What is HCAHPS: A Comprehensive Overview

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What is HCAHPS?

In the realm of hospitals and healthcare organizations, the term “HCAHPS survey” is a recurrent presence:

Hospital Administrator A: “The latest HCAHPS survey results just came out, and patients seem satisfied with…”

Hospital Administrator B: “Some of our past patients participated in the HCAHPS survey, but they expressed disappointment with…”

You might be left wondering, “What exactly is the HCAHPS survey?”

Allow me to elucidate.

The HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) is a standardized national survey that publicly reports patients’ satisfaction with and perspectives of their hospital experiences. Also known as the CAHPS® Hospital Survey, it is the first standardized survey ever developed that comprehensively evaluates patient experiences. While numerous hospitals conduct patient surveys for internal insights, HCAHPS introduces a uniform set of metrics and benchmarks, enabling valid comparisons of hospitals and patient experiences across the nation. There are three broad goals of the CAHPS® Hospital Survey: provide consumers with the means to compare hospital services, incentivize hospitals to improve their quality of care by publicly reporting scores, and enhance healthcare accountability and transparency. 

Delving into HCAHPS Survey Metrics

There are 19 substantive dimensions on which patient experiences are evaluated. An additional 10 items serve to align patient responses, account for variations among patients, and solidify the overall reporting integrity. These 29 items may sound exhaustive, but each item is critically important to understanding hospital experiences, as hospitals transition to a more outcome and value-based healthcare model.

The 19 substantive items aim to uncover patient perspectives on:

  • Communication with Nurses
  • Communication with Doctors
  • Responsiveness of Hospital Staff
  • Communication about Medicines
  • Discharge Information
  • Care Transition
  • Cleanliness of the Hospital Environment
  • Quietness of the Hospital Environment
  • Overall Rating of Hospital
  • Recommendation of Hospital

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HCAHPS Survey Participants and Administration

The HCAHPS is administered to random samples of adult patients between 48 hours and six weeks post-discharge. Patients are eligible if they were admitted to the medical, surgical, or maternity care service lines. Eligible patients must:

  • Be at least 18-years-old
  • Have stayed overnight at the hospital as an inpatient for at least one night
  • Be alive at the time of discharge
  • Have a non-psychiatric Medicare Severity-Diagnosis Related Group (MS-DRG)/principal diagnosis at discharge

There are some instances where patients satisfy the above criteria but are considered ineligible. For more information, visit the HCAHPS FAQs.  

For a hospital to participate in the HCAHPS survey, it must satisfy the requirements found on the Quality Assurance page of the HCAHPS website. Hospitals can use a professional survey vendor or can conduct their own HCAHPS surveys (only if preapproved by the Center for Medicare & Medicaid Services (CMS)). HCAHPS can be administered in four different modes: Mail Only, Telephone Only, Mail with Telephone follow-up, or Active Interactive Voice Response (IVR). The survey is available in the following languages in at least one format:

  • English
  • Spanish
  • Chinese
  • Russian
  • Vietnamese
  • Portuguese
  • German
  • Tagalog
  • Arabic

Unveiling HCAHPS Survey Results

Completed surveys are sent to the HCAHPS data warehouse where CMS cleans the data, analyzes the findings, and calculates the official scores. Official hospital-level HCAPHS scores are publicly reported on the Care Compare page found on Medicare.gov. Aggregate HCAPHS scores (current and historical) can be found in the Summary Analyses section of the Official HCAHPS website.

Leveraging HCAHPS Survey Insights

Hospitals can use HCAHPS survey results for self-improvement and to compare themselves to hospitals at the local, regional, and national levels. It is important to note here that HCAHPS is not designed for comparison within hospitals (ward to ward, floor to floor, nurse to nurse, etc.) or for assessing the performance of individual staff members. 

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Impact of the HCAHPS Survey on Hospitals

HCAHPS scores can influence your hospital’s number of overall patient visits, admission rates, and public image. When emergencies arise, customers will rush to a hospital that they believe suits their needs and quality standards. A quick glance at an HCAHPS report can lead patients to approach hospitals with greater scores, even if farther away from their residences. Hospitals with higher scores will have better reputations and therefore be highly trusted by the community. While this can increase the inflow of patients through your doors, it is important to always be prepared and maintain the highest quality of care. 

