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Frequently Asked Questions About CAHPS
Search or browse for answers to questions about the CAHPS program, patient experience surveys, and the CAHPS Database. Please send additional questions to firstname.lastname@example.org.
What is CAHPS?
CAHPS stands for Consumer Assessment of Healthcare Providers and Systems. The CAHPS surveys ask consumers and patients to report on their experiences with health care services in different settings. The surveys are a product of the Agency for Healthcare Research and Quality's CAHPS program, which is a public-private initiative to develop and maintain standardized surveys of patients' experiences with ambulatory and facility-level care.
Who is responsible for the CAHPS program and its products?
The CAHPS program is funded and administered by the Agency for Healthcare Research and Quality (AHRQ), which works closely with several private and public organizations; this group of organizations is referred to as the CAHPS Consortium. The CAHPS Consortium is responsible for conceiving, developing, testing, and refining the CAHPS survey products. AHRQ also contracts with Westat to support the Consortium, assist users of CAHPS products through the CAHPS User Network, and manage the CAHPS Database.
Public organizations that have supported and worked with the CAHPS Consortium include the Centers for Medicare & Medicaid Services (CMS), which provides additional funding to support the development of specific surveys, the National Cancer Institute, the Centers for Disease Control and Prevention, and the National Institute for Disability and Rehabilitation Research..
What is the role of the Centers for Medicare & Medicaid Services (CMS) with regards to CAHPS surveys?
While AHRQ is responsible for the CAHPS program, both agencies AHRQ and the Centers for Medicare & Medicaid Services (CMS) have funded the development and testing of CAHPS surveys. The key difference between AHRQ and CMS in the context of the CAHPS program is that AHRQ does not sponsor or require the implementation of any of the CAHPS surveys. CMS requires or administers several CAHPS surveys, including ones for hospitals, Medicare Advantage and prescription drug plans, home health care, hemodialysis centers, hospice care, and outpatient and ambulatory surgery centers.
The AHRQ website provides only basic information about the surveys required by CMS; users of those surveys are referred to CMS for the surveys and related documentation.
For information about CAHPS surveys that are or will be administered by CMS, go to: https://www.cms.gov/Research-Statistics-Data-and-Systems/Research/CAHPS/index.
What is the CAHPS User Network?
The CAHPS User Network is the principal source of CAHPS surveys and information about CAHPS-related products and services. User Network staff also provide free technical assistance and facilitate networking among survey users and researchers. It is funded by the Agency for Healthcare Research and Quality and administered by Westat.
When do I use the trademark with the CAHPS name?
The CAHPS name, which is an acronym for Consumer Assessment of Healthcare Providers and Systems, is a registered trademark held by the U.S. Agency for Healthcare Research and Quality. The trademark symbol should be used with the first mention of CAHPS, whether referring to the program, a survey, or another product or service (e.g., CAHPS® Database or CAHPS® Ambulatory Care Improvement Guide). In the context of a document with multiple sections (e.g., a book), it would be appropriate to use the symbol with the first reference to CAHPS in each section.
Using the CAHPS name can be an advantage for survey sponsors because it assures their constituencies and business partners that their data are valid and reliable and that the data are comparable to data from other similar health care organizations. Survey sponsors who wish to use the CAHPS name must field the complete core instrument without making any changes.
What can I say to clinicians who question the value of patient experience data?
While patients may not be the most knowledgeable informants about the technical quality of the care they receive, they are the most knowledgeable about their experiences with care. In addition, the aspects of patient experience addressed by CAHPS surveys represent areas that both patients and providers have indicated are qualities of a "good" provider visit. These areas include communication between providers and patients, accessibility and timeliness of care, and staff courtesy and respect. AHRQ’s CAHPS researchers systematically obtained input on survey content from patients and providers through focus groups, technical expert panels, and interviews.
- Goldstein E, et al. Measuring hospital care from the patients' perspective: An overview of the CAHPS hospital survey development process. Health Serv Res. 2005 Dec;40(6 Pt 2):1977-95.
- Harris-Kojetin LD, Fowler FJ Jr, Brown JA, Schnaier JA, Sweeny SF. The use of cognitive testing to develop and evaluate CAHPS 1.0 core survey items. Med Care. 1999 Mar;37(3 Suppl):MS10-21.
- Fowler FJ. Choosing questions to measure the quality of experience with medical care providers and health care plans. 1997 Proceedings of the Section on Survey Research Methods. 1997, 51-54.
- Weidmer BA, Cleary PD, Keller S, et al. Development and evaluation of the CAHPS (Consumer Assessment of Healthcare Providers and Systems) survey for in-center hemodialysis patients. Am J Kidney Dis. 2014 Nov;64(5):753-760.
- Quigley DD, Martino SC, Brown JA, et al. Evaluating the content of the communication items in the CAHPS Clinician and Group Survey and supplemental items with what high-performing physicians say they do. Patient. 2013 Sept,6(3):169-77.
- McInnes DK, Brown JA, Hays RD, et al. Development and evaluation of CAHPS questions to assess the impact of health information technology on patient experiences with ambulatory care.Med Care.2012 Nov,50(Suppl):S11-9.
