It’s not entirely your fault. While star ratings, in general, have been around for decades or more, their use for rating healthcare facilities is relatively new. CMS has slowly started including the popular rating system over the past several years, with HCAHPS Star Ratings arriving in 2016. One of the key differences between CMS’s star ratings and the star ratings you might see on any other review site is that CMS’s ratings are comprised of aggregate CAHPS survey responses instead of an individual average rating. The system is contentious, to be sure, with only 2.2 percent of participating hospitals earning the prestigious 5-star rating in their first-ever publication. Many hospitals were dissatisfied with this result, as the system was poised to have a disproportionate impact on facilities with an unfavorable demographic makeup. In fact, one article noted the following about this impact:

“…American Hospital Association Senior Associate Director for Policy Akin Demehin said the methodology does not sufficiently adjust for factors shown to influence patient outcomes such as income, family assistance, and community support.

This could have far-reaching implications on hospitals, which could subsequently end up in a vicious cycle of spending more money to influence patient perception just to keep up with their counterparts. Despite the volumes of feedback CMS received from interest groups and state representatives, the rating system still went forward.


By now, most Hospitals are certainly familiar with HCAHPS composite scores and how they are calculated. A brief reminder: the scores published on the Hospital Compare website each quarter are only those percentage of patients who gave a “top box” response for each item on the question set, for each composite. In other words, if your facility scored an 88% on the Quietness composite, this means that 88% of patients who completed the survey responded “Always” when asked about whether their room was quiet at night. The patients who responded “never”, “sometimes” or “usually” were excluded from CMS’s analysis.


With the introduction of Star Ratings, they have taken a different direction on the calculation of scores.

When Star Ratings are calculated each quarter, they are based on the linearized responses of patients. Learn more on this in the video below. That is, it includes all patients, no matter their response on the item set for each composite. So what does this mean for facilities who are trying to hone in on a specific area of improvement? Don’t be surprised if your composite scores go one direction and your star rating goes another – for the same composite. We’ve seen several instances of this in the first few CMS Star Rating publications, resulting in a wave of calls from clients wondering what they did wrong.

Perhaps you’re now wondering why CMS would make this move. This is what they had to say on their website:

Linear mean scores and Top-Box scores are alternative, statistically valid methods for summarizing HCAHPS performance. Linear mean scores incorporate the full range of survey response categories into a single metric for each HCAHPS measure. “Top-Box” scores, on the other hand, consist of only the most positive response to HCAHPS Survey items. Please note that Hospital Compare reports top-box, middle-box and bottom-box scores for all HCAHPS measures.

To further complicate the matter of achieving your targets, CMS also “re-draws” the cutoff points for each Star rating, every quarter. This means that what was good enough for a 5-star rating last time might not be good enough this time. Facilities are now, quite literally, aiming at a moving target.


Having made it this far into our breakdown, you’re probably wondering how to approach this issue tactfully. With budget concerns, quality improvement plans to roll out, and still managing to keep up with operations, there must be a singular answer to getting the best of both worlds. Luckily, we’ve worked through enough data to say that there is.

As most of our clients know, we encourage facilities to look at the whole picture right from the start. It’s not enough to have high-ranking top box scores if your dissatisfaction rates are high as well. Through the use of Arbor’s statistical analysis and improvement system, we walk you through a very simple, yet effective, way to boost your star ratings and composite scores at the same time:

  1. Review priorities as determined by Arbor’s analysis
  2. Evaluate factors to understand how to move patients from “dissatisfied” to “satisfied”
  3. Evaluate factors to understand how to move patients from “satisfied” to “Top Box”
  4. Conduct a budgetary analysis to determine the cost of improvements
  5. Carry out your improvement plan and evaluate impact upon future CMS publications

Want to learn more about Arbor’s system? Feel free to check with us today and find out how we can help.