Moreover, HCAHPS can offer hospitals valuable insights that might elude their internal observations. In the high-pressure environment of a hospital, it is easy to overlook some workflow hiccups. HCAHPS highlights dimensions where the hospital falls short of meeting patient expectations, granting them a third-person perspective. This external viewpoint is instrumental in guiding hospitals to enhance their services and approach patient care with empathy.   

More recently, CMS has adopted HCAHPS scores as the foundation for disbursing Medicare payments to acute care facilities. The introduction of HCAHPS aims to synchronize hospital incentives with the overarching policy goal of delivering an exceptional patient experience.

It is important to highlight that a significant portion of HCAHPS survey questions—over half, to be precise—are linked to provider-patient communication. To put it simply, hospitals that encourage a strong culture of effective communication in healthcare can thereby ensure its manifestation in elevated HCAHPS scores.

Strategies for Hospital Readiness

On that note, let’s quickly review 5 ways in which hospitals can improve their HCAHPS scores.

1. Prioritize Effective Communication:

Hospitals should place a strong emphasis on fostering clear and open communication between healthcare providers and patients. It is essential to educate staff members on the value of empathetic communication and active listening, and the implementation of regular communication training programs can significantly enhance their interpersonal skills.

Additionally, hospitals should prioritize technology integration, empowering providers with an elevated communication channel for streamlining collaboration and information sharing regarding patients. The goal is to create a reliable source of truth for patient-related communication, encompassing alerts, communication from various providers and urgent notifications from diverse medical systems.

One way to stay prepared is to make sure you have an effective clinical communication and collaboration tool at your disposal. Remember that pagers are notably unreliable and fail to be HIPAA-compliant. OnPage’s HIPAA-compliant clinical communication platform offers secure messaging, a native on-call scheduler, and critical alerting that can override a smartphone’s silent and do-not-disturb modes. For more information, schedule a FREE 30-minute demo.

2. Enhance Staff Responsiveness

Streamlining processes to reduce wait times and overall responsiveness can have a profound impact on the patient experience. Staff training programs should focus on promptly addressing patient needs and concerns, underlining the crucial role of responsiveness in healthcare delivery. Integrating technology, such as real-time communication systems, further improves staff responsiveness.

3. Focus on Patient Education

Developing comprehensive patient education programs in crucial for increasing patient understanding of medical conditions and treatments. Providing educational materials in accessible formats and languages ensures effective communication to diverse patient populations. Healthcare providers should allocate dedicated time during appointments to thoroughly educate patients.

4. Improve Environment and Amenities

Enhancing the physical environment of the healthcare facility, including cleanliness and comfort, contributes significantly to an overall positive patient experience. Investing in amenities, such as comfortable waiting areas and quality meal options, positively influences patient perceptions. Regular assessments of the facility’s ambiance are necessary to identify and address any issues impacting the patient experience.

5. Implement Follow-Up Procedures

Establishing post-discharge follow-up procedures allows healthcare providers to monitor patient progress and address any post-treatment concerns. Encouraging patients to provide feedback after discharge and using this information for continuous improvement is crucial. Leveraging technology, such as live call routing, facilitates care provider accessibility, enabling patient to reach on-call care teams by dialing one dedicated phone number to communicate their medical needs urgently.

At its core, you’ll notice that these five approaches tie into communication in some form or the other. Improving communication elevates care delivery, which transcends to improved HCAHPS scores.


Now that you have a more in-depth understanding of the HCAHPS, your hospital should regularly review HCAHPS score to ensure it is providing the highest quality of care possible. 


Is the HCAHPS survey for both inpatient and outpatient care?
No, the HCAHPS survey only records an individuals experience of their inpatient care. 
Does the HCAHPS survey measure the quality of medical care and patient outcomes?
No, HCAHPS only collects and reports on information about the patient experience and communication, not the patient’s medical outcome.
Can HCAHPS data be used to evaluate and improve internal departments' performance?
Yes, by analyzing your organization’s specific results, teams can identify areas where they may need improvement and focus on performance in those areas.

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