Extraordinary Circumstances Extension/Exception (ECE) due to Mississippi Severe Storms, Straight-Line Winds, and Tornadoes (05/18/2023)
To review the 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 providers and facilities located in areas affected by the Mississippi Severe Storms, Straight-Line Winds, and Tornadoes disaster, as identified by both a Health and Human Services (HHS) Public Health Emergency (PHE) declaration (https://aspr.hhs.gov/legal/PHE/Pages/ms-severe-storms-mar2023.aspx) and a Federal Emergency Management Agency (FEMA) disaster declaration (DR-4697-MS), to assist these providers and facilities while they direct their resources toward caring for their patients and addressing potential infrastructural challenges affecting their healthcare operations.
Affected areas covered by these exceptions are detailed on the Designated Areas: Disaster 4697 page, under section Public Assistance, designations PA-A and PA-B, of the FEMA website. If either the PHE declaration is extended or FEMA expands the emergency disaster declaration to include additional affected areas at a later date, CMS will likewise extend reporting requirement exceptions to accommodate these longer timeframes or areas but will not necessarily publish updated communications.
Providers and facilities should be aware of the potential impact to reporting requirements and payment programs when deciding whether or not to report data included in the exceptions. If data are voluntarily submitted, they will be publicly reported or used in scoring.
Please refer to the ECE request process and form specific to the program for additional information.
CMS is granting an exception for the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) Survey for the following quarters:
- October 1, 2022 - December 31, 2022 (4th Quarter 2022)
- Submission Deadline - 04/05/23
National Rural Health Resource Center’s “Study of HCAHPS Best Practices in High Performing CAHs” Now Available (05/08/2023)
These documents share improvement strategies and effective best practices for each component of the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) collected from high-performing critical access hospitals (CAH) across the US during focus group interviews conducted in late 2016. An update based on input collected during an HCAHPS Best Practice Summit convened in August 2022 includes strategies that high-performing CAHs employed to maintain the best possible health care experience for patients despite the coronavirus pandemic.
Please click here to access the Improving the Patient Experience page to view the study and associated documents.
Registration Available for FY 2024 IPPS/LTCH Proposed Rule Overview for Hospital Quality Programs Presentation (05/05/2023)
The event provides an overview of the Fiscal Year 2024 Inpatient Prospective System (IPPS)/Long-Term Care Hospital Prospective Payment System (LTCHPPS) Proposed Rule as it relates to the Hospital Inpatient Reporting (IQR) Program, Hospital Value-Based Purchasing (VBP) Program, Hospital-Acquired Condition (HAC) Reduction Program, Hospital Readmission Reduction (HRRP), and the Medicare Promoting Interoperability Program.
Participants in this presentation will be able to identify proposed program changes and understand the time period and methods to submit public comments to CMS.
The presentation is scheduled for Thursday, May 11, 2023 from 2:00 p.m. – 3:30 p.m. Eastern Time.
Interested participants may click here to register.
The July 2023 Public Report Preview Period Begins May 3, 2023 (05/03/2023)
The July 2023 Public Report Preview Reports are now available on the Hospital Quality Reporting (HQR) System (https://hqr.cms.gov/), formerly the QualityNet Secure Portal, to participating providers and Quality Improvement Organizations (QIOs). The Preview Reports will be available from May 3, 2023 through June 1, 2023. (To access the report, you must be registered as a HQR system 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 Care Compare for Medicare & Medicaid Services Web site for Medicare beneficiaries and the general public in July 2023.
Patient-Mix Adjustments and National Means for July 2023 HCAHPS Results Have Been Posted (05/03/2023)
The Patient-Mix Adjustments and National Means for the July 2023 HCAHPS results are now available. Please click here to access the Mode & Patient-Mix Adjustment page.
Star Ratings: July 2023 Technical Notes Have Been Posted (05/03/2023)
The Technical Notes for the July 2023 HCAHPS results are now available. The July 2023 HCAHPS Star Ratings are included in the hospital Preview Reports (available to hospitals from May 3, 2023 through June 1, 2023), and will be Publicly Reported on Care Compare in July 2023. Please click here to access the HCAHPS Star Ratings page.
