APPENDIX - II

QUESTIONNAIRES

1. QUESTIONNAIRE FOR HOSPITAL MANAGEMENT

SHARE YOUR OPINIONS

I need your help to answer the following questions which will be an

important part of the quality assurance process for the hospital. Please take a
few minutes to complete this survey. The information you provide will be
completely anonymous.

SECTION-1

1. Name of the hospital :

2. Type of the hospital :
3. Year of establishment :
4. Governing Body particulars :
5. No. of administrative staff :
6. No. of departments :
7. No. of departmental Heads :
8. No. of doctors (cadre- wise) :
9. No. of wards :
10. No. of nursing staff :
11. No. of paramedical staff :
12. No. students :
13. No. of patients (Per day) :
a) Outpatient :
b) Inpatients :
14. Rate of bed occupancy per month :
15. income of the hospital per month :
16. Expenditure of the hospital per month :
17. Equipment available :

SECTION -2

A) Mission, objectives of the hospital:

1. What are the aims and objectives of the hospital?

2. What is the mission of the hospital?
3. What are the long term objectives of the hospital?
4. What are the current (short term) issues faced by the hospital?
5. Give the organisation chart of the hospital. To what extent are the
management and decision making process decentralised?

xxiii
B) 1. In your opinion, how have patient satisfaction ratings changed at
your organization in the past year ?

Improved considerably
Improved somewhat
Has remained about the same
Has declined somewhat
Has declined considerably
Dont Know

2. In your opinion, how important is patient satisfaction at your organization?

Its a high priority

Its a mid-level priority
Its a low priority
Dont Know

3. Does your organization have managers /staff dedicated to patient-

satisfaction matters?

Yes
No
Dont know

4. How often does your organization track patient satisfaction?

Daily basis for each patient

Monthly or more often
Quarterly
Semi annually
Yearly or less often
We dont

5. How patient satisfaction is primarily tracked?

Questionnaires sent through the main (in-house efforts)

Follow-up telephone calls (in-house efforts)
An outside firm has been hired to track patient satisfaction
Suggestion boxes placed in facilities
Other

xxiv
6. Has your organization initiated programs to improve patient satisfaction
within the past year?

Yes
No
Dont know

7. What sector of the health care industry do you believe needs the most
improvement in patient satisfaction?

Hospitals
Physicians
Managed-care plans
Insurers
Nursing homes
Outpatient providers
Dont know
Other

8. What is the most compelling reason for your organization to improve

customer satisfaction?

Fear of losing patients to competitors

Fear of losing employer contracts
Fear of increase regulation
Fear of damage to organizations reputation
Other

9. In your opinion has patient satisfaction been shown to have a direct

effect on your organization bottom line?

Yes
No
Dont know

Thank you for your co-operation and assistance.

xxv
 2. QUESTIONNAIRE FOR DOCTORS

Explanation

Please answer them as honestly as possible ticking the most

appropriate point on the scale for each item. I greatly appreciate your opinions
and I keep them in confidential.

DEMOGRAPHIC DATA

1. Name of the respondent :

(Not applicable if not interested)
2. Name of the hospital :
3. Department :
4. Designation :
5. Age :
6. Qualifications :
7. Experience in Years :

S. Cant
Particulars Yes No
No. Say
Administrative Functions
Organization structure and Policies of the hospital is known to
1
every staff member
2 Annual plans are prepared based on long range plans

3 Budget exists for supplies and salaries

4 Duty schedules are prepared in advance

5 Detailed Job description is made available to each employee

There is regular communication between staff and the authority
6
concerned
Regular meeting are conducted with doctors to review the
7
progress of the Patient Satisfaction
8 When problems are identified corrective action is taken
Periodically performance of the hospital is measured and
9
compared with set standards
Doctors satisfaction on the Overall rating of the administrative
10
functions

xxvi
 Doctors role

11 I respect my patients

12 I listen to my patients and their families

13 I am prepared to spend extra time with the patient if needed

14 I give holistic care to the patients

15 I work in a team spirit with nurses and paramedical staff

I explain clearly the condition of the patient and prognosis to the
16
patient and family
17 I maintain confidentiality about my patients illness

18 Patients are satisfied with my interventions in patient care

19 Overall perception of doctors role on service to patients

Thank you for your co-operation and assistance.

xxvii
 3. QUESTIONNAIRE FOR NURSING STAFF

Explanation

Please answer them as honestly as possible ticking the most

appropriate point on the scale for each item. I greatly appreciate your opinions
and I keep them in confidential.

