HCAHPS V12.0 Appendix A – Mail Survey (English) January 2018

Transcript

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 th e 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   If No, No Go to Question 1 You may notice a num ber 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 2 5 in this survey are part of a national initiative to measure the quality - of care in hospitals. OMB #0938 - 0981 During this hospital stay, how often 3. Please answer the questions in this survey about your stay at the hospital named on did nurses explain things in a way the cover you could understand? letter . Do not include any other s hospital stay in your answers. 1 Never  2  Sometimes YOUR CARE FROM NURSES 3 Usually  During this hospital stay, how often 1. 4 Always  did nurses treat you with courtesy ? and respect During this hospital stay, after you 4. 1 pressed the call button, how often did  Never 2 you get help as soon as you wanted Sometimes  it? 3 Usually  1 4  Never  Always 2  Sometimes 3 During this hospital stay, how often 2. Usually  ? listen carefully to you did nurses 4  Always 1 9  Never never pressed the call button  I 2 Sometimes  3 Usually  4  Always 8 201 January 1

2 YOUR CARE FROM DOCTORS R EXPERIENCES IN THIS HOSPITAL YOU 5. During this hospital stay, how often During this hospital stay, did you 10. did doctors treat you with courtesy need help from nurses or other ? and respect hospital staff in getting to the bathroom or in using a bedpan? 1 Never  1 2 Yes   Sometimes 2 3  If No, Go to Question 12  No Usually  4  Always How often did you get help in g 11. etting to the bathroom or in using a bedpan During this hospital stay, how often 6. as soon as you wanted? ? listen carefully to you did doctors 1 1  Never  Never 2 2 Sometimes  Sometimes  3 3 Usually  Usually  4 4 Always   Always During this hospital stay, did you 12. During this hospital stay, how often 7. pain? any have in a way did doctors explain things 1 you could understand?  Yes 2 1  If No, Go to Question 15  No Never  2  Sometimes 13. During this hospital stay, how often 3  Usually did ital staff talk with you about hosp 4 Always  how much pain you had ? 1 Never  THE HOSPITAL ENVIRONMENT 2  Sometimes 8 During this hospital stay, how often . 3 Usually  were your room and bathroom kept 4 Always  clean? 1  Never During this hospital stay, how often 14. 2 you talk with did hospital staff about Sometimes  our pain? how to treat y 3  Usually 1 4  Never Always  2 Sometimes  9. During this hospital stay, how often 3  Usually was the area around your room quiet 4  Always at night? 1  Never 2 Sometimes  3  Usually 4 Always  2 January 2018

3 15. Durin g this hospital stay, were you During this hospital stay, did doctors, 19. given any medicine that you had not other hospital staff talk with nurses or taken before? you about whether you would have the help you needed when you left the 1  Yes hospital? 2  No  If No, Go to Question 18 1 Yes  2 Before giving you any new medicine, 16. No  how often did hospital staff tell you During this hospital stay, did you get 20. what the medicine was for? information in writing about what 1 Never  symptoms or health problems to look 2 Sometimes  left the hospital? out for after you 3  Us ually 1  Yes 4 Always  2 No  17. Before giving you any new medicine, OVERALL RATING OF HOSPITAL how often did hospital staff describe possible side effects in a way you Please answer the following questions could understand? about your stay at the hospital named on the cover . Do not include any other letter 1  Never s . hospital stays in your answer 2  Sometimes 21. Using any number from 0 to 10, where 3  Usually 0 is the worst hospital possible and 4  Always 10 is the best hospital possible, what number would you use to rate this WHEN YOU LEFT THE HOSPITAL hospital during your stay? 0 After you left the 18. hospital, did you go  Worst hospital possible 0 directly to your own home, to 1 1  someone else’s home, or to another 2 2  health facility? 3 3  1  Own home 4 4  2  Someone else’s home 5  5 3  Another health 6 6  facility Go to  If Another, 7  7 Question 21 8  8 9  9 10 Best hospital 10  possible 201 3 8 January

