Crosswalk: Survey

Attachment B:
ICH CAHPS Survey and Survey Package Crosswalk

Table. Crosswalk of changes made to the survey from the ICH CAHPS mode experiment, 2014, and current surveys

Mail Question Text	ME QX Number*	2014 QX Number	2016 QX Number
Where do you get your dialysis treatments?	1	1	1
1. At home (If At home, Go to Question 45)	X	X	X
2. At the dialysis center	X	X	X
3. I do not currently receive dialysis (If I do not currently receive dialysis, Go to Question 45)	NA	X	X
How long have you been getting dialysis at [SAMPLE FACILITY NAME]?	2	2	2
1. Less than 3 months (If Less than 3 months, Go to Question 45)	X	X	X
2. At least 3 months, but less than 1 year	X	X	X
3. At least 1 year, but less than 5 years	X	X	X
4. 5 years or more	X	X	X
5. I do not currently receive dialysis at this dialysis center. (If do not currently receive dialysis at this dialysis center, Go to Question 45)	X	X	X
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?	3	3	3
1. Never	X	X	X
2. Sometimes	X	X	X
3. Usually	X	X	X
4. Always	X	X	X
In the last 3 months, how often did your kidney doctors explain things in a way that was easy for you to understand?	4	4	4
1. Never	X	X	X
2. Sometimes	X	X	X
3. Usually	X	X	X
4. Always	X	X	X
In the last 3 months, how often did your kidney doctors show respect for what you had to say?	5	5	5
1. Never	X	X	X
2. Sometimes	X	X	X
3. Usually	X	X	X
4. Always	X	X	X
In the last 3 months, how often did your kidney doctors spend enough time with you?	6	6	6
1. Never	X	X	X
2. Sometimes	X	X	X
3. Usually	X	X	X
4. Always	X	X	X
In the last 3 months, how often did you feel your kidney doctors really cared about you as a person?	7	7	7
1. Never	X	X	X
2. Sometimes	X	X	X
3. Usually	X	X	X
4. Always	X	X	X
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?	8	8	8
0. 0 Worst kidney doctors possible	X	X	X
1. 1	X	X	X
2. 2	X	X	X
3. 3	X	X	X
4. 4	X	X	X
5. 5	X	X	X
6. 6	X	X	X
7. 7	X	X	X
8. 8	X	X	X
9. 9	X	X	X
10. 10 Best kidney doctors possible	X	X	X
Do your kidney doctors seem informed and up-to-date about the health care you receive from other doctors?	9	9	9
1. Yes	X	X	X
2. No	X	X	X
For the next questions, dialysis center staff does 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?	10	10	10
1. Never	X	X	X
2. Sometimes	X	X	X
3. Usually	X	X	X
4. Always	X	X	X
In the last 3 months, how often did the dialysis center staff explain things in a way that was easy for you to understand?	11	11	11
1. Never	X	X	X
2. Sometimes	X	X	X
3. Usually	X	X	X
4. Always	X	X	X
In the last 3 months, how often did the dialysis center staff show respect for what you had to say?	12	12	12
1. Never	X	X	X
2. Sometimes	X	X	X
3. Usually	X	X	X
4. Always	X	X	X
In the last 3 months, how often did the dialysis center staff spend enough time with you?	13	13	13
1. Never	X	X	X
2. Sometimes	X	X	X
3. Usually	X	X	X
4. Always	X	X	X
In the last 3 months, how often did you feel the dialysis center staff really cared about you as a person?	14	14	14
1. Never	X	X	X
2. Sometimes	X	X	X
3. Usually	X	X	X
4. Always	X	X	X
In the last 3 months, how often did dialysis center staff make you as comfortable as possible during dialysis?	15	15	15
1. Never	X	X	X
2. Sometimes	X	X	X
3. Usually	X	X	X
4. Always	X	X	X
In the last 3 months, did dialysis center staff keep information about you and your health as private as possible from other patients?	16	16	16
1. Yes	X	X	X
2. No	X	X	X
In the last 3 months, did you feel comfortable asking the dialysis center staff everything you wanted about dialysis care?	17	17	17
1. Yes	X	X	X
2. No	X	X	X
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?	18	18	18
1. Yes	X	X	X
2. No	X	X	X
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?	19	19	19
1. Yes	X	X	X
2. No	X	X	X
In the last 3 months, which one did they use most often to connect you to the dialysis machine?	20	20	20
1. Graft	X	X	X
2. Fistula	X	X	X
3. Catheter (If Catheter, Go to Question 22)	X	X	X
4. I don’t know (If Don’t Know, Go to Question 22)	X	X	X
In the last 3 months, how often did dialysis center staff insert your needles with as little pain as possible?	21	21	21
1. Never	X	X	X
2. Sometimes	X	X	X
3. Usually	X	X	X
