Form 1 Attachment B Child HCAHPS Survey 2019-03-11

Attachment B

Child HCAHPS Survey

Child HCAHPS Narrative Elicitation Pilot Test

CAHPS^® Hospital Survey

Version: Child Version

Language: English

File name: 90399401 Last updated: May 12, 2016

Survey Instructions

Answer each question by marking 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  If Yes, go to #1 on page 1

No

Please answer the questions about the child and hospital named in the cover letter. Do not include any other hospital stays in your answers.

When Your Child Was Admitted to this Hospital

1. Was your child born during this hospital stay?

¹ Yes  If Yes, go to #14 on page 3

² No

2. For this hospital stay, was your child admitted through this hospital’s Emergency Room?

¹ Yes

² No  If No, go to #5

3. Were you in this hospital’s Emergency Room with your child?

¹ Yes

² No  If No, go to #5

4. While your child was in this hospital’s Emergency Room, were you kept informed about what was being done for your child?

¹ Yes, definitely

² Yes, somewhat

³ No

5. During the first day of this hospital stay, were you asked to list or review all of the prescription medicines your child was taking at home?

¹ Yes, definitely

² Yes, somewhat

³ No

6. During the first day of this hospital stay, were you asked to list or review all of the vitamins, herbal medicines, and over-the-counter medicines your child was taking at home?

¹ Yes, definitely

² Yes, somewhat

³ No

Your Child’s Care After Admission to this Hospital

Do not include care received in the Emergency Room for the rest of the survey.

7. Is your child able to talk with nurses and doctors about his or her health care?

¹ Yes

² No  If No, go to #14 on page 3

Your Child’s Experience with Nurses

The next questions ask about your child’s experience during this hospital stay. You will be asked about your own experience during this hospital stay in later questions.

8. During this hospital stay, how often did your child’s nurses listen carefully to your child?

¹ Never

² Sometimes

³ Usually

⁴ Always

9. During this hospital stay, how often did your child’s nurses explain things in a way that was easy for your child to understand?

¹ Never

² Sometimes

³ Usually

⁴ Always

10. During this hospital stay, how often did your child’s nurses encourage your child to ask questions?

¹ Never

² Sometimes

³ Usually

⁴ Always

Your Child’s Experience with Doctors

11. During this hospital stay, how often did your child’s doctors listen carefully to your child?

¹ Never

² Sometimes

³ Usually

⁴ Always

12. During this hospital stay, how often did your child’s doctors explain things in a way that was easy for your child to understand?

¹ Never

² Sometimes

³ Usually

⁴ Always

13. During this hospital stay, how often did your child’s doctors encourage your child to ask questions?

¹ Never

² Sometimes

³ Usually

⁴ Always

Your Experience with Nurses

14. During this hospital stay, how often did your child’s nurses listen carefully to you?

¹ Never

² Sometimes

³ Usually

⁴ Always

15. During this hospital stay, how often did your child’s nurses explain things to you in a way that was easy to understand?

¹ Never

² Sometimes

³ Usually

⁴ Always

16. During this hospital stay, how often did your child’s nurses treat you with courtesy and respect?

¹ Never

² Sometimes

³ Usually

⁴ Always

Your Experience with Doctors

17. During this hospital stay, how often did your child’s doctors listen carefully to you?

¹ Never

² Sometimes

³ Usually

⁴ Always

18. During this hospital stay, how often did your child’s doctors explain things to you in a way that was easy to understand?

¹ Never

² Sometimes

³ Usually

⁴ Always

19. During this hospital stay, how often did your child’s doctors treat you with courtesy and respect?

¹ Never

² Sometimes

³ Usually

⁴ Always

Your Experience with Providers

20. A provider in the hospital can be a doctor, nurse, nurse practitioner, or physician assistant. During this hospital stay, how often were you given as much privacy as you wanted when discussing your child’s care with providers?

¹ Never

² Sometimes

³ Usually

⁴ Always

21. Things that a family might know best about a child include how the child usually acts, what makes the child comfortable, and how to calm the child’s fears. During this hospital stay, did providers ask you about these types of things?

¹ Yes, definitely

² Yes, somewhat

³ No

22. During this hospital stay, how often did providers talk with and act toward your child in a way that was right for your child’s age?

¹ Never

² Sometimes

³ Usually

⁴ Always

23. During this hospital stay, how often did providers keep you informed about what was being done for your child?

¹ Never

² Sometimes

³ Usually

⁴ Always

24. Tests in the hospital can include things like blood tests and x-rays. During this hospital stay, did your child have any tests?

¹ Yes

² No  If No, go to #26

25. How often did providers give you as much information as you wanted about the results of these tests?

¹ Never

² Sometimes

³ Usually

⁴ Always

Your Child’s Care in this Hospital

26. During this hospital stay, did you or your child ever press the call button?

¹ Yes

² No  If No, go to #28

27. After pressing the call button, how often was help given as soon as you or your child wanted it?

¹ Never

² Sometimes

³ Usually

⁴ Always

28. During this hospital stay, was your child given any medicine?

¹ Yes

² No  If No, go to #30

29. Before giving your child any medicine, how often did providers or other hospital staff check your child’s wristband or confirm his or her identity in some other way?

