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FOLLOW-UP: July 3, 2024 HCAHPS Data Submission Deadline (06/12/2024)

July 3, 2024 is the data submission deadline for patients discharged in January, February, and March (1Q24). March 2024 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).

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).


URGENT: Quality Assurance Plan (QAP) Submission (06/06/2024)

Survey vendors and self-administering hospitals approved to administer the HCAHPS Survey are obligated to develop and continually maintain a QAP for survey administration in accordance with the HCAHPS Quality Assurance Guidelines. Survey vendors and hospitals must update the QAP on an annual basis and at the time of process and/or key personnel changes as part of retaining approval status.

Survey vendors that were recently approved for Web-First mode(s) for the Updated HCAHPS Survey were originally asked to submit their Quality Assurance Plans (QAPs) by June 3, 2024. This submission date has been changed to June 14, 2024. QAPs must be developed and/or updated to reflect HCAHPS protocols, as outlined in the HCAHPS Quality Assurance Guidelines V19.0 and 2024 HCAHPS Training. Updates must include any additional approved mode(s) of survey administration and all other changes that will be implemented for January 1, 2025 patient discharges. HCAHPS QAPs may be submitted to the HCAHPS Project Team either via HCAHPS Technical Assistance (hcahps@hsag.com) or via the HCAHPS Secure Access File Exchange (SAFE) application.

Survey vendors and self-administering hospitals not adding a new mode must also update their QAP but do not need to submit it until requested directly by the HCAHPS Project Team.

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Updated HCAHPS Survey Materials and Attestation Statement Submission (05/17/2024)

Survey Material Submission
Survey vendors and self-administering hospitals currently approved to administer the HCAHPS Survey are required to submit all survey materials that will be used for the Updated HCAHPS Survey beginning with January 1, 2025 patient discharges.

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)

Submit the Updated HCAHPS Survey materials in English to the HCAHPS Project Team by June 28, 2024.

UPDATE: The submission due date for the Updated HCAHPS Survey materials in Spanish to the HCAHPS Project Team has been extended from June 28 to July 12, 2024. 

  • Note that all survey vendors and self-administering hospitals are required to submit Spanish language survey materials as administration of the Spanish survey is required for Spanish language-preferring patients.

Attestation Statement Submission
In addition, survey vendors and self-administering hospitals currently approved to administer the HCAHPS Survey are required to complete and submit an annual statement that attests to conformance with HCAHPS protocols and verifies that annual updates have been made to the organization’s HCAHPS Quality Assurance Plan (QAP). Please click here or on the Attestation Statement navigation button to access a copy of the HCAHPS Attestation Statement document.

Submit the executed Attestation Statement form to the HCAHPS Project Team by June 28, 2024.

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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2024 HCAHPS Training Agenda and Slides Have Been Posted (05/10/2024)

The 2024 HCAHPS Training slides and agendas are available on the Training Materials  page.

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HCAHPS DRAFT Quality Assurance Guidelines V19.0 (HCAHPS DRAFT QAG V19.0) Now Available Online (05/10/2024)

The HCAHPS Project Team is pleased to announce the release of the HCAHPS DRAFT Quality Assurance Guidelines V19.0. This manual has been revised from HCAHPS Quality Assurance Guidelines V18.0 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. Please use the HCAHPS DRAFT QAG V19.0 for January 1, 2025 patient discharges and forward.

 

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HCAHPS DRAFT Quality Assurance Guidelines V19.0 (HCAHPS DRAFT QAG V19.0) Survey Materials Now Posted (05/10/2024)

The HCAHPS DRAFT Quality Assurance Guidelines V19.0 mail, phone and web survey materials are now available. The HCAHPS DRAFT QAG V19.0 survey instruments are effective for January 1, 2025 discharges and forward (survey content subject to pending rulemaking August 2024). Please click here to access the Survey Instruments page.

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CMS to Update HCAHPS Survey Mode Adjustments Beginning with Patients Discharged in January 2025* (05/08/2024)

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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The July 2024 Public Report Preview Period Begins May 6, 2024 (05/06/2024)

The July 2024 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 6, 2024 through June 4, 2024. (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 2024.

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Patient-Mix Adjustments and National Means for July 2024 HCAHPS Results Have Been Posted (05/06/2024)

The Patient-Mix Adjustments and National Means for the July 2024 HCAHPS results are now available. Please click here to access the Mode & Patient-Mix Adjustment page.

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Star Ratings: July 2024 Technical Notes Have Been Posted (05/06/2024)

The Technical Notes for the July 2024 HCAHPS results are now available. The July 2024 HCAHPS Star Ratings are included in the hospital Preview Reports (available to hospitals from May 6, 2024 through June 4, 2024), and will be Publicly Reported on Care Compare in July 2024. Please click here to access the HCAHPS Star Ratings page.

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FY 2025 IPPS Proposed Rule Has Been Published (05/02/2024)

The FY 2025 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:

https://www.govinfo.gov/content/pkg/FR-2024-05-02/pdf/2024-07567.pdf 

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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.

