2 Patient experience survey

Form Approved
OMB No. 0935-XXXX
Exp. Date XX/XX/20XX

Patient Experience Survey

This survey is authorized under 42 U.S.C. 299a. Your responses to this survey are voluntary, and the confidentiality of your responses is protected by Sections 944(c) and 308(d) of the Public Health Service Act [42 U.S.C. 299c-3(c) and 42 U.S.C. 242m(d)]. Information that could identify you will not be disclosed unless you have consented to that disclosure. Public reporting burden for this collection of information is estimated to average 22 minutes per response, the estimated time required to complete the survey. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: AHRQ Reports Clearance Officer Attention: PRA, Paperwork Reduction Project (0935-XXXX) AHRQ, 5600 Fishers Lane, # 07W41A, Rockville, MD 20857.

2017

 

Survey Instructions

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 #1.

This survey asks about your experience at the hospital named in the cover letter.

Please answer these questions only for the surgery you had on the date(s) included in the cover letter. Do not include any other surgeries in your answers.

I. Before Your Surgery

1. Before your surgery, did your surgeon’s office or the hospital give you all the information you needed about your surgery?

1. Yes, definitely

2. Yes, somewhat

3. No

2. Before your surgery, did your surgeon’s office or the hospital give you easy to understand instructions about getting ready for your surgery?

1. Yes, definitely

2. Yes, somewhat

3. No

II. About your Surgery

3. Anesthesia is something that would make you feel sleepy or go to sleep during your surgery. Were you given anesthesia?

1. Yes

2. No If No, go to Question 6

4. Did your surgeon or anyone from the hospital explain the process of giving anesthesia in a way that was easy to understand?

1. Yes, definitely

2. Yes, somewhat

3. No

5. Did your surgeon or anyone from the hospital explain the possible side effects of the anesthesia in a way that was easy to understand?

1. Yes, definitely

2. Yes, somewhat

3. No

III. During Your Hospital Stay

6. During your hospital stay, how often did the doctors and nurses treat you with courtesy and respect?

1. Never

2. Sometimes

3. Usually

4. Always

7. During your hospital stay, how often did the doctors and nurses make sure you were as comfortable as possible?

1. Never

2. Sometimes

3. Usually

4. Always

8. During your hospital stay, did you need medicine for pain?

1. Yes

2. No  If No, Go to Question 11

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

1. Never

2. Sometimes

3. Usually

4. Always

10. During your hospital stay, how often did the hospital staff do everything they could to help you with your pain?

1. Never

2. Sometimes

3. Usually

4. Always

IV. Your Recovery

11. Did your surgeon or anyone from the hospital prepare you for what to expect during your recovery?

1. Yes, definitely

2. Yes, somewhat

3. No

12. Some ways to control pain include prescription medicine, over-the-counter pain relievers or ice packs. Before you left the hospital, did you get information about what to do if you had pain as a result of your surgery?

1. Yes, definitely

2. Yes, somewhat

3. No

13. At any time after leaving the hospital, did you have pain as a result of your surgery?

1. Yes

2. No

14. Before you left the hospital, did you get information about what to do if you had nausea or vomiting?

1. Yes, definitely

2. Yes, somewhat

3. No

15. At any time after leaving the hospital, did you have nausea or vomiting as a result of either your surgery or the anesthesia?

1. Yes

2. No

16. Possible signs of infection include fever, swelling, heat, drainage or redness. Before you left the hospital, did you get information about what to do if you had possible signs of infection?

1. Yes, definitely

2. Yes, somewhat

3. No

17. At any time after leaving the hospital, did you have any signs of infection?

1. Yes

2. No

18. Before you left the hospital, 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

V. Your Overall Experience

19. 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?

0 Worst hospital possible

1

2

3

4

5

6

7

8

9

10 Best hospital possible

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

1. Definitely no

2. Probably no

3. Probably yes

4. Definitely yes

VI. About You

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. In the past 7 days, to what extent have you been able to return to your everyday physical activities such as walking, climbing stairs, carrying groceries, or moving a chair?

1. Completely

2. Mostly

3. Moderately

4. A little

5. Not at all

24. What is your age?

1. 18 to 24

2. 25 to 34

3. 35 to 44

4. 45 to 54

5. 55 to 64

6. 65 to 74

7. 75 to 79

8. 80 to 84

9. 85 or older

25. Are you male or female?

1. Male

2. Female

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

1. 8^th 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

27. Are you of Hispanic or Latino origin or descent?

1. Yes, Hispanic or Latino

2. No, not Hispanic or Latino

28. What is your 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

29. Did someone help you complete this survey?

1. Yes

2. No Thank you.

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

30. 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:
   
   
   

END OF SURVEY

Thank you.

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

DRAFT VERSION – 12/22/2020 updated