Read the following instructions carefully

1. Select the root causes you think are barriers to transplant waitlist (multiple selections are allowed)
2. Describe any root cause(s) NOT listed by using the "Other" (comment) box.
***If you are completing RCAs for more than one facility each must be completed separately by CCN number***
WARNING: DO NOT USE PATIENT SPECIFIC INFORMATION SUCH AS NAMES, DOB, SOC SECURITY #, ETC. IN THIS SURVEY. SECURITY VIOLATIONS WILL BE REPORTED TO CMS.

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* 1. What are Facility Specific Barriers that you think are attributable to having a low Transplant Waitlist in your facility?

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* 2. What are Patient-Related Factors that you think are attributable to low Transplant Waitlist in your facility? Make sure to include your FPR to gather patients' perspective when completing this section. FPRs will be surveyed for participation throughout the course of project.

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* 3. What are Organizational Factors (operational, policies, systemic) that you think are attributable to low Transplant Waitlist in your facility?

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* 4. What are Product/Methods/Material Factors that you think are attributable to low Transplant Waitlist in your facility?

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* 5. Completion of this root cause analysis was effective and easy to do on-line.

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* 6. Did you obtain direct patient feedback to ensure patients' perspective was part of this activity?

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* 7. Provide first and last name of person completing this activity

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* 8. Any additional thoughts or comments you would like to provide about this process?

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* 9. Provide name of facility

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* 10. Provide 6-digit CMS provider number (CCN#, begins with a 45 or 67).

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* 11. I have printed a completed copy of this RCA survey with all the answers for my records (right-click over the survey and select "Print")

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