Form 1 NIH Inpatient Mock-up - NRC Health

B

OMB No. 0925-0648 Expiration Date: 03/2018

Please use the enclosed envelope and
mail the completed survey to:
NRC Health
Survey Processing Center
PO BOX 82660
Lincoln, NE 68501-2660
1-800-733-6714

Public reporting burden for this collection of information is estimated to average 30 minutes per response, including the time for reviewing instructions,
searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. 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: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-0648). Do not return the

completed form to this address.

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 completely filling in the circle 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:
E Yes
d No > If No, Go to Question 1
You may notice a number on the survey. This number is used to let us know if you
returned your survey so we don't have to send you reminders.
Please answer the questions in this survey about
your stay at the hospital named on the cover letter.
Do not include any other hospital stays in your
answers.
YOUR CARE FROM NURSES
1. During this hospital stay, how often did nurses treat
you with courtesy and respect?
E Never
E Sometimes
E Usually
E Always
2. During this hospital stay, how often did nurses listen
carefully to you?
E Never
E Sometimes
E Usually
E Always

B

3. During this hospital stay, how often did nurses
explain things in a way you could understand?
E Never
E Sometimes
E Usually
E Always

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4. During this hospital stay, after you pressed the call
button, how often did you get help as soon as you
wanted it?
E Never
E Sometimes
E Usually
E Always
E I never pressed the call button
YOUR CARE FROM DOCTORS
5. During this hospital stay, how often did doctors treat
you with courtesy and respect?
E Never
E Sometimes
E Usually
E Always
6. During this hospital stay, how often did doctors
listen carefully to you?
E Never
E Sometimes
E Usually
E Always

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7. During this hospital stay, how often did doctors
explain things in a way you could understand?
E Never
E Sometimes
E Usually
E Always

15. During this hospital stay, were you given any
medicine that you had not taken before?
E Yes
E No > Go to Question 18
16. Before giving you any new medicine, how often did
hospital staff tell you what the medicine was for?
E Never
E Sometimes
E Usually
E Always

THE HOSPITAL ENVIRONMENT
8. During this hospital stay, how often were your room
and bathroom kept clean?
E Never
E Sometimes
E Usually
E Always

17. Before giving you any new medicine, how often did
hospital staff describe possible side effects in a way
you could understand?
E Never
E Sometimes
E Usually
E Always

9. During this hospital stay, how often was the area
around your room quiet at night?
E Never
E Sometimes
E Usually
E Always

WHEN YOU LEFT THE HOSPITAL
18. After you left the hospital, did you go directly to your
own home, to someone else's home, or to another
health facility?
E Own home
E Someone else's home
E Another health facility > Go to Question 21

YOUR EXPERIENCES IN THIS HOSPITAL
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?
E Yes
E No > Go to Question 12
11. How often did you get help in getting to the bathroom
or in using a bedpan as soon as you wanted?
E Never
E Sometimes
E Usually
E Always
12. During this hospital stay, did you need medicine for
pain?
E Yes
E No > Go to Question 15

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?
E Yes
E No
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?
E Yes
E No

13. During this hospital stay, how often was your pain
well controlled?
E Never
E Sometimes
E Usually
E Always

B

14. During this hospital stay, how often did the hospital
staff do everything they could to help you with your
pain?
E Never
E Sometimes
E Usually
E Always

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OVERALL RATING OF HOSPITAL
Please answer the following questions about your
stay at the hospital named on the cover letter. Do
not include any other hospital stays in your
answers.
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?
E 0 Worst hospital possible
E 1
E 2
E 3
E 4
E 5
E 6
E 7
E 8
E 9
E 10 Best hospital possible
22. Would you recommend this hospital to your friends
and family?
E Definitely no
E Probably no
E Probably yes
E Definitely yes
UNDERSTANDING YOUR CARE WHEN YOU LEFT
THE HOSPITAL
23. During this hospital stay, staff took my preferences
and those of my family or caregiver into account in
deciding what my health care needs would be when I
left.
E Strongly disagree
E Disagree
E Agree
E Strongly agree

B

24. When I left the hospital, I had a good understanding
of the things I was responsible for in managing my
health.
E Strongly disagree
E Disagree
E Agree
E Strongly agree