- Scholle SH, Vuong O, Ding L, et al. Development of and field-test results for the CAHPS PCMH Survey. Med Care.2012 Nov,50(Suppl):S2-10.
What are the benefits of using CAHPS surveys?
There are several benefits to using CAHPS surveys. First, CAHPS surveys reflect years of research with patients and families to determine how they define quality experiences and how best to ask patients about critical aspects of their healthcare experiences.
Second, CAHPS surveys are available to everyone at no charge from the Agency for Healthcare Research and Quality (AHRQ).
Finally, because these surveys are standardized, health care organizations can use the results to:
- Compare and assess their performance vis-à-vis similar organizations.
- Pinpoint strengths and weaknesses in patients’ experiences.
- Evaluate the effectiveness of interventions to improve specific aspects of patients’ experiences.
When the survey results are reported, health care consumers and purchasers can use the information to compare and evaluate the performance of health plans, hospitals, and providers across the continuum of care and make informed choices.
Do I have to pay or receive permission to use a CAHPS survey?
No. All CAHPS instruments are available for free; you do not need permission to use them within the United States. Users from other countries should request permission from AHRQ. Contact CAHPS1@Westat.com for more information. As with any survey, there are costs associated with fielding the instrument and analyzing the results.
Is patient experience related to the quality of clinical care?
Evidence suggests that patient experience measures are correlated with some other quality measures, including outcomes, and that it is possible to support both better patient experiences and better clinical quality.
Cleary (2016) reported that positive patient experiences is often positively associated with best practice clinical processes, better hospital patient safety culture, lower unnecessary utilization, lower hospital readmissions, and desirable clinical outcomes. In a recent review of the literature, Anhang and colleagues (2014) found that in all but one of nearly three dozen studies (Xu et al., 2015), the correlation between patient experiences and clinical care quality was positive or non-significant.
- Cleary PD. Evolving concepts of patient-centered care and the assessment of patient care experiences; optimism and opposition. J Health Pol, Policy & Law, 2016, 41 (4): 675-696.
- Anhang Price R, Elliott MN, Zaslavsky AM, Hays RD, Lehrman WG, Rybowski L, Edgman-Levitan S, Cleary PD. Examining the role of patient experience surveys in measuring health care quality. Med Care Res Rev 2014, 71 (5):522-54.
- Xu X, Buta E, Price RA, Elliott MN, Hays RD, Cleary, PD. Methodological considerations when studying the association between patient-reported care experiences and mortality. Health Serv Res, 2015, 50 (4): 1146-1161.
Are CAHPS surveys required?
AHRQ does not require the implementation of any CAHPS surveys. However, other organizations, including the Centers for Medicare & Medicaid Services, require the use of certain CAHPS surveys. Please contact the organization or agency that has issued the requirement.
How do CAHPS surveys address informed consent and patient privacy issues?
The CAHPS surveys and guidance documents are designed to meet standards of informed consent and patient privacy consistent with institutional review board policies. Recommendations for recruitment, survey cover letters, and surveys provide the necessary and required information for participants to give informed consent. This information includes:
- The sponsorship and goals of the research.
- The benefits and risks of participation.
- An estimate of the time it will take to complete the survey.
- The names of all organizations who will have access to data or information that participants provide.
- An assurance of confidentiality.
- The name of a contact person.
- Information on how long direct identifiers will be retained.
These requirements apply specifically to the use of CAHPS surveys for research purposes. However, all survey sponsors and vendors should adhere to high standards of privacy and confidentiality protection when conducting CAHPS surveys and handling data. Specifically, CAHPS sponsors and vendors are expected to:
- Inform respondents that their participation is voluntary.
- Take steps to prevent the unauthorized release of CAHPS sampling data and survey responses to third parties.
- Use CAHPS survey responses only for the purposes for which they were collected.
All research activities conducted by the AHRQ CAHPS program to develop CAHPS instruments and reports meet the requirements of 42 CFR 46 (the Common Rule, which applies to research) and 42 CFR 64 (the Health Insurance Portability and Accountability Act [HIPAA], which governs the use of protected health information in operations and research).
The CAHPS Database, which acquires non-identifiable CAHPS data sets for use by researchers and others seeking comparisons for their own CAHPS data, reviews and approves the confidentiality and privacy provisions of all applications for CAHPS data before data will be released to applicants. Organizations requesting the dataset must submit Institutional Review Board (IRB) approval of the proposed research project, or a justification of why IRB approval is not needed for the proposed research.
Where can I find information about the CAHPS surveys implemented by the Centers for Medicare & Medicaid Services?
The Centers for Medicare & Medicaid Services (CMS) implements several CAHPS surveys nationwide:
- Medicare version of the Health Plan Survey (Medicare Advantage and Prescription Drug Plan (MA & PDP) CAHPS Survey)
- Adult Hospital (HCAHPS) Survey
- Accountable Care Organizations (ACO) Survey
- CAHPS for Merit-based Incentive Payment System Survey
- Home Health Care Survey
- In-Center Hemodialysis Survey
- Hospice Survey
- Outpatient and Ambulatory Surgery Survey
- Home and Community-Based Services Survey
The AHRQ CAHPS website provides basic information about these surveys as well as links to the survey instruments, administration specifications, and other instructions available from CMS.
