Quick links: FOLLOW-UP: Data Submission Closes April 3, 2019 | HCAHPS Survey Materials and Attestation Statement Submission | Training Slides for 2019 Introduction to HCAHPS Self-training Module | HCAHPS Participation Forms Now Available | HCAHPS Quality Assurance Guidelines V14.0 Now Available | Hospital Compare Has Been Refreshed | Summary Analyses Page Tables Have Been Updated | Star Ratings Distributions Have Been Updated | Patient-Mix Coefficients for April 2019 HCAHPS Results Have Been Posted | Star Ratings: April 2019 Technical Notes Have Been Posted | Updated Hospital/Survey Vendor HCAHPS Minimum Survey Requirements to Administer the HCAHPS Survey (Minimum Business Requirements) | Updated 32-Question HCAHPS Mail Survey with OMB Expiration Date Now Available | CMS Introduces HCAHPS Survey Individual Question Top-Box Scores to the Summary Analyses Page | CY 2019 OPPS Final Rule Now Published | Communication About Pain Measure Will Not Be Publicly Reported but Included in Preview Reports | Important Changes to the HCAHPS Survey in 2019 | V.36 MS-DRG Codes | Crosswalk of HCAHPS Service Line Categories and V.34 APR-DRG Codes | FY 2019 IPPS Final Rule Has Been Published | HCAHPS XML File Specifications V4.1 Have Been Posted | NEW! HCAHPS Podcast Now Available - HCAHPS Score Calculations Part III: Top-Box Composite Scores | NEW! HCAHPS Podcast Now Available - HCAHPS Score Calculations Part II: Patient-Mix Adjustment (PMA) | HCAHPS Podcast Now Available - HCAHPS Score Calculations Part I: From Patient Discharges to Completed Surveys | HCAHPS Public Reporting Periods for April 2018 Through July 2020 Have Been Posted | Self-Rated Mental Health to be Added to HCAHPS Patient-Mix Adjustment Model Beginning with July 2018 Discharges | Updates to All Documents Pertaining to April 2018 Public Report and the Pain Management Composite | CMS Will No Longer Report the HCAHPS Pain Management Composite Measure | Extraordinary Circumstances Exceptions (ECE) | 2019 QualityNet Maintenance and Downtime Schedule | Mode Adjustment Table Has Been Posted | CMS Finalizing Removal of the Pain Management Dimension from Hospital Value-Based Purchasing in FY 2018
April 3, 2019 is the data submission deadline for patients discharged in October, November, December 2018 (4Q18). December 2018 Dry Run data must also be submitted by this date.
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).
After you have uploaded your files, you should receive an email confirmation within twenty-four hours with a batch number indicating that your batch has been processed. If you do not receive this email, please contact the QualityNet Help Desk at firstname.lastname@example.org, or by telephone at 866.288.8912.
Should you encounter any data submission issues, be sure to open a ticket with the QualityNet Help Desk at email@example.com, 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 (firstname.lastname@example.org).
Survey vendors, hospitals administering HCAHPS for multiple sites, and self-administering hospitals approved to administer the HCAHPS Survey are required to submit all survey materials that will be used for October 1, 2019 patient discharges and forward to the HCAHPS Project Team via HCAHPS Technical Assistance by April 5, 2019.
Materials for the 29-question HCAHPS Survey include:
Note: Be sure to send survey material samples for all of the language translations utilized by your organization
All approved organizations must also submit an HCAHPS Attestation Statement form that acknowledges annual updates to the Quality Assurance Plan (QAP) are complete, comprehensive, and accurate in reflecting updates made to the HCAHPS Quality Assurance Guidelines V14.0, as well as any changes in key personnel, resources and processes.
Please click here to view and print the HCAHPS Attestation Statement form. The executed form must be submitted to the HCAHPS Project Team via HCAHPS Technical Assistance by April 5, 2019.
The 2019 Introduction to HCAHPS Training slides are available on the Training Materials page.
The HCAHPS Participation Forms are now available. Forms to request consideration for approval to administer the HCAHPS Survey must be submitted by March 22, 2019. The Participation Forms can be found on the Participation Forms page. Prior to completing the Participation Form, organizations requesting consideration for approval to administer the HCAHPS Survey must have successfully completed participation in the 2019 Introduction to HCAHPS Self-training module, and must meet the current HCAHPS Minimum Survey Requirements to administer the survey. Organizations meeting the above requirements will be scheduled to attend a Participation Teleconference to discuss their qualifications. Please note that approval status granted to organizations qualified to administer the HCAHPS Survey will be effective October 1, 2019.
The 2019 Introduction to HCAHPS Training agenda and HCAHPS Update Training slides and agendas are available on the Training Materials page.
The HCAHPS Project Team is pleased to announce the release of the HCAHPS Quality Assurance Guidelines V14.0. This manual has been revised from V13.0 and includes additional updates and enhancements that provide a comprehensive resource for hospitals and survey vendors participating in the HCAHPS initiative. This updated version is now available online to view or download on the Quality Assurance page.
