National Implementation of Hospital Consumer Assessment of Health Providers and Systems (HCAHPS)

Supporting Statement for the National Implementation of the Hospital CAHPS Survey

Appendix A

HCAHPS Survey Instrument and Supporting Materials

HCAHPS Survey Instrument and Supporting Materials:

HCAHPS Mail Survey (English)

• Survey Instrument

• Sample Initial Cover Letter

• Sample Follow-up Cover Letter

• OMB Paperwork Reduction Act Language

HCAHPS Survey

SURVEY INSTRUCTIONS

• You should only fill out this survey if you were the patient during the hospital stay named in the cover letter. Do not fill out this survey if you were not the patient.

• Answer all the questions by checking the box to the left of your answer.

• You are sometimes told to skip over some questions in this survey. When this happens you will see an arrow with a note that tells you what question to answer next, like this:

 Yes

 No  If No, Go to Question 1

You may notice a number on the survey. This number is ONLY used to let us know if you returned your survey so we don't have to send you reminders.

Please note: Questions 1-22 in this survey are part of a national initiative to measure the quality of care in hospitals. OMB #0938-0981

Please answer the questions in this survey about your stay at the hospital named on the cover letter. Do not include any other hospital stays in your answers.

YOUR CARE FROM NURSES



1. During this hospital stay, how often did nurses treat you with courtesy and respect?

¹ Never

² Sometimes

³ Usually

⁴ Always

2. During this hospital stay, how often did nurses listen carefully to you?

¹ Never

² Sometimes

³ Usually

⁴ Always

3. During this hospital stay, how often did nurses explain things in a way you could understand?

¹ Never

² Sometimes

³ Usually

⁴ Always

4. During this hospital stay, after you pressed the call button, how often did you get help as soon as you wanted it?

¹ Never

² Sometimes

³ Usually

⁴ Always

⁹ I never pressed the call button

YOUR CARE FROM DOCTORS



5. During this hospital stay, how often did doctors treat you with courtesy and respect?

¹ Never

² Sometimes

³ Usually

⁴ Always

6. During this hospital stay, how often did doctors listen carefully to you?

¹ Never

² Sometimes

³ Usually

⁴ Always

7. During this hospital stay, how often did doctors explain things in a way you could understand?

¹ Never

² Sometimes

³ Usually

⁴ Always

THE HOSPITAL ENVIRONMENT



8. During this hospital stay, how often were your room and bathroom kept clean?

¹ Never

² Sometimes

³ Usually

⁴ Always

9. During this hospital stay, how often was the area around your room quiet at night?

¹ Never

² Sometimes

³ Usually

⁴ Always

YOUR EXPERIENCES IN THIS HOSPITAL



10. During this hospital stay, did you need help from nurses or other hospital staff in getting to the bathroom or in using a bedpan?

¹ Yes

² No  If No, Go to Question 12

11. How often did you get help in getting to the bathroom or in using a bedpan as soon as you wanted?

¹ Never

² Sometimes

³ Usually

⁴ Always

12. During this hospital stay, did you need medicine for pain?

¹ Yes

² No  If No, Go to Question 15

13. During this hospital stay, how often was your pain well controlled?

¹ Never

² Sometimes

³ Usually

⁴ Always

14. During this hospital stay, how often did the hospital staff do everything they could to help you with your pain?

¹ Never

² Sometimes

³ Usually

⁴ Always

15. During this hospital stay, were you given any medicine that you had not taken before?

¹ Yes

² No  If No, Go to Question 18

16. Before giving you any new medicine, how often did hospital staff tell you what the medicine was for?

¹ Never

² Sometimes

³ Usually

⁴ Always

17. Before giving you any new medicine, how often did hospital staff describe possible side effects in a way you could understand?

¹ Never

² Sometimes

³ Usually

⁴ Always

WHEN YOU LEFT THE HOSPITAL



18. After you left the hospital, did you go directly to your own home, to someone else’s home, or to another health facility?

¹ Own home

² Someone else’s home

³ Another health

facility  If Another, Go to Question 21

19. During this hospital stay, did doctors, nurses or other hospital staff talk with you about whether you would have the help you needed when you left the hospital?

¹ Yes

² No

20. During this hospital stay, did you get information in writing about what symptoms or health problems to look out for after you left the hospital?

¹ Yes

² No

OVERALL RATING OF HOSPITAL



Please answer the following questions about your stay at the hospital named on the cover letter. Do not include any other hospital stays in your answers.

21. Using any number from 0 to 10, where 0 is the worst hospital possible and 10 is the best hospital possible, what number would you use to rate this hospital during your stay?

⁰ 0 Worst hospital possible

¹ 1

² 2

³ 3

⁴ 4

⁵ 5

⁶ 6

⁷ 7

⁸ 8

⁹ 9

¹⁰10 Best hospital possible

22. Would you recommend this hospital to your friends and family?

¹ Definitely no

² Probably no

³ Probably yes

⁴ Definitely yes

ABOUT YOU

There are only a few remaining items left.

23. In general, how would you rate your overall health?

¹ Excellent

² Very good

³ Good

⁴ Fair

⁵ Poor

24. What is the highest grade or level of school that you have completed?

¹ 8th grade or less

² Some high school, but did not graduate

³ High school graduate or GED

⁴ Some college or 2-year degree

⁵ 4-year college graduate

⁶ More than 4-year college degree

25. Are you of Spanish, Hispanic or

Latino origin or descent?

¹ No, not Spanish/Hispanic/Latino

² Yes, Puerto Rican

³ Yes, Mexican, Mexican American, Chicano

⁴ Yes, Cuban

⁵ Yes, other Spanish/Hispanic/Latino

26. What is your race? Please choose one or more.

¹ White

² Black or African American

³ Asian

⁴ Native Hawaiian or other Pacific Islander

⁵ American Indian or Alaska Native

27. What language do you mainly speak at home?

¹ English

² Spanish

³ Some other language (please print): _____________________

THANK YOU

Please return the completed survey in the postage-paid envelope.

[NAME OF SURVEY VENDOR OR SELF-ADMINISTERING HOSPITAL]

[RETURN ADDRESS OF SURVEY VENDOR OR SELF-ADMINISTERING HOSPITAL]

Sample Initial Cover Letter for the HCAHPS Survey

[HOSPITAL LETTERHEAD]

[SAMPLED PATIENT NAME]

[ADDRESS]

[CITY, STATE ZIP]

Dear [SAMPLED PATIENT NAME]:

Our records show that you were recently a patient at [NAME OF HOSPITAL] and discharged on [DISCHARGE DATE]. Because you had a recent hospital stay, we are asking for your help. This survey is part of an ongoing national effort to understand how patients view their hospital experience. Hospital results will be publicly reported and made available on the Internet at www.hospitalcompare.hhs.gov. These results will help consumers make important choices about their hospital care, and will help hospitals improve the care they provide.

Questions 1-22 in the enclosed survey are part of a national initiative sponsored by the United States Department of Health and Human Services to measure the quality of care in hospitals. Your participation is voluntary and will not affect your health benefits.

We hope that you will take the time to complete the survey. Your participation is greatly appreciated. After you have completed the survey, please return it in the pre-paid envelope. Your answers may be shared with the hospital for purposes of quality improvement. [OPTIONAL: You may notice a number on the survey. This number is ONLY used to let us know if you returned your survey so we don’t have to send you reminders.]

If you have any questions about the HCAHPS Survey, please call the toll-free number 1-800-xxx-xxxx. Thank you for helping to improve health care for all consumers.

Sincerely,

[HOSPITAL ADMINISTRATOR]

[HOSPITAL NAME]

Note: The OMB Paperwork Reduction Act language must be included in the mailing. This language can be either in the cover letter or on the front or back of the questionnaire. The exact OMB Paperwork Reduction Act language is included in this appendix. Please refer to the Mail Only, and Mixed Mode sections, for specific letter guidelines.

Sample Follow-up Cover Letter for the HCAHPS Survey

[HOSPITAL LETTERHEAD]

[SAMPLED PATIENT NAME]

[ADDRESS]

[CITY, STATE ZIP]

Dear [SAMPLED PATIENT NAME]:

Our records show that you were recently a patient at [NAME OF HOSPITAL] and discharged on [DATE OF DISCHARGE]. Approximately three weeks ago we sent you a survey regarding your hospitalization. If you have already returned the survey to us, please accept our thanks and disregard this letter. However, if you have not yet completed the survey, please take a few minutes and complete it now.

Because you had a recent hospital stay, we are asking for your help. This survey is part of an ongoing national effort to understand how patients view their hospital experience. Hospital results will be publicly reported and made available on the Internet at www.hospitalcompare.hhs.gov. These results will help consumers make important choices about their hospital care, and will help hospitals improve the care they provide.

Questions 1-22 in the enclosed survey are part of a national initiative sponsored by the United States Department of Health and Human Services to measure the quality of care in hospitals. Your participation is voluntary and will not affect your health benefits. Please take a few minutes and complete the enclosed survey. After you have completed the survey, please return it in the pre-paid envelope. Your answers may be shared with the hospital for purposes of quality improvement. [OPTIONAL: You may notice a number on the survey. This number is ONLY used to let us know if you returned your survey so we don’t have to send you reminders.]

If you have any questions about the HCAHPS Survey, please call the toll-free number 1-800-xxx-xxxx. Thank you again for helping to improve health care for all consumers.

Sincerely,

[HOSPITAL ADMINISTRATOR]

[HOSPITAL NAME]

Note: The OMB Paperwork Reduction Act language must be included in the mailing. This language can be either in the cover letter or on the front or back of the questionnaire. The exact OMB Paperwork Reduction Act language is included in this appendix. Please refer to the Mail Only, and Mixed Mode sections, for specific letter guidelines.

OMB Paperwork Reduction Act Language

The OMB Paperwork Reduction Act language must be included in the survey mailing. This language can be either in the cover letter or on the front or back of the questionnaire. The following is the language that must be used:

English Version

“According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-0981. The time required to complete this information collected is estimated to average 7 minutes per response for questions 1-22 on the survey, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: Centers for Medicare & Medicaid Services, 7500 Security Boulevard, C1-25-05, Baltimore, MD 21244-1850.”

HCAHPS Survey Instrument and Supporting Materials:

HCAHPS Mail Survey (Spanish)

• Survey Instrument

• Sample Initial Cover Letter

• Sample Follow-up Cover Letter

• OMB Paperwork Reduction Act Language

Encuesta CAHPS^® Sobre Atención Hospitalaria

INSTRUCCIONES

• Llene esta encuesta únicamente si usted es el paciente que estuvo hospitalizado durante la estancia que se menciona en la carta que vino con la encuesta. No llene esta encuesta si usted no fue el paciente.

• Conteste todas las preguntas marcando el cuadrito que aparece a la izquierda de la respuesta que usted elija.

• A veces hay que saltarse alguna pregunta del cuestionario Cuando esto ocurra, verá una flecha con una nota que le indicará la siguiente pregunta a la que tiene que pasar. Por ejemplo:

 Sí

 No  Si contestó “No”, pase a la pregunta 1

El número en la carta de presentación de esta encuesta SOLO sirve para saber que ya envió su respuesta y que no hay que enviarle recordatorios.

Por favor tenga en cuenta que las Preguntas 1-22 de esta encuesta forman parte de una iniciativa nacional para evaluar la calidad de la atención en los hospitales. OMB #0938-0981

Las siguientes preguntas se refieren sólo a la vez que estuvo en el hospital cuyo nombre aparece en la carta de presentación de esta encuesta. No incluya información sobre otras veces que estuvo en un hospital.

EL CUIDADO QUE RECIBIÓ DE LAS ENFERMERAS

1. Durante esta vez que estuvo en el hospital, ¿con qué frecuencia le trataban las enfermeras con cortesía y respeto?

¹ Nunca

² A veces

³ La mayoría de las veces

⁴ Siempre

2. Durante esta vez que estuvo en el hospital, ¿con qué frecuencia le escuchaban con atención las enfermeras?

¹ Nunca

² A veces

³ La mayoría de las veces

⁴ Siempre

3. Durante esta vez que estuvo en el hospital, ¿con qué frecuencia le explicaban las cosas las enfermeras en una forma que usted pudiera entender?

¹ Nunca

² A veces

³ La mayoría de las veces

⁴ Siempre

4. Durante esta vez que estuvo en el hospital, después de usar el botón para llamar a la enfermera, ¿con qué frecuencia le atendían tan pronto como usted quería?

¹ Nunca

² A veces

³ La mayoría de las veces

⁴ Siempre

⁹ Nunca usé el botón

EL CUIDADO QUE RECIBIÓ DE LOS DOCTORES

5. Durante esta vez que estuvo en el hospital, ¿con qué frecuencia le trataban los doctores con cortesía y respeto?

¹ Nunca

² A veces

³ La mayoría de las veces

⁴ Siempre

6. Durante esta vez que estuvo en el hospital, ¿con qué frecuencia le escuchaban con atención los doctores?

¹ Nunca

² A veces

³ La mayoría de las veces

⁴ Siempre

7. Durante esta vez que estuvo en el hospital, ¿con qué frecuencia le explicaban las cosas los doctores en una forma que usted pudiera entender?

¹ Nunca

² A veces

³ La mayoría de las veces

⁴ Siempre

EL AMBIENTE EN EL HOSPITAL

8. Durante esta vez que estuvo en el hospital, ¿con qué frecuencia mantenían su cuarto y su baño limpios?

¹ Nunca

² A veces

³ La mayoría de las veces

⁴ Siempre

9. Durante esta vez que estuvo en el hospital, ¿con qué frecuencia estaba silenciosa el área alrededor de su habitación por la noche?

¹ Nunca

² A veces

³ La mayoría de las veces

⁴ Siempre

SU EXPERIENCIA EN ESTE HOSPITAL

10. Durante esta vez que estuvo en el hospital, ¿necesitó que las enfermeras u otro personal del hospital le ayudaran a llegar al baño o a usar un orinal (bedpan)?

¹ Sí

² No  Si contestó “No”, pase a la pregunta 12

11. ¿ Con qué frecuencia, le ayudaron a llegar al baño o a usar un orinal (bedpan) tan pronto como quería?

¹ Nunca

² A veces

³ La mayoría de las veces

⁴ Siempre

12. Durante esta vez que estuvo en el hospital, ¿necesitó medicamentos para el dolor?

¹ Sí

² No  Si contestó “No”, pase a la pregunta 15

13. Durante esta vez que estuvo en el hospital, ¿con qué frecuencia le controlaban bien el dolor?

¹ Nunca

² A veces

³ La mayoría de las veces

⁴ Siempre

14. Durante esta vez que estuvo en el hospital, ¿con qué frecuencia hacía el personal del hospital todo lo que podía para aliviar su dolor?

