The short answer to this question is . . . No. Yes your office can conduct any survey and analyze the data but if your purpose is to meet or to test to see how your office compares to other clinics on the CMS mandated CG-CAHPS survey, you cannot. To properly test and process you must be certified to upload to CMS.

Clinics that have conducted any sort of patient experience/ patient satisfaction measurement should be commended for being forward thinking and for making a genuine effort to be a truly ‘Patient-Centered’ provider. However, CMS is very specific as to what questions are to be included in the CG-CAHPS measurement instrument [survey forms] and the precise procedures to:

  • Select the sample of patients to whom the survey is administered
  • Conduct the survey by mail, telephone or email
  • Code the data for submission to CMS

In fact, in order to upload the data to CMS, it must be verified as having been collected according to their procedures and an‘approved vendor’ must make the data submission to CMS.

I recently worked with a group consisting of 10+ providers who have been conducting a patient experience survey for some time. Their process involved handing the survey out to patients while they waited to see the physician /practitioner. When completed, the survey was handed to the receptionist and placed in a stack for data entry and analysis. This clinic had conducted this process for several years and had trended data to compare year-to-year performance and made adjustments to the clinic processes based on patient scores and comments. This was to be sure a noble and laudable effort. When we were asked to help analyze several years of data [upwards of 1,000 completed surveys in each year], we were confronted with several key obstacles or omissions in the data.

  • Handing a survey to a patient and waiting for them to respond on-site is strictly not an approved or valid data collection methodology – even if the effort is well intentioned.
  • There was no set policy on who was given a survey. They seemed to go most often to someone to keep them occupied in their wait.
  • When trying to compare the data to the CG questionnaire we found none of the questions used the CG wording or compatible scales, hence, comparison with CG was not possible.
  • While we could make some broad comparisons after converting some of the data [and recognizing such comparisons were not necessarily ‘valid’], we found that the questionnaires did not separate which practitioner treated the patient, hence, we could not drill down in the data to identify and compare provider outcomes or behaviors.

As you can see, this was a good and well-intentioned effort, but not truly effective for identifying specific problem areas and making the changes that might be required to score in the highest percentiles of the CG-CAHPS population of providers. To get this kind of utility from a patient experience measurement program or effort, one must be sure . . .

  • The survey form – whether the exact CG form or a ‘blended survey form – includes the key metrics from the CG-CAHPS survey;
  • Data is collected according to the procedures specifically outlined by CMS;
  • The process allows for analysis/drill-down to the specific provider and also to the clinic or departmental level to identify areas for remediation.

Hence, to do it right, it is always best to rely on the ‘proven’ and ‘approved’ standards of practice. This means consult a professional and follow their recommendation.


For more information, please use our CG-CAHPS Information Request Form.


Percy and Company Marketing CG-CAHPS

Percy & Company Market Research is led by our President, Adrian Percy. He holds a Masters of Business Administration from Louisiana State University with an emphasis in marketing. He was a faculty member of the LSU College of Business Administration from 1980-1988, and served as an instructor and consultant with the LSU Office of Government Programs in the mid 1990’s. Mr. Percy has published numerous academic and industry articles regarding the healthcare and financial industries.

Percy & Company, headquartered in Baton Rouge, Louisiana, has been in the business of market research and strategic planning since 1982. Providing expertise to medical practitioners, hospitals, small businesses, large corporations, and governmental agencies, the company has pioneered novel market research methods and applications across the United States.

Percy & Company are CMS approved for the CAHPS programs; one of less than 100 vendors with that designation. Our 30+ years of operation and many clients provide testimony to the effectiveness of the Percy & Company approach.

Some of our satisfied clients...