HCAHPS (NQF #0166) is a 29-item survey instrument that produces 10 publicly reported measures:
6 multi-item measures (communication with doctors, communication with nurses, responsiveness of hospital staff, communication about medicines, discharge information and care transition); and
4 single-item measures (cleanliness of the hospital environment, quietness of the hospital environment, overall rating of the hospital, and recommendation of hospital).
Note: The HCAHPS Survey originally included three items about pain which formed a composite measure, Pain Management. CMS discontinued publicly reporting this measure in July 2018. In January 2018, CMS replaced the original HCAHPS pain items with three items that asked about communication about pain. In compliance with the Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment (SUPPORT) for Patients and Communities Act (Pub. L. 115-271) of 2018 (Section 6104), CMS will remove the new communication about pain items from the HCAHPS Survey beginning with October 2019 discharges.
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1.14 Numerator
The HCAHPS Survey asks recently discharged patients about aspects of their hospital experience that they are uniquely suited to address. The core of the survey contains 19 items that ask “how often” or whether patients experienced a critical aspect of hospital care, rather than whether they were “satisfied” with their care. Also included in the survey are three screener items that direct patients to relevant questions, five items to adjust for the mix of patients across hospitals, and two items (race and ethnicity) that support Congressionally-mandated reports. Hospitals may include additional questions after the core HCAHPS items.
For full details, see the current HCAHPS Quality Assurance Guidelines, V.14.0, pp. 57-65,
under the “Quality Assurance” button on the official HCAHPS On-Line Web site at:
https://www.hcahpsonline.org/globalassets/hcahps/quality-assurance/2019_qag_v14.0.pdf
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1.15 Denominator
The target population for HCAHPS measures include eligible adult inpatients of all payer types who completed a survey. HCAHPS patient eligibility and exclusions are defined in detail in the sections that follow. A survey is defined as completed if the patient responded to at least 50% of questions applicable to all patients.
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Exclusions
There are a few categories of otherwise eligible patients who are excluded from the HCAHPS sample frame. As detailed below in sec S.9, these exclusions include patients excluded due to state regulations, no-publicity patients, and specific groups of patients with an admission source or discharge status that results in difficulty collecting patient experience data through a survey instrument.
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OLD 1.12 MAT output not attachedAttached
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Most Recent Endorsement ActivityEndorsed Patient Experience and Function Spring Cycle 2019Initial EndorsementLast Updated
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Steward Organization EmailSteward Organization Copyright
CAHPS® is a registered trademark of the Agency for Healthcare Research and Quality, a U.S. Government agency.
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Risk AdjustmentRisk adjustment approachOffRisk adjustment approachOffConceptual model for risk adjustmentOffConceptual model for risk adjustmentOff
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6.1.2 Current or Planned Use(s)6.1.3 Current Use(s)
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