 

You may notice a number on the survey. This number is used to let us know if you returned your survey so we don't have to send you reminders. Please note: Questions 1-29 in this survey are part of a national initiative to measure the quality of care in hospitals. OMB #0938-0981 (Expires January 31, 2025)

 

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2025131)

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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Care Compare Has Been Refreshed (04/24/2024)

The April 2024 Care Compare Refresh includes HCAHPS scores from July 2022 through June 2023 data collections.

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Summary Analyses Page Tables Have Been Updated (04/24/2024)

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

  • April 2024 Summary of HCAHPS Survey Results Table
  • April 2024 HCAHPS Percentiles Table
  • April 2024 HCAHPS Survey Individual Question Top-Box Scores
  • April 2024 HCAHPS Patient-Level Correlations Table
  • April 2024 HCAHPS Hospitals Characteristics Comparison Charts

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The Star Ratings Distributions Have Been Updated (04/24/2024)

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

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

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HCAHPS Survey Individual Question Top-Box Scores Table Has Been Updated (04/24/2024)

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

  • April 2024 Public Report: July 2022 – June 2023 discharges

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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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Important Changes to the HCAHPS Survey Coming in 2025 (10/27/23)

A new version of the HCAHPS Survey will be implemented beginning with January 1, 2025 patient discharges, pending rulemaking. This survey will be known as HCAHPS 2.0. The current HCAHPS Survey will remain in use for patients discharged through December 31, 2024 and will be referred to as legacy HCAHPS or HCAHPS 1.0. The HCAHPS 2.0 Survey will entail changes to survey administration and, pending future rulemaking, changes to survey content.

The FY 2024 IPPS Rule finalized a number of changes to the administration of the HCAHPS Survey beginning with patients discharged January 1, 2025. Among these changes is the addition of three new Web-First modes and a longer data collection period. More information about these changes can be found in the FY 2024 IPPS Rule at 2023-16252.pdf (govinfo.gov). A summary of these changes can be found here.

In future rulemaking CMS will propose changes to HCAHPS Survey content that will also begin with patients discharged in January 2025 if finalized through rulemaking. More information about the new survey content will be announced at a later date.

In preparation for the launch of HCAHPS 2.0 there will be updates to HCAHPS participation, training, and minimum business requirements in 2024. These include changes to the timeline for approval to administer the HCAHPS 2.0 Survey, the schedule for 2024 HCAHPS Training, and updated Minimum Business Requirements.

HCAHPS 2.0 Participation

There is a new Participation process for HCAHPS 2.0.

Survey Vendors

Currently Approved HCAHPS Survey Vendors:

·    Currently approved HCAHPS Survey vendors that seek to administer a new mode of survey administration, including the new Web-First modes, must go through the Participation process.

·    Currently approved HCAHPS Survey vendors that are not adding a new survey mode will not have to submit a Participation Form or go through the Participation process.

Organizations that are not currently approved HCAHPS Survey vendors:

·    Organizations that are not currently approved HCAHPS Survey vendors that are interested in applying to become approved for the HCAHPS 2.0 Survey must go through the Participation process.

Self-administering Hospitals

Currently Approved HCAHPS Self-administering Hospitals:

·    Currently approved HCAHPS self-administering hospitals that seek to administer a new mode of survey administration, including the new Web-First modes, must go through the Participation process.

·    Currently approved HCAHPS self-administering hospitals that are not adding a new survey mode will not have to submit a Participation Form or go through the Participation process.

Hospitals that are not currently approved to self-administer the HCAHPS Survey:

·    Hospitals that are not currently approved to self-administer the HCAHPS Survey that are interested in applying to become approved for the HCAHPS 2.0 Survey must go through the Participation process.

Note: For both survey vendors and self-administering hospitals that are required to submit an HCAHPS Participation Form to administer the HCAHPS 2.0 Survey, the HCAHPS Participation Form must be submitted for CMS review prior to training.

·    Organizations that receive conditional approval to administer HCAHPS 2.0 will then be required to attend HCAHPS Training in 2024.

·    The Participation period for HCAHPS 2.0 will open in early January 2024. Please monitor the HCAHPS Website for specific dates.

Organizations that submit a Participation Form in January 2024 and are subsequently conditionally approved may begin to administer the HCAHPS 2.0 Survey beginning with January 1, 2025 patient discharges.

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

HCAHPS 2.0 Training

HCAHPS 2.0 Training will be conducted the week of May 6, 2024. Participation in the 2024 HCAHPS Training is mandatory for all organizations (both currently and newly approved) to administer HCAHPS 2.0. This includes:

·    Currently approved survey vendors and self-administering hospitals that are not adding a new mode

·    Currently approved survey vendors and self-administering hospitals that are adding a new mode

·    Newly approved survey vendors and self-administering hospitals

·    Subcontractor(s)/partner(s) or other organization(s) performing major HCAHPS Survey administration functions (e.g., mail/phone/web operations, XML file preparation)

o   Note: Survey vendors (and self-administering hospitals, if applicable) must ensure that their subcontractor(s)/partner(s) participate in the 2024 HCAHPS Training.

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V.41 MS-DRG Codes Effective October 1, 2023 (10/06/2023)

CMS has adopted V.41 MS-DRG Codes effective October 1, 2023. Please click here for the Table of V.41 MS-DRG Codes and HCAHPS Service Line Categories.

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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 (06/12/24)