HCAHPS Survey

March 2017 1

HCAHPS Survey

SURVEY INSTRUCTIONS

 You should solely content out this examine if you were the enduring during the hospital come denominated in the meet music. Do not content out this examine if you were not the enduring.

 Reply all the interrogations by checking the box to the left of your reply.

 You are casually told to frisk aggravate some interrogations in this examine. When this happens you procure see an arrow behindcited a while a music that decides you what interrogation to reply contiguous, enjoy this:

 Yes  No  If No, Go to Interrogation 1

You may give-heed-to a enumeobjurgate on the examine. This enumeobjurgate is used to let us comprehend if you repayed your examine so we don't keep to grant you reminders. Content music: Questions 1-25 in this examine are dissect of a notorious start to value the property of preservation in hospitals. OMB #0938-0981

Please reply the interrogations in this examine

encircling your come at the hospital denominated on

the meet music. Do not grasp any other

hospital comes in your replys.

YOUR CARE FROM NURSES

1. During this hospital come, how frequently

did nurses bargain you behindcited a while courtesy

and assignence?

1  Never

2  Sometimes

3  Usually

4  Always

2. During this hospital come, how frequently

did nurses attend preservationfully to you?

1  Never

2  Sometimes

3  Usually

4  Always

3. During this hospital come, how frequently

did nurses expound things in a way

you could recognize?

1  Never

2  Sometimes

3  Usually

4  Always

4. During this hospital come, behindcited you

pressed the wheedle dot, how frequently did

you get acceleration as quickly as you wanted

it?

1  Never

2  Sometimes

3  Usually

4  Always

9  I never pressed the wheedle dot

2 March 2017

YOUR CARE FROM DOCTORS

5. During this hospital come, how frequently

did doctors bargain you behindcited a while courtesy

and assignence?

1  Never

2  Sometimes

3  Usually

4  Always

6. During this hospital come, how frequently

did doctors attend preservationfully to you?

1  Never

2  Sometimes

3  Usually

4  Always

7. During this hospital come, how frequently

did doctors expound things in a way

you could recognize?

1  Never

2  Sometimes

3  Usually

4  Always

THE HOSPITAL ENVIRONMENT

8. During this hospital come, how frequently

were your compass and bathcompass kept

clean?

1  Never

2  Sometimes

3  Usually

4  Always

9. During this hospital come, how frequently

was the area environing your compass quiet

at dimness?

1  Never

2  Sometimes

3  Usually

4  Always

YOUR EXPERIENCES IN THIS HOSPITAL

10. During this hospital come, did you

need acceleration from nurses or other

hospital staff in getting to the

bathcompass or in using a bedpan?

1  Yes

2  No  If No, Go to Interrogation 12

11. How frequently did you get acceleration in getting

to the bathcompass or in using a bedpan

as quickly as you wanted?

1  Never

2  Sometimes

3  Usually

4  Always

12. During this hospital come, did you

need physic for asceticism?

1  Yes

2  No  If No, Go to Interrogation 15

13. During this hospital come, how frequently

was your asceticism courteous governled?

1  Never

2  Sometimes

3  Usually

4  Always

14. During this hospital come, how frequently

did the hospital staff do everything

they could to acceleration you behindcited a while your asceticism?

1  Never

2  Sometimes

3  Usually

4  Always

March 2017 3

15. During this hospital come, were you

absorbed any physic that you had not

taken precedently?

1  Yes

2  No  If No, Go to Interrogation 18

16. Precedently giving you any new physic,

how frequently did hospital staff decide you

what the physic was for?

1  Never

2  Sometimes

3  Usually

4  Always

17. Precedently giving you any new physic,

how frequently did hospital staff describe

likely behalf proceeds in a way you

could recognize?

1  Never

2  Sometimes

3  Usually

4  Always

WHEN YOU LEFT THE HOSPITAL

18. Aftercited you left the hospital, did you go

directly to your own settlement, to

someone else’s settlement, or to another

heartiness adroitness?

1  Own settlement

2  Someone else’s settlement

3  Another heartiness

adroitness  If Another, Go to

Question 21

19. During this hospital come, did doctors,

nurses or other hospital staff chat behindcited a while

you encircling whether you would keep

the acceleration you needed when you left the

hospital?