Why are CAHPS surveys standardized?
Standardization is critical to supporting valid comparisons across health care settings and sponsors. This comparability is what makes the information from CAHPS surveys useful for quality improvement as well as public reporting. It also assures users of the results that the validity and reliability built into the instrument by the survey developers is maintained by the survey's sponsors.
While we recognize and support the need for survey sponsors to customize the questionnaire to meet the needs of their organizations and markets, certain aspects of CAHPS surveys are standardized:
- The instrument. The contents and format of CAHPS questionnaires are standardized so that everyone administering the survey is asking the same questions in the same way. However, sponsors are free to add additional questions following the CAHPS items to meet their own needs.
- Data collection protocol. The protocol for fielding the survey is standardized so that everyone adopts the same approach to drawing the sample, communicating with potential respondents, and collecting the data. This is important because the method of survey administration can affect the results.
- Analyses. CAHPS surveys include a set of analysis programs and instructions to minimize variations in how sponsors and vendors score and interpret the results of the survey.
- Reporting. CAHPS investigators have developed well-tested approaches to presenting survey results.
What's the process for developing a CAHPS survey?
All CAHPS surveys go through a similar development process that involves multiple steps. This process is designed to gather and apply input from patients, families, and stakeholders and to ensure the reliability and usefulness of CAHPS patient experience measures.
CAHPS survey development steps include:
- Identification of domains to be measured in the survey.
- Review of the literature.
- Collection and review of existing instruments and related measures (through calls for measures in the Federal Register and the collection of public domain instruments).
- Opportunities for stakeholder input and review (through Technical Expert Panels and requests for comments in the Federal Register).
- Focus groups with consumers or patients.
- Development of reliable and valid survey items and procedures.
- Cognitive interviews with potential survey respondents.
- Revisions to reflect findings from cognitive testing.
- Field testing and psychometric analysis of field test results.
- Final revision of the survey to reflect findings from field tests.
Learn more: Crofton C, Darby C, Farquhar M, Clancy CM. The CAHPS Hospital Survey: development, testing, and use. Jt Comm J Qual Patient Saf. 2005 Nov;31(11):655-9, 601.
How do I know that the results of CAHPS surveys will be reliable and accurate?
Two different and complementary approaches are used during the development of a CAHPS survey to assess its reliability and validity:
- Cognitive testing, which bases its assessments on feedback from people who are asked to react to the survey questions.
- Psychometric testing, which consists of analyses of data collected using the questionnaire.
Cognitive testing provides useful information about respondents' comprehension of the questions, their ability to answer the questions, and the adequacy of the response choices. It also helps identify terminology that can be used accurately and consistently across a range of consumers (e.g., commercially insured, Medicaid, fee-for-service, managed care, lower socioeconomic status (SES), middle SES, low literacy, higher literacy) and assesses whether key words and concepts are expressed equally well in both English and Spanish.
Field tests and psychometric analyses provide information about the items' reliability and validity. Many existing questionnaires about health care have been tested primarily or exclusively using a psychometric approach. The CAHPS research team views the combination of cognitive and psychometric approaches as essential to producing the best possible survey instrument.
- Hargraves JL, Hays RD, Cleary PD. Psychometric properties of the Consumer Assessment of Health Plans Study (CAHPS) 2.0 adult core survey. Health Serv Res. 2003 Dec;38(6 Pt 1):1509-27.
- Solomon LS, Hays RD, Zaslavsky AM, Ding L, Cleary PD. Psychometric properties of a group-level Consumer Assessment of Health Plans Study (CAHPS) instrument. Med Care. 2005 Jan;43(1):53-60.
- Keller S, O'Malley AJ, Hays RD, Mathew RA, Zaslavsky AM, Hepner KA, Cleary PD. Methods used to streamline the CAHPS Hospital Survey. Health Serv Res. 2005 Dec;40(6 Pt 2):2057-77.
- Levine RE, Fowler FJ Jr, Brown JA. Role of cognitive testing in the development of the CAHPS Hospital Survey. Health Serv Res. 2005 Dec;40(6 Pt 2):2037-56.
- Harris-Kojetin LD, Fowler FJ, Brown JA, et al. The use of cognitive testing to develop and evaluate CAHPS 1.0 core survey items. Med Care. 1999 Mar,37(3 Suppl): MS10-21.
- Read about cognitive testing in the context of healthcare quality reports.
For what reading level are CAHPS surveys designed?
CAHPS surveys are intended for use across a wide range of literacy levels. As part of the development process, independent consultants have evaluated the questionnaires and recommended ways to lower the reading level. The questionnaires have also undergone extensive cognitive testing across all population groups to reach the desired reading level.
The Health Plan Survey is at a sixth grade reading level. While many Medicaid programs are mandated to provide written materials at the fourth grade reading level, the questionnaires necessarily include topics and word choices that could only be reduced to the sixth grade level. The reading level of the Clinician & Group Survey is seventh grade. Some of the supplemental items available for these CAHPS surveys are even more complex, and as a result have a higher reading level.