In addition, the HCAHPS Quality Assurance Guidelines V14.0 manual, on CD-ROM, is in the process of being distributed to each organization’s contact person registered for the upcoming Introduction to HCAHPS or HCAHPS Update Training sessions.
The February 2019 Hospital Compare Refresh includes HCAHPS scores from April 2017 through March 2018 data collections.
The following tables have been added to the HCAHPS Web site Summary Analyses page:
The following tables have been added to the HCAHPS Web site Star Ratings page:
The Patient-Mix Coefficients for the April 2019 HCAHPS results are now available. Please click here to access the Mode & Patient-Mix Adjustment page.
The Technical Notes for the April 2019 HCAHPS results are now available. The April 2019 HCAHPS Star Ratings are included in the hospital Preview Reports (available to hospitals from February 8, 2019 through March 9, 2019), and will be Publicly Reported on Hospital Compare in April 2019. Please click here to access the HCAHPS Star Ratings page.
To administer the HCAHPS Survey, organizations must meet all of the HCAHPS Minimum Business Requirements. A hospital self-administering the HCAHPS Survey must meet ALL of the Self-administering Hospital Minimum Survey Requirements, and an independent survey vendor or a hospital administering the HCAHPS Survey for multiple sites must meet ALL of the Survey Vendor Minimum Survey Requirements. In addition, subcontractors or other organization(s) performing major HCAHPS Survey Administration functions (e.g., mail/telephone/IVR operations, XML file preparation) must also meet ALL of the HCAHPS Minimum Survey Requirements which pertain to that role. For more information regarding the HCAHPS Minimum Business Requirements, please click here or on the left-hand Quality Assurance navigation button.
The 32-Question HCAHPS Mail Survey has been updated to include the OMB expiration date of November 30, 2021 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 cover letter or on the front or back of the questionnaire.
The updated 32-Question HCAHPS Mail Survey is available for use beginning with April 1, 2019 patient discharges and forward.
Please click here to view or download the updated surveys in all available translations.
Beginning with the October 2018 Public Report, CMS is presenting HCAHPS Survey Individual Question Top-Box Scores in the Summary Analyses section of HCAHPS On-Line. This table will contain the national average “top-box” score for each of the 15 individual survey questions that are used to form the six HCAHPS composite measures. These scores can be viewed here. CMS plans to update this table each time HCAHPS are refreshed on the Hospital Compare Web site.
Please note: Individual question scores are presented for informational purposes only; they are not official HCAHPS measures. The simple average of the individual questions that comprise a composite measure may not always match the published national average for that composite.
The Final Rule and related tables are available at the following URL: https://www.gpo.gov/fdsys/pkg/FR-2018-11-21/pdf/2018-24243.pdf
Combating the Opioid Crisis
In response to recommendations from the President’s Commission on Combating Drug Addiction and the Opioid Crisis, to comply with the requirements of the Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment (SUPPORT) for Patients and Communities Act (P.L. 115-271), and to avoid any potential unintended consequences, under the Hospital Inpatient Quality Reporting (IQR) Program, CMS is finalizing the proposal to update the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) patient experience of care survey measure by removing the three recently revised pain communication questions. The removal of these questions is effective with October 2019 discharges, for the FY 2021 payment determination and subsequent years, earlier than proposed. As a related modification, CMS will not publicly report the three revised Communication About Pain questions.
As previously announced, the Communication About Pain questions will be removed from the HCAHPS Survey beginning with patients discharged October 1, 2019. The Communication About Pain measure will not be Publicly Reported. However, Preview Reports for the October 2019, January 2020, April 2020 and July 2020 Public Reporting periods will contain the hospital’s score for the Communication About Pain measure, along with the state and national averages. Preview Reports for the October 2020 Public Reporting period and forward will not contain the Communication About Pain measure.
There are two important updates from CMS for approved HCAHPS Survey vendors and self-administering hospitals regarding the HCAHPS Survey and Quality Assurance Guidelines.
Communication About Pain Items
On July 31, 2018, in the CY 2019 OPPS Proposed Rule, CMS proposed a plan to remove the HCAHPS Survey's Communication About Pain items (questions 12, 13 and 14 on the HCAHPS Survey). The recently released CY 2019 OPPS Final Rule requires that the pain items must be removed from all surveys beginning with patients discharged on October 1, 2019 and forward. This change will affect all survey translations and all survey modes.
Effective Date of Next Version of the HCAHPS Quality Assurance Guidelines (QAG)
HCAHPS Quality Assurance Guidelines V14.0 will address the removal of the pain items and other changes to the survey. QAG V14.0 will be released prior to the 2019 HCAHPS Training sessions, to be held in early 2019, but will take effect October 1, 2019. QAG V14.0 will contain the revised HCAHPS Survey in all survey modes and all language translations and the updated XML File Layout. In addition, all translations and modes of the HCAHPS Survey instruments will be posted on the HCAHPS Web site (www.hcahpsonline.org) in early 2019.
