Satisfaction Survey - National Research instituteTuberculosis and lung diseases

Step 1

Your answers to the following questions will be an important part of the quality assurance process for our hospital. Please take a few minutes to complete this form. We are asking you to “rate” your recent experience at our hospital by circling your level of satisfaction with various services provided throughout your inpatient stay. If you did not receive specific services mentioned, simply circle the number “6” for NA (not applicable).

I. Hospital Emergency Room/Department Ratings (please skip to item II if you were not admitted through the ER)
Circle the number that most closely approximates your experience in the ER

a) Over all rating of ER services

1) Completely

2) Satisfied

3) Somewhat

4) Satisfied

5) Neutral Somewhat

6) Dissatisfied

b) Level of care provided

1) Completely

2) Satisfied

3) Somewhat

4) Satisfied

5) Neutral Somewhat

6) Dissatisfied

c) Wait time

1) Completely

2) Satisfied

3) Somewhat

4) Satisfied

5) Neutral Somewhat

6) Dissatisfied

d) Explanation of procedures or services provided

1) Completely

2) Satisfied

3) Somewhat

4) Satisfied

5) Neutral Somewhat

6) Dissatisfied

e) Emergency department facility

1) Completely

2) Satisfied

3) Somewhat

4) Satisfied

5) Neutral Somewhat

6) Dissatisfied

f) Attending physician personality

1) Completely

2) Satisfied

3) Somewhat

4) Satisfied

5) Neutral Somewhat

6) Dissatisfied

g) Nursing staff personality

1) Completely

2) Satisfied

3) Somewhat

4) Satisfied

5) Neutral Somewhat

6) Dissatisfied

h) Quality of aftercare instruction

1) Completely

2) Satisfied

3) Somewhat

4) Satisfied

5) Neutral Somewhat

6) Dissatisfied

If you were somewhat or completely dissatisfied with any of the above items, please tell us why:

Step 2

II. Admissions and Discharge Services
Circle the number that most closely approximates your experience in the admissions and discharge process

a) Over all rating of the admissions process

1) Completely

2) Satisfied

3) Somewhat

4) Satisfied

5) Neutral Somewhat

6) Dissatisfied

b) Staff attention

1) Completely

2) Satisfied

3) Somewhat

4) Satisfied

5) Neutral Somewhat

6) Dissatisfied

c) Wait time

1) Completely

2) Satisfied

3) Somewhat

4) Satisfied

5) Neutral Somewhat

6) Dissatisfied

d) Explanation of procedures

1) Completely

2) Satisfied

3) Somewhat

4) Satisfied

5) Neutral Somewhat

6) Dissatisfied

e) Personality of admitting staff

1) Completely

2) Satisfied

3) Somewhat

4) Satisfied

5) Neutral Somewhat

6) Dissatisfied

f) Information provided on billing process

1) Completely

2) Satisfied

3) Somewhat

4) Satisfied

5) Neutral Somewhat

6) Dissatisfied

g) Transport to room

1) Completely

2) Satisfied

3) Somewhat

4) Satisfied

5) Neutral Somewhat

6) Dissatisfied

h) Overall rating of discharge process

1) Completely

2) Satisfied

3) Somewhat

4) Satisfied

5) Neutral Somewhat

6) Dissatisfied

i) Clear and understandable bill

1) Completely

2) Satisfied

3) Somewhat

4) Satisfied

5) Neutral Somewhat

6) Dissatisfied

j) Explanation of aftercare instructions

1) Completely

2) Satisfied

3) Somewhat

4) Satisfied

5) Neutral Somewhat

6) Dissatisfied

If you were somewhat or completely dissatisfied with any of the above items, please tell us why:

Step 3

What is your age?

Under 18

18 to 24

25 to 34

35 to 44

45 to 54

55 to 64

65 to 74

75+

What is your sex?

Male

Female

What is your marital status?

Married

Unmarried

Step 4

1- The comfort of the examining room (s).

Very poor

Poor

Fair

Good

Very good

2- The cleanliness of the ward.

Very poor

Poor

Fair

Good

Very good

3- The amount of time spent with your physician.

Very poor

Poor

Fair

Good

Very good

4- The quality of the care you received.

Very poor

Poor

Fair

Good

Very good

5- The privacy of the physician's consultation room and the examination room.

Very poor

Poor

Fair

Good

Very good

6- Would you recommend our practice to a family member or friend?

7- What would we have done better?

8- What else would you like to tell us about?

9- Nurse – related section friendliness / courtesy of the nurse

Very poor

Poor

Fair

Good

Very good

10- Promptness response to call nurse attitude toward requests

Very poor

Poor

Fair

Good

Very good

11- Attention to special / personal needs

Very poor

Poor

Fair

Good

Very good

12- Nurse kept you informed

Very poor

Poor

Fair

Good

Very good

13- Skill of the nurses

Very poor

Poor

Fair

Good

Very good

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