Hospital Roles and Responsibilities

Since FY 2008, as part of the Hospital Inpatient Quality Reporting Program (formerly known as Reporting Hospital Quality Data Annual Payment Update [RHQDAPU] program), hospitals that are subject to IPPS payment provisions must collect and submit HCAHPS data in order to receive their full APU. IPPS hospitals that fail to report the required quality measures, which include the HCAHPS Survey, may receive an APU that is reduced. Short-term, acute care hospitals that are not IPPS hospitals, such as Critical Access Hospitals, Veterans Affairs hospitals or Department of Defense hospitals, may voluntarily participate in HCAHPS.

Note: IPPS Hospitals with zero eligible HCAHPS patient discharges (“zero cases”) must submit monthly or quarterly, an HCAHPS Header Record (Survey Month Data) online via the Hospital Quality Reporting (HQR) system (https://hqr.cms.gov/), formerly the QualityNet Secure Portal. Please visit the HCAHPS Web site for more details or contact HCAHPS Information and Technical Support for more information.

Note: IPPS Hospitals with five or fewer eligible HCAHPS patient discharges in a month may choose not to survey those patients for that given month. If patients are not surveyed, an HCAHPS Header Record (Survey Month Data) will still need to be submitted online via the HQR system (https://hqr.cms.gov/). Please visit the HCAHPS Web site for more details or contact HCAHPS Information and Technical Support for more information.

Note: The zero cases and five or fewer eligible HCAHPS patient discharges submission protocols must not be used when hospitals or survey vendors missed surveying eligible patients, such as when hospitals do not submit discharge lists for the month to their survey vendor in a timely manner. In instances such as this, a Discrepancy Report must be completed and submitted.

Hospitals should monitor the HCAHPS Web site (https://www.hcahpsonline.org), as well as the HQR system (https://hqr.cms.gov/), for program updates, information and announcements regarding the completion/submission of required notice of participation and/or pledge forms.

Hospitals must ensure that their communications with patients do not violate HCAHPS requirements with regard to attempting to influence the way a patient might respond to the HCAHPS Survey. In particular, hospitals must not use HCAHPS wording and/or response categories in their communication with patients.

In addition, hospitals are responsible for ensuring the confidentiality of patients responding to the survey. While the data from HCAHPS may be used for quality improvement purposes, the patient’s identity should not be shared with direct care staff.

CMS provides the HCAHPS Survey in several languages. In the FY 2014 IPPS Final Rule, CMS strongly encourages hospitals with significant patient populations that speak any of the official HCAHPS languages (Spanish, Chinese, Russian, Vietnamese, Portuguese, and/or German) to offer the HCAHPS Survey in these languages. Only the official translations of the HCAHPS Survey instrument are permitted for HCAHPS Survey administration.

Hospitals participating in HCAHPS have the following options for conducting the survey:
(1) contract with an approved HCAHPS Survey vendor;
(2) self-administer their own HCAHPS Survey, provided they meet the Program Requirements (Rules of Participation and Minimum Survey Requirements); or
(3) administer the survey for multiple sites, provided they meet the Program Requirements (Rules of Participation and Minimum Survey Requirements).

Hospital Contracting with a Survey Vendor to Conduct HCAHPS

• Contract with an HCAHPS-approved Survey Vendor or Hospital Administering Surveys for Multiple Sites (hospitals acting as a survey vendor) to conduct HCAHPS Surveys
• Provide a primary and secondary (backup) HCAHPS contact person to HCAHPS-approved Survey Vendor (strongly recommended)
• Ascertain from the survey vendor the date the patient discharge list must be received. If a hospital excludes patients from the discharge list, then they must submit the total number of inpatient discharges in the month and a count of patients by exclusion category to the survey vendor, at a minimum on a monthly basis. Survey vendors set deadlines independently based on many factors, including survey administration timelines, due date for data file submission, and time they need to draw the random sample and generate the data file.
• Deliver the patient discharge list to their survey vendor by their specified date and according to the specified file layout, which allows the survey vendor to administer the survey and submit data files to the HQR system (https://hqr.cms.gov/) by the data submission deadline
  • As noted in the FY 2014 IPPS Final Rule, hospitals must provide the administrative data that is required for HCAHPS in a timely manner to their survey vendor. This includes the patient MS-DRG code at discharge, or alternative information that can be used to determine the patient’s service line.
    • Hospitals are strongly encouraged to submit their entire patient discharge list to their survey vendor, excluding patients who had requested “no publicity” status or who are excluded because of State regulations

  Note: If the hospital is unable to provide the patient discharge list by the survey vendor’s specified date, the survey vendor may not be able to proceed with survey administration for that hospital according to the HCAHPS timeline. As a result, the hospital’s HCAHPS scores may not be publicly reported, which could affect the hospital’s APU for the fiscal year.

