Where do you get your dialysis treatments? 1 At home If At home, Go to Question 45 2 At the dialysis center 3 I do not currently receive dialysis If I do not currently receive dialysis, Go to Question 45 How long have you been getting dialysis at [SAMPLE FACILITY NAME]? 1 Less than 3 months If Less than 3 months, Go to Question 45 2 At least 3 months but less than 1 year 3 At least 1 year but less than 5 years 4 5 years or more 5 I do not currently receive dialysis at this dialysis center If I do not currently receive dialysis at this dialysis center, Go to Question 45 Your kidney doctors are the doctor or doctors most involved in your dialysis care now. This includes kidney doctors that you see inside and outside the center. In the last 3 months, how often did your kidney doctors listen carefully to you? 1 Never 2 Sometimes 3 Usually 4 Always In the last 3 months, how often did your kidney doctors explain things in a way that was easy for you to understand? 1 Never 2 Sometimes 3 Usually 4 Always In the last 3 months, how often did your kidney doctors show respect for what you had to say? 1 Never 2 Sometimes 3 Usually 4 Always In the last 3 months, how often did your kidney doctors spend enough time with you? 1 Never 2 Sometimes 3 Usually 4 Always In the last 3 months, how often did you feel your kidney doctors really cared about you as a person? 1 Never 2 Sometimes 3 Usually 4 Always KIDNEY
In the last 12 months, were you as involved as much as you wanted in choosing the treatment for kidney disease that is right for you? 1 Yes 2 No In the last 12 months, were you ever unhappy with the care you received at the dialysis center or from your kidney doctors? 1 Yes 2 No If No, Go to Question 45 In the last 12 months, did you ever talk to someone on the dialysis center staff about this? 1 Yes 2 No If No, Go to Question 45 In the last 12 months, how often were you satisfied with the way they handled these problems? 1 Never 2 Sometimes 3 Usually 4 Always Medicare and your State have special agencies that check the quality of care at this dialysis center. In the last 12 months, did you make a complaint to any of these agencies? 1 Yes 2 No In general, how would you rate your overall health? 1 Excellent 2 Very good 3 Good 4 Fair 5 Poor In general, how would you rate your overall mental or emotional health? 1 Excellent 2 Very good 3 Good 4 Fair 5 Poor Are you being treated for high blood pressure? 1 Yes 2 No Are you being treated for diabetes or high blood sugar? 1 Yes 2 No Are you being treated for heart disease or heart problems? 1 Yes 2 No Are you deaf or do you have serious difficulty hearing? 1 Yes 2 No
What is your race? (One or more categories may be selected.) 1 White 2 Black or African American 3 American Indian or Alaska Native 4 Asian Indian 5 Chinese 6 Filipino 7 Japanese 8 Korean 9 Vietnamese 10 Other Asian 11 Native Hawaiian 12 Guamanian or Chamorro 13 Samoan 14 Other Pacific Islander Did someone help you complete this survey? 1 Yes 2 No Thank you. Please return the completed survey in the postage-paid envelope. Who helped you complete this survey? 1 A family member 2 A friend 3 A staff member at the dialysis center 4 Someone else (please print): ________________________ How did that person help you? Check all that apply. 1 Read the questions to me 2 Wrote down the answers I gave 3 Answered the questions for me 4 Translated the questions into my language 5 Helped in some other way (please print): ________________________ Thank you. Please return the survey in the enclosed envelope to: VENDOR’S NAME STREET ADDRESS 1 STREET ADDRESS 2 CITY, STATE, ZIP
In the last 3 months, how often did your kidney doctors spend enough time with you? Would you say… Never, Sometimes, Usually, or Always? M MISSING/DK In the last 3 months, how often did you feel your kidney doctors really cared about you as a person? Would you say… Never, Sometimes, Usually, or Always? M MISSING/DK Using any number from 0 to 10, where 0 is the worst kidney doctors possible and 10 is the best kidney doctors possible, what number would you use to rate the kidney doctors you have now? REPEAT QUESTION IF NECESSARY 00 0 Worst kidney doctors possible 01 1 02 2 03 3 04 4 05 5 06 6 07 7 08 8 09 9 10 10 Best kidney doctors possible M MISSING/DK
En los últimos 12 meses, ¿con qué frecuencia estuvo satisfecho con la manera en la que manejaron esos problemas? 1 Nunca 2 A veces 3 La mayoría de las veces 4 Siempre Medicare y su estado tienen agencias especiales que verifican la calidad del cuidado de este centro de diálisis. En los últimos 12 meses, ¿presentó alguna queja a cualquiera de estas agencias? 1 Sí 2 No En general, ¿cómo calificaría su estado de salud? 1 Excelente 2 Muy bueno 3 Bueno 4 Regular 5 Malo En general, ¿cómo calificaría su estado de salud mental o emocional? 1 Excelente 2 Muy bueno 3 Bueno 4 Regular 5 Malo ¿Está en tratamiento por tener la presión alta? 1 Sí 2 No ¿Está en tratamiento porque tiene diabetes o el nivel de azúcar en la sangre alto? 1 Sí 2 No ¿Está en tratamiento porque tiene una enfermedad cardiaca o problemas del corazón? 1 Sí 2 No ¿Es usted sordo o tiene mucha dificultad para oír? 1 Sí 2 No ¿Es usted ciego o tiene mucha dificultad para ver, aunque use lentes/anteojos? 1 Sí 2 No Debido a una condición física, mental o emocional, ¿tiene mucha dificultad para concentrarse, recordar o tomar decisiones? 1 Sí 2 No ¿Tiene mucha dificultad para caminar o subir escaleras? 1 Sí 2 No ¿Tiene dificultad para vestirse o bañarse? 1 Sí 2 No