DEMOGRAPHIC DATA

1. Name of the respondent :

(Not applicable if not interested)
2. Name of the hospital :
3. Department :
4. Designation :
5. Age :
6. Qualification :
7. Experience in Years :

Cant
S.No Particulars Yes No
say
Administrative Functions

Organization structure and Policies of the hospital is known to every

1
staff member

2 Annual plans are prepared based on long range plans

3 Budget exists for supplies and salaries

4 Duty schedules are prepared in advance

5 Detailed Job description is made available to each employee

There is regular communication between staff and the concerned

6
authority
Regular meeting are conducted with nurses to review the progress
7
of the Patient Satisfaction

8 When problems are identified corrective action is taken

Periodically performance of the hospital is measured and
9
compared with set standards
Nursing Staff Satisfaction on Overall rating of the administrative
10
functions

xxviii
 Nursing Staff Role

11 I respect my patients

12 I give a listening ear to my patients and their families

13 I am prepared to spend extra time with the patient if needed

14 I give holistic care to the patients

15 Nursing staff work as a team

I explain clearly the condition of the patient and prognosis to the

16
patient and family

17 I explain the test results, treatment and daily progress

18 I maintain confidentiality about my patients

19 Patients are satisfied with the equipment used in patient care

20 Overall rating of the nursing staff on service to patients

Thank you for your co-operation and assistance.

xxix
 4. QUESTIONNAIRE FOR OUT-PATIENTS SURVEY

SHARE YOUR OPINIONS

I need your help to answer the following questions which will be an

important part of the quality assurance process for the hospital. Please take a
few minutes to complete this survey. The information you provide will be
completely anonymous. I am asking you to rate your recent experience of
this hospital by marking your level of satisfaction with various services
provided through out your inpatient stay.

DEMOGRAPHIC DATA

1. Name of the Hospital :

2. Name of the Patient :

3. Gender : (a) Male ( )

(b) Female ( )

4. Age in years : (a) Below 30 Years ( )

(b) 31-60 years ( )
(c) 61 and above ( )

5. Area of Residence : (a) Urban ( )

(b) Rural ( )

6. Education : (a) No Formal Education ( )

(b) Below 12th class ( )
(c) Degree or above ( )

7. Yearly Income : (a) Below Rs. 50,000

(b) Rs.50,0011,00,000 ( )
(c) Above Rs. 1,00,000 ( )

8. Marital Status : (a) Married ( )

(b) Unmarried ( )

xxx
 OUT-PATIENT SATISFACTION SURVEY

I. REGISTRATION PROCEDURE

S. Partially Not
Particulars Satisfied
No Satisfied Satisfied

1 Reception services

2 Information available at reception counter

3 Time spent at registration counter

4 Present queue system at registration counter

5 Number of Counters provided for registration

6 Seating arrangements provided in waiting area

7 Security staff presence near registration counters

8 Overall rating of the registration process

If you were somewhat or completely dissatisfied with any of the above items, please tell us why:

Do you propose any changes, kindly give your valuable suggestions

xxxi
 II. CONSULTATION AND TREATMENT FACILITIES

S. Partially Not
Particulars Satisfied
No Satisfied Satisfied

1 Procedure adopted before consulting the doctor

Attitude of the staff at waiting area towards

2
patients problems

Time interval between patient arrival and consulting

3
the doctor.

4 Space and physical facilities at consulting room

5 Doctors listening capacity

6 Your opinion after consultation

7 Doctors explanation of the illness

8 The treatment given by the doctor

Overall rating of the Consultation and Treatment

9
Facilities

If you were somewhat or completely dissatisfied with any of the above items, please tell us why :

Do you propose any changes, kindly give your valuable suggestions

xxxii
 III. DIAGNOSTIC PROCEDURE

S. Partially Not
Particulars Satisfied
No Satisfied Satisfied
Investigations done for the ailment at outpatient
1
department

2 Facilities provided at investigation room

3 Laboratory Tests done on time

Availability of required medicines in the hospital

4
premises

5 Equipment used for investigations

6 Overall rating of the Diagnostic procedure

If you were somewhat or completely dissatisfied with any of the above items, please tell us why :

Do you propose any changes, kindly give your valuable suggestions

xxxiii
 IV. OTHER RELATED ISSUES

S. Partially Not
Particulars Satisfied
No Satisfied Satisfied
Timings and Performance of the outpatient
1
department

2 Opinion regarding behaviour of the staff

3 Doctors interest in the patients

Do you prefer to come to this hospital again if

4
necessary?

