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ICH CAHPS: Quality of Dialysis Center Care and Operations Measure (QDCCO)

CBE ID
0258-4-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 Quality of Dialysis Center Care and Operations (QDCCO) measure captures whether dialysis patients feel that their that dialysis center staff communicated well, kept patients as comfortable and pain-free as possible, behaved in a professional manner, and kept the center clean.

 

The questions included in this measure are: 

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

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

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

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

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

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

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?

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

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

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

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?

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

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

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 Quality of Dialysis Center Care and Operations (QDCCO) multi-item measure captures whether patients feel that their dialysis center staff communicated well, kept patients as comfortable and pain-free as possible, behaved in a professional manner, and kept the center clean. 

 

This measure reflects patient experiences with their dialysis facility across a variety of domains that were identified as important to patients and stakeholders based on focus groups and cognitive interviews during the survey revision development phase. 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.