Patient Feedback Survey 2

MEADOW HOUSE HOSPICE - Patient Feedback Survey 2011

Meadow House Hospice is continuously trying to improve the quality of care that you the patient receive. We would like you to take a few minutes of your time to complete this questionnaire about your experience of our service. All information you provide will be confidential and no attempt will be made to identify you from the details you provide.

Q.1

Was this the first time that you met with this member of staff?

YES
NO
Don't remember

Q.2

Which service have you been seen at? *

Patient Hospice Ward
Day Hospice
Lymphoedema
Community Team
Social worker
Bereavement Team/Counsellor
Consultant Out-patient appointment
other

Q.3

Did the member of staff you met with introduce him or herself to you today?

YES
NO
Don't remember/Didn't notice

Q.4

Was the member of staff wearing a name badge today? *

YES
NO
Don't remember/Didn't notice

Q.5

Do you know what number/who to contact if you need support out of hours (after 5pm)? *

YES
NO
Don't know
Not appropriate

Q.6

Did the member of staff ask permission before examining or treating you? *

YES
NO
I was not examined or treated today
Don't know/not sure

Q.7

Please say to what extent you agree or disagree with the following aspects of your care: (Please tick one for each row) *

	Definitely agree	Tend to agree	Tend to disagree	Definitely disagree	Don't know	Not Applicable
The member of staff I saw today listened to me
The member of staff I saw today understood me
I felt involved in the decision about my care and/or treatment I felt involved in the decision about my care and/or treatment as much as I wanted to be
The member of staff I saw today made an effort to cover my body during treatment/examination
The staff treated me with respect today

Q.8

Please say how satisfied or dissatisfied you are with the following aspects of the information *

	Very satisfied	Fairly satisfied	Fairly unsatisfied	Very unsatisfied	Don't know	Not Applicable
The amount of information given about your care or treatment
The quality of information given about your care or treatment
The amount of information given about what would happen next
The quality of information given about what would happen next

Q.9

Meadow House Hospice has a responsibility to ask your permission before sharing information about you with other healthcare professionals. We also have a legal duty to make sure you understand what information may be shared. *

	YES	NO	Don't know/can't remember	Not Applicable
Were you asked if information about you could be shared with
Were you asked if information about you could be shared with
Were you given enough time to discuss your condition with HC profs?

Q.10

Did staff clearly explain the purpose of any medication and side effects in a way that you could understand? *

	Very satisfied	Fairly satisfied	Fairly unsatisfied	Very unsatisfied	Don't know	Not Applicable
Did staff clearly explain the purpose of any medication
Did staff clearly explain side effects of medication

Q.11

Thinking about privacy, please say how satisfied or dissatisfied you are with the following aspects: *

	Very satisfied	Fairly satisfied	Fairly unsatisfied	Very unsatisfied	Don't know	Not Applicable
The privacy in the waiting area
The privacy in the assessment/clinic area

Q.12

Overall, how satisfied or dissatisfied were you with the service you received today? *

	Very satisfied	Fairly satisfied	Fairly unsatisfied	Very unsatisfied	Don't know	Not Applicable
Overall, how satisfied or dissatisfied were you with the service you received today?

Q.13

Enter comments on satisfaction/feedback here

Q.14

What gender are you?

Female
Male

Q.15

What is your age? (If you were not the patient, what is the age of the patient?)

18 to 24
25 to 34
35 to 44
45 to 54
55 to 59
60 to 64
65 or over

Q.16

Which of the following describes your ethnic origin? White/Mixed *

Q.17

Did you need an interpreter? *

YES
NO
Don't know/can't remember
NA

Q.18

Was an interpreter provided for you if you needed one? *

YES
NO
Don't know/can't remember
NA

Q.19

What language do you speak?

Q.20

Please enter the date of your response or visit to the service whichever is relevant

MM
/

DD
/

YYYY