¹ Nunca

² A veces

³ La mayoría de las veces

⁴ Siempre

15. Durante esta vez que estuvo en el hospital, ¿le dieron algún medicamento que no hubiera tomado antes?

¹ Sí

² No  Si contestó “No”, pase a la pregunta 18

16. Antes de darle algún medicamento nuevo, ¿con qué frecuencia le dijo el personal del hospital para qué era el medicamento?

¹ Nunca

² A veces

³ La mayoría de las veces

⁴ Siempre

17. Antes de darle algún medicamento nuevo, ¿con qué frecuencia le describió el personal del hospital los efectos secundarios posibles en una forma que pudiera entender?

¹ Nunca

² A veces

³ La mayoría de las veces

⁴ Siempre

CUANDO SALIÓ DEL HOSPITAL

18. Después de salir del hospital, ¿se fue directamente a su propia casa, a la casa de otra persona, o a otra institución de salud?

¹ A mi casa

² A la casa de otra persona

³ A otra institución de salud  Si contestó “Otra”, pase a la pregunta 21

19. Durante esta vez que estuvo en el hospital, ¿hablaron los doctores, enfermeras u otro personal del hospital con usted sobre si tendría la ayuda que necesitaba cuando se fuera del hospital?

¹ Sí

² No

20. Durante esta vez que estuvo en el hospital, ¿le dieron información por escrito sobre los síntomas o problemas de salud a los que debía poner atención cuando se fuera del hospital?

¹ Sí

² No

CALIFICACIÓN GENERAL DEL HOSPITAL

Por favor conteste las siguientes preguntas sobre la vez que estuvo en el hospital cuyo nombre aparece en la carta de presentación de esta encuesta. No incluya información sobre otras veces que estuvo en un hospital.

21. Usando un número del 0 al 10 el 0 siendo el peor hospital posible y el 10 el mejor hospital posible, ¿qué número usaría para calificar este hospital durante esta vez que estuvo en el hospital?

⁰ 0 El peor hospital posible

¹ 1

² 2

³ 3

⁴ 4

⁵ 5

⁶ 6

⁷ 7

⁸ 8

⁹ 9

¹⁰ 10 El mejor hospital posible

22. ¿Le recomendaría este hospital a

sus amigos y familiares?

¹ Definitivamente no

² Probablemente no

³ Probablemente sí

⁴ Definitivamente sí

ACERCA DE USTED

Sólo quedan unas cuantas preguntas.

23. En general, ¿cómo calificaría toda su salud?

¹ Excelente

² Muy buena

³ Buena

⁴ Regular

⁵ Mala

7

24. ¿Cuál es el grado o nivel escolar más alto que ha completado?

¹ 8 años de escuela o menos

² 9-12 años de escuela, pero sin graduarse

³ Graduado de la escuela secundaria (high school), Diploma de escuela secundaria, preparatoria, o su equivalente (o GED)

⁴ Algunos cursos universitarios o un título universitario de un programa de 2 años

⁵ Título universitario de 4 años

⁶ Título universitario de más de

4 años

25. ¿Es usted de origen o ascendencia hispana o latina?

¹ No, ni hispano ni latino

² Sí, Puertorriqueño

³ Sí, Mexicano, Mexicano- Americano, Chicano

⁴ Sí, Cubano

⁵ Sí, otro hispano/latino

26. ¿A qué raza pertenece? Por favor marque una o más.

¹ Blanca

² Negra o Afro Americana

³ Asiática

⁴ Nativa de Hawai o de otras Islas del Pacífico

⁵ Indígena Americana o Nativa

de Alaska

27. ¿Principalmente qué idioma habla en casa?

¹ Inglés

² Español

³ Algún otro idioma (Escriba su

respuesta usando letra de molde):

¡GRACIAS!

Por favor devuelva el cuestionario cuando lo haya completado en el sobre con el porte o franqueo pagado.

[NAME OF SURVEY VENDOR OR SELF-ADMINISTERING HOSPITAL]

[RETURN ADDRESS OF SURVEY VENDOR OR SELF-ADMINISTERING HOSPITAL]

Sample Initial Cover Letter for the HCAHPS Survey

[HOSPITAL LETTERHEAD]

[SAMPLED PATIENT NAME]

[ADDRESS]

[CITY, STATE ZIP]

Querido/Querida [SAMPLED PATIENT NAME]:

Nuestros registros indican que usted estuvo hospitalizado en [NAME OF HOSPITAL] y que le dieron de alta el [DATE OF DISCHARGE]. Como usted estuvo hospitalizado recientemente, queremos pedir su ayuda. La encuesta forma parte de un esfuerzo nacional continuo por entender el punto de vista de los pacientes respecto a su experiencia en el hospital. Los resultados se harán públicos y estarán disponibles por Internet, en www.hospitalcompare.hhs.gov. Estos resultados les servirán a los consumidores para tomar decisiones importantes sobre el cuidado que reciben en un hospital y les ayudarán a los hospitales a mejorar la atención que proveen.

Las preguntas 1 a 22 de la encuesta adjunta forman parte de una iniciativa nacional patrocinada por el Departamento de Salud y Servicios Sociales de los Estados Unidos con el fin de medir la calidad de la atención que se presta en hospitales. Su participación es voluntaria y no afectará sus prestaciones de salud.

Esperamos que dedique tiempo a contestar la encuesta. Le agradecemos mucho su participación. Después de que la haya contestado, devuélvala en el sobre con porte prepagado. Es posible que sus respuestas se envíen al hospital a fin de que éste emprenda tareas de mejoramiento de la calidad. [OPTIONAL: El número en la carta de presentación de esta encuesta SOLO sirve para saber que ya envió su respuesta y que no hay que enviarle recordatorios.]

Si tiene alguna pregunta, llame gratis al 1-800-xxx-xxxx. Le agradecemos por contribuir a mejorar la atención médica de todos los consumidores.

Atentamente,

[HOSPITAL ADMINISTRATOR]

[HOSPITAL NAME]

Note: The OMB Paperwork Reduction Act language must be included in the mailing. This language can be either in the cover letter or on the front or back of the questionnaire. The exact OMB Paperwork Reduction Act language is included in this appendix. Please refer to the Mail Only, and Mixed Mode sections, for specific letter guidelines.

Sample Follow-up Cover Letter for the HCAHPS Survey

[HOSPITAL LETTERHEAD]

[SAMPLED PATIENT NAME]

[ADDRESS]

[CITY, STATE ZIP]

Querido/Querida [SAMPLED PATIENT NAME]:

Nuestros registros indican que usted estuvo hospitalizado en [NAME OF HOSPITAL] y que le dieron de alta el [DATE OF DISCHARGE]. Hace aproximadamente tres semanas le enviamos una encuesta sobre su hospitalización. Si ya nos la envió, se lo agradecemos mucho y no tiene que hacer caso de esta carta. Sin embargo, si todavía no ha contestado la encuesta, por favor dedique unos minutos a hacerlo ahora.

Como usted estuvo hospitalizado recientemente, le estamos pidiendo su ayuda. La encuesta forma parte de un esfuerzo nacional continuo por entender el punto de vista de los pacientes respecto a su experiencia en el hospital. Los resultados se harán públicos y estarán disponibles por Internet, en www.hospitalcompare.hhs.gov. Estos resultados les servirán a los consumidores para tomar decisiones importantes sobre el cuidado que reciben en un hospital y les ayudarán a los hospitales a mejorar la atención que proveen.

Las preguntas 1 a 22 de la encuesta adjunta forman parte de una iniciativa nacional patrocinada por el Departamento de Salud y Servicios Sociales de los Estados Unidos con el fin de medir la calidad de la atención que se presta en hospitales. Su participación es voluntaria y no afectará sus prestaciones de salud. Por favor dedique unos minutos a contestar la encuesta adjunta. Después de que la haya contestado, devuélvala en el sobre con porte prepagado. Es posible que sus respuestas se envíen al hospital a fin de que éste emprenda tareas de mejoramiento de la calidad. [OPTIONAL: El número en la carta de presentación de esta encuesta SOLO sirve para saber que ya envió su respuesta y que no hay que enviarle recordatorios.]

Si tiene preguntas, llame gratis al 1-800-xxx-xxxx. Le agradecemos nuevamente por contribuir a mejorar la atención médica de todos los consumidores.

Atentamente,

[HOSPITAL ADMINISTRATOR]

[HOSPITAL NAME]

Note: The OMB Paperwork Reduction Act language must be included in the mailing. This language can be either in the cover letter or on the front or back of the questionnaire. The exact OMB Paperwork Reduction Act language is included in this appendix. Please refer to the Mail Only, and Mixed Mode sections, for specific letter guidelines.

OMB Paperwork Reduction Act Language

The OMB Paperwork Reduction Act language must be included in the survey mailing. This language can be either in the cover letter or on the front or back of the questionnaire. The following is the language that must be used:

Spanish Version

“Según la Ley de Reducción de Trámites (Paperwork Reduction Act) de 1995, no se exige que una persona responda a la recopilación de información a menos que la solicitud de recopilación tenga un número válido de control de la OMB (Office of Management and Budget). El número válido de control de la OMB para esta recopilación de información es el 0938-0981. Se calcula que el tiempo que se necesita para llenar esta recopilación de información es, en promedio, de 7 minutos por respuesta para las preguntas 1 a 22 de la encuesta. En este cálculo se incluye el tiempo que la persona tarda en leer las instrucciones, buscar en los recursos existentes de datos, reunir los datos necesarios y llenar y repasar la recopilación de información. Si usted tiene comentarios relacionados con la exactitud del cálculo de tiempo o si tiene sugerencias para mejorar este formulario, escriba a: Centers for Medicare & Medicaid Services, 7500 Security Boulevard, C1-25-05, Baltimore, MD 21244-1850.”

HCAHPS Survey Instrument and Supporting Materials:

HCAHPS Mail Survey (Chinese)

• Survey Instrument

• Sample Initial Cover Letter

• Sample Follow-up Cover Letter

• OMB Paperwork Reduction Act Language

HCAHPS意見調查

問卷指示

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• 請回答所有的問題。作答時，請在問題左邊的方格內打勾。

• 有時問卷會要求您跳過一些問題。這種情況發生時，您會看到箭頭並註明下一個該回答的問題，如：

 是

 否  如回答否，請跳到#1

您 也許注意到了此問卷上的號碼。 此號碼只是讓我們知道您是否已回覆了問卷，而我們就不必再寄信提醒您。

請注意：問卷中1-22題是屬於測量醫院照顧品質的全國性計劃的一部份。OMB #0938-0981

請針對印在信函上所列的醫院回答下列問題。不要牽涉其他您住過的醫院。

護士對您的護理



1. 此次住院期間，護士是否常以禮貌和尊重對待您?

¹ 從未如此

² 有時如此

³ 時常如此

⁴ 總是如此

2. 此次住院期間，護士是否常細心聆聽您說話?

¹ 從未如此

² 有時如此

³ 時常如此

⁴ 總是如此

3. 此次住院期間，護士是否常用您聽得懂 的方式來向您解釋事務?

¹ 從未如此

² 有時如此

³ 時常如此

⁴ 總是如此

4. 此次住院期間，在您按過求助鈴之後，是否常能得到所需要的及時協助?

¹ 從未如此

² 有時如此

³ 時常如此

⁴ 總是如此

⁹ 我從未按過求助鈴

醫生對您的醫護

5. 此次住院期間，醫生是否常以禮貌和尊重對待您?

¹ 從未如此

² 有時如此

³ 時常如此

⁴ 總是如此

6. 此次住院期間，醫生是否常細心聆聽您說話?

¹ 從未如此

² 有時如此

³ 時常如此

⁴ 總是如此

7. 此次住院期間，醫生是否常用您聽得懂的方式來向您解釋事務?

¹ 從未如此

² 有時如此

³ 時常如此

⁴ 總是如此

醫院的環境

8. 此次住院期間，您的病房及衛浴設備是否經常保持乾淨清潔?

¹ 從未如此

² 有時如此

³ 時常如此

⁴ 總是如此

9. 此次住院期間，您的病房周圍是否晚上經常很安靜?

¹ 從未如此

² 有時如此

³ 時常如此

⁴ 總是如此

您住這醫院的經驗

10. 此次住院期間，您曾需要醫生，護士或其他醫院員工來協助您使用廁所或床上尿便盆嗎?

¹ 是

² 否 ( 如回答否，請跳到#12

11. 在您需要使用廁所或床上尿便盆時，
您是否常能及時得到協助?

¹ 從未如此

² 有時如此

³ 時常如此

⁴ 總是如此

12. 此次住院期間，您曾需要使用止痛
藥嗎?

¹ 是

² 否 ( 如回答否，請跳到#15

13. 此次住院期間，您的痛楚是否經常得到控制?

¹ 從未如此

² 有時如此

³ 時常如此

⁴ 總是如此

14. 此次住院期間，醫院員工是否經常盡量做到他們所能的來協助您止痛?

¹ 從未如此

² 有時如此

³ 時常如此

⁴ 總是如此

15. 此次住院期間，是否有人給您以前從沒有使用過的藥物?

¹ 是

² 否 ( 如回答否，請跳到#18

16. 在提供您新藥之前，醫院員工是否告訴您新藥的功能為何?

¹ 從未如此

² 有時如此

³ 時常如此

⁴ 總是如此

17. 在給您新藥之前，醫院員工是否用您能了解的方式來解釋有關藥物可能產生的副作用?

¹ 從未如此

² 有時如此

³ 時常如此

⁴ 總是如此

您離開醫院以後

18. 您離開醫院以後是否直接回家，還是到別人的家裏或是進入另一個醫護機構?

¹ 自己的家

² 別人的家

³ 另一個醫護機構 ( 如回答另一個醫護機構，請跳到 #21

19. 住院時，您的醫生、護士或其他員工有沒有與您談論出院後是否會獲得所需要的協助?

¹ 是

² 否

20. 此次住院期間，您是否得到書面資料來解釋有關您離開醫院以後應如何觀察病狀或健康的問題?

¹ 是

² 否

醫院整體評分

請針對印在信函上所列的醫院回答下列問題。不要牽涉其他您住過的醫院。

21. 請用下列0到10中任何一個數字評價。0 是最差醫院，10 是最佳醫院。 您認為那一個數字最能代表您對此醫院的
評價?

⁰ 0 最差醫院

¹ 1

² 2

³ 3

⁴ 4

⁵ 5

⁶ 6

⁷ 7

⁸ 8

⁹ 9

¹⁰ 10 最佳醫院

22. 您是否會向您的朋友和家人推薦這間
醫院?

¹ 絕不會

² 也許不會

³ 可能會

⁴ 絕對會

有關您個人

下面只剩下幾個問題。

23. 概括而言，您對個人整體的健康作如何評價?

¹ 特佳

² 甚好

³ 好

⁴ 可以

⁵ 差

24. 您完成了下列那一項最高學業或學位?

¹ 八年級或以下

² 一些高中﹐但沒有畢業

³ 高中畢業或有同等學業文憑

⁴ 一些大學或二年制學位

⁵ 四年大學畢業

⁶ 四年大學畢業以上

25. 您是西班牙裔、西語族裔、或拉丁
裔嗎?

