CC Inpatient Survey

B

Your Clinical Center visit...
Please fill in the bubble that best describes your experience during your most recent Clinical Center stay. Only the
patient who was hospitalized should fill out this questionnaire.

ADMISSION...
1. Was your Clinical Center visit planned (e.g., according to your protocol, first visit) or unplanned due to a
complication?
E Planned
E Unplanned
2. Length of Stay
E 0 - 3 days

E 4 - 6 days

E 7 - 9 days

E 10 or more days

3. How organized was the admission process?
E Not at all organized
E Somewhat organized

E Very organized

EXAMPLE

4. Do you feel you had to wait an unnecessarily long time to go to your room?
E Yes, definitely
E Yes, somewhat
E No

5. If you had to wait to go to your room, did someone from the hospital explain the reason for the delay?
E Yes
E No
E Did not have to wait
6. How would you rate the courtesy of the staff who admitted you?
E Poor
E Fair
E Good
E Very Good
E Excellent
DOCTORS...
7. Was there one particular doctor in charge of your care in the hospital?
E Yes
E No
E Not sure
8. When you had important questions to ask a doctor, did you get answers you could understand?
E Yes, always
E Yes, sometimes
E No
E Did not have questions
9. If you had any anxieties or fears about your condition or treatment, did a doctor discuss them with you?
E Yes, completely
E Yes, somewhat
E No
E Did not have anxieties or fears
10. Did you have confidence and trust in the doctors treating you?
E Yes, always
E Yes, sometimes
E No

B

11. Did doctors talk in front of you as if you weren't there?
E Yes, often
E Yes, sometimes
E No
12. How would you rate the courtesy of your doctors?
E Poor
E Fair
E Good
E Very Good

E Excellent

13. How would you rate the availability of your doctors?
E Poor
E Fair
E Good
E Very Good

E Excellent

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NURSES...
14. When you had important questions to ask a nurse, did you get answers you could understand?
E Yes, always
E Yes, sometimes
E No
E Did not have questions
15. If you had any anxieties or fears about your condition or treatment, did a nurse discuss them with you?
E Yes, completely
E Yes, somewhat
E No
E Did not have anxieties or fears
16. Did you have confidence and trust in the nurses treating you?
E Yes, always
E Yes, sometimes
E No
17. Did nurses talk in front of you as if you weren't there?
E Yes, often
E Yes, sometimes
E No
18. How would you rate the courtesy of your nurses?
E Poor
E Fair
E Good
E Very Good

E Excellent

19. How would you rate the availability of your nurses?
E Poor
E Fair
E Good
E Very Good

E Excellent

HOSPITAL STAFF...
20. Sometimes in a hospital or clinic, one doctor or nurse will say one thing and another will say something quite
different. Did this happen to you?
E Yes, always
E Yes, sometimes
E No

EXAMPLE

21. Did you have enough say about your treatment?
E Yes, definitely
E Yes, somewhat
E No

22. Did your family or someone else close to you have enough opportunity to talk to your doctor?
E Yes, definitely
E No
E Family did not want or need to talk
E Yes, somewhat
E No family or friends were involved
23. How much information about your condition or treatment was given to your family or someone close to you?
E Not enough
E Too much
E Family did not want or need information
E Right amount
E No family or friends involved
24. Was it easy for you to find someone on the hospital staff to talk to about your concerns?
E Yes, definitely
E Yes, somewhat
E No
E Did not want to talk/no concerns
25. When you needed help getting to the bathroom, did you get it in time?
E Yes, always
E Yes, sometimes
E No
E Did not need help
26. How many minutes after you used the call button did it usually take before you got the help you needed?
E 0 minutes/right away
E 6-10 minutes
E 16-30 minutes
E Never used call button
E 1-5 minutes
E 11-15 minutes
E More than 30 minutes
E Never got help
27. Did a doctor or nurse explain the results of tests in a way you could understand?
E Yes, completely
E Yes, somewhat
E No
E No tests were done
28. Were your scheduled tests and procedures performed on time?
E Yes, always
E Yes, sometimes
E No
E No tests/procedures

