HC 405 Unit 4 patient satisfaction review example

Forty-One of 118 Patients Answered, and Few of Them Work: A Patient Experience Review of Gulfview Kidney Center's Fall 2025 Survey

Student Name

Health Care Administration, Herzing University

HC 405: Healthcare Quality

Instructor Name

February 5, 2026

Forty-One of 118 Patients Answered, and Few of Them Work: A Patient Experience Review of Gulfview Kidney Center's Fall 2025 Survey

Which Survey, When, and How Many Answered

Our composite facility, Gulfview Kidney Center, takes part in the federal in-center hemodialysis patient experience survey, a standardized survey the Centers for Medicare & Medicaid Services uses in its dialysis payment program, whose rules appear at 42 C.F.R. § 413.177. It is administered twice a year by an approved outside vendor to adult patients who have received in-center hemodialysis at the facility for at least three months. For the fall 2025 survey, the vendor mailed questionnaires in October with telephone follow-up through December. Of 118 eligible patients, 41 completed the survey, a response rate of 34.7%. The survey reports three composite measures, covering the nephrologists' communication and caring, the quality of dialysis center care and operations, and information given to patients, along with global ratings of the nephrologist, the staff and the center; the two main composites have shown good reliability in published testing, while the information composite has been less consistent (Wood et al., 2014).

Who Actually Replied

Before reading any result, the respondents were compared with all eligible patients, using the facility's own records.

What That Means for Reading the Results

The respondents are older, more likely to speak English, more established at the facility, and far less likely to work or to dialyze on the evening shift than the patients as a whole. Evening-shift patients, many of whom come after work and whose treatments start later when the day runs behind, are almost missing: 4 of 32 answered. Spanish-speaking patients are underrepresented despite the vendor's Spanish questionnaire. The federal program adjusts official scores for some patient characteristics, and research on patient experience surveys shows that survey mode and patient mix can shift results substantially (Elliott et al., 2009), but adjustment cannot restore the views of groups who largely did not answer. The results below are therefore best read as the experience of long-standing, older, daytime patients.

Results, Kept Apart

Percentage of respondents giving the most positive answer, fall 2025, with spring 2025 (38 respondents) for comparison. With about 40 respondents, a difference of less than about 15 percentage points between surveys may be chance.

Reading the Separate Measures

The measures point to different owners, which is why they are not averaged into one score. Nephrologist communication is the physicians' responsibility and is stable or slightly improved. Information to patients is the strongest area and reflects the education program run by the social worker and dietitian. Care and operations, which covers how staff treat patients and how well the center runs, is the weakest composite and fell five points; within it, the vendor's item-level report shows the lowest results on items about comfort and the running of the center rather than on staff respect or professionalism, which remained high. The change is within the range chance could produce, so it is a signal to investigate, not a conclusion.

Free-Text Comments, Treated as a Separate Source

The federal survey does not collect comments, so Gulfview also runs its own comment cards, which any patient can complete at any time. Fifty-two comments were received from October to December. They come from a different, self-selected group and are sorted by subject rather than mined for quotations: treatment start times and waiting, 17; praise for particular staff, 12; the treatment room being cold, 7; transportation, 6; parking, 4; rules about eating during treatment, 3; other, 3. Nine of the 17 waiting comments came from evening-shift patients, the group the survey barely reached.

The two sources agree on direction. The survey's weakest composite concerns how the center runs, and the most common comment concerns waiting. Published analysis of the same survey found that time in the waiting room was among the characteristics most consistently related to how patients rated their dialysis care (Wood et al., 2014). The review therefore supports the timeliness problem identified earlier in the course, and adds that the patients most affected by it are the least likely to answer the survey.

What the Survey Cannot Tell the Facility

Three limits shape how far the results can be pushed. First, the survey asks about the past three months in general, not about particular days or shifts, so it cannot show whether the problems respondents describe are concentrated on certain shifts or staff. Second, federal public reporting of the survey uses results pooled over two survey periods and adjusted for patient characteristics, so the facility's own raw percentages will not match what appears on the comparison website, and staff should not be surprised by the difference. Third, the survey measures experience, not outcomes: a patient can rate the center highly and still be dialyzing through a catheter, or rate it poorly for reasons, such as transportation, that sit partly outside the center's control.

None of these limits makes the survey less useful. They mean it should be read alongside the facility's own operational data rather than on its own, and that a single survey period should never drive a major decision. The quality committee will review the survey twice a year together with start-time data, missed treatments and the comment card summary, so that each source can check the others.

Actions

Ask the vendor to add a telephone attempt in Spanish and at evening hours for the spring survey; report evening-shift comments separately each month; and bring the start-time data to the quality committee alongside the survey, so that the facility does not wait for a small, unrepresentative survey sample to confirm what its own timestamps already show.

References

Elliott, M. N., Zaslavsky, A. M., Goldstein, E., Lehrman, W., Hambarsoomians, K., Beckett, M. K., & Giordano, L. (2009). Effects of survey mode, patient mix, and nonresponse on CAHPS hospital survey scores. Health Services Research, 44(2, Pt. 1), 501-518. https://doi.org/10.1111/j.1475-6773.2008.00914.x

End-Stage Renal Disease Quality Incentive Program, 42 C.F.R. § 413.177 (2025).

Wood, R., Paoli, C. J., Hays, R. D., Taylor-Stokes, G., Piercy, J., & Gitlin, M. (2014). Evaluation of the Consumer Assessment of Healthcare Providers and Systems in-center hemodialysis survey. Clinical Journal of the American Society of Nephrology, 9(6), 1099-1108. https://doi.org/10.2215/CJN.10121013