June 2021
National Implementation of the Hospital Consumer
Assessment of Healthcare Providers and Systems
(HCAHPS) Survey
(CMS 10102, OMB 0938-0981)
OMB Supporting Statement - Part A
Prepared by
Division of Consumer Assessment & Plan Performance
Centers for Medicare & Medicaid Services 7500 Security Boulevard
Baltimore, MD 21244
TABLE OF CONTENTS
Section Page
3. Use of Information Technology 6
8. Federal Register/Outside Consultation 9
9. Payments/Gifts to Respondents 10
12. Burden Estimates (Hours & Wages) 11
14. Cost to the Federal Government 12
16. Publication/Tabulation Dates 13
18. Certification Statement 13
EXHIBITS
Exhibit A-1: Annual Hours/Cost Burden of the HCAHPS Survey….…………… 11
LIST OF ATTACHMENTS
Attachment A -- HCAHPS Survey Instrument (Mail) and Supporting Material
Attachment B -- HCAHPS Survey Instrument (Telephone) and Supporting Material
Attachment C -- HCAHPS Survey Instrument (Interactive Voice Response) and
Supporting Material
Attachment D -- Sixty Day Federal Register Notice – HCAHPS (inserted later)
OMB SUPPORTING STATEMENT – Part A:
National Implementation of the Hospital CAHPS Survey
(CMS-10102, OMB-0938-0981)
The HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems)
Survey is the first national, standardized, publicly reported survey of patients’ perspectives of their hospital care. HCAHPS is a 29-item survey instrument and data collection methodology for measuring patients’ perceptions of their hospital experience. Since 2008, HCAHPS has allowed valid comparisons to be made across hospitals locally, regionally and nationally.
Three broad goals have shaped HCAHPS. First, the standardized survey and implementation protocol produce data that allow objective and meaningful comparisons of hospitals on topics that are important to consumers. Second, public reporting of HCAHPS results creates new incentives for hospitals to improve quality of care. Third, public reporting enhances accountability in health care by increasing transparency of the quality of hospital care provided in return for the public investment.
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 that support Congressionally-mandated reports. (See
Attachment A: HCAHPS Survey Instrument (Mail) and Supporting Materials.)
Since March of 2008, results from the HCAHPS survey have been publicly reported. Currently
HCAHPS results are publicly reported on the new Care Compare Web site, https://www.medicare.gov/care-compare/?providerType=Hospital&redirect=true, and in the new
Provider Data Catalog, https://data.cms.gov/provider-data/dataset/dgck-syfz
The HCAHPS Survey and its implementation protocols can be found in the current version of the HCAHPS Quality Assurance Guidelines (Version 15.0, March 2020), located at: www.hcahpsonline.org/en/quality-assurance/.
Beginning in 2002, CMS partnered with the Agency for Healthcare Research and Quality (AHRQ), another agency in the federal Department of Health and Human Services, to develop and test the HCAHPS Survey. AHRQ and its CAHPS Consortium carried out a rigorous and multi-faceted scientific process, including a public call for measures; literature review; cognitive interviews; consumer focus groups; stakeholder input; a three-state pilot test; extensive psychometric analyses; consumer testing; and numerous small-scale field tests. CMS provided three separate opportunities for the public to comment on HCAHPS and responded to over a thousand comments. The survey, its methodology and the results it produces are in the public domain.
In May 2005, the HCAHPS Survey was endorsed by the National Quality Forum, a national organization that represents the consensus of many healthcare providers, consumer groups, professional associations, purchasers, federal agencies, and research organizations. In December 2005, the federal Office of Management and Budget gave its final approval for the national implementation of HCAHPS for public reporting purposes. CMS implemented the HCAHPS Survey in October 2006 and the first public reporting of HCAHPS results occurred in March 2008.
Enactment of the Deficit Reduction Act of 2005 created an additional incentive for acute care hospitals to participate in HCAHPS. Since July 2007, hospitals subject to the Inpatient Prospective Payment System (IPPS) annual payment update provisions ("subsection (d) hospitals") must collect and submit HCAHPS data in order to receive their full annual payment update.
