ICH CAHPS FPR Participation Letter and List

Instructions: The staff person who is the Project Lead will answer  Questions #1 - #7  based on their experience and then will enter the answers to Questions #8 - #12 after using the paper survey to gather the answers from the Facility Patient Representative. At the end of the survey, select the button "Done" when complete. Complete the entire survey by 5pm Central, Wednesday, June 7, 2017.
 
ICH CAHPS stands for Consumer Assessment of Healthcare Providers and Systems In-Center Hemodialysis Survey.

DO NOT USE PATIENT-SPECIFIC INFORMATION SUCH AS PATIENT NAMES, DOB OR OTHER PATIENT IDENTIFYING INFORMATION AS THIS WILL BE CONSIDERED A SECURITY VIOLATION AND WILL BE REPORTED TO CMS.

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* 1. What is the name of your facility?

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* 2. Provide the 6-digit CMS certification number (begins with a 45 or 67).

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* 3. First and last name of Facility staff completing this survey

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* 4. Does your facility have a Facility Patient Representative (FPR)?

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* 5. Did you give the FPR Participation Letter and List for the project to the FPR?

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* 6. Did you have a conversation with the FPR, explaining the purpose of the FPR Participation Letter and List?

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* 7. How would you improve the FPR Participation Letter and List?

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* 8. Question for the FPR to answer: After reading the FPR Participation Letter and List, I have a better understanding of what my role is in this project?

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* 9. Question for the FPR to answer: After reading the FPR Participation Letter and List, I have a better understanding of what the ICH CAHPS Question #39 means and does NOT mean? (Question 39: Peritoneal Dialysis is dialysis given through the belly and is usually done at home.  In the past 12 months did either your kidney doctors or dialysis center staff talk to you about peritoneal dialysis?)

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* 10. Question for the FPR to answer: How useful is the FPR Participation Letter and List in supplying ideas for how you can be involved in this project?

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* 11. Question for the FPR to answer: I have done at least one of the activities listed below (check all that apply) or plan to within the next 30 days.

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* 12. Question for the FPR to answer: How would you improve the FPR Participation Letter and List?

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