A survey instrument from the Hospital CAHPS effort will be used to measure and publicly report patients' hospital experiences. A series of meetings with interested parties, a Web chat, and other activities have been held during development of the draft instrument. On January 15, 2003, the draft survey was submitted by the Agency for Healthcare Research and Quality (AHRQ) to the Centers for Medicare & Medicaid Services (CMS). Select for more information about HCAHPS.
To respond to questions about uses for this instrument and its development, CMS and AHRQ are providing information here as well as updating the HCAHPS effort.
Draft Questionnaire Development
Dissemination and Use of the Instrument
Approach to Instrument Development
Next Steps
In July of 2002, AHRQ published a "Call for Measures" in the Federal Register in which we asked organizations to submit items for the CAHPS team's consideration in development of the HCAHPS instrument. We thank those organizations responding to this request. They include:
We reviewed each instrument submitted and found items in each one that stimulated our thinking about items that should appear in the HCAHPS questionnaire and how they might be phrased. In developing the draft HCAHPS survey, we also drew on the following sources of information:
After consulting these sources of information, the CAHPS team developed a draft HCAHPS instrument and submitted it to CMS on January 15, 2003. After obtaining clearance from the Office of Management and Budget (OMB), CMS plans to pilot test this instrument through a contract with the Quality Improvement Organizations (QIOs) in three States (Arizona, Maryland and New York). As part of the OMB clearance process, CMS published a Federal Register notice requesting comments on the draft instrument in February 2003. When the Federal Register notice is published, AHRQ and CMS will provide information on their Web sites about how and where to submit comments. There will be an additional comment period some time in the coming months. A Federal Register notice will be published asking for additional comments on the draft instrument, and AHRQ and CMS will provide information on their Web sites about how and where to submit comments.
| The HCAHPS draft instrument is not in the public domain and may not be used without permission. It is premature at this point to say how closely the final instrument will resemble the draft. The final HCAHPS instrument will be in the public domain, as are all CAHPS® instruments. |
We would like to underscore the fact that the HCAHPS draft sent to CMS is just that: a draft instrument for CMS use in pilot testing. CAHPS® instruments typically undergo extensive testing before the team considers them ready for large scale dissemination and use. Even after that point, we continue to collect information from users concerning how well or poorly the instruments work in practice. Much of this information is obtained through the CAHPS® Survey User Network and such sources as the annual public comment period of the National Committee for Quality Assurance (NCQA) concerning HEDIS measures.
Because of CMS' urgent need for a pilot test instrument, we were only able to conduct a limited amount of cognitive testing. Our plans are to continue to conduct cognitive testing and to obtain additional information through pilot tests being conducted by organizations who have volunteered to collect data with the HCAHPS instrument and share their findings with us.
Because we feel so strongly that the January 15 draft will be greatly improved based on findings from the pilot test and other testing, it is premature to say how closely the final instrument will resemble this first draft. However, we also feel a responsibility to inform the stakeholders who are lending us their support during this enterprise. This has prompted us to send the draft survey to:
The Quality Improvement Organizations (QIOs) conducting the pilot test have also received the draft instrument. In addition, the American Hospital Association has published it on the "Members Only" section of its Web site. Others can access the draft instrument from the following Web site: cms.hhs.gov/regulations/pra/default.asp. This Web site contains CMS' and AHRQ's submission to OMB that includes the draft HCAHPS instrument. Any requestor who wants to collect data with the draft survey must obtain written permission from us. Contact:
Charles Darby
Phone: (301) 427-1324
E-mail: CDarby@ahrq.gov.
As stated, the draft HCAHPS instrument was distributed to a number of stakeholders. A few have commented that this draft resembles instruments developed by the Picker Institute for Patient-Centered Care. These instruments are now owned by the National Research Corporation (NRC).
There are similarities between CAHPS® instruments and the NRC/Picker instruments. One similarity concerns the questionnaire domains-respect for patients' values, preferences and expressed needs; coordination and integration of care; information, communication, and education; and others. We obtained these domains from a report published by the Institute of Medicine (IOM) in 2001, Crossing the Quality Chasm. The IOM based them in part on research performed by a team including the CEO of the former Picker Institute (Gerteis, Edgman-Levitan and Daley, 1993). Another similarity between the CAHPS® and NRC/Picker instruments concerns the CAHPS® decision to measure patients' reports of their experience of hospital care rather than patient's ratings of their experience with this care.
We chose the IOM categories as questionnaire domains for a number of reasons.
After reviewing all sources of information noted here, we have kept all domains proposed by the IOM but added a few of our own.
There is a long-standing debate in the research community concerning the measurement of reports vs. ratings of experience with care. Although this is by no means a resolved issue, the CAHPS® team feels that the weight of the evidence favors providing reports of the various aspects of care (e.g., communication with doctor) rather than ratings of these aspects of care, while providing a few selected overall ratings. We describe the thinking behind this decision and the research that supports it in the Medical Care Supplement, March 1999; Vol. 37, No. 3. The article entitled, "The Use of CAHPS® Cognitive Testing to Develop and Evaluate CAHPS® 1.0 Core Survey Items," is particularly relevant.
We chose the approach described in these two examples because our team of researchers (from Harvard Medical School, RAND, and Research Triangle Institute and in CAHPS II, American Institutes for Research) evaluated the available data, conducted research of our own when possible, and chose what we considered the best possible evidence-based alternative. These decisions may change as we and other organizations conduct and publish research.
In summary: Saying that there are similarities between the NRC/Picker instruments and HCAHPS is accurate. It is inaccurate and unwarranted to interprete these similarities to mean that:
Here is an overview of next steps in the HCAHPS development process: CMS plans to begin the pilot test as soon as it receives OMB clearance. The CAHPS® team will continue testing the draft instrument. There will be an additional comment period on the draft instrument, and a notice will be published in the Federal Register sometime in the future. In the early-to-mid summer, after all testing data and public comments are organized, the CAHPS® team will meet to review and implement recommendations for changes to the draft instrument.
In the near future, CMS plans to administer the revised survey nationwide. Check the AHRQ and CMS Web sites for progress reports as the HCAHPS work continues.
Current as of February 2003
Internet Citation:
Update on Hospital CAHPS (HCAHPS). February 2003. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/qual/cahps/hcahpsupdate.htm
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