QUESTIONNAIRE

Please provide details about you

Age
Gender
Marital status
Education
Occupation
Income

Part- A

RECEPTION SERVICES

1. The number of days you had to wait between making an appointment for regular or
routine care and actually seeing a doctor, was
( ) Same day
( ) 1-7 days
( ) 8-14 days
( ) 15-30 days
( ) 31 days or longer

2. After arriving at the clinic, the amount of time you waited in the waiting room
before seeing the doctor you want to see, was

( ) 10-15 minutes
( ) 16-30 minutes
( ) 31-45 minutes
( ) 1 hour
( ) Over 1 hour

3. The facilities in the waiting hall are:

( ) Adequate number of chairs
( ) TV
( ) news papers /magazines
( ) health related pamphlets/brochures / news letters
( ) any other, please specify

4. Would you tell your family and friends that reception is good in the hospital?
( ) Yes ( ) No

Ratings
(Please skip to item II if you were not admitted through the Emergency Room) Circle the
number that most closely approximates your experience in the Emergency Room.
 Scale: 5- Completely Satisfactory 4 – Somewhat satisfactory 3- Neutral 2-
Somewhat dissatisfactory 1- Completely dissatisfactory

S.No Statements scale

1 Reception services present a look of easy access. 5 4 3 2 1
2 The front desk staff answered all the questions 5 4 3 2 1
3 The staff at reception are friendly and helpful 5 4 3 2 1
4 Waiting time to see doctor 5 4 3 2 1
5 Seating arrangements 5 4 3 2 1
6 Hygiene in waiting hall 5 4 3 2 1
7 Reading materials (magazines, news paper, health 5 4 3 2 1
information etc
8 Posters giving details on diseases 5 4 3 2 1
9 TV 5 4 3 2 1

5. If you were somewhat or completely dissatisfied with any of the aspects in

reception, please tell us why:

6. Have you any suggestions to improve the services of reception ? If yes, list them
here.

Part -B
ADMISSION SERVICES
1. Did you come for admission with prior appointment? ( ) YES ( ) NO
2. How long did you wait for getting admission into a ward or room?

( ) Less than 30 minutes

( ) 30 minutes to 1 hour
( ) More than 1 hour
3. Are you informed about the following detailsbefore admission?

( ) Probable number of days of stay in hospital

( ) Kind of treatment to be given to you
( ) Services available to patient (washing clothes, food and drinks,
communications etc) -
( ) Facility available to attendant of patient
( ) Visiting hours of relatives and friends
( ) Probable medical expenditure involved in treatment
( ) Hospital layout map to locate various departments, services and
dispensary

4. What are your feelings on the admission process and procedure in the hospital?

( ) It is a long tedious process

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 ( ) Employees lack courtesy
( ) Too much waiting time
( ) It is boring as they don’t tell clearly when a room will be allotted.
( ) I feel our systems are poor. There is no use of prior appointment.

5. If you were somewhat or completely dissatisfied with any of the aspects in

admission services , please tell us why:

6. Have you any suggestions to improve the admission process ? If yes, list them
here.

Part- C EMERGENCYSERVICES

1. After arriving at the emergency, how much time the medical staff took to examine
you ------– minutes
2. How many days you received treatment in emergency room -----------days.
3. Circle the number that most closely approximates your experience in the Emergency
Room.
Scale: 5- Completely Satisfactory 4 - Somewhat satisfactory 3- Neutral 2-
Somewhat dissatisfactory 1- Completely dissatisfactory

S.No Statements Scale

1 Location of emergency services room 5 4 3 2 1
2 Level of care provided 5 4 3 2 1
3 Wait time for receiving treatment 5 4 3 2 1
4 Explanation of procedures or services provided to 5 4 3 2 1
patient or attendant
5 Facilities in the room 5 4 3 2 1
6 Quality of food served
7 Attending physician care 5 4 3 2 1
8 Nursing staff support 5 4 3 2 1
9 Quality of aftercare instructions given to patient 5 4 3 2 1
10 Hygiene 5 4 3 2 1

4. If you were somewhat or completely dissatisfied with any of the aspects in

emergency room services , please tell us why:

5. Have you any suggestions to improve the emergency room services ? If yes, list
them here.

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 .Part-D DIAGNOSTIC SERVICES

1. Circle the number that most closely approximates your experience with the
diagnostic services provided by the hospital.
Scale: 5- Completely Satisfactory 4 - Somewhat satisfactory 3- Neutral 2- Somewhat
dissatisfactory 1- Completely dissatisfactory

S.No Statements Scale

1 Waiting facility at diagnostic services 5 4 3 2 1
2 Transport from one centre to another ( the way escorts 5 4 3 2 1
moved you in a wheel chair or on a stretcher)
3 Waiting time 5 4 3 2 1
4 The capability of lab technicians in offering services 5 4 3 2 1
5 Courtesy in the behavior of lab technicians 5 4 3 2 1

