CMS-10543 EDPEC for Admitted Patients: HCAHPS Add-on Version A

ATTACHMENT 2 EDPEC HCAHPS Add-on Version A

EDPEC Survey—Admitted HCAHPS Addon Instrument, Version A
SURVEY INSTRUCTIONS
[IF NON-PROXY ONLY] 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 used to let us know
if you returned your survey so we don't have to send you reminders.
Please note: Questions 1-25 in this survey are part of a national initiative to
measure the quality of care in hospitals. OMB #0938-0981.

THE FIRST QUESTIONS IN THE SURVEY WILL ASK ABOUT YOUR HOSPITAL
STAY. LATER IN THE SURVEY, YOU WILL BE ASKED ABOUT THE
EMERGENCY ROOM VISIT IMMEDIATELY PRIOR TO YOUR HOSPITAL STAY.

ATTACHMENT 1 Admitted HCAHPS Add-on Instrument –Version A

Please answer these questions only about your stay at the hospital named on the cover
letter. Do not include any other stays in your answers. We will ask about your visit to the
emergency room later in the survey.
YOUR CARE FROM NURSES
1. During this hospital stay, how often did nurses treat you with courtesy and respect?
Never
Sometimes
Usually
Always
2. During this hospital stay, how often did nurses listen carefully to you?
Never
Sometimes
Usually
Always
3. During this hospital stay, how often did nurses explain things in a way you could
understand?
Never
Sometimes
Usually
Always
4. During this hospital stay, after you pressed the call button, how often did you get help
as soon as you wanted it?
Never
Sometimes
Usually
Always
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?
Never
Sometimes
Usually
Always

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ATTACHMENT 1 Admitted HCAHPS Add-on Instrument –Version A

6. During this hospital stay, how often did doctors listen carefully to you?
Never
Sometimes
Usually
Always
7. During this hospital stay, how often did doctors explain things in a way you could
understand?
Never
Sometimes
Usually
Always

THE HOSPITAL ENVIRONMENT
8. During this hospital stay, how often were your room and bathroom kept clean?
Never
Sometimes
Usually
Always
9. During this hospital stay, how often was the area around your room quiet at night?
Never
Sometimes
Usually
Always
YOUR EXPERIENCES IN THE 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?
Yes
No  If No, Go to Question 12

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ATTACHMENT 1 Admitted HCAHPS Add-on Instrument –Version A

11. How often did you get help in getting to the bathroom or in using a bedpan as soon
as you wanted?
Never
Sometimes
Usually
Always
12. During this hospital stay, did you need medicine for pain?
Yes
No  If No, Go to Question 15

13. During this hospital stay, how often was your pain well controlled?
Never
Sometimes
Usually
Always
14. During this hospital stay, how often did the hospital staff do everything they could to
help you with your pain?
Never
Sometimes
Usually
Always

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

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ATTACHMENT 1 Admitted HCAHPS Add-on Instrument –Version A

17. Before giving you any new medicine, how often did hospital staff describe possible
side effects in a way you could understand?
Never
Sometimes
Usually
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?
Own home
Someone else’s home
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?
Yes
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?
Yes
No

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ATTACHMENT 1 Admitted HCAHPS Add-on Instrument –Version A

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 or your experience in the
emergency room 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 Worst hospital possible
1
2
3
4
5
6
7
8
9
10 Best hospital possible
22. Would you recommend this hospital to your friends and family?
Definitely no
Probably no
Probably yes
Definitely yes
UNDERSTANDING YOUR CARE WHEN YOU LEFT THE HOSPITAL
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.
Strongly disagree
Disagree
Agree
Strongly agree
24. When I left the hospital, I had a good understanding of the things I was responsible
for in managing my health.
Strongly disagree
Disagree
Agree
Strongly agree

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ATTACHMENT 1 Admitted HCAHPS Add-on Instrument –Version A

25. When I left the hospital, I clearly understood the purpose for taking each of my
medications.
Strongly disagree
Disagree
Agree
Strongly agree
I was not given any medication when I left the hospital
GOING TO THE EMERGENCY ROOM
For these next questions, please think about the emergency room visit immediately prior
to this hospital admission. Please do not include your experiences after you were
admitted to the hospital.
26. Thinking about this visit, what was the main reason why you went to the emergency
room?
An accident or injury
A new health problem
An ongoing health condition or concern
27. For this visit, did you go to the emergency room in an ambulance?
Yes
No
28. When you first arrived at the emergency room, how long was it before someone
talked to you about the reason why you were there?
Less than 5 minutes
5 to 15 minutes
More than 15 minutes
DURING YOUR EMERGENCY ROOM VISIT
29. During this emergency room visit, did you get care within 30 minutes of getting to
the emergency room?
Yes
No

