Form CMS-10694 HCAHPS Survey Mode

HCAHPS Survey Mode 5 Version

SURVEY INSTRUCTIONS

• This survey asks about you and the care you received during the hospital stay named in the cover letter.

• 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 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.

YOUR CARE FROM NURSES



1. During this hospital stay, how often did nurses treat you with courtesy and respect?

¹ Never

² Sometimes

³ Usually

⁴ Always

2. During this hospital stay, how often did nurses listen carefully to you?

¹ Never

² Sometimes

³ Usually

⁴ Always

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

¹ Never

² Sometimes

³ Usually

⁴ Always

4. During this hospital stay, after you pressed the call button, how often did you get help as soon as you needed?

¹ Never

² Sometimes

³ Usually

⁴ Always

⁹ 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?

¹ Never

² Sometimes

³ Usually

⁴ Always

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

¹ Never

² Sometimes

³ Usually

⁴ Always

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

¹ Never

² Sometimes

³ Usually

⁴ Always

THE HOSPITAL ENVIRONMENT



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

¹ Never

² Sometimes

³ Usually

⁴ Always

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

¹ Never

² Sometimes

³ Usually

⁴ Always

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 Yes

² 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?

¹ Never

² Sometimes

³ Usually

⁴ Always

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

¹ Yes

² No  If No, Go to Question 15

13. Before giving you any new medicine, how often did hospital staff tell you what the medicine was for?

¹ Never

² Sometimes

³ Usually

⁴ Always

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

¹ Never

² Sometimes

³ Usually

⁴ Always

WHEN YOU LEFT THE HOSPITAL



15. After you left the hospital, did you go directly to your own home, to someone else’s home, or to another health facility?

¹ Own home

² Someone else’s home

³ Another health

facility  If Another, Go to Question 18

16. 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 Yes

² No

17. 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 Yes

² 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.

18. 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

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

¹ Definitely no

² Probably no

³ Probably yes

⁴ Definitely yes

ABOUT YOU

20. Was this hospital stay planned in advance?

¹ Yes, definitely

² Yes, somewhat

³ No

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

¹ Excellent

² Very good

³ Good

⁴ Fair

⁵ Poor

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

¹ Excellent

² Very good

³ Good

⁴ Fair

⁵ Poor

23. What language do you mainly speak at home?

¹ English

² Spanish

³ Chinese

⁴ Russian

⁵ Vietnamese

⁶ Portuguese

⁷ German

⁹ Some other language (please print): _____________________

24. 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

25. 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

⁵ Yes, other Spanish/Hispanic/Latino

26. What is your race? Please choose 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

MORE QUESTIONS ABOUT YOUR
EXPERIENCES IN THIS HOSPITAL

We have some additional questions about your experiences during this hospital stay.

27. During this hospital stay, when you asked for help right away, how often did you get help as soon as you needed?

¹ Never

² Sometimes

³ Usually

⁴ Always

⁹ I never asked for help right away

27. During this hospital stay, how often did doctors, nurses or other hospital staff give you the emotional support you needed?

¹ Never

² Sometimes

³ Usually

⁴ Always

27. During this hospital stay, did doctors, nurses or other hospital staff talk with you about any worries or concerns you had?

¹ Yes, definitely

² Yes, somewhat

³ No

⁹ I did not have worries or concerns

27. During this hospital stay, how often were doctors, nurses and other hospital staff informed and up-to-date about your care?

¹ Never

² Sometimes

³ Usually

⁴ Always

27. During this hospital stay, how often did doctors, nurses and other hospital staff work well together to care for you?

¹ Never

² Sometimes

³ Usually

⁴ Always

27. During this hospital stay, how often were you able to get the rest you needed?

¹ Never

² Sometimes

³ Usually

⁴ Always

27. During this hospital stay, did doctors, nurses and other hospital staff help you to rest and recover?

¹ Yes, definitely

² Yes, somewhat

³ No

MORE QUESTIONS ABOUT WHEN
YOU LEFT THE HOSPITAL

34. Did doctors, nurses or other hospital staff work with you and your family or caregiver in making plans for your care after you left the hospital?

¹ Yes, definitely

² Yes, somewhat

³ No

34. When you left the hospital, did you understand what each of your medications was for?

¹ Yes, definitely

² Yes, somewhat

³ No

⁹ I did not have medications

34. Did you understand what you would need to do to care for yourself after you left the hospital?

¹ Yes, definitely

² Yes, somewhat

³ No

34. During this hospital stay, did doctors, nurses or other hospital staff give your family or caregiver enough information about what symptoms or health problems to watch for after you left the hospital?

¹ Yes, definitely

² Yes, somewhat

³ No

⁹ I did not have family or a caregiver watch for symptoms or health problems

34. During this hospital stay, did doctors, nurses or other hospital staff give your family or caregiver enough information to care for you after you left the hospital?

¹ Yes, definitely

² Yes, somewhat

³ No

⁹ I did not have family or a caregiver care for me

34. During this hospital stay, did you get enough information about prescription or other medicines you would need to take after you left the hospital?

¹ Yes, definitely

² Yes, somewhat

³ No

34. During this hospital stay, did doctors, nurses or other hospital staff talk with you about the follow-up care you would need after you left the hospital?

¹ Yes, definitely

² Yes, somewhat

³ No

34. During this hospital stay, did doctors, nurses or other hospital staff give you enough information about symptoms or health problems to watch for?

¹ Yes, definitely

² Yes, somewhat

³ No

34. Did someone help you to complete this survey?

¹ Yes

34. ² No  Thank you. Please return

35. the completed survey in the pre-paid envelope.

43. How did that person help you? Please choose 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

THANK YOU

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

RAND CORPORATION

PO BOX 2138

SANTA MONICA, CA 90407-2138

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 0938-1370 (Expires November 30, 2022). The time required to complete this information collected is estimated to average 11 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 21244-1850.

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