2 [DATE] [FIRST NAME] [LAST NAME] [ADDRESS] [CITY, STATE AND ZIP] 來自美國聯邦醫療保險 (MEDICARE) 的重要資訊 尊敬的[LAST NAME]: 這是一份來自於美國聯邦醫療保險和醫療補助服務中心 (Centers for Medicare & Medicaid Services，也稱為CMS) 如何處理調查結果？ Medicare保險機構將會在這個透析設施比較，即Dialysis Facility Compare網站上公佈調查結果: 。此網站上的信息將幫助透析病人及家庭找到並比較Medicare保險機構認證的透析設施。 我下一步應該做什麼？ 在完成這份調查的過程中，請不要尋求[FACILITY NAME]的任何人的幫助，對您的透析治療，您應當真實反映自己的意見。 NAME]，他們的電話是[VENDOR PHONE NUMBER]。 感謝您的參與，我們期望收到您的問卷！ 誠摯敬意， [NAME]
聯邦醫療保險 (Medicare) 透析 中心 血液透析調查問卷 依據 1995 OMB 控制編號為 0938-0926。估計完成本表所需的平均時間為每份 16 CMS, Attn: PRA Reports Clearance Officer, 7500 Security Boulevard, Mail Stop C1-25-05, Baltimore, Maryland 21244-1850
調查問卷說明 此問卷中的問題和您在 [SAMPLE FACILITY NAME] 接受透析治療的經歷有關。 對於每個問題，請在問題左側的方塊勾選您的答案。 1 是 2 否 如果選擇「否」，請轉到第25題
您在哪裡接受透析治療？ 1 在家 如果在家，請轉到第45題 2 透析中心 3 我目前沒有接受治療 您在[SAMPLE FACILITY 1 少於 3 個月 2 至少 3 個月但少於 1 年 3 至少 1 年但少於 5 年 4 5 年或以上 5 您的腎臟醫師 過去 3 1 從來不會 2 有時候會 3 經常會 4 一直都會 過去 3 1 從來不會 2 有時候會 3 經常會 4 一直都會 過去 3 1 從來不會 2 有時候會 3 經常會 4 一直都會 過去 3 1 從來不會 2 有時候會 3 經常會 4 一直都會 過去 3 1 從來不會 2 有時候會 3 經常會 4 一直都會 治療
如果以數字 0 至 10 來評價您的腎臟醫師，0 代表最差，10 0 0 最差的腎臟醫師 1 1 2 2 3 3 4 4 5 5 6 6 7 7 8 8 9 9 10 10 最好的腎臟醫師 1 是 2 否 透析中心工作人員 過去 3 1 從來不會 2 有時候會 3 經常會 4 一直都會 過去 3 1 從來不會 2 有時候會 3 經常會 4 一直都會 過去 3 1 從來不會 2 有時候會 3 經常會 4 一直都會 過去 3 時間？ 1 從來不會 2 有時候會 3 經常會 4 一直都會 過去 3 1 從來不會 2 有時候會 3 經常會 4 一直都會
過去 3 1 從來不會 2 有時候會 3 經常會 4 一直都會 過去 3 1 是 2 否 過去 3 1 是 2 否 過去 3 1 是 2 否 1 是 2 否 過去 3 析機？ 1 人工血管 2 廔管 3 導管 22 4 不知道 22 過去 3 1 從來不會 2 有時候會 3 經常會 4 一直都會 5 我自己插入針頭
過去 3 1 從來不會 2 有時候會 3 經常會 4 一直都會 過去 3 1 是 2 否 如果選擇「否」，請轉到問題 25 過去 3 1 從來不能 2 有時候能 3 經常能 4 一直都能 過去 3 1 從來不會 2 有時候會 3 經常會 4 一直都會 過去 3 1 是 2 否 過去 3 1 從來不會 2 有時候會 3 經常會 4 一直都會 1 是 2 否 1 是 2 否 1 是 2 否
1 是 2 否 如果以數字 0 至 10 來評價透析中心工作人員，0 代表最差，10 0 0 最差的透析中心工作人員 1 1 2 2 3 3 4 4 5 5 6 6 7 7 8 8 9 9 10 10 最好的透析中心工作人員 透析中心 過去 3 15 分鐘內上機進行透析 治療？ 1 從來不會 2 有時候會 3 經常會 4 一直都會 過去 3 1 從來不會 2 有時候會 3 經常會 4 一直都會 如果以數字 0 至 10 來評價透析中心，0 代表最差，10 0 0 最差的透析中心 1 1 2 2 3 3 4 4 5 5 6 6 7 7 8 8 9 9 10 10 最好的透析中心
接下來的幾個問題將會詢問您在過去 12 FACILITY 12 1 是 2 否 您是否符合腎臟移植的條件？ 1 是 39 2 否 3 我不知道 39 過去 12 1 是 2 否 12 1 是 2 否 過去 12 1 是 2 否 過去 12 1 是 2 否 45 過去 12 1 是 2 否 45 過去 12 1 從來不會 2 有時候會 3 經常會 4 一直都會
12 1 是 2 否 有關您本人的資訊 1 極好 2 非常好 3 良好 4 一般 5 差 1 極好 2 非常好 3 良好 4 一般 5 差 您是否正在接受高血壓治療？ 1 是 2 否 您是否正在接受糖尿病或高血糖 治療？ 1 是 2 否 1 是 2 否 您是否失聰或有嚴重的聽力問題？ 1 是 2 否 1 是 2 否 1 是 2 否 1 是 2 否 您穿衣或洗澡是否有困難？ 1 是 2 否 1 是 2 否
您的最高教育程度是？ 1 沒有受過正規教育 2 5 年級或以下 3 6，7 或 8 年級 4 上過中學，但沒畢業 5 中學畢業或同等學歷 6 上過大學，或 2 年制學位 7 4 年制大學畢業 8 4 年制大學學歷以上 您在家主要講哪種語言？ 1 英文 2 西班牙语 3 中文 4 萨摩亚语 5 俄语 6 越南语 7 葡萄牙语 8 其他語言（請註明）: __________________ 1 2 是，我是波多黎各裔 3 4 是，我是古巴裔 5 1 白人 2 黑人或非裔美國人 3 美洲印第安人或阿拉斯加原 住民 4 亞裔印度人 5 中國人 6 菲律賓人 7 日本人 8 韓國人 9 越南人 10 其他亞洲人 11 夏威夷原住民 12 關島或查莫洛人 13 薩摩亞人 14 其他太平洋島民 是否有人協助您填寫本調查問卷？ 1 是 2 否 誰協助您填寫本調查問卷？ 1 家人 2 朋友 3 透析中心的工作人員 4 其他人（請以正楷寫明)）： ________________________
联邦医疗保险 (Medicare) 透析中心血液透析调查问卷 依据 1995 OMB 控制编号为 0938-0926。估计完成本表所需的平均时间为每份 16
CMS, Attn: PRA Reports Clearance Officer, 7500 Security Boulevard, Mail Stop C1-25-05, Baltimore, Maryland 21244-1850 调查问卷说明 此问卷中的问题和您在[SAMPLE FACILITY NAME]接受透析治疗的经历有关。 对于每个问题，请在问题左侧的方块勾选您的答案。 1 是 2 否 如果选择「否」，请转到第25题
您在哪里接受透析治疗？ 1 在家 如果在家，请转到第45题 2 透析中心 3 我目前没有接受治疗 您在[SAMPLE FACILITY 1 少于 3 个月 2 至少 3 个月但少于 1 年 3 至少 1 年但少于 5 年 4 5 年或以上 5 您的肾脏医师 过去 3 1 从来不会 2 有时候会 3 经常会 4 一直都会 过去 3 1 从来不会 2 有时候会 3 经常会 4 一直都会 过去 3 1 从来不会 2 有时候会 3 经常会 4 一直都会 过去 3 1 从来不会 2 有时候会 3 经常会 4 一直都会 治疗
过去 3 1 从来不会 2 有时候会 3 经常会 4 一直都会 如果以数字 0 至 10 来评价您的肾脏医师，0 代表最差，10 0 0 最差的肾脏医师 1 1 2 2 3 3 4 4 5 5 6 6 7 7 8 8 9 9 10 10 最好的肾脏医师 1 是 2 否 透析中心工作人员 过去 3 1 从来不会 2 有时候会 3 经常会 4 一直都会 过去 3 1 从来不会 2 有时候会 3 经常会 4 一直都会 过去 3 1 从来不会 2 有时候会 3 经常会 4 一直都会
过去 3 时间？ 1 从来不会 2 有时候会 3 经常会 4 一直都会 过去 3 1 从来不会 2 有时候会 3 经常会 4 一直都会 过去 3 1 从来不会 2 有时候会 3 经常会 4 一直都会 过去 3 1 是 2 否 过去 3 1 是 2 否 过去 3 1 是 2 否 1 是 2 否 过去 3 析机？ 1 人工血管 2 廔管 3 导管 22 4 不知道 如果选择「不知道」,
请转到问题 22 过去 3 1 从来不会 2 有时候会 3 经常会 4 一直都会 5 我自己插入针头 过去 3 1 从来不会 2 有时候会 3 经常会 4 一直都会 过去 3 1 是 2 否 如果选择「否」，请转到问题 25 过去 3 1 从来不能 2 有时候能 3 经常能 4 一直都能 过去 3 1 从来不会 2 有时候会 3 经常会 4 一直都会 过去 3 1 是 2 否
过去 3 1 从来不会 2 有时候会 3 经常会 4 一直都会 1 是 2 否 1 是 2 否 1 是 2 否 1 是 2 否 如果以数字 0 至 10 来评价透析中心工作人员，0 代表最差，10 0 0 最差的透析中心工作人员 1 1 2 2 3 3 4 4 5 5 6 6 7 7 8 8 9 9 10 10 最好的透析中心工作人员 透析中心 过去 3 15 分钟内上机进行透析 治疗？ 1 从来不会 2 有时候会 3 经常会 4 一直都会
过去 3 1 从来不会 2 有时候会 3 经常会 4 一直都会 如果以数字 0 至 10 来评价透析中心，0 代表最差，10 0 0 最差的透析中心 1 1 2 2 3 3 4 4 5 5 6 6 7 7 8 8 9 9 10 10 最好的透析中心 接下来的几个问题将会询问您在过去 12 [SAMPLE FACILITY NAME] 12 1 是 2 否 您是否符合肾脏移植的条件？ 1 是 39 2 否 3 我不知道 39 过去 12 1 是 2 否 12 1 是 2 否
