CMS-10432 PIX Survey

Patient Experience | Psychiatry Inpatient
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.
My cultural and personal preferences were respected during my treatment.

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.
I received a clear explanation of my diagnosis and symptoms.

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.
I was satisfied with the accessibility of supportive services (e.g.,
interpreters and accommodations for individuals with disabilities).

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.

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 7.25 minutes for questions 1-26 on the survey, 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, Mailstop, Baltimore, MD 21244-1850.

© 2022. All rights reserved.

Patient Experience | 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

Disability Status

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

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 7.25 minutes for questions 1-26 on the survey, 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, Mailstop, Baltimore, MD 21244-1850.

© 2022. All rights reserved.

Patient Experience | Psychiatry Inpatient
Original Research Article:
Klemanski DH, Barnes T, Bautista C, Tancreti C, Klink B, Dix E. Development and Validation of the Psychiatric Inpatient Experience (PIX)
Survey: A Novel Measure of Patient Experience Quality Improvement. Journal of Patient Experience. 2022;9.
doi:10.1177/23743735221105671

For questions or feedback, please contact the measure developer:
David Klemanski, Psy.D., MPH
Yale School of Medicine
[email protected]

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 7.25 minutes for questions 1-26 on the survey, 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, Mailstop, Baltimore, MD 21244-1850.

© 2022. All rights reserved.