2. If you were somewhat or completely dissatisfied with diagnostic services ,

please tell us why:

3. Have you any suggestions to improve the diagnostic services ? If yes, list them
here.

Part- E PHYSICIAN SERVICES

1. Is yourdoctor duty minded?

( ) YES ( ) NO ( ) SOME WHAT
2. Is he capable one in treating disease with which you joined hospital ?
( ) YES ( ) NO ( ) SOME WHAT
3. Do you find doctors chatting and delaying to respond to patients needs?
( ) YES ( ) NO ( ) SOME TIMES

4. Are doctor’s visits irregular? ( ) YES ( ) NO ( )SOMETIMES

5. Circle the number that most closely approximates your experience with the services
provided by nursing personnel while in your room/ ward.
Scale: 5- Completely Satisfactory 4 - Somewhat satisfactory 3- Neutral 2- Somewhat
dissatisfactory 1- Completely dissatisfactory

S.No Statements Scale

1 Professional approach of doctor 5 4 3 2 1

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2 Doctor’s attention and responsiveness to questions 5 4 3 2 1
3 Regular visits and check up 5 4 3 2 1
4 Explanation of procedures, tests, and treatments 5 4 3 2 1
5 Consideration for family and visitors 5 4 3 2 1
6 Courtesy in giving instructions 5 4 3 2 1
7 Concern for hygienic conditions 5 4 3 2 1
8 Before discharge instructions 5 4 3 2 1
6. If you were somewhat or completely dissatisfied with physician services, please tell
us why:

7. Have you any suggestions to improve the physician services? If yes, list them here.

Part-F NURSING SERVICES

1. Is there adequate number of nurses to attend to patients in the hospital from your
view point?
( ) YES ( ) NO
2. Are the nurses on the whole, duty minded? ( ) YES ( ) NO ( )SOME OF
THEM
3. Are the nurses capable in doing services? ( ) YES ( ) NO/ ( )SOME OF THEM
4. Do you find nurses chatting and delaying to respond to patients needs? ( ) YES
( )
NO
5. Nurses frequnlty move around and visit their patients and inquire their needs ( )YES
( ) NO
6. Circle the number that most closely approximates your experience with the services
provided by nursing personnel while in your room/ ward.
Scale: 5- Completely Satisfactory 4 - Somewhat satisfactory 3- Neutral 2-
Somewhat dissatisfactory 1- Completely dissatisfactory

S.No Statements Scale

1 Professional approach of nursing staff 5 4 3 2 1
2 Nursing attention to the needs of patients 5 4 3 2 1
3 Wait time on call light/bell 5 4 3 2 1
4 Explanation of procedures, tests, and treatments 5 4 3 2 1
5 Consideration for family and visitors 5 4 3 2 1
6 Giving medicines at proper timings 5 4 3 2 1
7 Giving food at right time 5 4 3 2 1
8 Giving instructions with courtesy 5 4 3 2 1
9 Help in getting to the bathroom or in using a 5 4 3 2 1

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 bedpan

7. If you were somewhat or completely dissatisfied with diagnostic services , please tell
us why:

8. Have you any suggestions to improve the diagnostic services ? If yes, list them here.

Part-G DIETARY SERVICES

1. Is foodnutritional?( ) YES ( ) NO/ ( )SOME WHAT

2. Is it served on time?( ) YES ( ) NO/ ( )SOME WHAT
3. Circle the number that most closely approximates your experience with the services
provided by nursing personnel while in your room/ ward.
Scale: 5- Completely Satisfactory 4 - Somewhat satisfactory 3- Neutral 2- Somewhat
dissatisfactory 1- Completely dissatisfactory

S.No Statements Scale

1 Hygiene in serving of food 5 4 3 2 1
2 Appearance of food 5 4 3 2 1
3 Taste of food 5 4 3 2 1
4 Flavor of food 5 4 3 2 1
5 Temperatureof food 5 4 3 2 1
6 Variety of food 5 4 3 2 1
8 Dietary counseling provided 5 4 3 2 1
9 Timely servicing of food 5 4 3 2 1

4. If you were somewhat or completely dissatisfied with any of the dietary services ,
please tell us why:

5. Have you any suggestions to improve the dietary services ofhospital ? If yes, list
them here.

Part-H WARD / ROOM SERVICES

1. Is the ward room spacious and ventilated? YES/NO

2. Is there adequate staff to attend to cleaning the hospital ward/room? ( ) YES ( )NO
3. Are the bed sheets changed by housekeeping staff daily? ( ) YES ( )NO
4. Did you face problems in getting help for cleaning up any food or other items spilled
on floor? ( ) YES ( )NO
5. Did you face problems in getting help for cleaning up toilets? ( ) YES ( )NO

6. Were you ever bothered by noise at night from other patients? ( ) YES
( )NO

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 7. Were you ever bothered by noise at night from hospital staff? ( ) YES
( )NO
8. Were you given enough privacy when being examined or treated? ( ) YES
( )NO

9. Circle the number that most closely approximates your experience with the services
provided by nursing personnel while in your room/ ward.

