Form #11 Form #11 Patient Survey

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

ATTACHMENT Q

PATIENT SURVEY INSTRUMENT AND

S

Public reporting burden for this collection of information is estimated to average 30 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.

OURCE OF SURVEY ITEMS

PATIENT SURVEY INSTRUMENT

SURVEY INSTRUCTIONS

♦ You should only fill out this survey if you were the patient during the hospital stay named in the cover letter. Do not fill out this survey if you were not the patient.

♦ 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 Question 1

Source of item*	Patient Survey Instrument
		Please answer the questions in this survey about your stay at the hospital named in the cover letter. Do not include any other hospital stays in your answers.
HCAHPS		1.	During this hospital stay, how often did nurses treat you with courtesy and respect?
	1		Never
	2		Sometimes
	3		Usually
	4		Always
HCAHPS		2.	During this hospital stay, how often did nurses listen carefully to you?
	1		Never
	2		Sometimes
	3		Usually
	4		Always
HCAHPS		3.	During this hospital stay, how often did nurses explain things in a way you could understand?
	1		Never
	2		Sometimes
	3		Usually
	4		Always
HCAHPS		4.	During this hospital stay, after you pressed the call button, how often did you get help as soon as you wanted it?
	1		Never
	2		Sometimes
	3		Usually
	4		Always
HCAHPS		5.	During this hospital stay, how often did doctors treat you with courtesy and respect?
	1		Never
	2		Sometimes
	3		Usually
	4		Always
HCAHPS		6.	During this hospital stay, how often did doctors listen carefully to you?
	1		Never
	2		Sometimes
	3		Usually
	4		Always
HCAHPS		7.	During this hospital stay, how often did doctors explain things in a way you could understand?
	1		Never
	2		Sometimes
	3		Usually
	4		Always
HCAHPS		8.	During this hospital stay, how often were your room and bathroom kept clean?
	1		Never
	2		Sometimes
	3		Usually
	4		Always
HCAHPS		9.	During this hospital stay, how often was the area around your room quiet at night?
	1		Never
	2		Sometimes
	3		Usually
	4		Always
HCAHPS		10.	During this hospital stay, did you need help from nurses or other hospital staff in getting to the bathroom or in using a bedpan?
	1		Yes
	2		No
HCAHPS		11.	How often did you get help in getting to the bathroom or in using a bedpan as soon as you wanted?
	1		Never
	2		Sometimes
	3		Usually
	4		Always
HCAHPS		12.	During this hospital stay, did you need medicine for pain?
	1		Yes
	2		No
HCAHPS		13.	During this hospital stay, how often was your pain well controlled?
	1		Never
	2		Sometimes
	3		Usually
	4		Always
HCAHPS		14.	During this hospital stay, how often did the hospital staff do everything they could to help you with your pain?
	1		Never
	2		Sometimes
	3		Usually
	4		Always
HCAHPS		15.	During this hospital stay, were you given any medicine that you had not taken before?
	1		Never
	2		Sometimes
	3		Usually
	4		Always
HCAHPS		16.	Before giving you any new medicine, how often did hospital staff tell you what the medicine was for?
	1		Never
	2		Sometimes
	3		Usually
	4		Always
HCAHPS		17.	Before giving you any new medicine, how often did hospital staff describe possible side effects in a way you could understand?
	1		Never
	2		Sometimes
	3		Usually
	4		Always
HCAHPS		18.	After you left the hospital, did you go directly to your own home, to someone else’s home, or to another health facility?
	1		Own home
	2		Someone else's home
	3		Another health facility
HCAHPS		19.	During this hospital stay, 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		Yes
	2		No
HCAHPS		20.	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
HCAHPS		21.	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		0 Worst possible care
	1		1
	2		2
	3		3
	4		4
	5		5
	6		6
	7		7
	8		8
	9		9
	10		10 Best possible care
HCAHPS		22.	Would you recommend this hospital to your friends and family?
	1		Definitely no
	2		Probably no
	3		Probably yes
	4		Definitely yes
		Next are a few more questions about your stay in the hospital.
New		23.	Was your admission to the hospital planned or scheduled ahead of time, or not planned because you needed urgent or emergency medical treatment?
	1		Planned
	2		Not planned
		Please mark how much you disagree or agree with each statement below about this hospital stay.
New		24.	Your doctors and nurses give you all the information you needed to understand your treatment.
	1		Disagree Strongly
	2		Disagree
	3		Agree
	4		Agree Strongly
New		25.	Your doctors and nurses answered all your questions.
	1		Disagree Strongly
	2		Disagree
	3		Agree
	4		Agree Strongly
New		26.	You knew who to talk to if you had questions or concerns about your health care.
	1		Disagree Strongly
	2		Disagree
	3		Agree
	4		Agree Strongly
New		27.	Your family or friends were able to be with you as much as you wanted them to be.
	1		Disagree Strongly
	2		Disagree
	3		Agree
	4		Agree Strongly
		The next questions are about your beliefs about patient and family involvement in their health care. Please mark how much you disagree or agree with each statement.
New		28.	It is important to be involved in making decisions about your medical treatment.
	1		Disagree Strongly
	2		Disagree
	3		Agree
	4		Agree Strongly
PPI		29.	It is important to be a partner in your health care with your doctor and other health care providers.
	1		Disagree Strongly
	2		Disagree
	3		Agree
	4		Agree Strongly
