Quick links: Extraordinary Circumstances Extension/Exception (ECE) Tropical Storm Barry | FOLLOW-UP: October 2, 2019 HCAHPS Data Submission Deadline | Next Steps in Reviewing and Revising the HCAHPS Survey | V.37 MS-DRG Codes | IPPS and OPPS Rules | Hospital Compare Has Been Refreshed | Summary Analyses Page Tables Have Been Updated | Star Ratings Distributions Have Been Updated | HCAHPS Survey Individual Question Top-Box Table Has Been Updated | NEW! HCAHPS Podcast Now Available - Recommended HCAHPS Data Quality Checks | NEW! HCAHPS Podcast Now Available - Advanced HCAHPS Data Quality Checks | Patient-Mix Adjustments and National Means for October 2019 HCAHPS Results Have Been Posted | Star Ratings: October 2019 Technical Notes Have Been Posted | NEW! HCAHPS Podcast Now Available - Updated Patient-Mix Adjustment: Self-Rated Mental Health | NEW! HCAHPS Podcast Now Available - HCAHPS Linear Mean Scores and Star Ratings Calculations | CMS to Review HCAHPS Content with Patients and Feasibility of Mixed Mode that Includes a Web Survey | HCAHPS 29-Question Survey Instruments Have Been Updated to Include the OMB Expiration Date | HCAHPS Quality Assurance Guidelines V14.0 Technical Corrections and Clarifications Document Available | HCAHPS Quality Assurance Guidelines V14.0 Change Matrix: Updates and Emphasis Has Been Posted | HCAHPS Quality Assurance Guidelines V14.0 Now Available | Updated 32-Question HCAHPS Mail Survey with OMB Expiration Date Now Available | Communication About Pain Measure Will Not Be Publicly Reported but Included in Preview Reports | Important Changes to the HCAHPS Survey in 2019 | HCAHPS XML File Specifications V4.1 Have Been Posted | 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
To review entire Quality Reporting Notification, please click here.
Key HCAHPS content is displayed below. Please review the entire notification 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 Tropical Storm/Hurricane Barry 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 Louisiana parishes listed below, all of which have been designated by the Federal Emergency Management Agency (FEMA) as an emergency disaster parish.
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 parishes designated by FEMA under the Tropical Storm Barry Emergency Declaration (EM-3416) and Hurricane Barry Major Disaster Declaration (DR-4458) for Louisiana, as of the date of this communication, are as follows:
• East Baton Rouge
• East Feliciana
• Iberia I
• Jefferson Davis
• Pointe Coupee
• St. Bernard
• St. Charles
• St. Helena
• St. James
• St. John the Baptist
• St. Landry
• St. Martin
• St. Mary
• St. Tammany
• West Baton Rouge
• West Feliciana
The healthcare providers located outside of the parishes 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 emergency disaster declaration for Tropical Storm/Hurricane Barry to include additional parishes, CMS will update this communication to reflect the expanded list of applicable parishes 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 parishes 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:
January 2020 HCAHPS submission deadlines for discharge periods:
July 1, 2019 – September 30, 2019 (3rd Quarter 2019)
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 firstname.lastname@example.org or call toll-free at (844) 472-4477.
October 2, 2019 is the data submission deadline for patients discharged in April, May, June (2Q19). June 2019 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 email@example.com, 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 firstname.lastname@example.org, 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 (email@example.com).
CMS believes that ongoing review and evaluation are vital for HCAHPS to continue to fulfill its mission of providing a national standard for collecting and publicly reporting information about patient experience of care that permits valid comparisons of hospitals.
As noted earlier, CMS is awaiting final approval from the Federal Office of Management and Budget to test an electronic (e-mail) mode for some of our experience-of-care surveys, including HCAHPS.
In addition, beginning in Fall 2019, CMS will initiate a multi-faceted review of survey content and design. The first step will be talking to recent hospital patients about their experience of care and their assessment of current, revised and potential survey items. Following this, CMS will gather input from stakeholders more broadly on potential changes to HCAHPS.
Please continue to monitor the HCAHPS Web site for updates on this topic.
CMS has adopted V.37 MS-DRG Codes effective October 1, 2019. Please click here for the Table of V.37 MS-DRG Codes and HCAHPS Service Line Categories.
FY 2020 IPPS Final Rule Has Been Published (08/16/2019)
The FY 2020 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:
Previous IPPS Final Rules:
CY 2019 OPPS Final Rule Now Published (11/21/2018)
The CY 2019 OPPS Final Rule is now published.
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.
Previous OPPS Final Rules:
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.
The July 2019 Hospital Compare Refresh includes HCAHPS scores from October 2017 through September 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 HCAHPS Survey Individual Question Top-Box Scores table has been added to the Summary Analyses page:
Please click here to view the Recommended HCAHPS Data Quality Checks podcast on the Podcast page.
Please click here to view the Advanced HCAHPS Data Quality Checks podcast on the Podcast page.
The Patient-Mix Adjustments and National Means for the October 2019 HCAHPS results are now available. Please click here to access the Mode & Patient-Mix Adjustment page.
The Technical Notes for the October 2019 HCAHPS results are now available. The October 2019 HCAHPS Star Ratings are included in the hospital Preview Reports (available to hospitals from July 16, 2019 through August 14, 2019, and will be Publicly Reported on Hospital Compare in October 2019. Please click here to access the HCAHPS Star Ratings page.
Please click here to view the Updated Patient-Mix Adjustment: Self-Rated Mental Health podcast on the Podcast page.
Please click here to view the HCAHPS Linear Mean Scores and Star Ratings Calculations podcast on the Podcast page.
CMS has begun to take steps to obtain feedback directly from patients about topics that are most important to them in the current HCAHPS Survey, as well as additional topics that might be added in the future. This is part of a broader effort that CMS is undertaking to evaluate the items currently included in HCAHPS. CMS also plans to investigate the feasibility of a new Mixed Mode that would include a Web survey. Pending approval from the Office of Management and Budget, CMS will test a web mode of administration for several patient experience surveys, including HCAHPS. Please continue to monitor the HCAHPS Web site for important updates on these topics.
OMB approval has been received for the 29-question HCAHPS Survey instruments. The OMB expiration date of November 30, 2021 must be used on all HCAHPS mail survey materials for patients discharged October 1, 2019 and forward. The OMB expiration date must appear in the OMB Paperwork Reduction Act language and on the front page of the questionnaire. The HCAHPS Survey instruments have been updated to include the OMB expiration date (Appendices A-G). Previous revisions were made to add the mandatory transition statement (Appendices A-M) and to revise the verbiage in question 29 (Appendices H-M). Please click here to access the Survey Instruments page.
Information on technical corrections to the HCAHPS Quality Assurance Guidelines V14.0 has been posted. Please click here to access the Quality Assurance page.
The HCAHPS Quality Assurance Guidelines V14.0 Change Matrix: Updates and Emphasis is a reference tool that highlights the major changes from the HCAHPS Quality Assurance Guidelines V13.0 to V14.0. The reference tool is available on the Quality Assurance 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 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.
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.
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.
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.
This page was last modified on (9/13/19)