Scale: 5- Completely Satisfactory 4 – Somewhat satisfactory 3- Neutral 2- Somewhat

dissatisfactory 1- Completely dissatisfactory

S.No Statements Scale

1 Ward /room has acceptable look 5 4 3 2 1
2 Cleanliness of bed sheets 5 4 3 2 1
3 Comfort 5 4 3 2 1
4 Quietness 5 4 3 2 1
5 Air circulation 5 4 3 2 1
6 Light 5 4 3 2 1
7 Hygiene in surroundings 5 4 3 2 1
8 Smell ( without odours of chemicals or any used 5 4 3 2 1
materials )
9 Responsive of staff concerned 5 4 3 2 1
10 Courtesy in the behavior of staff 5 4 3 2 1

10. If you were somewhat or completely dissatisfied with any of the ward/room and
services , please tell us why:

11. Have you any suggestions to improve the ward /room and services of doctors? If
yes, list them here.

Part-I GENERAL SERVICES

1. Were you moved by wheel chair or on stretcher for diagnostic services or any other
purposes? ( ) YES ( ) NO
2. If yes, was the handling by ward persons smooth and courteous? ( ) YES ( ) NO
3. Is your attendant troubled for any reason in the hospital? If yes, why?
4. If your attendant brought food from home, were there any problems at the gate in
permitting him or her?
5. Did any of your visitors face any problem in meeting you?
6. Have you heard of any problems faced in this hospital by fellow patients? If yes,
kindly give a brief.

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 7. If you were somewhat or completely dissatisfied with any of the general services ,
please tell us why:
8. Have you any suggestions to improve the general services? If yes, list them here.

Part- J BILLING AND DISCHARGE

1. How long they have taken for billing and discharge? ( ) SHORT TIME
( ) LONG TIME
2. Are you aware of the billing process? ( ) YES ( ) NO
3. What was the medical expenditure incurred by you? ------------------
rupees.
4. What is your view of the medical expenses?
( ) RESONABLE ( ) TOO HIGH ( ) LESS THAN EXPECTED
5. Is the bill given to you is clear and understandable? ( ) YES ( ) NO
6. Are you demanded to pay tips to the following?
( ) Nursing staff
( ) Ward persons
( ) Sweepers
( ) Any other

Part- K LEAVING HOSPITAL

1. Were there any hospital employees who provided you with exceptional service?
YES/NO
If yes, kindly describe.

2. What kind of feelings did you have at the time of discharge?

( ) Good feelings about hospital and care
( ) dissatisfaction for not providing right health care
( ) dissatisfaction for not showing courteous behavior
( ) Uneasy feeling for making treatment too expensive for people 3. Do
you recommend the hospital to friends and relatives? ( ) YES ( ) NO 4. If
this were your hospital, what would you do to make it a better place?
5. Would you recommend this hospital to others? If yes, why? If no, why?

Part-L PATIENT CHOICE AND EXPERIENCE

Need for hospital services

1. What is your health problem?

2. How long have you taken treatment before coming to this hospital?

Choice of hospital

3. Why did you choose this hospital? Tick the items that influenced your
decision.
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 ( ) A specialist was available
( ) Special hospital care was required that was not available in the local
hospital
( ) My physician practices there
( ) More familiar with the hospital
( ) Wanted a second opinion from another physician
( ) cost of treatment will be reasonable
( ) The public image of hospital is very good
( ) Recommendation of my family doctor
( ) Suggested by my friends and relatives
( ) Impressed by advertisements
( ) insurance coverage is available for treatment in corporate hospitals
( ) My employer (company /organization) reimburses expenditure (
) For my status, I prefer treatment in corporate hospitals only.

4. When making the decision to take treatment in the hospital who is the
primary decision maker?

( ) Spouse ( ) Children ( ) friends and relatives

Familiarity

5. How many times have you visited a friend or loved one in the hospital in
the
last year? ( )
6. How many times have you and other members of your family been a
patient
in the hospital in the last 3 years? ( )
7. From which information sources, have you known about the hospital?
( ) My personal visits
( ) My friends and relatives
( ) News papers and magazines
( ) insurance agents
( ) TV ads
( ) promotional campaigns of the hospital
( ) sponsored programs of the hospitals (TV or sports or cultural)
( ) doctors working in the hospital
( ) Nursing and other staff in the hospital

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 8. Information sharing during treatment

The following statements show the information sharing process before and during treatment.

