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Spring 2015 HCAHPS Executive Insight Letter


Welcome back again to HCAHPS Executive Insight, the gold button on the HCAHPS On-Line Web site, - and apologies, again, for the long hiatus.

In April 2015, the Centers for Medicare & Medicaid Services (CMS) refreshed the HCAHPS results on the Hospital Compare Web site, The new HCAHPS scores are based on patients discharged between July 2013 and June 2014.


  • The April 2015 HCAHPS results on Hospital Compare scores are based on more than 3.1 million completed surveys from 4,167 hospitals

    • On average, every day more than 30,000 patients are surveyed about their recent hospital experience; and every day more than 8,400 patients complete the HCAHPS Survey
  • The “Summary of HCAHPS Results” and “HCAHPS Percentiles” tables on the Summary Analyses page have been updated to include the newest HCAHPS scores

News and Notes from the HCAHPS Project Team

There have been a number of important developments in the HCAHPS world since we last updated HCAHPS Executive Insight:

    –  HCAHPS Star Ratings were added to the Hospital Compare Web site in April 2015.
        This is the first time that star ratings have been used on this Web site. For more
        information, please see below.

    –  The new HCAHPS Care Transition Measure was publicly reported for the first time in     December 2014.

    –  The HCAHPS Fact Sheet was updated in April 2015.

    –  CMS would like to reiterate that HCAHPS scores are designed and intended for use at
        the hospital level. That is, the comparison of hospitals to each other (designated by
        their CMS Certification Number). CMS does not review or endorse the use of
        HCAHPS scores for comparisons within hospitals
    , such as comparison of HCAHPS
        scores among wards, floors or individual staff members. Such comparisons are
        unreliable unless large sample sizes are collected at the ward, floor or
        individual staff member level.

    –  CMS would like to emphasize that the pain management questions on the HCAHPS
        Survey are intended to evaluate patients’ experience of their pain management.
        HCAHPS pain management results are not designed to judge or compare appropriate
        versus inappropriate provider prescribing behavior.

    –  CMS has modified the patient-mix adjustment for language spoken at home to
        make it more granular. This adjustment is now categorized into four language groups:
        English, Spanish, Chinese, and Russian/Vietnamese/Other.

    –  CMS is planning to conduct a new HCAHPS mode experiment in early 2016. Later this
        year we will be recruiting a nationally representative set of hospitals to participate in
        this mode experiment.

HCAHPS Star Ratings

As part of a new initiative to add five-star quality ratings to its Compare Web sites, CMS added HCAHPS Star Ratings to the Hospital Compare Web site in April 2015. Star ratings make it easier for consumers to use the information on the Compare Web sites and spotlight excellence in healthcare quality. Twelve HCAHPS Star Ratings will appear on Hospital Compare: one for each of the 11 publicly reported HCAHPS measures, plus a Summary Star Rating that combines (“rolls-up”) all of the HCAHPS Star Ratings. HCAHPS Star Ratings are derived from the same data used to create the HCAHPS measures on Hospital Compare. CMS plans to update the HCAHPS Star Ratings each quarter.

To receive HCAHPS Star Ratings, hospitals must have at least 100 completed HCAHPS surveys over a given four-quarter period. In addition, hospitals must be eligible for public reporting of HCAHPS measures. Hospitals with fewer than 100 completed HCAHPS surveys will not receive Star Ratings; however their HCAHPS measure scores will be publicly reported on Hospital Compare. Hospitals can see their HCAHPS Star Ratings in their CMS Preview Report for each reporting period.

More information about HCAHPS Star Ratings, including Frequently Asked Questions and HCAHPS Star Rating Technical Notes, can be found under the new maroon button on HCAHPS On-Line Web site, More information about HCAHPS Star Ratings can be found on the Hospital Compare Web site at “Survey of patients’ experiences,”

HCAHPS and Hospital Value-Based Purchasing

FY 2015 is the third year of the CMS’ Hospital Value-Based Purchasing (VBP) program, which applies to hospitals paid under the Inpatient Prospective Payment System (IPPS). The Baseline Period for the Patient Experience of Care Domain (HCAHPS) in the FY 2015 Hospital VBP program covers January 1 to December 31, 2011 discharges, while the Performance Period covers January 1 to December 31, 2013 discharges. In the FY 2015 program, the Patient Experience Domain will again constitute 30% of the Total Performance Score.

The Hospital VBP program compares a hospital’s HCAHPS scores in a Baseline Period to those in a later Performance Period. Because the Hospital VBP program runs continuously, the same calendar year will serve as the Performance Period for one iteration of the program, and as the Baseline Period for a later iteration. For example, HCAHPS results from patients discharged in calendar year 2013 will serve as the FY 2015 program’s Performance Period and the FY 2017 program’s Baseline Period.

Results for the FY 2015 Hospital VBP program are publicly reported on the Hospital Compare Web site. See

More Information about Hospital Value-Based Purchasing

For more information about the Patient Experience of Care Domain in Hospital VBP, see

For more information about the Hospital VBP program, visit the CMS dedicated Web site, The slide set from CMS’ July 2011 “Open Door Forum” on the Hospital VBP program can be found at . Slides 35 to 61 present a comprehensive summary of the Patient Experience of Care domain and how the score for this domain is calculated.

Another excellent source of information about the Hospital VBP program is the QualityNet Exchange web page. See .

To better assist hospitals and their survey vendors, the HPT outlines the steps taken in creating the Patient Experience Domain scores from HCAHPS data,

Background information about the role of HCAHPS in the Hospital VBP program can be found in the “HCAHPS and Hospital Value-Based Purchasing” section of the Autumn 2012 HCAHPS Executive Insight letter, which can be found in the archive below.

“What's New”

We encourage hospitals and their survey vendors to frequently check our “What’s New” button to find the latest information on HCAHPS, such as upcoming data submission deadlines. We also invite you to share the material presented on HCAHPS Executive Insight, but when you share or reproduce this material, please include the following citation:

Thanks for visiting HCAHPS Executive Insight. Comments or suggestions for HCAHPS Executive Insight should be directed to us, by email, at

Bill Lehrman and Liz Goldstein, editors

Division of Consumer Assessment & Plan Performance, Medicare Drug Benefit Group
Centers for Medicare & Medicaid Services (CMS)

CAHPS® is a registered trademark of the Agency for Healthcare Research and Quality, a U.S. Government agency.

Previous HCAHPS Executive Insight Letters Have Been Posted