Patient and Family Engagement
Facility Self-Assessment Tool
The Southeastern Kidney Council (SKC) encourages facilities to complete this tool to evaluate the degree to which patients and their caregivers are engaged at the dialysis facility. Discuss the results in your governing body and QAPI meetings, along with your ICH-CAHPS results and other assessments to identify strategies to increase engagement. We recommend you involve your patients in the assessment process. SKC will also use this tool when we conduct on-site visits.
After completing the assessment, transfer results here for easy reference.
Total # of
Items
#
Fully
Implemented
#
Partially
Implemented
Strengthening the Dialysis Facility’s Foundation for patient-centered care
Communicating Effectively with Patients, Families and caregivers
Personalization of Care
Continuity of Care
Access to Information
Family Engagement
Environment of Care
Spirituality
Care for the Facility Staff
Total
Plans to improve/increase patient and family engagement and patient-centered care:
9
7
11
2
12
6
5
5
5
62
Page | 1

Southeastern Kidney Council
Patient and Family Engagement
Facility Self-Assessment Tool
Degree of
Implementation
Examples/Notes
If you check fully or partially, briefly describe here
1.
Facility’s commitment to patient-centered care is consistently communicated with patients, families, caregivers, Facility Staff,
Leadership, and Medical Staff (e.g. mission, core values).
2.
Expectations for what staff can expect in a patient-centered environment are clearly stated and proactively shared.
3.
Patients, families, and caregivers have been invited to share their experiences-of-care with Facility.
4.
An advisory group of patients, families, and caregivers meets regularly and actively provides input to facility administration/governing body on facility operations.
5.
Patients, families, and caregivers participate as members on
Facility’s quality improvement/QAPI committees.
6.
The input provided by patients and families is used to guide
Facility’s strategic direction.
7.
Patient-centered behavior expectations are included in all job descriptions and performance evaluation tools.
8.
Staff at all levels, clinical and non-clinical, have the opportunity to voice their ideas and suggestions for improvement.
9.
Opportunities exist for formal and informal interaction between
Facility leadership and staff members from all work shifts.
10.
Opportunities exist for Leadership to interact directly with patients, families, and caregivers.
11.
Facility Managers are held accountable for “walking the talk” of patient-centered care.
12.
Facility Physicians are held accountable for “walking the talk” of patient-centered care.
TOTAL Responses for Section 1 Transfer results to Summary Table on Page 1
Page | 2

Southeastern Kidney Council
Patient and Family Engagement
Facility Self-Assessment Tool
Degree of
Implementation
Examples/Notes
If you check fully or partially, briefly describe here
13.
Patients are made aware of how to raise a concern related to patient safety and/or their care while they are in the facility.
14.
Patients, families and caregivers are encouraged to ask questions.
15.
Facility has system in place to get answers to questions that arise when caregivers are not present to answer those questions.
16.
Facility has system in place to assist patients, families, and caregivers in knowing each of the patient’s care providers and the role of each member of the patient’s care team.
17.
Changes in the dialysis schedule are communicated promptly and clearly and are respectful of the patient’s time, transportation and employment needs.
18.
Policy changes are communicated promptly and clearly and are respectful of patient needs.
TOTAL Responses for Section 2 Transfer results to Summary Table on Page 1
19.
Patients’ requests for treatment schedule changes are honored to the extent possible.
20.
Resources are available to Facility staff to educate them on different cultural beliefs and traditions related to patient health and healing.
21.
Patient plans of care are individualized and respectful of and responsive to patient preferences, wants, needs and values.
22.
Care planning sessions are scheduled at times most convenient for patients and their family/caregivers. Patients are able to participate by telephone if they desire.
23.
Patients are encouraged to attend care planning sessions.
Page | 3

