This is a survey-based measure and one of the family of surveys called CAHPS Surveys (Consumer Assessment of Healthcare Providers and Systems)that are focused on patient experience. The questionnaire asks End Stage Renal Disease (ESRD) patients receiving in-center hemodialysis care about the services and quality of care that they experience. Patients assess their dialysis providers, including nephrologists and medical and non-medical staff, the quality of dialysis care they receive, and information sharing about their disease. The survey is conducted twice a year, in the spring and fall with adult in-center hemodialysis patients. Publicly-reported measures focus on the proportion of survey respondents at each facility who choose the most favorable responses.
Three multi-item measures:
a. M1: Nephrologists’ Communication and Caring (NCC)
b. M2: Quality of Dialysis Center Care and Operations (QDCCO)
c. M3: Providing Information to Patients (PIP)
Three Global items:
a. M4: Rating of the nephrologist
b. M5: Rating of dialysis center staff
c. M6: Rating of the dialysis facility
The first three measures are created from six or more questions from the survey that are reported as one measure score. The three global items are single-item measures using a scale of 0 to 10 to report the respondent’s assessment.
The results are reported on Dialysis Facility Compare (DFC) on the Medicare.gov website.
- Electronic Clinical Quality Measure (eCQM)Level Of AnalysisCare SettingNumerator
There are a total of six ICH CAHPS measures. Three of them are multi-item measures and three are global ratings. Each measure is composed of the responses for all individual questions included in the measure. Missing data for individual survey questions are not included in the calculations. Only data from a "completed survey" is used in the calculations. Each measure score is at the facility level and averages the proportion of respondents who chose each answer option for all items in the measure. Each global rating is be scored based on the number of respondents in the distribution of top responses; e.g., the percentage of patients rating the facility a “9” or “10” on a 0 to 10 scale (with 10 being the best).
DenominatorPatients receiving in-center hemodialysis at sampled facility for the past 3 months or longer are included in the sample frame.
The denominator for each question is composed of the sample members that responded to the particular question.
Proxy respondents are not allowed.
Only complete surveys are used. A complete survey is defined as one where the sampled patient answered at least 50 percent of the questions that are applicable to all sample patients: Q1-Q20, Q22, Q23, Q25-Q37, Q39-Q41 (Appendix provides more details about these questions.)ExclusionsExclusions:
a. Patients less than 18 years of age
b. Patients not receiving dialysis at sampled facility for 3 months or more
c. Patients who are receiving hospice care
d. Any surveys completed by a proxy (mail only mode or mixed mode)
e. Any ineligible patients due to death, institutionalization, language barrier, physically or mentally incapable.Testing Data Sources
- Measure StructureClinical Condition Topic AreaNon Condition SpecificTarget PopulationMeasure Selection AttributesNational Quality Strategy PrioritiesPerson- and Family-Centered Care
- Risk Adjustment
- Current or planned use(s)Current Use(s)Use In Federal Program
- Most Recent Endorsement ActivityEndorsed Patient Experience and Function Spring Cycle 2019Initial EndorsementNext Planned Maintenance ReviewPatient Experience and Function Fall 2024Endorsement StatusLast Updated
- Steward Organization Email