OAS CAHPS 101: What HOPDs and ASCs need to know about this patient survey

If your hospital is Medicare-certified, chances are you’ve heard of the Outpatient and Ambulatory Surgery Consumer Assessment of Healthcare Providers & Systems, or OAS CAHPS. Survey development began in 2012, and it received CAHPS accreditation in 2015. In 2024, it became mandatory for HOPDs—and ASCs will follow suit in 2025. It’s vital to understand how this patient experience assessment works and its impact on your organization. Let’s remove the mystery and explore some key basics. 

What is OAS CAHPS?

Developed by the Centers for Medicare & Medicaid Services (CMS), the OAS CAHPS Survey collects patient care feedback in Medicare-certified hospital outpatient departments (HOPDs) and ambulatory surgery centers (ASCs). This survey gathers vital statistics about patient perspectives and assists with measuring patient experiences on care for a specific facility.

What is the OAS CAHPS reporting period?

OAS CAHPS surveys are administered on an ongoing basis. HOPDs should target 300 completed surveys annually, while ASCs should target 200 completed surveys over a 12-month reporting period once it becomes mandatory in 2025. Survey results from HOPDs and ASCs that collect and report the data to CMS are publicly available on the Provider Data Catalog website. This transparency step motivates high performance among HOPDs and ASCs and encourages patients to make informed decisions when selecting a facility for a surgery or procedure.  

Is participation in the OAS CAHPS Survey mandatory?

Yes—or soon will be. The OAS CAHPS Survey became mandatory for HOPDs in the beginning of 2024. It will become mandatory for ASCs in 2025. Noncompliant organizations are subject to annual rate reductions in their Medicare payments. All OAS CAHPS results are or will be publicly reported. 

OAS CAHPS became mandatory for HOPDs early in 2024. It will become mandatory for ASCs in 2025.

What types of questions does the survey ask?

OAS CAHPS contains 34 questions related to patients’ experiences. It asks things about communications with doctors, nurses, and staff about a surgery or procedure; HOPD or ASC cleanliness; preparation for discharge and recovery; overall rating of the facility; and willingness to recommend the facility to others. The survey also poses several basic demographic questions.  

How do I administer the OAS CAHPS Survey?

As CMS designed OAS CAHPS to be implemented nationally, with the objective of publicly reporting facility-level results, survey administration is standardized. Currently, Press Ganey offers three CMS-permitted administration modes: a digital-first mixed mode (initial email surveying and follow-up by mail or phone to non-respondents), mail-only, and telephone-only.

Why is it important to conduct OAS CAHPS?

These surveys enable your organization to better understand patient pain points, identify strategic actions you can take to improve patient experience, and generate real-time data that helps drive decision-making. Assessing this information can help you successfully align your team’s practices with standards of care and compare your organization’s performance to state and national averages.

Why should ASCs prepare before the OAS CAHPS Survey becomes mandatory in 2025?

ASCs should get ready now to streamline processes, ensure compliance with this patient experience measure, and ultimately elevate the delivery of care. 

What are the penalties for noncompliance with mandatory OAS CAHPS?

The Hospital Outpatient Quality Reporting Program (OQR) and the Ambulatory Surgical Center Quality Reporting (ASCQR) Program are pay-for-reporting, quality data programs administered by CMS. OAS CAHPS became a mandatory measure as part of the OQR in 2024 for HOPDs, and it will become mandatory as part of the ASCQR beginning in 2025 for ASCs. HOPDs and ASCs that do not administer and report OAS CAHPS when it becomes mandatory could be subject to a penalty of 2% of their annual Medicare payment update.   

Are there penalties or incentives tied to performance on OAS CAHPS?

Currently, the OQR and ASCQR programs do not base payments on performance related to measuring patient experiences. While other CAHPS surveys are utilized in pay-for-performance programs (e.g., HCAHPS VBP program), this is not currently contemplated for implementation of OAS CAHPS mandatory surveys in 2024-5.

How does my organization conduct OAS CAHPS Surveys?

To begin, it’s important to contact and work with a CMS-certified survey vendor. A reputable organization will advise you on next steps, equip you with necessary elements to implement OAS CAHPS, and ensure your company leaders are updated with any important regulatory announcements. Press Ganey goes beyond the basics, streamlining your survey delivery with a robust suite of automated and manual tools, complementary offerings to help drive score improvement, consulting solutions, industry-leading expertise, and compliance management.  

Can the OAS CAHPS survey be administered electronically?

CMS began allowing for web-based OAS CAHPS surveying via email in 2022, the first time the organization has accepted any digital regulatory surveying. Offering additional electronic modes allows patients more options when responding to the survey, ultimately providing your organization with more insights from a broader range of patients. To ensure accessibility, digital surveying is administered as a mixed mode with either mail or phone.

How do OAS CAHPS scores and these new measurement modes benefit patients?

OAS CAHPS gives patients the opportunity to provide feedback on many aspects of the care received from your organization. Offering additional electronic modes will allow patients more options when responding to the survey, ultimately providing your organization with more insights from a broader range of patients. Measuring patient experience results can help organizations make productive changes, improving overall safety and quality at the patient level.

How do OAS CAHPS scores help various types of healthcare teams improve care delivery?

By quantifying patient experience, OAS CAHPS provides organizations with tangible insights regarding opportunities for improvement. As these surveys are focused explicitly on critical healthcare aspects, as opposed to amenities, your team can generate a clear and targeted understanding of specific gaps in care.

While HOPDs are already well underway with the OAS CAHPS mandate, some ASCs may just be getting started. Either way, it’s important to know what’s expected. This includes discussing reporting periods, annual survey volume requirements, administration modes, and partnering with a verified survey vendor, like Press Ganey, when implementing or continuing with OAS CAHPS. 

Get in touch with a Press Ganey policy expert to see how we can help you prepare, make the transition smoother, and start leveraging patient feedback for quality improvement. 

Updated: July 10, 2024