| Patient Experience Survey (ICH-CAHPS-Type) | W.G.M. Rivero MD · FPCP · DPSN · · renalcarematters.com · 2026 |
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Patient-Experience Instrument · Section 6.8
Patient Experience Survey
Modeled on the In-Center Hemodialysis Consumer Assessment of Healthcare Providers and Systems (ICH-CAHPS) domains, for local tracking between official administration cycles — Dialysis Center QAPI vs. CQI field manual, Section 6.8.
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W.G.M. Rivero MD
FPCP · DPSN Nephrology
renalcarematters.com
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6 Experience domains tracked, matching the field manual |
~5 min For a patient or caregiver to complete |
Anonymous No name required — initials optional, for follow-up only |
🗳️ 1 · Offer Offer at chair-side or in the waiting area, on a rolling basis across the reporting cycle. |
✍️ 2 · Complete Patient or caregiver fills it in directly, or a staff member not involved in their care reads it aloud. |
📥 3 · Aggregate Drop completed forms in a sealed box; the quality officer tallies domain scores monthly or quarterly. |
Each domain below mirrors a tracked category in the field manual's dashboard (Section 6.8, "Patient experience & patient-reported outcomes"). This is a house instrument for local, frequent, low-stakes tracking — it is not the validated, CMS-administered ICH-CAHPS survey used for the official Percent of ICH-CAHPS Survey Composite Measures Reporting requirement or Five-Star ratings. Continue your unit's official CMS-approved-vendor ICH-CAHPS cycle in parallel; use this form to catch problems between those cycles.
| Unit / facility name | Month / quarter | Mode☐Self · ☐Read-aloud | Modality☐HD · ☐PD | Patient initials (optional) |
| In the last month, how often did your kidney doctor… | Never | Sometimes | Usually | Always |
|---|---|---|---|---|
| …explain things in a way you could understand? | ☐ | ☐ | ☐ | ☐ |
| …listen carefully to you? | ☐ | ☐ | ☐ | ☐ |
| …treat you with courtesy and respect? | ☐ | ☐ | ☐ | ☐ |
| …spend enough time with you? | ☐ | ☐ | ☐ | ☐ |
| In the last month, how often did the dialysis-unit staff… | Never | Sometimes | Usually | Always |
|---|---|---|---|---|
| …treat you with courtesy and respect? | ☐ | ☐ | ☐ | ☐ |
| …listen carefully to you? | ☐ | ☐ | ☐ | ☐ |
| …keep you informed about wait times or delays? | ☐ | ☐ | ☐ | ☐ |
| …work well as a team during your treatment? | ☐ | ☐ | ☐ | ☐ |
Scale: Never = 1 · Sometimes = 2 · Usually = 3 · Always = 4. Domain score = mean of item scores; report the % of respondents answering "Usually" or "Always" (the standard CAHPS top-box convention) alongside the mean.
| Educational data-collection aid. A house instrument modeled on ICH-CAHPS domains — not the validated, CMS-administered ICH-CAHPS survey. Does not replace your official CMS-approved-vendor survey cycle. | renalcarematters.com Page 1 of 2 · renalcarematters.com/guides/dialysis-qapi-vs-cqi.html |
Patient Experience Survey — continued Being Kept Informed · Global Ratings · Comments · Office Use |
Page 2 of 2 · renalcarematters.com |
| Since starting dialysis at this center… | Never | Sometimes | Usually | Always |
|---|---|---|---|---|
| …were you told what to expect from your treatment schedule? | ☐ | ☐ | ☐ | ☐ |
| …were you told about kidney transplant as an option, if eligible? | ☐ | ☐ | ☐ | ☐ |
| …did staff explain any change in your care plan before making it? | ☐ | ☐ | ☐ | ☐ |
Using any number from 0 to 10, how would you rate your kidney doctor?
| 0 | 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | 10 |
Using any number from 0 to 10, how would you rate the dialysis center staff?
| 0 | 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | 10 |
Using any number from 0 to 10, how would you rate this dialysis facility overall?
| 0 | 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | 10 |
Reporting convention: report the % of respondents scoring 9–10 (top-box) for each global rating, alongside the mean — the same convention CMS uses for the official ICH-CAHPS global ratings.
If something below needs a direct response, please add your name or ask a staff member to route this to the quality officer — a comment describing a specific unresolved concern should also be logged on the Grievance / Complaint Log.
| Administered by | Date received | Domain scores entered into Scorecard?☐Yes ☐No | Concern routed to grievance log?☐Yes ☐N/A |
| Educational data-collection aid. A house instrument modeled on ICH-CAHPS domains — not the validated, CMS-administered ICH-CAHPS survey. File alongside your official survey-cycle documentation. | renalcarematters.com Page 2 of 2 · renalcarematters.com/guides/dialysis-qapi-vs-cqi.html |