Patient Experience Survey

Dispelling the myth of CG-CAHPS

There is a great deal of uncertainty in the healthcare environment related to payment reforms and CMS participation requirements. Healthcare professionals find themselves inundated with vague, seemingly conflicting and often misleading information surrounding patient experience surveying, particularly whether fielding a CAHPS survey is mandated by CMS or other agencies. When practices don’t completely understand the regulatory reform intricacies, they often default to doing more than is necessary, just to be safe. This leads to unnecessary stress and spending.

The CAHPS Clinician & Group Survey (CG-CAHPS) is one of several surveys in the Agency for Healthcare Research and Quality’s family of CAHPS surveys. Each CAHPS survey evaluates a specific type of health care service. CG-CAHPS is focused on the assessment of patients’ experiences with healthcare providers and other staff members in doctors’ offices.

MYTH: The CG-CAHPS survey is a requirement for all medical practices.

FACT:  For groups or practices participating in the Merit-based Incentive Payment System (MIPS), use of any CAHPS survey (including CG-CAHPS) is OPTIONAL and COMPLETELY VOLUNTARY.

The Quality Payment Program (QPP) has two tracks you can choose:

  • Advanced Alternative Payment Models (APMs) or
  • The Merit-based Incentive Payment System (MIPS)

If your practice is already participating in an Advanced Alternative Payment Model (APM), then you may already be using a CAHPS survey as a requirement of that APM program. If your practice does not currently participate in an APM, then you should check you MIPS participation status (if you have not done so already) by going to The great news is that MIPS has changed much of the regulatory requirements for patient experience surveying.

In the age of consumerism, collection of the voice of the customer is a vital business tool and choosing a high-quality vendor is imperative.

If you meet QPP requirements and choose the MIPS option, then use of a patient experience survey is optional, BUT it can also be used to meet a required Improvement Activity.

There are 3 options within the Improvement Activity category related to patient experience surveying:

  1. Using a CAHPS survey or supplemental questionnaire to measure the patient experience
  2. Collection of patient experience and satisfaction data to improve access to care
  3. Collection of patient experience and satisfaction data to improve beneficiary engagement

In the age of consumerism, collection of the voice of the customer is a vital business tool and choosing a high-quality vendor is imperative. In evaluating a survey vendor, it is important to question whether their survey instrument includes:

  • Items related to access to care and patient engagement metrics
  • Data reported in real-time so that decisions on improvements are relevant
  • Data reported over time so that your practice can measure improvements
  • Benchmarking – including national, CG-CAHPS and practice
  • Monthly report cards for ease of review and dissemination
  • A HIPAA compliant platform
  • A free text comment opportunity to capture voice of the customer
  • A specialty-specific survey to capture your practice’s unique characteristics

Choosing the right survey provider can help you meet your business objectives and most importantly, improve your patient’s perception of your practice. It starts with measurement….and ends with success.

Categories : Blog

About Author

Stephanie Sargent

    As the Chief Clinical and Quality Officer, Stephanie oversees the continued development of the Physician Empowerment Suite©, and ensures the ongoing growth and success of the Suite and other related SE Healthcare programs. Stephanie is a seasoned clinical and Lean Six Sigma professional with more than 22 years of experience in health care. As a certified Lean Six Sigma Black Belt, she is skilled in identifying clinical and operational performance gaps to decrease professional liability risk, meet regulatory and accreditation requirements, improve clinical quality and patient outcomes and reduce waste and inefficiencies.

    Share via
    Copy link