¹ 否，非西班牙人、西裔、拉丁裔

² 是，波多黎各裔

³ 是，墨裔、墨裔美人、美國出生的墨裔美人

⁴ 是，古巴人

⁵ 是，其他西班牙人、西裔、拉丁裔

26. 您屬於哪一種族？請選一個或一個以上的回答。

¹ 白種人

² 黑種人﹐非裔美人

³ 亞洲人

⁴ 夏威夷原住民或其他太平洋島民

⁵ 美洲印第安人或阿拉斯加原住民

27. 您在家說的主要語言是什麼?

¹ 英語

² 西班牙語

³ 一些其他語言 （請註明）:

謝謝您

請將填妥的問卷放入已付郵資的信封內寄回。

[NAME OF SURVEY VENDOR OR SELF-ADMINISTERING HOSPITAL]

[RETURN ADDRESS OF SURVEY VENDOR OR SELF-ADMINISTERING HOSPITAL]

Sample Initial Cover Letter for the HCAHPS Survey

[HOSPITAL LETTERHEAD]

[NAME]

[ADDRESSS]

[CITY, STATE, ZIP]

親愛的 [SAMPLED PATIENT NAME]:

我們的資料顯示您最近是[NAME OF HOSPITAL]的病人，在[DATE OF DISCHARGE]出院。因為您最近住過院，所以我們懇請您幫個忙。這份意見調查屬於全國性計劃的一部份，該計劃針對與消費者相關的重大議題 ─ 醫院照顧方面提供具體的比較。醫院評估結果會向大眾公佈並在網站www.hospitalcompare.hhs.gov上供查詢。這些結果能幫助消費者在醫院照顧方面做重要的抉擇，同時也能幫助醫院改善所提供的照顧。

附上的意見調查1-22題是測量醫院照顧品質的全國性計劃的一部份，此計劃由United States Department of Health and Human Services贊助。您的參與屬自願性質，不會影響您的醫療福利。

我們希望您能撥冗完成這份調查。非常謝謝您的參與。當您填完這份問卷後，請放入已付郵資的回郵信封寄回。您的回答可能會被醫院不同單位共用以便改進品質。

[ OPTIONAL: 您也許注意到了此問卷上的號碼。 此號碼只是讓我們知道您是否已回覆了問卷，而我們就不必再寄信提醒您。]

如果您有任何問題，請撥打免費電話1-800-xxx-xxxx。謝謝您幫助我們改善對大眾的健康照顧。

謹此

HOSPITAL ADMINISTRATOR

HOSPITAL NAME

Note: The OMB Paperwork Reduction Act language must be included in the mailing. This language can be either in the cover letter or on the front or back of the questionnaire. Refer to Appendix J for the exact OMB Paperwork Reduction Act language and Section VII—Mail Only, and Section IX—Mixed Mode, for specific letter guidelines.

Sample Follow-Up Cover Letter for the HCAHPS Survey

[HOSPITAL LETTERHEAD]

[NAME]

[ADDRESS]

[CITY, STATE, ZIP]

親愛的 [SAMPLED PATIENT NAME]:

我們的資料顯示您最近是[NAME OF HOSPITAL]的病人，在[DATE OF DISCHARGE]出院。大約三個星期前我們寄給您一份有關您住院的調查。如果您已經寄還給我們，請接受我們的謝意，並請不要繼續讀這封信。但是如果您尚未完成這份調查的話，請現在花幾分鐘時間填寫。

因為您最近住過院，所以我們懇請您幫個忙。這份意見調查屬於全國性計劃的一部份，該計劃針對與消費者相關的重大議題 ─ 醫院照顧方面提供具體的比較。醫院評估結果會向大眾公佈並在網站www.hospitalcompare.hhs.gov上供查詢。這些結果能幫助消費者在醫院照顧方面做重要的抉擇，同時也能幫助醫院改善所提供的照顧。

附上的意見調查1-22題是測量醫院照顧品質的全國性計劃的一部份，此計劃由United States Department of Health and Human Services贊助。您的參與屬自願性質，不會影響您的醫療福利。請花幾分鐘填完附上的調查。當您填完這份問卷後，請放入已付郵資的回郵信封寄回。您的回答可能會被醫院不同單位共用以便改進品質。

[OPTIONAL: 您也許注意到了此問卷上的號碼。 此號碼只是讓我們知道您是否已回覆了問卷，而我們就不必再寄信提醒您。]

如果您有任何問題，請撥打免費電話1-800-xxx-xxxx。謝謝您幫助我們改善對大眾的健康照顧。

謹此

HOSPITAL ADMINISTRATOR

HOSPITAL NAME

Note: The OMB Paperwork Reduction Act language must be included in the mailing. This language can be either in the cover letter or on the front or back of the questionnaire. Refer to Appendix J for the exact OMB Paperwork Reduction Act language and Section VII—Mail Only, and Section IX—Mixed Mode, for specific letter guidelines.

OMB 減低公文法案

Overview

The OMB Paperwork Reduction Act language must be included in the survey mailing. This language can be either in the cover letter or on the front or back of the questionnaire. The following is the language that should be used:

Chinese Version

根據1995年減低公文法案(Paperwork Reduction Act)，除非資料收集文件附有正式的OMB號碼，任何人都無須對此類文件作出回應。這份資料收集文件的正式OMB號碼是0938-0981。完成這份資料收集中1-22題的每個問題所需的時間估計是平均7分鐘，這包括閱讀指示的時間、查詢現有數據來源、收集所需資料及完成並檢查填寫的資料。如果您對估計時間的準確性有任何指教或有改進本表格的建議，請寫信到：Centers for Medicare & Medicaid Services, 7500 Security Boulevard, C1-25-05, Baltimore, MD 21244-1850。　

HCAHPS Survey Instrument and Supporting Materials:

HCAHPS Mail Survey (Russian)

• Survey Instrument

• Sample Initial Cover Letter

• Sample Follow-up Cover Letter

• OMB Paperwork Reduction Act Language

Опрос с целью оценки удовлетворенности клиентов планами медицинского обслуживания (HCAHPS)

ИНСТРУКЦИИ ПО ПРОВЕДЕНИЮ ОПРОСА

• Вам следует заполнить эту анкету только в том случае, если вы были пациентом больницы, указанной в сопроводительном письме. Не заполняйте эту анкету, если вы не являлись пациентом этой больницы.

• Ответьте на все вопросы, отметив ячейку слева от вашего ответа.

• Иногда вам будет предложено пропустить некоторые вопросы данной анкеты. При этом вы увидите стрелку с примечанием о том, на какой вопрос вам следует отвечать дальше, например:

 Да

 Нет  Если «Нет», перейдите к вопросу 1

На этой анкете вы можете увидеть номер. Этот номер используется ТОЛЬКО, чтобы сообщить нам о том, что вы вернули свою анкету и нам не нужно посылать вам напоминания.

Внимание: Вопросы 1-22 в данном опросе являются частью национальной инициативы с целью оценки качества медицинского обслуживания в больницах. OMB #0938-0981

Пожалуйста, ответьте на вопросы этой анкеты о данном пребывании в больнице, указанной в сопроводительном письме. Не включайте в свои ответы информацию о каких-либо других пребываниях в больнице.

МЕДИЦИНСКОЕ ОБСЛУЖИВАНИЕ, ПРЕДОСТАВЛЯЕМОЕ ВАМ МЕДСЕСТРАМИ



1. Во время данного пребывания в больнице как часто медсестры относились к вам вежливо и уважительно?

¹ Никогда

² Иногда

³ Как правило

⁴ Всегда

2. Во время данного пребывания в больнице как часто медсестры внимательно вас выслушивали?

¹ Никогда

² Иногда

³ Как правило

⁴ Всегда

3. Во время данного пребывания в больнице как часто медсестры давали вам понятные объяснения?

¹ Никогда

² Иногда

³ Как правило

⁴ Всегда

4. Во время данного пребывания в больнице, после того как вы нажали кнопку вызова, как часто вам предоставляли помощь по первому требованию?

¹ Никогда

² Иногда

³ Как правило

⁴ Всегда

⁹ Я никогда не нажимал (а) кнопку вызова

МЕДИЦИНСКОЕ ОБСЛУЖИВАНИЕ, ПРЕДОСТАВЛЯЕМОЕ ВАМ ВРАЧАМИ



5. Во время данного пребывания в больнице как часто врачи относились к вам вежливо и уважительно?

¹ Никогда

² Иногда

³ Как правило

⁴ Всегда

6. Во время данного пребывания в больнице как часто врачи внимательно вас выслушивали?

¹ Никогда

² Иногда

³ Как правило

⁴ Всегда

7. Во время данного пребывания в больнице как часто врачи давали вам понятные объяснения?

¹ Никогда

² Иногда

³ Как правило

⁴ Всегда

БОЛЬНИЧНАЯ СРЕДА



8. Во время данного пребывания в больнице как часто в вашей комнате и туалете проводили уборку?

¹ Никогда

² Иногда

³ Как правило

⁴ Всегда

9. Во время данного пребывания в больнице как часто возле вашей комнаты соблюдалась тишина в ночное время?

¹ Никогда

² Иногда

³ Как правило

⁴ Всегда

ОПЫТ ВАШЕГО ПРЕБЫВАНИЯ В ДАННОЙ БОЛЬНИЦЕ



10. Во время данного пребывания в больнице требовалась ли вам помощь медсестер или другого персонала больницы для сопровождения вас в туалет или при использовании подкладного судна?

¹ Да

² Нет  Если «Нет», перейдите к вопросу 12

11. Как часто вы получали помощь для сопровождения вас в туалет или при использовании подкладного судна по первому требованию?

¹ Никогда

² Иногда

³ Как правило

⁴ Всегда

12. Во время данного пребывания в

больнице требовались ли вам

болеутоляющие лекарства?

¹ Да

² Нет  Если «Нет», перейдите к вопросу 15

13. Во время данного пребывания в больнице как часто вашу боль хорошо контролировали?

¹ Никогда

² Иногда

³ Как правило

⁴ Всегда

14. Во время данного пребывания в больнице как часто персонал больницы делал все возможное, чтобы помочь вам снять боль?

¹ Никогда

² Иногда

³ Как правило

⁴ Всегда

15. Во время данного пребывания в больнице давали ли вам какие-либо лекарства, которые вы не принимали до этого?

¹ Да

² Нет  Если «Нет»,

перейдите к вопросу

18

16. Прежде чем дать вам новое лекарство, как часто персонал больницы объяснял вам, для чего оно?

¹ Никогда

² Иногда

³ Как правило

⁴ Всегда

17. Прежде чем дать вам новое лекарство, как часто персонал больницы описывал возможные побочные действия понятным вам способом?

¹ Никогда

² Иногда

³ Как правило

⁴ Всегда

КОГДА ВЫ ВЫШЛИ ИЗ БОЛЬНИЦЫ



18. После того как вы вышли из больницы, вы сразу направились домой, к кому-либо еще или в другое медицинское учреждение?

¹ Домой

² К кому-либо еще

³ В другое медицинское
учреждение  Если «В другое», перейдите к вопросу 21

19. Во время данного пребывания в больнице разговаривали ли с вами врачи, медсестры или другие сотрудники больницы о том, что вам может потребоваться помощь, когда вы выйдете из больницы?

¹ Да

² Нет

20. Во время данного пребывания в больнице получали ли вы информацию в письменной форме о симптомах и возможных проблемах со здоровьем, на которые вам следует обратить внимание после выписки из больницы?

¹ Да

² Нет

ОБЩИЙ РЕЙТИНГ БОЛЬНИЦЫ



Пожалуйста, ответьте на следующие вопросы опроса о данном пребывании в больнице, указанной в сопроводительном письме . Не включайте в свои ответы информацию о каких-либо других пребываниях в больницах.

21. Используя цифры от 0 до 10, где 0 обозначает самую худшую больницу, а 10 – самую лучшую больницу, какую цифру вы бы поставили для оценки данной больницы во время вашего пребывания в ней?

⁰ 0 Самая худшая больница из возможных

¹ 1

² 2

³ 3

⁴ 4

⁵ 5

⁶ 6

⁷ 7

⁸ 8

⁹ 9

¹⁰10 Самая лучшая больница из

возможных

22. Рекомендовали бы вы данную больницу вашим друзьям и родственникам?

¹ Определенно нет

² Возможно нет

³ Возможно да

⁴ Определенно да

О ВАС

Осталось только несколько пунктов.

23. В целом, как бы вы оценили ваше общее состояние здоровья?

¹ Отличное

² Очень хорошее

³ Хорошее

⁴ Удовлетворительное

⁵ Плохое

24. Укажите последний класс или уровень учебного заведения, которое вы закончили?

¹ 8-й класс или меньше

² Средняя школа, не закончил (а)

³ Выпускник средней школы либо диплом об общем образовании

⁴ Колледж или диплом о двухгодичном обучении

⁵ Выпускник колледжа четырехгодичного обучения

⁶ Выпускник колледжа более 4-х лет обучения

25. Вы испанец, испано- или

латиноамериканец по

происхождению?

¹ Нет, не испанец/испано-/латиноамериканец

² Да, пуэрториканец

³ Да, мексиканец, американец мексиканского происхождения, чикано

⁴ Да, кубинец

⁵ Да, другое, испанец/испано-/латиноамериканец

26. Ваша раса? Пожалуйста, выберите один или более пунктов.

¹ Белый

² Чернокожий или афроамериканец

³ Азиат

⁴ Уроженец Гавайских островов или островов Тихого океана

⁵ Американский индеец или уроженец Аляски

27. На каком языке вы в основном говорите дома?

¹ Английский

² Испанский

³ Какой-либо другой язык (пожалуйста, напишите печатными буквами): _____________________

БЛАГОДАРИМ ВАС

Пожалуйста, верните заполненную форму опроса в оплаченном почтовом конверте.

[NAME OF SURVEY VENDOR OR SELF-ADMINISTERING HOSPITAL]

[RETURN ADDRESS OF SURVEY VENDOR OR SELF-ADMINISTERING HOSPITAL]

Sample Initial Cover Letter for the HCAHPS Survey

[HOSPITAL LETTERHEAD]

[SAMPLED PATIENT NAME]

[ADDRESS]

[CITY, STATE ZIP]

Дорогой [SAMPLED PATIENT NAME]

Наши данные показывают, что вы недавно были пациентом [NAME OF HOSPITAL] и были выписаны [DATE OF DISCHARGE]. Поскольку вы недавно лечились в больнице, мы просим вас о помощи. Данный опрос является частью проводимой национальной программы, призванной выяснить, как пациенты относятся к своему пребыванию в больнице. Результаты опроса будут опубликованы в Интернете в открытом доступе на сайте www.hospitalcompare.hhs.gov. Данные результаты помогут потребителям сделать важный выбор в отношении медицинского обслуживания, а больницам – улучшить предоставляемые услуги.

