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ICH CAHPS: Providing Information to Patients measure (PIP)

CBE ID
0258-3-m
Endorsement Status
1.0 New or Maintenance
1.1 Measure Structure
1.1a Instrument or Derived Measure
Previous Endorsement Cycle
Is Under Review
Yes
Next Maintenance Cycle
Spring 2025
1.6 Measure Description

The ICH CAHPS Survey is designed to measure the experiences of people receiving in-center hemodialysis care from Medicare-certified dialysis centers. The survey is designed to meet the following three broad goals:

  • Produce comparable data from the patient’s perspective that will allow objective and meaningful comparisons between dialysis centers on domains that are important to consumers.
  • Create incentives for dialysis centers to improve their quality of care.
  • Enhance public accountability in health care by increasing the transparency of the quality of care provided in return for public investment.

Specifically, the survey measures patients’ experiences on topics that are important from the perspective of patients and help them make more informed choices when selecting a dialysis center as well as helping dialysis centers improve the quality of dialysis care for their patients.

 

The survey is administered semiannually to patients who have received in-center hemodialysis for at least 3 months from Medicare-certified dialysis centers. Data collection for each survey period is 12 weeks. The survey is available in mail-only, phone-only, and mail with phone follow-up. 

 

Survey results publicly reported include two ratings and two measures:

•           Global rating of dialysis center staff 

•           Global rating of dialysis center

•           Quality of Dialysis Center Care and Operations measure (QDCCO, calculated from 13 survey questions)

•           Providing Information to Patients measure (PIP, calculated from 9 survey questions) 

1.6 Measure Description (derived)

The ICH CAHPS Providing Information to Patients (PIP) measure captures whether patients feel that their kidney doctors and dialysis center staff gave them the information they needed to take care of their health. For example, how to care for a graft, fistula, or catheter, patient rights, right treatment options, and how to get off a machine if there is an emergency.

 

The measure includes the following questions: 

Q10: 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?

Q17: 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?

Q18: Did dialysis center staff at this center ever review your rights as a patient with you?

Q19: Has dialysis center staff ever told you what to do if you experience a health problem at home?

Q20:  Has any dialysis center staff ever told you how to get off the machine if there is an emergency at the center?

Q25: 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?

Q27: In the last 12 months, has a doctor or dialysis center staff explained to you why you are not eligible for a kidney transplant?

Q28: 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?

Q29: 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?

Measure Specs
General Information
1.8 Level of Analysis
1.9 Care Setting
1.9b Other Care Setting
In-center Hemodialysis Facility
1.10 Measure Rationale

One of the goals of the CMS National Quality Strategy is to foster engagement and to bring the voices of patients to the forefront. As part of fostering engagement, it is critical to hear the voice of individuals by obtaining feedback from them on in-center hemodialysis (ICH) facility performance and incorporating it as part of CMS’s comprehensive approach to quality. Patient-centeredness is a central goal of dialysis care and can be directly measured through surveys of dialysis patients. CMS created the In-Center Hemodialysis CAHPS® Survey, a component of the End-Stage Renal Disease (ESRD) Quality Incentive Program (QIP), to ensure that an assessment of the patient-centeredness of care would be included to monitor dialysis facility performance, promote quality improvement, and inform consumer decision making in the selection of a dialysis facility via public reporting of results. The ICH CAHPS Survey is a standardized survey instrument and data collection methodology for measuring ICH patients’ perspectives on their care in Medicare-certified dialysis centers. The survey is administered semiannually to patients who have received dialysis for at least 3 months from Medicare-certified dialysis centers.

1.10 Measure Rationale (derived)

The ICH CAHPS Providing Information to Patients (PIP) multi-item measure captures whether patients feel that their kidney doctors and dialysis center staff gave them the information they needed to take care of their health. 

 

This measure reflects patient experiences with their dialysis facility across a variety of domains that have been identified as important to patients and stakeholders based on focus groups and cognitive interviews during the survey revision development stage. This measure will be publicly reported on Medicare.gov Care Compare tool to help ICH facilities with quality improvement and help ESRD patients find high quality dialysis facilities.

1.20 Types of Data Sources
1.20a Other Data Source
EQRS source data for demographic information for case-mix adjustors.
1.20c Format: Patient-Reported Data and/or Survey Data
Non-digital
1.20d Format: Other Data Source
Digital
1.25 Data Source Details

In addition to survey responses from patients, we receive data from a CMS database. ICH facilities are required to enter dialysis information for all patients into the ESRD Quality Reporting System (EQRS). EQRS data are then used to create the samples for each ICH CAHPS Survey period. In addition, information such as sex and age are pulled from the EQRS data and merged with survey response data files for analysis purposes. We work with the EQRS team on a continuous basis to remain up to speed on the data, changes to the data or data format, and to mitigate any issues with the data.