• Strive to obtain 300 completed surveys in a 12-month period when there are sufficient eligible discharges from the hospital
  
  Note: In the FY 2014 IPPS Final Rule, CMS stated that hospitals paid under the IPPS system must submit at least 300 completed HCAHPS Surveys in a rolling four-quarter period. The absence of a sufficient number of HCAHPS-eligible patient discharges is the only acceptable reason for submitting fewer than 300 completed surveys.
  
  
• Authorize the survey vendor or hospital acting as a survey vendor to submit data via the HQR system (https://hqr.cms.gov/) on the hospital’s behalf
• Review the HCAHPS Warehouse Feedback Reports to verify that the survey vendor has submitted the data accurately and on time. These reports include: HCAHPS Warehouse Provider Survey Status Summary Report, HCAHPS Warehouse Data Submission Detail Report and Hospital IQR Reporting – Provider Participation Report.
• Review the HCAHPS Submission Results Report (formerly the Review and Correction Report)
• Preview HCAHPS results prior to public reporting

Use of HCAHPS Outside of Official HCAHPS Purposes The HCAHPS Survey and the questions that comprise it are in the public domain and thus can be used outside of official HCAHPS purposes (e.g., for non-HCAHPS eligible patients, etc.). When used in an unofficial capacity, the HCAHPS OMB language, HCAHPS OMB number and expiration date must not be used, all references to HCAHPS and the “United States Department of Health and Human Services” sponsorship must be removed, and the copyright statement for the Care Transition Measure (CTM) items must be used.

Use of HCAHPS with Other Hospital Inpatient Surveys

In this section, CMS provides guidelines to employ when asking patients questions regarding their hospital stay. CMS’ intent is to minimize the burden on patients, prevent the introduction of bias to HCAHPS Survey responses and not deteriorate the likelihood that patients will complete the HCAHPS Survey.

In general, activities and encounters that are intended to provide or assess clinical care or promote patient/family well-being are permissible. However, activities and encounters that are primarily intended to influence how patients, or which patients, respond to HCAHPS Survey items must be avoided. If patients are asked questions during their inpatient stay, we suggest that such questions be worded in a neutral tone and not tilted toward a particular outcome. In addition, questions must not resemble HCAHPS items or their response categories. Hospitals should focus on overall quality of care rather than the measures reported to CMS.

Inpatients should not be given any survey during their hospital stay or at the time of discharge. The word “survey” in this instance refers to a formal, HCAHPS-like, patient experience/ satisfaction survey. A formal survey, regardless of the mode employed, is one in which the primary goal is to ask standardized questions of a significant portion of a hospital’s patient population.

When asking non-HCAHPS Survey questions, do not use HCAHPS-like response categories (for instance, “Always,” “Usually,” “Sometimes,” “Never”)

• It is permissible for patients to be asked about their hospital experience during their hospital stay or during discharge calls where this is a normal part of clinical rounds, leadership rounds, or patient treatment/care activities
• Patient-initiated or hospital-initiated (including the hospital’s agents) contact, comment, response, or communication, whether before, during or after the hospital stay, must not influence the likelihood of a patient receiving the HCAHPS Survey
• The following are examples of the types of questions that are NOT permissible:
  • “Did the nurses always answer your questions?”
  • “On a scale of 0 to 10, how would you rate your hospital stay?”
  • “Is there a way we could always….?”
  • “Did your doctor/nurse explain things in a way you could understand?”
  • “Overall, how would you rate the care you received from your doctors/nurses?”
• Alternative questions that would not violate HCAHPS protocols include:
  • “Are the nurses answering your questions?”
  • “Please share with us how we could improve your hospital stay.”
  • “Tell us about your stay.”
  • “Did your doctor/nurse address any communication barriers regarding information about your healthcare?”
  • “Was our staff attentive to your needs?”

