Crosswalk

Attachment B:
ICH CAHPS Survey Crosswalk

B-1

ICH CAHPS Survey Crosswalk

Table 1 Crosswalk of changes made to the survey from the previously cleared ICH CAHPS
survey (2015) and the current survey version (2018)
Mail Question Text

2015 QX
Number

2018 QX
Number

1
X
NA

1
NA
X

2. At the dialysis center
3. I do not currently receive dialysis - If I do not currently receive
dialysis, Go to Question 45

X
X

X
X

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
In the last 3 months, how often did your kidney doctors listen carefully to you?

2
X
X
X
X
X

2
X
X
X
X
X

3

3

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?

X
X
X
X
4

X
X
X
X
4

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?

X
X
X
X
5

X
X
X
X
5

1. Never
2. Sometimes
3. Usually
4. Always
In the last 3 months, how often did your kidney doctors spend enough time
with you?

X
X
X
X
6

X
X
X
X
6

X
X

X
X

Where do you get your dialysis treatments?
1. At home - If At home, Go to Question 45
1. At home or at a skilled nursing home where I live - If At home or at a
skilled nursing home where I live, Go to Question 45

1. Never
2. Sometimes

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ICH CAHPS Survey Crosswalk

3. Usually
4. Always

X
X

X
X

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

7

7

1. Never
2. Sometimes
3. Usually
4. Always
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?

X
X
X
X
8

X
X
X
X
8

0. 0 Worst kidney doctors possible
1. 1
2. 2
3. 3
4. 4
5. 5
6. 6
7. 7
8. 8
9. 9
10. 10 Best kidney doctors possible
Do your kidney doctors seem informed and up-to-date about the health care
you receive from other doctors?

X
X
X
X
X
X
X
X
X
X
X
9

X
X
X
X
X
X
X
X
X
X
X
9

1. Yes
2. No
In the last 3 months, how often did the dialysis center staff listen carefully to
you?

X
X
10

X
X
10

1. Never
2. Sometimes
3. Usually
4. Always
In the last 3 months, how often did the dialysis center staff explain things in a
way that was easy for you to understand?

X
X
X
X
11

X
X
X
X
11

1. Never
2. Sometimes
3. Usually
4. Always
In the last 3 months, how often did the dialysis center staff show respect for
what you had to say?

X
X
X
X
12

X
X
X
X
12

X

X

1. Never

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ICH CAHPS Survey Crosswalk

2. Sometimes
3. Usually
4. Always
In the last 3 months, how often did the dialysis center staff spend enough time
with you?

X
X
X
13

X
X
X
13

1. Never
2. Sometimes
3. Usually
4. Always
In the last 3 months, how often did you feel the dialysis center staff really
cared about you as a person?

X
X
X
X
14

X
X
X
X
14

1. Never
2. Sometimes
3. Usually
4. Always
In the last 3 months, how often did dialysis center staff make you as
comfortable as possible during dialysis?

X
X
X
X
15

X
X
X
X
15

1. Never
2. Sometimes
3. Usually
4. Always
In the last 3 months, did dialysis center staff keep information about you and
your health as private as possible from other patients?

X
X
X
X
16

X
X
X
X
16

1. Yes
2. No
In the last 3 months, did you feel comfortable asking the dialysis center staff
everything you wanted about dialysis care?

X
X
17

X
X
17

1. Yes
2. No
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?

X
X
18

X
X
18

1. Yes
2. No
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?

X
X
19

X
X
19

1. Yes
2. No
In the last 3 months, which one did they use most often to connect you to the
dialysis machine?

X
X
20

X
X
20

X
X

X
X

1. Graft
2.Fistula

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ICH CAHPS Survey Crosswalk

3. Catheter If Catheter, Go to Question 22
4. I don’t know If Don’t Know, Go to Question 22
In the last 3 months, how often did dialysis center staff insert your needles
with as little pain as possible?

X
X
21

X
X
21

1. Never
2. Sometimes
3. Usually
4. Always
5. I inserted my own needles
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?

X
X
X
X
X
22

X
X
X
X
X
22

1. Never
2. Sometimes
3. Usually
4. Always
In the last 3 months, did any problems occur during your dialysis?
1. Yes
2. No
In the last 3 months, how often was the dialysis center staff able to manage
problems during your dialysis?

X
X
X
X
23
X
X
24

X
X
X
X
23
X
X
24

1. Never
2. Sometimes
3. Usually
4. Always
In the last 3 months, how often did dialysis center staff behave in a
professional manner?

X
X
X
X
25

X
X
X
X
25

1. Never
2. Sometimes
3. Usually
4. Always
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?

X
X
X
X

X
X
X
X

26

26

X
X
27

X
X
27

X
X
X

X
X
X

1. Yes
2. No
In the last 3 months, how often did dialysis center staff explain blood test
results in a way that was easy to understand?
1. Never
2. Sometimes
3. Usually

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ICH CAHPS Survey Crosswalk

4. Always
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?

X
28

X
28

1. Yes
2. No
Did dialysis center staff at this center ever review your rights as a patient with
you?

X
X
29

X
X
29

1. Yes
2. No
Has dialysis center staff ever told you what to do if you experience a health
problem at home?

X
X
30

X
X
30

1. Yes
2. No
Has any dialysis center staff ever told you how to get off the machine if there
is an emergency at the center?

