SHEP_InCtrHemodialysis Survey

®

CAHPS In-Center Hemodialysis Survey
Version: Adult Questionnaire
Language: English

File name: 551a_ICH_Survey_English.doc
Last updated: May 6, 2009

CAHPS In-Center Hemodialysis Survey

Adult Questionnaire – Core Items

Instructions for Front Cover
• Replace the cover of this document with your own front cover. Include a user-friendly title
and your own logo.

• Include this text regarding the confidentiality of survey responses:
Your Privacy is Protected. All information that would let someone identify you or
your family will be kept private. {VENDOR NAME} will not share your personal
information with anyone without your OK. Your responses to this survey are also
completely confidential. You may notice a number on the cover of the survey. This
number is used only to let us know if you returned your survey so we don’t have to
send you reminders.
Your Participation is Voluntary. You may choose to answer this survey or not. If
you choose not to, this will not affect the health care you get.
What To Do When You’re Done. Once you complete the survey, place it in the
envelope that was provided, seal the envelope, and return the envelope to [INSERT
VENDOR ADDRESS].
If you want to know more about this study, please call XXX-XXX-XXXX.

Instructions for Format of Questionnaire
Proper formatting of a questionnaire improves response rates, the ease of completion, and the
accuracy of responses. The CAHPS team’s recommendations include the following:

• If feasible, insert blank pages as needed so that the survey instructions (see next page)
and the first page of questions start on the right-hand side of the questionnaire booklet.

• Maximize readability by using two columns, serif fonts for the questions, and ample white
space.

• Number the pages of your document, but remove the headers and footers inserted to help
sponsors and vendors distinguish among questionnaire versions.

Additional guidance is available in Preparing a Questionnaire Using the
CAHPS In-Center Hemodialysis Survey:
https://www.cahps.ahrq.gov/cahpskit/files/52_ICH_Preparing_a_Questionnaire.pdf

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CAHPS In-Center Hemodialysis Survey

Adult Questionnaire – Core Items

Survey Instructions
Answer each question by marking the box to the left of your answer.
You are sometimes told to skip over some questions in this survey. When this happens
you will see an arrow with a note that tells you what question to answer next, like this:
Yes → If Yes, go to #1 on page 1
No

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CAHPS In-Center Hemodialysis Survey

1.

Adult Questionnaire – Core Items

Where do you get your dialysis treatments?
1

2

4.

At home → If At home, stop here.
Please return this survey in the
postage-paid envelope.
At the dialysis center

In the last 3 months, how often did your
kidney doctors explain things in a way that
was easy to understand?
1
2
3
4

2.

How long have you been getting dialysis at
this dialysis center?
1

2
3
4

5.

Less than 3 months → If Less than 3
months, stop here. Please return
this survey in the postage-paid
envelope.
At least 3 months but less than 1 year
At least 1 year but less than 5 years
5 years or more

3.

2
3
4

6.

For the questions that follow, “your kidney
doctors” means the doctor or doctors most
involved in your dialysis care now. This
could include 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
2
3
4

In the last 3 months, how often did your
kidney doctors show respect for what you
had to say?
1

Your Kidney Doctors

2
3
4

7.

1
2

4

1

Never
Sometimes
Usually
Always

In the last 3 months, how often did you feel
your kidney doctors really cared about you
as a person?

3

Core ICH Survey with Supplemental Items.doc

Never
Sometimes
Usually
Always

In the last 3 months, how often did your
kidney doctors spend enough time with
you?
1

Never
Sometimes
Usually
Always

Never
Sometimes
Usually
Always

Never
Sometimes
Usually
Always

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CAHPS In-Center Hemodialysis Survey

8.

Adult Questionnaire – Core Items

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?

11. In the last 3 months, how often did the
dialysis center staff explain things in a way
that was easy to understand?
1
2

0 Worst kidney doctors possible
1
2
3
4
5
6
7
8
9
10 Best kidney doctors possible
9.

3
4

12. In the last 3 months, how often did the
dialysis center staff show respect for what
you had to say?
1
2
3
4

2

Never
Sometimes
Usually
Always

13. In the last 3 months, how often did the
dialysis center staff spend enough time with
you?

Do your kidney doctors seem informed and
up to date about the health care you receive
from other doctors?
1

Never
Sometimes
Usually
Always

1

Yes
No

2
3
4

Never
Sometimes
Usually
Always

The Dialysis Center Staff
14. In the last 3 months, how often did you feel
the dialysis center staff really cared about
you as a person?

