Form #6 Form #6 Patient questionnaire

A

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

ttachment H. Patient survey

HOSPITAL DISCHARGE SURVEY

Telephone Script (English)

Overview

This telephone interview script is provided to assist interviewers while attempting to reach the respondent. The script explains the purpose of the survey and confirms necessary information about the respondent. Interviewers must not conduct the survey with a proxy respondent.

General Interviewing Instructions

Survey is administered to patients beginning 30 days after the date of index hospital discharge

Patients are called up to 60 days after the date of index hospital discharge

All questions and all answer categories must be read exactly as they are worded

No changes are permitted to the order of the answer categories

All transitional statements must be read

Index admission date: ___ ___ /___ ___ /___ ___ ___ ___

Index discharge date: ___ ___ /___ ___ /___ ___ ___ ___

Date initial call attempt: ___ ___ /___ ___ /___ ___ ___ ___

Caller records the call attempts and time talking with patient:

#1: Date(mo/day/yr): ______ /______ /____________ Time of day ____:______­action taken/time with subject:__________

#2: Date(mo/day/yr): ______ /______ /____________ Time of day ____:______­action taken/time with subject:__________

#3: Date(mo/day/yr): ______ /______ /____________ Time of day ____:______­action taken/time with subject:__________

#4: Date(mo/day/yr): ______ /______ /____________ Time of day ____:______­action taken/time with subject:__________

#5: Date(mo/day/yr): ______ /______ /____________ Time of day ____:______­action taken/time with subject:__________

#6: Date(mo/day/yr): ______ /______ /____________ Time of day ____:______action taken/time with subject:__________

#7: Date(mo/day/yr): ______ /______ /____________ Time of day ____:______action taken/time with subject:__________

#8: Date(mo/day/yr): ______ /______ /____________ Time of day ____:______action taken/time with subject:__________

Contact notes: ____________________________________________________________________________________________________________________________________________

Public reporting burden for this collection of information is estimated to average 10 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, 540 Gaither Road, Room # 5036, Rockville, MD 20850.

INTRODUCTION

Hello [name of subject]? May I please speak to [patient name].

This is [name of caller] from [hospital name]. We are conducting a survey about the hospital discharge process. I am calling to talk to {patient name} about a recent healthcare experience.

Our records show that you were recently a patient at {name of hospital} and discharged on {date of discharge}. Because you had a recent hospital stay, we are asking for your help. This survey is part of an ongoing effort at {name of hospital} to improve the hospital discharge process. These results will help this hospital to understand if their improvements are affecting patients.

Your participation is voluntary and will not affect your health benefits. Your responses will be kept confidential to the extent permitted by law, including AHRQ’s confidentiality statute, 42 USC 299c-3(c). Your answers will be shared with the hospital for purposes of quality improvement.

If you have any questions about this survey, please call {hospital project manager name} at {project manager phone number}. Thank you for helping to improve health care for all consumers.

This survey will take approximately 10 minutes. Are you willing to complete the survey now? With acknowledgement, caller continues.

****************************************************************************************************

According to our records, you stayed in {hospital name} from {start date} to {discharge date}. Most of the questions on this survey are about this stay in the hospital.

Please tell me which response most closely matches your answer.

********************************************************************************************

HOSPITAL UTILIZATION

1. Have you stayed in a hospital overnight since you left the hospital on {discharge date}? This means being admitted to a hospital floor (not just the emergency room).

• Yes

• No

If YES, please fill out the table below for each hospital visit. List the hospital, date of arrival, and reason for each hospitalization.

Hospital	Date You Arrived	Reason
1.
2.
3.
4.
5.

2. Have you been to the emergency room since you left the hospital on {discharge date}? These would be emergency room visits that did not cause you to be admitted to the hospital (and so you stayed in the emergency room the entire time and went home from the emergency room).

• Yes

• No

If YES, please fill out the table below for each emergency room visit. List the hospital, date of arrival, and reason for each visit.

Hospital	Date You Arrived	Reason
1.
2.
3.
4.
5.

APPOINTMENTS

These next questions are about any appointments you had after you left the hospital on {discharge date}.

