CMS Releases HCAHPS National Pandemic Performance Data

Doctor and nurse reviewing patient information in a hospital bed

Last year, CMS published a table that summarized changes in individual hospital level scores seen during the first three quarters of 2020. Now, they have updated that table to contain data through Q3 2021.

They compared mode and patient mix adjusted top box scores for hospitals that had at least 25 completed surveys each quarter (to yield an annual N of at least 100 surveys). Looking at the same quarters, they also accounted for seasonal fluctuations in the data.

A year ago, we saw that in pre-pandemic quarters, generally, hospitals improved quarter to quarter, although those improvements were always less than one percentage point of a top-box score.

The scores we saw from Q3 2020 showed what felt like surprisingly large decreases from pre-pandemic scores. However, now, we see even larger negative changes for hospitals in Q3 2021 compared to Q3 2019, which mirrors what PRC heard from many of our partner hospitals. CMS anticipates we will see similar scores in Q4 2021 due to the rise of COVID variants.

They also discussed the increased staffing shortages in 2021, and the implications that they had on patient care as measured by the HCAHPS survey. For example, staff responsiveness scores, on average, were 4.39 points lower than in Q3 2019, and to a lesser degree, we see decreases in communications with staff and hospital environment.

2022 HCAHPS National Pandemic Performance Chart
Table V.I.-01, from the IPPS FY2022 Proposed Rule, FR 2022-08268, publication date 05/10/2022

We encourage you to review the discussion in the proposed rule and consider these observed effects when evaluating your own performance during the pandemic. If you have more questions about this proposed rule, please reach out to our CAHPS® team at [email protected].