Вопросы 1-22 в прилагаемом опросе являются частью национальной инициативы, финансируемой Департаментом здравоохранения и социального обеспечения США (Department of Health and Human Services) с целью оценки качества медицинского обслуживания в больницах. Ваше участие является добровольным и не влияет на ваши медицинские льготы.

Мы надеемся, что вы уделите время участию в данном опросе. Мы будем очень признательны за ваше участие. После того как вы заполните данную форму опроса, пожалуйста, верните ее в предварительно оплаченном конверте. Ваши ответы могут быть сообщены больнице с целью улучшения качества обслуживания. [OPTIONAL: На этой анкете вы можете увидеть номер. Этот номер используется ТОЛЬКО, чтобы сообщить нам о том, что вы вернули свою анкету и нам не нужно посылать вам напоминания.]

Если у вас есть какие-либо вопросы, пожалуйста, позвоните по бесплатному номеру 1-800-xxx-xxxx. Благодарим за содействие в улучшении качества медицинского обслуживания для всех потребителей.

С уважением,

[HOSPITAL ADMINISTRATOR]

[HOSPITAL NAME]

Note: The OMB Paperwork Reduction Act language must be included in the mailing. This language can be either in the cover letter or on the front or back of the questionnaire. The exact OMB Paperwork Reduction Act language is included in this appendix. Please refer to the Mail Only section for specific letter guidelines.

Sample Follow-up Cover Letter for the HCAHPS Survey

[HOSPITAL LETTERHEAD]

[SAMPLED PATIENT NAME]

[ADDRESS]

[CITY, STATE ZIP]

Дорогой [SAMPLED PATIENT NAME]

Наши данные показывают, что вы недавно были пациентом [NAME OF HOSPITAL] и были выписаны [DATE OF DISCHARGE]. Приблизительно три недели назад мы отправили вам анкету о вашем пребывании в больнице. Если вы уже отправили нам эту анкету, пожалуйста, примите нашу благодарность и не обращайте внимания на это письмо. Однако если вы еще не заполнили данную анкету, пожалуйста, уделите несколько минут и заполните ее сейчас.

Поскольку вы недавно лечились в больнице, мы просим вас о помощи. Данный опрос является частью проводимой национальной программы, призванной выяснить, как пациенты относятся к своему пребыванию в больнице. Результаты опроса будут опубликованы в Интернете в открытом доступе на сайте www.hospitalcompare.hhs.gov. Данные результаты помогут потребителям сделать важный выбор в отношении медицинского обслуживания, а больницам – улучшить предоставляемые услуги.

Вопросы 1-22 в прилагаемом опросе являются частью национальной инициативы, финансируемой Департаментом здравоохранения и социального обеспечения США (Department of Health and Human Services) с целью оценки качества медицинского обслуживания в больницах. Ваше участие является добровольным и не влияет на ваши медицинские льготы. Пожалуйста, уделите несколько минут и заполните прилагаемую анкету. После того как вы заполните данную форму опроса, пожалуйста, верните ее в предварительно оплаченном конверте. Ваши ответы могут быть сообщены больнице с целью улучшения качества обслуживания. [OPTIONAL: На этой анкете вы можете увидеть номер. Этот номер используется ТОЛЬКО, чтобы сообщить нам о том, что вы вернули свою анкету и нам не нужно посылать вам напоминания.]

Если у вас есть какие-либо вопросы, пожалуйста, позвоните по бесплатному номеру 1-800-xxx-xxxx. Еще раз благодарим вас за содействие в улучшении качества медицинского обслуживания для всех потребителей.

С уважением,

[HOSPITAL ADMINISTRATOR]

[HOSPITAL NAME]

Note: The OMB Paperwork Reduction Act language must be included in the mailing. This language can be either in the cover letter or on the front or back of the questionnaire. The exact OMB Paperwork Reduction Act language is included in this appendix. Please refer to the Mail Only section for specific letter guidelines.

OMB Paperwork Reduction Act Language

The OMB Paperwork Reduction Act language must be included in the survey mailing. This language can be either in the cover letter or on the front or back of the questionnaire. The following is the language that must be used:

Russian Version

«В соответствии с Постановлением о сокращении документооборота от 1995 г. никто не обязан предоставлять сведения, если на форме опроса не указан действующий контрольный номер OMB. Действующий контрольный номер OMB для данного опроса – 0938-0981. Время для заполнения данного опроса составляет в среднем 7 минут на каждый ответ для вопросов 1-22, включая время для просмотра инструкций, поиска существующих данных, сбора необходимых данных и заполнения и проверки анкеты. Если у вас есть какие-либо комментарии в отношении точности предлагаемого ориентировочного времени или предложения по улучшению данной анкеты, просьба написать по адресу: Centers for Medicare & Medicaid Services, 7500 Security Boulevard, C1-25-05, Baltimore, MD 21244-1850».

HCAHPS Survey Instrument and Supporting Materials:

HCAHPS Mail Survey (Vietnamese)

• Survey Instrument

• Sample Initial Cover Letter

• Sample Follow-up Cover Letter

• OMB Paperwork Reduction Act Language

THĂM DÒ Ý KIẾN HCAHPS

CHỈ DẪN TRẢ LỜI BẢN THĂM DÒ Ý KIẾN

• Quý vị chỉ nên điền bản thăm dò ý kiến này nếu quý vị là bệnh nhân nằm tại bệnh viện có tên trong thư đính kèm. Vui lòng đừng điền bản thăm dò ý kiến nếu quý vị không phải là bệnh nhân.

• Xin trả lời tất cả các câu hỏi bằng cách đánh dấu vào ô phía bên trái của câu trả lời.

• Đôi khi quý vị được chỉ dẫn bỏ một số câu hỏi trong bản thăm dò ý kiến này. Khi đó, quý vị sẽ thấy một mũi tên và một chỉ dẫn cho quý vị biết cần phải trả lời tiếp sang câu nào, như thế này:

 Có

 Không  Nếu Không, trả lời tiếp sang câu 1

Quý vị hẳn thấy một con số trên bản thăm dò ý kiến. Số này CHỈ được dùng để cho chúng tôi biết quý vị đã gửi trở lại bản thăm dò ý kiến này và chúng tôi sẽ không gửi thư nhắc quý vị.

Xin chú ý: Câu hỏi 1-22 trong bản thăm dò ý kiến này là một phần của một dự án toàn quốc để đo lường phẩm chất sự chăm sóc y tế tại bệnh viện. OMB #0938-0981

Xin vui lòng trả lời các câu hỏi trong bản thăm dò ý kiến này về thời gian quý vị nằm tại bệnh viện có tên trên trang bìa thư. Xin đừng trả lời về những lần vào bệnh viện nào khác.

VIỆC CHĂM SÓC CỦA Y TÁ

ĐỐI VỚI QUÝ VỊ



1. Trong lần nằm bệnh viện này, y tá trong bệnh viện có thường tôn trọng và lịch sự đối với quý vị không?

¹ Không bao giờ

² Thỉnh thoảng

³ Thường thường

⁴ Luôn luôn

2. Trong lần nằm bệnh viện này, y tá trong bệnh viện có thường lắng nghe những điều quý vị bày tỏ không?

¹ Không bao giờ

² Thỉnh thoảng

³ Thường thường

⁴ Luôn luôn

3. Trong lần nằm bệnh viện này, y tá trong bệnh viện có thường giải thích một cách dễ hiểu những điều quý vị cần biết không?

¹ Không bao giờ

² Thỉnh thoảng

³ Thường thường

⁴ Luôn luôn

4. Trong lần nằm bệnh viện này, khi quý vị bấm nút gọi cho y tá, quý vị có thường được người đến giúp đỡ cho quý vị ngay như quý vị muốn không?

¹ Không bao giờ

² Thỉnh thoảng

³ Thường thường

⁴ Luôn luôn

⁹ Tôi không hề bấm nút gọi

VIỆC CHĂM SÓC CỦA BÁC SĨ

ĐỐI VỚI QUÝ VỊ



5. Trong lần nằm bệnh viện này, bác sĩ trong bệnh viện có thường tôn trọng và lịch sự đối với quý vị không?

¹ Không bao giờ

² Thỉnh thoảng

³ Thường thường

⁴ Luôn luôn

6. Trong lần nằm bệnh viện này, bác sĩ trong bệnh viện có thường lắng nghe những điều quý vị bày tỏ không?

¹ Không bao giờ

² Thỉnh thoảng

³ Thường thường

⁴ Luôn luôn

7. Trong lần nằm bệnh viện này, bác sĩ trong bệnh viện có thường giải thích một cách dễ hiểu những điều quý vị cần biết không?

¹ Không bao giờ

² Thỉnh thoảng

³ Thường thường

⁴ Luôn luôn

MÔI TRƯỜNG BỆNH VIỆN



8. Trong lần nằm bệnh viện này, phòng nằm và phòng vệ sinh của quý vị có thường được lau dọn sạch sẽ không?

¹ Không bao giờ

² Thỉnh thoảng

³ Thường thường

⁴ Luôn luôn

9. Trong lần nằm bệnh viện này, những nơi chung quanh phòng của quý vị có thường được giữ yên tịnh ban đêm không?

¹ Không bao giờ

² Thỉnh thoảng

³ Thường thường

⁴ Luôn luôn

KINH NGHIỆM CỦA QUÝ VỊ

TẠI BỆNH VIỆN NÀY



10. Trong lần nằm bệnh viện này, quý vị có cần y tá hoặc nhân viên bệnh viện giúp quý vị đi vào phòng vệ sinh hoặc giúp dùng bô tiêu tiểu không?

¹ Có

² Không  Nếu Không, trả lời

tiếp sang câu 12

11. Khi quý vị cần, quý vị có thường được giúp đi vào phòng vệ sinh hoặc giúp dùng bô tiêu tiểu một cách kịp thời không?

¹ Không bao giờ

² Thỉnh thoảng

³ Thường thường

⁴ Luôn luôn

12. Trong lần nằm bệnh viện này, quý vị có cần thuốc để giảm đau không?

¹ Có

² Không  Nếu Không, trả lời

tiếp sang câu 15

13. Trong lần nằm bệnh viện này, cơn đau của quý vị có thường được chữa trị đúng mức không?

¹ Không bao giờ

² Thỉnh thoảng

³ Thường thường

⁴ Luôn luôn

14. Trong lần nằm bệnh viện này, nhân viên bệnh viện có thường tận tâm trong việc giúp giảm cơn đau cho quý vị không?

¹ Không bao giờ

² Thỉnh thoảng

³ Thường thường

⁴ Luôn luôn

15. Trong lần nằm bệnh viện này, quý vị có được cho uống loại thuốc nào mà quý vị chưa hề uống không?

¹ Có

² Không  Nếu Không, trả lời

tiếp sang câu 18

16. Trước khi cho quý vị uống một loại thuốc mới, nhân viên bệnh viện có thường cho quý vị biết thuốc này dùng để chữa trị gì không?

¹ Không bao giờ

² Thỉnh thoảng

³ Thường thường

⁴ Luôn luôn

17. Trước khi cho quý vị uống một loại thuốc mới, nhân viên bệnh viện có thường giải thích về các phản ứng phụ của loại thuốc này một cách dễ hiểu không?

¹ Không bao giờ

² Thỉnh thoảng

³ Thường thường

⁴ Luôn luôn

KHI QUÝ VỊ XUẤT VIỆN



18. Sau khi quý vị xuất viện, quý vị về thẳng nhà riêng, về nhà người khác, hay đến một trung tâm y tế khác?

¹ Nhà riêng

² Nhà người khác

³ Một trung tâm y tế

khác  Nếu đến một trung tâm y tế khác, trả lời tiếp sang câu 21

19. Trong lần nằm bệnh viện này, bác sĩ, y tá hay một nhân viên nào khác trong bệnh viện có hỏi xem quý vị có sẵn những người hay dịch vụ cần thiết để trợ giúp cho quý vị sau khi xuất viện không?

¹ Có

² Không

20. Trong lần nằm bệnh viện này, quý vị có được cung cấp thông tin bằng văn bản về các triệu chứng hay vấn đề y tế mà quý vị cần lưu ý sau khi xuất viện không?

¹ Có

² Không

NHẬN XÉT VÀ ĐÁNH GIÁ

TỔNG QUÁT VỀ BỆNH VIỆN



Xin vui lòng trả lời các câu hỏi trong bản thăm dò ý kiến này về thời gian quý vị nằm tại bệnh viện có tên trên trang bìa thư. Xin đừng trả lời về những lần vào bệnh viện nào khác.

21. Dùng từ số 0 đến số 10 để đánh giá bệnh viện này, số 0 dành cho bệnh viện tệ nhất và số 10 dành cho bệnh viện tốt nhất, quý vị sẽ chọn số nào để đánh giá bệnh viện trong lần nằm bệnh viện này?

⁰ 0 Bệnh viện tệ nhất

¹ 1

² 2

³ 3

⁴ 4

⁵ 5

⁶ 6

⁷ 7

⁸ 8

⁹ 9

¹⁰ 10 Bệnh viện tốt nhất

22. Quý vị sẽ giới thiệu bệnh viện này với gia đình và bạn hữu không?

¹ Chắc chắn là không

² Có thể là không

³ Có thể là có

⁴ Chắc chắn là có

THÔNG TIN VỀ QUÝ VỊ

Sau đây chỉ còn một vài câu hỏi mà thôi.

23. Nói chung, quý vị thấy tình trạng sức khỏe của mình như thế nào?

¹ Xuất sắc

² Rất tốt

³ Tốt

⁴ Được

⁵ Kém

24. Quý vị đã học xong đến lớp nào hoặc trình độ nào?

¹ Lớp 8 trở xuống

² Học trung học một thời gian, nhưng chưa tốt nghiệp

³ Có bằng trung học hoặc bằng tương đương GED

⁴ Học đại học một thời gian hoặc tốt nghiệp cao đẳng (đại học hai năm)

⁵ Có bằng cử nhân đại học (đại học bốn năm)

⁶ Học vấn cao hơn cử nhân đại học (đại học bốn năm)

25. Quý vị có phải là người gốc Tây Ban Nha, Bán đảo Iberia (Hispanic) hay Châu Mỹ La tinh không?

¹ Không, không phải là người gốc Tây Ban Nha/Bán đảo Iberia (Hispanic)/Châu Mỹ La tinh

² Phải, người Puerto Rico

³ Phải, người Mễ Tây Cơ, người Mỹ gốc Mễ Tây Cơ, người Chicano (người gốc Mễ Tây Cơ sinh tại Mỹ)

⁴ Phải, người Cuba

⁵ Phải, người gốc Tây Ban Nha/Bán đảo Iberia (Hispanic)/Châu Mỹ La tinh khác

26. Quý vị thuộc chủng tộc nào? Xin chọn một hay một số các chủng tộc sau đây.

¹ Người da trắng

² Người da đen hay người Mỹ gốc Phi châu

³ Người Á đông

⁴ Người bản xứ Hạ Uy Di hay người thuộc các Quần đảo Thái Bình Dương

⁵ Người Mỹ bản xứ hay người bản xứ Alaska

27. Quý vị dùng ngôn ngữ nào trong nhà?

¹ Tiếng Anh

² Tiếng Tây Ban Nha

³ Một ngôn ngữ khác (xin ghi bằng

chữ in)

THÀNH THẬT CÁM ƠN QUÝ VỊ

Vui lòng dùng bao thư đính kèm có sẵn bưu phí và gửi trở lại bản thăm dò
ý kiến sau khi trả lời đầy đủ.

