Session: Surfs Up—Rolling Out the OAS CAHPS Survey

Editor's Note

In this session, Gail Avigne, MSN, BA, RN, senior consultant, strategic consulting, at Press Ganey Associates LLC, spoke to OR Business Management Conference attendees about the rollout of the Outpatient and Ambulatory Surgery CAHPS (OAS CAHPS) survey, which is a mandatory requirement for ambulatory surgery centers (ASCs) in 2025, following its 2024 implementation for hospital outpatient departments (HOPDs). This initiative aims to improve patient experience measurement and standardize quality assessment across ASCs and HOPDs, Avigne noted, emphasizing that nurse leaders play a critical role in ensuring compliance, implementing best practices, and leveraging data for improvement.

Some key takeaways from her session included:

1. OAS CAHPS is now mandatory

   • ASCs must target at least 200 completed surveys annually, with a minimum of 60 surveys per year to meet reporting requirements.
   • Non-compliance risks a 2% reduction in annual Medicare reimbursement.
   • Data must be collected at the Centers for Medicare & Medicaid Services (CMS) Certification Number (CCN) level and submitted through an approved vendor.
   • Early adopters (since 2016) have significantly higher "likely to recommend" scores.

2. Data collection process

   • Eligible patients must have undergone at least one outpatient procedure in a given sample month. (Excludes patients in nursing homes, hospice care, or those admitted as inpatients.)
   • Contract with an approved survey vendor.
   • Identify eligible CPT codes and collaborate with IT/data analytics to extract patient files.
   • Implement survey via mail, phone, or digital methods (email and text now approved).

3. Importance of connection in patient care

   • Patient experience is rooted in connection, communication, and courtesy—not just clinical competence.
   • Government-mandated surveys now focus on relational aspects of care—the top national patient complaint remains poor communication.
   • Building rapport with patients takes less than 56 seconds and can be initiated by using a patient’s preferred name, making eye contact, and acknowledging their emotions.

4. Standardized patient experience evaluation

   • The survey covers three key areas:
     • Facilities and staff—Cleanliness, courtesy, and professionalism of staff
     • Communication—Clarity of preop, procedural, and postop instructions
     • Discharge and recovery—Patients’ understanding of postop care, including signs of complications.
   • Global measures assess the likelihood of recommending the facility and overall patient satisfaction.

5. Best practices for improving patient experience scores

   • Focus on communication clarity:
     • Staff should ask for preferred names, engage with patients personally, and use clear, non-medical jargon in explanations.
     • Staff should also encourage patients to repeat back instructions to ensure understanding.
   • Implement daily huddles and reinforce key behaviors before each shift.
   • A 41% improvement in patient experience scores has been observed when follow-up calls are conducted.

6. Leveraging data for performance improvement

   • Benchmark across locations: Compare ASC performance regionally and nationally.
   • Identify and reduce “friction” (negative experiences that erode loyalty) points: Data can reveal process breakdowns that negatively impact the patient experience.
   • Address patient friction: Facilities with less friction report significantly higher patient loyalty.
   • Analyze disparities: Segment patient satisfaction scores by demographics (eg, race, language, socioeconomic status) to identify gaps in care equity.

Bottom Line: OAS CAHPS is not just about compliance—it is an opportunity to drive meaningful improvements in patient experience, ASC efficiency, and financial performance while protecting reimbursement rates.