Project Guidelines

Beginning in 2014, administration of the ICH CAHPS survey is required at all dialysis facilities that served 30 or more eligible patients in the prior calendar year. The ICH CAHPS survey focuses on gaining facility specific data on patient satisfaction and experience of care. Data is then used by the Centers for Medicare & Medicaid Services (CMS) as a measure in the ESRD QIP (Quality Incentive Program), which means that a portion of facility reimbursement is related, in part, to these scores.

The Network analyzed In-Center Hemodialysis Consumer Assessment of Healthcare Providers and Systems (ICH CAHPS) scores nationwide and throughout the Network service area to identify a single question within the survey that received the highest percentage of negative scores from patient respondents and has reasonable potential for positive change. The Network has identified ICH CAHPS Question 18 based on the spring 2016 ICH CAHPS data. Question 18 states, “In the last 3 months, has anyone on the dialysis center staff asked you about how your kidney disease affects other parts of your life?” This question evaluates the patient experience, and reflects the effectiveness of a facility in utilizing a patient-centered care approach. In a patient centered model, patients become active participants in their own care and receive serviced designed to focus on their individual needs and preferences, in addition to receiving advice and counsel from health professionals.


Facilities must increase their percentage of positive responses to Q. 18 based on monthly surveys administered to 1/8 of the facility population during the project timeline. Through the promotion of positive interactions, learning processes and best practices related to the ICH CAHPS survey the Network strives to assist facilities with creating a foundation for changing staff interactions with patients to be in line with a patient-centered approach. Reducing the percentage of negative scores from patient respondents is key to improving QIP scores and maximizing reimbursement.


Facilities are selected and notified of their participation in January. The Network will work with the facilities to implement interventions between February and September. The re-measurement will be completed in September based on monthly surveys collected confidentially from patients and submitted by facilities.

Facility Selection

The facilities that performed poorest on this question were selected to participate in this activity to make up 5% of the total ESRD Network population. Facilities were excluded from selection if they did not participate in ICH CAHPS or achieved less than a 10% patient response rate on the survey.

Baseline Data

Spring 2016 ICH CAHPS Survey responses were used to perform the facility selection.
Re-Measurement Data: Data for this QIA will be submitted monthly by facilities and reviewed by the ESRD Network with final data being collected in September.

Re-Measurement Data

Data for this QIA will be submitted monthly by facilities and reviewed by the ESRD Network with final data being collected in September.

Tools and Resources

Network Resources

Interactive Posters have been created as a platform to help promote better communication between facility staff and patients by understanding more about the perspective of each other.

ICH CAHPS “What Matters” Implementation Guide

NW6 Patient Interactive "What Matters to You?" Poster
NW6 Professional Interactive "What Would You Say?" Poster

Project Webinars

May 10, 2017 ICH CAHPS QIA Kickoff  Slides

July, 18, 2017 QIA Interventions Part II  Slides

Other Resources

Institute for Healthcare Improvement What Matters Video

IHI's What Matters webpage

In-Center Hemodialysis CAHPS Survey:

Upset female patient

Project Lead

Melissa Arrington, MSW
Patient Services Director