过去 12 1 是 2 否 过去 12 1 是 2 否 45 过去 12 1 是 2 否 45 过去 12 1 从来不会 2 有时候会 3 经常会 4 一直都会 联邦医疗保险 (Medicare) 12 1 是 2 否 有关您本人的信息 1 极好 2 非常好 3 良好 4 一般 5 差 1 极好 2 非常好 3 良好 4 一般 5 差 您是否正在接受高血压治疗？ 1 是 2 否
O oe o se Sipaniolo, Hispanic, poo Latino i le tupuaga? 1 Leai e le o au o se Sipaniolo/Hispanic/Latino 2 Ioe Puteriko 3 Ioe Mexican, Mexican American, Chicano 4 Ioe Cuban 5 Ioe, nisi Sipaniolo/Hispanic/Latino O le a lou Tupuaga? (Tasi pe tele vaega e mafai ona filifilia.) 1 Paepae 2 Uli poo Aferika Amerika 3 Amerika Initia poo tagatanuu Alaska 4 Asia Initia 5 Saina 6 Filipino 7 Sapani 8 Kolea 9 Vietnamese 10 Isi Asia 11 Tagatanuu Hawaii 12 Guamanian poo Chamorroo 13 Samoa 14 Isi Tagata Pasefika Na iai se isi na fesoasoani i le faatumuga o lenei suesuega? 1 Ioe 2 Leai Faafetai. Faamolemole faafoi mai le suesuega ua maea i le teutusi ua uma ona totogi. O ai na fesoasoani ia te oe e faauma le suesuega? 1 Tagata o lou aiga 2 Lau uo 3 Tagata faigaluega i le Fale faamamatoto 4 Se isi tagata (faamolemole lolomi): ________________________ E faapefea ona fesoasoani atu lea tagata ia te oe? Maka uma tali e fetaui. 1 Faitau mai fesili ia te au 2 Tusi i lalo tali ou te avatua 3 Tali fesili mo au 4 Faaliliu fesili i la’u gagana 5 Fesoasoani mai i nisi auala (faamolemole lolomi): ________________________ Faafetai. Faamolemole faafoi mai le suesuega i le teutusi o loo iai i le tuatusi o loo i lalo: VENDOR’S NAME STREET ADDRESS 1 STREET ADDRESS 2 CITY, STATE, ZIP
S2. 有時透析中心的工作人員會遮蓋患者，或使用窗簾來保護患者的隱私。過去 3 個月內，你曾需要透析中心的工作人員，以這種方式來保護您的隱私嗎？ 1 是 2 否 如果選擇「否」，請轉到第 4題 S3. 過去 3 個月內，透析中心的工作人員多經常會遮蓋，或使用窗簾來保護您的隱私？ 1 從來不會 2 有時候會 3 經常會 4 一直都會 S4. 過去 3 個月內，透析中心的工作人員多經常會如您希望的那樣，儘快回復這些問題？ 1 從來不會 2 有時候會 3 經常會 4 一直都會 S5. 過去 3 個月內，透析中心的工作人員換下一個病人時，會多經常更換手套？ 1 從來不會 2 有時候會 3 經常會 4 一直都會 5 我不知道 S6. 是否有您的家庭成員或朋友參與您的透析治療？ 1 是 2 否 如果選擇「否」，請轉到第 8題 S7. 透析中心的工作人員是否如您希望的那樣，儘量包括您的家庭成員或朋友？ 1 是 2 否
S18. 過去 3 個月內，您多經常因需要等待一個翻譯而導致問題？ 1 從來不 2 有時候 3 經常 4 一直 S19. 過去 3 個月內，當您在透析中心需要一個翻譯來幫您時，透析中心多經常會提供翻譯？ 1 從來不會 2 有時候會 3 經常會 4 一直都會 S20. 過去 3 1 透析中心的工作人員 2 朋友或家人 SKIP Q21跳至第21題 3 其他人 誰? ____________________________ S21. 如果以數字 0 至 10 來評價，0 代表最差的翻譯，10 0 0 最差的翻譯 1 1 2 2 3 3 4 4 5 5 6 6 7 7 8 8 9 9 10 10 最好的翻譯
PATIENT RESPONSE RECORD (continued) XML Element Attributes Description Valid Values Data Type Field Size Data Element Required Q6 dr-time Each element must have a closing tag that is the same as the opening tag but with a forward slash. This patient response data element should only occur once per patient. Example: dr-time1/dr-time None In the last 3 months, how often did your kidney doctors spend enough time with you? Never 1 Sometimes 2 Usually 3 4 NOT APPLICABLE X MISSING/DK M Alphanumeric character 1 Yes Q7 dr-care Each element must have a closing tag that is the same as the opening tag but with a forward slash. This patient response data element should only occur once per patient. Example: dr-care1/dr-care None In the last 3 months, how often did you feel your kidney doctors really cared about you as a person? Never 1 Sometimes 2 Usually 3 4 NOT APPLICABLE X MISSING/DK M Alphanumeric character 1 Yes
PATIENT RESPONSE RECORD (continued) XML Element Attributes Description Valid Values Data Type Field Size Data Element Required Q8 rate-dr Each element must have a closing tag that is the same as the opening tag but with a forward slash. This patient response data element should only occur once per patient. Example: rate-dr1/rate-dr None Using any number from 0 to 10, where 0 is the worst kidney doctors possible and 10 is the best kidney doctors possible, what number would you use to rate the kidney doctors you have now? Worst kidney doctors possible 0 1 1 2 2 3 3 4 4 5 5 6 6 7 7 8 8 9 9 Best kidney doctors possible 10 NOT APPLICABLE X MISSING/DK M Alphanumeric character 2 Yes Q9 dr-informed Each element must have a closing tag that is the same as the opening tag but with a forward slash. This patient response data element should only occur once per patient. Example: dr-informed1/dr-informed — Do your kidney doctors seem informed and up-to-date about the health care you receive from other doctors? Yes 1 No 2 NOT APPLICABLE X MISSING/DK M Alphanumeric character 1 Yes
PATIENT RESPONSE RECORD (continued) XML Element Attributes Description Valid Values Data Type Field Size Data Element Required Q13 staff-time Each element must have a closing tag that is the same as the opening tag but with a forward slash. This patient response data element should only occur once per patient. Example: staff-time1/staff-time None In the last 3 months, how often did the dialysis center staff spend enough time with you? Never 1 Sometimes 2 Usually 3 4 NOT APPLICABLE X MISSING/DK M Alphanumeric character 1 Yes Q14 staff-care Each element must have a closing tag that is the same as the opening tag but with a forward slash. This patient response data element should only occur once per patient. Example: staff-care1/staff-care None In the last 3 months, how often did you feel the dialysis center staff really cared about you as a person? Never 1 Sometimes 2 Usually 3 4 NOT APPLICABLE X MISSING/DK M Alphanumeric character 1 Yes Q15 make-comfortable Each element must have a closing tag that is the same as the opening tag but with a forward slash. This patient response data element should only occur once per patient. Example: None In the last 3 months, how often did dialysis center staff make you as comfortable as possible during dialysis? Never 1 Sometimes 2 Usually 3 4 NOT APPLICABLE X MISSING/DK M Alphanumeric character 1 Yes
