Groundwork for ESRD CAHPS: The Feasibility Report

1. Groundwork for ESRD CAHPS: The Feasibility Report Beth Kosiak, Ph.D. Center for Quality Improvement and Patient Safety, AHRQ

2. CMS to AHRQ—Can One Patient Survey Serve Two Purposes? • CMS urged by IG, GAO, MedPAC, others to field a patient survey and publicly report results • CMS has been pursuing a quality agenda that includes both public reporting and internal quality improvement • Many facilities administer their own patient surveys for quality improvement and CMS wants to encourage such activity

3. Answer: Maybe • Unlike other populations for which CAHPS surveys have been developed, in-center hemodialysis patients have a lot of experience with care, lots of observations to draw upon • This enables them to answer a broader range of questions with greater specificity; e.g., if needles sticks are painful, if the center is usually clean, if staff take precautions to prevent infection • These kinds of questions are interesting both to patients and facilities

4. Background Research to Investigate the Question • Comprehensive literature review of patient surveys conducted, characteristics of the population relevant to survey administration (e.g., literacy levels, cognitive impairment, etc.) • Focus groups with patients and their families • Focus groups with nephrologists • Interviews with facility administrators and Network executives • Meeting with TEP to get input on content of survey (TEP composed of representatives from facilities, Networks, research, provider, and patient advocacy communities

5. Major Findings (Purpose and Use of Survey) • Strong to moderate support for standardized survey, but concerns about losing valuable information from current surveys (especially since they are often a vehicle for communication with patients), burden and cost • Patients and professionals agree that if a patient survey is administered, improvement of care should occur • Professionals do not think comparative information will be usable for consumer choice but patients say they might switch to a higher rated facility

6. Major Findings (Domains) • Communication • Education • Concern and helpfulness of staff • Patient (and family) involvement in care • Coordination of care • Patient perception of staff proficiency • Patient safety • Facility amenities and physical environment • Access and convenience of care • Handling of grievances and complaints • Interpersonal relationships in the dialysis center

7. Major Findings (Methods and Survey Administration) • Site of survey administration (in the center, at home) • Low literacy levels, fatigue, cognitive impairment, poor vision • Periodicity—once or twice a year • Quick turnaround of results • Administration by independent third party • Inclusion of all patients in survey at small facilities: 1) patients expect to be included; 2) small numbers makes their inclusion essential for statistical reasons

8. Ten Recommendations • Develop a standardized survey and involve the renal community • Initial survey development is for in-center hemodialysis, and focus is on quality improvement and public reporting. Assess need for translation into languages other than Spanish • Consider which items are and are not under control of facility (e.g., transportation) • Develop separate reports for patients and providers • Support efforts to determine how patients will make use of reports and the best methods of dissemination to them

9. Ten Recommendations (continued) • Independent third party administration • Examine eligibility criteria, such as number of months • Look at mode effects, response rates, cost and case-mix issues in field test • Investigate number of patients per facility needed for accurate • Investigate proxy issues—how much and what kind of help patients

10. CMS Accepted Report and Recommendations • Gave green light for survey construction and cognitive testing • Plans to create consumer and provider reports • Plans to take final survey and test its use for quality improvement in a few selected facilities for learning purposes

11. Groundwork for ESRD CAHPS: The Feasibility Report • Beth Kosiak, Ph.D. • Center for Quality Improvement and Patient Safety, AHRQ