1  Yes

2  No

20. During this hospital come, did you get

notice in tallyableness encircling what

symptoms or heartiness problems to look

out for behindcited you left the hospital?

1  Yes

2  No

OVERALL RATING OF HOSPITAL

Please reply the behindcited interrogations

encircling your come at the hospital denominated on

the meet music. Do not grasp any other

hospital comes in your replys.

21. Using any enumeobjurgate from 0 to 10, where

0 is the conquer hospital enjoyly and

10 is the best hospital enjoyly, what

enumeobjurgate would you use to objurgate this

hospital during your come?

0  0 Conquer hospital enjoyly

1  1

2  2

3  3

4  4

5  5

6  6

7  7

8  8

9  9

10 10 Best hospital enjoyly

4 March 2017

22. Would you praise this hospital

to your friends and rise? 1  Definitely no

2  Probably no

3  Probably yes

4  Definitely yes

UNDERSTANDING YOUR CARE

WHEN YOU LEFT THE HOSPITAL

23. During this hospital come, staff took

my preferences and those of my

rise or preservationgiver into totality in

deciding what my heartiness preservation needs

would be when I left.

1  Strongly dissent

2  Disagree

3  Agree

4  Strongly concur

24. When I left the hospital, I had a amiable-natured

understanding of the things I was

responsible for in managing my

health.

1  Strongly dissent

2  Disagree

3  Agree

4  Strongly concur

25. When I left the hospital, I clearly

understood the resolve for taking

each of my medications.

1  Strongly dissent

2  Disagree

3  Agree

4  Strongly concur

5  I was not absorbed any medication when

I left the hospital

ABOUT YOU

There are solely a few fostering items left.

26. During this hospital come, were you

admitted to this hospital through the

Emergency Room?

1  Yes

2  No

27. In unconcealed, how would you objurgate your

overall heartiness?

1  Excellent

2  Very amiable-natured

3  Good

4  Fair

5  Poor

28. In unconcealed, how would you objurgate your

overall intellectual or tender heartiness?

1  Excellent

2  Very amiable-natured

3  Good

4  Fair

5  Poor

29. What is the main capacity or roll of

initiate that you keep fulld?

1  8th capacity or short

2  Some noble initiate, but did not

furrow 3  Noble initiate furrow or GED

4  Some seed-plot or 2-year capacity

5  4-year seed-plot furrow

6  Aggravate than 4-year seed-plot capacity

March 2017 5

30. Are you of Spanish, Hispanic or

Latino rise 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

31. What is your preservationer? Content choose

one or aggravate.

1  White

2  Black or African American

3  Asian

4  Native Hawaiian or other Pacific

Islander 5  American Indian or Alaska Native

32. What accents do you primarily speak

at settlement?

1  English

2  Spanish

3  Chinese

4  Russian

5  Vietnamese

6  Portuguese

9  Some other accents (content imprint):

_____________________

THANK YOU

Please repay the fulld examine in the postage-paid wrap.

[NAME OF SURVEY VENDOR OR SELF-ADMINISTERING HOSPITAL]

[RETURN ADDRESS OF SURVEY VENDOR OR SELF-ADMINISTERING

HOSPITAL]

Questions 1-22 and 26-32 are dissect of the HCAHPS Examine and are works of the U.S. Government. These HCAHPS interrogations are in the exoteric inclosure and hence are NOT theme to U.S. copyright laws. The three Preservation Transitions Measure® interrogations (Questions 23-25) are copyright of Eric A. Coleman, MD, MPH, all hues bashful.

6 March 2017

March 2017 7

HCAHPS Survey

SURVEY INSTRUCTIONS

 You should solely content out this examine if you were the enduring during the hospital come denominated in the meet music. Do not content out this examine if you were not the enduring.

 Reply all the interrogations by fully contenting in the divergence to the left of your reply.

 You are casually told to frisk aggravate some interrogations in this examine. When this happens you procure see an arrow behindcited a while a music that decides you what interrogation to reply contiguous, enjoy this:

0 Yes

0 No  If No, Go to Interrogation 1

You may give-heed-to a enumeobjurgate on the examine. This enumeobjurgate is used to let us comprehend if you

returned your examine so we don't keep to grant you reminders. Content music: Questions 1-25 in this examine are dissect of a notorious start to value the property of preservation in hospitals. OMB #0938-0981

Please reply the interrogations in this examine

encircling your come at the hospital denominated on

the meet music. Do not grasp any other

hospital comes in your replys.

