Form CMS-10542 HCAHPS Survey+9 Supplemental Items

HCAHPS Survey+9 Supplemental Items
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 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

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.

3.

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

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?

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

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

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

November 2014

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

6.

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

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

7.

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

 Never
 Sometimes
3
 Usually
4
 Always
1

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

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

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

9.

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

 Never
 Sometimes
3
 Usually
4
 Always
1

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?

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

2

2

November 2014

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




1
2

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
3
 Usually
4
 Always
1
2

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
2

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
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 

November 2014

If Another, Go to
Question 21

Yes
No

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

Best hospital possible

3

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

 Definitely no
 Probably no
3
 Probably yes
4
 Definitely yes
1

MORE QUESTIONS
ABOUT MEDICINE
We have some additional questions about
your experiences during this hospital stay.

2

26.




1
2

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
3
 Agree
4
 Strongly agree
1

During this hospital stay, did you
have any pain?

27.

Yes
No  If No, Go to Question 30

During this hospital stay, how
often did hospital staff try to help
reduce your pain?

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

2

24. When I left the hospital, I had a
good understanding of the things I
was responsible for in managing
my health.

 Strongly disagree
2
 Disagree
3
 Agree
4
 Strongly agree
1

25. When I left the hospital, I clearly
understood the purpose for taking
each of my medications.

28. During this hospital stay, did you
get medicine for pain?




1
2

Yes
No  If No, Go to Question 30

29. Before giving you pain medicine,
did hospital staff describe
possible side effects in a way you
could understand?




1
2

Yes
No

 Strongly disagree
 Disagree
3
 Agree
4
 Strongly agree
5
 I was not given any medication
1
2

when I left the hospital

4

November 2014

30. During this hospital stay, did you
take any medicine that you had
not taken before?




1
2

Yes
No  If No, Go to Question 34

31. Did you and hospital staff talk
about the reasons you might want
to take the medicine?




1
2

Yes
No

ABOUT YOU
There are only a few remaining items
left.
35. During this hospital stay, were you
admitted to this hospital through
the Emergency Room?

 Yes
 No

1
2

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

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

32. Did you and hospital staff talk
about the reasons you might not
want to take the medicine?




1
2

Yes
No

33. When you and hospital staff talked
about taking the new medicine,
did they ask what you thought was
best for you?

 Yes
 No
9
 Hospital staff did not talk with me
1
2

about taking the new medicine

MORE QUESTIONS ABOUT
WHEN YOU LEFT THE HOSPITAL
34. During this hospital stay, did
hospital staff give you a telephone
number to call if you had problems
after you left the hospital?


2

1

2

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

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

38. 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

Yes
No

November 2014

4

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

5

39. Are you of Spanish, Hispanic or
Latino origin or descent?

41. What language do you mainly
speak at home?

 No, not Spanish/Hispanic/Latino
2
 Yes, Puerto Rican
3
 Yes, Mexican, Mexican American,
1

Chicano
 Yes, Cuban
5
 Yes, other
Spanish/Hispanic/Latino
4

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

 English
 Spanish
3
 Chinese
4
 Russian
5
 Vietnamese
6
 Portuguese
9
 Some other language (please
1
2

print): _____________________

 White
 Black or African American
3
 Asian
4
 Native Hawaiian or other Pacific
1
2



5

Islander
American Indian or Alaska
Native

THANK YOU
Please return the completed survey in the postage-paid envelope.
RAND Corporation
PO Box 2138
Santa Monica, CA 90407-2138

Questions 1-22 and 35-41 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).

6

November 2014

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-NEW. The time required to complete this
information collected is estimated to average 10 minutes, including the time to review
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November 2014

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