Quick links: Important Changes to the HCAHPS Survey in 2019 | HCAHPS 2019 Training Sessions | CY 2019 OPPS Final Rule Now on Display | Hospital Compare Has Been Refreshed | Summary Analyses Page Tables Have Been Updated | The Star Ratings Distributions Have Been Updated | Updated - January 2019 Public Report Review Period Begins November 17, 2018 | Patient-Mix Coefficients for January 2019 HCAHPS Results Have Been Posted | Star Ratings: January 2019 Technical Notes Have Been Posted | Updated Extraordinary Circumstances Extension/Exception (ECE) due to Hurricane Florence | 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) | 2018 QualityNet Maintenance and Downtime Schedule | HCAHPS Patient-Mix Adjustment for Service Line and Gender | Mode Adjustment Table Has Been Posted | CMS Finalizing Removal of the Pain Management Dimension from Hospital Value-Based Purchasing in FY 2018
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.
The 2019 HCAHPS Training sessions will be scheduled the week beginning February 25, 2019 (PLEASE MARK THIS DATE ON YOUR CALENDAR). Please note, Introduction to HCAHPS Training will be conducted via a self-training module and HCAHPS Update Training will be conducted via webinar. More information regarding the training schedule and training materials will be posted on the HCAHPS Web site prior to the HCAHPS Training sessions.
The CY 2019 OPPS Final Rule is on display. The final rule is scheduled to be published on November 21, 2018.
A PDF version is available at the following URL: https://s3.amazonaws.com/public-inspection.federalregister.gov/2018-24243.pdf
Combating the Opioid Crisis
In response to recommendations from the President’s Commission on Combatting 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.
The October 2018 Hospital Compare Refresh includes HCAHPS scores from January 2017 through December 2017 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 January 2019 Public Report Preview Reports will be available on the QualityNet Secure Portal to participating providers and Quality Improvement Organizations (QIOs). The Preview Reports will be available from November 17, 2018 through December 16, 2018. (To access the report, you must be registered as a QualityNet Secure Portal user and have been assigned the QIO Clinical Data Warehouse Feedback Report role). The data that appear in the Preview Reports will be reported on Hospital Compare, the Centers for Medicare & Medicaid Services Web site for Medicare beneficiaries and the general public, in January 2019.
The Patient-Mix Coefficients for the January 2019 HCAHPS results are now available. Please click here to access the Mode & Patient-Mix Adjustment page.
The Technical Notes for the January 2019 HCAHPS results are now available. The January 2019 HCAHPS Star Ratings are included in the hospital Preview Reports (available to hospitals from October 19, 2018 through November 27, 2018), and will be Publicly Reported on Hospital Compare in January 2019. Please click here to access the HCAHPS Star Ratings page.
Key HCAHPS content is displayed below. Please review the entire notifications for additional detail.
The Centers for Medicare & Medicaid Services (CMS) is granting exceptions under certain Medicare quality reporting and value-based purchasing programs to hospitals, skilled nursing facilities, home health agencies, hospices, inpatient rehabilitation facilities, renal dialysis facilities, long-term care hospitals, and ambulatory surgical centers, as well as Merit-Based Incentive Payment System (MIPS) eligible clinicians, located in areas affected by Hurricane Florence due to the devastating impact of the storm. These healthcare providers and suppliers will be granted exceptions if they are located in one of the North Carolina or South Carolina counties listed below, all of which have been designated by the Federal Emergency Management Agency (FEMA) as a major disaster county.
The scope and duration of the exception under each Medicare quality reporting program and value-based purchasing program is described below. CMS is granting exceptions to assist these providers while they direct their resources toward caring for their patients and repairing structural damages to facilities.
CMS is closely monitoring the situation for future potential widespread catastrophic events, and will update exception lists soon after any events occur in the future.
The affected counties designated by FEMA under the North Carolina Hurricane Florence (DR-4393), the South Carolina Hurricane Florence (DR-4394), and the Virginia Hurricane Florence (DR-4401) Major Disaster Declarations, as of the date of this communication, are as follows:
North Carolina Counties
South Carolina Counties
The healthcare providers located outside of the counties listed above are not covered by this communication, but may request an exception to the reporting requirements under one or more Medicare quality reporting or value-based purchasing programs it participates in using the applicable extraordinary circumstances exception procedure for the respective program(s). CMS will assess and decide upon each extraordinary circumstances exception request on a case-by-case basis.
If FEMA expands the current disaster declaration for Hurricane Florence to include additional counties, CMS will update this communication to reflect the expanded list of applicable counties for which healthcare providers would be eligible to receive an exception without submitting a request. In addition, CMS will continue to monitor the situation and adjust exempted reporting periods and submission deadlines accordingly.
CMS is granting an exception to subsection (d) hospitals located in designated counties for the following reporting requirements under the Hospital Inpatient Quality Reporting (IQR) Program.
For the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) Survey:
October 2018 and January 2019 HCAHPS submission deadlines for discharge periods:
April 1, 2018 – June 30, 2018 (2nd Quarter 2018)
July 1, 2018 – September 30, 2018 (3rd Quarter 2018)
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 email@example.com or call toll-free at (844) 472-4477.
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.
HCAHPS Podcast Now Available – HCAHPS Score Calculations Part I: From Patient Discharges to Completed Surveys (07/24/2018)
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 Hurricane Nate, Hurricane Irma, Hurricane Harvey, and the California Wildfires, 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 HCAHPS Patient-Mix Adjustment (PMA) model has been updated to incorporate more detailed information about patient Service Line and Gender.
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 (11/5/18)