CMS updates HCAHPS survey amid declining scores

The Centers for Medicare and Medicaid Services is revising its patient experience survey to address low response rates and expand data on care quality.

Announced Aug.1 as part of the agency's inpatient prospective payment system final rule, the modifications to the Hospital Consumer Assessment of Healthcare Providers and Systems survey have been years in the making.

Before the COVID-19 pandemic, stakeholders advocated for CMS to improve the HCAHPS survey by changing its response format and fine-tuning the measures included. Now, with more patients reporting declines in their hospital experiences, CMS is sharpening its focus on improving the survey process. 

Here’s what you need to know about the HCAHPS survey and patient perception of hospital care.

What does the survey focus on?

The HCAHPS survey, given to a random sample of adult hospital patients after their discharge, asks 29 questions about the quality of the care they received.

Core areas of the survey ask patients to rate their communication with clinicians; the hospital's environment and cleanliness; and information they were given about medications and discharge planning. Patients also report how likely they would be to recommend the hospital to others.

Each year, more than 3 million patients from 4,000 hospitals complete HCAHPS surveys. The surveys can affect hospitals’ annual payment through the Hospital Value-Based Purchasing program.

How is CMS changing HCAHPS?

Starting with the 2025 reporting period, respondents will be able to take the surveys online. Historically, the survey has only been administered by mail or telephone.

CMS also plans to extend the data collection period from 42 to 49 days, reduce the number of supplemental survey items and require an official survey translation for Spanish-speaking patients.

Changes also are being made to several of CMS’ other data reporting programs, and have already resulted in higher response rates from younger, more diverse patient demographics, according to the agency.

Some say the survey should poll minority patient populations on whether they experienced discrimination during their treatment or received culturally competent care, and that results should show how scores varied by respondents’ race, ethnicity and preferred language.

How are hospitals performing on the surveys?

Patient perception of their hospital care continued to worsen during the pandemic. The average percentage of patients who would definitely recommend a hospital was 69% in 2022, compared with 71% in fiscal year 2021.

Recent data have shown minor declines in patient experience, with less of the surveyed population reporting they understood their care upon leaving the hospital, or that staff always explained new medications and their potential side effects.

To industry experts, patient perception is a reflection of the stressors on a hospital, including staff workload and a lack of training, recruitment challenges and budget deficits. All of these factors may mean clinicians aren't able to be as attentive as possible to patient needs, resulting in lower experience scores.

With COVID-19's focus on hand hygiene and personal protective equipment, patients may also be more critical of hospital cleanliness.

What were the main barriers to high scores?

Challenging circumstances caused by the pandemic have been points of friction for patients, with many feeling anxious, confused and frustrated.

One major change to the care environment was the lack of families and visitors due to COVID-19 restrictions. It negatively affected patients’ mental health and their ability to keep track of information related to discharge planning and medication side effects.

In many hospitals, nurses were also not in patient rooms as often throughout the pandemic to preserve protective equipment and reduce the spread of infection, which further exacerbated patient loneliness and the ability to provide feedback on their experience.

“When providers were able to take off their masks for most patients under their care, that eased communication,” said Nancy Foster, vice president for quality and patient safety policy at the AHA.

How are health systems working to improve?

Hospitals are implementing a number of strategies to target various areas of performance on the HCAHPS survey, from hiring dedicated staff to oversee patient experience to training clinicians on how to better communicate with patients and each other.

Some systems have begun experimenting with QR codes that patients can scan to immediately alert staff to any grievances or issues with their hospital experience, like an overflowing trash can or a room that is too hot.