¹ Never

² Sometimes

³ Usually

⁴ Always

30. Mistakes in your child’s health care can include things like giving the wrong medicine or doing the wrong surgery. During this hospital stay, did providers or other hospital staff tell you how to report if you had any concerns about mistakes in your child’s health care?

¹ Yes, definitely

² Yes, somewhat

³ No

31. During this hospital stay, did your child have pain that needed medicine or other treatment?

¹ Yes

² No  If No, go to #33

32. During this hospital stay, did providers or other hospital staff ask about your child’s pain as often as your child needed?

¹ Yes, definitely

² Yes, somewhat

³ No

The Hospital Environment

33. During this hospital stay, how often were your child’s room and bathroom kept clean?

¹ Never

² Sometimes

³ Usually

⁴ Always

34. During this hospital stay, how often was the area around your child’s room quiet at night?

¹ Never

² Sometimes

³ Usually

⁴ Always

35. Hospitals can have things like toys, books, mobiles, and games for children from newborns to teenagers. During this hospital stay, did the hospital have things available for your child that were right for your child’s age?

¹ Yes, definitely

² Yes, somewhat

³ No

When Your Child Left this Hospital

36. As a reminder, a provider in the hospital can be a doctor, nurse, nurse practitioner, or physician assistant. Before your child left the hospital, did a provider ask you if you had any concerns about whether your child was ready to leave?

¹ Yes, definitely

² Yes, somewhat

³ No

37. Before your child left the hospital, did a provider talk with you as much as you wanted about how to care for your child’s health after leaving the hospital?

¹ Yes, definitely

² Yes, somewhat

³ No

38. Before your child left the hospital, did a provider tell you that your child should take any new medicine that he or she had not been taking when this hospital stay began?

¹ Yes

² No  If No, go to #41

39. Before your child left the hospital, did a provider or hospital pharmacist explain in a way that was easy to understand how your child should take these new medicines after leaving the hospital?

¹ Yes, definitely

² Yes, somewhat

³ No

40. Before your child left the hospital, did a provider or hospital pharmacist explain in a way that was easy to understand about possible side effects of these new medicines?

¹ Yes, definitely

² Yes, somewhat

³ No

41. A child’s regular activities can include things like eating, bathing, going to school, or playing sports. Before your child left the hospital, did a provider explain in a way that was easy to understand when your child could return to his or her regular activities?

¹ Yes, definitely

² Yes, somewhat

³ No

42. Before your child left the hospital, did a provider explain in a way that was easy to understand what symptoms or health problems to look out for after your child left the hospital?

¹ Yes, definitely

² Yes, somewhat

³ No

43. Before your child left the hospital, did you get information in writing about what symptoms or health problems to look out for after your child left the hospital?

¹ Yes, definitely

² Yes, somewhat

³ No

Your Teen’s Care in this Hospital

44. During this hospital stay, was your child 13 years old or older?

¹ Yes

² No  If No, go to #48

45. During this hospital stay, how often did providers involve your child in discussions about his or her health care?

¹ Never

² Sometimes

³ Usually

⁴ Always

46. Before your child left the hospital, did a provider ask your child if he or she had any concerns about whether he or she was ready to leave?

¹ Yes, definitely

² Yes, somewhat

³ No

47. Before your child left the hospital, did a provider talk with your child about how to take care of his or her health after leaving the hospital?

¹ Yes, definitely

² Yes, somewhat

³ No

Overall Rating of This Hospital

As a reminder, please answer the questions about the child and hospital named in the cover letter. Do not include any other hospital stays in your answers.

48. 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 child’s stay?

0 Worst hospital possible

1

2

3

4

5

6

7

8

9

10 Best hospital possible

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

¹ Definitely no

² Probably no

³ Probably yes

⁴ Definitely yes

About Your Child

50. In general, how would you rate your child’s overall health?

¹ Excellent

² Very good

³ Good

⁴ Fair

⁵ Poor

51. What is your child’s age?

Less than 1 year old

______ YEARS OLD (write in)

52. Is your child male or female?

¹ Male

² Female

53. Is your child of Hispanic or Latino origin or descent?

¹ Yes, Hispanic or Latino

² No, not Hispanic or Latino

54. What is your child’s race? Mark 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

⁶ Other

About You

55. How are you related to the child?

¹ Mother

² Father

³ Grandmother

⁴ Grandfather

⁵ Other relative or legal guardian

⁶ Someone else

Please print:

56. What is your age?

⁰ Under 18

¹ 18-24

² 25-34

³ 35-44

⁴ 45-54

⁵ 55-64

⁶ 65-74

⁷ 75 and older

57. 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

58. What is your preferred language?

¹ English

² Spanish

³ Chinese

⁴ Vietnamese

⁵ Korean

⁶ Russian

⁷ Other language

Please print:

59. During your child’s hospital stay, how much of the time were you at the hospital?

¹ None of the time

² A little of the time

³ Some of the time

⁴ Most of the time

⁵ All or nearly all of the time

60. Is there anything else you would like to say about the care your child received during this hospital stay?

Please print:

61. Did someone help you complete this survey?

¹ Yes

² No  Thank you.

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

62. How did that person help you? Mark one or more.

¹ Read the questions to me

² Wrote down the answers I gave

³ Answered the questions for me

⁴ Translated the questions into my language

⁵ Helped in some other way

Please print:

Thank you.

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