YOUR CARE FROM NURSES

1. During this hospital come, how frequently

did nurses bargain you behindcited a while courtesy

and assignence?

10 Never 20 Casually 30 Usually 40 Always

2. During this hospital come, how frequently

did nurses attend preservationfully to you?

10 Never 20 Casually 30 Usually 40 Always

3. During this hospital come, how frequently

did nurses expound things in a way

you could recognize?

10 Never 20 Casually 30 Usually 40 Always

4. During this hospital come, behindcited you

pressed the wheedle dot, how frequently did

you get acceleration as quickly as you wanted

it?

10 Never 20 Casually 30 Usually 40 Always 90 I never pressed the wheedle dot

8 March 2017

YOUR CARE FROM DOCTORS

5. During this hospital come, how frequently

did doctors bargain you behindcited a while courtesy

and assignence?

10 Never 20 Casually 30 Usually 40 Always

6. During this hospital come, how frequently

did doctors attend preservationfully to you?

10 Never 20 Casually 30 Usually 40 Always

7. During this hospital come, how frequently

did doctors expound things in a way

you could recognize?

10 Never 20 Casually 30 Usually 40 Always

THE HOSPITAL ENVIRONMENT

8. During this hospital come, how frequently

were your compass and bathcompass kept

clean?

10 Never 20 Casually 30 Usually 40 Always

9. During this hospital come, how frequently

was the area environing your compass quiet

at dimness?

10 Never 20 Casually 30 Usually 40 Always

YOUR EXPERIENCES IN THIS HOSPITAL

10. During this hospital come, did you

need acceleration from nurses or other

hospital staff in getting to the

bathcompass or in using a bedpan?

10 Yes 20 No  If No, Go to Interrogation 12

11. How frequently did you get acceleration in getting

to the bathcompass or in using a bedpan

as quickly as you wanted?

10 Never 20 Casually 30 Usually 40 Always

12. During this hospital come, did you

need physic for asceticism?

10 Yes 20 No  If No, Go to Interrogation 15

13. During this hospital come, how frequently

was your asceticism courteous governled?

10 Never 20 Casually 30 Usually 40 Always

March 2017 9

14. During this hospital come, how frequently

did the hospital staff do everything

they could to acceleration you behindcited a while your asceticism?

10 Never 20 Casually 30 Usually 40 Always

15. During this hospital come, were you

absorbed any physic that you had not

taken precedently?

10 Yes 20 No  If No, Go to Interrogation 18

16. Precedently giving you any new physic,

how frequently did hospital staff decide you

what the physic was for?

10 Never 20 Casually 30 Usually 40 Always

17. Precedently giving you any new physic,

how frequently did hospital staff describe

likely behalf proceeds in a way you

could recognize?

10 Never 20 Casually 30 Usually 40 Always

WHEN YOU LEFT THE HOSPITAL

18. Aftercited you left the hospital, did you go

directly to your own settlement, to

someone else’s settlement, or to another

heartiness adroitness?

10 Own settlement 20 Someone else’s settlement 30 Another heartiness

adroitness  If Another, Go to

Question 21

19. During this hospital come, did doctors,

nurses or other hospital staff chat behindcited a while

you encircling whether you would keep

the acceleration you needed when you left the

hospital?

10 Yes 20 No

20. During this hospital come, did you get

notice in tallyableness encircling what

symptoms or heartiness problems to look

out for behindcited you left the hospital?

10 Yes 20 No

OVERALL RATING OF HOSPITAL

Please reply the behindcited interrogations

encircling your come at the hospital denominated on

the meet music. Do not grasp any other

hospital comes in your replys.

21. Using any enumeobjurgate from 0 to 10, where

0 is the conquer hospital enjoyly and

10 is the best hospital enjoyly, what

enumeobjurgate would you use to objurgate this

hospital during your come?

00 0 Conquer hospital enjoyly 10 1 20 2 30 3 40 4 50 5 60 6 70 7 80 8 90 9

100 10 Best hospital enjoyly

10 March 2017

22. Would you praise this hospital

to your friends and rise?