X
X
31

X
X
31

1. Yes
2. No
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?

X
X
32

X
X
32

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

X
X
X
X
X
X
X
X
X
X
X
33

X
X
X
X
X
X
X
X
X
X
X
33

1. Never
2. Sometimes
3. Usually
4. Always
In the last 3 months, how often was the dialysis center as clean as it could be?

X
X
X
X
34

X
X
X
X
34

X

X

1. Never

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ICH CAHPS Survey Crosswalk

2. Sometimes
3. Usually
4. Always
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?

X
X
X
35

X
X
X
35

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

X
X
X
X
X
X
X
X
X
X
X

X
X
X
X
X
X
X
X
X
X
X

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

1. Yes
2. No
Are you eligible for a kidney transplant?
1. Yes If Yes, Go to Question 39
2. No
3. Don’t know If Don’t Know, Go to Question 39
In the last 12 months, has a doctor or dialysis center staff explained to you
why you are not eligible for a kidney transplant?

X
X
37
X
X
X
38

X
X
37
X
X
X
38

1. Yes
2. No
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?

X
X
39

X
X
39

1. Yes
2. No
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?

X
X
40

X
X
40

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ICH CAHPS Survey Crosswalk

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?

X
X
41

X
X
41

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?

X
X
42

X
X
42

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?

X
X
43

X
X
43

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?

X
X
X
X
44

X
X
X
X
44

1. Yes
2. No
ABOUT YOU
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?

X
X

X
X

45
X
X
X
X
X
46
X
X
X
X
X
47
X
X
48
X
X
49

45
X
X
X
X
X
46
X
X
X
X
X
47
X
X
48
X
X
49

B-8

ICH CAHPS Survey Crosswalk

1. Yes
2. No
Are you deaf or do you have serious difficulty hearing?
1. Yes
2. No
Are you blind or do you have serious difficulty seeing, even when wearing
glasses?

X
X
50
X
X
51

X
X
50
X
X
51

1. Yes
2. No
Because of a physical, mental, or emotional condition, do you have serious
difficulty concentrating, remembering, or making decisions?

X
X
52

X
X
52

1. Yes
2. No
Do you have serious difficulty walking or climbing stairs?
1. Yes
2. No
Do you have difficulty dressing or bathing?
1. Yes
2. No
Because of a physical, mental, or emotional condition, do you have difficulty
doing errands alone, such as visiting a doctor’s office or shopping?

X
X
53
X
X
54
X
X
55

X
X
53
X
X
54
X
X
55

1. Yes
2. No
What is your age?
1. 18 to 24
2. 25 to 34
3. 35 to 44
4. 45 to 54
5. 55 to 64
6. 65 to 74
7. 75 or older
What language do you mainly speak at home?

X
X
NA
NA
NA
NA
NA
NA
NA
NA
57
X
X
X
X
X
X
X
X

X
X
NA
NA
NA
NA
NA
NA
NA
NA
57
X
X
X
X
X
X
X
X

1. English
2. Spanish,
3. Chinese,
4. Samoan,
5. Russian,
6. Vietnamese,
7. Portuguese, or
8. Some other language (please identify)

B-9

ICH CAHPS Survey Crosswalk

What is your sex?
1. Male
2. Female
What is the highest grade or level of school that you have completed?
1.No formal education
2. 5th grade or less
3. 6th, 7th or 8th grade
4. Some high school, but did not graduate
8. More than 4-year college degree
6. Some college or 2-year degree
7. 4-year college graduate
8. More than 4-year college degree
How well do you speak English?
1. Very well
2. Well
3. Not well
4. Not at all
Do you speak a language other than English at home?
1. Yes
2. No If No, Go to Question 61
What Language is that?
1. Spanish
2. Chinese
3. Samoan
4. Other Language (please identify):
Are you of Spanish, Hispanic, or Latino origin or descent?
1. No, not Spanish/Hispanic/ Latino
2. Yes, Puerto Rican
3. Yes, Mexican, Mexican American, Chicano
4. Yes, Cuban
5. Yes, other Spanish/Hispanic/ Latino
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

B-10

NA
NA
NA
56
X
X
X
X
X
X
X
X
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
58
X
X
X
X
X
59
X
X
X
X
X
X
X
X
X

NA
NA
NA
56
X
X
X
X
X
X
X
X
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
58
X
X
X
X
X
59
X
X
X
X
X
X
X
X
X

ICH CAHPS Survey Crosswalk

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.

X
X
X
X
X
60
X
X

X
X
X
X
X
60
X
X

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):

61
X
X
X
X
62
X
X
X
X
X

61
X
X
X
X
62
X
X
X
X
X

B-11