Satisfaction survey

March 2015 1

HCAHPS Survey

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

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 note: Questions 1-25 in this survey are part of a national initiative to measure the quality of care in hospitals. OMB #0938-0981

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? 1 Never 2 Sometimes 3 Usually 4 Always

2. During this hospital stay, how

often did nurses listen carefully to you?

1 Never 2 Sometimes 3 Usually 4 Always

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

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 9 I never pressed the call button

2 March 2015

YOUR CARE FROM DOCTORS

5. During this hospital stay, how often did doctors treat you with courtesy and respect? 1 Never 2 Sometimes 3 Usually 4 Always

6. During this hospital stay, how

often did doctors listen carefully to you? 1 Never 2 Sometimes 3 Usually 4 Always

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

THE HOSPITAL ENVIRONMENT

8. During this hospital stay, how often were your room and bathroom kept clean? 1 Never 2 Sometimes 3 Usually 4 Always

9. During this hospital stay, how

often was the area around your room quiet at night? 1 Never 2 Sometimes 3 Usually 4 Always

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? 1 Yes 2 No  If 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? 1 Never 2 Sometimes 3 Usually 4 Always

12. During this hospital stay, did you

need medicine for pain? 1 Yes 2 No  If No, Go to Question 15

13. During this hospital stay, how

often was your pain well controlled? 1 Never 2 Sometimes 3 Usually 4 Always

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

March 2015 3

15. During this hospital stay, were you given any medicine that you had not taken before? 1 Yes 2 No  If No, Go to Question 18

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

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

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? 1 Own home 2 Someone else’s home 3 Another health facility  If Another, Go to

Question 21

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

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

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? 0 0 Worst hospital possible 1 1 2 2 3 3 4 4 5 5 6 6 7 7 8 8 9 9

1010 Best hospital possible

4 March 2015

22. Would you recommend this

hospital to your friends and family? 1 Definitely no 2 Probably no 3 Probably yes 4 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. 1 Strongly disagree 2 Disagree 3 Agree 4 Strongly agree

24. When I left the hospital, I had a good understanding of the things I was responsible for in managing my health. 1 Strongly disagree 2 Disagree 3 Agree 4 Strongly agree

25. When I left the hospital, I clearly

understood the purpose for taking each of my medications. 1 Strongly disagree 2 Disagree 3 Agree 4 Strongly agree 5 I was not given any medication

when I left the hospital

ABOUT YOU

There are only a few remaining items left. 26. During this hospital stay, were you

admitted to this hospital through the Emergency Room? 1 Yes 2 No

27. In general, how would you rate

your overall health? 1 Excellent 2 Very good 3 Good 4 Fair 5 Poor

28. In general, how would you rate your overall mental or emotional health? 1 Excellent 2 Very good 3 Good 4 Fair 5 Poor

29. 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 More than 4-year college degree

March 2015 5

30. Are you of Spanish, Hispanic or Latino origin or descent? 1 No, not Spanish/Hispanic/Latino 2 Yes, Puerto Rican 3 Yes, Mexican, Mexican American,

Chicano 4 Yes, Cuban 5 Yes, other

Spanish/Hispanic/Latino 31. What is your race? Please choose

one or more. 1 White 2 Black or African American 3 Asian 4 Native Hawaiian or other Pacific

Islander 5 American Indian or Alaska

Native

32. What language do you mainly speak at home? 1 English 2 Spanish 3 Chinese 4 Russian 5 Vietnamese 6 Portuguese 9 Some other language (please

print): _____________________

THANK YOU

Please return the completed survey in the postage-paid envelope.

[NAME OF SURVEY VENDOR OR SELF-ADMINISTERING HOSPITAL]

[RETURN ADDRESS OF SURVEY VENDOR OR SELF-ADMINISTERING HOSPITAL]

Questions 1-22 and 26-32 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 The Care Transitions Program® (www.caretransitions.org).

March 2015 7

HCAHPS Survey

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:

0 Yes 0 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 note: Questions 1-25 in this survey are part of a national initiative to measure the quality of care in hospitals. OMB #0938-0981

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? 10 Never 20 Sometimes 30 Usually 40 Always

2. During this hospital stay, how often

did nurses listen carefully to you?