PATIENT RESPONSE RECORD (continued) XML Element Attributes Description Valid Values Data Type Field Size Data Element Required Q22 check-closely Each element must have a closing tag that is the same as the opening tag but with a forward slash. This patient response data element should only occur once per patient. Example: check-closely1/check-closely None In the last 3 months, how often did dialysis center staff check you as closely as you wanted while you were on the dialysis machine? Never 1 Sometimes 2 Usually 3 4 NOT APPLICABLE X MISSING/DK M Alphanumeric character 1 Yes Q23 problems Each element must have a closing tag that is the same as the opening tag but with a forward slash. This patient response data element should only occur once per patient. Example: problems1/problems None In the last 3 months, did any problems occur during your dialysis? Yes 1 No 2 NOT APPLICABLE X MISSING/DK M Alphanumeric character 1 Yes Q24 manage-problems Each element must have a closing tag that is the same as the opening tag but with a forward slash. This patient response data element should only occur once per patient. Example: None In the last 3 months, how often was the dialysis center staff able to manage problems during your dialysis? Never 1 Sometimes 2 Usually 3 4 NOT APPLICABLE X MISSING/DK M Alphanumeric character 1 Yes
PATIENT RESPONSE RECORD (continued) XML Element Attributes Description Valid Values Data Type Field Size Data Element Required Q31 getoff-machine Each element must have a closing tag that is the same as the opening tag but with a forward slash. This patient response data element should only occur once per patient. Example: None Has any dialysis center staff ever told you how to get off the machine if there is an emergency at the center? Yes 1 No 2 NOT APPLICABLE X MISSING/DK M Alphanumeric character 1 Yes Q32 rate-staff Each element must have a closing tag that is the same as the opening tag but with a forward slash. This patient response data element should only occur once per patient. Example: rate-staff2/rate-staff None Using any number from 0 to 10, where 0 is the worst dialysis center staff possible and 10 is the best dialysis center staff possible, what number would you use to rate your dialysis center staff? Worst dialysis center staff possible 0 1 1 2 2 3 3 4 4 5 5 6 6 7 7 8 8 9 9 Best dialysis center staff possible 10 NOT APPLICABLE X MISSING/DK M Alphanumeric character 2 Yes
PATIENT RESPONSE RECORD (continued) XML Element Attributes Description Valid Values Data Type Field Size Data Element Required Q37 eligible-transplant Each element must have a closing tag that is the same as the opening tag but with a forward slash. This patient response data element should only occur once per patient. Example: None Are you eligible for a kidney transplant? Yes 1 No 2 I don’t know 3 NOT APPLICABLE X MISSING/DK M Alphanumeric character 1 Yes Q38 explain-ineligible Each element must have a closing tag that is the same as the opening tag but with a forward slash. This patient response data element should only occur once per patient. Example: None In the last 12 months, has a doctor or dialysis center staff explained to you why you are not eligible for a kidney transplant? Yes 1 No 2 NOT APPLICABLE X MISSING/DK M Alphanumeric character 1 Yes Q39 talk-peritoneal Each element must have a closing tag that is the same as the opening tag but with a forward slash. This patient response data element should only occur once per patient. Example: None Peritoneal dialysis is dialysis given through the belly and is usually done at home. In the last 12 months, did either your kidney doctors or dialysis center staff talk to you about peritoneal dialysis? Yes 1 No 2 NOT APPLICABLE X MISSING/DK M Alphanumeric character 1 Yes
PATIENT RESPONSE RECORD (continued) XML Element Attributes Description Valid Values Data Type Field Size Data Element Required Q40 choose-treatment Each element must have a closing tag that is the same as the opening tag but with a forward slash. This patient response data element should only occur once per patient. Example: None In the last 12 months, were you as involved as much as you wanted in choosing the treatment for kidney disease that is right for you? Yes 1 No 2 NOT APPLICABLE X MISSING/DK M Alphanumeric character 1 Yes Q41 unhappy-care Each element must have a closing tag that is the same as the opening tag but with a forward slash. This patient response data element should only occur once per patient. Example: unhappy-care1/unhappy-care None In the last 12 months, were you ever unhappy with the care you received at the dialysis center or from your kidney doctors? Yes 1 No 2 NOT APPLICABLE X MISSING/DK M Alphanumeric character 1 Yes Q42 talk-withstaff Each element must have a closing tag that is the same as the opening tag but with a forward slash. This patient response data element should only occur once per patient. Example: talk-withstaff1/talk-withstaff None In the last 12 months, did you ever talk to someone on the dialysis center staff about this? Yes 1 No 2 NOT APPLICABLE X MISSING/DK M Alphanumeric character 1 Yes
