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pdfIntroduction
Hello. May I please speak with [participant name]?
If the participant is not available, please provide a callback number for the participant to call back before
[auto populate the end date of the survey calls cycle], thank the person on the phone, and end the call
by saying, “Thank you for your time. If we do not hear back from [participant name], we will call back.
What is the best time to call back?”
[Time captured needs to be based on participants’ time zone and rescheduled in the scheduler].
If the participant answers the phone, state the following:
Good [morning/afternoon/evening, participant name]. My name is [surveyor name].
I’m calling because you may be interested in completing a survey about how [Network name] handled
your complaint. The survey should take less than 15 minutes. If you participate in the survey you will
help Medicare by answering some questions about your experience with [Network name]. I’m with the
[Subcontractor Name] and as explained in the letter you received I’m not with [Network name] or
Medicare. Everything you tell me will be private. Are you interested in taking the survey? If yes,
continue. If no, thank the participant says no, thank them for their time and say good-bye.
Is this a good time for you to talk?
If yes, continue with the survey. If no, schedule a follow-up call.
Grievance/Process: The following questions are about the way the [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)
1
ESRD NCC Grievance Satisfaction Survey V3.0 _ February 2019
OMB Control Number: 0938-1185 ESRD Grievant Satisfaction Survey
Expiration Date: 04/30/2019
Date: November 25, 2014 previous rev. June 5, 2015
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
Good understanding
(4)
(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. After your conversation with your ESRD Network, did a patient representative or someone who
works with patients at your dialysis facility help you with your grievance?
2
ESRD NCC Grievance Satisfaction Survey V3.0 _ February 2019
OMB Control Number: 0938-1185 ESRD Grievant Satisfaction Survey
Expiration Date: 04/30/2019
Date: November 25, 2014 previous rev. June 5, 2015
Yes
No
4. How respected did you feel 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)
5. 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)
6. 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)
7. How satisfied were you that the Network acted in your best interest?
Very satisfied
(4)
Somewhat satisfied
(3)
Neither satisfied nor dissatisfied(2)
3
ESRD NCC Grievance Satisfaction Survey V3.0 _ February 2019
OMB Control Number: 0938-1185 ESRD Grievant Satisfaction Survey
Expiration Date: 04/30/2019
Date: November 25, 2014 previous rev. June 5, 2015
Somewhat dissatisfied (1)
Very dissatisfied
(0)
No answer/Don’t know (9)
8. Did you get a letter from [Network Name] with results of their work to resolve your grievance? (Item
is not scored.) [All grievances flagged as immediate advocacy will be programmed to skip this question].
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)
9. 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)
10. How comfortable are you with the Network grievance process to file another grievance?
Very comfortable
(4)
Somewhat comfortable (3)
Neither comfortable nor uncomfortable (2)
Somewhat uncomfortable
Very uncomfortable
(1)
(0)
4
ESRD NCC Grievance Satisfaction Survey V3.0 _ February 2019
OMB Control Number: 0938-1185 ESRD Grievant Satisfaction Survey
Expiration Date: 04/30/2019
Date: November 25, 2014 previous rev. June 5, 2015
No answer/Don’t know (9)
11. Prior to contacting the Network, did you attempt to file a grievance at your dialysis facility?
Yes
No
11A. 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?
a.
b.
c.
Yes
No
I prefer not to answer
12A. If yes, then how did the center take action against you?
13. When you attempted to file a grievance at your dialysis facility, did anyone at the facility ever try to
talk you out of filing a grievance?
Yes
No
I prefer not to answer
I did not file a grievance at the facility
13.A If yes, what did they say to you?
14. When you filed a grievance at your dialysis facility, did you feel that the staff at your dialysis facility
took actions against you after you filed your grievance?
Yes
No
I prefer not to answer
I did not file a grievance at the facility
14.A If yes, how did the center take action against you?
Wrap up question: Would you like to add any thoughts about your contact with [Network Name] during
the time you filed your grievance?
Conclusion
5
ESRD NCC Grievance Satisfaction Survey V3.0 _ February 2019
OMB Control Number: 0938-1185 ESRD Grievant Satisfaction Survey
Expiration Date: 04/30/2019
Date: November 25, 2014 previous rev. June 5, 2015
On behalf of [name of survey vendor], I want to thank you for your time today. Medicare oversees all
dialysis facilities, transplant centers, and Networks. Even if you don’t have Medicare, your feedback
about your experience is important. Again, if you have any questions or concerns about this survey or
the way I asked questions, please contact CMS Representative at XXX-XXX-XXXX or
[email protected]
Supplemental Script for Survey Administrator [To be used as Frequently Asked Questions by the
Survey Participant]
If the patient refuses to take the survey due to not getting the outcome they desired: I’m sorry you did
not get the outcome you desired from filing a grievance, but we would be very grateful if you would
participate in the survey. Your experience is very important feedback for us to report to Medicare.
If the patient refuses to take the survey due to a lack of clarity of Medicare’s involvement: I understand
you don’t have Medicare, but the Social Security Act makes Medicare responsible to oversee the quality
of care for all patients in a dialysis facility, transplant center or the Network, not just those receiving
Medicare benefits. Your experience is very important feedback for us to report to Medicare.
If the patient refuses due to lack of clarity about who is calling: I work for the Subcontractor Name.
Medicare hired my firm to do this survey, so patients can be sure everything they say is private. As the
letter you received stated your answers will be added to all the other patients responding in your
Network, without names, before being given to Medicare. Your experience is very important feedback
for us to report to Medicare.
6
ESRD NCC Grievance Satisfaction Survey V3.0 _ February 2019
OMB Control Number: 0938-1185 ESRD Grievant Satisfaction Survey
Expiration Date: 04/30/2019
Date: November 25, 2014 previous rev. June 5, 2015
| File Type | application/pdf |
| File Modified | 0000-00-00 |
| File Created | 0000-00-00 |