Form 2 Patient experience survey

AHRQ Safety Program for Improving Surgical Care and Recovery

Attachment D_Patient Experience Survey_Data collection instrument_20170727

Attachment D – Patient Experience Survey_Data collection instrument

OMB: 0935-0239

Document [docx]
Download: docx | pdf

Shape1

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







Patient Experience Survey

2017

Shape2

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.


 

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. Shape3 Yes, definitely

  2. Shape4 Yes, somewhat

  3. Shape5 No

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

  1. Shape6 Yes, definitely

  2. Shape7 Yes, somewhat

  3. Shape8 No

II. About your Surgery

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

  1. Shape9 Yes

  2. Shape10 No If No, go to Question 6

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

  1. Shape11 Yes, definitely

  2. Shape12 Yes, somewhat

  3. Shape13 No

  1. 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. Shape14 Yes, definitely

  2. Shape15 Yes, somewhat

  3. Shape16 No

III. During Your Hospital Stay

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

  1. Shape17 Never

  2. Shape18 Sometimes

  3. Shape19 Usually

  4. Shape20 Always

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

  1. Shape21 Never

  2. Shape22 Sometimes

  3. Shape23 Usually

  4. Shape24 Always

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

  1. Shape25 Yes

  2. Shape26 No If No, Go to Question 11

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

  1. Shape27 Never

  2. Shape28 Sometimes

  3. Shape29 Usually

  4. Shape30 Always

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

  1. Shape31 Never

  2. Shape32 Sometimes

  3. Shape33 Usually

  4. Shape34 Always

IV. Your Recovery

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

  1. Shape35 Yes, definitely

  2. Shape36 Yes, somewhat

  3. Shape37 No

  1. 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. Shape38 Yes, definitely

  2. Shape39 Yes, somewhat

  3. Shape40 No

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

  1. Shape41 Yes

  2. Shape42 No

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

  1. Shape43 Yes, definitely

  2. Shape44 Yes, somewhat

  3. Shape45 No

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

  1. Shape46 Yes

  2. Shape47 No



  1. 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. Shape48 Yes, definitely

  2. Shape49 Yes, somewhat

  3. Shape50 No

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

  1. Shape51 Yes

  2. Shape52 No

  1. 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. Shape53 Yes

  2. Shape54 No

V. Your Overall Experience

  1. 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?

Shape55 0 Worst hospital possible

Shape56 1

Shape57 2

Shape58 3

Shape59 4

Shape60 5

Shape61 6

Shape62 7

Shape63 8

Shape64 9

Shape65 10 Best hospital possible


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

  1. Shape66 Definitely no

  2. Shape67 Probably no

  3. Shape68 Probably yes

  4. Shape69 Definitely yes


VI. About You

  1. In general, how would you rate your overall health?

  1. Shape70 Excellent

  2. Shape71 Very good

  3. Shape72 Good

  4. Shape73 Fair

  5. Shape74 Poor

  1. In general, how would you rate your overall mental or emotional health?

  1. Shape75 Excellent

  2. Shape76 Very good

  3. Shape77 Good

  4. Shape78 Fair

  5. Shape79 Poor

  1. 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. Shape80 Completely

  2. Shape81 Mostly

  3. Shape82 Moderately

  4. Shape83 A little

  5. Shape84 Not at all

  1. What is your age?

  1. Shape85 18 to 24

  2. Shape86 25 to 34

  3. Shape87 35 to 44

  4. Shape88 45 to 54

  5. Shape89 55 to 64

  6. Shape90 65 to 74

  7. Shape91 75 to 79

  8. Shape92 80 to 84

  9. Shape93 85 or older

  1. Are you male or female?

  1. Shape94 Male

  2. Shape95 Female

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

  1. Shape96 8th grade or less

  2. Shape97 Some high school, but did not graduate

  3. Shape98 High school graduate or GED

  4. Shape99 Some college or 2-year degree

  5. Shape100 4-year college graduate

  6. Shape101 More than 4-year college degree

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

  1. Shape102 Yes, Hispanic or Latino

  2. Shape103 No, not Hispanic or Latino

  1. What is your race? Mark one or more.

  1. Shape104 White

  2. Shape105 Black or African American

  3. Shape106 Asian

  4. Shape107 Native Hawaiian or Other Pacific Islander

  5. Shape108 American Indian or Alaska Native

  6. Shape109 Other

  1. Did someone help you complete this survey?

  1. Shape110 Yes

  2. Shape111 No Thank you.

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





  1. How did that person help you? Mark one or more.

  1. Shape112 Read the questions to me

  2. Shape113 Wrote down the answers I gave

  3. Shape114 Answered the questions for me

  4. Shape115 Translated the questions into my language

  5. Shape116 Helped in some other way:


END OF SURVEY

Thank you.

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




DRAFT VERSION – 03/30/17 clean

File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
AuthorTheresa Famolaro
File Modified0000-00-00
File Created2021-01-22
© 2025 OMB.report | Privacy Policy