The incentive for IPPS hospitals to improve patient experience was further strengthened by the Patient Protection and Affordable Care Act of 2010 (P.L. 111-148), which specifically included HCAHPS performance in the calculation of the value-based incentive payment in the Hospital Value-Based Purchasing program beginning with October 2012 discharges.
As noted above, there are three broad goals of the HCAHPS Survey. These goals are of value to consumers and providers of health care services as well as to CMS. First, the standardized survey and implementation protocol produce data that allow objective and meaningful comparisons of hospitals on topics that are important to consumers. Second, public reporting of HCAHPS results creates new incentives for hospitals to improve quality of care. Third, public reporting enhances accountability in health care by increasing transparency of the quality of hospital care provided in return for the public investment. HCAHPS scores have been publicly reported on the Hospital Compare Web site since 2008 and since 2012 have been used in the payment determination for Inpatient Prospective
Payment System (IPPS) hospitals that participate in the Hospital Value-Based Purchasing
(Hospital VBP) program. HCAHPS scores are also used in the CMS PPS-Exempt Cancer Hospital program and Comprehensive Care for Joint Replacement program, in other federal and state government programs, in hospital rating services such as Consumer Reports and U.S. News & World Report, in hospital quality improvement projects, and in scholarly research and publications.
The national implementation of HCAHPS is designed to allow third-party CMS-approved survey vendors to administer HCAHPS using mail-only, telephone-only, mixed-mode (mail with telephone follow-up), or active IVR (interactive voice response).
With respect to a telephone-only or mixed-mode survey, the CMS-approved survey vendors use electronic data collection or CATI systems. CATI is also used for telephone follow-up with mail survey non-respondents. With respect to IVR survey administration, the IVR technology gathers information from respondents by prompting respondents to answer questions by pushing the numbers on a touch-tone telephone. Patients selected for IVR mode are able to opt out of the interactive voice response system and return to a “live” interviewer if they wish to do so. There are numerous advantages to administering a telephone interview using a CATI system or IVR technology, including the following:
costs less than in-person data collection
allows for a shorter data collection period
allows for less item nonresponse because the system controls the flow of the interview
increases data quality by allowing consistency and data range checks on respondent answers
creates a centralization of process/quality control
reduces post-interview processing time and cost
CMS has tested new modes for the HCAPHS Survey, specifically a Speech Enabled Interactive Voice Response mode and a Web-based mode, but concluded at that time that issues stemming from differences in response rate and mode effects across implementations make such models unsuitable for the HCAHPS Survey at this time. Results of the investigation for using these modes of survey implementation are presented in Elliott, Brown, et al. (2013),
“A Randomized Experiment Investigating the Suitability of Speech-Enabled IVR and Web
Modes for Publicly Reported Surveys of Patients’ Experience of Hospital Care”, Medical Care Research and Review, 70 (2): 165-184.
In recent years, CMS has received feedback from hospitals, hospital associations, survey vendors, and other stakeholders requesting the option to administer the survey using a web mode as an alternative to the existing approved modes. Separate from this OMB PRA package, under the “Application to Use Burden/Hours from Generic PRA Clearance: Testing of Web Survey Design and Administration for CMS Experience of Care Surveys (CMS-10694, OMB 09381370”, CMS plans to test an e-mail HCAHPS survey as the first mode in three novel mixed mode designs: email-mail, email-telephone, and email-mail-telephone.
The HCAHPS Survey does not require a signature from respondents. In fact, all information obtained through the survey is reported in the aggregate and no individual respondent’s information is ever reported independently or with any identifying information.
HCAPHS collects information that is fundamentally different from other CAHPS or patient experience of care surveys. CMS is not aware of any existing validated survey instrument where the unit of analysis is the acute care hospital and the focus of the survey is patient reported experience of care. The information collected through this survey will therefore not duplicate any other effort and is not obtainable from any other source.
Many hospitals carry out their own patient experience of care surveys. These diverse, proprietary surveys do not allow for comparisons across hospitals. Making comparative performance information available to the public assists consumers in making informed choices when selecting an acute care hospital and creates incentives for facilities to improve the care they provide.