[NAME OF SURVEY VENDOR OR SELF-ADMINISTERING HOSPITAL]

[RETURN ADDRESS OF SURVEY VENDOR OR SELF-ADMINISTERING HOSPITAL]

Sample Initial Cover Letter for the HCAHPS Survey

[HOSPITAL LETTERHEAD]

[SAMPLED PATIENT NAME]

[ADDRESS]

[CITY, STATE ZIP]

Kính chào [SAMPLED PATIENT NAME]:

Hồ sơ chúng tôi cho thấy rằng vừa qua quý vị là bệnh nhân tại [NAME OF HOSPITAL] và được xuất viện vào ngày [DATE OF DISCHARGE]. Vì quý vị vừa có kinh nghiệm nằm bệnh viện, chúng tôi mong được sự giúp đỡ của quý vị. Cuộc thăm dò ý kiến này là một phần của một phong trào hoạt động toàn quốc để tìm hiểu về kinh nghiệm và cảm tưởng của bệnh nhân về thời gian nằm bệnh viện. Kết quả về những bệnh viện này sẽ được công bố và phát hành qua mạng Internet tại www.hospitalcompare.hhs.gov. Kết quả này sẽ giúp người tiêu dùng trong những quyết định quan trọng khi lựa chọn bệnh viện và giúp bệnh viện luôn cải tiến phương pháp phục vụ và chăm sóc bệnh nhân.

Câu hỏi 1-22 trong bản thăm dò ý kiến đính kèm là một phần của một phong trào vận động toàn quốc để đo lường phẩm chất của sự chăm sóc y tế tại bệnh viện qua sự bảo trợ của Bộ Y tế Xã hội Hoa Kỳ. Sự tham gia của quý vị là một tham gia tự nguyện và sẽ không có ảnh hưởng đến quyền lợi y tế của quý vị.

Chúng tôi hy vọng rằng quý vị sẽ bỏ chút thì giờ trả lời bản thăm dò ý kiến này và chúng tôi thành thật cảm tạ sự tham gia của quý vị. Sau khi trả lời đầy đủ bản thăm dò ý kiến này, xin quý vị dùng bao thư đính kèm có sẵn bưu phí và gửi trở lại chúng tôi. Các câu trả lời của quý vị sẽ được tiết lộ với bệnh viện nhằm giúp bệnh viện cải tiến phẩm chất dịch vụ y tế. [OPTIONAL: Quý vị hẳn thấy một con số trên bản thăm dò ý kiến. Số này CHỈ được dùng để cho chúng tôi biết quý vị đã gửi trở lại bản thăm dò ý kiến này và chúng tôi sẽ không gửi thư nhắc quý vị.]

Nếu có thắc mắc, xin quý vị vui lòng gọi số điện thoại miễn phí 1-800-xxx-xxxx. Thành thật cám ơn sự giúp đỡ của quý vị trong việc cải tiến dịch vụ chăm sóc y tế cho tất cả những người tiêu dùng.

Trân trọng,

[HOSPITAL ADMINISTRATOR]

[HOSPITAL NAME]

Note: The OMB Paperwork Reduction Act language must be included in the mailing. This language can be either in the cover letter or on the front or back of the questionnaire. The exact OMB Paperwork Reduction Act language is included in this appendix. Please refer to the Mail Only section for specific letter guidelines.

Sample Follow-up Cover Letter for the HCAHPS Survey

[HOSPITAL LETTERHEAD]

[SAMPLED PATIENT NAME]

[ADDRESS]

[CITY, STATE ZIP]

Kính chào [SAMPLED PATIENT NAME]:

Hồ sơ chúng tôi cho thấy rằng vừa qua quý vị là bệnh nhân tại [NAME OF HOSPITAL] và được xuất viện vào ngày [DATE OF DISCHARGE]. Cách nay gần ba tuần, chúng tôi có gửi cho quý vị một bản thăm dò ý kiến về lần quý vị nằm bệnh viện. Chúng tôi thành thật cảm ơn quý vị nếu quý vị đã gửi bản trả lời về cho chúng tôi và xin quý vị bỏ qua lá thư này. Tuy nhiên, nếu quý vị chưa trả lời bản thăm dò ý kiến này, xin quý vị vui lòng bỏ chút thì giờ trả lời các câu hỏi này ngay.

Vì quý vị vừa có kinh nghiệm nằm bệnh viện chúng tôi mong được sự giúp đỡ của quý vị. Cuộc thăm dò ý kiến này là một phần của một phong trào hoạt động toàn quốc để tìm hiểu về kinh nghiệm và cảm tưởng của bệnh nhân về thời gian nằm bệnh viện. Kết quả về những bệnh viện này sẽ được công bố và phát hành qua mạng Internet tại www.hospitalcompare.hhs.gov. Kết quả này sẽ giúp người tiêu dùng trong những quyết định quan trọng khi lựa chọn bệnh viện và giúp bệnh viện luôn cải tiến phương pháp phục vụ và chăm sóc bệnh nhân.

Câu hỏi 1-22 trong bản thăm dò ý kiến đính kèm là một phần của một phong trào vận động toàn quốc để đo lường phẩm chất của sự chăm sóc y tế tại bệnh viện qua sự bảo trợ của Bộ Y tế Xã hội Hoa Kỳ. Sự tham gia của quý vị là một tham gia tự nguyện và sẽ không có ảnh hưởng đến quyền lợi y tế của quý vị. Xin quý vị vui lòng bỏ chút thì giờ trả lời bản thăm dò ý kiến được đính kèm theo đây. Sau khi trả lời đầy đủ bản thăm dò ý kiến này, xin quý vị dùng bao thư đính kèm có sẵn bưu phí và gửi trở lại chúng tôi. Các câu trả lời của quý vị sẽ được tiết lộ với bệnh viện nhằm giúp bệnh viện cải tiến phẩm chất dịch vụ y tế. [OPTIONAL: Quý vị hẳn thấy một con số trên bản thăm dò ý kiến. Số này CHỈ được dùng để cho chúng tôi biết quý vị đã gửi trở lại bản thăm dò ý kiến này và chúng tôi sẽ không gửi thư nhắc quý vị.]

Nếu có thắc mắc, xin quý vị vui lòng gọi số điện thoại miễn phí 1-800-xxx-xxxx. Một lần nữa, chúng tôi thành thật cám ơn sự giúp đỡ của quý vị trong việc cải tiến dịch vụ chăm sóc y tế cho tất cả những người tiêu dùng.

Trân trọng,

[HOSPITAL ADMINISTRATOR]

[HOSPITAL NAME]

Note: The OMB Paperwork Reduction Act language must be included in the mailing. This language can be either in the cover letter or on the front or back of the questionnaire. The exact OMB Paperwork Reduction Act language is included in this appendix. Please refer to the Mail Only section for specific letter guidelines.

OMB Paperwork Reduction Act Language

The OMB Paperwork Reduction Act language must be included in the survey mailing. This language can be either in the cover letter or on the front or back of the questionnaire. The following is the language that must be used:

Vietnamese Version

Thể theo Đạo luật Giảm thiểu Thủ tục Giấy tờ năm 1995, không một ai bị bắt buộc phải trả lời và cung cấp thông tin trừ khi trên bản câu hỏi có ghi rõ số kiểm soát OMB có hiệu lực. Số kiểm soát OMB có hiệu lực cho bản thu thập thông tin này là 0938-0981. Thời gian cần thiết để trả lời các câu hỏi này được ước tính trung bình là 7 phút cho các câu hỏi 1-22 trong bản thăm dò ý kiến này, kể cả thời gian đọc hướng dẫn, thời gian tìm kiếm, thu thập và xác nhận thông tin được yêu cầu, hoàn tất và kiểm tra lại bản trả lời. Nếu quý vị có ý kiến gì về mức chính xác của thời gian ước tính hoặc đề nghị gì trong việc đơn giản hóa bản thăm dò ý kiến này, vui lòng gửi thư về: Centers for Medicare & Medicaid Services, 7500 Security Boulevard, C1-25-05, Baltimore, MD 21244-1850.”

HCAHPS Survey Instrument and Supporting Materials:

HCAHPS Telephone Script

(English)

Overview

This telephone interview script is provided to assist interviewers while attempting to reach the patient. The script explains the purpose of the survey and confirms necessary information about the patient. Interviewers must not conduct the survey with a proxy.

General Interviewing Conventions and Instructions

• All text that appears in lowercase letters must be read out loud

• Text in UPPERCASE letters must not be read out loud

• All questions and all answer categories must be read exactly as they are worded

• No changes are permitted to the order of the question and answer categories for the core and “About You” HCAHPS questions

• The “About You” HCAHPS questions must remain together

• All transitional statements must be read

• Text that is underlined must be emphasized

• Characters in < > must not be read

• [Square brackets] are used to show programming instructions that must not actually appear on electronic telephone interviewing system screens.

• Only one language (i.e., English or Spanish) must appear on the electronic interviewing system screen

• MISSING/DON’T KNOW (DK) is a valid response option for each item in the electronic telephone interviewing system scripts. This allows the telephone interviewer to go to the next question if a patient is unable to provide a response for a given question (or refuses to provide a response). In the survey file layouts, a value of MISSING/DK is coded as “M - Missing/Don't know.”

• Skip patterns should be programmed into the electronic telephone interviewing system.

  • Appropriately skipped questions should be coded as “8 - Not applicable.” For example, if a patient answers “No” to Question 10 of the HCAHPS survey, the program should skip Question 11, and go to Question 12. Question 11 must then be coded as “8 - Not applicable.” Coding may be done automatically by the telephone interviewing system or later during data preparation.

  • When a response to a screener question is not obtained, the screener question and any questions in the skip pattern should be coded as “M - Missing/Don't know.” For example, if the patient does not provide an answer to Question 10 of the HCAHPS survey and the interviewer selects “M – Missing/Don’t Know” to Question 10, then the telephone interviewing system should be programmed to skip Question 11, and go to Question 12. Question 11 must then be coded as “M - Missing/Don't know.”Coding may be done automatically by the telephone interviewing system or later during data preparation.

INITIATING CONTACT

START Hello, may I please speak to [SAMPLED PATIENT NAME]?

1. YES [GO TO INTRO]

2. NO [REFUSAL]

3. NO, NOT AVAILABLE RIGHT NOW [SET CALLBACK]

IF ASKED WHO IS CALLING:

This is [INTERVIEWER NAME] calling from [DATA COLLECTION CONTRACTOR]. We are conducting a survey about healthcare. I am calling to talk to [SAMPLED PATIENT NAME].

IF ASKED WHETHER PERSON CAN SERVE AS PROXY FOR SAMPLED PATIENT:

For this survey, we need to speak directly to [SAMPLED PATIENT NAME]. Is [SAMPLED PATIENT NAME] available?

IF THE SAMPLED PATIENT IS NOT AVAILABLE:

Can you tell me a convenient time to call back to speak with (him/her)?

IF THE SAMPLED PATIENT SAYS THIS IS NOT A GOOD TIME:

If you don’t have the time now, when is a more convenient time to call you back?

SPEAKING WITH SAMPLED PATIENT

INTRO Hi, this is [INTERVIEWER NAME] calling on behalf of [HOSPITAL NAME]. [HOSPITAL NAME] is participating in a survey about the care people receive in the hospital. This survey is part of a national initiative to measure the quality of care in hospitals. Survey results can be used by people to choose a hospital. Your answers may be shared with the hospital for purposes of quality improvement.

Participation in the survey is completely voluntary and will not affect your health care or your benefits. It should take about 7 minutes [OR VENDOR SPECIFY] to answer.

This call may be monitored [recorded] for quality improvement purposes.

OPTIONAL QUESTION TO INCLUDE:

I’d like to begin the survey now, is this a good time for us to continue?

NOTE: THE NUMBER OF MINUTES WILL DEPEND ON WHETHER HCAHPS IS INTEGRATED WITH HOSPITAL-SPECIFIC QUESTIONS.

S1 Our records show that you were discharged from [HOSPITAL NAME] on or about [DISCHARGE DATE]. Is that right?

READ YES/NO RESPONSE CHOICES ONLY IF NECESSARY

<1> YES [GO TO Q1_INTRO]

<2> NO [GO TO INEL1]

<3> DON’T KNOW [GO TO INEL1]

<4> REFUSAL [GO TO INEL1]

CONFIRMING INELIGIBLE PATIENTS

INEL1: Were you ever at this hospital?

1. YES [GO TO INEL2]

2. NO [GO TO INEL_END]

INEL2: Were you a patient at this hospital in the last year?

<1> YES [GO TO INEL3]

<2> NO [GO TO INEL_END]

INEL3: When was this?

IF ANY DATE WAS WITHIN TWO WEEKS OF [DISCHARGE DATE], GO TO Q1_INTRO; OTHERWISE, GO TO INEL_END.

INEL_END: Thank you for your time. It looks like we made a mistake. Have a good (day/evening).

BEGIN HCAHPS QUESTIONS

Q1_INTRO Please answer the questions in this survey about this stay at [HOSPITAL NAME]. When thinking about your answers, do not include any other hospital stays. The first questions are about the care you received from nurses during this hospital stay.

Be prepared to probe if the PATIENT answers outside of the ANSWER Categories provided. Probe by repeating the answer categories only; do not interpret for THE PATIENT.

Q1 During this hospital stay, how often did nurses treat you with courtesy and respect? Would you say…

1. Never,

2. Sometimes,

3. Usually, or

4. Always?

<M> MISSING/DK

Q2 During this hospital stay, how often did nurses listen carefully to you? Would you say…

1. Never,

2. Sometimes,

3. Usually, or

4. Always?

<M> MISSING/DK

Q3 During this hospital stay, how often did nurses explain things in a way you could understand? Would you say…

1. Never,

2. Sometimes,

3. Usually, or

4. Always?

<M> MISSING/DK

Q4 During this hospital stay, after you pressed the call button, how often did you get help as soon as you wanted it? Would you say…

1. Never,

2. Sometimes,

3. Usually,

4. Always, or

<9> I never pressed the call button?

<M> MISSING/DK



Q5_INTRO The next questions are about the care you received from doctors during this hospital stay.