Please note that the current survey and XML File Layout (XML File Layout Version 4.1) found in the HCAHPS QAG V13.0 will continue to be used for all patients discharged prior to October 1, 2019.
The HCAHPS Project Team will provide further information during the HCAHPS Training sessions to be held in early 2019.
CMS has adopted V.36 MS-DRG Codes effective October 1, 2018. Please click here for the Table of V.36 MS-DRG Codes and HCAHPS Service Line Categories.
The crosswalk for HCAHPS Service Line Categories and V.34 APR-DRG Codes is now available. Please click here, or click on the Technical Specifications navigation button, to access this resource.
The FY 2019 IPPS Final Rule, establishing the Hospital Inpatient Prospective Payment System (IPPS), is now available on the Federal Register.
The Final Rule and related tables are available at the following URL: https://federalregister.gov/d/2018-16766
The HCAHPS XML File Specifications Version 4.1 have been added to the HCAHPS Web site Technical Specifications page. The HCAHPS Technical File Specifications V4.1 are to be used starting with July 1, 2018 patient discharges.
Please click here to view the HCAHPS Score Calculations Part III on the HCAHPS Survey Podcast page.
Please click here to view the HCAHPS Score Calculations Part II on the HCAHPS Survey Podcast page.
Please click here to view the HCAHPS Score Calculations Part I on the HCAHPS Survey Podcast page.
Click here to view the HCAHPS Public Reporting Periods document. This document indicates which calendar quarters of HCAHPS results will be publicly reported on the Hospital Compare Web site through July 2020.
Please Note: The dates of future preview periods and public reporting are estimates based on current timetables and are subject to change.
The HCAHPS Patient-Mix Adjustment (PMA) model will be updated to add Question 28, patient’s self-reported overall mental or emotional health, beginning with July 1, 2018 (Quarter 3, 2018) discharges. The new PMA variable will be called Self-Rated Mental Health. In addition, the label for overall health will be changed to “Self-Rated Overall Health.”
Self-Rated Mental Health will follow the same linear parameterization as Self-Rated Overall Health: patient responses are coded as 1 (“Excellent”) through 5 (“Poor”). The patient-mix adjustment model will thus include both Self-Rated Overall Health and Self-Rated Mental Health.
On May 23, 2018, the Hospital Compare Web site posted the following announcement regarding the HCAHPS Pain Management composite scores:
May 23, 2018 update: The Centers for Medicare & Medicaid Services (CMS) has suppressed the HCAHPS Pain Management composite scores on Hospital Compare and in the downloadable databases. In July, CMS is planning to remove the Pain Management composite from Hospital Compare and downloadable databases, and exclude it from the calculation of the HCAHPS Summary Star Rating and the Hospital Compare Overall Hospital Quality Star Rating.
As a result, HCAHPS Online is making the corresponding updates to all documents pertaining to the April 2018 public report period that are posted on this web site.
The survey questions comprising Pain Management Composite 4 were removed from the HCAHPS Survey in the FY 2018 IPPS/LTCH PPS Final Rule (81 FR 38342). Composite 4 is no longer needed and will no longer be reported on Hospital Compare. July 2018 Preview Reports and public reporting will display “N/A” and Footnote 5 for the Pain Management measure and will display “N/A” and Footnote 15 for the Pain Management star rating. In addition, Pain Management is no longer included in the calculation of the HCAHPS Summary Star Rating or the Hospital Compare Overall Hospital Quality Star Rating.
For recent Extraordinary Circumstances Extensions (ECE) the key HCAHPS content is displayed below. Please review the entire notification for additional details.
To review the entire Quality Reporting Notifications for California Wildfires, Hurricane Michael, Hurricane Florence, Hurricane Nate, Hurricane Irma, and Hurricane Harvey please click below:
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.
The HCAHPS Project Team is alerting approved HCAHPS Survey vendors and self-administering hospitals of upcoming regular QualityNet maintenance weekends. During this time organizations will not be able to upload HCAHPS data to the HCAHPS Data Warehouse. This alert is provided so that survey vendors and self-administering hospitals can plan data submission as needed.
Please see the Technical Specifications page for a schedule of upcoming regular QualityNet maintenance weekends.
The CY 2017 OPPS Final Rule has been published and is now available on the Federal Register.
The Final Rule is available at the following URL: https://federalregister.gov/d/2016-26515
CMS is finalizing the removal of the Pain Management dimension from the scoring formula used in the Hospital Value-Based Purchasing Program (Hospital VBP), beginning with the FY 2018 payment adjustments. The Pain Management dimension is derived from Questions 12, 13 and 14 on the HCAHPS Survey.
Please note that the Pain Management questions will remain on the HCAHPS Survey and the Pain Management measure will continue to be publicly reported on Hospital Compare.
Please monitor the HCAHPS Web site for future announcements about the Pain Management measure.
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This page was last modified on (3/11/19)