Do you recommend this hospital to your friends and

5
relatives?

6 Overall rating of the other related Issues

If you were somewhat or completely dissatisfied with any of the above items, please tell us why :

Do you propose any changes, kindly give your valuable suggestions

Thank you for your co-operation and assistance.

xxxiv
 5. QUESTIONNAIRE FOR IN-PATIENTS SURVEY

SHARE YOUR OPINIONS

I need your help to answer the following questions which will be an

important part of the quality assurance process for the hospital. Please take a
few minutes to complete this survey. The information you provide will be
completely anonymous. I am asking you to rate your recent experience of
this hospital by marking your level of satisfaction with various services
provided through out your inpatient stay.

DEMOGRAPHIC DATA

1. Name of the Hospital :

2. Name of the Patient :

3. Gender : (a) Male ( )

(b) Female ( )

4. Age in years : (a) Below 30 Years ( )

(b) 31-60 years ( )
(c) 61 and above ( )

5. Area of Residence : (a) Urban ( )

(b) Rural ( )

6. Education : (a) No Formal Education ( )

(b) Below 12th class ( )
(c) Degree or above ( )

7. Yearly Income : (a) Below Rs. 50,000

(b) Rs.50,0011,00,000 ( )
(c) Above Rs. 1,00,000 ( )

8. Marital Status : (a) Married ( )

(b) Unmarried ( )

xxxv
 IN-PATIENT SATISFACTION SURVEY

I. ADMISSION PROCEDURE

S. Partially Not
Particulars Satisfied
No Satisfied Satisfied

1 Opinion regarding receptivity of the staff.

2 Courtesy and respect of the staff.

3 Opinion regarding registration process.

4 Adequacy of information provided at reception.

5 Information regarding insurance facilities.

6 Time taken for admission

Readiness of room (bed) at the time of your

7
admission

8 Physical and transporting facilities at reception.

9 Overall rating of the admission process.

If you were somewhat or completely dissatisfied with any of the above items, please tell us why :

Do you propose any changes, kindly give your valuable suggestions

xxxvi
 II. PHYSICIAN SERVICES

S. Partially Not
Particulars Satisfied
No Satisfied Satisfied
Opinion regarding attention and attitude of the
1
doctors

Doctors listening to patients queries and

2
explaining condition

3 Method of the diagnostic tests and treatment

The courtesy and respect (friendliness, kindness)

4
shown

5 Doctors ability and skill

6 The daily rounds of doctors

7 At ease with the instructions of the doctors

8 Overall rating of the physician services

If you were somewhat or completely dissatisfied with any of the above items, please tell us why :

Do you propose any changes, kindly give your valuable suggestions

xxxvii
 III. NURSING SERVICES

S. Partially Not
Particulars Satisfied
No Satisfied Satisfied
1 Daily morning greeting

2 Attention and behaviour of the staff

3 Listening attitude towards patients needs

4 Explanation of procedures in an understandable way

5 Attention to the call light.

6 Opinion regarding tests and treatment

7 Timely administration of medication

8 Information regarding your daily progress

9 Confidentiality of the nurses

Role of nursing staff in making hospital stay as

10
pleasant

11 The consideration shown towards family and visitors

12 Overall rating of the nursing services

If you were somewhat or completely dissatisfied with any of the above items, please tell us why :

Do you propose any changes, kindly give your valuable suggestions

xxxviii
 IV. DIAGNOSTIC SERVICES

S. Partially Not
Particulars Satisfied
No Satisfied Satisfied
Opinion regarding the general behaviour of the
1
paramedical and technical staff

