CMS-10102 Appendix A

Supporting Statement for the National Implementation of the Hospital CAHPS Survey

Appendix A
HCAHPS Survey Instrument and Supporting Materials

March 2011

1

HCAHPS Survey Instrument and Supporting Materials:

HCAHPS Mail Survey (English)
Survey Instrument
Sample Initial Cover Letter
Sample Follow-up Cover Letter
OMB Paperwork Reduction Act Language

March 2011

2

HCAHPS Survey
SURVEY INSTRUCTIONS
You should only fill out this survey if you were the patient during the hospital stay
named in the cover letter. Do not fill out this survey if you were not the patient.
Answer all the questions by checking the box to the left of your answer.
You are sometimes told to skip over some questions in this survey. When this happens
you will see an arrow with a note that tells you what question to answer next, like this:



Yes
No

 If No, Go to Question 1

You may notice a number on the survey. This number is ONLY used to let us
know if you returned your survey so we don't have to send you reminders.
Please note: Questions 1-22 in this survey are part of a national initiative to measure the quality
of care in hospitals. OMB #0938-0981

Please answer the questions in this survey

2.

During this hospital stay, how often did

about your stay at the hospital named on the

nurses listen carefully to you?

cover letter. Do not include any other hospital

1

 Never
 Sometimes
3
 Usually
4
 Always
2

stays in your answers.

YOUR CARE FROM NURSES
1.

During this hospital stay, how often did
nurses treat you with courtesy and
respect?

 Never
 Sometimes
3
 Usually
4
 Always
1
2

March 2011

3

3.

During this hospital stay, how often did
nurses explain things in a way you could
understand?

 Never
2
 Sometimes
3
 Usually
4
 Always
1

YOUR CARE FROM DOCTORS
5.

During this hospital stay, how often did
doctors treat you with courtesy and
respect?

 Never
 Sometimes
3
 Usually
4
 Always
1
2

4. During this hospital stay, after you
6. During this hospital stay, how often did
pressed the call button, how often did you
doctors listen carefully to you?
get help as soon as you wanted it?

 Never
 Sometimes
3
 Usually
4
 Always
1

 Never
 Sometimes
3
 Usually
4
 Always
9
 I never pressed the call button
1
2

2

7. During this hospital stay, how often did
doctors explain things in a way you could
understand?

 Never
 Sometimes
3
 Usually
4
 Always
1
2

THE HOSPITAL ENVIRONMENT
8. During this hospital stay, how often
were your room and bathroom kept clean?

 Never
 Sometimes
3
 Usually
4
 Always
1
2

March 2011
2

9. During this hospital stay, how often

YOUR EXPERIENCES IN THIS
HOSPITAL

was the area around your room quiet at

10. During this hospital stay, did you need

night?

help from nurses or other hospital staff in

 Never
2
 Sometimes
3
 Usually
4
 Always
1

getting to the bathroom or in using a
bedpan?




1

2

Yes
No  If No, Go to Question 12

11. How often did you get help in getting
to the bathroom or in using a bedpan as
soon as you wanted?

 Never
 Sometimes
3
 Usually
4
 Always
1
2

12. During this hospital stay, did you need
medicine for pain?




1
2

Yes
No  If No, Go to Question 15

13. During this hospital stay, how often
was your pain well controlled?

 Never
 Sometimes
3
 Usually
4
 Always
1
2

14. During this hospital stay, how often did
the hospital staff do everything they could
to help you with your pain?
March 2011
3

 Never
2
 Sometimes
3
 Usually
4
 Always
1

15. During this hospital stay, were you
given any medicine that you had not taken
before?
1
 Yes
2
 No  If No, Go to Question 18

16. Before giving you any new medicine,
how often did hospital staff tell you what
the medicine was for?

 Never
 Sometimes
3
 Usually
4
 Always
1
2

17. Before giving you any new medicine,
how often did hospital staff describe
possible side effects in a way you could
understand?

 Never
 Sometimes
3
 Usually
4
 Always
1
2

WHEN YOU LEFT THE HOSPITAL
18. After you left the hospital, did you go
directly to your own home, to someone
else’s home, or to another health facility?

 Own home
 Someone else’s home
3
 Another health
1
2

facility 

March 2011
4

If Another, Go to
Question 21

19. During this hospital stay, did doctors,
nurses or other hospital staff talk with you
about whether you would have the help
you needed when you left the hospital?
1
 Yes
2
 No

20. During this hospital stay, did you get
information in writing about what
symptoms or health problems to look out
for after you left the hospital?




1
2

Yes
No

OVERALL RATING OF HOSPITAL
Please answer the following questions about
your stay at the hospital named on the cover
letter. Do not include any other hospital stays
in your answers.
21. Using any number from 0 to 10, where
0 is the worst hospital possible and 10 is
the best hospital possible, what number
would you use to rate this hospital during
your stay?



2

3

4

5

6

7

0

0
1
2
3
4
5
6
7
March 2011
5
1

Worst hospital possible

8
9
10
10
8
9

Best hospital possible

22. Would you recommend this hospital to
your friends and family?
1
 Definitely no
2
 Probably no
3
 Probably yes
4
 Definitely yes

ABOUT YOU

25. Are you of Spanish, Hispanic or
Latino origin or descent?
1
 No, not Spanish/Hispanic/Latino
2
 Yes, Puerto Rican
3
 Yes, Mexican, Mexican American,
Chicano
4
 Yes, Cuban
5
 Yes, other
Spanish/Hispanic/Latino

There are only a few remaining items left.
23. In general, how would you rate your

26.

or more.

overall health?

