Confirm that your hospital is enrolled in the Hospital IQR program and that your selected HCAHPS survey vendor is on the CMS-approved vendor list published on the HCAHPS website.
Ensure the survey vendor administers the HCAHPS instrument using an approved mode (mail, telephone, interactive voice response, or mixed mode) within the required eligibility and timing window — typically within 6 weeks of discharge for eligible adult inpatient discharges.
Transmit discharge records (eligible patient sample) to the vendor in the required format and on the schedule specified in the CMS HCAHPS Quality Assurance Guidelines.
The vendor submits the survey results to the HCAHPS Data Warehouse; do not attempt to submit HCAHPS data directly — only approved vendors may submit.
After the quarterly data submission deadline, use the HCAHPS Online reporting tools or the QualityNet portal to review your facility's top-box scores and case mix adjustment results.
Compare your reported HCAHPS scores to the data posted on Care Compare (Medicare.gov) to confirm consistency before the official public release date.
Known gotchas
HCAHPS data must be submitted by an approved vendor; hospitals that attempt to self-administer without CMS vendor approval or submit data outside the approved mode will have their data rejected.
The HCAHPS patient eligibility criteria exclude specific patient populations (psychiatric patients, patients discharged to hospice, and others); including ineligible patients inflates the denominator and can trigger data quality flags.
HCAHPS scores publicly reported on Care Compare reflect a rolling 4-quarter average; a single bad quarter may not move the reported score much, but sustained underperformance accumulates over multiple reporting periods.
Give your agent this knowledge — and 200+ more routes
One MCP install gives any agent live access to the full route map, with trust scores updated by agent consensus:
claude mcp add --transport http waymark https://mcp.waymark.network/mcp