9 Key Points to Consider When Administering Patient Surveys Such as CAHPS for MIPS

Last Updated: Apr 24, 2018

By Tara Gensemer, CAHIMS; Practice Support Specialist for PAMED’s Practice Support Team

CAHPS-for-MIPS-articlePatient input is essential when addressing value-based care. Administering a patient satisfaction survey is one tool providers can use to listen to the patient, change with the marketplace, and improve your practice. A survey can show your community your commitment to quality and that you realize there is a need for improvement.

As a practice, you can determine your level of survey participation — Consumer Assessment of Healthcare Providers and Systems for the Merit-based Incentive Payment System (CAHPS for MIPS), the Clinician and Group CAHPS (CG-CAHPS) Survey, or a general patient satisfaction survey.

Participation in CAHPS for MIPS is an optional quality measure for groups of two or more eligible clinicians. This is not a measure available to individual clinicians. Your group can also earn points under the improvement activities category for administering the survey. Please note that CAHPS for MIPS is not appropriate for practices that do not include primary care.

How to Administer the Survey for a Quality Measure

To administer the survey for a quality measure, your group must complete these steps:

Step 1 — Elect to participate in CAHPS for MIPS by registering on the Quality Payment Program website (qpp.cms.gov). An Enterprise Identity Management (EIDM) account is needed to log in. To register for an EIDM visit the Centers for Medicare and Medicaid Services (CMS) Enterprise Portal (portal.cms.gov).

Groups must indicate they are participating in the CAHPS for MIPS survey.  Please note: The registration period for 2019 data submission ended on June 30, 2019. This does not mean you needed to administer your survey by this date.  This time period only applies to registration for the survey.

Step 2 — Select and authorize a CMS-approved survey vendor to collect and report your survey data to CMS. This list of 2019 approved vendors is available via CMS' QPP Resource Library.

It is important for you to monitor your performance throughout the process. Make sure patients are participating. The survey will be administered in three stages:

  1. CMS pre-notification letter
  2. Two survey mailings
  3. Up to six phone calls

Scores will be provided to you from CMS and will be available for public reporting on Physician Compare.

For solo clinicians, CAHPS for MIPS is not an option, but you can still administer the CG-CAHPS survey. The survey will offer you feedback on your practice as well as earn your practice 20 points toward Improvement Activities for MIPS. Vendors can administer your survey in the same manner as CAHPS for MIPS and provide feedback from your patients. Vendors distribute surveys based on a 6- or 12-month look-back, or visit specific, and are distributed in two waves, either by mail or email.

If your goal is to only solicit feedback for improvement and not meet a quality measure, a general patient satisfaction survey would be appropriate. Many templates are available online and through specialty societies.

Elizabeth Woodcock, medical group operations consultant, says, “I always encourage physicians to begin the survey process by looking at CG-CAHPS. It’s lengthy, but it’s available for free and has some really good elements.”

Rather than reinventing the wheel, practices can use the CG-CAHPS survey in its entirety, customize it, or use selected questions.* To view and download the CG-CAHPS survey, visit the Agency for Healthcare Research (ARHQ) at www.ahrq.gov.

9 Key Points to Consider When Administering Your Survey

Almost ready to administer your patient survey? Here’s what to consider before you do:

  1. Sample size — Try to survey the largest group possible. Optimal response rate is usually 10 to 20 percent. For example, a sample size of 300 surveys would optimally yield 50 responses.
  2. When distributing a paper-based survey, to prevent a missed opportunity, hand out the survey the same way each time.
  3. Paper-based, e-delivery, telephone, or a combination of the three could be used.
  4. Include demographic data — A patient experience can even vary based on the type of health plan they participate in.
  5. Act on key items that are causing dissatisfaction.
  6. Using feedback, organize an improvement process focused on weaknesses.
  7. Include one or two open-ended questions like, “What are we doing well?” or “What can we improve?”
  8. Ensure anonymity.
  9. Keep patients informed of your progress; it makes patients feel appreciated for their time.

Distribution and data analysis of a general survey would fall on the hands of the practice liaison. This person analyzes the data, provides updates, and encourages staff by keeping them informed; assuring them the main goal of the survey is to improve quality.

The quality improvement team should consist of individuals from each area of the practice to share ideas, determine workflow, and assess staffing needs to implement change based on the results of the survey.

While you don’t have to act on every patient suggestion, you should take action on key items that are causing dissatisfaction. Remember your goal is to improve quality, not to place blame.** If you commit to a patient satisfaction survey, commit to acting on the results. In return, chances are you will not only work toward improving your practice, you will gain a cooperative and fulfilled patient.


*How You Can Use Patient Satisfaction Surveys to Improve Performance” [Internet]: The Profitable Practice; [cited 2014 Mar 19]. Available from: https://www.softwareadvice.com/resources/use-patient-satisfaction-surveys-to-improve-performance/

**“Measuring Patient Satisfaction: How to Do it and Why Bother” [Internet] Leawood (KS): Family Practice Management; [cited Vol. 6/No. 1 (Jan, 1999)]. Available from: www.aafp.org/fpm/1999/0100/p40.html

A version of this article appeared in the fall 2017 issue of
Pennsylvania Physician Magazine, PAMED’s print magazine, and was reprinted with permission.

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