10 Never 20 Sometimes 30 Usually 40 Always

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

10 Never 20 Sometimes 30 Usually 40 Always

4. During this hospital stay, after you

pressed the call button, how often did you get help as soon as you wanted it? 10 Never 20 Sometimes 30 Usually 40 Always 90 I never pressed the call button

8 March 2015

YOUR CARE FROM DOCTORS

5. During this hospital stay, how often did doctors treat you with courtesy and respect? 10 Never 20 Sometimes 30 Usually 40 Always

6. During this hospital stay, how often

did doctors listen carefully to you? 10 Never 20 Sometimes 30 Usually 40 Always

7. During this hospital stay, how often

did doctors explain things in a way you could understand? 10 Never 20 Sometimes 30 Usually 40 Always

THE HOSPITAL ENVIRONMENT

8. During this hospital stay, how often were your room and bathroom kept clean? 10 Never 20 Sometimes 30 Usually 40 Always

9. During this hospital stay, how often was the area around your room quiet at night? 10 Never 20 Sometimes 30 Usually 40 Always

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? 10 Yes 20 No  If 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? 10 Never 20 Sometimes 30 Usually 40 Always

12. During this hospital stay, did you need

medicine for pain? 10 Yes 20 No  If No, Go to Question 15

13. During this hospital stay, how often

was your pain well controlled? 10 Never 20 Sometimes 30 Usually 40 Always

March 2015 9

14. During this hospital stay, how often did the hospital staff do everything they could to help you with your pain? 10 Never 20 Sometimes 30 Usually 40 Always

15. During this hospital stay, were you

given any medicine that you had not taken before? 10 Yes 20 No  If No, Go to Question 18

16. Before giving you any new medicine,

how often did hospital staff tell you what the medicine was for? 10 Never 20 Sometimes 30 Usually 40 Always

17. Before giving you any new medicine,

how often did hospital staff describe possible side effects in a way you could understand? 10 Never 20 Sometimes 30 Usually 40 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? 10 Own home 20 Someone else’s home 30 Another health facility  If Another, Go to

Question 21

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? 10 Yes 20 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? 10 Yes 20 No

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? 00 0 Worst hospital possible 10 1 20 2 30 3 40 4 50 5 60 6 70 7 80 8 90 9

100 10 Best hospital possible

10 March 2015

22. Would you recommend this hospital to your friends and family? 10 Definitely no 20 Probably no 30 Probably yes 40 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. 10 Strongly disagree 20 Disagree 30 Agree 40 Strongly agree

24. When I left the hospital, I had a good understanding of the things I was responsible for in managing my health. 10 Strongly disagree 20 Disagree 30 Agree 40 Strongly agree

25. When I left the hospital, I clearly

understood the purpose for taking each of my medications. 10 Strongly disagree 20 Disagree 30 Agree 40 Strongly agree 50 I was not given any medication when I left the hospital

ABOUT YOU There are only a few remaining items left. 26. During this hospital stay, were you

admitted to this hospital through the Emergency Room? 10 Yes 20 No

27. In general, how would you rate your

overall health? 10 Excellent 20 Very good 30 Good 40 Fair 50 Poor

28. In general, how would you rate your overall mental or emotional health? 10 Excellent 20 Very good 30 Good 40 Fair 50 Poor

29. What is the highest grade or level of

school that you have completed? 10 8th grade or less 20 Some high school, but did not

graduate 30 High school graduate or GED 40 Some college or 2-year degree 50 4-year college graduate 60 More than 4-year college degree

March 2015 11

30. Are you of Spanish, Hispanic or Latino origin or descent? 10 No, not Spanish/Hispanic/Latino 20 Yes, Puerto Rican 30 Yes, Mexican, Mexican American,

Chicano 40 Yes, Cuban 50 Yes, other Spanish/Hispanic/Latino

31. 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

32. What language do you mainly speak at home? 10 English 20 Spanish 30 Chinese 40 Russian 50 Vietnamese 60 Portuguese 90 Some other language (please print):

_____________________

THANK YOU

Please return the completed survey in the postage-paid envelope.