10. For the questions that follow, dialysis
center staff do not include doctors. Dialysis
center staff means nurses, technicians,
dietitians, and social workers at this dialysis
center. In the last 3 months, how often did
the dialysis center staff listen carefully to
you?
1
2
3
4

1
2
3
4

Never
Sometimes
Usually
Always

15. In the last 3 months, how often did dialysis
center staff make you as comfortable as
possible during dialysis?
1
2
3
4

Core ICH Survey with Supplemental Items.doc

Never
Sometimes
Usually
Always

2

Never
Sometimes
Usually
Always

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CAHPS In-Center Hemodialysis Survey

Adult Questionnaire – Core Items

16. In the last 3 months, did dialysis center staff
keep information about you and your health
as private as possible from other patients?
1
2

21. In the last 3 months, how often did dialysis
center staff insert your needles with as little
pain as possible?
1

Yes
No

2
3
4

17. In the last 3 months, did you feel
comfortable asking the dialysis center staff
everything you wanted about dialysis care?
1
2

5

22. 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?

Yes
No

18. In the last 3 months, has anyone on the
dialysis center staff asked you about how
your kidney disease affects other parts of
your life?
1
2

1
2
3
4

Yes
No

2

1
2

Yes
No

2
3
4

1
2
3
4

Graft
Fistula
Catheter → If Catheter, go to #22
Don’t know → If Don’t know, go
to #22

Never
Sometimes
Usually
Always

25. In the last 3 months, how often did dialysis
center staff behave in a professional
manner?
1
2
3
4

Core ICH Survey with Supplemental Items.doc

Yes
No → If No, go to #25

24. In the last 3 months, how often were the
dialysis center staff able to manage
problems during your dialysis?

20. In the last 3 months, which one did they use
most often to connect you to the dialysis
machine?
1

Never
Sometimes
Usually
Always

23. In the last 3 months, did any problems
occur during your dialysis?

19. The dialysis center staff can connect you to
the dialysis machine through a graft, fistula,
or catheter. Do you know how to take care
of your graft, fistula, or catheter?
1

Never
Sometimes
Usually
Always
I insert my own needles

3

Never
Sometimes
Usually
Always

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CAHPS In-Center Hemodialysis Survey

Adult Questionnaire – Core Items

26. Please remember that, for these questions,
dialysis center staff do not include doctors.
Dialysis center staff means nurses,
technicians, dietitians, and social workers at
this dialysis center. In the last 3 months, did
dialysis center staff talk to you about what
you should eat and drink?
1
2

31. Have any dialysis center staff ever told you
how to get off the machine if there is an
emergency at the center?
1
2

32. 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?

Yes
No

27. In the last 3 months, how often did dialysis
center staff explain blood test results in a
way that was easy to understand?
1
2
3
4

0 Worst dialysis center staff possible
1
2
3
4
5
6
7
8
9
10 Best dialysis center staff possible

Never
Sometimes
Usually
Always

28. As a patient, you have certain rights. For
example, you have the right to be treated
with respect and the right to privacy. Did
this dialysis center ever give you any
written information about your rights as a
patient?
1
2

Yes
No

The Dialysis Center
33. In the last 3 months, when you arrived on
time, how often did you get put on the
dialysis machine within 15 minutes of your
appointment or shift time?

29. Did dialysis center staff at this center ever
review your rights as a patient with you?
1
2

Yes
No

1
2
3
4

30. Have dialysis center staff ever told you
what to do if you experience a health
problem at home?
1
2

Yes
No

Never
Sometimes
Usually
Always

Yes
No

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CAHPS In-Center Hemodialysis Survey

Adult Questionnaire – Core Items

37. Are you eligible for a kidney transplant?

34. In the last 3 months, how often was the
dialysis center as clean as it could be?
1
2
3
4

1

Never
Sometimes
Usually
Always

2
3

38. In the last 12 months, have either your
kidney doctors or dialysis center staff
explained to you why you are not eligible
for a kidney transplant?

35. Using any number from 0 to 10, where 0 is
the worst dialysis center possible and 10 is
the best dialysis center possible, what
number would you use to rate this dialysis
center?

1
2

0 Worst dialysis center possible
1
2
3
4
5
6
7
8
9
10 Best dialysis center possible

1
2

Yes
No

40. 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
2

The next few questions ask about your care in
the last 12 months.

Yes
No

41. In the last 12 months, were you ever
unhappy with the care you received at the
dialysis center or from your kidney
doctors?