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ATTACHMENT 1 Admitted HCAHPS Add-on Instrument –Version A

30. During this emergency room visit, did you have any pain?
Yes
No If No, Go to Question 34
31 During this emergency room visit, did the doctors and nurses try to help reduce your
pain?
Yes, Definitely
Yes, Somewhat
No
32. During this emergency room visit, did you get medicine for pain?
Yes
NoIf No, Go to Question 34
33. Before giving you pain medicine, did the doctors and nurses describe possible side
effects in a way you could understand?
Yes, Definitely
Yes, Somewhat
No
PEOPLE WHO TOOK CARE OF YOU IN THE EMERGENCY ROOM
Please answer the following questions about the people who took care of you while you
were in the emergency room.
34. During this emergency room visit, how often did nurses treat you with courtesy and
respect?
Never
Sometimes
Usually
Always
35. During this emergency room visit, how often did nurses explain things in a way you
could understand?
Never
Sometimes
Usually
Always

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ATTACHMENT 1 Admitted HCAHPS Add-on Instrument –Version A

36. During this emergency room visit, did nurses spend enough time with you?
Yes
No
37. During this emergency room visit, how often did doctors treat you with courtesy and
respect?
Never
Sometimes
Usually
Always
LEAVING THE EMERGENCY ROOM
38. Once you found out you would have to stay in the hospital, were you kept informed
about how long it would be before you went to another part of the hospital?
Yes, definitely
Yes, somewhat
No
OVERALL EMERGENCY ROOM EXPERIENCE
39. Using any number from 0 to 10, where 0 is the worst care possible and 10 is the
best care possible, what number would you use to rate your care during this
emergency room visit?
0 – Worst care possible
1
2
3
4
5
6
7
8
9
10 – Best care possible

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ATTACHMENT 1 Admitted HCAHPS Add-on Instrument –Version A

40. In the last 6 months, how many times have you visited any emergency room to get
care for yourself? Please include the emergency room visit you have been
answering questions about in this survey.
1 time
2 times
3 times
4 times
5 to 9 times
10 or more times
ABOUT YOU
There are only a few remaining items left.
41. In general, how would you rate your overall health?
Excellent
Very good
Good
Fair
Poor
42. In general, how would you rate your overall mental or emotional health?
Excellent
Very good
Good
Fair
Poor
43. What is the highest grade or level of school that you have completed?
8th grade or less
Some high school, but did not graduate
High school graduate or GED
Some college or 2-year degree
4-year college graduate
More than 4-year college degree

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ATTACHMENT 1 Admitted HCAHPS Add-on Instrument –Version A

44. Are you of Spanish, Hispanic or Latino origin or descent?
No, not Spanish/Hispanic/Latino
Yes, Puerto Rican
Yes, Mexican, Mexican American, Chicano
Yes, Cuban
Yes, other Spanish/Hispanic/Latino
45. What is your race? Please choose one or more.
White
Black or African American
Asian
Native Hawaiian or other Pacific Islander
American Indian or Alaska Native
46. What language do you mainly speak at home?
English
Spanish
Chinese
Russian
Vietnamese
Portuguese
Some other language (please print): _____________________
47. Did someone help you complete this survey?
Yes
No → Thank you. Please return the completed survey in the postage-paid
envelope.
48. How did that person help you? Mark one or more.
Read the questions to me
Wrote down the answers I gave
Answered the questions for me
Translated the questions into my language
Helped in some other way
Please print: __________________

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ATTACHMENT 1 Admitted HCAHPS Add-on Instrument –Version A

49. Was the person who helped you with you at any time during this emergency room
visit?
Yes
No
THANK YOU

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

Questions 1-22 and 41-46 are part of the HCAHPS Survey and are works of the U.S. Government. These
HCAHPS questions are in the public domain and therefore are NOT subject to U.S. copyright laws. The
three Care Transitions Measure® questions (Questions 23-25) are copyright of The Care Transitions
Program® (www.caretransitions.org).
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 xxxx-xxxx. The time required to complete this information collected is estimated
to average 12.5 minutes, 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 212441850.

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