National Implementation of Hospital Consumer Assessment of Health Providers and Systems (HCAHPS)

CAHPS^® Hospital Survey

(English)

CAHPS^ Hospital 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 cover of this survey. This number is ONLY used to let us know if you returned your survey so we don't have to send you reminders.

Please note: Questions 1-22 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. Do not include any other hospital stay 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

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

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. Do not include any other hospital stays in your answer.

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

⁰¹ 1

⁰² 2

⁰³ 3

⁰⁴ 4

⁰⁵ 5

⁰⁶ 6

⁰⁷ 7

⁰⁸ 8

⁰⁹ 9

¹⁰ 10 Best hospital possible

22. Would you recommend this hospital to your friends and family?

¹ Definitely no

² Probably no

³ Probably yes

⁴ Definitely yes

ABOUT YOU

There are only a few remaining items left.

23. In general, how would you rate your overall health?

¹ Excellent

² Very good

³ Good

⁴ Fair

⁵ Poor

24. 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

25. 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

26. 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

27. What language do you mainly speak at home?

¹ English

² Spanish

³ Some other language (please print): _____________________

THANK YOU

Please return the completed survey in the postage-paid envelope

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 7 minutes per response for questions 1-22 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, S1-13-05, Baltimore, MD 21244-1850.