36. You can treat kidney disease with dialysis
at a center, a kidney transplant, or dialysis
at home. In the last 12 months, did either
your kidney doctors or dialysis center staff
talk to you as much as you wanted about
which treatment is right for you?
2

Yes
No

39. 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?

Treatment

1

Yes → If Yes, go to #39
No
Don’t know → If Don’t know, go
to #39

1
2

Yes
No → If No, go to #45

Yes
No

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Adult Questionnaire – Core Items

42. In the last 12 months, did you ever talk to
someone on the dialysis center staff about
this?
1
2

About You
45. In general, how would you rate your overall
health?

Yes
No → If No, go to #45

1
2
3

43. In the last 12 months, how often were you
satisfied with the way they handled these
problems?
1
2
3
4

4
5

Never
Sometimes
Usually
Always

46. In general, how would you rate your overall
mental or emotional health?
1
2
3

44. 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
2

Excellent
Very good
Good
Fair
Poor

4
5

Excellent
Very good
Good
Fair
Poor

47. Are you being treated for high blood
pressure?

Yes
No

1
2

Yes
No

48. Are you being treated for diabetes or high
blood sugar?
1
2

Yes
No

49. Are you being treated for heart disease or
heart problems?
1
2

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Yes
No

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CAHPS In-Center Hemodialysis Survey

Adult Questionnaire – Core Items

50. What is your age?
1
2
3
4
5
6
7

55. What language do you mainly speak at
home?

18 to 24
25 to 34
35 to 44
45 to 54
55 to 64
65 to 74
75 or older

1
2
3
4

English
Spanish
Both English and Spanish equally
Some other language

Please print: _______________________
__________________________________

51. Are you male or female?
1
2

56. Did someone help you complete this
survey?

Male
Female

1
2

52. What is the highest grade or level of school
that you have completed?
1
2

3
4
5
6

8th grade or less
Some high school, but did not
graduate
High school graduate or GED
Some college or 2-year degree
4-year college graduate
More than 4-year college degree

57. Who helped you complete this survey?
1
2
3
4

2

A family member
A friend
A staff member at the dialysis center
Someone else

Please print: _______________________

53. Are you of Hispanic or Latino origin or
descent?
1

Yes
No → If No, stop here. Please
return this completed
survey in the postage-paid
envelope.

__________________________________

Yes, Hispanic or Latino
No, not Hispanic or Latino

54. What is your race? Please mark one or
more.
1
2
3
4

5

American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific
Islander
White

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CAHPS In-Center Hemodialysis Survey

Adult Questionnaire – Core Items

58. How did that person help you? Please mark
one or more.
1
2
3
4

5

Read the questions to me
Wrote down the answers I gave
Answered the questions for me
Translated the questions into my
language
Helped in some other way

Please print: _______________________
__________________________________
__________________________________

Thank you.
Please return this completed survey in the enclosed postage-paid envelope.

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®

CAHPS In-Center Hemodialysis Survey
Supplemental Items for the Adult Questionnaire
Language: English

File name: 551a_ICH_Survey_English.doc
Last updated: May 6, 2009

CAHPS In-Center Hemodialysis Survey

Adult Questionnaire – Supplemental Items

TABLE OF CONTENTS
Quality Improvement.................................................................................................................11
Physical Plant, Transportation, and Access..............................................................................13
Interpreter Services ..................................................................................................................14

Important instructions
Placing Supplemental Items in the Core Questionnaires. After you copy one or more supplemental
items into the core questionnaire:

• Fix the formatting of the items as needed to fit into the two-column format.
• Renumber the supplemental item and ALL subsequent items so that they are consecutive.
• Revise ALL skip instructions in the questionnaire to make sure they point the respondent to the
correct item number.

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CAHPS In-Center Hemodialysis Survey

Adult Questionnaire – Supplemental Items

Quality Improvement
The team of researchers who developed the CAHPS In-Center Hemodialysis Survey included the
following set of items in their cognitive tests and field tests of the questionnaire. These tests proved the
strong reliability and validity of these items. Although the survey developers decided to remove them
from the core questionnaire, facilities may use them for quality improvement purposes. The placement
information provided above each question shows where the survey developers included these
supplemental items in the field test version of the questionnaire.
Insert S1 before core question 8.
S1.

In the last 3 months, did your kidney doctors keep you informed and up to date about your
condition?
1
2

Yes
No

Insert S2-S3 before core question 17.
S2.

Sometimes dialysis center staff cover patients or use a curtain to protect a patient’s privacy. In
the last 3 months, did you ever need dialysis center staff to protect your privacy in this way?
1
2

S3.