The CAHPS team encourages use of layout, spacing, and type styles that optimize the readability of the survey questions. However, if you anticipate that the reading level of the survey will be a problem for your sampled population, you may want to conduct the survey over the telephone.
- Fongwa MN, Setodji CM, Paz SH, et al. Readability and missing data rates in CAHPS 2.0 Medicare survey in African American and white Medicare respondents. Health Outcomes Res Med 2010 July;1(1): e39-49.
- Fredrickson DD, Jones TL, Molgaard CA, et al. Optimal design features for surveying low-income populations. J Health Care Poor Underserved. 2005 Nov;16(4):677-90.
- Morales LS, Weidmer-Ocampo B, Hays RD. Readability of CAHPS 2.0 child and adult core surveys. Seventh Conf Health Survey Res Methods 2001 Feb. 83-90.
- Brown JA, Nederend SE, Hays RD, et al. Special issues in assessing care of Medicaid recipients. Med Care. 1999 Mar;37(3 Suppl):MS79-88.
Why does CAHPS repeat the reference period in every question?
The reference period is the time period the respondent is being asked to consider when answering the question. CAHPS instruments use an explicit reference period to standardize the assessment of quality across survey respondents. Questions that fail to make reference periods explicit leave room for the respondents to interpret the items differently. In particular, without a specified reference period, respondents with varying enrollment histories might base their answers on different periods of time. A person who has been enrolled in a health plan for 5 years could answer about the previous 5 years, while a person enrolled for 8 months could respond about those 8 months.
What are the response scales for CAHPS surveys?
All CAHPS surveys use three different response scales:
- 0–10 Scale.
- Yes/No or Yes, definitely/Yes, somewhat/No.
Why do CAHPS surveys present response options with the negative wording first?
CAHPS surveys present the never-to-always response options in the order from "never" to "always." Studies have shown that respondents tend to be reluctant to use negative response options. Putting the negative responses first yields a better distribution of responses.
- Kalton G, Collins M, Brook C. Experiments in wording opinion questions. Appl Stat. 1978:27,149-161.
- Krosnick JA, Alwin DF. An evaluation of a cognitive theory of response-order effects. Public Opinion Q. 1987:51,201-219.
- Dillman DA, Brown TL, Carlson JE, Carpenter EH, Lorenz FO, Mason R, Saltiel J, Sangster RL. Effects of category order on answers to mail and telephone surveys. Rural Sociology 1995 60(4):674-687.
Why do CAHPS surveys use a 0 to 10 rating scale and not an adjectival rating scale?
During the cognitive testing phases for the original CAHPS Health Plan Survey, the development team examined four alternative rating scales:
- Excellent, very good, good, fair, poor.
- Very good, good, OK, not very good, not good at all.
- Excellent, very good, good, OK, not very good, not good at all.
- A scale from 0 to 10, where 0 is as bad as something can be, 10 is as good as something can be, and 5 is okay or average.
The research team considered four criteria to determine that the 0 to 10 rating scale compares favorably with any of the adjectival alternatives:
- Psychometrics. In general, having more response alternatives is better in terms of reliability and discrimination.
- Appropriateness for self-administration and telephone use. An advantage of the 0 to 10 response task is that respondents have no difficulty in retaining awareness of all the response alternatives on the telephone. Respondents have more trouble with the task of recalling five or six adjectives.
- Appropriateness for use in other languages. An advantage of the 0 to 10 task is the ease of translation of numbers from one language to another. In particular, the words "fair" and "poor" are difficult to translate into Spanish in a way that retains equivalent distance between categories.
- Respondent acceptance. When respondents were asked about their preferences among the various rating scales outlined above, the numerical rating was as acceptable to respondents as the adjectival ratings.
What is the rationale for the format of the mail questionnaires?
The self-administered mail questionnaires are formatted so that the questions are clearly displayed and easy to read. The two-column format, white space, font type, and font size (12-point) all help to enhance readability and comprehension.
Although this format means that CAHPS surveys may have more pages than survey instruments that use a smaller font and compressed spacing, the response burden is acceptable; most respondents are able to complete a survey of 50 to 65 items in about 15 minutes or less.
Why are CAHPS surveys formatted in two columns?
The CAHPS surveys use a two-column format because it reduces the number of pages in the surveys and is user-friendly. The two-column format has been tested with a variety of consumers including Medicare beneficiaries. Results show that respondents are comfortable using the two-column format to complete the CAHPS surveys.
Why are the CAHPS materials available in only one foreign language (Spanish)?
The CAHPS research team develops and tests surveys in English and Spanish. The number of Spanish speakers in the United States was a factor in the decision to produce a Spanish-language translation of the surveys. According to U.S. census data, Spanish is the most common non-English language spoken in homes in the United States. A second factor was that the questionnaires and other materials could be translated into Spanish using terms that are understood by almost all Spanish speakers, including those who speak different dialects. This is not the case with other languages.
If a sponsor needs to field a CAHPS survey in a language other than English or Spanish, are there any resources available to support this?
The CAHPS website offers guidance on translating surveys and other materials. You can learn about a recommended process involving parallel translations and a translation review committee. You can also read about the roles of the translators and the translation reviewer, the qualifications that each should have, and the process of selecting individuals or translation firms to fulfill these roles.
