare Care Compare

Webinar Recordings Now Available

 

Go to the “Videos” Section on the CMS National Training Program page here. Direct links below:

Provider Data Catalog (PDC) Webinar (Recorded August 10, 2020)

eMedicare: Improving Compare Tools (Recorded August 24, 2020)

 

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Extraordinary Circumstances Extension (ECE) (01/30/2024)

For recent Extraordinary Circumstances Extensions (ECE) the key HCAHPS content is displayed below.  To review the entire Quality Reporting Notifications please click below:

• Mississippi Storms (Q4 2022) please click here
• Hurricane Ian (Q2 2022) please click here
• Hurricane Ida (Q2-Q3 2021) please click here
• Texas Winter Storms (Q1 2021) please click here
• Hurricane Laura (Q3 2020) please click here
• California and Oregon Wildfires (Q3 2020) please click here
• Hurricane Dorian (Q3 2019) please click here
• Tropical Storm Barry (Q3 2019) please click here
• California Wildfires (Q3 2018) please click here
• Hurricane Michael (Q3 2018) please click here
• Hurricane Florence (Q2-Q3 2018) please click here
• California Wildfires (Q3-Q4 2017) please click here
• Hurricane Nate (Q2-Q3 2017) please click here
• Hurricane Irma (Q2-Q3 2017) please click here
• Hurricane Harvey (Q2-Q3 2017) please click here

The National Support Team for the Hospital IQR Program is available to answer questions or supply any additional information you may need. Please contact the team at InpatientSupport@viqrc1.hcqis.org or call toll-free at (844) 472-4477.

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This page was last modified on (12/20/24)