Hospitals are not generally considered to be small businesses. All hospitals have the option to conduct HCAHPS as a stand-alone survey or to integrate it with their existing survey activities. They can choose to administer HCAHPS by mail, phone, mail with telephone follow-up, or active IVR. Costs associated with collecting HCAHPS will vary depending on:
The method hospitals currently use to collect patient survey data,
The number of patients surveyed (target is 300 completed surveys per year)
Whether it is possible to incorporate HCAHPS into their existing survey
Some smaller hospitals that participate in HCAHPS might be unable to reach the target of 300 completed surveys in a 12-month period. In such cases, the hospital should sample all discharges (census) and attempt to obtain as many completes as possible. HCAHPS scores based on fewer than 100 or 50 completed surveys are publicly reported but the lower reliability of these scores is noted by an appropriate footnote. CMS does not publicly report HCAHPS scores based on 25 or fewer completed surveys.
Great effort was expended considering how often HCAHPS data should be collected. We solicited and received much comment on this issue when HCAHPS was being developed. Two options for the frequency of data collection were suggested: once during the year, or continuous sampling. The majority of hospitals/vendors suggested continuous sampling would be easier to integrate into their current data collection processes. Thus we decided to require sampling of discharges on a continuous basis (i.e., a monthly basis) and cumulate these samples to create rolling estimates based on 12- months of data. We chose to pursue the continuous sampling approach for the following reasons:
It is more easily integrated with many existing survey processes used for internal improvement
Improvements in hospital care can be more quickly reflected in hospital scores (e.g.,
12- month estimates could be updated on a quarterly or semi-annual basis)
Hospital scores are less susceptible to unique events that could affect hospital performance at a specific point in time
It is less susceptible to gaming (e.g., hospitals being on their best behavior at the time of an annual survey)
There is less variation in time between discharge and data collection
Less frequent data collection would result in a longer gap between when survey respondents experienced hospital care, and when their survey results were publicly reported, which would diminish the value of HCAHPS data in public reporting and hospital quality improvement efforts.
There are no special circumstances associated with this information collection request.
The 60-day Federal Register notice published in the Federal Register on 03/31/2021 (86 FR 16739).
CMS received one comment, from a nurses association, that requested the HCAHPS Survey list each type of provider, change the label of the current “Your Care from Doctors” measure to “Your Care from Providers”, and specifically ask patients about communication with and care from advance practice nurses, including nurse practitioners.
CMS responded that, the reason the HCAHPS Survey refers generally to “nurses” and “doctors” is that, during the development and consumer testing of the HCAHPS Survey, CMS found that while patients were able to distinguish nurses from doctors, patients typically cannot remember, identify, or distinguish among the different types of nurses and doctors who treated them during their hospital stay. As such, CMS declined to modify the survey in the manner suggested in the comment.
The 30-day Federal Register notice published in the Federal Register on 06/17/2021 (86 FR 32268).
.
There are no provisions for payments or gifts to survey respondents.
All information obtained through the HCAHPS Survey is reported in the aggregate. No individual respondent’s information is reported independently or with identifying information.
We have designed the data files so that the hospital/vendor submits a de-identified dataset to CMS. No protected health information is submitted to CMS. In all the modes of survey administration, guidelines are included on issues related to confidentiality:
Cover letters are not to be attached to the survey
Respondents’ names do not appear on the survey
Interviewers are not to leave messages on answering machines or with household members since this could violate a respondent’s privacy
Please see HCAHPS Quality Assurance Guidelines, V15.0, pp. 53-54, for detailed information on patient confidentiality, www.hcahpsonline.org/en/quality-assurance/.
There are no questions of a sensitive nature on the HCAHPS Survey.
To calculate the cost for survey respondents, we use the Average Hourly Earnings of $29.96 as reported by the U.S. Bureau of Labor Statistics, preliminary January 2021 estimates at https://www.bls.gov/eag/eag.us.htm (last modified February 24, 2021). The HCAHPS survey averages approximately 2,839,017 participating survey respondents (completed surveys) a year, as evidenced throughout the 2018 through 2019 reporting periods. We utilize HCAHPS data from CY 2019 because CMS made HCAHPS data collection and submission optional in Q1 and Q2 2020 due to the impact of the COVID-19 public health emergency on hospitals.
