Form GenIC#5 ESRD Greivant Satisfaction Survey Version 2.0

1979 Marcus Avenue, Suite 105 • Lake Success, NY 11042-1072
Phone: 516-209-5253 • Fax: 516-326-7805 • ncc@ncc.esrd.net
www.esrdncc.org • www.kcercoalition.com

ESRD Grievant Satisfaction Survey
Introduction
Hello. May I please speak with [participant name]?
If the participant is not available, please provide a callback number for the participant to
call back before [auto populate the end date of the survey calls cycle], thank the person
on the phone, and end the call by saying, “Thank you for your time. If we do not hear
back from [participant name], we will call back. What is the best time to call back?”
[Time captured needs to be based on participants’ time zone and rescheduled in the
scheduler].
If the participant answers the phone, state the following:
Good [morning/afternoon/evening, participant name]. My name is [surveyor name].
I’m calling because you told [Network name] when you filed your grievance you’d help
Medicare by answering some questions about your experience with [Network name].
I’m with the Subcontractor Name and as explained in the letter you received I’m not with
[Network name] or Medicare. Everything you tell me will be private.
Our records show you contacted [Network Name] around [date] to file a grievance. Is
this correct?
If yes, continue with the survey. If no, ask if the date is wrong and obtain the correct
date. [This date will need to be captured for reporting purposes]. If the patient didn’t file
a grievance, conclude the survey and thank the respondent.
Is this a good time for you to talk?
If yes, continue with the survey. If no, schedule a follow-up call.
We will use what we learn today to help improve the Network grievance process. We
will talk for about 15 minutes today. What you say will be kept private, will not be shared
with your dialysis facility or Network, and will not change your Medicare benefits.

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Grievance/ Process
The following questions are about the way [Network Name] handled your grievance.
Please consider only the question I ask. Try not to think about whether your grievance
turned out the way you wanted. I will give you a list of answers for each question, and
you can choose the best one.
1.

2A.

How satisfied were you with the customer service you received from [Network
Name] when you first told them about your grievance?
Very satisfied
Somewhat satisfied
Neither satisfied nor dissatisfied
Somewhat dissatisfied
Very dissatisfied

(4)
(3)
(2)
(1)
(0)

No answer/Don’t know

(9)

Did your Network explain your right to file a grievance to you?
Yes (go to 2B)
No (go to 3A)

2B.

3A.

After you spoke with the Network; did you have a good understanding of your
right to file a grievance?
Very good understanding
Good understanding
Neither good nor poor understanding
Poor understanding
Very poor understanding

(4)
(3)
(2)
(1)
(0)

No answer/Don’t know

(9)

Did you talk more than once with [Network Name] while your grievance was in
process?
Yes
No (go to 3C)

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3B.

3C.

How satisfied were you with the customer service you received from [Network
Name] in follow-up talks during your grievance?
Very satisfied
Somewhat satisfied
Neither satisfied nor dissatisfied
Somewhat dissatisfied
Very dissatisfied

(4)
(3)
(2)
(1)
(0)

No answer/Don’t know

(9)

Did a patient representative or someone who works with patients at your dialysis
facility help you with your grievance?
Yes
No

4.

5.

Did you feel respected while [Network Name] processed your grievance?
Very respected
Somewhat respected
Neither respected nor disrespected
Somewhat disrespected
Very disrespected

(4)
(3)
(2)
(1)
(0)

No answer/Don’t know

(9)

How satisfied were you that the Network listened to your concerns and
understood them?
Very satisfied
Somewhat satisfied
Neither satisfied nor dissatisfied
Somewhat dissatisfied
Very dissatisfied

(4)
(3)
(2)
(1)
(0)

No answer/Don’t know

(9)

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6.

7.

8.