MCG-revised		30.	The quality of health care is improved when patients and families are involved in making decisions about their care.
	1		Disagree Strongly
	2		Disagree
	3		Agree
	4		Agree Strongly
MCG-revised		31.	Health care is safer when patients and families are involved in making decisions about their care.
	1		Disagree Strongly
	2		Disagree
	3		Agree
	4		Agree Strongly
		The next questions are about your stay in the hospital (the one named on the cover letter).
New		32.	During this hospital stay, did you want to be involved in decisions about your health care?
	1		Yes
	2		No  IF NO, GO TO Question 34
HP-CAHPS		33.	During this hospital stay, how often were you involved as much as you wanted in decisions about your health care?
	1		Never
	2		Sometimes
	3		Usually
	4		Always
HP-CAHPS		34.	During this hospital stay, how often was it easy to get your doctors or other health providers to agree with you on the best way to manage your health conditions or problems?
	1		Never
	2		Sometimes
	3		Usually
	4		Always
PPI		35.	During this hospital stay, how often did your doctors and other health care providers ask your opinion about your medical treatment?
	1		Never
	2		Sometimes
	3		Usually
	4		Always
	As you may know, nurse shift changes occur when nurses who are going off duty share information about you with nurses coming on duty. At this hospital, this shift change may have happened at your bedside.
New		36.	During this hospital stay, did shift changes happen at your bedside during your hospital stay?
	1		YES
	2		NO or NOT SURE  IF NO or NOT SURE, GO TO Question 41
	Please mark how much you disagree or agree with each statement about bedside shift changes during this hospital stay.
New		37.	The bedside shift change was helpful.
	1		Disagree Strongly
	2		Disagree
	3		Agree
	4		Agree Strongly
New		38.	I felt involved in the bedside shift change.
	1		Disagree Strongly
	2		Disagree
	3		Agree
	4		Agree Strongly
New		39.	I knew when bedside shift changes would take place.
	1		Disagree Strongly
	2		Disagree
	3		Agree
	4		Agree Strongly
New		40.	I was able to ask questions during bedside shift changes.
	1		Disagree Strongly
	2		Disagree
	3		Agree
	4		Agree Strongly
		The next questions are about what happened when you were getting ready to leave the hospital. This is called making discharge plans.
New		41.	During this hospital stay, when did a doctor or nurse first talk with you about discharge plans?
	1		On the day I was discharged
	2		Before the day I was discharged
		Please mark how much you disagree or agree with each statement about making plans for leaving the hospital.
New		42.	I felt included in making my discharge plans.
	1		Disagree Strongly
	2		Disagree
	3		Agree
	4		Agree Strongly
New		43.	My doctors and other health providers asked my opinion about my discharge plans.
	1		Disagree Strongly
	2		Disagree
	3		Agree
	4		Agree Strongly
New		44.	My family and friends were involved in talks about my discharge plans as much as I wanted them to be.
	1		Disagree Strongly
	2		Disagree
	3		Agree
	4		Agree Strongly
New		45.	I understood what I needed to do for my care after leaving the hospital.
	1		Disagree Strongly
	2		Disagree
	3		Agree
	4		Agree Strongly
New		46.	I knew who to call if I had questions after I left the hospital.
	1		Disagree Strongly
	2		Disagree
	3		Agree
	4		Agree Strongly
		Below are some statements that people sometimes make when they talk about their health. Please indicate how much you agree or disagree with each statement as it applies to you personally by circling your answer. If the statement does not apply to you, mark "Not Applicable".
		Your answers should be what is true for you and not just what you think the doctor or nurse wants you to say.
PAM		47.	When all is said and done, I am the person who is responsible for managing my health condition.
	1		Disagree Strongly
	2		Disagree
	3		Agree
	4		Agree Strongly
	5		Not Applicable
PAM		48.	Taking an active role in my own health care is the most important factor in determining my health and ability to function.
	1		Disagree Strongly
	2		Disagree
	3		Agree
	4		Agree Strongly
	5		Not Applicable
PAM		49.	I am confident that I can take actions that will help prevent or minimize some symptoms or problems associated with my health condition.
	1		Disagree Strongly
	2		Disagree
	3		Agree
	4		Agree Strongly
	5		Not Applicable
PAM		50.	I know what each of my prescribed medications does.
	1		Disagree Strongly
	2		Disagree
	3		Agree
	4		Agree Strongly
	5		Not Applicable
PAM		51.	I am confident that I can tell when I need to go get medical care and when I can handle a health problem myself.
	1		Disagree Strongly
	2		Disagree
	3		Agree
	4		Agree Strongly
	5		Not Applicable
PAM		52.	I am confident that I can tell a doctor concerns I have, even when he or she does not ask.
	1		Disagree Strongly
	2		Disagree
	3		Agree
	4		Agree Strongly
	5		Not Applicable
PAM		53.	I am confident that I can follow through on medical treatments I need to do at home.
	1		Disagree Strongly
	2		Disagree
	3		Agree
	4		Agree Strongly
	5		Not Applicable
PAM		54.	I understand the nature and causes of my health condition.
	1		Disagree Strongly
	2		Disagree
	3		Agree
	4		Agree Strongly
	5		Not Applicable
PAM		55.	I know the different medical treatment options available for my health condition.
	1		Disagree Strongly
	2		Disagree
	3		Agree
	4		Agree Strongly
	5		Not Applicable

