2020 Modalities QIA (Transplant and Home) Root Cause Analysis

Please select your facility CCN from the Dropdown:*

(If you cannot find your facility in this drop down, you are not in this QIA)

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Please enter the FIRST and LAST NAME of the person completing this survey.*

Please enter EMAIL address of the person completing this survey.*

What are FACILITY SPECIFIC BARRIERS that you think are attributable to having lower TRANSPLANT WAIT LISTING rates in your facility?*

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If you answered "Other" on the previous question, please add other root causes NOT listed above and that are present in your facility

What FACILITY SPECIFIC BARRIERS are attributable to having LOW RATES OF HOME DIALYSIS in your facility?*

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If you answered "Other" on the previous question, please add other root causes NOT listed above and that are present in your facility

What are PATIENT RELATED FACTORS that you think are attributable to LOW TRANSPLANT WAITING LIST rates 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.

Select or enter value

If you answered "Other" on the previous question, please add other root causes NOT listed above and that are present in your facility

What are PATIENT RELATED FACTORS that you think are attributable to LOW RATES OF HOME DIALYSIS 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.

Select or enter value

If you answered "Other" on the previous question, please add other root causes NOT listed above and that are present in your facility

What are ORGANIZATIONAL FACTORS (operational, policies, systemic) that you think are attributable to LOW TRANSPLANT WAITING LIST in your facility?*

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If you answered "Other" on the previous question, please add other root causes NOT listed above and that are present in your facility

What are ORGANIZATIONAL FACTORS (operational, policies, systemic) that you think are attributable to LOW HOME DIALYSIS rates in your facility?*

Select or enter value

If you answered "Other" on the previous question, please add other root causes NOT listed above and that are present in your facility

What are PRODUCT/ METHOD/ MATERIAL FACTORS that you think are attributable to LOW TRANSPLANT WAIT LISTING in your facility?*

Select or enter value

If you answered "Other" on the previous question, please add other root causes NOT listed above and that are present in your facility

What are PRODUCT/ METHOD/ MATERIAL FACTORS that you think are attributable to LOW RATE OF HOME DIALYSIS in your facility?*

Select or enter value

If you answered "Other" on the previous question, please add other root causes NOT listed above and that are present in your facility

Completion of this root cause analysis was an EFFECTIVE INTERVENTION easy to do on-line.*

Yes

No

Did you obtain DIRECT PATIENT FEEDBACK to ensure patients’ perspective was part of this activity?*

Yes

No

Please enter the name of the PROJECT LEAD of your facility's “Modality Expert Team”.*

Do you have a FACILITY PATIENT REPRESENTATIVE (FPR) who will be part of your facility's “Modality Expert Team”? DO NOT ENTER ANY PATIENT SPECIFIC INFORMATION IN THIS FORM.*

Yes

No

Will select one by 2/28/2020

Do you have a TRANSPLANT CHAMPION who can be part of your facility's “Modality Expert Team”? DO NOT ENTER ANY PATIENT SPECIFIC INFORMATION IN THIS FORM.*

Yes

No

Will select one by 2/28/2020

Do you have a HOME DIALYSIS CHAMPION who can be part of your facility's “Modality Expert Team”? DO NOT ENTER ANY PATIENT SPECIFIC INFORMATION IN THIS FORM.*

Yes

No

Will select one by 2/28/2020

Please enter name of the STAR PATIENT CARE TECHNICIAN (SPCT) of your facility's “Modality Expert Team”.*

Please enter the name of your regional/corporate contact (ROD, CSS, etc)

Please enter the email of your regional/corporate contact (ROD, CSS, etc)

Please enter the phone number of your regional/corporate contact (ROD, CSS, etc)

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

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