Name of the Individual: ____________________________________ Date: _____________ Sex: __________ Age: ___________ Marital Status: _______________ Address: ___________________________________________________

City: ________________ State: ______________ Zip: ______________ Telephone: ____________________ Email: ________________________ Name of the hospital: _____________________________________

A survey on customer satisfaction in hospital services

1. Respondent Name:

2. Age :

(a) 20-30 (b) 30-40 (c)40-50 (d)50 and above

3. Gender:

(a)Male (b)Female

4. Occupation:

(a)Business (b)Employed professional (c)Home maker (d)Student

5. Are you aware of hospital?

(a)Yes (b)No

6. If No, mention the hospital / clinic you have visited for treatment

7. If yes what made you to visit .. . hospital?

(a)Accessibility (b)Referral (c)Media (d) Hospital image

8. (A)How many days did you wait to get appointment?

(a)Spot appointment (b)Two days (c)One week (d) More than a week

(B)Do they follow appointmentTime / go by the appointment time?

(a)Yes (b)No

Q1. Have you received treatment in this hospital before? a) Yes b) No Q2. How do you rate the medical care costs of the hospital as compared to others?

a) It is the most expensive b) It is costlier than most c) It is among the costliest d) It is not as costly as others e) It charges one of the lowest medical fees f) Cant say

Q3. Are the doctors and medical staff of this hospital competent? a) Yes b) No Q4. Which of the following aspects of this hospital are good according to you? a) Good infrastructure b) Knowledgeable staff c) Competent doctors d) Highly Professional staff e) Organized f) State of the art equipments

g) No long queue for outpatients h) Easy accessibility to medical care Q5. Which of the following did you experience in the hospital? a) You were kept informed

b) Proper diagnosis and explanation c) Proper information about treatment d) Response to nurse call e) Availability of doctors f) Availability of medicines

g) Awareness of your medical condition h) Overall high standard of care Q6. Do you have any suggestions for patient satisfaction?

1.Have you received treatment from our facility in the last three months? Yes _________________ No _____________________

2.If Yes, you received treatment as In-patient _____________ Out-patient ____________________

3.How can you describe your health condition after treatment from the hospital? Excellent__ Good__ Fair__ Worse__ 4.How can you rate the service you received from the healthcare professionals? Very Satisfactory______________

Somehow satisfactory___________ Not too satisfactory_____________ Not satisfactory________________

For the two questions below answer with Strongly Agree, Agree, Disagree or Strongly Disagree
5.You were involved directly in decisions about your medical care _______________________ _______________________ _______________________ _______________________ 6.How can you rate the courtesy and respect showed by the healthcare professionals who attended to you _______________________ _______________________ _______________________ _______________________ 7.What about the healthcare service would you like to be changed? _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _________

8.How do the healthcare professionals relate with the patients? _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _________ 9.Would seek healthcare services from the hospital again? Yes ________________________ No ___________________________

Q1: Please give your feedback on the way you were treated on your arrival and admission in the hospital a) Excellent b) Very Good c) Good d) Fair e) Poor Q2: Were you made aware with all the treatment procedures and the formalities that will be undertaken? a) Yes b) Not completely c) Not at all Q3: Were your opinions sought before the treatment was started? a) Yes b) No

c) I dont know Q4: Was the outcome of the treatment clearly explained to you beforehand? a) Yes completely b) Yes to some extent c) No information was given regarding the outcome Q5: How were your queries and concerns handled by the hospital personnel? a) Excellently b) Good c) Satisfactorily d) Not satisfactorily Q6: Did you trust the doctors, nurses, and assistants would do a good job? a) Yes b) No Q7: Please rate the individual attention given on a scale of 1 to 5 where 1 is the lowest and 5 is the highest? a) 1 b) 2 c) 3 d) 4 e) 5

Q8. How could we have improved the services provided to you? _____________________________________________________________________ ____ Q1: On a scale of ten, how would you rate the hygiene and cleanliness of the hospital, keeping in mind the outdoor space as well as the cabins and inner chambers? 1. 0-3 2. 4-6 3. 7-10 Q2: Which place of the hospital did you find needs better cleaning and hygiene? _____________________________________________________________________ _____________________________________________________________________ ______ Q3: How would you assess your monetary charges for treatment? Would you consider some of the tests as extraneous? _____________________________________________________________________ _____________________________________________________________________ ______ Q4: How would you evaluate the quality of food served to you during the duration of your stay as a patient here? a. Excellent b. Decent c. Dissatisfactory d. Any other comments: _____________________________________________________________________ _______________________________________________________________

Q5: Are you satisfied with the level of care offered by our staff members? Do you have any specific complaints? _____________________________________________________________________ _____________________________________________________________________ ______ Q6: Would you recommend this hospital to your acquaintances? What would you consider our area of expertise? _____________________________________________________________________ _____________________________________________________________________ ______ Q7: Are you satisfied with your doctor in charge? a. Yes most definitely 1. No Q8: If you have chosen no as your answer to the last question, please state the reason. _____________________________________________________________________ _____________________________________________________________________ ______ Q9: Would you like to make any other suggestions for the improvement in the services offered at the hospital? _____________________________________________________________________ ________________

How often did nurses communicate well with patients? During this hospital stay

 how often did nurses treat you with courtesy and respect? (Q1) how often did nurses listen carefully to you? (Q2) how often did nurses explain things in a way you could understand? (Q7) How often did doctors communicate well with patients? During this hospital stay

how often did doctors treat you with courtesy and respect? (Q5) how often did doctors listen carefully to you? (Q6) how often did doctors explain things in a way you could understand? (Q7) How often did patients receive help quickly from hospital staff? During this hospital stay

after you pressed the call button, how often did you get help as soon as you wanted it? (Q4) how often did you get help in getting to the bathroom or in using a bedpan as soon as you wanted? (Q11) How often was patients' pain well controlled? During this hospital stay

how often was your pain well controlled? (Q13) how often did the hospital staff do everything they could to help you with your pain? (Q14) How often did staff explain about medicines before giving them to patients? Before giving you any new medicine

how often did hospital staff tell you what the medicine was for? (Q16) how often did hospital staff describe possible side effects in a way you could understand? (Q17) How often were patients' rooms and bathrooms kept clean? During this hospital stay

how often were your room and bathroom kept clean? (Q8) How often was the area around patients' rooms quiet at night?

During this hospital stay

how often was the area around your room quiet at night? (Q9) Were patients given information about what to do during their recovery at home? Before giving you any new medicine

did hospital staff talk with you about whether you would have the help you needed when you left the hospital? (Q19) did you get information in writing about what symptoms or health problems to look out for after you left the hospital? (Q20) How do patients rate the hospital? 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? (Q21) Would patients recommend the hospital to friends and family? Would you recommend this hospital to your friends and family? (Q22)