3. Do you have a particular doctor’s office, clinic, health center, or other place that you usually see if you are sick or need advice about your health?

• Yes

• No

4. Since you left the hospital on {discharge date}, have you seen your medical provider, sometimes called a primary care provider, (or someone in their office)?

• Yes

• No

If YES, What date did you see this person? __________________________________________________

DIAGNOSIS

5. During your hospital stay, the doctors and nurses may have told you the name of your primary diagnosis or main problem. Do you know what your main problem was?

• Yes

• No

• N/A, reason: _______________________

These next questions ask about your visit at {hospital name}, from {admit date} to {discharge date}.

YOUR HOSPITAL STAY



6. During this hospital stay, how often did nurses listen carefully to you?

¹ Never

² Sometimes

³ Usually

⁴ Always

7. During this hospital, stay, how often did nurses explain things in a way you could understand?

¹ Never

² Sometimes

³ Usually

⁴ Always

8. During this hospital stay, how often were your questions answered to your satisfaction?

¹ Never

² Sometimes

³ Usually

⁴ Always



9. How often did hospital staff listen to you when they decided the plan for your care?

¹ Never

² Sometimes

³ Usually

⁴ Always

MEDICATIONS

10. During this hospital stay, were you told to take any medicine after you left the hospital? Include prescription and non-prescription medicines as well as any medicines you were already taking before your hospital stay.

¹ Yes

² No  If No, Go to Question 17

11. During this hospital stay, did hospital staff explain the purpose of each of the medicines you were to take at home?

¹ Yes

² No  If No, Go to Question 13

12. How often was the explanation easy to understand?

¹ Never

² Sometimes

³ Usually

⁴ Always

13. During this hospital stay, did hospital staff explain how much to take of each medicine and when to take it when you were at home?

¹ Yes

² No  If No, Go to Question 15

14. How often was the explanation easy to understand?

¹ Never

² Sometimes

³ Usually

⁴ Always

15. During this hospital stay, did hospital staff ask you to describe how much you would take of each medicine and when you would take it when you were at home?

¹ Yes

² No

16. During this hospital stay, did hospital staff tell you whom to call if you had questions about your medicines?

¹ Yes

² No

WHEN YOU LEFT THE HOSPITAL

-----------------------------------------------------------------------------------------------------------------------

17. After you left the hospital, did you go directly to your own home, to some else’s home, or to another health facility?

¹ Own home

² Someone else’s home

³ Another health facility  If Another, go to question 23

18. During this hospital stay, did hospital staff talk with you about whether you would have the help you needed when you left the hospital?

¹ Yes

² No

19. During this hospital stay, did you get information in writing about what symptoms or health problems to look out for after you left the hospital?

¹ Yes

² No

20. Were the written instructions easy to understand?

¹ Yes

² No

21. After you left the hospital, did someone from the hospital call you to check how you were doing?

¹ Yes

² No

If YES, please tell me how much you agree with each of the following statements.

22. After the call, all of my questions about my medical care were answered.

 Strongly disagree

 Disagree

 Agree

 Strongly Agree

OVERALL RATING OF HOSPITAL

23. 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 during your stay?

_________ (0-10)

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

• Definitely no

• Probably no

• Probably yes

• Definitely yes

ABOUT YOU

There are only a few remaining items left.

25. What is your age?

10 18-30 years

20 31-50 years

30 51-70 years

40 71-above years

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

10 Excellent

20 Very good

30 Good

40 Fair

50 Poor

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

10 Some elementary or high school, but did not graduate

20 High school graduate or GED

30 Some college or 2-year degree

40 4-year college graduate

28. Are you of Spanish, Hispanic or Latino origin or descent?

10 No, not Spanish/Hispanic/Latino

20 Yes

29. What is your race? Please choose one or more.

10 White

20 Black or African American

30 Asian

40 Native Hawaiian or other Pacific Islander

50 American Indian or Alaska Native

30. What language do you mainly speak at home?

10 English

20 Spanish

30 Some other language (please print): _____________________

Those are all the questions I have. Thank you for your time. Have a good (day/evening).