PAM		56.	I have been able to maintain the lifestyle changes for my health condition that I have made.
	1		Disagree Strongly
	2		Disagree
	3		Agree
	4		Agree Strongly
	5		Not Applicable
PAM		57.	I know how to prevent further problems with my health condition.
	1		Disagree Strongly
	2		Disagree
	3		Agree
	4		Agree Strongly
	5		Not Applicable
PAM		58.	I am confident I can figure out solutions when new situations or problems arise with my health condition.
	1		Disagree Strongly
	2		Disagree
	3		Agree
	4		Agree Strongly
	5		Not Applicable
PAM		59.	I am confident that I can maintain lifestyle changes, like diet and exercise, even during times of stress.
	1		Disagree Strongly
	2		Disagree
	3		Agree
	4		Agree Strongly
	5		Not Applicable
		Please answer the last few questions about you.
HCAHPS		60.	In general, how would you rate your overall health?
	1		Excellent
	2		Very Good
	3		Good
	4		Fair
	5		Poor
HCAHPS		61.	What is the highest grade or level of school that you have completed?
	1		8th grade or less
	2		Some high school but did not graduate
	3		High school graduate or GED
	4		Some college or 2-year degree
	5		4-year college graduate
	6		6 More than 4-year college degree
OMB		62.	Are you Hispanic or Latino/Latina?
	1		No
	2		Yes
OMB		63.	What is your race? Please choose one or more.
	1		American Indian or Alaska Native
	2		Asian
	3		Native Hawaiian or other Pacific Islander
	4		Black or African American
	5		White
HCAHPS		64.	What language do you mainly speak at home?
	1		English
	2		Spanish
	3		Other language:
			Specify: _________________________
MCG		65.	What is your age?
			__________ years
*Key
HCAHPS:	Hospital Consumer Assessment of Healthcare Providers and Systems survey is a national, standardized survey of patients' perspectives of hospital care for measuring patients’ perceptions of their hospital experience.
HP-CAHPS	Consumer Assessment of Healthcare Providers and Systems ® Health Plan Survey 4.0 Supplemental Items for the Adult Questionnaires
MCG-revised:	Medical College of Georgia Patient and Family Centered Care Survey - Culture Survey ©2005. Revised questions to reflect patient perspective on care.
PPI:	Patients' Perceived Involvement in care scale. LermanC. E., Brody, D. S., Caputo, G. C., Smith, D. G., Lazaro, C. G., and Wolfson, H. G. (1990). Patients' perceived involvement in care scale: Relationship to attitudes about illness and medical care. Journal of General Internal Medicine, 5, 29-33.
PAM:	Patient Activation Measure. Patient Activation Measure License Package. May 2007 © Insignia Health 2006

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