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HCAHPS 101: What HCAHPS Surveys mean for hospitals

Over 7,000 patients respond to a Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey every day. Since 2002, HCAHPS has been a staple measurement tool for hospitals across the country. As healthcare organizations increasingly look to patient and consumer experience for competitive insights, it’s vital to review foundational HCAHPS information and how this survey can affect your organization. 

What is HCAHPS?

Developed by the Centers for Medicare & Medicaid Services (CMS) and Agency for Healthcare Research and Quality (AHRQ), the HCAHPS survey collects patient experience feedback on care received during a hospital inpatient stay. HCAHPS is the first national, standardized, and publicly reported survey of patient perceptions of hospital care.  

What is the HCAHPS reporting period? 

HCAHPS surveys are administered on an ongoing basis and are triggered by a patient’s discharge after an inpatient stay at the hospital. CMS publicly reports hospitals’ HCAHPS scores for a rolling 12-month period on the Care Compare website, and the data is typically updated on a quarterly basis.  

Is participation in the HCAHPS survey mandatory? 

CMS requires hospitals who bill Medicare through the Inpatient Prospective Payment System (IPPS) to conduct HCAHPS surveys. IPPS hospitals that fail to report HCAHPS scores to CMS are subject to possible Medicare payment reductions. Non-IPPS hospitals, like critical access hospitals, can voluntarily participate in HCAHPS. 

What types of questions does the Survey ask? 

HCAHPS survey questions cover patient perceptions of doctor communication, nurse communication, staff responsiveness, medication communication, hospital environment, discharge information, food service, and overall patient experience. The survey also includes standard demographic questions.  

How do I administer the HCAHPS Survey? 

HCAHPS surveys can be administered in four ways: mail-only, telephone-only, mail with telephone follow-up, and interactive voice response (IVR), an automated phone system that communicates with respondents through voice and dial pad. As CMS found delivery mode can affect responses during a large-scale study, they apply an adjustment to HCAHPS scores to account for variations caused by the mode through which a patient responded to the HCAHPS survey questions. Similarly, to account for differences in patients’ ratings that are beyond the hospital’s control, CMS also applies a patient-mix adjustment to the HCAHPS scores before publicly reporting them.

Why is it important to conduct HCAHPS? 

These surveys enable your organization to better understand the patient experience, identify areas for improvement, and maximize Medicare reimbursement. Additionally, HCAHPS results are translated into a patient survey rating and, along with an overall star rating which incorporates other quality measures, are made available to the public on Medicare’s Care Compare website. This simple ranking allows consumers to easily review your hospital’s quality compared with other hospitals. 

How does my organization conduct HCAHPS Survey?

If your hospital is required to participate in HCAHPS, a CMS-approved survey vendor like Press Ganey can advise you on the necessary steps to administer your HCAHPS surveys and ensure your company leaders are up to date on all important regulatory announcements. Press Ganey provides digital, mail, and phone survey delivery tools, consulting solutions, industry-leading expertise, and compliance management to help hospitals meet requirements and work toward improving HCAHPS scores.  

How do HCAHPS scores benefit patients?

HCAHPS surveys offer patients the opportunity to provide input on the care they experienced during an inpatient stay, from the bedside to discharge. These insights can help your hospital leaders better understand patient needs and address areas for improvement. As these survey results are publicly available on Care Compare, they can help patients make more informed decisions when choosing a hospital. 

How do HCAHPS scores help various types of healthcare teams improve care delivery?

By obtaining feedback directly from patients on their experiences with many aspects of care delivery, HCAHPS provides hospital teams with valuable insights. Your teams can use this data to determine where environmental and care gaps exist and develop targeted improvement efforts.  

HCAHPS surveys have become a core patient experience measurement for hospitals throughout the nation. It’s crucial to understand your hospital’s reporting requirements, how HCAHPS results are publicly reported, and who the reputable and experienced vendors are when implementing your HCAHPS surveys. 

Read more on our CAHPS surveys and regulatory offerings or speak with an expert about how your organization can best measure patient experience and comply with CMS requirements. 

About the author

Press Ganey, a leading healthcare performance improvement solutions company, offers an integrated suite of solutions that put Human Experience at the center of healthcare enterprise transformation. Delivered through a cutting-edge digital platform built on a foundation of data security, Press Ganey solutions address patient experience, healthcare consumer experience, workforce engagement, safety, clinical excellence and more. Guided by its team of renowned healthcare thought leaders, Press Ganey works with more than 41,000 healthcare facilities to reduce patient suffering, enhance caregiver resilience and improve the overall safety, quality and experience of care. Press Ganey is a PG Forsta company.

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