2 NIH Outpatient 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 visit 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. If a question does
not apply, do not answer it.
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
E 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. Questions 1-25 in this survey are part of a national initiative to
measure the quality of care in hospitals.

Please answer the questions in this survey
about your visit at the hospital named on the
cover letter. Do not include any other hospital
visit in your answers.
RECEPTION
1. Were clerks and receptionists at this facility as
helpful as you thought they should be?52655
1 No
E
2 Yes, somewhat
E
3 Yes, mostly
E
4 Yes, definitely
E

B

2. Did clerks and receptionists at this facility treat
you with courtesy and respect?52656
1 No
E
2 Yes, somewhat
E
3 Yes, mostly
E
4 Yes, definitely
E

*001AMD14*

3. During this outpatient visit, how often did your
appointment/procedure/treatment begin on
time?53126
1 Never
E
2 Sometimes
E
3 Usually
E
4 Always
E
4. If your appointment/procedure/treatment did not
begin on time, did the staff keep you informed
about delays?53127
1 No
E
2 Yes, somewhat
E
3 Yes, mostly
E
4 Yes, definitely
E
-89
E Did not have to wait
YOUR CARE FROM NURSES
5. During your visit, were you seen by a nurse?52657
1 Yes
E
2 No > Go to Question 11
E

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6. During this outpatient visit, how often did
nurses treat you with courtesy and respect?

13. During this outpatient visit, how often did
doctors listen carefully to you?52665
1 Never
E
2 Sometimes
E
3 Usually
E
4 Always
E

52658
1 Never
E
2 Sometimes
E
3 Usually
E
4 Always
E

14. During this outpatient visit, how often did
doctors explain things in a way you could
understand?52666
1 Never
E
2 Sometimes
E
3 Usually
E
4 Always
E

7. During this outpatient visit, how often did
nurses listen carefully to you?
52659
1 Never
E
2 Sometimes
E
3 Usually
E
4 Always
E

15. During this outpatient visit, how often were you
able to discuss your worries or concerns with
doctors?52667
1 Never
E
2 Sometimes
E
3 Usually
E
4 Always
E
-89
E Did not have any worries or concerns

8. During this outpatient visit, how often did
nurses explain things in a way you could
understand?
52660
1 Never
E
2 Sometimes
E
3 Usually
E
4 Always
E

16. During this outpatient visit, how often did you
have confidence and trust in the doctors treating
you?52668
1 Never
E
2 Sometimes
E
3 Usually
E
4 Always
E

9. During this outpatient visit, how often were you
able to discuss your worries or concerns with
nurses?52661
1 Never
E
2 Sometimes
E
3 Usually
E
4 Always
E
-89
E Did not have any worries or concerns

YOUR EXPERIENCES IN THIS HOSPITAL
17. During this outpatient visit, did you need
medicine for pain?52669
1 Yes
E
2 No > Go to Question 20
E

10. During this outpatient visit, how often did you
have confidence and trust in the nurses treating
you?
52662
1 Never
E
2 Sometimes
E
3 Usually
E
4 Always
E

18. During this outpatient visit, how often was your
pain well controlled?52670
1 Never
E
2 Sometimes
E
3 Usually
E
4 Always
E

YOUR CARE FROM DOCTORS
11. During this outpatient visit, were you seen by a
doctor?52663
1 Yes
E
2 No > Go to Question 17
E

B

12. During this outpatient visit, how often did
doctors treat you with courtesy and respect?52664
1 Never
E
2 Sometimes
E
3 Usually
E
4 Always
E

*001AMD25*

19. During this outpatient visit, how often did the
hospital staff do everything they could to help
you with your pain?52671
1 Never
E
2 Sometimes
E
3 Usually
E
4 Always
E

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20. During this outpatient visit, were you given any
medicine that you had not taken before?52672
1 Yes
E
2 No > Go to Question 23
E
21. Before giving you any new medicine, how often
did hospital staff tell you what the medicine was
for?52673
1 Never
E
2 Sometimes
E
3 Usually
E
4 Always
E
22. Before giving you any new medicine, how often
did hospital staff describe possible side effects
in a way you could understand?52674
1 Never
E
2 Sometimes
E
3 Usually
E
4 Always
E
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 outpatient
visit?52675
0 0 Worst hospital possible
E
1 1
E
2 2
E
3 3
E
4 4
E
5 5
E
6 6
E
7 7
E
8 8
E
9 9
E
1E
0 10 Best hospital possible

