CMS-10432 IPFQR_PIX Survey

YPX Insights | 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.

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.

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. This information collection associated with the Inpatient
Psychiatric Facility Quality Reporting Program promotes higher quality and more efficient healthcare for Medicare beneficiaries by collecting and
reporting on quality-of-care metrics. The information collected via this survey as well as the other information collection requirements approved
under 0938-1171 is made available to consumers, both to empower Medicare beneficiaries and inform decision-making, as well as to provide
incentive for healthcare facilities to make continued improvements. The time required to complete this survey is estimated to average less than 5
minutes per response, including the time to review instructions, search existing data resources, gather the data needed, to review and complete the
information collection. In accordance with section 1886(s)(4)(C) of the Social Security Act as added and amended by sections 3401 and 10322 of
the Patient Protection and Affordable Care Act (ACA) and further amended by section 4125(c) of the Consolidated Appropriations Act, 2023, this
information collection is required to obtain or retain a benefit. The information will be kept private to the extent provided by law. 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

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