PATIENT RESPONSE RECORD (continued) XML Element Attributes Description Valid Values Data Type Field Size Data Element Required Q43 satisfied-problems Each element must have a closing tag that is the same as the opening tag but with a forward slash. This patient response data element should only occur once per patient. Example: None In the last 12 months, how often were you satisfied with the way they handled these problems? Never 1 Sometimes 2 Usually 3 4 NOT APPLICABLE X MISSING/DK M Alphanumeric character 1 Yes Q44 make-complaint Each element must have a closing tag that is the same as the opening tag but with a forward slash. This patient response data element should only occur once per patient. Example: None Medicare and your State have special agencies that check the quality of care at this dialysis center. In the last 12 months, did you make a complaint to any of these agencies? Yes 1 No 2 NOT APPLICABLE X MISSING/DK M Alphanumeric character 1 Yes Q45 overall-health Each element must have a closing tag that is the same as the opening tag but with a forward slash. This patient response data element should only occur once per patient. Example: overall-health1/overall-health None In general, how would you rate your overall health? Excellent 1 Very good 2 Good 3 Fair 4 Poor 5 MISSING/DK M Alphanumeric character 1 Yes
PATIENT RESPONSE RECORD (continued) XML Element Attributes Description Valid Values Data Type Field Size Data Element Required Q46 mental-health Each element must have a closing tag that is the same as the opening tag but with a forward slash. This patient response data element should only occur once per patient. Example: mental-health1/mental-health None In general, how would you rate your overall mental or emotional health? Excellent 1 Very good 2 Good 3 Fair 4 Poor 5 MISSING/DK M Alphanumeric character 1 Yes Q47 high-bloodpressure Each element must have a closing tag that is the same as the opening tag but with a forward slash. This patient response data element should only occur once per patient. Example: None Are you being treated for high blood pressure? Yes 1 No 2 MISSING/DK M Alphanumeric character 1 Yes Q48 diabetes Each element must have a closing tag that is the same as the opening tag but with a forward slash. This patient response data element should only occur once per patient. Example: diabetes1/diabetes None Are you being treated for diabetes or high blood sugar? Yes 1 No 2 MISSING/DK M Alphanumeric character 1 Yes
PATIENT RESPONSE RECORD (continued) XML Element Attributes Description Valid Values Data Type Field Size Data Element Required Q52 difficulty-concentrating Each element must have a closing tag that is the same as the opening tag but with a forward slash. This patient response data element should only occur once per patient. Example: None Because of a physical, mental, or emotional condition, do you have serious difficulty concentrating, remembering, or making decisions? Yes 1 No 2 MISSING/DK M Alphanumeric character 1 Yes Q53 difficulty-walking Each element must have a closing tag that is the same as the opening tag but with a forward slash. This patient response data element should only occur once per patient. Example: None Do you have serious difficulty walking or climbing stairs? Yes 1 No 2 MISSING/DK M Alphanumeric character 1 Yes Q54 difficulty-dressing Each element must have a closing tag that is the same as the opening tag but with a forward slash. This patient response data element should only occur once per patient. Example: None Do you have difficulty dressing or bathing? Yes 1 No 2 MISSING/DK M Alphanumeric character 1 Yes
PATIENT RESPONSE RECORD (continued) XML Element Attributes Description Valid Values Data Type Field Size Data Element Required Q55 difficulty-errands Each element must have a closing tag that is the same as the opening tag but with a forward slash. This patient response data element should only occur once per patient. Example: None Because of a physical, mental, or emotional condition, do you have difficulty doing errands alone, such as visiting a doctor’s office or shopping? Yes 1 No 2 MISSING/DK M Alphanumeric character 1 Yes