Q5 During this hospital stay, how often did doctors treat you with courtesy and respect? Would you say…

1. Never,

2. Sometimes,

3. Usually, or

4. Always?

<M> MISSING/DK

Q6 During this hospital stay, how often did doctors listen carefully to you? Would you say…

1. Never,

2. Sometimes,

3. Usually, or

4. Always?

<M> MISSING/DK

Q7 During this hospital stay, how often did doctors explain things in a way you could understand? Would you say…

1. Never,

2. Sometimes,

3. Usually, or

4. Always?

<M> MISSING/DK

Q8_INTRO The next set of questions is about the hospital environment.

Q8 During this hospital stay, how often were your room and bathroom kept clean? Would you say…

1. Never,

2. Sometimes,

3. Usually, or

4. Always?

<M> MISSING/DK

Q9 During this hospital stay, how often was the area around your room quiet at night? Would you say…

1. Never,

2. Sometimes,

3. Usually, or

4. Always?

<M> MISSING/DK

Q10_INTRO The next questions are about your experiences in this hospital.

Q10 During this hospital stay, did you need help from nurses or other hospital staff in getting to the bathroom or in using a bedpan?

READ YES/NO RESPONSE CHOICES ONLY IF NECESSARY

1. YES

2. NO [GO TO Q12]

<M> MISSING/DK [GO TO Q12]

Q11 How often did you get help in getting to the bathroom or in using a bedpan as soon as you wanted? Would you say…

1. Never,

2. Sometimes,

3. Usually, or

4. Always?

<8> NOT APPLICABLE

<M> MISSING/DK

[NOTE: IF Q10 = “2 - NO” THEN Q11 = “8 - NOT APPLICABLE” OR IF Q10 = “M - MISSING/DK” THEN Q11 = “MISSING/DK”]

Q12 During this hospital stay, did you need medicine for pain?

READ YES/NO RESPONSE CHOICES ONLY IF NECESSARY

<1> YES

<2> NO [GO TO Q15]

<M> MISSING/DK [GO TO Q15]

Q13 During this hospital stay, how often was your pain well controlled? Would you say…

1. Never,

2. Sometimes,

3. Usually, or

4. Always?

<8> NOT APPLICABLE

<M> MISSING/DK

[NOTE: IF Q12 = “2 - NO” THEN Q13 = “8 - NOT APPLICABLE” OR IF Q12 = “M - MISSING/DK” THEN Q13 = “M - MISSING/DK”]

Q14 During this hospital stay, how often did the hospital staff do everything they could to help you with your pain? Would you say…

1. Never,

2. Sometimes,

3. Usually, or

4. Always

<8> NOT APPLICABLE

<M> MISSING/DK

[NOTE: IF Q12 = “2 - NO” THEN Q14 = “8 - NOT APPLICABLE” OR IF Q12 = “M - MISSING/DK” THEN Q14 = “M - MISSING/DK”]

Q15 During this hospital stay, were you given any medicine that you had not taken before?

READ YES/NO RESPONSE CHOICES ONLY IF NECESSARY

<1> YES

<2> NO [GO TO Q18_INTRO]

<M> MISSING/DK [GO TO Q18_INTRO]

Q16 Before giving you any new medicine, how often did hospital staff tell you what the medicine was for? Would you say…

1. Never,

2. Sometimes,

3. Usually, or

4. Always?

<8> NOT APPLICABLE

<M> MISSING/DK

[NOTE: IF Q15 = “2 - NO” THEN Q16 = “8 - NOT APPLICABLE” OR IF Q15 = “M - MISSING/DK” THEN Q16 = “M - MISSING/DK”]

Q17 Before giving you any new medicine, how often did hospital staff describe possible side effects in a way you could understand? Would you say…

1. Never,

2. Sometimes,

3. Usually, or

4. Always?

<8> NOT APPLICABLE

<M> MISSING/DK

[NOTE: IF Q15 = “2 - NO” THEN Q17 = “8 - NOT APPLICABLE” OR IF Q15 = “M - MISSING/DK” THEN Q17 = “M - MISSING/DK”]

Q18_INTRO The next questions are about when you left the hospital.

Q18 After you left the hospital, did you go directly to your own home, to someone else’s home, or to another health facility?

READ RESPONSE CHOICES 1, 2 AND 3 ONLY IF NECESSARY

<1> OWN HOME

<2> SOMEONE ELSE’S HOME

<3> ANOTHER HEALTH FACILITY [GO TO Q21]

<M> MISSING/DK [GO TO Q21]

Q19 During this hospital stay, did doctors, nurses, or other hospital staff talk with you about whether you would have the help you needed when you left the hospital?

READ YES/NO RESPONSE CHOICES ONLY IF NECESSARY

<1> YES

<2> NO

<8> NOT APPLICABLE

<M> MISSING/DK

[NOTE: IF Q18 = “3 - ANOTHER HEALTH FACILITY” THEN Q19 = “8 - NOT APPLICABLE” IF Q18 = “M - MISSING/DK” THEN Q19 = “M - MISSING/DK”]

Q20 During this hospital stay, did you get information in writing about what symptoms or health problems to look out for after you left the hospital?

READ YES/NO RESPONSE CHOICES ONLY IF NECESSARY

<1> YES

<2> NO

<8> NOT APPLICABLE

<M> MISSING/DK

[NOTE: IF Q18 = “3 - ANOTHER HEALTH FACILITY” THEN Q20 = “8 - NOT APPLICABLE” IF Q18 = “M - MISSING/DK” THEN Q20 = “M - MISSING/DK”]

Q21 We want to know your overall rating of your stay at [FACILITY NAME]. This is the stay that ended around [DISCHARGE DATE]. Please do not include any other hospital stays in your answer.

Using any number from 0 to 10, where 0 is the worst hospital possible and 10 is the best hospital possible, what number would you use to rate this hospital during your stay?

READ RESPONSE CHOICES ONLY IF NECESSARY

<0> 0

<1> 1

<2> 2

<3> 3

<4> 4

<5> 5

<6> 6

<7> 7

<8> 8

<9> 9

<10> 10

<M> MISSING/DK

Q22 Would you recommend this hospital to your friends and family? Would you say…

<1> Definitely no,

<2> Probably no,

<3> Probably yes, or

<4> Definitely yes?

<M> MISSING/DK

Q23_INTRO This last set of questions is about you. Please listen to all response choices before you answer the following questions.

Q23 In general, how would you rate your overall health? Would you say that it is…

<1> Excellent,

<2> Very good,

<3> Good,

<4> Fair, or

<5> Poor?

<M> MISSING/DK

Q24 What is the highest grade or level of school that you have completed? Please listen to all six response choices before you answer. Did you ..

<1> Complete the 8^th grade or less,

<2> Complete some high school, but did not graduate,

<3> Graduate from high school or earn a GED,

<4> Complete some college or earn a 2-year degree,

<5> Graduate from a 4-year college, or

<6> Complete more than 4-year college degree?

<M> MISSING/DK

ACADEMIC TRAINING BEYOND A HIGH SCHOOL DIPLOMA THAT DOES NOT LEAD TO A BACHELORS DEGREE SHOULD BE CODED AS 4. IF THE PATIENT DESCRIBES NON-ACADEMIC TRAINING, SUCH AS TRADE SCHOOL, PROBE TO FIND OUT IF S/HE HAS A HIGH SCHOOL DIPLOMA AND CODE 2 OR 3, AS APPROPRIATE.

Q25 Are you of Spanish, Hispanic or Latino origin or descent? Please listen to all five response choices before you answer. Would you say…

<1> No, not Spanish/Hispanic/Latino,

<2> Yes, Puerto Rican,

<3> Yes, Mexican, Mexican-American, Chicano,

<4> Yes, Cuban, or

<5> Yes, other Spanish/Hispanic/Latino?

<M> MISSING/DK

[FOR TELEPHONE INTERVIEWING, QUESTION 26 IS BROKEN INTO PARTS A-E.]

READ ALL RACE CATEGORIES PAUSING AT EACH RACE CATEGORY TO ALLOW PATIENT TO REPLY TO EACH RACE CATEGORY.

IF THE PATIENT REPLIES, “WHY ARE YOU ASKING MY RACE?”:

We ask about your race for demographic purposes. We want to be sure that the people we survey accurately represent the racial diversity in this country.

IF THE PATIENT REPLIES, “I ALREADY TOLD YOU MY RACE”:

I understand, however the survey requires me to ask about all races so results can include people who are multiracial. If the race does not apply to you please answer no. Thanks for your patience.

Q26 When I read the following list, please tell me if the category describes your race. You may choose one or more.

Q26A Are you White?

<1> YES/WHITE

<0> NO/NOT WHITE

<M> MISSING/DK

Q26B Are you Black or African-American?

<1> YES/BLACK OR AFRICAN-AMERICAN

<0> NO/NOT BLACK OR AFRICAN-AMERICAN

<M> MISSING/DK

Q26C Are you Asian?

<1> YES/ASIAN

<0> NO/NOT ASIAN

<M> MISSING/DK

Q26D Are you Native Hawaiian or other Pacific Islander?

<1> YES/NATIVE HAWAIIAN OR OTHER PACIFIC ISLANDER

<0> NO/NOT NATIVE HAWAIIAN OR OTHER PACIFIC ISLANDER

<M> MISSING/DK

Q26E Are you American Indian or Alaska Native?

<1> YES/AMERICAN INDIAN OR ALASKA NATIVE

<0> NO/NOT AMERICAN INDIAN OR ALASKA NATIVE

<M> MISSING/DK

Q27 What language do you mainly speak at home? Would you say that you mainly speak…

<1> English,

<2> Spanish, or

<3> Some other language? [GO TO Q27A]

<M> MISSING/DK

Q27A What other language do you mainly speak at home?

[NOTE: PLEASE DOCUMENT LANGUAGE AND MAINTAIN IN YOUR INTERNAL RECORDS.]

END: Those are all the questions I have. Thank you for your time. Have a good (day/evening).

HCAHPS Survey Instrument and Supporting Materials:

HCAHPS Telephone Script

(Spanish)

Overview

This telephone interview script is provided to assist interviewers while attempting to reach the respondent. The script explains the purpose of the survey and confirms necessary information about the respondent. Interviewers must not conduct the survey with a proxy.

General Interviewing Conventions and Instructions

• All text that appears in lowercase letters must be read out loud

• Text in UPPERCASE letters must not be read out loud

• All questions and all answer categories must be read exactly as they are worded

• No changes are permitted to the order of the questions answer categories for the core and “About You” HCAHPS questions

• The “About You” HCAHPS questions must remain together

• All transitional statements must be read

• Text that is underlined must be emphasized

• Characters in <> must not be read

• [Square brackets] are used to show programming instructions that must not actually appear on electronic telephone interviewing system screens

• Only one language (i.e., English or Spanish) must appear on the electronic interviewing system screen

• MISSING/DON’T KNOW (DK) is a valid response option for each item in the electronic telephone interviewing system scripts. This allows the telephone interviewer to go to the next question if a patient is unable to provide a response for a given question (or refuses to provide a response). In the survey file layouts, a value of MISSING/DK is coded as “M - Missing/Don’t know.”

• Skip patterns should be programmed into the electronic telephone interviewing system

  • Appropriately skipped questions should be coded as “8 – Not Applicable.” For example, if a respondent answers “No” to question 10 of the HCAHPS survey, the program should skip Question 11, and go to question 12. Question 11 must then be coded as “8 -Not Applicable.” Coding may be done automatically by the telephone interviewing system or later during data preparation.

  • When a response to a screener question is not obtained, the screener question and any questions in the skip pattern should be coded as “M – Missing/Don’t know.” For example, if the patient does not provide an answer to Question 10 of the HCAHPS survey and the interviewer selects “M – Missing/Don’t Know” to Question 10, then the telephone interviewing system should be programmed to skip question 11, and go to Question 12. Question 11 must then be coded as “M – Missing/Don’t know.” Coding may be done automatically by the telephone interviewing system or later during data preparation.

INITIATING CONTACT

START Buenos días/tardes, ¿podría hablar con [SAMPLED PATIENT NAME]?

<1> Sí [GO TO INTRO]

<2> NO (REFUSAL)

<3> NO, NOT AVAILABLE RIGHT NOW [SET CALLBACK]

IF ASKED WHO IS CALLING: Me llamo [INTERVIEWER NAME] y le estoy llamando de [DATA COLLECTION CONTRACTOR]. Estamos llevando a cabo una encuesta sobre la atención médica. Estoy llamando para hablar con [SAMPLED PATIENT NAME].

IF ASKED WHETHER PERSON CAN SERVE AS PROXY FOR SAMPLED PATIENT:

La encuesta requiere que hablemos directamente con [SAMPLED PATIENT NAME]. ¿Está disponible para hablar conmigo [SAMPLED PATIENT NAME]?

IF THE SAMPLED PATIENT IS NOT AVAILABLE:

¿Puede decirme usted un tiempo conveniente para volver a llamar para hablar con (él/ella)?

IF THE SAMPLED PATIENT SAYS THIS IS NOT A GOOD TIME:

¿Si usted no tiene el tiempo ahora, cuándo es un tiempo más conveniente para llamarle?

SPEAKING WITH SAMPLED PATIENT

INTRO Buenos días/tardes, me llamo [INTERVIEWER NAME], y le estoy llamando de parte de [HOSPITAL NAME]. “[HOSPITAL NAME] está participando en una encuesta para obtener información sobre la atención que recibe la gente en los hospitales. Esta encuesta forma parte de una iniciativa nacional para medir la calidad del cuidado en hospitales. Los resultados de la encuesta pueden ser utilizados por personas para escoger un hospital. Sus respuestas pueden ser compartidas con el hospital para propósitos de mejorar la calidad.

Su participación en esta encuesta es completamente voluntaria y no va a afectar su atención médica o sus beneficios. Debe de tomar más o menos 7 minutos.

Esta llamada puede ser supervisada [grabada] para propósitos de control calidad.

OPTIONAL QUESTION TO INCLUDE:

¿Me gustaria empezar la encuesta ahora, es un tiempo bueno para continuar?

NOTE: THE NUMBER OF MINUTES WILL DEPEND ON WHETHER HCAHPS IS INTEGRATED WITH HOSPITAL-SPECIFIC QUESTIONS.

S1 La información que tenemos indica que usted salió del hospital [HOSPITAL NAME] el [DISCHARGE DATE] o más o menos el [DISCHARGE DATE]. ¿Correcto?

READ SI/NO RESPONSE CHOICES ONLY IF NECESSARY

<1> Sí

<2> NO [GO TO INEL1]

<3> DON’TKNOW [GO TO INEL1]

<4> REFUSAL [GO TO INEL1]

CONFIRMING INELIGIBLE PATIENTS

INEL 1: ¿Estuvo usted alguna vez en este hospital?

<1> Sí [GO TO INEL2]

<2> NO [GO TO INEL_END]

INEL2: ¿Fue usted paciente de este hospital en el último año?

<1> Sí [GO TO INEL3]

<2> NO [GO TO INEL_END]

INEL3: ¿Cuándo?