FY 2024 IPPS Proposed Rule Has Been Published (05/02/2023)
The FY 2024 IPPS Proposed Rule, establishing the Hospital Inpatient Prospective Payment System (IPPS), is now available on the Federal Register.
The Proposed Rule and related tables are available at the following URL: 2023-07389.pdf (govinfo.gov)
Care Compare Has Been Refreshed (04/26/2023)
The April 2023 Care Compare Refresh includes HCAHPS scores from July 2021 through June 2022 data collections.
Summary Analyses Page Tables Have Been Updated (4/26/2023)
The following tables have been added to the HCAHPS Web Site Summary Analyses page:
- April 2023 Summary of HCAHPS Survey Results Table
- April 2023 HCAHPS Percentiles Table
- April 2023 HCAHPS Survey Individual Question Top-Box Scores
- April 2023 HCAHPS Patient-Level Correlations Table
- April 2023 HCAHPS Hospital Characteristics Comparison Charts
The Star Ratings Distributions Have Been Updated (04/26/2023)
The following tables have been added to the HCAHPS Web site Star Ratings page:
- April 2023 HCAHPS Star Rating Distributions
- April 2023 HCAHPS Summary Star Distributions by US State
HCAHPS Survey Individual Question Top-Box Scores Table Has Been Updated (04/26/2023)
The HCAHPS Survey Individual Question Top-Box Scores table has been added to the Summary Analyses page:
- April 2023 Public Report: July 2021 – June 2022 discharges
End of COVID-19 Public Health Emergency – Exception Request for Survey Operations from Remote Location (03/27/2023)
On January 30, 2023, the Biden-Harris Administration announced its intent to end the national emergency and public health emergency (PHE) declarations related to the COVID-19 pandemic on May 11, 2023.
As a result, all previously approved Exception Requests (ERs) to conduct remote HCAHPS Survey administration activities for the duration of the PHE will end on May 11, 2023.
If your organization intends to request approval to conduct HCAHPS Survey operations from a remote location (other than your place of business), please complete and submit a new Exception Request Form online via the HCAHPS Web site (www.hcahpsonline.org) no later than April 11, 2023.
Please contact HCAHPS Technical Assistance at hcahps@hsag.com should you have questions regarding this information.
URGENT: HCAHPS Survey Materials and Attestation Statement Submission (3/24/2023)
Survey vendors, hospitals administering HCAHPS for multiple sites, and self-administering hospitals currently approved to administer the HCAHPS Survey are required to submit all survey materials that will be used for July 1, 2023 patient discharges.
Survey Materials for the HCAHPS Survey include:
• HCAHPS Mail Survey Packet (questionnaires, cover letters, outgoing and return envelopes)
• Telephone Interviewer Screen Shots and/or Scripts
• IVR Screen Shots and/or Scripts
Note: Be sure to send survey material samples for all of the language translations utilized by your organization
HCAHPS Quality Assurance Guidelines V18.0 Change Matrix: Updates and Emphasis Has Been Posted (02/22/2023)
The HCAHPS Quality Assurance Guidelines V18.0 Change Matrix: Updates and Emphasis is a reference tool that highlights the major changes from the HCAHPS Quality Assurance Guidelines V17.0 to V18.0. The reference tool is available on the Quality Assurance page.
HCAHPS Quality Assurance Guidelines V18.0 Survey Materials Now Posted (02/22/2023)
The HCAHPS mail, telephone and IVR survey materials are now available. Please click here to access the Survey Instruments page.
CMS to Update HCAHPS Survey Mode Adjustments in January 2023 (12/20/22)
In 2021, CMS conducted a large-scale experiment that will serve a number of purposes. The experiment produced updated adjustments for current HCAHPS measures in the Mail Only, Telephone Only, and Mixed modes of the HCAHPS Survey, which will be applied beginning with patients discharged in January 2023.
To view HCAHPS survey mode adjustments for both the pre- and post-2023 periods, please click here to access the Mode and Patient-Mix Adjustment page.
HCAHPS Public Reporting Periods for April 2022 Through October 2024 Have Been Updated (12/01/2022)
Click here to view the HCAHPS Public Reporting Periods document. This document indicates which calendar quarters HCAHPS results will be publicly reported on Care Compare on Medicare.gov (https://www.medicare.gov/care-compare) through October 2024.
