Date of Award


Degree Type


Degree Name

Doctor of Management (DMgt)

First Advisor

Dominick Volini, PhD

Second Advisor

Larry M. Starr, PhD

Third Advisor

Teresa Wolfgang, DMgt


The healthcare industry has undergone substantial changes that influence how hospitals evaluate success. Legislation from the Centers for Medicare and Medicaid Services (, 2023) that informs reimbursement levels of patient populations in all U.S. hospitals require organizations to focus on patient experiences, more specifically on scores from the Hospital Consumer Assessment of Healthcare Providers and Systems Survey, referred to as HCAHPS (pronounced H-caps). The Consumer Assessment of Healthcare Providers and Systems Survey or CAHPS® Hospital Survey or Hospital CAHPS® (CAHPS ® is a registered trademark of the Agency for Healthcare Research and Quality). This standardized survey instrument and data collection methodology has been in use since 2006 to measure patients’ perspectives of hospital care. This research aims to identify deficiencies in the methodology and administration of the HCAHPS survey and make tactical recommendations on how those deficiencies could be overcome or altogether eliminated. The data for the project was collected through a thorough review of existing literature, including similar research efforts in the past, face to face interviews with healthcare stakeholders familiar with the HCAHPS survey, and a historical analysis of HCAHPS survey output retrieved from the CMS archives. Upon review of the methodology and administration of the survey, numerous deficiencies were identified in the areas of respondent mix, response rate, survey administration and reporting. For each of these areas the details surrounding the deficiencies have been explained and recommendations have been made to overcome/eliminate them. These findings indicate a need to develop and implement a real-time data collection tool to accurately reflect the patient experience and create accountability for the care team.


A dissertation submitted in partial fulfillment of the requirements for the degree Doctor of Management in Strategic Leadership