The Centers for Medicare & Medicaid Services also provides translations in multiple languages for the CAHPS surveys it implements. Please visit the CMS websites for those surveys.
What determines the topics covered by CAHPS surveys?
To identify survey topics, the developers of CAHPS surveys review the relevant literature and conduct qualitative research with patients and their families, providers, and other stakeholders to determine what they think are important aspects of care. This research typically involves focus groups and key informant interviews.
Topics are limited to those for which consumers and patients are the best and/or only source of information. CAHPS surveys do not attempt to collect information that can be gathered more accurately through other means (e.g., through medical records or from healthcare providers). The survey developers also focus on identifying issues that are salient to patients and influence their decisions, such as the communication skills of providers and access to services.
This exhaustive formative research produces a set of potential domains of interest and, for many domains, potential questions. The developers then confirm the appropriateness and usefulness of these domains and questions through cognitive testing and field testing of the survey.
Why don't CAHPS surveys collect information on technical quality?
Technical quality of care is usually assessed by measuring outcomes such as morbidity, mortality, and/or health-related quality of life, or by assessing process measures that have been shown in studies to be related to outcomes. Assessing technical quality accurately often requires detailed information about a patient's medical condition, as well as care processes that are not directly observed by patients and/or outcomes that are best measured a substantial period after the care is provided. This information typically comes from administrative records and medical charts.
Although patients can report accurately about certain processes (e.g., whether they received a flu shot), CAHPS surveys are usually not the best way to assess technical quality of care because most patients do not have all the necessary information to make such assessments.
- Gillies RR, Chenok KE, Shortell SM, Pawlson G, Wimbush JJ. The impact of health plan delivery system organization on clinical quality and patient satisfaction. Health Serv Res. 2006 Aug;41(4 Pt 1):1181-99.
- Rollow W, Lied TR, McGann P, Poyer J, LaVoie L, Kambic RT, Bratzler DW, Ma A, Huff ED, Ramunno LD. Assessment of the Medicare quality improvement organization program. Ann Intern Med. 2006 Sep 5;145(5):342-53.
How do the CAHPS surveys deal with patient visits for urgent or immediate care?
Both the Health Plan Survey and the Clinician & Group Survey include a question about how often people were able to get urgent or immediate care (i.e., care they needed right away).
Do CAHPS surveys ask about health status? How do they use this information?
The CAHPS surveys all ask at least one question about overall health (excellent, very good, good, fair, poor). Some also ask a similar question about perceived mental health. Other questions are included in selected surveys for specific reasons. For example, the Medicare versions of the CAHPS Health Plan Survey have a longer set of items, including some related to the SF-12.
Analysts and sponsors use health status items in three ways:
- To describe the respondents.
- To examine the different experiences of those who have special needs and make higher demands on their health plans.
- To adjust the results to account for this difference in populations across plans.
Health status usually is positively related to patients' reports about their care. If units that are being compared (e.g., plans) differ significantly in the composition of the populations they serve with respect to health status, that difference could account for different ratings and answers.
Analyses conducted by the CAHPS research team show that the single question on self-reported health status alone accounts for almost all the variance in ratings of health care and health plans that can be associated with health status. Adding other items from the SF-12 or a Chronic Condition List adds very little to the ability to adjust populations in this way. A question about global mental health does contribute to explaining between-unit variations and thus is recommended in some CAHPS applications including the Medicare fee-for-service version of the Health Plan Survey.
Why are race and ethnicity separate items in CAHPS surveys?
The CAHPS race and ethnicity items were developed by the Federal Office of Management and Budget in order to create standard measures for use by Federal agencies and others to collect uniform data on race and ethnicity. Race and ethnicity are often used for descriptive purposes in analyses and presentations of CAHPS data.
Do I need special permission to modify CAHPS surveys to better suit my organization's needs?
You do not need permission to modify a CAHPS survey. Users are free to add CAHPS supplemental items or items of their own choosing. However, if you delete core items from the questionnaire (i.e., items necessary to create the composite measures), the survey is no longer comparable to other CAHPS surveys and cannot use the CAHPS name.
Furthermore, analyses have shown that modifications to the survey can cause context or order effects. That is, if you insert a question into a survey, it can alter the response pattern for the subsequent question; responses to this survey may no longer be comparable to responses to an unmodified survey.
Learn more about modifying CAHPS surveys.
Who sponsors a CAHPS survey?
CAHPS surveys are sponsored by a variety of healthcare organizations. These organizations range from providers seeking to assess their patients’ experiences with care to public agencies and multistakeholder organizations that are measuring and comparing patient experience across a community or region. In most cases, the sponsor of a CAHPS survey contracts with a vendor to administer the survey, collect the data, and analyze the results.
AHRQ does not administer any of the CAHPS surveys.
How long does it take to complete a CAHPS survey?
Most CAHPS surveys can be completed in 15 minutes or less. However, the amount of time required to complete a CAHPS survey depends on the use of additional (supplemental) items, the medium (self-administered or interviewer-administered), and the formatting.
For example, the formatting of the mail questionnaires (available in Word and PDF) is an important design feature that makes it easier for respondents to complete the questionnaires correctly and quickly.
