JOES-Ambulatory Survey_10.4.2024

Joint Outpatient Experience Survey – Ambulatory

OMB CONTROL NUMBER: XXXX-XXXX

OMB EXPIRATION DATE: XX/XX/XXXX

AGENCY DISCLOSURE NOTICE

The public reporting burden for this collection of information, [Insert OMB Control Number], is estimated to average 5 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding the burden estimate or burden reduction suggestions to the Department of Defense, Washington Headquarters Services, at whs.mc-alex.esd.mbx.dd-dod-information-collections@mail.mil. Respondents should be aware that notwithstanding any other provision of law, no person shall be subject to any penalty for failing to comply with a collection of information if it does not display a currently valid OMB control number.

PRIVACY STATEMENT

Providing information in this survey is voluntary. There is no penalty nor will your benefits be affected if you choose not to respond.

However, maximum participation is encouraged so that the data will be complete and representative. Your survey response will be treated as confidential, identifying information will be used only by persons engaged in, and for the purposes of, the survey research.

However, if during this survey you indicate a direct threat to harm yourself or others, we are required to forward information about that threat to appropriate authorities for action, which will likely include their contacting you.

Question 1:

Our records indicate the visit you’ve been rating was an outpatient surgical visit. Which one of the following best describes the visit that you’ve been rating in this survey?

A visit before my surgery date

The surgical visit itself

A visit after my surgery date

I did not have an outpatient surgery

Question 2:

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

Please select one response

Yes, definitely

Yes, somewhat

No

Question 3:

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

Please select one response

Yes, definitely

Yes, somewhat

No

Questions 4 to 10:

The next questions ask about the day of your procedure.

Please select only one answer for each item.

Yes, definitely

Yes, somewhat

No

Did the check-in process run smoothly?

Was the facility clean?

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

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

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

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

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

Question 11:

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

Yes

No

Question 12:

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

Please select one response

Yes, definitely

Yes, somewhat

No

Question 13:

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

Please select one response

Yes, definitely

Yes, somewhat

No

Question 14:

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?

Please select one response

0 Worst facility possible

1

2

3

4

5

6

7

8

9

10 Best facility possible

Question 15:

Would you recommend this facility to your friends and family?

Please select one response

Definitely no

Probably no

Probably yes

Definitely yes

[TO SHOW IN A LINK ON EACH WEBPAGE:]

PRIVACY STATEMENT

This statement serves to inform you of the purpose for collecting personal information as required by the Privacy Act of 1974, as amended, and how that information will be stored and used.

AUTHORITY: 5 U.S.C. 301, Departmental Regulations; 10 U.S.C. 136, Under Secretary of Defense for Personnel and Readiness; Public Law 104-191, Health Insurance Portability and Accountability Act of 1996; 10 U.S.C., Ch. 55, Medical and Dental Care; 45 CFR 164, Security and Privacy; Department of Defense (DoD) Instruction 6015.23, Foreign Military Personnel Care and Uniform Business Offices in Military Treatment Facilities (MTFS); DoD Manual 6025.18, Implementation of the Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule in DoD Health Care Programs; and E.O. 9397 (SSN), as amended.

PURPOSE: The JOES Survey Suite is a survey system used by the military to gather feedback about outpatient care. The surveys help measure patient satisfaction and guide efforts to make the health system better.

ROUTINE USES: In addition to those disclosures generally permitted under 5 U.S.C. § 552a(b) of the Privacy Act of 1974, as amended, these records may specifically be disclosed outside the DoD as a routine use pursuant to 5 U.S.C. § 552a(b)(3) as follows: to contractors and others performing or working for the Federal Government when necessary to accomplish an agency function related to this System of Records; For a complete listing of the Routine Uses for this system, refer to the below hyperlinked SORN.

Any protected health information (PHI) in your records may be used and disclosed generally as permitted by the HIPAA Rules, as implemented within DoD. Permitted uses and disclosures of PHI include, but are not limited to, treatment, payment, and healthcare operations.

APPLICABLE SORN: EDHA 07, Military Health Information System (June 15, 2020; 85 FR 36190) https://dpcld.defense.gov/Portals/49/Documents/Privacy/SORNs/DHA/EDHA-07.pdf

DISCLOSURE: Voluntary, Completing the Survey is voluntary; you may stop the Survey at any time and skip any questions you choose. There is no penalty if you choose not to respond, although maximum participation is encouraged so the data will be complete and representative.