B

29. Did you feel like you were treated with respect and dignity while you were in the hospital?
E Yes, always
E Yes, sometimes
E No

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PAIN...
30. Were you ever in any pain?
E Yes
E No (Go to #37)
31. When you had pain, was it usually severe, moderate, or mild?
E Severe
E Moderate
E Mild
32. Did you have a machine that you could use to give yourself pain medicine?
E Yes (Go to #35)
E No
33. Did you ever request pain medicine?
E Yes
E No (Go to #35)
34. How many minutes after you requested pain medicine did it usually take before you got it?
E 0 minutes/right away
E 11-15 minutes
E Never got medicine
E 1-5 minutes
E 16-30 minutes
E Did not request pain medicine
E 6-10 minutes
E More than 30 minutes
35. Do you think that the hospital staff did everything they could to help control your pain?
E Yes, definitely
E Yes, somewhat
E No
36. Overall, how much pain medicine did you get?
E Not enough
E Right amount
E Too much
SURGERY...

E Did not request pain medicine

EXAMPLE

37. Did you have surgery at the Clinical Center?
E Yes
E No (Go to #42)

38. Did the surgeon explain the risks and benefits of the surgery in a way you could understand?
E Yes, completely
E No
E I did not want anything explained
E Yes, somewhat
E Explained to spouse or someone else
39. Did the surgeon or any of your other doctors answer your questions about the surgery in a way you could
understand?
E Yes, completely
E Yes, somewhat
E No
E I did not have any questions
40. Did a doctor or nurse tell you accurately how you would feel after surgery?
E Yes, completely
E Yes, somewhat
E No
41. Were the results of the surgery explained in a way you could understand?
E Yes, completely
E Yes, somewhat
E No
E Explained to spouse or someone else
CLINICAL RESEARCH QUESTIONS...
42. Before you agreed to participate in a research protocol, did a doctor explain the protocol requirements including
both risks and benefits in a way you could understand?
E Yes, completely
E Yes, somewhat
E No

B

43. Prior to signing the informed consent form, did the research team talk with you about the details of the study on
which you were enrolled?
E Yes, completely
E Yes, somewhat
E No

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44. Did time pass between when the research team talked with you about the study and the informed consent process
and when you signed the form?
E No, I signed the form immediately
E Yes, more than 2 hours but on the same day
E Yes, less than 1 hour
E Yes, 2 - 7 days later
E Yes, more than 1 hour but less than 2 hours
E Yes, more than 1 week later
45. Did the informed consent form that you signed explain the details of the study for which you are enrolled?
E Yes, completely
E Yes, somewhat
E No
46. Thinking back is there any part of the research study that you wish you had known more about before you signed
the informed consent to participate in the study?
E Yes
E No
47. If yes, what part (please check all that apply)
E Serious risks
E Amount of time participation would require
E Common but not serious risks
E Amount of money to be paid for participating
E Procedures involved in the study
E Who to call if I had problems

E Other

48. On a scale of 1 to 10, where 1 is not at all informed and 10 is extremely informed, how well informed do you feel
about the study you are on?
10
1 Not at all
Extremely
informed
2
3
4
5
6
7
8
9
informed
E
E
E
E
E
E
E
E
E
E
49. Did you feel pressure from physicians, nurses, or other people at the NIH to sign up for the study you are on?
E A great amount of pressure
E A small amount of pressure
E A moderate amount of pressure
E No pressure

EXAMPLE

50. If, for any reason, you decided that you wanted to withdraw from the protocol in which you are enrolled, when could
you stop participation?
E I do not know
E To change to another study
E Once the first test is completed
E Only when the protocol is over
E If I obtain the physician's approval
E I can stop at any time I want
E When I am between courses of treatment

B

51. When you decided to participate in the study you are on, what was the most important reason for participating?
(Please use any number from 1 to 10, where 1 is the MOST IMPORTANT reason.)
a. Find out more about my disease
1 Most
important
2
3
E
E
E