4. Always	X	X	X
5. I inserted my own needles	X	X	X
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?	22	22	22
1. Never	X	X	X
2. Sometimes	X	X	X
3. Usually	X	X	X
4. Always	X	X	X
In the last 3 months, did any problems occur during your dialysis?	23	23	23
1. Yes	X	X	X
2. No	X	X	X
In the last 3 months, how often was the dialysis center staff able to manage problems during your dialysis?	24	24	24
1. Never	X	X	X
2. Sometimes	X	X	X
3. Usually	X	X	X
4. Always	X	X	X
In the last 3 months, how often did dialysis center staff behave in a professional manner?	25	25	25
1. Never	X	X	X
2. Sometimes	X	X	X
3. Usually	X	X	X
4. Always	X	X	X
Please remember that for these questions, dialysis center staff does 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?	26	26	26
1. Yes	X	X	X
2. No	X	X	X
In the last 3 months, how often did dialysis center staff explain blood test results in a way that was easy to understand?	27	27	27
1. Never	X	X	X
2. Sometimes	X	X	X
3. Usually	X	X	X
4. Always	X	X	X
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?	28	28	28
1. Yes	X	X	X
2. No	X	X	X
Did dialysis center staff at this center ever review your rights as a patient with you?	29	29	29
1. Yes	X	X	X
2. No	X	X	X
Has dialysis center staff ever told you what to do if you experience a health problem at home?	30	30	30
1. Yes	X	X	X
2. No	X	X	X
Has any dialysis center staff ever told you how to get off the machine if there is an emergency at the center?	31	31	31
1. Yes	X	X	X
2. No	X	X	X
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?	32	32	32
0. 0 Worst dialysis center staff possible	X	X	X
1. 1	X	X	X
2. 2	X	X	X
3. 3	X	X	X
4. 4	X	X	X
5. 5	X	X	X
6. 6	X	X	X
7. 7	X	X	X
8. 8	X	X	X
9. 9	X	X	X
10. 10 Best dialysis center staff possible	X	X	X
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?	33	33	33
1. Never	X	X	X
2. Sometimes	X	X	X
3. Usually	X	X	X
4. Always	X	X	X
In the last 3 months, how often was the dialysis center as clean as it could be?	34	34	34
1. Never	X	X	X
2. Sometimes	X	X	X
3. Usually	X	X	X
4. Always	X	X	X
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?	35	35	35
0. 0 Worst dialysis center possible	X	X	X
1. 1	X	X	X
2. 2	X	X	X
3. 3	X	X	X
4. 4	X	X	X
5. 5	X	X	X
6. 6	X	X	X
7. 7	X	X	X
8. 8	X	X	X
9. 9	X	X	X
10. 10 Best dialysis center possible	X	X	X
The next few questions ask about your care in the last 12 months. As you answer these questions, think only about your experience at [SAMPLE FACILITY NAME], even if you have not been receiving care there for the entire 12 months.
You can treat kidney disease with dialysis at a center, a kidney transplant, or with dialysis at home. In the last 12 months, did your kidney doctors or dialysis center staff talk to you as much as you wanted about which treatment is right for you?	36	36	36
1. Yes	X	X	X
2. No	X	X	X
Are you eligible for a kidney transplant?	37	37	37
1. Yes (If Yes, Go to Question 39)	X	X	X
2. No	X	X	X
3. Don’t know (If Don’t Know, Go to Question 39)	X	X	X
In the last 12 months, has a doctor or dialysis center staff explained to you why you are not eligible for a kidney transplant?	38	38	38
1. Yes	X	X	X
2. No	X	X	X
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?	39	39	39
1. Yes	X	X	X
2. No	X	X	X
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?	40	40	40
1. Yes	X	X	X
2. No	X	X	X
In the last 12 months, were you ever unhappy with the care you received at the dialysis center or from your kidney doctors?	41	41	41
1. Yes	X	X	X
2. No (If No, Go to Question 45)	X	X	X
In the last 12 months, did you ever talk to someone on the dialysis center staff about this?	42	42	42
1. Yes	X	X	X
2. No (If No, Go to Question 45)	X	X	X
In the last 12 months, how often were you satisfied with the way they handled these problems?	43	43	43
1. Never	X	X	X
2. Sometimes	X	X	X
3. Usually	X	X	X
4. Always	X	X	X
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?	44	44	44
1. Yes	X	X	X
2. No	X	X	X
About You
In general, how would you rate your overall health?	45	45	45
1. Excellent	X	X	X
2. Very good	X	X	X
3. Good	X	X	X
4. Fair	X	X	X
5. Poor	X	X	X
In general, how would you rate your overall mental or emotional health?	46	46	46
1. Excellent	X	X	X
