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Patient satisfaction metrics to interpret CAHPS scores

Understanding terms like net promoter scores, global scores or top-box scores can help practice leaders assess CAHPS scores and patient satisfaction metrics.

Sara Heath, Executive Editor

Published: 29 Jul 2024

The forces of healthcare consumerism have taken hold of the medical industry, and with that has come a laser focus on the patient experience, patient satisfaction surveying and the ability to interpret metrics like CAHPS scores.

Of course, the concept of patient satisfaction surveying wasn't invented when patients began assuming the role of healthcare consumer.

The Consumer Assessment of Healthcare Providers and Systems (CAHPS) surveys in all of their various practice-specific iterations launched nearly three decades ago in 1995. Private satisfaction survey and consulting firms, such as Press Ganey and NRC Health, launched their services not long after.

But with the rise of value-based care and its focus on good health outcomes, including a good patient experience, healthcare organizations have had to zero in on their patient satisfaction best practices. Add in trends of healthcare consumerism and organizations have put an emphasis on patient satisfaction metrics.

Measuring patient experience is a core part of health system operations. But after consumers have completed surveys and assessments, how can they make sense of patient satisfaction metrics?

Below, we'll discuss key patient satisfaction surveying metrics and benchmarks, including the net promoter scores, top-box scores and bottom-box scores.

Importantly, healthcare organizations use many mechanisms to measure patient satisfaction. Numerous private companies sell their patient satisfaction surveying services, while some health systems might develop their own internal surveying tools. For this article, we will focus on metrics gleaned specifically from CAHPS surveys.

Understanding CAHPS surveys

The Agency for Healthcare Research and Quality (AHRQ) developed CAHPS in 1995 to create a national, standardized tool for measuring patient experience. Today, CAHPS helps healthcare organizations understand the patient experience and guide practice improvement efforts.

Additionally, CMS and HHS use CAHPS scores to inform certain value-based reimbursements as well as certain aspects of the Hospital Star Ratings and Hospital Compare tools offered to patients comparing providers.

There are several different CAHPS iterations based on provider type. For example, HCAHPS refers to the survey administered by hospitals. Other specific forms of CAHPS surveys include the following:

CAHPS Health Plan Survey: For assessing experiences with health plans, including Medicaid, Medicare, and commercial plans.
CAHPS Clinician & Group Survey (CG-CAHPS): For assessing experiences with individual healthcare providers and their practices.
CAHPS Hospital Survey (HCAHPS): For assessing hospital care experiences.
CAHPS Home Health Care Survey (HHCAHPS): For assessing experiences with home healthcare agencies.
CAHPS In-Center Hemodialysis Survey: For assessing experiences with in-center hemodialysis care.
CAHPS Hospice Survey: For assessing experiences with hospice care.
CAHPS Nursing Home Survey: For assessing experiences with long-term and short-term nursing home care.
CAHPS Dental Plan Survey: For assessing experiences with dental plans.
CAHPS American Indian Survey: For assessing the healthcare experiences of American Indians.
CAHPS Surgical Care Survey: For assessing experiences with surgical care and surgeons.
CAHPS Mental Health Care Surveys: For assessing experiences with mental healthcare providers and services.
CAHPS Emergency Department Survey: For assessing experiences with emergency department services.
CAHPS Outpatient and Ambulatory Surgery Survey (OAS CAHPS): For assessing experiences with outpatient and ambulatory surgery centers.
CAHPS Home and Community-Based Services (HCBS) Survey: For assessing experiences with home and community-based services for Medicaid beneficiaries.

CMS requires healthcare organizations to administer CAHPS surveys, which are usually sent to patients up to a month after a healthcare encounter. While CMS uses CAHPS scores for some reimbursement and public reporting purposes, healthcare organizations can also use them to guide their own practice improvement goals.

To make the most of patient satisfaction survey responses, healthcare organizations need to understand some key terms to help them interpret results.

Net promoter score

Created in 2003 and included in CAHPS since 2016, the net promoter score (NPS) question aims to look at the overall experience of care and assess patient loyalty. NPS borrows from other service industries assessing consumer experience by asking patients about their likelihood to recommend a hospital or healthcare organization.

Calculating the net promoter score

Respondents are asked to rank their likelihood on a 0-10 scale, with zero being the least likely and 10 being the most likely to recommend. Respondents can also complete an open-ended, free-text item to provide further insights for survey administrators.

These scores allow survey admins to separate respondents into three groups:

Promoters (score 9-10).
Passives (score 7-8).
Detractors (score 0-6).