How satisfied were you with the Network’s effort to resolve your grievance?
Very satisfied
Somewhat satisfied
Neither satisfied nor dissatisfied
Somewhat dissatisfied
Very dissatisfied

(4)
(3)
(2)
(1)
(0)

No answer/Don’t know

(9)

How satisfied were you that the Network acted in your best interest?
Very satisfied
Somewhat satisfied
Neither satisfied nor dissatisfied
Somewhat dissatisfied
Very dissatisfied

(4)
(3)
(2)
(1)
(0)

No answer/Don’t know

(9)

Did you get a letter from [Network Name] with results of their work to resolve
your grievance? (Item is not scored.) [All grievances flagged as immediate
advocacy will be programmed to skip this question].
Yes (if yes, go to 8A)
No (if no, go to 9)

8A.

How satisfied were you with the letters you received from the Network?
Very satisfied
Somewhat satisfied
Neither satisfied nor dissatisfied
Somewhat dissatisfied
Very dissatisfied

(4)
(3)
(2)
(1)
(0)

No answer/Don’t know

(9)

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9.

10.

11.

Overall, how satisfied were you with the help you received from [Network Name]
to resolve your grievance?
Very satisfied
Somewhat satisfied
Neither satisfied nor dissatisfied
Somewhat dissatisfied
Very dissatisfied

(4)
(3)
(2)
(1)
(0)

No answer/Don’t know

(9)

Are you comfortable enough with the Network grievance process to file another
grievance?
Very comfortable
Somewhat comfortable
Neither comfortable nor uncomfortable
Somewhat uncomfortable
Very uncomfortable

(4)
(3)
(2)
(1)
(0)

No answer/Don’t know

(9)

When you contacted your ESRD Network, did anyone at the Network ever try to
talk you out of filing the grievance?
a. Yes
b. No
c. I prefer not to answer

11A. If yes, what did they say to you?

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12.

When you contacted your dialysis facility, did anyone at the facility ever try to talk
you out of filing the grievance?
a.
b.
c.
d.

Yes
No
I prefer not to answer
Did not file grievance at facility

12A. If yes, what did they say to you?

13.

When you filed a grievance with your ESRD Network, did you feel that the staff at
your dialysis facility took actions against you after you filed your grievance?
a. Yes
b. No
c. I prefer not to answer

13A. If yes, then how did the center take action against you?

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14.

When you filed a grievance with your facility, did you feel that the staff at your
dialysis facility took actions against you after you filed your grievance?
a.
b.
c.
d.

Yes
No
I prefer not to answer
Did not file grievance at facility

Wrap-Up Question
15. Would you like to add any thoughts about your contact with [Network Name] during
the time you filed your grievance?

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Conclusion
On behalf of [name of survey vendor], I want to thank you for your time today. Medicare
oversees all dialysis facilities, transplant centers, and Networks. Even if you don’t have
Medicare your feedback on your experience is important. Again, if you have any
questions or concerns about this survey or the way I asked questions, please contact
CMS Representative at XXX-XXX-XXXX or FirstName.LastName@cms.hhs.gov
Supplemental Script [To be used as Frequently Asked Questions by the surveyor]
If the patient refuses to take the survey due to not getting the outcome they desired: I’m
sorry you did not get the outcome you desired from filing a grievance, but we would be
very grateful if you would participate in the survey. Your experience is very important
feedback for us to report to Medicare.
If the patient refuses to take the survey due to a lack of clarity of Medicare’s
involvement: I understand you don’t have Medicare, but the Social Security Act makes
Medicare responsible to oversee the quality of care for all patients in a dialysis facility,
transplant center or the Network, not just those receiving Medicare benefits. Your
experience is very important feedback for us to report to Medicare.
If the patient refuses due to lack of clarity about who is calling: I work for the
[Subcontractor Name]. Medicare hired my firm to do this survey so patients can be sure
everything they say is private. As the letter you received stated your answers will be
added to all the other patients responding in your Network, without names, before being
given to Medicare. Your experience is very important feedback for us to report to
Medicare.

ESRD National Coordinating Center (NCC)
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Version 2.0 • Revision Date: 10/22/2015
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