CMS-10102 Appendix C

Supporting Statement for the National Implementation of the Hospital CAHPS Survey

Appendix C
Expanded HCAHPS Survey
July 2012

(New items are highlighted)

August 2011

1

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

 Never
 Sometimes
3
 Usually
4
 Always

Please answer the questions in this survey

1
2

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?

 Never
 Sometimes
3
 Usually
4
 Always
1
2

2.

During this hospital stay, how often did
nurses listen carefully to you?
August 2011

2

3.

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

 Never
2
 Sometimes
3
 Usually
4
 Always
1

YOUR CARE FROM DOCTORS
5.

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

 Never
 Sometimes
3
 Usually
4
 Always
1
2

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

 Never
 Sometimes
3
 Usually
4
 Always
1

 Never
 Sometimes
3
 Usually
4
 Always
9
 I never pressed the call button
1
2

2

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

 Never
 Sometimes
3
 Usually
4
 Always
1
2

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

 Never
 Sometimes
3
 Usually
4
 Always
1
2

March 2011
2

9. During this hospital stay, how often

YOUR EXPERIENCES IN THIS
HOSPITAL

was the area around your room quiet at

10. During this hospital stay, did you need

night?

help from nurses or other hospital staff in

 Never
2
 Sometimes
3
 Usually
4
 Always
1

getting to the bathroom or in using a
bedpan?




1

2

Yes
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?

 Never
 Sometimes
3
 Usually
4
 Always
1
2

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




1
2

Yes
No  If No, Go to Question 15

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

 Never
 Sometimes
3
 Usually
4
 Always
1
2

14. During this hospital stay, how often did
the hospital staff do everything they could
to help you with your pain?
March 2011
3

 Never
2
 Sometimes
3
 Usually
4
 Always
1

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?

 Never
 Sometimes
3
 Usually
4
 Always
1
2

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

 Never
 Sometimes
3
 Usually
4
 Always
1
2

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?

 Own home
 Someone else’s home
3
 Another health
1
2

facility 

If Another, Go to
Question 21

19. During this hospital stay, did doctors,
nurses or other hospital staff talk with you
March 2011
4

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?


2

1

Yes
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
1
2
2
3
3
4
4
5
5
6
6
7
7
8
8
9
9
10
10
0

Worst hospital possible

1

March 2011
5

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

27. In general, how would you rate your

UNDERSTANDING YOUR CARE
WHEN YOU LEFT THE HOSPITAL

overall health?

Please answer a few more questions
about when you left the hospital.

 Excellent
 Very good
3
 Good
4
 Fair
5
 Poor
1
2

23. During this hospital stay, staff took my
preferences and those of my family or
caregiver into account in deciding what my
health care needs would be when I left.
1
 Strongly disagree
2
 Disagree
3
 Agree
4
 Strongly agree

28. In general, how would you rate your
overall mental or emotional health?

24. When I left the hospital, I had a good
understanding of the things I was
responsible for in managing my health.
1
 Strongly disagree
2
 Disagree
3
 Agree
4
 Strongly agree
25. When I left the hospital, I clearly
understood the purpose for taking each of
my medications.
1
 Strongly disagree
2
 Disagree
3
 Agree
4
 Strongly agree
5
 I was not given any medication
when I left the hospital

 Excellent
 Very good
3
 Good
4
 Fair
5
 Poor
1
2

29.

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

 8th grade or less
 Some high school, but did not

1
2



5

6

3
4

ABOUT YOU
There are only a few remaining items left.
26.

graduate
High school graduate or GED
Some college or 2-year degree
4-year college graduate
More than 4-year college degree

During this hospital stay, were you
admitted to this hospital through the
Emergency Room?

 Yes
 No

1
2

March 2011
6

30. 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

 Yes, other

5

Spanish/Hispanic/Latino

March 2011
7

31.

What is your race? Please choose one

32.

What language do you mainly speak at

or more.

home?

 White
2
 Black or African American
3
 Asian
4
 Native Hawaiian or other Pacific

1

1



5

Islander
American Indian or Alaska
Native

March 2011
8

 English
 Spanish
3
 Chinese
4
 Russian
5
 Vietnamese
6
 Some other language (please
2

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]

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