Southeastern Kidney Council
Patient and Family Engagement
Facility Self-Assessment Tool
Degree of
Implementation
Examples/Notes
If you check fully or partially, briefly describe here
TOTAL Responses for Section 3 Transfer results to Summary Table on Page 1
24.
Patients, families, and caregivers are able to participate in monthly rounds.
25.
Patient care plans are written in language that patients, families, and caregivers can understand.
26.
Opportunities exist for patients, families, and caregivers to meet at the same time with multiple members of their health care team.
27.
Tools are provided to help patients manage their medications, appointments and other healthcare needs
28.
Facility staff contact and coordinate with other providers including nursing home and hospital discharge planners to ensure continuity of care and effective transitions including medications and infection control.
TOTAL Responses for Section 4 Transfer results to Summary Table on Page 1
29.
Facility has a process by which patients, family, and/or patient’s legal representative may request additional information regarding diagnosis, treatment options, etc.
30.
Patient education and orientation are continually offered to patients and families, not only during the new patient orientation period.
31.
Patients and family members have an opportunity to meet with other patients as peer mentors or contacts.
32.
Patients have access to their medical record and are helped to understand its contents.
33.
Patients are made aware of the opportunity to review their
Page | 4

Southeastern Kidney Council
Patient and Family Engagement
Facility Self-Assessment Tool
Degree of
Implementation
Examples/Notes
If you check fully or partially, briefly describe here medical record with the support of a health care professional.
34.
Patients are able to provide their own progress notes to be included in their medical record.
35.
Patient education materials appropriate for readers of varying literacy levels and for speakers of different native languages are readily available at Facility.
36.
Facility has a protocol to disclose “unanticipated outcomes” to patients, families, caregivers, and patients’ legal representatives.
37.
Trained interpreters are available.
TOTAL Responses for Section 5 Transfer results to Summary Table on Page 1
TOTAL Responses for Section 5
38.
Facility honors the patient’s definition of “Family.”
39.
Facility has a written “Visitor Policy” that is flexible and patientdirected.
40.
Facility training and education is available for a patient‘s caregiver as appropriate.
41.
Patients, families, and caregivers are able to readily locate
Facility Staff in the event of an emergency.
42.
Facility support is provided to patients, families, and caregivers involved in an adverse event.
43.
Comfortable spaces with amenities (such as television) are available within Facility.
44.
Patients’ informal caregivers receive support.
Transfer results to Summary Table on Page 1
Page | 5

Southeastern Kidney Council
Patient and Family Engagement
Facility Self-Assessment Tool
Degree of
Implementation
Examples/Notes
If you check fully or partially, briefly describe here
45.
The following spaces create a first impression of “welcome”,
“comfort”, and “healing”:

Main Lobby

Reception Desk

Nurses’ Stations

Parking Lots
46.
Patients are personally greeted and welcomed when they arrive at the dialysis facility for each treatment.
47.
Patients are afforded privacy during check-in and treatment.
48.
Private space is available for patients to have confidential conversations with their care team.
49.
A range of activities (besides television) are available to patients and visitors.
50.
Overhead paging has been eliminated (with the exception of emergent needs).
51.
Pleasant-smelling, non-toxic cleaning products are used in
Facility.
52.
Patients have a view to the outdoors.
53.
Dialysis chairs are clean, comfortable and in good working order.
54.
Facility signs reflect the primary languages of the populations served and Facility signs contain symbols or icons to aid in understanding.
55.
Patients can easily find their way from the parking areas to
Facility.
TOTAL Responses for Section 7
56.
Resources are available to Facility Staff to educate them on different religious beliefs and traditions related to health and
Page | 6
Transfer results to Summary Table on Page 1

Southeastern Kidney Council
Patient and Family Engagement
Facility Self-Assessment Tool
Degree of
Implementation
Examples/Notes
If you check fully or partially, briefly describe here healing.
57.
Spiritual assessments give consideration to a patient’s faith and traditions as well as to what comforts and centers them.
TOTAL Responses for Section 8 Transfer results to Summary Table on Page 1
58.
Staff members’ stress-reduction and wellness needs are addressed.
59.
Staff members are routinely acknowledged for their good work by Facility Administration, by their staff peers, and by patients, families, and caregivers.
60.
Staff members have opportunities to participate in making the workplace better for all.
61.
Adequate space is available for staff members to “decompress” between patients and/or shifts.
62.
Support is provided to staff members involved in an adverse event.
TOTAL Responses for Section 9 Transfer results to Summary Table on Page 1
TOTAL RESPONSES FOR ASSESSMENT Transfer results to Summary Table on Page 1
Page | 7