[NAME OF SURVEY VENDOR OR SELF-ADMINISTERING HOSPITAL]

[RETURN ADDRESS OF SURVEY VENDOR OR SELF-ADMINISTERING HOSPITAL]

Questions 1-22 and 26-32 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 The Care Transitions Program® (www.caretransitions.org).

March 2015 13

Sample Initial Cover Letter for the HCAHPS Survey

[HOSPITAL LETTERHEAD]

[SAMPLED PATIENT NAME] [ADDRESS] [CITY, STATE ZIP] Dear [SAMPLED PATIENT NAME]: 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 national effort to understand how patients view their hospital experience. Hospital results will be publicly reported and made available on the Internet at www.medicare.gov/hospitalcompare. These results will help consumers make important choices about their hospital care, and will help hospitals improve the care they provide. Questions 1-25 in the enclosed survey are part of a national initiative sponsored by the United States Department of Health and Human Services to measure the quality of care in hospitals. Your participation is voluntary and will not affect your health benefits. We hope that you will take the time to complete the survey. Your participation is greatly appreciated. After you have completed the survey, please return it in the pre-paid envelope. Your answers may be shared with the hospital for purposes of quality improvement. [OPTIONAL: 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.] If you have any questions about the enclosed survey, please call the toll-free number 1-800-xxx- xxxx. Thank you for helping to improve health care for all consumers. Sincerely, [HOSPITAL ADMINISTRATOR] [HOSPITAL NAME] Note: The OMB Paperwork Reduction Act language must be included in the mailing. This language can be either on the front or back of the cover letter or questionnaire, but cannot be a separate mailing. The exact OMB Paperwork Reduction Act language is included in this appendix. Please refer to the Mail Only, and Mixed Mode sections, for specific letter guidelines.

March 2015 15

Sample Follow-up Cover Letter for the HCAHPS Survey

[HOSPITAL LETTERHEAD]

[SAMPLED PATIENT NAME] [ADDRESS] [CITY, STATE ZIP] Dear [SAMPLED PATIENT NAME]: Our records show that you were recently a patient at [NAME OF HOSPITAL] and discharged on [DATE OF DISCHARGE]. Approximately three weeks ago we sent you a survey regarding your hospitalization. If you have already returned the survey to us, please accept our thanks and disregard this letter. However, if you have not yet completed the survey, please take a few minutes and complete it now. Because you had a recent hospital stay, we are asking for your help. This survey is part of an ongoing national effort to understand how patients view their hospital experience. Hospital results will be publicly reported and made available on the Internet at www.medicare.gov/hospitalcompare. These results will help consumers make important choices about their hospital care, and will help hospitals improve the care they provide. Questions 1-25 in the enclosed survey are part of a national initiative sponsored by the United States Department of Health and Human Services to measure the quality of care in hospitals. Your participation is voluntary and will not affect your health benefits. Please take a few minutes and complete the enclosed survey. After you have completed the survey, please return it in the pre-paid envelope. Your answers may be shared with the hospital for purposes of quality improvement. [OPTIONAL: 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.] If you have any questions about the enclosed survey, please call the toll-free number 1-800-xxx- xxxx. Thank you again for helping to improve health care for all consumers. Sincerely, [HOSPITAL ADMINISTRATOR] [HOSPITAL NAME] Note: The OMB Paperwork Reduction Act language must be included in the mailing. This language can be either on the front or back of the cover letter or questionnaire, but cannot be a separate mailing. The exact OMB Paperwork Reduction Act language is included in this appendix. Please refer to the Mail Only, and Mixed Mode sections, for specific letter guidelines.

March 2015 17

OMB Paperwork Reduction Act Language The OMB Paperwork Reduction Act language must be included in the survey mailing. This language can be either on the front or back of the cover letter or questionnaire, but cannot be a separate mailing. The following is the language that must be used: English Version “According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-0981. The time required to complete this information collected is estimated to average 8 minutes for questions 1-25 on the survey, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: Centers for Medicare & Medicaid Services, 7500 Security Boulevard, C1-25-05, Baltimore, MD 21244- 1850.”