4
E

5
E

6
E

7
E

8
E

9
E

10 Least
important
E

b. Get the newest treatments
1 Most
important
2
E
E

4
E

5
E

6
E

7
E

8
E

9
E

10 Least
important
E

c. No other medical options available
1 Most
important
2
3
E
E
E

4
E

5
E

6
E

7
E

8
E

9
E

10 Least
important
E

d. Get health care at no cost
1 Most
important
2
E
E

4
E

5
E

6
E

7
E

8
E

9
E

10 Least
important
E

3
E

3
E

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51. When you decided to participate in the study you are on, what was the most important reason for participating?
(Please use any number from 1 to 10, where 1 is the MOST IMPORTANT reason.)
e. To benefit others
1 Most
10 Least
important
2
3
4
5
6
7
8
9
important
E
E
E
E
E
E
E
E
E
E
f. NIH reputation for providing quality clinical care
1 Most
important
2
3
4
E
E
E
E

5
E

6
E

7
E

8
E

9
E

10 Least
important
E

g. My physician encouraged me to come to NIH
1 Most
important
2
3
4
E
E
E
E

5
E

6
E

7
E

8
E

9
E

10 Least
important
E

h. To earn money
1 Most
important
2
E
E

4
E

5
E

6
E

7
E

8
E

9
E

10 Least
important
E

i. My friends participated in research at NIH
1 Most
important
2
3
4
E
E
E
E

5
E

6
E

7
E

8
E

9
E

10 Least
important
E

9
E

10 Least
important
E

j. Some other reason
1 Most
important
2
E
E

3
E

EXAMPLE
3
E

4
E

5
E

6
E

7
E

8
E

52. Besides participating in the research study at the NIH Clinical Center, what other treatment options do you have
available to you? (Mark all that apply.)
E No other options are available
E Another research study at the NIH Clinical Center
E Research studies at other medical centers
E Treatments or care I was receiving before I came to the NIH Clinical Center
PATIENT SAFETY...
53. How often did you need to explain to staff something about your condition or treatment that you thought they
should already know?
E Often
E Sometimes
E Never
54. Did you ever receive the wrong medicine or the wrong dosage of medicine?
E Yes, often
E Yes, sometimes
E No
E Did not receive any medicine during visit
55. Did a family member or someone close to you ever have to do something or say something to staff to assure that
your medical needs were attended to?
E Yes, often
E No
E Yes, sometimes
E Did not have family member or someone close to me present
56. Did staff ask your name and date of birth before giving you any medicines, treatments, or tests?
E Yes, always
E Yes, sometimes
E No

B

57. Did staff appear to be in too much of a hurry?
E Yes, often
E Yes, sometimes
E No

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58. When you used the call button, did nurses respond as quickly as you thought they should?
E Yes, always
E Yes, sometimes
E No
E Did not use call button
GOING HOME...
59. Did someone on the hospital staff explain the purpose of the medicines you were to take at home in a way you
could understand?
E Yes, completely
E No
E No medicines at home
E Yes, somewhat
E Did not need explanation
60. Did someone tell you about medication side effects to watch for when you went home?
E Yes, completely
E No
E No medicines at home
E Yes, somewhat
E Did not need explanation
61. Did they tell you what danger signals about your illness or operation to watch for after you went home?
E Yes, completely
E Yes, somewhat
E No
E Not applicable
62. Did they tell you when you could resume your usual activities, such as when to go back to work or drive a car?
E Yes, completely
E Yes, somewhat
E No
E Not applicable
63. Did the doctors and nurses give your family or someone close to you all the information they needed to help you
recover?
E Yes, definitely
E No
E Family did not want or need information
E Yes, somewhat
E No family or friends involved
OVERALL IMPRESSION...