Yes
No → If No, go to core question 17

In the last 3 months, how often did dialysis center staff cover you or use a curtain to protect
your privacy?
1
2
3
4

Never
Sometimes
Usually
Always

Insert S4 before core question 24.
S4.

In the last 3 months, how often did dialysis center staff respond to these problems as soon as
you wanted?
1
2
3
4

Never
Sometimes
Usually
Always

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Adult Questionnaire – Supplemental Items

Insert S5 before core question 26.
S5.

In the last 3 months, how often did dialysis center staff change their gloves between patients?
1
2
3
4
5

Never
Sometimes
Usually
Always
Don’t know

Insert S6-S7 before core question 32.
S6.

Is there a family member or friend involved with your dialysis care?
1
2

S7.

Yes
No → If No, go to core question 32

Do dialysis center staff include your family member or friend as much as you want?
1
2

Yes
No

Insert S8 before core question 34.
S8.

In the last 3 months, how often was the dialysis center as calm and quiet as it could be?
1
2
3
4

Never
Sometimes
Usually
Always

Insert S9 before core question 44.
S9.

Medicare and your state have special agencies that check the quality of care at this dialysis
center. Has anyone at the dialysis center ever given you information about how to make a
complaint to these agencies?
1
2

Yes
No

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CAHPS In-Center Hemodialysis Survey

Adult Questionnaire – Supplemental Items

Physical Plant, Transportation, and Access
The team that developed the CAHPS In-Center Hemodialysis Survey did not include the following items
in their cognitive tests and field tests of the questionnaire. Therefore, their validity and reliability remain
undetermined. However, because they cover topics of interest to many ESRD stakeholders, the team
decided to make them available for optional use in the survey. The placement instructions provided
above each question show where these supplemental items should go in the questionnaire.
Insert S10-S15 after core question 44 and before the “About You” section.
S10.

In the last 3 months, how often was the temperature at the dialysis center comfortable for you?
1
2
3
4

S11.

In the last 3 months, how often was your dialysis station kept clean?
1
2
3
4

S12.

2

Yes
No → If No, go to question S14

In the last 3 months, how often did the help with transportation meet your needs?
1
2
3
4

S14.

Never
Sometimes
Usually
Always

Some dialysis centers arrange transportation to the center for patients. This help can be a
shuttle bus or van or tokens or vouchers for a bus or taxi. In the last 3 months, did you ask the
center for help with transportation?
1

S13.

Never
Sometimes
Usually
Always

Never
Sometimes
Usually
Always

Do you need to park at the center where you go for treatment?
1
2

Yes
No → If No, go to core question 45 [If items S16-S20 are included: go to
question S16]

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CAHPS In-Center Hemodialysis Survey

S15.

Adult Questionnaire – Supplemental Items

In the last 3 months, how often were you able to park in a convenient location?
1
2
3
4

Never
Sometimes
Usually
Always

Interpreter Services
The team that developed the CAHPS In-Center Hemodialysis Survey did not include the following items
in their cognitive tests and field tests of the questionnaire. Therefore, their validity and reliability remain
undetermined. However, because they cover topics of interest to many ESRD stakeholders, the team
decided to make them available for optional use in the survey. The placement instructions provided
above each question show where these supplemental items should go in the questionnaire.
Insert S16-S20 after core question 44 and before the “About You” section.
S16.

An interpreter is someone who helps you talk with others who don’t speak the same language
as you. During the last 3 months, did you ever need an interpreter to help you talk with your
kidney doctors or dialysis center staff?
1
2

S17.

During the last 3 months, how often did you have problems at this dialysis center because you
had to wait for an interpreter?
1
2
3
4

S18.

Yes
No → If No, go to core question 45

Never
Sometimes
Usually
Always

During the last 3 months, when you needed an interpreter to help you at this dialysis center,
how often did the dialysis center provide one?
1
2
3
4

Never
Sometimes
Usually
Always

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CAHPS In-Center Hemodialysis Survey

S19.

Adult Questionnaire – Supplemental Items

During the last 3 months, who usually acted as your interpreter when you needed to talk with
your kidney doctors or dialysis center staff?
1
2
3

A member of the dialysis center staff
A friend or family member → If a friend or family member, go to core question 45
Someone else

Please specify: ________________________________________________________________
S20.

Using any number from 0 to 10, where 0 is the worst possible interpreter and 10 is the best
possible interpreter, what number would you give the interpreters that the dialysis center
provided most often in the last 3 months? Do not include friends and family members.
0 Worst possible interpreter
1
2
3
4
5
6
7
8
9
10 Best possible interpreter

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