B

24. Would you recommend this hospital to your
friends and family?52676
1 Definitely no
E
2 Probably no
E
3 Probably yes
E
4 Definitely yes
E

*001AMD36*

UNDERSTANDING YOUR CARE WHEN YOU
LEFT THE HOSPITAL
25. During this hospital visit, 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.52677
1 Strongly disagree
E
2 Disagree
E
3 Agree
E
4 Strongly agree
E
26. When I left the hospital, I had a good
understanding of the things I was responsible
for in managing my health.52678
1 Strongly disagree
E
2 Disagree
E
3 Agree
E
4 Strongly agree
E
27. When I left the hospital, I clearly understood the
purpose for taking each of my medications.52679
1 Strongly disagree
E
2 Disagree
E
3 Agree
E
4 Strongly agree
E
-89
E I was not given any medication when I
left the hospital
MORE QUESTIONS ABOUT YOUR
OUTPATIENT VISIT TO THE HOSPITAL
The next set of questions will give us more
detailed information about how we can improve
the care and treatment we provide.
HOSPITAL STAFF
28. During this outpatient visit, 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?52680
1 Never
E
2 Sometimes
E
3 Usually
E
4 Always
E
-89
E No new medicine

*001AMD36*

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29. During this outpatient visit, before giving you
any medicine, how often did the hospital staff
check your ID band or otherwise confirm your
identity?52681
1 Never
E
2 Sometimes
E
3 Usually
E
4 Always
E
-88
E Did not notice
-89
E No medicine given

35. How often was there good communication
between the different staff members treating
you?52687
1 Never
E
2 Sometimes
E
3 Usually
E
4 Always
E
36. During this outpatient visit, how often were you
given enough input or say in your care?52688
1 Never
E
2 Sometimes
E
3 Usually
E
4 Always
E

30. If you had worries or concerns during your
treatment, how often did someone on the staff
discuss them with you? 52682
1 Never
E
2 Sometimes
E
3 Usually
E
4 Always
E
-89
E Did not have any worries or concerns

37. How often did you have enough privacy?52689
1 Never
E
2 Sometimes
E
3 Usually
E
4 Always
E

31. How often were the staff members consistent
with each other in providing you information and
care?52683
1 Never
E
2 Sometimes
E
3 Usually
E
4 Always
E
32. During this outpatient visit, how often did the
hospital staff include your family or someone
close to you in discussions about your care?52684
1 Never
E
2 Sometimes
E
3 Usually
E
4 Always
E
33. During this outpatient visit, how often was your
family or someone close to you allowed to be
with you as much as you wanted?52685
1 Never
E
2 Sometimes
E
3 Usually
E
4 Always
E

B

34. During this outpatient visit, how often was it
easy for you to find someone on the hospital
staff to talk to about your concerns?52686
1 Never
E
2 Sometimes
E
3 Usually
E
4 Always
E
-89
E Did not want or need to talk

*001AMD47*

GOING HOME
38. During this outpatient visit, did someone on the
hospital staff explain what to do if problems or
symptoms continued, got worse, or came back?52690
1 No
E
2 Yes, somewhat
E
3 Yes, mostly
E
4 Yes, definitely
E
39. During this outpatient visit, did someone on the
hospital staff explain the purpose of the
medicines you were to take at home in a way you
could understand?52691
1 No
E
2 Yes, somewhat
E
3 Yes, mostly
E
4 Yes, definitely
E
-89
E No meds or explanation needed
HAND HYGIENE
Please answer the following questions about
your experience regarding sanitation and hand
washing practices you observed during this
visit.
40. Did you observe any posted notices or signs
about hand washing/sanitizing?52698
1 Yes
E
2 No
E

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41. How often did nurses voluntarily wash or
sanitize their hands before caring for you?52699
1 Never
E
2 Sometimes
E
3 Usually
E
4 Always
E

47. Were the risks and benefits of joining the study
included in the informed consent form?53086
1 No
E
2 Yes, somewhat
E
3 Yes, mostly
E
4 Yes, completely
E
5 Do not remember
E

42. How often did doctors voluntarily wash or
sanitize their hands before caring for you?52700
1 Never
E
2 Sometimes
E
3 Usually
E
4 Always
E

