Form #1 Form #1 Survey Instrument

Use of Narrative Data to Explore Disparities in Patient Experience

[Add OMB number]

Attachment B

Survey Instrument

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

This survey is designed to explore the many kinds of experiences people have with their health care providers, both negative and positive. Please respond to these questions thinking about the provider you usually see if you need a check-up, want advice about a health problem, or get sick or hurt.

Public reporting burden for this collection of information is estimated to average 17 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.

Visits with your Provider in Person, by Phone, or by Video

The questions in this survey will refer to refer to the provider you usually see if you need a check-up, want advice about a health problem, or get sick or hurt.. As you answer these questions, please think of the in-person, phone, and video visits you had with that person in the last 12 months.

1. How long have you been going to this provider?

¹ Less than 6 months

² At least 6 months but less than 1 year

³ At least 1 year but less than 3 years

⁴ At least 3 years but less than 5 years

⁵ 5 years or more

Your Care from This Provider in the Last 6 Months

These questions ask about your own health care. Do not include care you got when you stayed overnight in a hospital. Do not include the times you went for dental care visits.

2. In the last 12 months, how many times did you visit this provider to get care for yourself?

None ® If None, go to #21

1 time

2

3

4

5 to 9

10 or more times

3. In the last 12 months, did you contact this provider’s office to get an appointment for an illness, injury, or condition that needed care right away?

¹ Yes

² No ® If No, go to #5

4. In the last 12 months, when you contacted this provider’s office to get an appointment for care you needed right away, how often did you get an appointment as soon as you needed?

¹ Never

² Sometimes

³ Usually

⁴ Always

5. In the last 12 months, did you make any appointments for a check-up or routine care with this provider?

¹ Yes

² No ® If No, go to #7

6. In the last 12 months, when you made an appointment for a check-up or routine care with this provider, how often did you get an appointment as soon as you needed?

¹ Never

² Sometimes

³ Usually

⁴ Always

7. In the last 12 months, did you contact this provider’s office with a medical question during regular office hours?

¹ Yes

² No ® If No, go to #9

8. In the last 12 months, when you contacted this provider’s office during regular office hours, how often did you get an answer to your medical question that same day?

¹ Never

² Sometimes

³ Usually

⁴ Always

9. In the last 12 months, how often did this provider explain things in a way that was easy to understand?

¹ Never

² Sometimes

³ Usually

⁴ Always

10. In the last 12 months, how often did this provider listen carefully to you?

¹ Never

² Sometimes

³ Usually

⁴ Always

11. In the last 12 months, how often did this provider seem to know the important information about your medical history?

¹ Never

² Sometimes

³ Usually

⁴ Always

12. In the last 12 months, how often did this provider show respect for what you had to say?

¹ Never

² Sometimes

³ Usually

⁴ Always

13. In the last 12 months, how often did this provider spend enough time with you?

¹ Never

² Sometimes

³ Usually

⁴ Always

14. In the last 12 months, did this provider order a blood test, x-ray, or other test for you?

¹ Yes

² No ® If No, go to #16

15. In the last 12 months, when this provider ordered a blood test, x-ray, or other test for you, how often did someone from this provider’s office follow up to give you those results?

¹ Never

² Sometimes

³ Usually

⁴ Always

16. Using any number from 0 to 10, where 0 is the worst provider possible and 10 is the best provider possible, what number would you use to rate this provider?

0 Worst provider possible

1

2

3

4

5

6

7

8

9

10 Best provider possible

17. In the last 12 months, did you take any prescription medicine?

¹ Yes

² No ® If No, go to #19

18. In the last 12 months, how often did you and someone from this provider’s office talk about all the prescription medicines you were taking?

¹ Never

² Sometimes

³ Usually

⁴ Always

Clerks and Receptionists at This Provider’s Office

19. In the last 12 months, how often were clerks and receptionists at this provider’s office as helpful as you thought they should be?

¹ Never

² Sometimes

³ Usually

⁴ Always

20. In the last 12 months, how often did clerks and receptionists at this provider’s office treat you with courtesy and respect?

¹ Never

² Sometimes

³ Usually

⁴ Always

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 last 12 months, were any of your visits with this provider...

                                                   Yes    No

a.  In person?....................... ⃞     ⃞

b.  By phone?...................... ⃞     ⃞

c.  By video call?................. ⃞     ⃞

In Your Own Words

Healthcare providers value comments from their patients because these details tell them what is working well and what may need improvement. The next questions ask you to describe the care you get from this provider in your own words. Please avoid including in your description any personal information (e.g., names, locations, or reference to a specific health condition) that could be used to identify you or your health care provider.

24. What are the most important things that you look for in a healthcare provider and their staff?

[Box for open-ended text response]

25. When you think about the things that are most important to you, how do this provider and their staff measure up?

[Box for open-ended text response]

26. What has gone well in your experiences with this provider and their staff in the last 6 months? Please explain what happened, how it happened, and how it felt to you.

[Box for open-ended text response]

27. Was there anything you wish had gone differently in your experiences with this provider and their staff in the last 12 months? If so, please explain what happened, how it happened, and how it felt to you.

[Box for open-ended text response]

28. Please describe your interactions with this provider and how you get along.

[Box for open-ended text response]

29. In the last 12 months, did anyone from this provider’s office treat you in an unfair or insensitive way because of any of the following things about you?

Yes No

a.  Health condition c c

b.  Disability c c

c.  Age c c

d.  Culture or religion c c

e.  Language or accent c c

f.  Race or ethnicity c c

g.  Sex (female or male) c c

h.  Sexual orientation c c

i.  Gender or gender
identity c c

j.  Income c c

[Question 30 only asked if responded “Yes” to at least one category in question 29.]

30. Please describe the unfair or insensitive treatment.

[Box for open-ended text response]