Form GenIC #5 GenIC #5 ESRD Grievant

1979 Marcus Avenue, Suite 105  Lake Success, NY 11042-1072

Phone: 516-209-5253  Fax: 516-326-7805  [email protected]

www.esrdncc.org  www.kcercoalition.com

ESRD Grievant Satisfaction Survey

Introduction

Hello. May I please speak with [participant name]?

If the participant is not available, thank the person on the phone, and end the call by saying, “Thank you for your time.”

If the participant answers the phone, state the following:

Good [morning/afternoon/evening, participant name]. My name is [surveyor name]. I’m calling from [name of survey vendor]. We provide survey services for Medicare. Please know we have no connection to the ESRD Network or your dialysis center.

I’m calling to ask you questions about your contact with [Network name] when you filed your grievance.

Our records show you contacted [Network Name] around [date] to file a grievance. Is this correct?

If yes, continue with the survey. If no, conclude the survey and thank the respondent.

Is this a good time for you to talk?

If yes, continue with the survey. If no, schedule a follow-up call.

You might want to take some notes while we talk. If you want to get a pencil and paper before we begin, I can wait. Wait for respondent to get pencil and paper.

We will use what we learn today to help improve the Network grievance process. We will talk for about 15 minutes today. What we talk about is private; we will not share what you say with your ESRD Network or with any dialysis centers. Again, the information you share with us will not change your Medicare benefits. And you do not have to take the survey if you don’t want to.

While we are talking, you might have questions about the survey or the [name of survey vendor]’s role. So before we begin, I want to give you the phone number for the Medicare contact who can help answer your questions.

The contact’s name is Kathleen Egan (spell out). Her phone number is xxx-xxx-xxxx.

Before we start, I want to remind you:

• [Name of survey vendor] does not work with [Network Name] or the dialysis center;

• What you tell us today is private;

• We will not share your answers with [Network Name] or your dialysis center; and

• Your answers will not change your Medicare benefits or the care you receive.

Grievance/ Process: The following questions are about the way [Network Name] handled your grievance. Please consider only the question I ask. Try not to think about whether your grievance turned out the way you wanted. I will give you a list of answers for each question, and you can choose the best one.

1. How satisfied were you with the customer service you received from [Network Name] when you first told them about your grievance?

Very satisfied (4)

Somewhat satisfied (3)

Neither satisfied nor dissatisfied (2)

Somewhat dissatisfied (1)

Very dissatisfied (0)

No answer/Don’t know (9)

2A. Did your Network explain your right to file a grievance to you?

Yes (go to 2B)

No (go to 3A)

2B. After you spoke with the Network, did you have a good understanding of your right to file a grievance?

Very good understanding (4)

Good understanding (3)

Neither good nor poor understanding (2)

Poor understanding (1)

Very poor understanding (0)

No answer/Don’t know (9)

3A. Did you talk more than once with [Network Name] while your grievance was in process?

Yes

No (go to 3C)

3B. How satisfied were you with the customer service you received from [Network Name] in follow-up talks during your grievance?

Very satisfied (4)

Somewhat satisfied (3)

Neither satisfied nor dissatisfied (2)

Somewhat dissatisfied (1)

Very dissatisfied (0)

No answer/Don’t know (9)

3C. Did a patient representative or someone who works with patients at your dialysis facility help you with your grievance?

Yes

No

4. Did you feel respected while [Network Name] processed your grievance?

Very respected (4)

Somewhat respected (3)

Neither respected nor disrespected (2)

Somewhat disrespected (1)

Very disrespected (0)

No answer/Don’t know (9)

4. How satisfied were you that the Network listened to your concerns and understood them?

Very satisfied (4)

Somewhat satisfied (3)

Neither satisfied nor dissatisfied (2)

Somewhat dissatisfied (1)

Very dissatisfied (0)

No answer/Don’t know (9)

4. How satisfied were you with the Network’s effort to resolve your grievance?

Very satisfied (4)

Somewhat satisfied (3)

Neither satisfied nor dissatisfied (2)

Somewhat dissatisfied (1)

Very dissatisfied (0)

No answer/Don’t know (9)

4. How satisfied were you that the Network acted in your best interest?

Very satisfied (4)

Somewhat satisfied (3)

Neither satisfied nor dissatisfied (2)

Somewhat dissatisfied (1)

Very dissatisfied (0)

No answer/Don’t know (9)

4. Did you get a letter from [Network Name] with results of their work to resolve your grievance? (Item is not scored.)

Yes (if yes, go to 8A)

No (if no, go to 9)

8A. How satisfied were you with the letters you received from the Network?

Very satisfied (4)

Somewhat satisfied (3)

Neither satisfied nor dissatisfied (2)

Somewhat dissatisfied (1)

Very dissatisfied (0)

No answer/Don’t know (9)

4. Overall, how satisfied were you with the help you received from [Network Name] to resolve your grievance?
   
   

Very satisfied (4)

Somewhat satisfied (3)

Neither satisfied nor dissatisfied (2)

Somewhat dissatisfied (1)

Very dissatisfied (0)

No answer/Don’t know (9)

4. Did you file for reconsideration based on the Network’s decision about your grievance?

No (go to question 11)

Yes (go to 10A)

10A. How satisfied were you with the Network reconsideration process?

Very satisfied (4)

Somewhat satisfied (3)

Neither satisfied nor dissatisfied (2)

Somewhat dissatisfied (1)

Very dissatisfied (0)

No answer/Don’t know (9)

11. Are you comfortable enough with the Network grievance process to file another grievance?

Very comfortable (4)

Somewhat comfortable (3)

Neither comfortable nor uncomfortable (2)

Somewhat uncomfortable (1)

Very uncomfortable (0)

No answer/Don’t know (9)

Additional Questions: At this point, I wanted to see if you would feel comfortable answering some questions about any concerns you may have had with your Network or dialysis facility when filing your grievance.

Would you feel comfortable answering these questions?

1. Yes (If yes, go to 12)

2. No (If no, go to 16)

12. When you contacted your ESRD Network, did anyone at the Network ever try to talk you out of filing the grievance?

1. Yes

2. No

3. I prefer not to answer

12A. If yes, what did they say to you?

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

12. When you contacted your dialysis facility, did anyone at the facility ever try to talk you out of filing the grievance?

1. Yes

2. No

3. I prefer not to answer

4. Did not file grievance at facility

13A. If yes, what did they say to you?

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

12. When you filed a grievance with your ESRD Network, did you feel that the staff at your dialysis facility took actions against you after you filed your grievance?

1. Yes

2. No

3. I prefer not to answer

14A. If yes, then how did the center take action against you?

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

12. When you filed a grievance with your facility, did you feel that the staff at your dialysis facility took actions against you after you filed your grievance?

1. Yes

2. No

3. I prefer not to answer

4. Did not file grievance at facility

15A. If yes, then how did the center take action against you?

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Wrap-Up Question

16. Would you like to add any thoughts about your contact with [Network Name] during the time you filed your grievance?

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Conclusion

On behalf of [name of survey vendor], I want to thank you for your time today. Again, if you have any questions or concerns about this survey or the way I asked questions, please contact Ms. Kathleen Egan at xxx-xxx-xxxx or [email protected]