48. Was the informed consent form written in a way
that you could understand?53087
1 No
E
2 Yes, somewhat
E
3 Yes, mostly
E
4 Yes, completely
E
5 Do not remember
E

CLINICAL RESEARCH PARTICIPATION
Please answer the following questions about
the research study in which you participated
during this visit.
43. Was the study explained to you in a way that
you knew what you were being asked to do as a
research subject?53082
1 No
E
2 Yes, somewhat
E
3 Yes, mostly
E
4 Yes, completely
E

49. During your discussion about the study, did you
feel pressure from the research team to join the
study?53088
1 No
E
2 Yes, somewhat
E
3 Yes, mostly
E
4 Yes, completely
E

44. Were the details about the research study
described in way that you could understand?53083
1 No
E
2 Yes, somewhat
E
3 Yes, mostly
E
4 Yes, completely
E
5 Do not remember
E
45. Did someone explain the risks and benefits of
joining the study in a way that you could
understand?53084
1 No
E
2 Yes, somewhat
E
3 Yes, mostly
E
4 Yes, completely
E
5 Do not remember
E
46. Were the details about the study included in the
informed consent form?53085
1 No
E
2 Yes, somewhat
E
3 Yes, mostly
E
4 Yes, completely
E
5 Do not remember
E

50. After the study was explained to you, did you
have enough time to think about your decision
before signing the informed consent form?53089
1 No
E
2 Yes, somewhat
E
3 Yes, mostly
E
4 Yes, completely
E
51. Did the informed consent form prepare you for
what to expect during the study?53090
1 No
E
2 Yes, somewhat
E
3 Yes, mostly
E
4 Yes, completely
E
52. Did you ever consider leaving the study?53091
1 No
E
2 Yes, briefly
E
3 Yes, a great deal
E
4 Yes, I left the study
E
53. Did you feel you were a valued partner in the
research process?53092
1 Never
E
2 Sometimes
E
3 Usually
E
4 Always
E

B

54. Would you have liked to receive a summary of
the results of the study?53093
1 No
E
2 Yes
E
3 Received a summary of the study
E

*001AMD58*

*001AMD58*

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55. Was the summary of the results of the study
written in a way you could understand?53094
1 No
E
2 Yes, somewhat
E
3 Yes, mostly
E
4 Yes, completely
E
5 Did not receive a summary of the results
E

60. 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?1660
e. To help others53103

56. Did the information and discussions you had
before participating in the research study
prepare you for your experience in the study?53095
1 No
E
2 Yes, somewhat
E
3 Yes, mostly
E
4 Yes, completely
E
57. If you wanted to leave the study, do you think
you would have been allowed to do so by the
research team?53096
1 No
E
2 Yes
E

Very important
1
E
Very important
1
E
Very important
1
E

Very important
1
E

Not very important
3
E

Very important
1
E

c. To gain access to new treatment/therapy53101
Very important
1
E

Somewhat
important
2
E

Not very important
3
E

d. To obtain free health care53102

B

Very important
1
E

Somewhat
important
2
E

Not very important
3
E

Not important at
all
4
E
Not important at
all
4
E

*001AMD69*

Somewhat
important
2
E

Not very important
3
E

Somewhat
important
2
E

Not very important
3
E

Somewhat
important
2
E

Not very important
3
E

Somewhat
important
2
E

Not very important
3
E

k. To earn money/payment53109
Very important
1
E

Not important at
all
4
E
Not important at
all
4
E

Not important at
all
4
E

Somewhat
important
2
E

Not very important
3
E

Not important at
all
4
E
Not important at
all
4
E

l. Because my caregiver encouraged me53110
Very important
1
E

Not important at
all
4
E
Not important at
all
4
E

Not important at
all
4
E

j. Because of family influence/involvement53108

Somewhat
important
2
E

Not very important
3
E

Not important at
all
4
E

Not very important
3
E

Not important at
all
4
E

m. Other reasons53111
Very important
1
E

b. Because no other medical options were available53100
Somewhat
important
2
E

Not very important
3
E

g. Because I am concerned about the topic of study53105

a. To find out more about my disease53099

Very important
1
E

Somewhat
important
2
E

i. Because of a positive experience in another
study53107

60. 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?1660
Not very important
3
E