4 Would you recommend this hospital 22. ABOUT YOU to your friends and family? There are only a few remaining items left. 1 Definitely no  2 26. During this hospital stay, were you Probably no  admitted to this hospital through the 3  Probably yes Emergency Room? 4  Definitely yes 1 Yes  2 UNDERSTANDING YOUR CARE No  WHEN YOU LEFT THE HOSPITAL 2 In general, how would you rate your . 7 3 2 During this hospital stay, staff took . ll health? overa those of my my preferences and 1 Excellent  family or caregiver into account in 2 deciding what my health care needs Very good  3 would be when I left.  Good 1 4 Strongly disagree   Fair 2 5  Disagree  Poor 3  Agree 28. In general, how would you rate your 4 Strongly agree  health mental or emotional ? overall 1 24. When I left the hospital, I had a good  Excellent 2 understanding of the things I was  Very good or in managing my responsible f 3  Good health. 4  Fair 1 Strongly disagree  5  Poor 2  Disagree 3 . 29 What is the highest grade or level of  Agree 4 school that you have completed ?  Strongly agree 1 8th grade or less  When I left the hospital, I clearly 25. 2 Some high school, but did not  understood the purpose for taking graduate each of my medications. 3  High school graduate or GED 1 Strongly disagree  4 - Some college or 2 year degree  2  Disagree 5 year college graduate  4 - 3  Agree 6  year college degree - More than 4 4  Strongly agree 5 t given  when any medication I was no I left the hospital 4 January 2018

5 . 32 Are you of Spanish, Hispanic or mainly speak 30. What language do you at home? escent? Latino origin or d 1 1  No, not Spanish/Hispanic/Latino English  2 2  Yes, Puerto Rican Spanish  3 3 Yes, Mexican, Mexican American,   Chinese 4 Chicano  Russian 4 5  Yes, Cuban Vietnamese  5 6 Yes, other Spanish/Hispanic/Latino  Portuguese  9  Some other language (please print): 31. What is your race? Please choose ________ _____________ one or more. 1  White 2 Black or African American  3 n  Asia 4 Native Hawaiian or other Pacific  Islander 5  American Indian or Alaska Native THANK YOU Please return the completed survey in the postage - paid envelope. [NAME OF SURVEY VENDOR OR SELF - ADMINISTERING HOSPITAL] - ADMINISTERING [RETURN ADDRESS OF SURVEY VENDOR OR SELF HOSPITAL] Questions 1 - 22 and 26 - 32 are pa rt of the H CAHPS S urvey 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 eman, MD, MPH, all rights reserved Eric A. Col - 201 5 8 January

6 January 6 8 201

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 a ll 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  If No, 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. iative to measure the quality of care Please note: Questions 1 2 5 in this survey are part of a national init - in hospitals. OMB #0938 - 0981 During this hospital stay, how often 3. Please answer the questions in this survey explain things about your stay at the hospital named on did nurses in a way you could understand? letter . Do not include any other the cover hospital stay s in your answers. 1 Never 0 2 0 Sometimes YOUR CARE FROM NURSES 3 Usually 0 1. During this hospital stay, how often 4 0 Always courtesy did nurses treat you with ? and respect During this hospital stay, after you 4. 1 0 Never pressed the call button, how often did 2 s you wanted you get help as soon a Sometimes 0 3 it? 0 Usually 4 1 0 Always 0 Never 2 Sometimes 0 3 During this hospital stay, how often 2. Usually 0 did nurses listen carefully to you ? 4 0 Always 1 9 0 Never 0 I never pressed the call button 2 0 Sometimes 3 0 Usually 4 0 Always 7 8 201 January

8 9. During this hospital stay, how often YOUR CARE FROM DOCTORS quiet was the area around your room 5. During this hospital stay, how often at night? did doctors treat you with courtesy 1 Never 0 ? and respect 2 1 0 Sometimes 0 Never 3 2 0 Usually Sometimes 0 4 3 Always 0 0 y Usuall 4 0 Always YOUR EXPERIENCES IN THIS HOSPITAL During this hospital stay, did you 10. 6. During this hospital stay, how often need help from nurses or other did doctors listen carefully to you ? hospital staff in getting to the 1 0 Never bathroom or in using a bedpan? 2 0 Sometimes 1 Yes 0 3 Usually 0 2 If No, Go to Question 12 0 No  4 0 Always How often did you get help in getting 11. 7. During this hospital stay, how often to the bathroom or in using a bedpan in a way explain things did doctors as soon as you wanted? you could understand? 1 Never 0 1 0 Never 2 Sometimes 0 2 0 Sometimes 3 0 Usually 3 0 Usually 4 0 Always 4 Always 0 12. During this hospital stay, did you THE HOSPITAL ENVIRONMENT pain? have any During this hospital stay, how often 8. 1 Yes 0 were your room and bathroom kept 2 If No, Go to No  0 Question 15 clean? 1 Never 0 13. During this hospital stay, how often 2 did hospital staff talk with you about 0 Sometimes how much pain you had ? 3 0 Usually 1 4 0 Never Always 0 2 Sometimes 0 3 0 Usually 4 Always 0 201 8 January 8