From there, survey administrators subtract the percentage of detractors from the percentage of promoters. That yields a score between -100 and +100, with a positive NPS being considered good and a negative score being considered bad.

Using the net promoter score

The NPS is lauded as a simple measure to help healthcare organizations assess patient loyalty and experience. Providers might use NPS to pinpoint practice improvement areas and gain insights into healthcare consumer experiences.

But like other patient experience measures, the NPS can be fraught because it is challenging to assign a subjective score to an objective matter, such as patient experience and satisfaction.

One 2022 literature review published in the international journal Health Expectations found that the NPS can be effective because it's easily understood by survey respondents. The two-question item is quick to respond to, so healthcare organizations can get a high response rate. However, some healthcare staff members have said it can be hard to manage and act on such a breadth of data, the literature review showed.

The study also found that the NPS might be more useful in settings where patients can choose their provider, like a general practitioner or a therapist, as opposed to the emergency department, where patients cannot usually choose their providers.

There's also the issue of outside influence on NPS, like the medical condition the patient presents with or the patient's age. These have little bearing on the care provided to the patient but can influence the NPS.

"As such, NPS may be more useful when monitoring longitudinal performance (such as change over time) for a more specific group, such as one hospital site, department and/or patient cohort," the researchers explained. "NPS may also be better used to evaluate discrete cohorts, such as categorized according to admission type (i.e., emergency or elective admission), with localized and site‐specific NPS evaluation."

Top-box scores

Like the NPS, top-box scores borrow from consumer satisfaction surveys across numerous other service sectors. Top-box scores refer to the proportion of consumers who gave the highest rating for a certain question on a satisfaction survey.

For example, a top-box score for the CAHPS survey refers to the percentage of patients who said "yes, definitely" or "always" for a given hospital experience question, according to the CAHPS Analysis Program, sometimes referred to as the CAHPS Macro.

Top-box values are shown at the 5th, 10th, 25th, 50th, 75th, 90th and 95th percentiles.

Using top-box scores

Like other elements of patient experience survey scores, hospitals and health systems can use top-box scores to better understand patient preferences and to guide practice improvement. A low top-box score will indicate a need for stronger patient experience best practices, for example.

Healthcare organizations can also compare their top-box scores to other organizations when data is available. This will be key as organizations continue to fight for market share in a crowded healthcare industry.

Some researchers have begun to link certain hospital qualities with higher top-box scores, although most of the data is inconclusive and conflicting.

In 2020, a report in the Western Journal of Emergency Medicine linked patient age, race and emergency department (ED) treatment area with top-box scores. While older patients were linked with higher top-box scores, a higher proportion of Asian patients and patients treated in urgent and vertical areas of the ED were linked with lower top-box scores.

Meanwhile, a separate 2021 study in the Journal of Patient Experience found that few factors could reliably predict high top-box scores. However, the researchers did find a link between HCAHPS questions related to communication and overall hospital rating.

Overall, patient experience experts have pointed out that top-box scores can be effective for assessing success and determining improvement goals but that other metrics will also be key to getting a full picture of the hospital experience.

What are bottom-box scores?

The inverse to top-box scores, bottom-box scores measure the proportion of patients giving the least favorable answer to a patient satisfaction survey question. A high bottom-box score means more patients who view a health system unfavorably.

Like top-box scores, bottom-box scores can help guide practice improvement efforts.

Overall satisfaction, global rating

Overall satisfaction scores, known primarily as the global rating under the CAHPS surveying system, refer to a patient's overall impression of their healthcare experience. The CAHPS global rating question asks patients to rank their healthcare experience on a 0-10 scale.

This measure gives healthcare organizations an impression of a patient's overall experience of care. This can be useful for health system leaders seeking a broad view of patient sentiment. However, looking at results for a more specific CAHPS question or other metrics like top-box scores or the NPS can give a more granular view of how the health system might improve.

Linking healthcare consumerism to other service sectors

Notably, many patient satisfaction metrics apply to customer satisfaction surveys intended for other service sectors. Retail shops, the food industry, the travel industry and numerous other businesses might look at metrics like the NPS or top-box scores.

This is noteworthy, considering the increasing role consumerism has begun to play in healthcare.

As the rise in high-deductible health plans has left patients responsible for more of their healthcare costs, many have become savvy healthcare shoppers. This has led to an emphasis on price transparency, convenient care access and especially patient or customer service.

In response to that, healthcare organizations need to not only measure patient satisfaction and sentiment, but synthesize those results and turn them into action steps. In doing so, hospitals and health systems can better serve a patient population with growing healthcare needs.

Sara Heath has covered news related to patient engagement and health equity since 2015.