The CAHPS initiative is a standardized method for measuring and publicly reporting patient experiences across various healthcare settings. Developed and overseen by the Agency for Healthcare Research and Quality (AHRQ), these surveys collect patient feedback on aspects of care, such as communication and access to services. CAHPS surveys provide a common language for understanding the quality of care delivered by health plans, hospitals, and medical groups. This systematic collection of patient data enables organizations to identify areas for improvement and promotes transparency.
The General Administration Cycle
The administration of CAHPS surveys generally follows an annual cycle, though specific timing varies based on the type of care assessed. Most major programs use a defined period for data collection to ensure comparability. The Centers for Medicare & Medicaid Services (CMS) often mandates specific CAHPS tools for quality programs, linking compliance to reimbursement incentives.
The cycle begins with defining a patient sample, followed by the survey fielding period, and concludes with data submission. Vendors handle sampling, printing, mailing, or initiating electronic and telephone surveys. This fielding phase often spans several months to maximize response rates through multiple contact attempts.
After data collection closes, the final steps involve data validation and submission to a central warehouse. Submission deadlines are rigid and the process is governed by detailed protocols. These guidelines ensure the integrity and comparability of results.
Timing Differences by Survey Type
Timing is heavily influenced by the setting of care being measured. Hospital CAHPS (HCAHPS), which measures experiences after a hospital stay, is administered continuously throughout the year. Hospitals survey a random sample of eligible patients monthly, typically starting the process 48 hours to six weeks after discharge.
Health Plan CAHPS surveys (e.g., Medicare Advantage) are seasonal, concentrating administration into a specific annual window. These surveys are commonly administered in the spring (February to May) to capture experiences over the previous calendar year. This annual collection contrasts with the ongoing, monthly sampling required for HCAHPS.
The Clinician & Group CAHPS (CG-CAHPS) survey, assessing care in physician offices, usually follows an annual cycle. While some groups survey year-round, mandatory reporting for programs like the Merit-based Incentive Payment System (MIPS) often sets a specific annual timeframe. The Outpatient and Ambulatory Surgery CAHPS (OAS CAHPS) survey is also administered continuously throughout the year.
Patient Eligibility and Selection Windows
Patient eligibility is determined by the “look-back” period, which defines the timeframe of care experience the survey covers. For HCAHPS, patients are selected from a random sample of those discharged within a specific window. The survey process is initiated within 42 calendar days of discharge to ensure the patient’s memory of the stay is fresh.
For Health Plan CAHPS, selection focuses on patients enrolled for a substantial period during the prior calendar year. The process involves random sampling of eligible members who meet criteria like continuous enrollment. CG-CAHPS surveys use a six-month reference period, asking patients about experiences over the half-year leading up to administration.
Data Finalization and Public Reporting
After surveys are collected and the submission deadline passes, a period of data finalization and validation begins before results become public. Survey vendors submit raw data to data warehouses, such as those managed by AHRQ or CMS. Here, the data undergoes rigorous quality checks and cleaning to ensure adherence to technical specifications required for public reporting.
The time lag between the end of administration and public release can be substantial, often taking several months to over a year. Data collected throughout a full year may not be publicly reported until the second or third quarter of the following year. Public reporting platforms, such as Care Compare, display finalized scores, typically using a rolling four quarters of data. Facilities are often given a 30-day preview period to review results before public release.