PATIENT RESPONSE RECORD (continued) XML Element Attributes Description Valid Values Data Type Field Size Data Element Required Q59-phone race-african-amer-phone Each element must have a closing tag that is the same as the opening tag but with a forward slash. This patient response data element should only occur once per patient. Example: None What is your race? You may choose one or more of the following. Are you… Black or African American 1 NOT APPLICABLE X MISSING/DK M Alphanumeric character 1 Yes Q59-phone race-amer-indian-phone Each element must have a closing tag that is the same as the opening tag but with a forward slash. This patient response data element should only occur once per patient. Example: None What is your race? You may choose one or more of the following. Are you… American Indian or Alaska Native 1 NOT APPLICABLE X MISSING/DK M Alphanumeric character 1 Yes Q59-phone race-asian-phone Each element must have a closing tag that is the same as the opening tag but with a forward slash. This patient response data element should only occur once per patient. Example: None What is your race? You may choose one or more of the following. Are you… Asian 1 NOT APPLICABLE X MISSING/DK M Alphanumeric character 1 Yes
PATIENT RESPONSE RECORD (continued) XML Element Attributes Description Valid Values Data Type Field Size Data Element Required Q59-phone race-nativehawaiian-pacific-phone Each element must have a closing tag that is the same as the opening tag but with a forward slash. This patient response data element should only occur once per patient. Example: None What is your race? You may choose one or more of the following. Are you… Native Hawaiian or Pacific Islander 1 NOT APPLICABLE X MISSING/DK M Alphanumeric character 1 Yes Q59-phone race-noneofabove-phone Each element must have a closing tag that is the same as the opening tag but with a forward slash. This patient response data element should only occur once per patient. Example: None What is your race? You may choose one or more of the following. Are you… NONE OF ABOVE 1 NOT APPLICABLE X MISSING/DK M Alphanumeric character 1 Yes Q59a-phone race-asian-indian-phone Each element must have a closing tag that is the same as the opening tag but with a forward slash. This patient response data element should only occur once per patient. Example: None Which groups best describes you? You may choose one or more of the following. Are you… Asian Indian 1 NOT APPLICABLE X MISSING/DK M Alphanumeric character 1 Yes
PATIENT RESPONSE RECORD (continued) XML Element Attributes Description Valid Values Data Type Field Size Data Element Required Q59a-phone race-korean-phone Each element must have a closing tag that is the same as the opening tag but with a forward slash. This patient response data element should only occur once per patient. Example: None Which groups best describes you? You may choose one or more of the following. Are you… Korean 1 NOT APPLICABLE X MISSING/DK M Alphanumeric character 1 Yes Q59a-phone race-vietnamese-phone Each element must have a closing tag that is the same as the opening tag but with a forward slash. This patient response data element should only occur once per patient. Example: None Which groups best describes you? You may choose one or more of the following. Are you… Vietnamese 1 NOT APPLICABLE X MISSING/DK M Alphanumeric character 1 Yes Q59a-phone race-otherasian-phone Each element must have a closing tag that is the same as the opening tag but with a forward slash. This patient response data element should only occur once per patient. Example: None Which groups best describes you? You may choose one or more of the following. Are you… Other Asian 1 NOT APPLICABLE X MISSING/DK M Alphanumeric character 1 Yes
PATIENT RESPONSE RECORD (continued) XML Element Attributes Description Valid Values Data Type Field Size Data Element Required Q59a-phone race-noneofabove-asian-phone Each element must have a closing tag that is the same as the opening tag but with a forward slash. This patient response data element should only occur once per patient. Example: None Which groups best describes you? You may choose one or more of the following. Are you… NONE ABOVE 1 NOT APPLICABLE X MISSING/DK M Alphanumeric character 1 Yes Q59b-phone race-nativehawaiian-phone Each element must have a closing tag that is the same as the opening tag but with a forward slash. This patient response data element should only occur once per patient. Example: None Which groups best describes you? You may choose one or more of the following. Are you… Native Hawaiian 1 NOT APPLICABLE X MISSING/DK M Alphanumeric character 1 Yes Q59b-phone race-guam-chamarro-phone Each element must have a closing tag that is the same as the opening tag but with a forward slash. This patient response data element should only occur once per patient. Example: None Which groups best describes you? You may choose one or more of the following. Are you… Guamanian or 1 NOT APPLICABLE X MISSING/DK M Alphanumeric character 1 Yes
