CMS-10823 Appendix B

Appendix B: Facility Administrator Interview Protocol
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection
of information unless it displays a valid OMB control number. The valid OMB control number for this
information collection is 0938-XXXX (Expires XX/XX/XXXX). This is a voluntary information collection.
The time required to complete this information collection is estimated to average one hour per
response, including the time to review instructions, search existing data resources, gather the data
needed, and complete and review the information collection. If you have comments concerning the
accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500
Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland
21244-1850. Please do not send applications, claims, payments, medical records or any documents
containing sensitive information to the PRA Reports Clearance Office. Please note that any
correspondence not pertaining to the information collection burden approved under the associated
OMB control number listed on this form will not be reviewed, forwarded, or retained. If you have
questions or concerns regarding where to submit your documents, please contact Christopher King at
[email protected] or (410) 786-6972.

Introduction
Hello. My name is [interviewer name] from Insight Policy Research, and I want to thank you again for
agreeing to speak with me today about your involvement in activities related to dialysis care. I’m joined
today by [note taker name] from Insight, who will be taking notes for the interview.
We were hired by the Centers for Medicare & Medicaid Services, otherwise known as CMS, to conduct
an evaluation of the ESRD Quality Incentive Program (QIP). CMS is interested in learning how this
initiative may have affected dialysis patients’ health, outcomes, satisfaction, access to care, quality of
care, and healthcare spending. CMS has also asked us to learn about other topics that are less directly
related to the QIP.
This year we are focusing on the following topics related to ESRD care and will be asking you about them
today:


Quality of dialysis care



Health Equity and access to ESRD care



Factors associated with access to home dialysis



Factors associated with access to transplant



Quality of life for individuals with ESRD

Informed Consent
Let me also take a minute to review the informed consent for the interview and how we’ll handle the
information you provide:


We will use the information you share with us for research purposes only.



All your responses will be kept confidential. No one except the Insight research team will have
access to the information you provide.

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

We will use your answers to produce summaries from our collective set of interviews.



We will not report information in any way that identifies you or the organization you are
affiliated with to anyone outside the research team, except with your permission or as required
by law. CMS will not see your name or your organization’s name connected to your individual
responses.



All information identifying you is stored securely and will be destroyed at the end of the study.



We’d also like to emphasize that your participation is completely voluntary:





Your participation or nonparticipation will not be reported to anyone.



You can stop the interview at any time for any reason, and you can decline to discuss any
topic we raise.

We expect that this call will take about 60 minutes.

You should have received an attachment to the email confirmation for the interview that covers this
information. That document also includes contact information for the project director if you have
questions about the study. Do you recall seeing that document?
[If no] We’ll send you that document again so you have a written copy of this information.
With your permission, we’d like to audio record the interview to ensure we capture and analyze your
remarks accurately. Only the research team will have access to the recording, and it will be destroyed at
the end of the project. Would it be okay to audio record the interview?
Do you have any questions before we begin?

Introduction of Interviewee(s)
[If there are several interviewees on the phone, call out each one individually and ask them the same
introductory question below.]
1. Before we start our discussion, would you please share with me your job title and your role at
[facility name]? How long have you been working in the ESRD field?
2. Can you please describe the area where your facility is located?
a. [Probe: Urban, rural, suburban]

Dialysis Quality
My first set of questions has to do with the quality of care dialysis patients receive
1. From your perspective, what are the highest priorities for patients when selecting a dialysis provider
for treatment?
a. [Probe: How clean the facility is? How often they see the nephrologist? How easy it is to reach
staff in an emergency?]

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2. How does your facility evaluate the quality of care you provide to your patients? (i.e., which survey
or metrics do you use to measure quality)?
a. [Probe: ICH-CAHPS? QIP? Five Star?]
3. Are there any QIP measures that are challenging to maintain or improve your score? If so, please
explain.
a. Are there any QIP measures that are challenging to collect data? If so, please explain.

Access to Care
Now, I would like to ask about patient access to ESRD care.
1. How would you describe your facility’s overall patient population?
a. [Probe: High percentage of low-income patients; Multiple comorbidities; High/low access to
transportation.]
2. What do you see as the most significant challenges your patients face in accessing treatment for
their ESRD?
a. [Probe: Access to financial resources, adequate facilities to choose from, transportation,
specialists, social support, distance to treatment.]
3. Have you noticed a change in the degree to which patients have access to ESRD care over the past
five years? If yes, can you explain why you think this is the case?
a. Do you think QIP has had any impact on access? Please explain.
4. Does your facility collect data on patients’ health-related social needs? If so, which needs are most
common?
a. [Probe: Food insecurity, stable housing, mobility impairment, transportation barriers]
5. [If “Yes” to Q9,] What does your facility do with the information collected related to these needs?
a. [Probe: Make note in patient chart; referrals for social needs programs; additional screening]
6. What strategies, if any, has your facility adopted to address other issues that may affect health, such
as housing, food security, transportation, access to social workers, financial security to pay for
health care?
7. Did the QIP encourage the development and implementation of any of these strategies? If so, how?
8. Were other CMS initiatives or Models influential? If so, which ones and how?
a. [Probe: Five Star rating system, Kidney Care Choices model, ESRD Treatment Choices model]

Home Dialysis
As you may know, over the past several years there has been a push to get more dialysis patients access
to home dialysis because of the potential quality of life benefits associated with it.

