CMS-10105 Medicare In-Center Hemodialysis Survey (English)

OMB #: 0938-0926
Expiration Date: XXX

Medicare In-Center Hemodialysis
Survey

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 0938-0926. This information collection produces comparable data from dialysis
facilities to help individuals choose a facility and improve care. The time required to complete this
information collection is estimated to average less than 12 minutes per response, including the time to
review instructions, search existing data resources, gather the data needed, to review and complete the
information collection. This information collection is mandatory for qualifying dialysis facilities under 42
CFR §413.178(c)(iii) to meet program requirements and voluntary for survey respondents. Confidentiality
is assured under 5 U.S.C. 552a (Privacy Act of 1974). 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 C1-25-05, Baltimore, Maryland 21244-1850.
****CMS Disclosure**** 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
ICHCAHPS@cms.hhs.gov.

Survey Instructions
This survey is about your experiences with dialysis care at [SAMPLE FACILITY
NAME].

Answer each question by marking the box to the left of your answer.
You are sometimes told to skip over some questions in this survey. When this happens
you will see an arrow with a note that tells you what question to answer next, like this:
1
2

Yes
No → If No, Go to Question 25

1.

Where do you get your dialysis
treatments?
1

2
3

2.

4.

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 32
At the dialysis center
I do not currently receive dialysis
→ If I do not currently receive
dialysis, Go to Question 32

1
2
3
4

5.

How long have you been getting
dialysis at [SAMPLE FACILITY
NAME]?
1

2
3
4
5

2

Less than 3 months → If Less
than 3 months, Go to
Question 32
At least 3 months but less than
1 year
At least 1 year but less than
5 years
5 years or more
I do not currently receive dialysis
at this dialysis center → If I do
not currently receive dialysis at
this dialysis center, Go to
Question 32

3
4

6.

2
3
4

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.

2
3
4

8.

1
2
3
4

Never
Sometimes
Usually
Always

Never
Sometimes
Usually
Always

In the last 3 months, did you feel
comfortable asking the dialysis
center staff everything you wanted
about dialysis care?
1
2

1

Never
Sometimes
Usually
Always

In the last 3 months, how often did
dialysis center staff make you as
comfortable as possible during
dialysis?
1

In the last 3 months, how often did
the dialysis center staff listen
carefully to you?

Never
Sometimes
Usually
Always

In the last 3 months, how often did
the dialysis center staff spend
enough time with you?
1

7.

Never
Sometimes
Usually
Always

In the last 3 months, how often did
the dialysis center staff show
respect for what you had to say?
1

THE DIALYSIS CENTER STAFF

3.

In the last 3 months, how often did
the dialysis center staff explain
things in a way that was easy for
you to understand?

Yes
No

9.

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?
1
2

14. In the last 3 months, how often did
dialysis center staff behave in a
professional manner?
1
2

Yes
No

3
4

10. In the last 3 months, which one did
they use most often to connect you
to the dialysis machine?
1
2
3
4

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.

Graft
Fistula
Catheter
I don’t know

15. In the last 3 months, how often did
dialysis center staff explain blood
test results in a way that was easy to
understand?

11. 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?
1
2
3
4

1
2
3

Never
Sometimes
Usually
Always

4

2

Yes
No → If No, Go to Question 14

1
2

13. In the last 3 months, how often was
the dialysis center staff able to
manage problems during your
dialysis?
1
2
3
4

Never
Sometimes
Usually
Always

16. 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?

12. In the last 3 months, did any
problems occur during your
dialysis?
1

Never
Sometimes
Usually
Always

Yes
No

17. Did dialysis center staff at this
center ever review your rights as a
patient with you?

Never
Sometimes
Usually
Always

1
2

Yes
No

18. Has dialysis center staff ever told
you what to do if you experience a
health problem at home?
1
2

2

Yes
No

19. Has any dialysis center staff ever
told you how to get off the machine
if there is an emergency at the
center?

22. In the last 3 months, how often was
the dialysis center as clean as it
could be?

Yes
No

1
2

2
3
4

20. 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?
0
1
2
3
4
5
6
7
8
9
10

Never
Sometimes
Usually
Always

1

23. 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?

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

0
1
2
3
4
5
6
7
8
9
10

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

THE DIALYSIS CENTER

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.

21. 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?
1
2
3
4

Never
Sometimes
Usually
Always

24. 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?
1
2

3

Yes
No

31. In the last 12 months, how often
were you satisfied with the way they
handled these problems?

25. Are you eligible for a kidney
transplant?
1
2
3

Yes → If Yes, Go to Question 27
No
I don’t know → If Don’t Know,
Go to Question 27

1
2
3
4

26. In the last 12 months, has a doctor
or dialysis center staff explained to
you why you are not eligible for a
kidney transplant?
1
2

ABOUT YOU
32. In general, how would you rate your
overall health?

Yes
No

1

27. 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?
1
2

2
3
4
5

2

1
2
3
4
5

Yes
No

2

1
2
3
4

Yes
No → If No, Go to Question 32

5
6

30. In the last 12 months, did you ever
talk to someone on the dialysis
center staff about this?
1
2

Excellent
Very good
Good
Fair
Poor

34. What is the highest grade or level of
school that you have completed?

29. In the last 12 months, were you ever
unhappy with the care you received
at the dialysis center or from your
kidney doctors?
1

Excellent
Very good
Good
Fair
Poor

33. In general, how would you rate your
overall mental or emotional health?

Yes
No

28. 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?
1

Never
Sometimes
Usually
Always

7
8

Yes
No → If No, Go to Question 32

4

No formal education
5th grade or less
6th, 7th, or 8th grade
Some high school, but did not
graduate
High school graduate or GED
Some college or 2-year degree
4-year college graduate
More than 4-year college degree

Thank you. Please return the
survey in the enclosed envelope to:

35. What language do you mainly speak
at home? Please mark only one
response.
1
2
3
4
5
6
7
8

DIALYSIS SURVEY
Address
City, State, Zip

English
Spanish
Chinese
Samoan
Russian
Vietnamese
Portuguese
Some other language (please
identify):
_______________________

36. What is your race or ethnicity?
Please mark one or more.
1
2
3
4
5
6
7

American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latino
Middle Eastern or North African
Native Hawaiian or Pacific
Islander
White
HELP

37. Did someone help you complete this
survey?
1
2

Yes
No → Thank you. Please return
the completed survey in the
postage-paid envelope.

38. How did that person help you?
Please mark one or more.
1
2
3
4
5

Read the questions to me
Wrote down the answers I gave
Answered the questions for me
Translated the questions into my
language
Helped in some other way (please
print):
________________________
5