Form #9 Form #9 Patient Outcome Survey

Attachment J

LEP Patient Outcomes Survey

L

Form Approved
OMB No. 0935-XXXX
Exp. Date XX/XX/20XX

EP Patient Survey

SCREENING QUESTION

What is your preferred language?

¹ English  If English, end questions

² Spanish

³ Chinese

⁴ French

⁵ Italian

⁶ German

⁷ Korean

⁸ Vietnamese

⁹ Polish

¹⁰ Japanese

¹¹ American Sign Language

¹² Some other language

1. How well do you speak English?

¹ Very well

² Well

³ Not well

⁴ Not at all

2. How well do you understand English?

¹ Very well

² Well

³ Not well

⁴ Not at all

 If 1. and 2.=very well, end questions

Remember that hospital staff include doctors, nurses, nurses aides, and anyone else who helped you while you were in the hospital.

3. During this hospital stay, how often did hospital staff speak to you in your preferred language?

¹ Never

² Sometimes

³ Usually

⁴ Always  If Always, Go to Question 11

4. An interpreter is someone who helps you talk with others who do not speak your language. During this hospital stay, did hospital staff tell you that you had a right to interpreter services free of charge?

¹ Yes

² No

5. During this hospital stay, did a child younger than 18 interpret for you?

¹ Yes

² No

6. During this hospital stay, how often did you use friends or family members as interpreters when you talked with hospital staff?

¹ NeverIf Never, Go to Question 9

² Sometimes

³ Usually

⁴ Always

7. During this hospital stay, how often did you use friends or family members as interpreters because no other interpreter was available?

¹ Never

² Sometimes

³ Usually

⁴ Always

8. During this hospital stay, how often did you use friends or family members as interpreters because you preferred them to using an interpreter provided by the hospital?

¹ Never

² Sometimes

³ Usually

⁴ Always

9. During this hospital stay, did the hospital ever provide you with an interpreter? Include telephone interpreters and bilingual hospital staff who helped you speak with someone else at the hospital.

¹ Yes

² No  If No, Go to Question 11

10. During this hospital stay, how often did you need an interpreter to help you talk with hospital staff but did not get one?

¹ Never

² Sometimes

³ Usually

⁴ Always

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

¹ Never

² Sometimes

³ Usually

⁴ Always

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

¹ Never

² Sometimes

³ Usually

⁴ ^Always

13. 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

14. During this hospital stay, did hospital staff tell you how to take care of yourself at home?

¹ Yes

² No  If No, Go to Question 16

15. Was the information easy to understand?

¹ Yes

² No

16. During this hospital stay, did you get instructions in writing about how to take care of yourself at home?

¹ Yes

² No  If No, Go to Question 19

17. Were the instructions available in your preferred language?

¹ Yes

² No

18. Were the written instructions easy to understand?

¹ Yes

² No

O VERALL RATING OF HOSPITAL



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

19. 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

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

¹ Definitely no

² Probably no

³ Probably yes

⁴ Definitely yes

Public reporting burden for this collection of information is estimated to average 10 minutes per response, the estimated time required to complete the survey. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: AHRQ Reports Clearance Officer Attention: PRA, Paperwork Reduction Project (0935-XXXX) AHRQ, 540 Gaither Road, Room # 5036, Rockville, MD 20850.