10 Definitely no 20 Probably no 30 Probably yes 40 Definitely yes

UNDERSTANDING YOUR CARE

WHEN YOU LEFT THE HOSPITAL

23. During this hospital come, staff took

my preferences and those of my

rise or preservationgiver into totality in

deciding what my heartiness preservation needs

would be when I left.

10 Strongly dissent 20 Dissent 30 Concur 40 Strongly concur

24. When I left the hospital, I had a amiable-natured

understanding of the things I was

responsible for in managing my

health.

10 Strongly dissent 20 Dissent 30 Concur 40 Strongly concur

25. When I left the hospital, I clearly

understood the resolve for taking

each of my medications.

10 Strongly dissent 20 Dissent 30 Concur 40 Strongly concur 50 I was not absorbed any medication when I left the hospital

ABOUT YOU

There are solely a few fostering items left.

26. During this hospital come, were you

admitted to this hospital through the

Emergency Room?

10 Yes 20 No

27. In unconcealed, how would you objurgate your

overall heartiness?

10 Excellent 20 Very amiable-natured-natured 30 Good-natured 40 Fair 50 Poor

28. In unconcealed, how would you objurgate your

overall intellectual or tender heartiness?

10 Excellent 20 Very amiable-natured-natured 30 Good-natured 40 Fair 50 Poor

29. What is the main capacity or roll of

initiate that you keep fulld?

10 8th capacity or short 20 Some noble initiate, but did not

furrow 30 Noble initiate furrow or GED 40 Some seed-plot or 2-year capacity 50 4-year seed-plot furrow 60 Aggravate than 4-year seed-plot capacity

March 2017 11

30. Are you of Spanish, Hispanic or

Latino rise or descent?

10 No, not Spanish/Hispanic/Latino 20 Yes, Puerto Rican 30 Yes, Mexican, Mexican American,

Chicano 40 Yes, Cuban 50 Yes, other Spanish/Hispanic/Latino

31. What is your preservationer? Content choose

one or aggravate.

10 White 20 Black or African American 30 Asian 40 Native Hawaiian or other Pacific

Islander 50 American Indian or Alaska Native

32. What accents do you primarily speak

at settlement?

10 English 20 Spanish 30 Chinese 40 Russian 50 Vietnamese 60 Portuguese 90 Some other accents (content imprint):

_____________________

THANK YOU

Please repay the fulld examine in the postage-paid wrap.

[NAME OF SURVEY VENDOR OR SELF-ADMINISTERING HOSPITAL]

[RETURN ADDRESS OF SURVEY VENDOR OR SELF-ADMINISTERING

HOSPITAL]

Questions 1-22 and 26-32 are dissect of the HCAHPS Examine and are works of the U.S. Government. These HCAHPS interrogations are in the exoteric inclosure and hence are NOT theme to U.S. copyright laws. The three Preservation Transitions Measure® interrogations (Questions 23-25) are copyright of Eric A. Coleman, MD, MPH, all hues bashful.

12 March 2017

March 2017 13

Sample Initial Meet Music for the HCAHPS Survey

[HOSPITAL LETTERHEAD]

[SAMPLED PATIENT NAME]

[ADDRESS]

[CITY, STATE ZIP]

Dear [SAMPLED PATIENT NAME]:

Our chronicles pretence that you were new-fangledly a enduring at [NAME OF HOSPITAL] and discharged on

[DATE OF DISCHARGE (mm/dd/yyyy)]. Because you had a new-fangled hospital come, we are exploration

for your acceleration. This examine is dissect of an ongoing notorious trial to recognize how endurings opinion

their hospital trial. Hospital results procure be exotericly reputed and made profitable on the

Internet at www.medicare.gov/hospitalcompare. These results procure acceleration consumers create

main choices encircling their hospital preservation, and procure acceleration hospitals ameliorate the preservation they prepare.

Questions 1-25 in the enclosed examine are dissect of a notorious start sponsored by the United

States Department of Heartiness and Human Services to value the property of preservation in hospitals.

Your dissecticipation is discretional and procure not seek your heartiness benefits.

We desire that you procure select the occasion to full the examine. Your dissecticipation is greatly

appreciated. Aftercited you keep fulld the examine, content repay it in the pre-paid wrap. Your

answers may be shared behindcited a while the hospital for resolves of property amelioratement. [OPTIONAL: You

may give-heed-to a enumeobjurgate on the examine. This enumeobjurgate is used to let us comprehend if you repayed your

examine so we don’t keep to grant you reminders.]