Circle the number that most closely approximates your view

Scale- 5 –strongly agree 4- agree 3 – neutral 2 – disagree 1-strongly disagree

S.No Statements Scale

1 Consulting doctor in the hospital explained me 5 4 3 2 1
what my health problem and the treatment that
will be given
2 I am involved as much as I wanted to be in
decisions made about my care and treatment

2 I am also informed about the number of days of 5 4 3 2 1

stay by my doctor
3 I am also given an estimate of expenditure 5 4 3 2 1
involved.
4 During treatment doctors listened to my problems 5 4 3 2 1
carefully
5 Nurses listened to me carefully 5 4 3 2 1
6 Nurses explained things in a way I could 5 4 3 2 1
understand
7 Doctors explained things in a way you could 5 4 3 2 1
understand?
8 Nurse/doctor explained the purpose of the 5 4 3 2 1
medicines I given to me during treatment
9 During my treatment, I faced problems in getting 5 4 3 2 1
information from doctor
10 During my treatment, I faced problems in getting 5 4 3 2 1
information from nurses
11 Doctors/Nurses told me about medicines and care 5 4 3 2 1
I should take after I went home
12 Doctor /nurse told me about medication side 5 4 3 2 1
effects to watch for when I went home?
13 Doctors talk in front of me as if I weren’t there to 5 4 3 2 1
other staff or to my relatives

Experience

9. At the time of joining the hospital what were your feelings?

( ) confident that my health problems will be resolved (
) scared that the expenditure may be too high
( ) worried about comfort of attendant staying with
me ( ) worried whether I get good care in the hospital
( ) Any other, please specify.
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 10. How many days did you stay in the hospital?
----days.
11. Is the treatment successful?
( ) YES ( ) NO ( ) PARTLY
12. Is your privacy during treatment safeguarded?

( ) YES ( ) NO ( ) PARTLY

13. Is your dignity as an individual protected during treatment?

( ) YES ( ) NO ( ) PARTLY

14. From my experience, I am happy I made a right choice in choosing the

hospital.
( ) YES ( ) NO ( ) CANNOT SAY

Satisfaction

15. What are your satisfaction ratings of the hospital services?

Circle the number that most closely approximates your experience with the services
provided by nursing personnel while in your room/ ward.
Scale: 5- Completely Satisfactory 4 – Somewhat satisfactory 3- Neutral 2- Somewhat
dissatisfactory 1- Completely dissatisfactory

S.No Statements Scale

1 Reception services 5 4 3 2 12 Admission
services 5 4 3 2 13 Emergency services 5
4 3 2 14 Diagnostic services 5 4 3
2 15 Doctor services 5 4 3 2 1
6 House surgeons /other doctors services 5 4 3 2 1
6 Nursing staff services 5 4 3 2 1 7 Services of ward boys 5 4 3 2 1 7 Hygiene and
sanitation 5 4 3 2 1
8 Ward /room accommodation comfort 5 4 3 2 1 9 Food and drinks services 5 4 3 2 1 10
Dispensary services 5 4 3 2 1 11 Billing services 5 4 3 2 1
12 Services relating to discharge and leaving 5 4 3 2
1
General views
16. Listed below are some statements that show
general views about the hospital.
Do you agree with them?
Circle the number that most closely approximates your view
Scale- 5 –strongly agree 4- agree 3 – neutral 2 – disagree 1-strongly disagree

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S.No Statements Scale
1 The hospital has got good name. 5 4 3 2 1
2 The hospital location is not good- it is difficult for 5 4 3 2 1
students to reach.
3 The hospital has good doctors. 5 4 3 2 1
4 Nursing care is good in the hospital
5 The hospital has good equipment for treatment of 5 4 3 2 1
patients.
6 .The hospital has good diagnostics services. 5 4 3 2 1
7 The hospital offers treatment to a wide variety of 5 4 3 2 1
patients.
8 The hospital sufficient space for comfortable stay of in – 5 4 3 2 1
patients.
10 It takes very long time to get admission into the hospital 5 4 3 2 1
11 Patients go to the hospital with a confidence of recovery 5 4 3 2 1
12 Post operative care is not good in the hospital 5 4 3 2 1
13 The hospital offers treatment at affordable prices 5 4 3 2 1
14 The hospital is for rich; not for middle income people 5 4 3 2 1
15 For those who do not have insurance coverage and 5 4 3 2 1
employer reimbursement, treatment charges are difficult
to bear

17. What are the two good things about the hospital?

1
2

18. What are the two bad things about the hospital?

1
2

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