9 19. During this hospital stay, did doctors, 14. During this hospital stay, how often nurses or other hospital staff talk with talk with you about did hospital staff you about whether you would have how to treat yo ur pain ? the help you needed when you left the 1 0 Never hospital? 2 Sometimes 0 1 0 Yes 3 Usually 0 2 No 0 4 Always 0 20. During this hospital stay, did you get During this hospital stay, were you 15. ut what information in writing abo given any medicine that you had not symptoms or health problems to look taken before? out for after you left the hospital? 1 1 Yes 0 0 Yes 2 2 No 0  If No, Go to Question 18 0 No 16. Before giving you any new medicine, OVERALL RATING OF HOSPITAL how often did hospital staff t ell you what the medicine was for? Please answer the following questions about your stay at the hospital named on 1 Never 0 . Do not include any ot her the cover letter 2 0 Sometimes s . hospital stays in your answer 3 Usually 0 Using any number from 0 to 10, where 21. 4 Always 0 0 is the worst hospital possible and 10 is the best hospital possible, what 17. Before giving you any new medicine, number would you use to rate this how often did hospital staff describe hospital during your stay? possible side effects in a way you 0 0 Worst hospital possible 0 could understand? 1 0 1 1 0 Never 2 0 2 2 Sometimes 0 3 0 3 3 0 Usually 4 4 0 4 Always 0 5 0 5 6 6 0 EN YOU LEFT THE HOSPITAL WH 7 0 7 After you left the hospital, did you go 18. 8 0 8 directly to your own home, to 9 9 0 someone else’s home, or to another 10 health facility? Best hospital possible 0 10 1 0 Own home 2 0 Someone else’s home 3 Another health 0 Go to If Another,  facility on 21 Questi 9 8 201 January

10 22. Would you recommend this hospital ABOUT YOU to your friends and family? There are only a few remaining items left. 1 0 Definitely no 26. During this hospital stay, were you 2 0 Probably no admitted to this hospital through the 3 Emergency Room? 0 Probably yes 4 1 Definitely yes 0 0 Yes 2 0 No UNDERSTANDING YOUR CARE WHEN YOU LEFT THE HOSPI TAL 2 In general, how would you rate your . 7 overall health? 3 . During this hospital stay, staff took 2 1 my preferences and those of my 0 Excellent family or caregiver into account in 2 0 Very good deciding what my health care needs 3 0 Good would be when I left. 4 1 0 Fair 0 Strongly disagree 5 2 0 Poor 0 Disagree 3 0 Agree In general, how would you rate your 28. 4 Strongly agree 0 overall health ? mental or emotional 1 Excellent 0 24. When I left the hospi tal, I had a good 2 Very good 0 understanding of the things I was 3 responsible for in managing my Good 0 health. 4 0 Fair 1 5 0 Strongly disagree 0 Po or 2 Disagree 0 3 What is the highest grade or level of 29 . 0 Agree ? completed school that you have 4 0 Strongly agree 1 8th grade or less 0 2 25. When I left the hospital, I clearly Some high school, but did not 0 understood the purpose for taking graduate each of my medications. 3 High school graduate or GED 0 1 4 0 Str ongly disagree Some college or 2 - year degree 0 2 5 Disagree 0 year college graduate 4 0 - 3 6 Agree 0 0 lege degree year col - More than 4 4 Strongly agree 0 5 any medication I was not given 0 when I left the hospital 8 201 January 10