PATIENT RESPONSE RECORD (continued) XML Element Attributes Description Valid Values Data Type Field Size Data Element Required Q59b-phone race-samoan-phone Each element must have a closing tag that is the same as the opening tag but with a forward slash. This patient response data element should only occur once per patient. Example: None Which groups best describes you? You may choose one or more of the following. Are you… Samoan 1 NOT APPLICABLE X MISSING/DK M Alphanumeric character 1 Yes Q59b-phone race-otherpacificislander-phone Each element must have a closing tag that is the same as the opening tag but with a forward slash. This patient response data element should only occur once per patient. Example: None Which groups best describes you? You may choose one or more of the following. Are you… Other Pacific Islander 1 NOT APPLICABLE X MISSING/DK M Alphanumeric character 1 Yes Q59b-phone race-noneofabove-pacific-phone Each element must have a closing tag that is the same as the opening tag but with a forward slash. This patient response data element should only occur once per patient. Example: None Which groups best describes you? You may choose one or more of the following. Are you… NONE ABOVE 1 NOT APPLICABLE X MISSING/DK M Alphanumeric character 1 Yes
PATIENT RESPONSE RECORD (continued) XML Element Attributes Description Valid Values Data Type Field Size Data Element Required Q59-mail race-otherasian-mail Each element must have a closing tag that is the same as the opening tag but with a forward slash. This patient response data element should only occur once per patient. Example: None What is your race? (One or more categories may be selected.) Other Asian 1 NOT APPLICABLE X MISSING/DK M Alphanumeric character 1 Yes Q59-mail race-nativehawaiian-mail Each element must have a closing tag that is the same as the opening tag but with a forward slash. This patient response data element should only occur once per patient. Example: None What is your race? (One or more categories may be selected.) Native Hawaiian 1 NOT APPLICABLE X MISSING/DK M Alphanumeric character 1 Yes Q59-mail race-guamanian-chamorro-mail Each element must have a closing tag that is the same as the opening tag but with a forward slash. This patient response data element should only occur once per patient. Example: None What is your race? (One or more categories may be selected.) Guamanian or 1 NOT APPLICABLE X MISSING/DK M Alphanumeric character 1 Yes
PATIENT RESPONSE RECORD (continued) XML Element Attributes Description Valid Values Data Type Field Size Data Element Required Q59-mail race-samoan-mail Each element must have a closing tag that is the same as the opening tag but with a forward slash. This patient response data element should only occur once per patient. Example: None What is your race? (One or more categories may be selected.) Samoan 1 NOT APPLICABLE X MISSING/DK M Alphanumeric character 1 Yes Q59-mail race-other-pacificislander-mail Each element must have a closing tag that is the same as the opening tag but with a forward slash. This patient response data element should only occur once per patient. Example: mail None What is your race? (One or more categories may be selected.) Other Pacific Islander 1 NOT APPLICABLE X MISSING/DK M Alphanumeric character 1 Yes Q60-mail help-you Each element must have a closing tag that is the same as the opening tag but with a forward slash. This patient response data element should only occur once per patient. Example: help-you1/help-you None Did someone help you complete this survey? Yes 1 No 2 NOT APPLICABLE X MISSING/DK M Alphanumeric character 1 Yes
CAHPS To submit this form online, please go to . Date Submitted: I. One DNR is required for each discrepancy reason. If you have multiple CCNs with the same discrepancy reason, please include all CCNs on one DNR. If you have more than one discrepancy reason, you will need to submit a DNR for each discrepancy reason. To complete this form, please complete the following sections: Section I—Select the affected Survey Period and the reason for the discrepancy from the drop down boxes. Section II—Enter all CCNs that are impacted by the discrepancy reason. Section III—Provide a detailed description of the discrepancy being reported for each CCN and include the number of affected patients. If you do not know the number of affected patients, please enter UNK. If the number of affected patients is not applicable, enter NA. Section IV—Include a description of the corrective action your organization has taken to address the discrepancy. Section V—Provide any additional information about the discrepancy that you feel the ICH CAHPS Coordination Team will need. PERIOD: DISCREPANCY REASON: II. CCN #s Please enter your CCN number(s) for which you are filing the discrepancy. If you have multiple CCN numbers, please enter them as a comma separated list, as shown in the example below. After entering your CCN number(s), click on the “Lookup Facility Names” button. Do not include dashes in the CCN number. Example: 111111, 222222, 333333 III. Please complete the items below in detail for each facility listed.