2. Very good	X	X	X
3. Good	X	X	X
4. Fair	X	X	X
5. Poor	X	X	X
Are you being treated for high blood pressure?	47	47	47
1. Yes	X	X	X
2. No	X	X	X
Are you being treated for diabetes or high blood sugar?	48	48	48
1. Yes	X	X	X
2. No	X	X	X
Are you being treated for heart disease or heart problems?	49	49	49
1. Yes	X	X	X
2. No	X	X	X
Are you deaf or do you have serious difficulty hearing?	50	50	50
1. Yes	X	X	X
2. No	X	X	X
Are you blind or do you have serious difficulty seeing, even when wearing glasses?	51	51	51
1. Yes	X	X	X
2. No	X	X	X
Because of a physical, mental, or emotional condition, do you have serious difficulty concentrating, remembering, or making decisions?	52	52	52
1. Yes	X	X	X
2. No	X	X	X
Do you have serious difficulty walking or climbing stairs?	53	53	53
1. Yes	X	X	X
2. No	X	X	X
Do you have difficulty dressing or bathing?	54	54	54
1. Yes	X	X	X
2. No	X	X	X
Because of a physical, mental, or emotional condition, do you have difficulty doing errands alone, such as visiting a doctor’s office or shopping?	55	55	55
1. Yes	X	X	X
2. No	X	X	X
What is your age?	56	56	NA
1. 18 to 24	X	X	NA
2. 25 to 34	X	X	NA
3. 35 to 44	X	X	NA
4. 45 to 54	X	X	NA
5. 55 to 64	X	X	NA
6. 65 to 74	X	X	NA
7. 75 or older	X	X	NA
What language do you mainly speak at home?	NA	NA	57
1. English	NA	NA	X
2. Spanish,	NA	NA	X
3. Chinese,	NA	NA	X
4. Samoan,	NA	NA	X
5. Russian,	NA	NA	X
6. Vietnamese,	NA	NA	X
7. Portuguese, or	NA	NA	X
8. Some other language (please identify)	NA	NA	X
What is your sex?	57	57	NA
1. Male	X	X	NA
2. Female	X	X	NA
What is the highest grade or level of school that you have completed?	58	58	56
1. No formal education	X	X	X
2. 5th grade or less	X	X	X
3. 6th, 7th or 8th grade	X	X	X
4. Some high school, but did not graduate	X	X	X
5. High school graduate or GED	X	X	X
6. Some college or 2-year degree	X	X	X
7. 4-year college graduate	X	X	X
8. More than 4-year college degree	X	X	X
How well do you speak English?	59	59	NA
1. Very well	X	X	NA
2. Well	X	X	NA
3. Not well	X	X	NA
4. Not at all	X	X	NA
Do you speak a language other than English at home?	60	60	NA
1. Yes	X	X	NA
2. No (If No, Go to Question 61)	X	X	NA
What Language is that?	60 a.	60 a.	NA
1. Spanish	X	X	NA
2. Chinese	NA	X	NA
3. Samoan	NA	X	NA
4. Other Language (please identify):	X	X	NA
Are you of Spanish, Hispanic, or Latino origin or descent?	61	61	58
1. No, not Spanish/Hispanic/ Latino	X	X	X
2. Yes, Puerto Rican	X	X	X
3. Yes, Mexican, Mexican American, Chicano	X	X	X
4. Yes, Cuban	X	X	X
5. Yes, other Spanish/Hispanic/ Latino	X	X	X
What is your race? (One or more categories may be selected.)	62	62	59
1. White	X	X	X
2. Black or African American	X	X	X
3. American Indian or Alaska Native	X	X	X
4. Asian Indian	X	X	X
5. Chinese	X	X	X
6. Filipino	X	X	X
7. Japanese	X	X	X
8. Korean	X	X	X
9. Vietnamese	X	X	X
10. Other Asian	X	X	X
11. Native Hawaiian	X	X	X
12. Guamanian or Chamorro	X	X	X
13. Samoan	X	X	X
14. Other Pacific Islander	X	X	X
Did someone help you complete this survey?	63	63	60
1. Yes	X	X	X
2. No. Thank you. Please return the completed survey in the postage-paid envelope.	X	X	X
Who helped you complete this survey?	64	64	61
1. A family member	X	X	X
2. A friend	X	X	X
3. A staff member at the dialysis center	X	X	X
4. Someone else (please print):	X	X	X
How did that person help you? Check all that apply.	65	65	62
1. Read the questions to me	X	X	X
2. Wrote down the answers I gave	X	X	X
3. Answered the questions for me	X	X	X
4. Translated the questions into my language	X	X	X
5. Helped in some other way (please print):	X	X	X

*ME QX = Mode Experiment Questions

Crosswalk for Changes to National Implementation of the In-Center Hemodialysis CAHPS Survey CMS-10105)

Section on Original CMS-10105 (06/13/16) Submission	Subsection on Original CMS-10105 (06/13/16) Submission	Type of Change	Rationale for Change
Attachment C	N/A	CMS Group Director (signatory on prenotification letters) name change	Subsequent to the publication of the FRN, the Group Director of Medicare Drug Benefit and C&D Data Group (signatory on prenotification letters) changed her name, which is reflected in the pre-notification letters in Attachment C

B-1