ICH CAHPS Patient Survey Q#39  -  Poor Scores

A root cause analysis (RCA)  is a quality improvement tool used to identify any causes or reasons behind a specific issue. Completion of a thorough and credible RCA will assist you in the next steps of the project which include organizing and holding small patient group discussions and designing and implementing a facility-specific intervention. This RCA was designed to address poor patient survey scores for ICH CAHPS Question #39 which states: "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?"


Please read the description of the RCA categories below before starting the survey:

•Human Resource-Related Factors: examples include lack of staff training on talking to patients\providing information to patients about PD, time constraints (physician delegation, staff turnover, lack of staff to talk to patient about PD as modality), staff bias toward in-center hemodialysis over PD, kidney doctors (multiple reasons)

•Patient-Related Factors: examples include lack of ICH CAHPS survey knowledge, health literacy – language barrier, does not understand what Q#39 means, misinterprets Q#39, unclear healthcare terminology used, poor cognitive status, tired of answering surveys, does not answer the question truthfully

•Process-Related Factors: examples include staff not following the plan of care for talking to patients (i.e., educating patients) about different modalities including PD, no modality educational process in place, urgent HD initiation with no follow-up PD discussion as option, organizational culture, ineffective patient teaching practices, not involving patients in the design and implementation of solutions, lack of using QI methods to make improvements

•Equipment/Machine/Material-Related Factors: examples include vendor issues, national or regional shortage of PD dialysate deters doctors and staff from talking to patients about PD
 
INSTRUCTIONS FOR COMPLETING THIS ROOT CAUSE ANALYSIS SURVEY
STEP 1: Complete the questions below by selecting the root cause or root causes which you think are  attributable to negative patient scores for Q#39. (multiple selections allowable per question)
STEP 2: Describe any root cause(s) NOT listed in the Other (comment) box for Questions 4-7.
STEP 3: BEFORE submitting this Root Cause Analysis, Save and Print a copy to keep at the facility. You will use this document for a future activity in this project. Right click on your mouse, select the Print option. Then click on the "Submit Root Cause Analysis" button.
 
Deadline: Complete Root Cause analysis by close of business on Thursday, March 30, 2017. Not completing project requirements may lead to facility being placed on the CMS Watch List.

WARNING: DO NOT USE PATIENT SPECIFIC INFORMATION SUCH AS NAMES, DOB, SOC SECURITY #, E

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* 1. Provide first and last name of person completing this survey

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* 2. Provide name of facility

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

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* 4. What are Human Resource Factors that you think are attributable to poor patient scores for Q#39?

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* 5. What are Patient-Related Factors that you think are attributable to poor patient scores for Q#39?

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* 6. What are Process Factors that you think are attributable to poor patient scores for Q#39?

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* 7. What are Equipment/Machine/Material Factors that you think are attributable to poor patient scores for Q#39?

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* 8. Completion of this root cause analysis was easy to do on-line.

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

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