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25. When I left the hospital, I clearly understood the
purpose for taking each of my medications.
E Strongly disagree
E Disagree
E Agree
E Strongly agree
E I was not given any medication when I left the
hospital
MORE QUESTIONS ABOUT YOUR STAY AT THE
HOSPITAL
Please answer the following questions to provide
us with a bit more detail about your experience.
ADMISSION INTO THE HOSPITAL
26. If you had to wait to go to your room, did someone
from the hospital explain the reason for the delay?
E No
E Yes, somewhat
E Yes, mostly
E Yes, definitely
E Did not have to wait
27. How organized was the admission process?
E Not at all organized
E Somewhat organized
E Very organized
E Completely organized
HOSPITAL STAFF
28. During this hospital stay, before giving you any new
medicine, how often did the hospital staff ask you
about your allergies or other medications you may
have been taking?
E Never
E Sometimes
E Usually
E Always
E No allergies/other meds
29. During this hospital stay, before giving you any
medicine, how often did the hospital staff check your
ID band or otherwise confirm your identity?
E Never
E Sometimes
E Usually
E Always
E Did not notice

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30. During this hospital stay, how often were you able to
discuss your worries or concerns with nurses?
E Never
E Sometimes
E Usually
E Always
E Did not have any worries or concerns

37. During this hospital stay, how often was your family
or someone close to you allowed to be with you as
much as you wanted?
E Never
E Sometimes
E Usually
E Always

31. During this hospital stay, how often did you have
confidence and trust in the nurses treating you?
E Never
E Sometimes
E Usually
E Always

38. During this hospital stay, how often was it easy for
you to find someone on the hospital staff to talk to
about your concerns?
E Never
E Sometimes
E Usually
E Always
E Did not want or need to talk

32. During this hospital stay, how often were you able to
discuss your worries or concerns with doctors?
E Never
E Sometimes
E Usually
E Always
E Did not have any worries or concerns
33. During this hospital stay, how often did you have
confidence and trust in the doctors treating you?
E Never
E Sometimes
E Usually
E Always
34. How often were the different doctors and nurses
consistent with each other in providing you
information and care?
E Never
E Sometimes
E Usually
E Always
E Did not notice
35. During this hospital stay, how often was your family
or someone close to you able to talk to your doctor?
E Never
E Sometimes
E Usually
E Always

B

36. During this hospital stay, how often did the hospital
staff include your family or someone close to you in
discussions about your care?
E Never
E Sometimes
E Usually
E Always

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39. During this hospital stay, how often was there good
communication between the different doctors and
nurses?
E Never
E Sometimes
E Usually
E Always
40. During this hospital stay, how often were you given
enough input or say in your care?
E Never
E Sometimes
E Usually
E Always
GOING HOME
41. During this hospital stay, did someone on the
hospital staff explain when you would be allowed to
leave?
E No
E Yes, somewhat
E Yes, mostly
E Yes, definitely
42. During this hospital stay, did someone on the
hospital staff explain what to do if problems or
symptoms continued, got worse, or came back?
E No
E Yes, somewhat
E Yes, mostly
E Yes, definitely

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43. During this hospital stay, did someone on the
hospital staff explain the purpose of the medicines
you were to take at home in a way you could
understand?
E No
E Yes, somewhat
E Yes, mostly
E Yes, definitely
E No meds or explanation needed
HAND HYGIENE

Please answer the following questions about the
bedside dining services you received during this
hospital stay.
50. How often did the staff who brought you your food
treat you with courtesy and respect?
E Never
E Sometimes
E Usually
E Always

Please answer the following questions about your
experience regarding sanitation and hand washing
practices you observed during this visit.
44. Did you observe any posted notices or signs about
hand washing/sanitizing?
E Yes
E No

51. How often did you get all of the food items you
ordered?
E Never
E Sometimes
E Usually
E Always
E Not applicable

45. How often did nurses voluntarily wash or sanitize
their hands before caring for you?
E Never
E Sometimes
E Usually
E Always

52. How often was the flavor of your food excellent?
E Never
E Sometimes
E Usually
E Always

46. How often did doctors voluntarily wash or sanitize
their hands before caring for you?
E Never
E Sometimes
E Usually
E Always
HOUSEKEEPING
Please answer the following questions about the
housekeeping staff who may have cleaned your
room, provided towels, etc. during this hospital
stay.
47. Did any housekeeping staff visit your room?
E Yes
E No > Go to Question 50
48. How often did housekeeping staff treat you with
courtesy and respect?
E Never
E Sometimes
E Usually
E Always
49. How often did housekeeping staff show respect for
your privacy?
E Never
E Sometimes
E Usually
E Always