Not important at
all
4
E

f. Because of the NIH Clinical Center's reputation53104

Very important
1
E

59. Were you ever told that you could stop being in
the study, at any time, and for any reason?53098
1 No
E
2 Yes
E

Somewhat
important
2
E

Not very important
3
E

h. To obtain education and learning53106

58. If you considered leaving the study, did you feel
pressure from the research team to stay?53097
1 No
E
2 Yes, somewhat
E
3 Yes, mostly
E
4 Yes, completely
E

Very important
1
E

Somewhat
important
2
E

Somewhat
important
2
E

61. Below is a list of possible reasons for leaving a
research study. How important were these
reasons for you in considering leaving the
study?1645
a. Pain or discomfort related to participation53112
Very important
1
E

Somewhat
important
2
E

Not very important
3
E

b. Worried about risks of treatment53113
Very important
1
E

*001AMD69*

Somewhat
important
2
E

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Not very important
3
E

Not important at
all
4
E
Not important at
all
4
E

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61. Below is a list of possible reasons for leaving a
research study. How important were these
reasons for you in considering leaving the
study?1645
c. Side effects that occurred during study53114
Very important
1
E

Somewhat
important
2
E

Not very important
3
E

Not important at
all
4
E

Not very important
3
E

Not important at
all
4
E

d. Invasion of privacy53115
Very important
1
E

Somewhat
important
2
E

62. Is there anything else you would like to say
about the care you received or your research
participation during this visit?

e. Too much time spent waiting around53116
Very important
1
E

Somewhat
important
2
E

Not very important
3
E

f. Time commitment required53117
Very important
1
E

Somewhat
important
2
E

Not very important
3
E

Not important at
all
4
E
Not important at
all
4
E

g. Family/work issues unrelated to study53118
Very important
1
E

Somewhat
important
2
E

Not very important
3
E

Not important at
all
4
E

h. Interactions with research team53119
Very important
1
E

Somewhat
important
2
E

Not important at
Not very important
all
3
4
E
E

i. Not getting test results53120
Very important
1
E

Somewhat
important
2
E

Not very important
3
E

j. Undue pressure to stay in study53121
Very important
1
E

Somewhat
important
2
E

Not very important
3
E

k. Problems with study payment53122
Very important
1
E

Somewhat
important
2
E

Not very important
3
E

Not important at
all
4
E
Not important at
all
4
E
Not important at
all
4
E

l. Unexpected tests and procedures that occurred
during study53123
Very important
1
E

Somewhat
important
2
E

Not very important
3
E

m. Transportation/parking53124
Very important
1
E

Somewhat
important
2
E

Not very important
3
E

Not important at
all
4
E

Not very important
3
E

Not important at
all
4
E

n. Other reasons53125

B

Very important
1
E

Somewhat
important
2
E

Not important at
all
4
E

*001AMD7A*

ABOUT YOU
63. In general, how would you rate your overall
health?52692
1 Excellent
E
2 Very Good
E
3 Good
E
4 Fair
E
5 Poor
E
64. In general, how would you rate your overall
mental or emotional health?52693
1 Excellent
E
2 Very Good
E
3 Good
E
4 Fair
E
5 Poor
E
65. What is the highest grade or level of school that
you have completed?52694
1 8th grade or less
E
2 Some high school, but did not graduate
E
3 High school graduate or GED
E
4 Some college or 2-year degree
E
5 4-year college graduate
E
6 More than 4-year college degree
E
66. Are you of Spanish, Hispanic or Latino origin or
descent? 52695
1 No, not Spanish/Hispanic/Latino
E
2 Yes, Puerto Rican
E
3 Yes, Mexican, Mexican American,
E
Chicano
4 Yes, Cuban
E
5 Yes, other Spanish/Hispanic/Latino
E

*001AMD7A*

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67. What is your race? Please choose one or more.52696
1 White
F
2 Black or African American
F
3 Asian
F
4 Native Hawaiian or other Pacific Islander
F
5 American Indian or Alaska Native
F
68. What language do you mainly speak at home?52697
1 English
E
2 Spanish
E
3 Chinese
E
4 Russian
E
5 Vietnamese
E
6 Some other language (please print):
E
______________
Thank you.
Please return the completed survey in the
postage-paid envelope.

B

Mail the completed survey to NRC Health
Survey Processing Center, PO Box 82660,
Lincoln, NE 68501-2660. NRC Health phone: 1800-733-6714.

*001AMD8B*

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