Will the length of a questionnaire affect the response rate?
Survey sponsors often express concern that longer survey instruments yield significantly diminished response rates. Research conducted by members of the CAHPS team and others indicates only negligible loss in response rates in longer surveys.
- CAHPS Survey Administration: What We Know and Potential Research Questions (PDF, 738 KB; 15 pages).
- A summary of a research meeting on advances in survey methodology
- Burkhart Q, Orr N, Brown JA, et al. Associations of Mail Survey Length and Layout With Response Rates. Med Care Res Rev. 2019 Nov.
Can AHRQ recommend a vendor to administer the CAHPS survey?
AHRQ does not certify or approve survey vendors and does not recommend vendors of CAHPS surveys. Some organizations that require CAHPS surveys also approve vendors for administering the survey. These lists of approved CAHPS vendors might be a good resource if you are trying to identify vendors with experience conducting CAHPS surveys.
To learn more, please read: Hiring a vendor for a CAHPS survey.
What are the recommended modes for survey administration?
Based on several studies, the CAHPS research team generally recommends mail and/or web surveys with follow-up by telephone for those who do not respond to the initial invitation. This approach tends to result in higher response rates than any single method alone. In addition, the characteristics of the respondent pool yielded by this mixed mode are closer to those of the total population. This is because the types of people who do not respond to mail surveys differ from those who do not respond to telephone surveys; in essence, the nonresponse biases balance out. For similar reasons, a mixed mode with mail or telephone follow-up is also recommended after a web administration.
Personal interviews are generally more expensive, but they may be necessary to gather information from certain populations in specific healthcare settings, such as nursing home residents. The CAHPS research team cannot recommend the use of other survey modes until the potential mode effects are better understood. The CAHPS team is continuing to assess the feasibility of other techniques and the possibility of mode adjustments to compensate for differences.
Learn more in a summary of a research meeting on advances in survey methodology.
Why isn't web only (i.e., without follow-up by mail or telephone) a recommended mode of administration?
Web-based surveying is an increasingly popular mode of survey administration given its cost-effectiveness. However, the CAHPS research team has found that healthcare organizations are unlikely to have valid email addresses for a representative portion of their patient or enrollee population. Further, research indicates that a web-based administration, by itself, of CAHPS surveys consistently yields the lowest response rates. Therefore, to minimize nonresponse bias and increase response rates, web administration is currently recommended only as part of a mixed mode protocol.
How many returned questionnaires are needed to get reliable data for CAHPS surveys?
The goal is to get enough responses to generate scores that have sufficient precision (reliability) to allow you to identify meaningful differences in the data. The document with guidance on how to field each survey (for example, Fielding the CAHPS Clinician & Group Survey [PDF, 554 KB; 30 pages]) suggests a target number of completed questionnaires for that survey, assuming reliability of 0.70 or above at the appropriate unit of analysis. For the Health Plan Survey, for example, the guidance suggests aiming for 300 completed questionnaires for each health plan product.
What is the basis for the target number of completed surveys?
The target number of completed surveys recommended in the survey administration guidance is based on the number of completed surveys needed for the majority of survey users to achieve reliability of 0.70 across all measures in the core survey. The CAHPS research team determines these targets by examining data from field tests; over time, the targets may be re-evaluated and refined based on implementation data.
Reliability is a way of determining how well the survey results can differentiate between the units of comparison, such as health plans or practice sites. A 0.70 level of reliability balances the need for a sufficient level of reliability for “high stakes” uses of the survey results, such as payment incentives, with the desire to minimize the number of completed surveys required. More completed surveys generally mean higher levels of reliability.
The actual reliability of your results will vary, depending on the number of units being compared as well as the variation in results among those units. As users gain experience with the survey, they can calculate the reliability of their own data and adjust the target number of completed surveys.
How do I determine how many surveys to distribute to achieve the target number of completed surveys?
Your starting sample size is a function of the target number of completed surveys and the anticipated response rate. For example, the target number of completed surveys for the CAHPS Health Plan Survey is 300 per plan. Based on previous surveying experience, you may estimate that your response rate is 40 percent. Your starting sample would then be 750 (or 300/0.40).
You may also want to make adjustments for poor contact information or other types of data errors that may result in non-response.
Is it possible to achieve the target response rate with the recommended survey administration mode?
The CAHPS team's studies indicate that a mixed-mode protocol involving a mail or web questionnaire combined with telephone follow-up achieves sufficiently high response rates. A phone-only or phone-followed-by-mail protocol may also achieve the target response rate. It is difficult, however, to achieve the target response rates with a mail questionnaire only. Learn more in CAHPS Survey Administration: What We Know and Potential Research Questions (PDF, 738 KB; 15 pages).
How are scores for composite measures calculated?
The standard practice when analyzing and reporting CAHPS results is to aggregate responses across all respondents in a given entity (e.g., health plan) and then combine related items into composite measures. Thus, these measures are summaries of the responses to the questions in that composite.
The CAHPS Analysis Program (also known as the CAHPS macro) calculates composite scores for the unit of comparison (e.g., health plan, physician practice) by summing the responses of the items in that composite measure. The macro basically calculates a mean of each item for all those who responded to that item and then calculates the mean of the individual item means.
