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OAS CAHPS 101: What HOPDs and ASCs need to know before the survey becomes mandatory

If your hospital is Medicare-certified, chances are you’ve heard of the Outpatient and Ambulatory Surgery Consumer Assessment of Healthcare Providers & Systems, or OAS CAHPS. Survey development began in 2012, and it received CAHPS accreditation in 2015. Because the survey will be mandatory beginning in 2024 for hospital outpatient departments (HOPDs) and 2025 for ambulatory surgery centers (ASCs), it’s vital to understand how this patient experience assessment works and how it will affect your organization. Let’s remove the mystery and explore some key basics.

What is OAS CAHPS?

Developed by the Centers for Medicare & Medicaid Services (CMS), the OAS CAHPS Survey collects patient care feedback in Medicare-certified hospital outpatient departments (HOPDs) and ambulatory surgery centers (ASCs). This survey gathers vital statistics about patient perspectives and assists with measuring patient experiences on care for a specific facility.

What is the OAS CAHPS reporting period?

OAS CAHPS surveys are administered on an ongoing basis. Annually, participating organizations are expected to collect a minimum of 300 completed surveys. When the survey becomes mandatory, HOPDs should target 300 completed surveys, while ASCs should target 200 completed surveys, over a 12-month reporting period. Survey results from HOPDs and ASCs that collect and report the data to CMS are publicly available on the Provider Data Catalog website. This transparency step motivates high performance among HOPDs and ASCs and encourages patients to make informed decisions when selecting a facility for a surgery or procedure.

Is participation in the OAS CAHPS mandatory?

Conducting this survey is currently voluntary. In November 2021, CMS announced OAS CAHPS will continue to be voluntary through 2023 and will be mandatory beginning in 2024 for HOPDs and 2025 for ASCs. Non-compliant organizations will be subject to annual rate reductions in their Medicare payments. Once OAS CAHPS is mandatory, all OAS CAHPS results will also be publicly reported.

OAS CAHPS will be mandatory beginning in 2024 for HOPDs and 2025 for ASCs

What types of questions does the survey ask?

OAS CAHPS questions ask about patients’ experiences, including communications with doctors, nurses, and staff about a surgery or procedure, HOPD or ASC cleanliness, preparation for discharge and recovery, overall rating of the facility, and willingness to recommend the facility to others. The survey also poses several basic demographic questions.

How do I administer the OAS CAHPS Survey?

As CMS designed OAS CAHPS to be implemented nationally, with the objective of publicly reporting facility-level results, survey administration is standardized. Currently, Press Ganey offers three CMS-permitted administration modes: a digital-first mixed mode (initial email surveying and follow-up by mail or phone to non-respondents), mail-only, and telephone-only.

Why is it important to conduct OAS CAHPS?

These surveys enable your organization to better understand patient pain points, identify strategic actions you can take to improve patient experience, and generate real-time data that helps drive decision-making. Assessing this information can help you successfully align your team’s practices with standards of care and compare your organization’s performance to state and national averages.

Why should I administer the OAS CAHPS Survey before it’s mandatory?

Conducting OAS CAHPS before it becomes mandatory will also help your organization prepare and know what to expect once there are financial implications and the data is publicly reported.

What are the penalties for non-compliance with mandatory OAS CAHPS?

The Hospital Outpatient Quality Reporting Program (OQR) and the Ambulatory Surgical Center Quality Reporting (ASCQR) Program are pay-for-reporting, quality data programs administered by CMS. OAS CAHPS becomes a mandatory measure as part of the OQR in 2024 for HOPDs and as part of the ASCQR beginning in 2025 for ASCs. HOPDs and ASCs that do not administer and report OAS CAHPS when it becomes mandatory could be subject to a penalty of 2% of their annual Medicare payment update.

Are there penalties or incentives tied to performance on OAS CAHPS?

Currently, the OQR and ASCQR programs do not base payments on performance related to measuring patient experiences. While other CAHPS surveys are utilized in pay-for-performance programs (e.g., HCAHPS VBP program), this is not currently contemplated for implementation of OAS CAHPS mandatory surveys in 2024-5.

Are OAS CAHPS results publicly reported?

Survey results from ASCs that voluntarily collect and report the data to CMS are publicly available on the Provider Data Catalog website. This transparency motivates high performance among ASCs and encourages patients to make informed decisions when selecting a facility for a surgery or procedure.

Other CAHPS survey results (e.g., HCAHPS) are translated into overall star ratings, which are made available to the public on Medicare's Care Compare website. This simple ranking allows consumers, in the case of hospitals and HCAHPS, to easily review a hospital's quality compared with other hospitals. CMS has indicated plans to develop OAS CAHPS Star Ratings for inclusion on the Care Compare website, but they have not announced when OAS CAHPS-based Star Ratings for ASCs will be available and published.

How does my organization conduct OAS CAHPS Surveys?

Any Medicare-certified HOPD or ASC can administer OAS CAHPS. To begin, it’s important to contact and work with a CMS-certified survey vendor. A reputable organization will advise you on next steps, equip you with necessary elements to implement OAS CAHPS, and ensure your company leaders are updated with any important regulatory announcements. Press Ganey goes beyond the basics, streamlining your survey delivery with a robust suite of automated and manual tools, consulting solutions, industry-leading expertise, and compliance management.

Can the OAS CAHPS survey be administered electronically?

CMS began allowing for web-based OAS CAHPS surveying via email in 2022, the first time the organization has accepted any digital regulatory surveying. Offering additional electronic modes allows patients more options when responding to the survey, ultimately providing your organization with more insights from a broader range of patients. To ensure accessibility, digital surveying is administered as a mixed mode with either mail or phone.

How do OAS CAHPS scores and these new measurement modes benefit patients?

OAS CAHPS gives patients the opportunity to provide feedback on many aspects of the care received from your organization. Offering additional electronic modes will allow patients more options when responding to the survey, ultimately providing your organization with more insights from a broader range of patients. Measuring patient experience results can help organizations make productive changes, improving overall safety and quality at the patient level.

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

By quantifying patient experience, OAS CAHPS provides organizations with tangible insights regarding opportunities for improvement. As these surveys are focused explicitly on critical healthcare aspects, as opposed to amenities, your team can generate a clear and targeted understanding of specific gaps in care.

Whether your organization already conducts OAS CAHPS or you’re just considering implementing this survey, it’s important to know what’s expected once it becomes mandatory in the upcoming years. This includes discussing reporting periods, annual survey volume requirements, administration modes, and partnering with a verified survey vendor, such as Press Ganey, when implementing OAS CAHPS.

Read more on our CAHPS surveys and regulatory offerings or speak with a CAHPS survey expert about how your organization can begin measuring patient experience in line with these CMS standards.

Updated: April 18, 2023

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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