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Free form: Patient satisfaction survey

Hospitalist Leadership Connection, December 14, 2010

The feedback from patients regarding their hospital experience should be out in the open. The indicators your facility chooses for measuring patient satisfaction should be shared widely with all members of the healthcare team, including hospitalists. When hospitalists know which skills are being specifically measured, they will likely focus even more attention on them, which can only improve the overall impression patients have of their hospital stays.

Find below a sample form for surveying patients who have recently been under the care of a hospitalist in your program.

To be completed by the recent patient of [name of hospital/hospitalist service]

Instructions:
For each statement below, please indicate the extent of your agreement or disagreement by placing a check in the appropriate spot.

1.    How would you rate the daily visits made by your hospital physician (e.g., amount of time spent, quality of visit)?
[  ] Excellent
[  ] Very good
[  ] Good
[  ] Fair
[  ] Poor

2.    How would you rate your hospitalist’s ability to communicate with you (listening, giving clear explanations)?
[  ] Excellent
[  ] Very good
[  ] Good
[  ] Fair
[  ] Poor

3.    How would you rate your hospitalist’s ability communicate with your family (e.g., listening, giving clear explanations)?
[  ] Excellent
[  ] Very good
[  ] Good
[  ] Fair
[  ] Poor

4. How would your rate the way you were treated by the hospitalist (e.g., kindness, respect, dignity)?
[  ] Excellent
[  ] Very good
[  ] Good
[  ] Fair
[  ] Poor

5. How would you rate the overall medical care that you received from the hospitalist?

[  ] Excellent
[  ] Very good
[  ] Good
[  ] Fair
[  ] Poor

6. Who was your hospitalist?

7. Was a physician assistant or nurse practitioner involved in your care?

8. If yes, can you identify him/her? What is his/her name?

Please provide any additional comments you have regarding the [name of hospital] hospitalist program as a whole, or any individual hospitalist who treated you.

FOR OFFICE USE ONLY

Patient’s admission date:

Patient was admitted from:
[  ] Doctor’s office
[  ] Emergency room
[  ] Direct from home
[  ] Nursing facility
[  ] Other

Discharged to:

Primary care physician:
Physician’s name:
Office phone:
E-mail:

The above excerpt is adapted from Tools and Strategies for an Effective Hospitalist Program, published by HCPro, Inc.

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