How and why do you combine the response categories for the "never/sometimes/usually/always" composite measures?
The CAHPS research team recommends combining the never and sometimes response options, resulting in three categories: (1) never or sometimes, (2) usually, and (3) always.
Analyses of CAHPS survey data have shown that respondents rarely pick the "never" response option. For example, typically less than five percent of respondents pick "never" in response to the question, "How often did doctors or other health care providers listen carefully to you?" In addition, combining "never" and "sometimes" simplifies the presentation of survey results while sacrificing little information.
What are case mix adjusters and how are they incorporated into a CAHPS survey?
CAHPS survey results can be adjusted to account for external factors such as respondent age or other socio-demographic characteristics that are beyond the control of the entity (e.g., health plan, practice site) but may affect the entity’s scores. Without such adjustment, score differences between entities could be due to differences in external factors rather than true differences in performance on the CAHPS measures. CAHPS surveys include items to collect demographic data to use as case-mix adjusters.
Are programs available to help me analyze the data from CAHPS surveys?
Yes. The CAHPS Analysis Program (also referred to as the CAHPS macro) is a free program written for SAS (version 6.0 or later) that enables survey users to conduct the analyses needed to produce valid comparisons of performance across similar health care organizations. Available for use with all CAHPS surveys, the macro adjusts the data for case mix, generates a distribution of survey results for each of the measures, calculates the average score for both individual survey items and composite measures, and indicates whether an entity’s scores are statistically different from the average.
To download the CAHPS macro and instructions for its use, visit: https://www.ahrq.gov/cahps/surveys-guidance/helpful-resources/analysis/index.html.
Can the CAHPS Analysis Program be used for analysis of supplemental items?
The CAHPS Analysis Program (the CAHPS macro) is very flexible and can be used for analyses of all survey questions, including supplemental items.
Learn more about analyzing CAHPS survey data: https://www.ahrq.gov/cahps/surveys-guidance/helpful-resources/analysis/index.html.
Can I get support with analyzing CAHPS survey data?
Users of CAHPS surveys can download the CAHPS Analysis Program (the CAHPS macro) as well as guidance on preparing the data for analysis and instructions for using the program at https://www.ahrq.gov/cahps/surveys-guidance/helpful-resources/analysis/index.html.
Contact the CAHPS Help Line at email@example.com or 1-800-492-9261 with specific questions about data analysis. This assistance is also free of charge.
Why should my organization participate in the CAHPS Database?
Participation in the CAHPS Database confers several benefits related to the use of survey findings for quality improvement and ongoing research. Organizations that voluntarily submit survey data:
- Receive a Private Feedback Report in Excel comparing their own CAHPS survey results to relevant groups (for example, by region, size, ownership, and specialty).
- Gain access to a large and growing pool of aggregated results that can complement the client averages available from survey vendors.
- Contribute to a research database that is used to answer important questions related to assessing and improving the patient experience.
All organizations also have access to annual Chartbooks that present summary-level survey results by selected characteristics (region, sector, facility size, etc.).
Is it mandatory for users of CAHPS surveys to submit data to the CAHPS Database?
Participation in the CAHPS Database is entirely voluntary. AHRQ encourages all survey sponsors to submit data, since the broader the participation, the more valuable and representative the resulting data for comparison purposes.
I am interested in submitting data to the CAHPS Database. What is required?
New users must complete a registration form to access the CAHPS Database. Prior to data submission, each participating organization is required to sign a Data Use Agreement that can be uploaded via the submission site. Users must also must also upload a copy of their CAHPS survey so that it can be reviewed for compliance with Database requirements. For technical assistance with data submission, please email CAHPSDatabase@westat.com.
Do I need a survey vendor to submit data to the CAHPS Database?
It is not necessary to use a vendor to submit survey data. The CAHPS Database is open to all organizations that are able to follow the submission requirements.
Does the CAHPS Database provide comparative information for the commercial version of the CAHPS Health Plan Survey?
The CAHPS Database no longer collects or reports CAHPS Health Plan Survey data for commercial health plans. Please direct questions about survey data for commercial health plans to the National Committee for Quality Assurance (NCQA) at CAHPS@ncqa.org.
The CAHPS Database collects and provides comparative Health Plan Survey results for Medicaid and CHIP plans.
Who has access to individual organization or program results in the CAHPS Database? Can organizations see one another's results?
Names of submitting organizations (e.g., health plans, medical groups, state agencies, home and community-based service providers, etc.) are never released to the general public. They are only released in private feedback reports provided to the submitting organization. Results shown in the online reporting system and made available to the public are aggregated to a summary level. The results of individual organizations are not reported. Researchers must submit a proposal to gain access to the de-identified data files, which do not include any organization identifiers.
Does the CAHPS Database provide comparative information for Medicare CAHPS?
The CAHPS Database does not collect data for the Medicare version of the Health Plan Survey (known as Medicare CAHPS) or support a comparative database for that survey. However, aggregated results for Medicare managed care plans are included for comparison purposes in the Health Plan Survey Chartbook and the Online Reporting System.
What does it cost to participate in the CAHPS Database?
