Reporting And Data

MBQIP - Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS)

Latest Update: August 11, 2020

Reporting Information

Part of the Medicare Beneficiary Quality Improvement Project (MBQIP), the intent of the HCAHPS initiative is to provide a standardized survey instrument and data collection methodology for measuring patients’ perspectives on hospital care. While many hospitals have collected information on patient satisfaction, prior to HCAHPS there was no national standard for collecting or publicly reporting patients’ perspectives of care information that would enable valid comparisons to be made across all hospitals. The HCAHPS Survey is composed of 29 items: 19 items that encompass critical aspects of the hospital experience (communication with nurses, communication with doctors, responsiveness of hospital staff, communication about medicines, discharge information, care transition, cleanliness of the hospital environment, quietness of the hospital environment, overall rating of hospital, and recommendation of hospital); three items to skip patients to appropriate questions; five items to adjust for the mix of patients across hospitals; and two items to support congressionally-mandated reports.

Responsible Party

Who Must Report?

Critical Access Hospitals (CAHs)


When Do I Report?

Hospitals are encouraged to send their data file to their vendor at least monthly (more often if appropriate). Quarterly deadlines for HCAHPS data submission to CMS are listed on the HCAHPS website and coincide with the beginning of January, April, July, and October. Following the HCAHPS data submission deadline, survey vendors will have a one week opportunity to correct data previously submitted for the quarter.


How Do I Report?

All CAHs in Nevada submit data files to a contracted HCAHPS vendor which then submits data to CMS on the hospitals' behalf. Hospitals must ensure that the vendor is authorized in QualityNet. NRHP currently has a group contract with J.L. Morgan.

Contact Information

Becky Bayley, MBA
Director of Strategic Initiatives

Nevada Rural Hospital Partners
4600 Kietzke Lane, Suite I-209
Reno, NV 89502

Phone: (775) 827-4770


Laima Etchegoyhen, MPH
Outreach and Technical Assistance Coordinator
Nevada Flex Program Coordinator

Office of Statewide Initiatives
University of Nevada, Reno School of Medicine
604 West Moana Lane, MS 3150
Reno, Nevada 89509

work-phone: 775-682-8471
cell-phone: 775-338-9841

website: https://med.unr.edu/statewide


Why Should I Report?

Potential loss of grant funding for not meeting eligibility requirements.

Publicly Displayed

Link to the website/ranking/grading/etc. where the data is published

Results and a star rating are displayed on Hospital Compare for those facilities with large enough volume.


The legal mandate requiring reporting

MBQIP Memorandum of Understanding (MOU)


Any other pertinent information

For more information go to: https://hcahpsonline.org/en/

Although many of these requirements apply to individual medical professionals and other types of hospitals and health care facilities, the information is presented solely to support Critical Access Hospitals. The reporting requirements and legal mandates on this site are not an exhaustive list and Nevada Rural Hospital Partners, Inc. bears no responsibility or liability for any hospitals' or providers' failure to comply with Federal or State laws or regulations.