Sophisticated equipments and latest techniques used

2
towards diagnostic procedures

Opinion regarding laboratory and Radiology

3
departments facilities

4 Are the investigations are done on time

5 Your opinion in the speedy test results

Your impression of the information, preparation and

6
care during diagnostic procedures

7 Being at ease during diagnostic procedures

Opinion regarding the behaviour of the transport

8
personnel

9 Overall rating of the diagnostic services

If you were somewhat or completely dissatisfied with any of the above items, please tell us why :

Do you propose any changes, kindly give your valuable suggestions

xxxix
 V. ICU SERVICES

S. Partially Not
Particulars Satisfied
No Satisfied Satisfied

1 Opinion of the doctors attention

2 Quality of nursing Services

3 Explanation procedures in ICU

4 Staff courtesy and respect

5 Services of Paramedical and Class IV employees

6 Physical facilities and Cleanliness of ICU

7 Facilities provided to the attendants

8 Overall rating of ICU Services

If you were somewhat or completely dissatisfied with any of the above items, please tell us why :

Do you propose any changes, kindly give your valuable suggestions

xl
 VI. DIETARY SERVICES

S. Partially Not
Particulars Satisfied
No Satisfied Satisfied

1 Quality of diet served

2 Diet served is Palatable

3 Dietary therapy provided

4 The receptivity of the dietary staff

5 Diet supply is well-timed

6 Overall rating of dietary services

If you were somewhat or completely dissatisfied with any of the above items, please tell us why :

Do you propose any changes, kindly give your valuable suggestions

xli
 VII. ACCOMMODATIONS / PHYSICAL FACILITY

S. Partially Not
Particulars Satisfied
No Satisfied Satisfied

1 Comforts provided and facilities available

2 Opinion regarding the hospital environment

3 Cleanliness of the wards and corridors

4 Opinion regarding the available equipments

5 Opinion regarding water and electricity facilities

6 Opinion regarding the canteen facilities

7 Your impression of the ambulance services

8 Facilities provided to the attendants and visitors

9 Your impression of the toilet facilities and cleanliness.

Overall rating of the accommodation / physical

10
facilities

If you were somewhat or completely dissatisfied with any of the above items, please tell us why :

Do you propose any changes, kindly give your valuable suggestions

xlii
 VIII. DISCHARGE SERVICES

S. Partially Not
Particulars Satisfied
No Satisfied Satisfied
Information regarding prognosis and discharge
1
instructions

2 Information about hospital payment

3 Helpfulness of staff in billing office

4 Health Education by the staff at discharge

5 Anxieties and concerns handled by the staff

6 Over all rating of the discharge service

If you were somewhat or completely dissatisfied with any of the above items, please tell us why :

Do you propose any changes, kindly give your valuable suggestions

xliii
 IX. OVERALL SATISFACTION OF THE HOSPITAL DEPARMENTS

S. Partially Not
Particulars Satisfied
No Satisfied Satisfied

1 Registration and Admission

2 Reception and Enquiry

3 Critical Care Unit

4 Diagnostic and Laboratory units

5 Pharmacy

6 In-Patient Rooms/Wards

7 Canteen

8 Waiting Room

9 Parking area

10 Dietary department

11 Laundry

If you were somewhat or completely dissatisfied with any of the above items, please tell us why :

Do you propose any changes, kindly give your valuable suggestions

xliv
 X. OVERALL SATISFACTION OF THE HOSPITAL PERSONNEL
SERVICES

S. Partially Not
Particulars Satisfied
No Satisfied Satisfied

1 Doctors services

2 Nursing services

3 Paramedical staff services

4 Class IV Employees services

5 Security personnel services

6 Inter Departmental Co-ordination and Team spirit

If you were somewhat or completely dissatisfied with any of the above items, please tell us why :

Do you propose any changes, kindly give your valuable suggestions

xlv
 XI. VARIED SERVICES

S. Partially Not
Particulars Satisfied
No Satisfied Satisfied

1 Total Cost of the hospital services

2 Billing Procedure

3 Hospitality

4 Cleanliness of Environment

5 Communication facilities

6 Prayerful atmosphere

7 Entertainment

If you were somewhat or completely dissatisfied with any of the above items, please tell us why:

Do you propose any changes, kindly give your valuable suggestions

Thank you for your co-operation and assistance.

xlvi