There is no charge to participate in the CAHPS Database. Maintenance of the CAHPS Database is supported by the Agency for Healthcare Research and Quality (AHRQ).
Why do CAHPS surveys use composite measures?
A composite measure summarizes the answers to two or more related survey questions or items. They are useful for two reasons. First, composites can represent concepts that are too complex to be measured with a single item. For example, the concept of "good doctor-patient communication" touches on a variety of issues, such as how well a doctor listens to patients, how clearly a doctor explains things, and whether a doctor establishes and maintains a personal connection to patients. A single item about any one of these issues would provide only part of the picture on doctor-patient communication; a composite, on the other hand, gives the bigger picture.
Second, using composite measures helps consumers evaluate the information quickly and easily. Research shows that when people get too many pieces of information at once, their ability to process that information is compromised. Composite measures summarize several pieces of information to assist consumers in making sense of the survey findings.
How are composite measures developed?
The development of composite measures for a CAHPS survey involves both quantitative and qualitative analyses. CAHPS researchers do psychometric testing to assess how strongly the questions relate to one another, how well a composite measure captures a concept, and how strongly the composite measure relates to other measures.
The Consortium also uses a variety of qualitative methods, including focus groups, small group interviews, and one-on-one cognitive interviews (a technique that involves soliciting consumers' thoughts in real-time as they examine information) to decide whether the ways in which questions are asked and grouped together in composite measures make sense to consumers. These methods also help in evaluating consumers' understanding of the labels created for the composite measures and whether those labels call to mind the kinds of questions that are grouped in the measures.
Can we incorporate responses to our own questions into existing composite measures?
No. The CAHPS Consortium advises against adding other items to the CAHPS composite measures. All sponsors of a given CAHPS survey produce composite measures with the same set of core items to ensure that survey results are standardized and comparable.
Survey items are grouped into composite measures based on two criteria: (1) the items all relate to conceptually similar events and (2) the items have a demonstrated statistical relationship. Also, in most cases, the response options to questions in composite measures are the same.
Adding other items to existing composite measures changes the measurement properties of the measures (even if the items seem pertinent to the existing composite measure), which makes comparisons between different sponsors' surveys impossible and poses the risk of confusing report users.
One option is to include other items that you believe are similar to a composite measure in the same section of a public or private report. For example, a sponsor may ask health plan members questions that seem similar to CAHPS items about getting information from written materials, filling out paperwork, and getting help from customer services. Members' responses to these questions could be reported in the same section of a report as the Health Plan Information and Customer Service composite measure.
How can I make the statistical significance of differences in performance apparent to readers?
Many report sponsors want to show whether differences across plans or providers are statistically significant. Others are concerned that when the number of survey respondents is very large, small differences may be statistically significant.
If you decide to present information on statistical significance in a report, it is important to ensure that this additional information does not mislead readers or get in the way. Charts using word icons or symbols to present results can be constructed so that providers are only portrayed as "better" or "not as good" if their scores are, in fact, statistically different. Those worried about high sample sizes can set a minimum absolute difference that must be observed, in addition to statistical significance, to be reported to the public. When reporting absolute data, as in bar graphs, you can include text to warn users not to pay too much attention to very small differences. If you use this approach, specify numerically what you mean by a "very small difference."
The scores for some items and composite measures show almost no variation across providers. Can we eliminate these scores from the report?
The CAHPS Consortium recommends including all composite measures in public reports. The public may be interested in the general level of performance, even when there is little, if any, variation. If performance is high, then they may decide not to worry about that issue and focus on areas where there are differences or low scores. If performance is low, on the other hand, there are two reasons to report that information:
- First, publicly reported information tends to galvanize quality improvement efforts more than quality information that is not publicly reported.
- Second, policy makers and purchasers may recognize that a low or mediocre level of performance is widespread and take steps to drive quality improvement across the board.
Should a CAHPS report include information about methodology?
All readers need to know that the scores come from a survey of a large number of consumers about their experiences with healthcare. It is also helpful to note that the data have been collected and analyzed by an independent and objective source, in order to convey that the information can be trusted.
Longer and more detailed information about methodology is of interest to two groups of readers: those who want to read about it and those who want to know it is there but are unlikely to read it. It should be placed where interested readers can readily find it, but should not be in the way of those who want to get directly to the information they care about. This generally means making it accessible on a lower-level page on a website or putting the information toward the end of the report.
Can CAHPS survey results be reported at the level of individual patients?
No. CAHPS surveys are designed to assess patients’ experiences with an entity (e.g., a health plan, a hospital, a clinic, a clinician) and support comparisons of healthcare quality across those entities. The survey results should not be used to assess an individual’s experience with care or compare one person’s experience to the experiences of others. They should also not be used to initiate unsolicited follow-up with individual patients.
Can CAHPS survey results be reported at the level of individual patients?
No. CAHPS surveys are designed to assess patients’ experiences with an entity (e.g., a health plan, a hospital, a clinic, a clinician) and support comparisons of healthcare quality across those entities. The survey results should not be used to assess an individual’s experience with care or compare one person’s experience to the experiences of others. They should also not be used to initiate unsolicited follow-up with individual patients.