Form CMS-10500 OAS CAHPS (Mail Survey)

Attachment A

Consumer Assessment of Healthcare Providers and Systems Outpatient and Ambulatory Surgery Survey

(OAS CAHPS^®)

A patient experience of care survey about outpatient and ambulatory surgeries and procedures

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 0938-1240 (Expires: TBD). The time required to complete this information collection is estimated to average 8 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

Survey Instructions

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 #1

This survey asks about your experience at the facility named in the cover letter. For this survey, we use the term “procedure” for diagnostic, surgical or other procedures. We refer to “facility” as the place where you had your procedure.

Please answer these questions only for the procedure(s) you had on the date included in the cover letter. Do not include any other procedures in your answers.

I. Before Your Procedure

The first few questions are about getting ready for your procedure. Include any information you received before and on the day of your procedure.

1. Before your procedure, did your doctor or anyone from the facility give you all the information you needed about your procedure?

1. Yes, definitely

2. Yes, somewhat

3. No

2. Before your procedure, did your doctor or anyone from the facility give you easy to understand instructions about getting ready for your procedure?

1. Yes, definitely

2. Yes, somewhat

3. No

II. About the Facility and Staff

The next questions ask about the day of your procedure.

3. Did the check-in process run smoothly?

1. Yes, definitely

2. Yes, somewhat

3. No

4. Was the facility clean?

1. Yes, definitely

2. Yes, somewhat

3. No

5. Were the clerks and receptionists at the facility as helpful as you thought they should be?

1. Yes, definitely

2. Yes, somewhat

3. No

6. Did the clerks and receptionists at the facility treat you with courtesy and respect?

1. Yes, definitely

2. Yes, somewhat

3. No

7. Did the doctors and nurses treat you with courtesy and respect?

1. Yes, definitely

2. Yes, somewhat

3. No

8. Did the doctors and nurses make sure you were as comfortable as possible?

1. Yes, definitely

2. Yes, somewhat

3. No

III. Communications About your Procedure

As a reminder, please include any information you received before and on the day of the procedure.

9. Did the doctors and nurses explain your procedure in a way that was easy to understand?

1. Yes, definitely

2. Yes, somewhat

3. No

10. Anesthesia is something that would make you feel sleepy or go to sleep during your procedure. Were you given anesthesia?

1. Yes

2. No If No, go to #13

11. Did your doctor or anyone from the facility explain the process of giving anesthesia in a way that was easy to understand?

1. Yes, definitely

2. Yes, somewhat

3. No

12. Did your doctor or anyone from the facility explain the possible side effects of the anesthesia in a way that was easy to understand?

1. Yes, definitely

2. Yes, somewhat

3. No

13. Discharge instructions include things like symptoms you should watch for after your procedure, instructions about medicines, and home care. Before you left the facility, did you get written discharge instructions?

1. Yes

2. No

IV. Your Recovery

14. Did your doctor or anyone from the facility prepare you for what to expect during your recovery?

1. Yes, definitely

2. Yes, somewhat

3. No

15. Some ways to control pain include prescription medicine, over-the-counter pain relievers or ice packs. Did your doctor or anyone from the facility give you information about what to do if you had pain as a result of your procedure?

1. Yes, definitely

2. Yes, somewhat

3. No

16. At any time after leaving the facility, did you have pain as a result of your procedure?

1. Yes

2. No

17. Before you left the facility, did your doctor or anyone from the facility give you information about what to do if you had nausea or vomiting?

1. Yes, definitely

2. Yes, somewhat

3. No

18. At any time after leaving the facility, did you have nausea or vomiting as a result of either your procedure or the anesthesia?

1. Yes

2. No

19. Before you left the facility, did your doctor or anyone from the facility give you information about what to do if you had bleeding as a result of your procedure?

1. Yes, definitely

2. Yes, somewhat

3. No

20. At any time after leaving the facility, did you have bleeding as a result of your procedure?

1. Yes

2. No

21. Possible signs of infection include fever, swelling, heat, drainage or redness. Before you left the facility, did your doctor or anyone from the facility give you information about what to do if you had possible signs of infection?

1. Yes, definitely

2. Yes, somewhat

3. No

22. At any time after leaving the facility, did you have any signs of infection?

1. Yes

2. No

V. Your Overall Experience

23. Using any number from 0 to 10, where 0 is the worst facility possible and 10 is the best facility possible, what number would you use to rate this facility?

0 Worst facility possible

1

2

3

4

5

6

7

8

9

10 Best facility possible

24. Would you recommend this facility to your friends and family?

1. Definitely no

2. Probably no

3. Probably yes

4. Definitely yes

VI. About You

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

1. Excellent

2. Very good

3. Good

4. Fair

5. Poor

26. In general, how would you rate your overall mental or emotional health?

1. Excellent

2. Very good

3. Good

4. Fair

5. Poor

27. What is your age?

1. 18 to 24

2. 25 to 34

3. 35 to 44

4. 45 to 54

5. 55 to 64

6. 65 to 74

7. 75 to 79

8. 80 to 84

9. 85 or older

28. Are you male or female?

1. Male

2. Female

29. What is the highest grade or level of school that you have completed?

1. 8^th 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

30. Are you of Hispanic, Latino, or Spanish origin?

1. Yes, Hispanic, Latino, or Spanish

2. No, not Hispanic, Latino, or Spanish If No, go to #32

31. Which group best describes you?

1. Mexican, Mexican American, Chicano

2. Puerto Rican

3. Cuban

4. Another Hispanic, Latino, or Spanish origin

32. What is your race? You may select one or more categories.

1. White

2. Black or African American

3. American Indian or Alaska Native

4. Asian Indian

5. Chinese

6. Filipino

7. Japanese

8. Korean

9. Vietnamese

10. Other Asian

11. Native Hawaiian

12. Guamanian or Chamorro

13. Samoan

14. Other Pacific Islander

33. How well do you speak English?

1. Very well

2. Well

3. Not well

4. Not at all

34. Do you speak a language other than English at home?

1. Yes

2. No If No, go to #36

35. What is that language?

1. Spanish

2. Other Language
   (PLEASE SPECIFY):
   
   (Please print.)

36. Did someone help you complete this survey?

1. Yes

2. No If No, go to END.

37. How did that person help you? Check all that apply.

1. Read the questions to me

2. Wrote down the answers I gave

3. Answered the questions for me

4. Translated the questions into my language

5. Helped in some other way:
   (EXPLAIN):
   
   (Please print.)

6. No one helped me complete this survey

END