If you keep any interrogations encircling the enclosed examine, content wheedle the toll-free enumeobjurgate 1-800-xxx-

xxxx. Thank you for accelerationing to ameliorate heartiness preservation for all consumers.

Sincerely,

[HOSPITAL ADMINISTRATOR]

[HOSPITAL NAME]

Note: The OMB Paperwork Reduction Act accents must be graspd in the mailing. This

accents can be either on the face or tail of the meet music or interrogationnaire, but cannot be a

sepaobjurgate mailing. The proper OMB Paperwork Reduction Act accents is graspd in this

appendix. Content assign to the Mail Only, and Mixed Mode sections, for keep-aparticular music guidelines. http://www.medicare.gov/hospitalcompare

14 March 2017

March 2017 15

Sample Follow-up Meet Music for the HCAHPS Survey

[HOSPITAL LETTERHEAD]

[SAMPLED PATIENT NAME]

[ADDRESS]

[CITY, STATE ZIP]

Dear [SAMPLED PATIENT NAME]:

Our chronicles pretence that you were new-fangledly a enduring at [NAME OF HOSPITAL] and discharged on

[DATE OF DISCHARGE (mm/dd/yyyy)]. Approximately three weeks ago we sent you a examine

regarding your hospitalization. If you keep already repayed the examine to us, content sanction our

thanks and inattention this music. However, if you keep not yet fulld the examine, content select a

few minutes and full it now.

Because you had a new-fangled hospital come, we are exploration for your acceleration. This examine is dissect of an

ongoing notorious trial to recognize how endurings opinion their hospital trial. Hospital

results procure be exotericly reputed and made profitable on the Internet at

www.medicare.gov/hospitalcompare. These results procure acceleration consumers create main choices

encircling their hospital preservation, and procure acceleration hospitals ameliorate the preservation they prepare.

Questions 1-25 in the enclosed examine are dissect of a notorious start sponsored by the United

States Department of Heartiness and Human Services to value the property of preservation in hospitals.

Your dissecticipation is discretional and procure not seek your heartiness benefits. Content select a few minutes

and full the enclosed examine. Aftercited you keep fulld the examine, content repay it in the

pre-paid wrap. Your replys may be shared behindcited a while the hospital for resolves of property

improvement. [OPTIONAL: You may give-heed-to a enumeobjurgate on the examine. This enumeobjurgate is used to let

us comprehend if you repayed your examine so we don’t keep to grant you reminders.]

If you keep any interrogations encircling the enclosed examine, content wheedle the toll-free enumeobjurgate 1-800-xxx-

xxxx. Thank you intermittently for accelerationing to ameliorate heartiness preservation for all consumers.

Sincerely,

[HOSPITAL ADMINISTRATOR]

[HOSPITAL NAME]

Note: The OMB Paperwork Reduction Act accents must be graspd in the mailing. This

accents can be either on the face or tail of the meet music or interrogationnaire, but cannot be a

sepaobjurgate mailing. The proper OMB Paperwork Reduction Act accents is graspd in this

appendix. Content assign to the Mail Only, and Mixed Mode sections, for keep-aparticular music guidelines. Working%20Folder/www.medicare.gov/hospitalcompare

16 March 2017

March 2017 17

OMB Paperwork Reduction Act Language

The OMB Paperwork Reduction Act accents must be graspd in the examine mailing. This

accents can be either on the face or tail of the meet music or interrogationnaire, but cannot be a

sepaobjurgate mailing. The behindcited is the accents that must be used:

English Version

“According to the Paperwork Reduction Act of 1995, no beings are required to suit to a

collation of notice unshort it displays a efficient OMB govern enumerate. The efficient OMB govern

enumeobjurgate for this notice collation is 0938-0981. The occasion required to full this

notice firm is venerated to mean 8 minutes for interrogations 1-25 on the examine,

including the occasion to reopinion instructions, pursuit stout axioms instrument, supplement the axioms needed,

and full and reopinion the notice collation. If you keep any comments relating the

accuracy of the occasion venerate(s) or suggestions for comely this contrive, content transcribe to: Centers

for Medipreservation & Medicaid Services, 7500 Security Boulevard, C1-25-05, Baltimore, MD 21244-

1850.”

18 March 2017

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