CMS-10432 Psychiatric Inpatient Experience (PIX) Survey

YPX Insights | Psychiatry Inpatient
PRA Disclosure Statement 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 0938-1171. The time required to complete this
information collection is estimated to average 7 minutes per response, including the time to review instructions, search existing data resources, gather the
data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for
improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland
21244-1850.
Directions: Please answer each statement based on your current hospitalization experience. If a question does not apply to you, please select "Does not
apply." We encourage you to answer truthfully and candidly.
Treatment Team Relationship

Strongly
Agree

Agree

Neutral

Disagree

Strongly
Disagree

Does
Not
Apply

Strongly
Agree

Agree

Neutral

Disagree

Strongly
Disagree

Does
Not
Apply

Strongly
Agree

Agree

Neutral

Disagree

Strongly
Disagree

Does
Not
Apply

Strongly
Agree

Agree

Neutral

Disagree

Strongly
Disagree

Does
Not
Apply

My Doctor/Provider treated me with care and respect.
My Doctor/Provider valued my opinion even if we didn't always agree.
My Doctor/Provider helped me understand my treatment options.
I had input into decisions about my treatment.
My Social Worker helped me include family or other supports in my
treatment if I wished.

Environment
The unit was clean.
I felt physically safe on the unit.
I had access to quiet space if I needed it.
Healthy food options were available.
I had enough access to fresh air and/or natural light.
I was satisfied with the services available on the weekends.
I was supported in keeping busy and finding social/recreational activities.

Treatment Effectiveness
The symptoms/problems that brought me to the hospital have improved.
Group therapy was helpful.
I have skills to help manage symptoms/problems I face in daily life.
My medications will help me.
I will have the resources I need to be successful after I leave the hospital.

Nursing Team Presence
Nurses were caring and respectful.
Counselors/Technicians were caring and respectful.
Nurses were attentive to my needs.
Counselors/Technicians were attentive to my needs.
Staff paid attention to what was happening on the unit.
Staff worked together to care for me.

How likely is it that you would recommend this hospital to a family member, friend, or colleague?
Not at all Likely

1

Likely

2

3

4

5

Extremely Likely

6

7

8

9

10

How can we improve? Please let us know if you have suggestions to improve our care.

What did we do well? Please let us know what we are doing well and any staff who you would like to recognize.

© 2022. All rights reserved.

YPX Insights | Psychiatry Inpatient
Demographic Questions [Optional]

Suggested Item Choices

Did you receive assistance completing this survey?

Yes
No

Age

12 – 17
18 – 24
25 – 34
35 – 44
45 – 54
55 – 64
65 – 74
75 and over

Gender

Female
Male
Transgender Male
Transgender Female
Non-binary
Other
Prefer Not to Say

Sexual Orientation

Heterosexual/Straight
Homosexual/Gay
Homosexual/Lesbian
Bisexual
Other
Prefer Not to Say

Race/Ethnicity

Asian/Pacific Islander
Black or African American
Hispanic or Latino
Native American or American Indian
Biracial/Multiracial
White
Other
Prefer Not to Say

Religious/Faith Tradition

Buddhist
Christian
Hindu
Islam
Judaism
Mormon
None/No Religious or Faith Tradition
Other
Prefer Not to Say

Disability Status

None
Deaf or Hearing Problems
Blind or Vision Problems
Learning Difficulty
Difficulty Walking
Difficulty Thinking/Remembering
Other
Prefer Not to Say

© 2022. All rights reserved.

Demographics

Patient Experience Survey
A few questions about you before we begin...

Age (optional)
12 - 17

18 - 24

25 - 34

35 - 44

45 - 54

Gender (optional)
Female
Male
Non-binary
Prefer not to say
Transgender
Other

55 - 64

65 - 74

75+

Sexual Orientation (optional)
Heterosexual or straight
Gay
Lesbian
Bisexual
Prefer not to say
Other

Race / Ethnicity (optional)
Asian / Pacific Islander
Black or African American
Hispanic or Latino
Native American or American Indian
Multiple
White
Other

Religious / Faith Tradition (optional)
None
Buddhist
Christian
Hindu
Islam
Judaism
Mormon
Other

Disability (optional)
None
Deaf/hearing problems
Blind/vision problems
Learning difficulty
Difficulty walking/with daily activities
Difficulty thinking/remembering
Introduction

Respond to each statement based on your experience during your
current hospitalization. If a question does not apply to you, please
select "Does not apply."
Please answer openly and honestly.

These are your answer options

Strongly Disagree

Somewhat
Disagree

Neutral

Somewhat
Agree

Strongly
Agree

Does not apply

© 2022. All rights reserved.