B

DINING SERVICES

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53. How often was the freshness and appearance of your
food excellent?
E Never
E Sometimes
E Usually
E Always
54. How often was the temperature of your food hot OR
cold enough?
E Never
E Sometimes
E Usually
E Always
55. How often were you provided napkins, utensils,
salt/pepper and the right condiments when your food
was delivered?
E Never
E Sometimes
E Usually
E Always
56. Was there enough variety of food choices?
E No
E Yes, somewhat
E Yes, mostly
E Yes, definitely
E Not applicable

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CLINICAL RESEARCH PARTICIPATION

63. During your discussion about the study, did you feel
pressure from the research team to join the study?
E No
E Yes, somewhat
E Yes, mostly
E Yes, completely

Please answer the following questions about the
research study in which you participated during this
hospital stay.
57. Was the study explained to you in a way that you
knew what you were being asked to do as a research
subject?
E No
E Yes, somewhat
E Yes, mostly
E Yes, completely

64. After the study was explained to you, did you have
enough time to think about your decision before
signing the informed consent form?
E No
E Yes, somewhat
E Yes, mostly
E Yes, completely

58. Were the details about the research study described
in way that you could understand?
E No
E Yes, somewhat
E Yes, mostly
E Yes, completely
E Do not remember
59. Did someone explain the risks and benefits of joining
the study in a way that you could understand?
E No
E Yes, somewhat
E Yes, mostly
E Yes, completely
E Do not remember
60. Were the details about the study included in the
informed consent form?
E No
E Yes, somewhat
E Yes, mostly
E Yes, completely
E Do not remember
61. Were the risks and benefits of joining the study
included in the informed consent form?
E No
E Yes, somewhat
E Yes, mostly
E Yes, completely
E Do not remember

B

62. Was the informed consent form written in a way that
you could understand?
E No
E Yes, somewhat
E Yes, mostly
E Yes, completely
E Do not remember

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65. Did the informed consent form prepare you for what
to expect during the study?
E No
E Yes, somewhat
E Yes, mostly
E Yes, completely
66. Did you ever consider leaving the study?
E No
E Yes, briefly
E Yes, a great deal
E Yes, I left the study
67. Did you feel you were a valued partner in the
research process?
E Never
E Sometimes
E Usually
E Always
68. Would you have liked to receive a summary of the
results of the study?
E No
E Yes
E Received a summary of the study
69. Was the summary of the results of the study written
in a way you could understand?
E No
E Yes, somewhat
E Yes, mostly
E Yes, completely
E Did not receive a summary of the results
70. Did the information and discussions you had before
participating in the research study prepare you for
your experience in the study?
E No
E Yes, somewhat
E Yes, mostly
E Yes, completely

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71. If you wanted to leave the study, do you think you
would have been allowed to do so by the research
team?
E No
E Yes
72. If you considered leaving the study, did you feel
pressure from the research team to stay?
E No
E Yes, somewhat
E Yes, mostly
E Yes, completely
73. Were you ever told that you could stop being in the
study, at any time, and for any reason?
E No
E Yes
74. Below is a list of possible reasons for joining a
research study. When you considered joining the
study how important were these reasons for you?
a. To find out more about my disease
Very important

Somewhat
important

Not very
important

Not important
at all

E

E

E

E

b. Because no other medical options were available
Very important

Somewhat
important

Not very
important

Not important
at all

E

E

E

E

74. Below is a list of possible reasons for joining a
research study. When you considered joining the
study how important were these reasons for you?
i. Because of a positive experience in another study
Very important

Somewhat
important

Not very
important

Not important
at all

E

E

E

E

Somewhat
important

Not very
important

Not important
at all

E

E

E

E

Somewhat
important

Not very
important

Not important
at all

E

E

E

E

Very important

Somewhat
important

Not very
important

Not important
at all

E

E

E

E

Somewhat
important

Not very
important

Not important
at all

E

E

E

Very important

Somewhat
important

Not very
important

Not important
at all

E

E

E

E

Very important

E
m. Other reasons

75. Below is a list of possible reasons for leaving a
research study. How important were these reasons
for you in considering leaving the study?
a. Pain or discomfort related to participation
Very important