IF ANY DATE WAS WITHIN TWO WEEKS OF [DISCHARGE DATE], GO TO Q1_INTRO; OTHERWISE, GO TO INEL_END.

INEL_END: Gracias por su tiempo. Parece que hemos cometido un error. Disculpe. Que tenga buen (día/ noche).

BEGIN HCAHPS QUESTIONS

Q1_INTRO Por favor conteste las preguntas en esta encuesta sobre la vez que estuvo hospitalizado/a en el hospital [HOSPITAL NAME]. Al pensar en sus respuestas, no incluya información sobre otras veces que estuvo en un hospital. Las primeras preguntas son sobre la atención que recibió de las enfermeras durante esta vez que estuvo en el hospital.

Be prepared to probe if the respondent answers outside of the Categories provided. Probe using the answer categories only; do not interpret for the PATIENt.

Q1 Durante esta vez que estuvo en el hospital, ¿con qué frecuencia le trataban las enfermeras con cortesía y respeto? Diría que...

<1> Nunca,

<2> A veces,

<3> La mayoría de las veces, o

<4> Siempre?

<M> MISSING/DK

Q2. Durante esta vez que estuvo en el hospital, ¿con qué frecuencia le escuchaban con atención las enfermeras? Diría que...

<1> Nunca

<2> A veces

<3> La mayoría de las veces, o

<4> Siempre?

<M> MISSING/DK

Q3 Durante esta vez que estuvo en el hospital, ¿con qué frecuencia le explicaban las cosas las enfermeras en una forma que usted pudiera entender? Diría que...

<1> Nunca

<2> A veces

<3> La mayoría de las veces, o

<4> Siempre?

<M> MISSING/DK

Q4 Durante esta vez que estuvo en el hospital, después de usar el botón para llamar a la enfermera, ¿con qué frecuencia le atendían tan pronto como usted quería? Diría que...

<1> Nunca

<2> A veces

<3> La mayoría de las veces

<4> Siempre, o

<9> Nunca usé el botón?

<M> MISSING/DK

Q5_INTRO Las siguientes preguntas se tratan de la atención que recibió de los doctores durante esta vez que estuvo en el hospital.

Q5 Durante esta vez que estuvo en el hospital, ¿con qué frecuencia le trataban los doctores con cortesía y respeto? Diría que...

<1> Nunca

<2> A veces

<3> La mayoría de las veces, o

<4> Siempre?

<M> MISSING/DK

Q6 Durante esta vez que estuvo en el hospital, ¿con qué frecuencia le escuchaban con atención los doctores? Diría que...

<1> Nunca

<2> A veces

<3> La mayoría de las veces, o

<4> Siempre?

<M> MISSING/DK

Q7 Durante esta vez que estuvo en el hospital, ¿con qué frecuencia le explicaban las cosas los doctores en una forma que usted pudiera entender? Diría que...

<1> Nunca

<2> A veces

<3> La mayoría de las veces, o

<4> Siempre?

<M> MISSING/DK

Q8_INTRO Las siguientes preguntas se tratan sobre el ambiente en el hospital.

Q8 Durante esta vez que estuvo en el hospital, ¿con qué frecuencia mantenían su cuarto y su baño limpios? Diría que...

<1> Nunca

<2> A veces

<3> La mayoría de las veces, o

<4> Siempre?

<M> MISSING/DK

Q9 Durante esta vez que estuvo en el hospital, ¿con qué frecuencia estaba silenciosa el área alrededor de su habitación por la noche? Diría que...

<1> Nunca

<2> A veces

<3> La mayoría de las veces, o

<4> Siempre?

<M> MISSING/DK

Q10_INTRO Las siguientes preguntas se tratan sobre su experiencia en este hospital.

Q10 Durante esta vez que estuvo en el hospital, ¿necesitó que las enfermeras u otro personal del hospital le ayudaran a llegar al baño o a usar un orinal (bedpan)?

READ SI/NO RESPONSE CHOICES ONLY IF NECESSARY

<1> Sí

<2> No [GO TO Q12]

<M> MISSING/DK [GO TO Q12]

Q11 ¿ Con qué frecuencia, le ayudaron a llegar al baño o a usar un orinal (bedpan) tan pronto como quería? Diría que...

<1> Nunca

<2> A veces

<3> La mayoría de las veces, o

<4 Siempre?

<8> NOT APPLICABLE

<M> MISSING/DK

[NOTE: IF Q10 = “2 - NO” THEN Q11 = “8 - NOT APPLICABLE” OR IF Q10 = “M - MISSING/DK” THEN Q11 = “MISSING/DK”]

Q12 Durante esta vez que estuvo en el hospital, ¿necesitó medicamentos para el dolor?

READ SI/NO RESPONSE CHOICES ONLY IF NECESSARY

<1> Sí

<2> No [GO TO Q15]

<M> MISSING/DK [GO TO Q15]

Q13 Durante esta vez que estuvo en el hospital, ¿con qué frecuencia le controlaban bien el dolor? Diría que...

<1> Nunca

<2> A veces

<3> La mayoría de las veces, o

<4> Siempre?

<8> NOT APPLICABLE

<M> MISSING/DK

[NOTE: IF Q12 = “2 - NO” THEN Q13 = “8 - NOT APPLICABLE” OR IF Q12 = “M - MISSING/DK” THEN Q13 = “M - MISSING/DK”]

Q14 Durante esta vez que estuvo en el hospital, ¿con qué frecuencia hacía el personal del hospital todo lo que podía para aliviar su dolor? Diría que...

<1> Nunca

<2> A veces

<3> La mayoría de las veces, o

<4> Siempre?

<8> NOT APPLICABLE

<M> MISSING/DK

[NOTE: IF Q12 = “2 - NO” THEN Q14 = “8 - NOT APPLICABLE” OR IF Q12 = “M - MISSING/DK” THEN Q14 = “M - MISSING/DK”]

Q15 Durante esta vez que estuvo en el hospital, ¿le dieron algún medicamento que no hubiera tomado antes?

READ SI/NO RESPONSE CHOICES ONLY IF NECESSARY

<1> Sí

<2> No [GO TO Q18_INTRO]

<M> MISSING/DK [GO TO Q18_INTRO]

Q16 Antes de darle algún medicamento nuevo, ¿con qué frecuencia le dijo el personal del hospital para qué era el medicamento? Diría que...

<1> Nunca

<2> A veces

<3> La mayoría de las veces, o

<4> Siempre?

<8> NOT APPLICABLE

<M> MISSING/DK

[NOTE: IF Q15 = “2 - NO” THEN Q16 = “8 - NOT APPLICABLE” OR IF Q15 = “M - MISSING/DK” THEN Q16 = “M - MISSING/DK”]

Q17 Antes de darle algún medicamento nuevo, ¿con qué frecuencia le describió el personal del hospital los efectos secundarios posibles en una forma que pudiera entender? Diría que...

<1> Nunca

<2> A veces

<3> La mayoría de las veces, o

<4> Siempre?

<8> NOT APPLICABLE

<M> MISSING/DK

[NOTE: IF Q15 = “2 - NO” THEN Q17 = “8 - NOT APPLICABLE” OR IF Q15 = “M - MISSING/DK” THEN Q17 = “M - MISSING/DK”]

Q18_INTRO Las siguientes preguntas se tratan de cuando salió del hospital.

Q18 Después de salir del hospital, ¿se fue directamente a su propia casa, a la casa de otra persona, o a otra institución de salud?

READ RESPONSE CHOICES 1, 2 AND 3 ONLY IF NECESSARY

<1> A mi casa

<2> A la casa de otra persona

<3> A otra institución de salud  [GO TO Q21]

<M> MISSING/DK [GO TO Q21]

Q19 Durante esta vez que estuvo en el hospital, ¿hablaron los doctores, enfermeras u otro personal del hospital con usted sobre si tendría la ayuda que necesitaba cuando se fuera del hospital?

READ SI/NO RESPONSE CHOICES ONLY IF NECESSARY

<1> Sí

<2> No

<8> NOT APPLICABLE

<M> MISSING/DK

[NOTE: IF Q18 = “3 - ANOTHER HEALTH FACILITY” THEN Q19 = “8 - NOT APPLICABLE” IF Q18 = “M - MISSING/DK” THEN Q19 = “M - MISSING/DK”]

Q20 Durante esta vez que estuvo en el hospital, ¿le dieron información por escrito sobre los síntomas o problemas de salud a los que debía poner atención cuando se fuera del hospital?

READ SI/NO RESPONSE CHOICES ONLY IF NECESSARY

<1> Sí

<2> No

<8> NOT APPLICABLE

<M> MISSING/DK

[NOTE: IF Q18 = “3 - ANOTHER HEALTH FACILITY” THEN Q20 = “8 - NOT APPLICABLE” IF Q18 = “M - MISSING/DK” THEN Q20 = “M - MISSING/DK”]

Q21 Queremos saber la calificación en general que le daría a su estancia en el hospital [HOSPITAL NAME]. Esta es la estancia que terminó más o menos el [DISCHARGE DATE]. No incluya información sobre otras veces que estuvo en un hospital.

Usando un número del 0 al 10, el 0 siendo el peor hospital posible y el 10 el mejor hospital posible, ¿qué número usaría para calificar este hospital durante esta vez que estuvo en el hospital?

READ RESPONSE CHOICES ONLY IF NECESSARY

<0> 0

<1> 1

<2> 2

<3> 3

<4> 4

<5> 5

<6> 6

<7> 7

<8> 8

<9> 9

<10> 10

<M> MISSING/DK

Q22 ¿Le recomendaría éste hospital a sus amigos y familiares? Diría que...

<1> Definitivamente no

<2> Probablemente no

<3> Probablemente sí, o

<4> Definitivamente sí?

<M> MISSING/DK

Q23_INTRO Las últimas preguntas son sobre usted. Por favor escuche todas las respuestas antes de contestar las siguientes preguntas.

Q23 En general, ¿cómo calificaría toda su salud? Diría que...

<1> Excelente

<2> Muy buena

<3> Buena

<4> Regular, o

<5> Mala?

<M> MISSING/DK

7

Q24 Por favor escuche todas las respuestas antes de contestar la siguiente pregunta. ¿Cuál es el grado o nivel escolar más alto que ha completado? Completó...

<1> 8 años de escuela o menos,

<2> 9-12 años de escuela, pero sin graduarse,

<3> Graduado de la escuela secundaria (high school), Diploma de escuela secundaria, preparatoria, o su equivalente (o GED),

<4> Algunos cursos universitarios o un título universitario de un programa de 2 años,

<5> Título universitario de 4 años, o

<6> Título universitario de más de 4 años?

<M> MISSING/DK

ACADEMIC TRAINING BEYOND A HIGH SCHOOL DIPLOMA THAT DOES NOT LEAD TO A BACHELORS DEGREE SHOULD BE CODED AS 4. IF THE PATIENT DESCRIBES NON-ACADEMIC TRAINING, SUCH AS TRADE SCHOOL, PROBE TO FIND OUT IF S/HE HAS A HIGH SCHOOL DIPLOMA AND CODE 2 OR 3, AS APPPROPRIATE.

Q25 Por favor escuche todas las respuestas antes de contestar la siguiente pregunta.

¿Es usted de origen o ascendencia hispana o latina? Diría que...

<1> No, ni hispano ni latino

<2> Sí, Puertorriqueño

<3> Sí, Mexicano, Mexicano-Americano, Chicano

<4> Sí, Cubano, o

<5> Sí, otro hispano/latino?

<M> MISSING/DK

[FOR TELEPHONE INTERVIEWING QUESTION 26 IS BROKEN INTO PARTS A-E]

READ ALL RACE CATEGORIES PAUSING AT EACH RACE CATEGORY TO ALLOW PATIENT TO REPLY TO EACH RACE CATEGORY.

IF THE PATIENT REPLIES, “WHY ARE YOU ASKING MY RACE? ”

Pregunt amos por su raza para propositos demograficos. Queremos estar seguros que las personas que responden a esta encuesta representan exactamente la diversidad racial en este pais.

IF THE PATIENT REPLIES, “I ALREADY TOLD YOU MY RACE:”

Comprendo, sin embargo la encuesta me requiere preguntar sobre todas las razas porque los resultados pueden incluir a personas que son multirraciales. Si la raza no aplica a usted por favor conteste no. Gracias por su paciencia.

Q26 Cuándo le lea la siguiente lista, por favor dígame si la categoría describe su raza. Puede escoger más de una respuesta.

Q26A ¿Es usted blanco/a?

<1> Sí/Blanco/a

<0> No/No Blanco/a

<M> MISSING/DK

Q26B ¿Es usted Negro/a o Afro Americano/a?

<1> Sí/Negro/a o Afro Americano/a

<0> No/No Negro/a o Afro Americano/a

<M> MISSING/DK

Q26C ¿Es usted Asiático/a?

<1> Sí/Asiático/a

<0> No/No Asiático/a

<M> MISSING/DK

Q26D ¿Es usted Nativo/a de Hawai o de otras Islas del Pacífico?

<1> Sí/Nativo/a de Hawai o de otras Islas del Pacífico

<0> No/No Nativo/a de Hawai o de otras Islas del Pacífico

<M> MISSING/DK

Q26E ¿Es usted Indígena Americano/a o Nativo/a de Alaska?

<1> Sí/Indígena Americano/a o Nativo/a de Alaska

<0> No/No Indígena Americano/a o Nativo/a de Alaska

<M> MISSING/DK

Q27 ¿Principalmente qué idioma habla en casa? Diría que habla principalmente...

<1> Inglés

<2> Español, o

<3> Algún otro idioma [GO TO Q27A]

<M> MISSING/DK

Q27a ¿Qué otro idioma habla principalmente en casa?

[NOTE: PLEASE DOCUMENT LANGUAGE AND MAINTAIN IN YOUR INTERNAL RECORDS.]

END1: Estas son todas las preguntas que le tengo. Muchas gracias por su tiempo. Que tenga muy buen día/muy buenas tardes/noches.

HCAHPS Survey Instrument and Supporting Materials:

HCAHPS

Active Interactive Voice Response Script

Overview

This active interactive voice response (IVR) interview script is provided to assist operators while attempting to reach the patient. The script explains the purpose of the survey and confirms necessary information about the patient before the patient is connected to the IVR system. Operators must not conduct the survey with a proxy.

General Interviewing Conventions and Instructions

• All text that appears in lowercase letters must be read out loud

• Text in UPPERCASE letters must not be read out loud

• All questions and all answer categories must be read exactly as they are worded

• No changes are permitted in the order of the question and answer categories for the core and “About You” HCAHPS questions

• The “About You” HCAHPS questions must remain together

• All transitional statements must be read

• Text that is underlined must be emphasized

• Characters in < > must not be read

• [Square brackets] are used to show programming instructions that must not actually appear on IVR screens

• Each question must be programmed so that the patient can go to the next question in cases where they do not know the answer or refuse to answer

• Each question must have the option for the respondent to be connected to a live operator at any time during the survey

• MISSING/DON’T KNOW (DK) is a valid response option for each item in the IVR script. This allows the IVR system to go to the next question if a patient is unable to provide a response for a given question (or refuses to provide a response). In the survey file layouts, a value of MISSING/DK is coded as “M - Missing/Don't know.”