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1. When we think about someone who is just starting dialysis, what are the challenges associated with
starting them on home dialysis instead of in-center?
a. [Probe: Nephrologist recommendation; Crashing into dialysis vs managing CKD for a while; Cost;
Health literacy]
b. What are the supports or factors that encourage them to start home dialysis before trying incenter?
i.

[Probe: Family support; Nephrologist support; Space in the home; Cost; COVID; their facility
does not offer home dialysis]

2. [If COVID-19 not mentioned in Q17] How, if at all, has the COVID-19 pandemic influenced patients’
decisions to receive home dialysis?
3. To confirm, does your facility currently offer home dialysis?
a. [If yes] Approximately what percentage of your patient population is on home dialysis?
b. [If no] What are the reasons that your facility doesn’t offer home dialysis?
4. When we think about someone switching from in-center to home dialysis, what are the challenges
that keep them in-center?
a. [Probe: Complexity of patient healthcare needs; shortage of home nurses; shortage of home
supplies; lack of patient family support; lack of space in patients’ home]
b. What are the factors that encourage them to switch to home dialysis once they’ve already been
attending in-center?
i.

[Probe: Catching patients before they crash into dialysis; Nephrologist comfort with home
modalities; Patient family support; Patient space in the home]

5. How do those social needs we discussed earlier (housing, transportation, food security, etc) affect
patients’ access to home dialysis?
6. Do you feel like ESRD QIP has impacted your facility’s approach to helping patients to access home
dialysis? Please explain.

Access to Transplant
Similar to the effort to get more patients on home dialysis, there has been a push to improve access to
kidney transplants for patients who are good candidates.
1. When thinking about someone who is interested in pursuing transplant, what are some of the
challenges associated with getting on the waitlist and ultimately obtaining a transplant?
a. [Probe: Lack of knowledge, lack of interest, lack of providers, restrictive transplant center
practices, long deceased donor waiting list, finances, access to living donors, mental health
concerns]
b. What are some of the factors that help those who are interested in pursuing transplant to get
on the waitlist or obtain a transplant?
i.

[Probe: Robust patient education, broad waitlist criteria, streamlined assessments, access to
several transplant centers, supplemental funding sources]

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2. [If COVID-19 not mentioned in Q25] How, if at all, has the COVID-19 pandemic influenced patients’
decisions to pursue a transplant?
3. Do you believe your facility’s location affects patients’ transplant decisions? If so, how?
a. [Probe: distance to nearest transplant centers, number of transplant centers available in the
region] How do those social needs we discussed earlier (housing, transportation, food security,
etc) affect patients’ access to transplant?
4. What are your facility’s approaches to patient engagement related to transplantation as a treatment
option?
a. [Probe: patient education about finding a donor and referral for assessment for transplant
viability.]
b. Has the patient engagement approach changed in the past five years? If so, why and what was
the change?
5. Can you please characterize your facility’s relationship with the transplant center (or centers) that
you use for patient referrals or waitlists?
a. Does your facility have regular contact with transplant centers? Please describe the frequency
and focus of the communications.
6. Do you feel that ESRD QIP has impacted your facility’s approach to helping patient pursuit of
transplants? Please explain.
a. [Probe: Facilitates transplant education, referral, and assessment]
7. How, if at all, has the PPPW measure1 influenced your facility’s approach to discussing transplant
with patients?
8. Do you feel like ESRD QIP has impacted your facility’s approach to helping patients to access
transplant assessments?
a. [Probe: Inhibits transplant education, referral, and assessment]

Quality of Life
As part of this research, we are trying to understand the quality of life that individuals living with ESRD
experience and what can be done at the policy level to ensure the highest possible quality of life for this
patient population.
1. From your perspective, what are some aspects of everyday life that you would consider signs of a
higher quality of life for someone living with ESRD?
a. [Probe: Having more energy; Feeling independent; Accessing healthy foods that are enjoyable;
Getting good sleep]

1

The PPPW is the Percentage of Prevalent Patients Waitlisted measure. It holds the facilities accountable for the percentage of their patients
currently on a kidney transplant waitlist. The only exclusions as of 2022 are patients residing in nursing homes and patients over the age of 75.

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2. Are there interventions that dialysis providers (including dialysis facilities and nephrology practices)
have been able to implement to improve the quality of life for individuals living with ESRD?
a. [Probe: Social workers arranging transportation; Nephrologists helping them transition to home
dialysis; Improved coordination with transplant centers; Peer-to-peer support; Streamlining
screenings for depression]
3. How, if at all, does your facility measure patient quality of life? Why did your facility select these
measures or data collection tools?
a. [If KDQoL not mentioned] Do you administer the Kidney Disease Quality of Life instrument –
otherwise known as the KDQOL questionnaire or the Health-Related Quality of Life (or the
HRQOL)?
b. What does your facility do with quality-of-life data once it is collected?
4. In your experience, have you noticed the quality of life for individuals living with ESRD changed over
time? What is the reason for the change?
a. [Probe: access to social services, screening of SDOH need, patient interest or eligibility for home
dialysis and/or transplant]

Closing
Before we finish, is there anything you would like to share that I haven’t asked about or anything you
would like to elaborate on that you didn’t get a chance to discuss about the QIP or providing care to
dialysis patients?
Thank you for taking the time to speak with me today. Your input is helpful, and we look forward to
summarizing all the information we hear from stakeholders. If you have questions after the call or wish
to offer additional feedback, please feel free to reach out to me.

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