Please Note: The dates of future preview periods and public reporting are estimates based on current timetables and are thus subject to change.
Extraordinary Circumstances Extension/Exception (ECE) due to Hurricane Ian (10/25/2022)
To review the 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 located in areas affected by the Florida Hurricane Ian disaster to assist these providers while they direct their resources toward caring for patients and repairing structural damages to facilities.
Affected counties designated by the Federal Emergency Management Agency (FEMA) under the Florida Hurricane Ian (DR-4673) disaster declaration are located at Designated Areas: Disaster 4673 under sections Public Assistance PA-A and PA-B of the FEMA website.
If FEMA expands the current emergency disaster declarations to include additional counties, sections PA-A and PA-B will be updated to reflect the newly designated counties.
Providers located outside the counties listed in the FEMA disaster declaration are not covered by this communication, but they may request an exception to the reporting requirements under one or more Medicare quality reporting or value-based purchasing programs they participate in using the applicable ECE procedure for the respective program(s). In addition, providers located within a county listed in the FEMA disaster declaration who seek an exception for a reporting requirement not covered by this communication may request an individual exception using the applicable ECE procedure for the respective program(s). CMS will assess and decide upon each extraordinary circumstances exception request on a case-by-case basis.
Hospitals should be aware of the potential impact to reporting requirements and payment programs when deciding whether or not to report data included in the exceptions. If data are submitted, it may be publicly reported or used in scoring.
Please refer to the ECE request process and form specific to the program for additional information.
CMS is granting an exception for the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) Survey for the following quarters:
§ April 1, 2022 – June 30, 2022 (2nd Quarter 2022)
o Submission Deadline – 10/5/22
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.
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.
CMS Clarifies Policy Regarding Requirement of 300 Completed HCAHPS Surveys in Periods Affected by the COVID-19 ECE (10/05/2020)
The 300 completed HCAHPS Surveys standard applies to every 4-quarter roll-up period in which HCAHPS data collection and submission were required in all four quarters. However, the 300 competes standard does NOT apply to any 4-quarter roll-up period in which HCAHPS data collection was not required for one or more quarter. Due to the COVID-19 ECE for Q1 and Q2 2020, the 300 completes standard does NOT apply to the following 4-quarter roll-up periods:
- Q2 2019/Q3 2019/Q4 2019/Q1 2020
- Q3 2019/Q4 2019/Q1 2020/Q2 2020
- Q4 2019/Q1 2020/Q2 2020/Q3 2020
- Q1 2020/Q2 2020/Q3 2020/Q4 2020
- Q2 2020/Q3 2020/Q4 2020/Q1 2021
Please refer to the CMS Exceptions and Extension for Quality Reporting Requirements memorandum dated March 27, 2020, for Q1 and Q2 2020 information.
NEW! 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)
Important Information for HCAHPS Survey Vendors and Self-administering Hospitals: Impact of COVID-19 on HCAHPS Survey Operations (03/23/2020)
In light of the 2019 Novel Coronavirus (COVID-19) outbreak, CMS is providing new guidance. Please see the attached documents, which can be accessed by clicking here and here.
Please contact HCAHPS Technical Assistance at hcahps@hsag.com should you have questions regarding this information.
The National Quality Forum (NQF) Has Renewed its Endorsement of the HCAHPS Survey (11/21/2019)
On October 25, 2019, the National Quality Forum (NQF) announced its re-endorsement of the HCAHPS Survey. The NQF is a voluntary consensus and standard-setting organization established to standardize healthcare quality measurement and reporting. The NQF originally reviewed and endorsed the HCAHPS Survey in May 2005 and since then has reviewed and re-endorsed HCAHPS in 2010, 2015, and 2019.
For more information about NQF endorsement renewal, please click here.
CMS to Review HCAHPS Content with Patients and Feasibility of Mixed Mode that Includes a Web Survey (06/21/2019)
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.
HCAHPS Pain Management Composite Measure Information
- 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.
Extraordinary Circumstances Extension (ECE) (04/26/2022)
For recent Extraordinary Circumstances Extensions (ECE) the key HCAHPS content is displayed below. To review the entire Quality Reporting Notifications please click below:
- 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.
This page was last modified on (05/18/23)