11 32 Are you of Spanish, Hispanic or mainly speak . 30. What language do you at home? Latino origin or descent? 1 1 English 0 No, not Spanish/Hispanic/Latino 0 2 2 0 Yes, Puerto Rican Spanish 0 3 3 0 Yes, Mexican, Mexican American, 0 Chinese 4 Chicano 0 Russian 4 5 0 Yes, Cuban 0 Vietnamese 5 6 0 Yes, other Spanish/Hispanic/Latino u 0 Port guese 9 Some other language (please print): 0 choose 31. What is your race? Please _____________________ one or more. 1 0 White 2 Black or African American 0 3 0 Asian 4 0 Native Hawaiian or other Pacific Islander 5 0 American Indian or Alaska Native THANK YOU Please return the completed survey in the postage paid envelope. - - ADMINISTERING HOSPITAL] [NAME OF SURVEY VENDOR OR SELF [RETURN ADDRESS OF SURVEY VENDOR OR SELF - ADMINISTERING HOSPITAL] 22 S and are works of the U.S. urvey - and 26 Questions 1 - 32 are part of the HCAHPS HCAHPS Government. These questions are in the public domain and therefore are NOT ons Measure® questions (Questions subject to U.S. copyright laws. The three Care Transiti Eric A. Coleman, MD, MPH, all rights reserved 23 - 25) are copyright of . 11 8 201 January

12 12 January 201 8

13 S the HCAHPS Survey ample Initial Cover Letter for [HOSPITAL LETTERHEAD] [ SAMPLED PATIENT NAME ] [ ADDRESS ] [ CITY, STATE ZIP ] T NAME Dear SAMPLED PATIEN [ ]: [ NAME OF HOSPITAL ] and discharged on Our records show that you were recently a patient at [ DATE OF DISCHARGE (mm/dd/yyyy) ] . 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 consu mers make important choices about their hospital care, and will help hospitals improve the care they provide. in the enclosed survey are part of a national initiative sponsored by the United 5 - 2 Questions 1 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 surve y, 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 hav e to send you reminders. ] enclosed xxx - If you have any questions about the - 800 s urvey, please call the toll - free number 1 - xxxx. Thank you for helping to improve health care for all consumers. Sincerely, [ HOSPITAL ADMINISTRATOR ] ] HOSPITAL NAME [ The OMB Paperwork Reduction Act language must be included in the mailing. This Note: the cover letter or questionnaire the front or back of , but cannot be a language can be either on n this . The exact OMB Paperwork Reduction Act language is included i separate mailing appendix. Please refer to the Mail Only, and Mixed Mode sections, for specific letter guidelines. 13 8 201 January

14 January 14 201 8

15 Sample - up Cover Letter for the HCAHPS Survey Follow [HOSPITAL LETTERHEAD] SAMPLED PATIENT NAME ] [ [ ] ADDRESS [ CITY, STATE ZIP ] Dear [ SAMPLED PATI ENT NAME ]: you were recently a patient at [ NAME OF HOSPITAL ] and discharged on Our records show that [ DATE OF DISCHARGE (mm/dd/yyyy) ] . Approximately three weeks ago we sent you a survey regarding your hospitalization. If you have already returned the surv ey 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 available made and at Internet the on results will be publicly reported www. . These results will help consumers make important choices pare medicare.gov/hospitalcom about their hospital care, and will help hospitals improve the care they provide. - 2 5 in the enclosed survey are part of a national initiative sponsored by the United Questions 1 States Depart ment 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 pu rposes of quality This number is used to let improvement. [ OPTIONAL : You may notice a number on the survey. us know if you returned your survey so we don’t have to send ] you reminders. 800 enclosed s urvey, please call the toll - free number 1 - If you have any questions about the - xxx - xxxx. Thank you again for helping to improve health care for all consumers. Sincerely, [ HOSPITAL ADMINISTRATOR ] [ HOSPITAL NAME ] OMB Paperwork Reduction Act language must be included in the mailing. This Note: The the front or back of the cover letter or questionnaire language can be either on , but cannot be a . The exact OMB Paperwork Reduction Act language is included in th separate mailing is appendix. Please refer to the Mail Only, and Mixed Mode sections, for specific letter guidelines. 15 8 201 January

16 16 January 201 8

17 OMB Paperwork Reduction Act Language The OMB Paperwork Reduction Act language must be included in the survey mailing. This front or back of the cover letter or questionnaire , but cannot be a on the language can be either separate mailing . The following is the language that be used: must 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 minutes for questions 1 8 information collected is estimated to average rvey, - 2 5 on the su 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 ng this form, please write to: Centers accuracy of the time estimate(s) or suggestions for improvi - 1 25 - for Medicare & Medicaid Services, 7500 Security Boulevard, 05, Baltimore, MD 21244 - C 1850.” 17 8 201 January

18 January 18 201 8

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