Questions
My Doctor/Provider treated me with care and respect.

Strongly Disagree

Somewhat
Disagree

Neutral

Somewhat
Agree

Strongly
Agree

Does not apply

My Doctor/Provider valued my opinion even if we didn’t always agree.

Strongly Disagree

Somewhat
Disagree

Neutral

Somewhat
Agree

Strongly
Agree

Does not apply

My Doctor/Provider helped me understand my treatment options.

Strongly Disagree

Somewhat
Disagree

Neutral

Somewhat
Agree

Strongly
Agree

Does not apply

© 2022. All rights reserved.

I had input into decisions about my treatment.

Strongly Disagree

Somewhat
Disagree

Neutral

Somewhat
Agree

Strongly
Agree

Does not apply

My Social Worker helped me include family or other supports in my treatment
if I wished.

Strongly Disagree

Somewhat
Disagree

Neutral

Somewhat
Agree

Strongly
Agree

Does not apply

Somewhat
Agree

Strongly
Agree

Does not apply

I felt physically safe on the unit.

Strongly Disagree

Somewhat
Disagree

Neutral

© 2022. All rights reserved.

I had access to quiet space if I needed it.

Strongly Disagree

Somewhat
Disagree

Neutral

Somewhat
Agree

Strongly
Agree

Does not apply

Somewhat
Agree

Strongly
Agree

Does not apply

Somewhat
Agree

Strongly
Agree

Does not apply

Staff paid attention to what was happening on the unit.

Strongly Disagree

Somewhat
Disagree

Neutral

Nurses were caring and respectful.

Strongly Disagree

Somewhat
Disagree

Neutral

© 2022. All rights reserved.

Nurses were attentive to my needs.

Strongly Disagree

Somewhat
Disagree

Neutral

Somewhat
Agree

Strongly
Agree

Does not apply

Strongly
Agree

Does not apply

Strongly
Agree

Does not apply

Counselors/Techs were caring and respectful.

Strongly Disagree

Somewhat
Disagree

Neutral

Somewhat
Agree

Counselors/Techs were attentive to my needs.

Strongly Disagree

Somewhat
Disagree

Neutral

Somewhat
Agree

© 2022. All rights reserved.

The symptoms/problems that brought me to the hospital have improved.

Strongly Disagree

Somewhat
Disagree

Neutral

Somewhat
Agree

Strongly
Agree

Does not apply

Neutral

Somewhat
Agree

Strongly
Agree

Does not apply

Group therapy was helpful.

Strongly Disagree

Somewhat
Disagree

I have skills to help manage symptoms/problems I face in daily life.

Strongly Disagree

Somewhat
Disagree

Neutral

Somewhat
Agree

Strongly
Agree

Does not apply

Neutral

Somewhat
Agree

Strongly
Agree

Does not apply

My medications will help me.

Strongly Disagree

Somewhat
Disagree

© 2022. All rights reserved.

I will have the resources I need to be successful after I leave the hospital.

Strongly Disagree

Somewhat
Disagree

Neutral

Somewhat
Agree

Strongly
Agree

Does not apply

I was satisfied with the services available on the weekends.

Strongly Disagree

Somewhat
Disagree

Neutral

Somewhat
Agree

Strongly
Agree

Does not apply

I was supported in keeping busy and finding social/recreational activities.

Strongly Disagree

Somewhat
Disagree

Neutral

Somewhat
Agree

Strongly
Agree

Somewhat
Agree

Strongly
Agree

Does not apply

Staff worked together to care for me.

Strongly Disagree

Somewhat
Disagree

Neutral

Does not apply
© 2022. All rights reserved.

The unit was clean.

Strongly Disagree

Somewhat
Disagree

Neutral

Somewhat
Agree

Strongly
Agree

Does not apply

Somewhat
Agree

Strongly
Agree

Does not apply

Strongly
Agree

Does not apply

Healthy food options were available.

Strongly Disagree

Somewhat
Disagree

Neutral

I had enough access to fresh air and/or natural light.

Strongly Disagree

Somewhat
Disagree

Neutral

Somewhat
Agree

© 2022. All rights reserved.

Comments

How likely is it that you would recommend this hospital to a friend,
family member or colleague?
Not at all likely
0
1

2

3

4

5

6

7

8

Extremely likely
9
10

How can we improve? Please let us know if there is something
we can do to improve our care...

© 2022. All rights reserved.

What did we do well? Please let us know what we're doing well
and any staff who you'd like to recognize...

© 2022. All rights reserved.