• Skip patterns should be programmed into the IVR system.

• Appropriately skipped questions should be coded as “8 - Not applicable.” For example, if a patient answers “No” to Question 10 of the HCAHPS survey, the program should skip Question 11, and go to Question 12. Question 11 must then be coded as “8 - Not applicable.” Coding may be done automatically by the IVR system or later during data preparation.

• When a response to a screener question is not obtained, the screener question and any questions in the skip pattern should be coded as “M - Missing/Don't know.” For example, if the patient does not provide an answer to Question 10 of the HCAHPS survey, then the IVR system should be programmed to skip Question 11, and go to Question 12. Question 11 must then be coded as “M - Missing/Don't know.” Coding may be done automatically by the IVR system or later during data preparation.

INITIATING CONTACT

START Hello, may I please speak to [SAMPLED PATIENT NAME]?

1. YES [GO TO INTRO]

2. NO [REFUSAL]

3 NO, NOT AVAILABLE RIGHT NOW [SET CALLBACK]

IF ASKED WHO IS CALLING:

This is [OPERATOR NAME] calling from [DATA COLLECTION CONTRACTOR]. We are conducting a survey about healthcare. I am calling to talk to [SAMPLED PATIENT NAME].

IF ASKED WHETHER PERSON CAN SERVE AS PROXY FOR SAMPLED PATIENT:

For this survey, we need to speak directly to [SAMPLED PATIENT NAME]. Is [SAMPLED PATIENT NAME] available?

IF THE SAMPLED PATIENT IS NOT AVAILABLE:

Can you tell me a convenient time to call back to speak with (him/her)?

IF THE SAMPLED PATIENT SAYS THIS IS NOT A GOOD TIME:

If you don’t have the time now, when is a more convenient time to call you back?

SPEAKING WITH SAMPLED PATIENT

INTRO Hi, this is [OPERATOR NAME], calling on behalf of [HOSPITAL NAME]. [HOSPITAL NAME] is participating in a survey about the care people receive in the hospital. This survey is part of a national initiative to measure the quality of care in hospitals. Survey results can be used by people to choose a hospital. Your answers may be shared with the hospital for purposes of quality improvement.

Participation in the survey is completely voluntary and will not affect your health care or your benefits. It should take about 7 minutes [OR VENDOR SPECIFY] to answer.

This call may be monitored [recorded] for quality improvement purposes.

OPTIONAL QUESTION TO INCLUDE;

I’d like to begin the survey now, is this a good time for us to continue?

NOTE: THE NUMBER OF MINUTES WILL DEPEND ON WHETHER HCAHPS IS INTEGRATED WITH HOSPITAL-SPECIFIC QUESTIONS.

S1 Our records show that you were discharged from [HOSPITAL NAME] on or about [DISCHARGE DATE]. Is that right?

READ YES/NO RESPONSE CHOICES ONLY IF NECESSARY

1 YES [GO TO S2]

2 NO [GO TO INEL1]

3 DON”T KNOW [GO TO INEL1]

4 REFUSAL [GO TO INEL1]

S2: Thank you. You will now be connected to an automated interviewing system. If at any time you would like to speak with a live operator, please press [VENDOR SPECIFY] to be connected with someone.

CONFIRMING INELIGIBLE RESPONDENTS

INEL1: Were you ever at this hospital?

1. YES [GO TO INEL2]

2. NO [GO TO INEL_END]

INEL2: Were you a patient at this hospital in the last year?

1 YES [GO TO INEL3]

2 NO [GO TO INEL_END]

INEL3: When was this?

IF ANY DATE WAS WITHIN TWO WEEKS OF [DISCHARGE DATE], GO TO S2; OTHERWISE, GO TO INEL_END.

INEL_END: Thank you for your time. It looks like we made a mistake. Have a good (day/evening).

BEGIN HCAHPS QUESTIONS

MESSAGE 1: You have been successfully connected to the automated interviewing system. The survey will now begin. You may enter [VENDOR SPECIFY] at any time to return to the telephone operator. If you cannot choose one of the response options after a particular question, please wait for further instruction.

Q1_INTRO Please answer the questions in this survey about your stay at [HOSPITAL NAME]. When thinking about your answers, do not include any other hospital stays. The first questions are about the care you received from nurses during this hospital stay.

Q1 During this hospital stay, how often did nurses treat you with courtesy and respect? Would you say never, sometimes, usually, or always?

For “Never”, press '1'

For “Sometimes”, press '2'

For “Usually”, press '3'

For “Always”, press '4'

M MISSING/DK

Q2 During this hospital stay, how often did nurses listen carefully to you? Would you say never, sometimes, usually, or always?

For “Never”, press '1'

For “Sometimes”, press '2'

For “Usually”, press '3'

For “Always”, press '4'

M MISSING/DK

Q3 During this hospital stay, how often did nurses explain things in a way you could understand? Would you say never, sometimes, usually, or always?

For “Never”, press '1'

For “Sometimes”, press '2'

For “Usually”, press '3'

For “Always”, press '4'

M MISSING/DK

Q4 During this hospital stay, after you pressed the call button, how often did you get help as soon as you wanted it? Would you say never, sometimes, usually, always, or I never pressed the call button?

For “Never”, press '1'

For “Sometimes”, press '2'

For “Usually”, press '3'

For “Always”, press '4'

For “I never pressed the call button”, press '9'

M MISSING/DK

Q5_INTRO The next questions are about the care you received from doctors during this hospital stay.

Q5 During this hospital stay, how often did doctors treat you with courtesy and respect? Would you say never, sometimes, usually, or always?

For “Never”, press '1'

For “Sometimes”, press '2'

For “Usually”, press '3'

For “Always”, press '4'

M MISSING/DK

Q6 During this hospital stay, how often did doctors listen carefully to you? Would you say never, sometimes, usually, or always?

For “Never”, press '1'

For “Sometimes”, press '2'

For “Usually”, press '3'

For “Always”, press '4'

M MISSING/DK

Q7 During this hospital stay, how often did doctors explain things in a way you could understand? Would you say never, sometimes, usually, or always?

For “Never”, press '1'

For “Sometimes”, press '2'

For “Usually”, press '3'

For “Always”, press '4'

M MISSING/DK

Q8_INTRO The next set of questions is about the hospital environment.

Q8 During this hospital stay, how often were your room and bathroom kept clean? Would you say never, sometimes, usually, or always?

For “Never”, press '1'

For “Sometimes”, press '2'

For “Usually”, press '3'

For “Always”, press '4'

M MISSING/DK

Q9 During this hospital stay, how often was the area around your room quiet at night? Would you say never, sometimes, usually, or always?

For “Never”, press '1'

For “Sometimes”, press '2'

For “Usually”, press '3'

For “Always”, press '4'

M MISSING/DK

Q10_INTRO The next questions are about your experiences in this hospital.

Q10 During this hospital stay, did you need help from nurses or other hospital staff in getting to the bathroom or in using a bedpan?

For “Yes”, press '1'

For “No”, press '2' [GO TO Q12]

M MISSING/DK [GO TO Q12]

Q11 How often did you get help in getting to the bathroom or in using a bedpan as soon as you wanted? Would you say never, sometimes, usually, or always?

For "Never”, press '1'

For “Sometimes”, press '2'

For “Usually”, press '3'

For “Always”, press '4'

8 NOT APPLICABLE

M MISSING/DK

[NOTE: IF Q10 = “2 - NO” THEN Q11 = “8 - NOT APPLICABLE” OR IF Q10 = “M - MISSING/DK” THEN Q11 = “M - MISSING/DK”]

Q12 During this hospital stay, did you need medicine for pain?

For “Yes”, press '1'

For “No”, press '2' [GO TO Q15]

M MISSING/DK [GO TO Q15]

Q13 During this hospital stay, how often was your pain well controlled? Would you say never, sometimes, usually, or always?

For “Never”, press '1'

For “Sometimes”, press '2'

For “Usually”, press '3'

For “Always”, press '4'

8 NOT APPLICABLE

M MISSING/DK

[NOTE: IF Q12 = “2 - NO” THEN Q13 = “8 - NOT APPLICABLE” OR IF Q12 = “M - MISSING/DK” THEN Q13 = “M - MISSING/DK”]

Q14 During this hospital stay, how often did the hospital staff do everything they could to help you with your pain? Would you say never, sometimes, usually, or always?

For “Never”, press '1'

For “Sometimes”, press '2'

For “Usually”, press '3'

For “Always”, press '4'

8 NOT APPLICABLE

M MISSING/DK

[NOTE: IF Q12 = “2 - NO” THEN Q14 = “8 - NOT APPLICABLE” OR IF Q12 = “M - MISSING/DK” THEN Q14 = “M - MISSING/DK”]

Q15 During this hospital stay, were you given any medicine that you had not taken before?

For “Yes”, press '1'

For “No”, press '2' [GO TO Q18_INTRO]

M MISSING/DK [GO TO Q18_INTRO]

Q16 Before giving you any new medicine, how often did hospital staff tell you what the medicine was for? Would you say never, sometimes, usually, or always?

For “Never”, press '1'

For “Sometimes”, press '2'

For “Usually”, press '3'

For “Always”, press '4'

8 NOT APPLICABLE

M MISSING/DK

[NOTE: IF Q15 = “2 - NO” THEN Q16 = “8 - NOT APPLICABLE” OR IF Q15 = “M - MISSING/DK” THEN Q16 = “M - MISSING/DK”]

Q17 Before giving you any new medicine, how often did hospital staff describe possible side effects in a way you could understand? Would you say never, sometimes, usually, or always?

For “Never”, press '1'

For “Sometimes”, press '2'

For “Usually”, press '3'

For “Always”, press '4'

8 NOT APPLICABLE

M MISSING/DK

[NOTE: IF Q15 = “2 - NO” THEN Q17 = “8 - NOT APPLICABLE” OR IF Q15 = “M - MISSING/DK” THEN Q17 = “M - MISSING/DK”]

Q18_INTRO The next questions are about when you left the hospital.

Q18 After you left the hospital, did you go directly to your own home, to someone else’s home, or to another health facility?

For “Own home” press '1'

For “Someone else's home”, press '2'

For “Another health facility”, press '3' [GO TO Q21]

M MISSING/DK [GO TO Q21]

Q19 During this hospital stay, did doctors, nurses or other hospital staff talk with you about whether you would have the help you needed when you left the hospital?

For “Yes”, press '1'

For “No”, press '2'

8. NOT APPLICABLE

M MISSING/DK

[NOTE: IF Q18 = “3 - ANOTHER HEALTH FACILITY” THEN Q19 = “8 - NOT APPLICABLE” IF Q18 = “M - MISSING/DK” THEN Q19 = “M - MISSING/DK”]

Q20 During this hospital stay, did you get information in writing about what symptoms or health problems to look out for after you left the hospital?

For “Yes”, press '1'

For “No”, press '2'

8 NOT APPLICABLE

M MISSING/DK

[NOTE: IF Q18 = “3 - ANOTHER HEALTH FACILITY” THEN Q20 = “8 - NOT APPLICABLE” IF Q18 = “M - MISSING/DK” THEN Q20 = “M - MISSING/DK”]

Q21 We want to know your overall rating of your stay at [FACILITY NAME]. This is the stay that ended around [DISCHARGE DATE]. Please do not include any other hospital stays in your answer.

Using any number from 0 to 10, where 0 is the worst hospital possible and 10 is the best hospital possible, what number would you use to rate this hospital during your stay?

[VENDOR SPECIFIES HOW TO ENTER BOTH “0” AND “10” INTO THEIR SYSTEM.] Please press this number now.

Q22 Would you recommend this hospital to your friends and family? Would you say definitely no, probably no, probably yes, or definitely yes?

For “Definitely no”, press '1'

For “Probably no”, press '2'

For “Probably yes”, press '3'

For “Definitely yes”, press '4'

M MISSING/DK

Q23_INTRO This last set of questions is about you.

Q23 In general, how would you rate your overall health? Would you say that it is excellent, very good, good, fair, or poor?

For “Excellent”, press '1'

For “Very good”, press '2'

For “Good”, press '3'

For “Fair”, press '4'

For “Poor”, press '5’

M MISSING/DK

Q24 What is the highest grade or level of school that you have completed? Did you complete the 8th grade or less, complete some high school but did not graduate, graduate from high school or earn a GED, complete some college or earn a 2-year degree, graduate from a 4-year college, or complete more than a 4-year college degree?

For “Completed the 8th grade or less”, press '1'

For “Completed some high school, but did not graduate”, press '2'

For “Graduated from high school or earned a GED”, press '3'

For “Completed some college or earned a 2-year degree”, press '4'

For “Graduated from a 4-year college”, press '5'

For “Completed more than a 4-year college degree”, press '6'

M MISSING/DK

Q25 Are you of Spanish, Hispanic or Latino origin or descent? Would you say no, not Spanish/Hispanic/Latino; yes, Puerto Rican; yes, Mexican, Mexican American, Chicano; Yes, Cuban; or Yes, other Spanish/ Hispanic/Latino?

For “No, not Spanish/Hispanic/Latino”, press '1'

For “Yes, Puerto Rican”, press '2'

For “Yes, Mexican, Mexican American, Chicano”, press '3'

For “Yes, Cuban”, press '4'

For “Yes, other Spanish/Hispanic/Latino”, press '5'

M MISSING/DK

[FOR IVR QUESTION 26 IS BROKEN INTO PARTS A-E]

Q26 When I read the following list, please tell me if the category describes your race. You may choose one or more.

Q26A Are you White?

For “Yes”, press '1'

For “No”, press '2'

M MISSING/DK

Q26B Are you Black or African-American?

For “Yes”, press '1'

For “No”, press '2'

M MISSING/DK

Q26C Are you Asian?

For “Yes”, press '1'

For “No”, press '2'

M MISSING/DK

Q26D Are you Native Hawaiian or other Pacific Islander?

For “Yes”, press '1'

For “No”, press '2'

M MISSING/DK

Q26E Are you American Indian or Alaska Native?

For “Yes”, press '1'

For “No”, press '2'

M MISSING/DK

NOTE: “1” and “2” SHOULD BE CONVERTED TO “1” AND “0”, RESPECTIVELY IN THE DATA FILE. FOR VALID VALUES, REFER TO APPENDIX L — DATA FILE STRUCTURE.

Q27 What language do you mainly speak at home? Would you say that you mainly speak English, Spanish, or some other language?

For “English”, press '1'

For “Spanish”, press '2'

For “Some other language”, press '3'

M MISSING/DK

END Those are all the questions I have. Thank you for your time. Have a good (day/evening).