EXAMPLE

64. How would you rate how well the doctors and nurses worked together?
E Poor
E Fair
E Good
E Very Good
E Excellent
65. Overall, how would you rate the care you received at the hospital?
E Poor
E Fair
E Good
E Very Good
E Excellent
66. Would you recommend this hospital to your friends and family?
E Yes, definitely
E Yes, probably
E No

67. Did the actual care and services you received exceed your expectations, meet your expectations, or fall below your
expectations?
E Exceeded my expectations
E Fell below my expectations
E Met my expectations
E I did not have any expectations

Please fill in the bubble that best describes your evaluation of each one of the following areas:

68. Food Services
a. Did you receive food services?
E Yes
E No (Go to #69)
b. Courtesy and helpfulness of staff who served your food
E Poor
E Fair
E Good
E Very Good

B

c. Variety of menu items
E Very Good
E Fair
E Good
E Poor

E Very Poor
E Don't Know

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E Excellent

E Does Not Apply

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68. Food Services
d. Accuracy of receiving the food items you ordered
E Poor
E Fair
E Good
E Very Good
e. Taste of the food
E Poor
E Fair

E Excellent

E Does Not Apply

E Good

E Very Good

E Excellent

E Does Not Apply

f. Temperature of the food
E Poor
E Fair
E Good

E Very Good

E Excellent

E Does Not Apply

g. Overall quality of food
E Poor
E Fair

E Good

E Very Good

E Excellent

E Does Not Apply

a. Cleanliness of your room
E Poor
E Fair
E Good

E Very Good

E Excellent

69. Housekeeping

b. Friendliness and courtesy shown to you by housekeeping staff
E Poor
E Fair
E Good
E Very Good
E Excellent
70. Transporters
a. Courtesy and helpfulness
E Poor
E Fair
E Good
71. Other Hospital Staff

E Very Good

E Excellent

E Does Not Apply

EXAMPLE

a. Courtesy of parking attendants
E Poor
E Fair
E Good

E Very Good

E Excellent

E Does Not Apply

b. Courtesy of people who took your x-rays
E Poor
E Fair
E Good
E Very Good

E Excellent

E Does Not Apply

c. Courtesy of people who took your blood samples
E Poor
E Fair
E Good
E Very Good

E Excellent

E Does Not Apply

72. Courtesy of security guards
E Poor
E Fair
E Good

E Very Good

E Excellent

E Does Not Apply

73. Courtesy of information desk
E Poor
E Fair
E Good

E Very Good

E Excellent

E Does Not Apply

74. Facilities
a. Cleanliness of the facility
E Poor
E Fair
E Good

E Very Good

E Excellent

75. Location and clarity of signs around the NIH Clinical Center
E Poor
E Fair
E Good
E Very Good
E Excellent
76. Ease of finding your way around the NIH Clinical Center
E Poor
E Fair
E Good
E Very Good
E Excellent

B

77. Comfort of waiting areas
E Poor
E Fair
E Good

E Very Good

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E Excellent

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78. Equipment and Facilities
79. Television
E Poor

E Fair

E Good

E Very Good

E Excellent

E Does Not Apply

80. Access to the internet
E Poor
E Fair

E Good

E Very Good

E Excellent

E Does Not Apply

81. Telephone
E Poor

E Good

E Very Good

E Excellent

E Does Not Apply

E Fair

82. In general, how would you rate your health?
E Poor
E Fair
E Good
E Very Good

E Excellent

83. How many times have you been hospitalized (either at the Clinical Center or in other hospitals) in the last six
months?
E Once
E More than once
84. What was the last year of school you completed?
E College graduate
E Less than high school graduate
E Post college graduate education
E High school graduate or GED
E Some college, trade, or tech school

EXAMPLE

85. What is your age now?
E 18 - 40 years
E 41 - 64 years
86. Are you...
E Female

E Male

E 65 - 74 years

E 75 years or over

87. If you could change one thing about the Clinical Center or if you have additional comments that you would like to share
please use the space below. If you need additional space please attach an additional sheet of paper.

THANK YOU FOR TAKING THE TIME TO COMPLETE THIS SURVEY.

B

Copyright 1995, The Picker Institute, Inc. All Rights Reserved.

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