What is HCAHPS?
HCAHPS stands for Hospital Consumer Assessment of Healthcare Providers and Systems. The goal of this public reporting instrument is to provide consumers with information that might be helpful in choosing a hospital.

How much will it cost us to do HCAHPS?
At CFRI, we charge an annual fee of $300 plus $9 per completed telephone survey.
So, if we reach 300 completed surveys, then the yearly cost would come out to be $3000.
If after we contact every eligible patient, over a 12-month period, we only complete 150 completes (due to low number of patient discharges), then the yearly cost would be $1650.

What is the Dry Run?
Dry Runs give hospitals an opportunity to become familiar with the HCAHPS processes before they begin National Implementation. Hospitals would only participate in a Dry Run if they are new to HCAHPS.
Dry Runs will be available during the last month of each calendar quarter. Hospitals new to HCAHPS would begin submitting data for National Implementation the first month of the quarter following the Dry Run.

What if my hospital is not already participating in national implementation?
In order to meet CMS requirements and to achieve the full payment update in the 2008 fiscal year and forward, participation in HCAHPS was required beginning with July 2007 discharges. New hospitals are required to start participating in HCAHPS beginning with the first month of the quarter following receipt of their CMS Certification Number (CCN).

Which hospitals are eligible to participate in HCAHPS?
Hospitals that report clinical data to CMS are eligible to participate in HCAHPS. It is not intended to be used for pediatric hospitals, psychiatric hospitals, or other specialty hospitals.

If HCAHPS is for general acute care hospitals, can you specify which types of specialty hospitals would be excluded from the HCAHPS process?
HCAHPS is designed for acute care hospitals. The majority of specialty hospitals (e.g., pediatric, psychiatric) are excluded. Any hospital that is reimbursed under the Inpatient Prospective Payment System and is eligible for the Annual Payment Update (referred to as RHQDAPU) will need to participate in HCAHPS in order to receive full reimbursement updates. If you are unsure if your hospital should participate in HCAHPS contact This e-mail address is being protected from spambots. You need JavaScript enabled to view it or call 1-888-884-4007.

What patients are eligible to receive an HCAHPS survey?
The survey is designed for all (not just Medicare) adult patients discharged from general acute care hospitals after an overnight stay. Patients to be excluded include: patients who are under 18, those who died in the hospital, patients discharged to hospice, patients who received psychiatric or rehabilitative services, prisoners, and patients with international addresses.

Do we have to send all eligible patient records to CFRI?
Yes, it is a CMS requirement designed to ensure that all eligible patient discharges are reported. You cannot sample records before sending the files to CFRI. Per CMS guidelines, CFRI must be able to count the number of eligible discharges and attest to the randomness of the sample. All eligible records must be sent and all required fields must be populated in the upload.

How often should a patient receive a survey?
A patient should receive a survey for every inpatient stay. The only allowable exclusion is for a patient who has multiple stays in one calendar month.

What happens if a hospital gets fewer than 300 HCAHPS surveys completed - for instance if the number of completed surveys turns out to be 150 instead of 300?
Hospitals should be targeting to collect at least 300 completed HCAHPS surveys over a twelve month period. For those hospitals that cannot collect 300 completed HCAHPS surveys, CMS will note, on Hospital Compare, that results are based on less than 100 completed surveys or between 100 and 299 completed HCAHPS surveys.

What methodologies are allowed for HCAHPS?
The survey can be administered via any of the following: mail only survey, telephone only survey, combined mail/phone survey, or Active Interactive Voice Response (Active IVR). Here at CFRI, we conduct the telephone only survey.

Will there be peer groups or adjustments for hospital characteristics (e.g., size)?
Reports will provide a national and state norm. There will not be peer group comparisons on the Hospital Compare webisite. But we do offer an online service that would provide this.

I have heard discussions of patient-mix adjustment. What is that?
Patient-mix adjustment is a calculation to adjust a hospital’s results, based on patient and hospital demographics, to reflect what one would expect from a “typical” patient population. The intent of patient-mix adjustments is to make data comparable across different settings. CMS will apply patient-mix adjustments to a hospital’s data before it is publicly reported.