Somewhat
important

Not very
important

Not important
at all

E

E

E

E

b. Worried about risks of treatment
Very important

Somewhat
important

Not very
important

Not important
at all

E

E

E

E

c. Side effects that occurred during study

Not very
important

Not important
at all

E

E

E

E

Very important

Somewhat
important

Not very
important

Not important
at all

E

E

E

E

Somewhat
important

Not very
important

Not important
at all

E

E

E

E

Very important

Somewhat
important

Not very
important

Not important
at all

E

E

E

E

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Not important
at all

E

E

Very important

Somewhat
important

Not very
important

Not important
at all

E

E

E

E

Very important

Somewhat
important

Not very
important

Not important
at all

E

E

E

E

Not very
important

Not important
at all

f. Time commitment required
Very important

h. To obtain education and learning

Not very
important

e. Too much time spent waiting around

g. Because I am concerned about the topic of study
Very important

Somewhat
important

E
E
d. Invasion of privacy

f. Because of the NIH Clinical Center's reputation

B

Very important

Very important
Somewhat
important

E

l. Because my caregiver encouraged me

e. To help others
Very important

Not important
at all

k. To earn money/payment

d. To obtain free health care
Very important

Not very
important

E
E
E
j. Because of family influence/involvement

c. To gain access to new treatment/therapy
Very important

Somewhat
important

Somewhat
important

E
E
E
g. Family/work issues unrelated to study

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E

Very important

Somewhat
important

Not very
important

Not important
at all

E

E

E

E

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75. Below is a list of possible reasons for leaving a
research study. How important were these reasons
for you in considering leaving the study?

ABOUT YOU
There are only a few remaining items left.
77. In general, how would you rate your overall health?
E Excellent
E Very Good
E Good
E Fair
E Poor

h. Interactions with research team
Very important

Somewhat
important

Not very
important

Not important
at all

E

E

E

E

i. Not getting test results
Very important

Somewhat
important

Not very
important

Not important
at all

E

E

E

E

78. In general, how would you rate your overall mental or
emotional health?
E Excellent
E Very Good
E Good
E Fair
E Poor

j. Undue pressure to stay in study
Very important

Somewhat
important

Not very
important

Not important
at all

E

E

E

E

Very important

Somewhat
important

Not very
important

Not important
at all

E

E

E

E

k. Problems with study payment

l. Unexpected tests and procedures that occurred during
study
Very important

Somewhat
important

Not very
important

Not important
at all

E

E

E

E

m. Transportation/parking
Very important

Somewhat
important

Not very
important

Not important
at all

E

E

E

E

Very important

Somewhat
important

Not very
important

Not important
at all

E

E

E

E

n. Other reasons

We would greatly appreciate your feedback about
the following.
76. Is there anything else you would like to say about
the care you received or your research participation
during this visit?

79. What is the highest grade or level of school that you
have completed?
E 8th grade or less
E Some high school, but did not graduate
E High school graduate or GED
E Some college or 2-year degree
E 4-year college graduate
E More than 4-year college degree
80. Are you of Spanish, Hispanic or Latino origin or
descent?
E No, not Spanish/Hispanic/Latino
E Yes, Puerto Rican
E Yes, Mexican, Mexican American, Chicano
E Yes, Cuban
E Yes, other Spanish/Hispanic/Latino
81. What is your race? Please choose one or more.
E White
E Black or African American
E Asian
E Native Hawaiian or other Pacific Islander
E American Indian or Alaska Native
82. What language do you mainly speak at home?
E English
E Spanish
E Chinese
E Russian
E Vietnamese
E Portuguese
E Some other language (please

B

print):____________________

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THANK YOU!
Please return the completed survey in the postagepaid envelope.
Mail the completed survey to: NRC Health, Survey
Processing Center, PO Box 82660, Lincoln, NE
68501-2660. NRC Health phone: 1-800-733-6714.
© NRC Health, All Rights Reserved

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Questions 1-22 and the About You section are part of
the HCAHPS survey and are works of the U.S.
Government. These HCAHPS questions are in the
public domain and therefore are NOT subject to U.S.
copyright laws. The three Care Transitions Measure®
questions (Questions 23-25) are copyright of Eric A.
Coleman, MD, MPH, all rights reserved.

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