2016 (ESRD) Alabama: NETWORK 8, INC. NETWORK 8 1-877-936-9260 Alaska: NORTHWEST RENAL NETWORK NETWORK 16 1-800-262-1514 American Samoa: WESTERN PACIFIC RENAL NETWORK, LLC NETWORK 17 1-800-232-3773 Arizona: INTERMOUNTAIN ESRD NETWORK, INC. NETWORK 15 1-800-783-8818 Arkansas: FMQAI: ESRD NETWORK 13 NETWORK 13 1-800-472-8664 California (Northern): WESTERN PACIFIC RENAL NETWORK, LLC 17 1-800-232-3773 California (Southern): FMQAI: ESRD NETWORK 18 NETWORK 18 1-800-637-4767 Colorado: INTERMOUNTAIN ESRD NETWORK, INC. NETWORK 15 1-800-783-8818 Connecticut: IPRO ESRD NETWORK OF NEW ENGLAND NETWORK 1 1-866-286-3773 Delaware: QUALITY INSIGHTS NETWORK 4 NETWORK 4 1-800-548-9205 Florida: FMQAI: THE FLORIDA ESRD NETWORK NETWORK 7 1-800-826-3773 Georgia: SOUTHEASTERN COUNCIL, INC. NETWORK 6 1-800-524-7139 Guam: WESTERN PACIFIC RENAL NETWORK, LLC NETWORK 17 1-800-232-3773 Hawaii: WESTERN PACIFIC RENAL NETWORK, LLC NETWORK 17 1-800-232-3773 Idaho: NORTHWEST RENAL NETWORK NETWORK 16 1-800-262-1514 Illinois: THE RENAL NETWORK, INC. NETWORK 10 1-800-456-6919 Indiana: THE RENAL NETWORK, INC. NETWORK 9 1-800-456-6919 Iowa: HEARTLAND KIDNEY NETWORK NETWORK 12 1-800-444-9965
Ohio: THE RENAL NETWORK, INC. NETWORK 9 1-800-456-6919 Oklahoma: FMQAI: ESRD NETWORK 13 NETWORK 13 1-800-472-8664 Oregon: NORTHWEST RENAL NETWORK NETWORK 16 1-800-262-1514 Pennsylvania: QUALITY INSIGHTS RENAL NETWORK 4 NETWORK 4 1-800-548-9205 Puerto Rico: QUALITY INSIGHTS RENAL NETWORK 3 NETWORK 3 1-888-877-8400 Rhode Island: IPRO ESRD NETWORK OF NEW ENGLAND NETWORK 1 1-866-286-3773 South Carolina: SOUTHEASTERN KIDNEY COUNCIL, INC. NETWORK 6 1-800-524-7139 South Dakota: RENAL NETWORK OF THE UPPER MIDWEST, INC. NETWORK 11 1-800-973-3773 Tennessee: NETWORK 8, INC. NETWORK 8 1-877-936-9260 Texas: ESRD NETWORK OF TEXAS, INC. NETWORK 14 1-877-886-4435 Utah: INTERMOUNTAIN ESRD NETWORK, INC. NETWORK 15 1-800-783-8818 Vermont: IPRO ESRD NETWORK OF NEW ENGLAND NETWORK 1 1-866-286-3773 Virgin Islands: QUALITY INSIGHTS RENAL NETWORK 3 NETWORK 3 1-888-877-8400 Virginia: MID-ATLANTIC RENAL COALITION NETWORK 5 1-866-651-6272 Washington (state): NORTHWEST RENAL NETWORK NETWORK 16 1-800-262-1514 West Virginia: MID-ATLANTIC RENAL COALITION NETWORK 5 1-866-651-6272 Wisconsin: RENAL NETWORK OF THE UPPER MIDWEST, INC. NETWORK 11 1-800-973-3773 Wyoming: INTERMOUNTAIN ESRD NETWORK, INC. NETWORK 15 1-800-783-8818 Washington, DC: MID-ATLANTIC RENAL COALITION NETWORK 5 1-866-651-6272 THE OFFICE OF MEDICARE: 1-800-MEDICARE OR 1-800-633-4227