The HCAHPS Survey should be administered prior to any other inpatient survey. As noted above, it is permissible for patients to be asked about their hospital experience during their hospital stay when the focus is on the clinical care of the individual patient. The hospital or its agents must not seek to influence which patients receive the HCAHPS Survey or how patients answer HCAHPS Survey items. For additional guidance in the use of HCAHPS in conjunction with other inpatient surveys refer to HCAHPS Bulletin Number 2009-01 Revised which is posted on the HCAHPS Web site (https://www.hcahpsonline.org/en/quality-assurance/) and Appendix Z.

While the over-riding goal of CMS is to minimize survey burden and prevent introducing potential bias to the HCAHPS Survey responses, on occasion CMS may initiate and implement projects or studies to investigate and improve the healthcare of patients. If a hospital accepts an offer to participate in another CMS or CMS-sponsored project that includes an inpatient survey which may contravene HCAHPS, the hospital must file an Exception Request to alert and inform the HCAHPS Project Team of its participation (see the Exception Request/Discrepancy Report Processes chapter).

Communicating with Patients about the HCAHPS Survey

HCAHPS guidelines allow hospitals/survey vendors to communicate about the HCAHPS Survey before or at discharge; for example, hospitals may inform patients that they may receive this survey after discharge asking about their stay in the hospital. Patients should be encouraged to complete the survey and share their experiences during the hospital stay. Hospitals may use posters or other written communications to notify patients that they may receive a survey and to promote participation in the survey. However, certain types of communications (oral, written or in the HCAHPS Survey materials, e.g., cover letters and telephone/IVR scripts) are not permitted because they may introduce bias in the survey results. For instance, hospitals/survey vendors or their agents are not allowed to:

• ask any HCAHPS or HCAHPS-like questions of patients prior to administration of the survey after discharge
• attempt to influence or encourage patients to answer HCAHPS questions in a particular way
• wear buttons or display signage denoting “Always” or “10”
• imply that the hospital, its personnel or agents will be rewarded or gain benefits for positive feedback from patients by asking patients to choose certain responses, or indicate that the hospital is hoping for a given response, such as a “10,” “Definitely yes,” or an “Always”
• ask patients to explain why he or she chose their specific response; for example, it is not acceptable to ask patients why they indicated that they would not recommend the hospital to friends and family
• indicate that the hospital’s goal is for all patients to rate them as a “10,” “Definitely yes,” or an “Always”
• offer incentives of any kind for participation in the survey
• show or provide the HCAHPS Survey or cover letters to patients while they are in the hospital or at any time prior to the administration of the survey
• mail any pre-notification letters or postcards informing patients about the HCAHPS Survey; however, it is permissible to notify the patient while in the hospital or at discharge that they may receive the survey after discharge

Other Communications with Patients

When communicating with patients while in the hospital regarding their healthcare, hospitals/survey vendors should take care to avoid introducing bias in the way a patient may answer questions on the HCAHPS Survey. Many of the guidelines above in the Use of HCAHPS with Other Hospital Inpatient Surveys and Communicating with Patients about the HCAHPS Survey sections apply to general communications with patients.

• Examples of statements that comply with HCAHPS protocols include:
  • “We are looking for ways to improve your stay. Please share your comments with us.”
  • “What can we do to improve your care?”
  • “We want to hear from you, please share your experience with us.”
  • “Please let us know if you have any questions about your treatment plan.”
  • “Let us know if your room is not comfortable.”
• Hospitals/Survey vendors or their agents should not:
  • Wear buttons, stickers, etc. that state “Always” or “10.”
  • Emphasize HCAHPS response options in posters, white boards, rounding questions, in room television, or other media accessible to patients:
    • “We expect to be the best hospital possible.”
    • “Our goal is to always address your needs.”
    • “Let us know if we are not listening carefully to you.”
    • “We treat our patients with courtesy and respect.”
    • “In order to provide the best possible care, please tell us how we can always…”
    • “Our doctors and nurses always listen carefully to you.”
    • “We want to always explain things to you in a way you can understand.”
    • “We want you to recommend us to family and friends.”