PROGRAM REQUIREMENTS

Overview
This section describes the Program Requirements, which includes roles and responsibilities for
participating organizations, the Rules of Participation and Minimum Survey Requirements to
administer the CAHPS Hospital Survey (HCAHPS). The HCAHPS Rules of Participation listed
below apply to hospitals self-administering the HCAHPS survey, hospitals administering the
HCAHPS survey for multiple sites, and survey vendors. In addition, there are two different sets
of Minimum Survey Requirements: one for self-administering hospitals, and one for survey
vendors. A hospital self-administering the HCAHPS survey (without using a survey vendor)
must meet the Self-administering Hospital Minimum Survey Requirements. Survey vendors and
hospitals administering the HCAHPS survey for multiple sites must meet the Survey Vendor
Minimum Survey Requirements.

Communicating with Patients about the HCAHPS Survey

HCAHPS guidelines allow hospitals/survey vendors to communicate about the HCAHPS survey.
However, certain types of promotional communications (either oral or written) are not permitted
since they may introduce bias in the survey results. Hospitals/Survey vendors or their agents are
not allowed to:

attempt to influence or encourage patients to answer HCAHPS questions in a particular

way
imply that the hospital, its personnel or agents will be rewarded or gain benefits for
positive feedback from patients by asking patients to choose certain responses, or indicate
that the hospital is hoping for a given response, such as a “10” or an “Always”
ask patients to explain why they did not rate a hospital with the most favorable rating
possible
indicate that the hospital’s goal is for all patients to rate them as a “10” or an “Always”
offer incentives of any kind for participation in the survey

Roles and Responsibilities

The following content clarifies the roles and responsibilities of participating organizations.

CMS Roles and Responsibilities

CMS supports the standardization of the survey administration and data collection methodologies
for measuring and publicly reporting patients’ perspectives of hospital care as follows:

Train hospitals/survey vendors to administer HCAHPS surveys

Provide technical assistance via HCAHPS Information and Technical Support and
distribute information about survey administration procedures and policy updates on the
HCAHPS website at: www.hcahpsonline.org
Process data files submitted by hospitals/survey vendors

Centers for Medicare & Medicaid Services 15

HCAHPS Quality Assurance Guidelines