As such, 2019 is the most recent complete year of HCAHPS data.
On average, it takes respondents 7.25 minutes (0.120833 hours) to complete the survey, for a total 343,047 hours annual burden (2,839,017 respondents by 0.120833 hours). The annual cost burden of the HCAHPS Survey for survey respondents is thus $10,277,718 (343,047 total respondent hours X $29.96 average hourly earnings).
Number of Total Average Hourly Estimated Data Collection
HCAHPS Survey Respondents Burden Hours Earnings* Cost to Respondents
Total 2,839,017 343,047 $29.96 $10,277,718
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*Average Hourly Earnings of $29.96, based on average hourly earnings of all employees on private nonfarm payrolls, seasonally adjusted, preliminary January 2021 estimates, U.S. Bureau of Labor Statistics.
Since 2018 the number of hospitals participating in HCAHPS has been fairly stable at approximately 4,500 hospitals for each four quarter period through December 2019. Over the next three years, we anticipate that about 4,600 hospitals will participate in HCAHPS. To derive average costs for hospitals, we estimate an amount of $4,000 per hospital for HCAHPS data collection activities, the annual cost burden totaling $18,400,000. Assuming a one hour per hospital time cost, the annual burden for hospitals is 4,600 hours.
In total, the annual cost burden of the survey is:
(survey respondents $10,277,718) + (hospitals $18,400,000) = $28,677,718.
The annual hour burden is:
(survey respondents 343,047) + (hospitals 4,600 hours) = 347,647 hours.
Hospitals have the option to conduct HCAHPS as a stand-alone survey or to integrate it with an existing survey. Hospitals can choose to administer HCAHPS by mail, phone, mail with telephone follow-up, or active IVR. Costs associated with collecting HCAHPS will vary depending on:
The method hospitals currently use to collect patient survey data
The number of patients surveyed (target is 300 completed surveys per year)
Whether it is possible to incorporate HCAHPS into their existing survey
Over the next three years, we anticipate that about 4,600 hospitals will participate in HCAHPS. Using the estimate of $4,000 per hospital for HCAHPS data collection, the annual cost burden is $18,400,000.
Costs to the government include: hospital/vendor training and technical assistance; approving hospitals/vendors for conducting surveys; ensuring the integrity of the data; accumulating the data; analyzing the data; making adjustments for patient-mix and mode of administration; and public reporting. The annual cost to the Federal Government is estimated to be $3,500,000.
Since 2018, the number of hospitals participating in HCAHPS has been fairly stable at approximately 4,500 hospitals. We estimate that the number of hospitals will increase to about 4,600 over the next three years. Using the estimate of $4,000 per hospital for HCAHPS data collection, the annual cost burden has increased to $18,400,000.
The amount of time needed to complete the HCAHPS Survey has not changed, but the number of respondents has decreased since the previous PRA approval in 2019, resulting in a lower annual hour burden. However, the increase in the average hourly wage has resulted in a higher annual cost burden for respondents.
Since October 2006, the HCAHPS Survey has been administered on a continuous basis. From
March 2008 to December 2020, HCAHPS results were publicly reported on the CMS Hospital Compare website four times per year. Beginning in 2021, HCAHPS results are publicly reported on the CMS Care Compare Web site,
https://www.medicare.gov/carecompare/?providerType=Hospital&redirect=true, and in the Provider Data Catalog, https://data.cms.gov/provider-data/dataset/dgck-syfz four times per year. This pattern will continue into the foreseeable future.
CMS will display the OMB number and expiration date. This information appears inside a box at the beginning of the mail survey and in the OMB Paperwork Reduction Act language, which is placed either in the survey cover letter, or in the survey instrument.
The proposed data collection does not involve any exceptions to the certification statement.
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| File Title | National Implementation of the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) Survey |
| Author | Christine Payne |
| File Modified | 0000-00-00 |
| File Created | 2021-06-18 |