Question Title

* 2. Complete the below information.

Question Title

* 3. Please list the Primary and Secondary Contacts for this project. (If UNKNOWN, list the Facility Administrator for the Project Lead and Regional Corporate Representative as the Backup)

Question Title

* 4. Do you know what a Home Modality Learning and Action Network (LAN) is?

Question Title

* 5. Do you have a Facility Patient Representative (FPR), Patient Subject Matter Expert (SME) or an actively engaged patient?

Question Title

* 6. If not, do you think there is a patient who may be interested in becoming a Facility Patient Representative (FPR) or Patient Subject Matter Expert (SME) for your facility?

Question Title

* 7. Do you think your facility serves patients from a vulnerable population? If so, please select all that apply.

Question Title

* 8. Do you think your facility serves patients with health disparities? If so, please select all that apply.

Question Title

* 9. Does your facility hold monthly patient engagement or educational activities for all patients?

Question Title

* 10. When is your facility's monthly QAPI meeting held?

Enter the date closest to typical meeting date.

Question Title

* 11. Why do you think a facility may have a low rate of patients who get trained for a home modality?

Question Title

* 12. Have you notified your regional corporate representative that your facility has been selected to participate in the 2018 Home Dialysis QIA?

Question Title

* 13. Do you feel that you have or will have the resources and support necessary for your facility to successfully participate in the 2019 Home Dialysis QIA?

Question Title

* 14. If you answered NO to Q13, what do you need (from the Network or from your organization) in order to be successful and able to participate fully in the 2019 Home Dialysis QIA?

Question Title

* 15. What do you hope to gain by participating in this Quality Improvement Activity?

T