 White
 Black or African American
3
 Asian
4
 Native Hawaiian or other Pacific

 Excellent
2
 Very good
3
 Good
4
 Fair
5
 Poor

1

1

24.

What is the highest grade or level of
school that you have completed?

 8th grade or less
2
 Some high school, but did not
1



5

6

3
4

graduate
High school graduate or GED
Some college or 2-year degree
4-year college graduate
More than 4-year college degree

What is your race? Please choose one

2



5

27.

Islander
American Indian or Alaska
Native

What language do you mainly speak at
home?

 English
 Spanish
3
 Chinese
4
 Russian
5
 Vietnamese
6
 Some other language (please
1
2

print): _____________________

THANK YOU
Please return the completed survey in the postage-paid envelope.

[NAME OF SURVEY VENDOR OR SELF-ADMINISTERING HOSPITAL]

March 2011
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[RETURN ADDRESS OF SURVEY VENDOR OR SELF-ADMINISTERING
HOSPITAL]

March 2011
2

Sample Initial Cover Letter for the HCAHPS Survey
[HOSPITAL LETTERHEAD]

[SAMPLED PATIENT NAME]
[ADDRESS]
[CITY, STATE ZIP]
Dear [SAMPLED PATIENT NAME]:
Our records show that you were recently a patient at [NAME OF HOSPITAL] and discharged
on [DISCHARGE DATE]. Because you had a recent hospital stay, we are asking for your help.
This survey is part of an ongoing national effort to understand how patients view their hospital
experience. Hospital results will be publicly reported and made available on the Internet at
www.hospitalcompare.hhs.gov. These results will help consumers make important choices
about their hospital care, and will help hospitals improve the care they provide.
Questions 1-22 in the enclosed survey are part of a national initiative sponsored by the United
States Department of Health and Human Services to measure the quality of care in hospitals.
Your participation is voluntary and will not affect your health benefits.
We hope that you will take the time to complete the survey. Your participation is greatly
appreciated. After you have completed the survey, please return it in the pre-paid envelope.
Your answers may be shared with the hospital for purposes of quality improvement.
[OPTIONAL: You may notice a number on the survey. This number is ONLY used to let us
know if you returned your survey so we don’t have to send you reminders.]
If you have any questions about the HCAHPS Survey, please call the toll-free number 1-800xxx-xxxx. Thank you for helping to improve health care for all consumers.
Sincerely,

[HOSPITAL ADMINISTRATOR]
[HOSPITAL NAME]

Note: The OMB Paperwork Reduction Act language must be included in the mailing. This
language can be either in the cover letter or on the front or back of the questionnaire. The
exact OMB Paperwork Reduction Act language is included in this appendix. Please refer to
the Mail Only, and Mixed Mode sections, for specific letter guidelines.

1

Sample Follow-up Cover Letter for the HCAHPS Survey
[HOSPITAL LETTERHEAD]

[SAMPLED PATIENT NAME]
[ADDRESS]
[CITY, STATE ZIP]
Dear [SAMPLED PATIENT NAME]:
Our records show that you were recently a patient at [NAME OF HOSPITAL] and discharged
on [DATE OF DISCHARGE]. Approximately three weeks ago we sent you a survey regarding
your hospitalization. If you have already returned the survey to us, please accept our thanks and
disregard this letter. However, if you have not yet completed the survey, please take a few
minutes and complete it now.
Because you had a recent hospital stay, we are asking for your help. This survey is part of an
ongoing national effort to understand how patients view their hospital experience. Hospital
results will be publicly reported and made available on the Internet at
www.hospitalcompare.hhs.gov. These results will help consumers make important choices
about their hospital care, and will help hospitals improve the care they provide.
Questions 1-22 in the enclosed survey are part of a national initiative sponsored by the United
States Department of Health and Human Services to measure the quality of care in hospitals.
Your participation is voluntary and will not affect your health benefits. Please take a few
minutes and complete the enclosed survey. After you have completed the survey, please return
it in the pre-paid envelope. Your answers may be shared with the hospital for purposes of
quality improvement. [OPTIONAL: You may notice a number on the survey. This number is
ONLY used to let us know if you returned your survey so we don’t have to send you
reminders.]
If you have any questions about the HCAHPS Survey, please call the toll-free number 1-800xxx-xxxx. Thank you again for helping to improve health care for all consumers.
Sincerely,

[HOSPITAL ADMINISTRATOR]
[HOSPITAL NAME]

Note: The OMB Paperwork Reduction Act language must be included in the mailing. This
language can be either in the cover letter or on the front or back of the questionnaire. The
exact OMB Paperwork Reduction Act language is included in this appendix. Please refer to
the Mail Only, and Mixed Mode sections, for specific letter guidelines.

2

OMB Paperwork Reduction Act Language
The OMB Paperwork Reduction Act language must be included in the survey mailing. This
language can be either in the cover letter or on the front or back of the questionnaire. The
following is the language that must be used:
English Version
“According to the Paperwork Reduction Act of 1995, no persons are required to respond to a
collection of information unless it displays a valid OMB control number. The valid OMB
control number for this information collection is 0938-0981. The time required to complete this
information collected is estimated to average 7 minutes per response for questions 1-22 on the
survey, including the time to review instructions, search existing data resources, gather the data
needed, and complete and review the information collection. If you have any comments
concerning the accuracy of the time estimate(s) or suggestions for improving this form, please
write to: Centers for Medicare & Medicaid Services, 7500 Security Boulevard, C1-25-05,
Baltimore, MD 21244-1850.”

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