AHRQ Hospital-Public Report (H-PR) Survey

Version 1.0

CAHPS Database - Hospital Component email updates

Hospital Survey on Patient Safety Culture email updates

TalkingQuality and Report Card Compendium email updates

AHRQ's Public Report Surveys are designed to provide developers of Web-based public reports with information on how well their reports are meeting consumers' needs, and thereby inform redesign considerations. The primary aim of the surveys is to provide information on consumers' use and perceptions of any given public report Web site, but they also track views of other groups of people who visit a particular Web site. This survey focuses on hospital reports.

Survey formatting notes:

Survey directions are in blue (i.e., anything blue is not visible in survey).
"Page x" refers to a new survey page.
Survey Pages 1 and 2 appear for all respondents. After Page 2, the survey branches to separate question sets for each Persona on Page 1. The answer to "What best describes you?" on Page 1 determines which question set is presented to the respondent. In the document below, each Persona-specific question set starts with a new header and new document page.
For Patients (including Health Care Professionals who indicate that they are "Choosing a hospital for myself") and Friend or Family Members, survey software can be programmed to show a subset of survey pages. For example, survey software can be programmed to show only three of the five question topics (Purpose of Visit, Topics of Interest, Using the Web site, What would you like added or changed, Demographic questions) and can be programmed to choose which three to show at random.

**Survey invitation [pops up upon arrival at the Webpage where code for the popup is inserted]

We'd like your feedback.

Your participation in this 2-minute survey will help improve this nonprofit Web site, making it easier for everyone to find a good hospital.

The survey will appear at the end of your Web site visit.

Take Our Survey No Thanks

All Web site visitors are being asked only once to participate in this research survey and participation is voluntary. All results are strictly confidential and anonymously collected. If you have any questions about the survey, please contact us at: youremailhere@xxxx.com

**If a visitor agrees to take the survey by selecting "Take our survey," the survey window opens behind the open browser window and the visitor can continue the visit without further interruption. The survey window remains open to be completed later.

**Page 1

Thank you for agreeing to participate in our survey!
Please answer these questions after you complete your Web site visit.

**Item 1
[This is a required question]

What best describes you? I am a:

Patient (or an interested member of the public) **[branch to PATIENT questions]

Friend or family member of a patient **[branch to FRIEND OR FAMILY MEMBER questions]

Health care professional (for example, doctor, nurse, hospital executive) **[branch to HEALTH CARE PROFESSIONAL questions]

Employer or Labor Union representative **[branch to EMPLOYER OR LABOR UNION questions]

Insurer **[branch to INSURER questions]

Other (for example, media, advocate, elected official, researcher, etc.) **[branch to OTHER questions]

**Page 2

20% complete

**Item 1

How would you rate your experience using the Web site?

Poor					Excellent
1	2	3	4	5	6	7	8	9	10

**Item 2

How easy was it to use the Web site? (for example, not too many clicks, easy to search the Web site)

Very Difficult					Very Easy
1	2	3	4	5	6	7	8	9	10

Patient (or interested member of the public)

**Page 3

30% complete

Purpose of your visit

**Item 1

What was the primary purpose of your visit to the Web site today? To:
(choose only one)
Choose the best hospital for myself or compare hospitals
See how good my hospital is
Prepare for a talk with my doctor
Get information for my family or friends **[branch to FRIEND OR FAMILY MEMBER]
Learn about a particular disease
Get practical information about a hospital (phone number, location)
Find out how much I would have to pay at a hospital
Other: **[free text]

**Item 2 Were you able to accomplish the primary purpose of your visit?
Definitely
Mostly
Only partially
Not at all

**Item 3

Did you have other reasons (in addition to the primary reason above) for your visit today? To:
(choose all that apply)
Choose the best hospital for myself or compare hospitals
See how good my hospital is
Prepare for a talk with my doctor
Get information for my family and friends
Learn about a particular disease
Get practical information about a hospital (phone number, location)
Find out how much I would have to pay at a hospital
No, I had no other reason
Other: **[free text]

**Page 4

40% complete

Topics of interest to you

**Item 1

What medical conditions are you looking for information about today?
(choose all that apply)
Heart disease (for example, heart attacks or heart failure)
Surgery (for example, hip or knee replacement, or gallbladder surgery)
Obstetrics and gynecology (for example, having a baby)
Pediatric conditions
Cancer
Asthma
Pneumonia
None of the above
Other: **[free text]

**Item 2

What types of information about hospital care are you looking for today?
(choose all that apply)
How often complications or errors occur
How often infections occur
How patients rate their care (for example, how many patients would recommend the hospital)
How often patients survive
How often patients get the correct care (for example, how many stroke patients get the right medicine)
None of the above
Other: **[free text]

**Page 5

50% complete

Using information from the Web site

**Item 1

How likely are you to use the Web site information now to choose a hospital or change hospitals?
Very likely
Likely
Unlikely **[branch to page 6]
Very unlikely **[branch to page 6]

**Item 2

How likely are you to use the Web site information to have a conversation with your doctor or other health care provider?
Very likely
Likely
Unlikely
Very unlikely

**Item 3

What do you like about the Web site?
(choose all that apply)
The number of hospitals included
The range of conditions and treatments included
Information provided about quality of care (for example, whether the right treatments were given)
Information about how to talk to your doctor
Information about how to choose a doctor
Nothing (I do not like anything about the Web site)
Other: **[free text]

**Item 4

If you searched using Google (or Yahoo, Bing, or other search engine) to get to the Web site, did you search for a:
Specific hospital (for example, "St. Francis Medical Center")
Web site comparing hospitals
Medical problem or treatment (for example, "heart failure" or "high blood sugar")
I did not use Google or another search engine
I do not know
Other: **[free text]

**Page 6

55% complete

**Item 1

Why are you unlikely to use the information to choose a hospital?
(choose all that apply)
I do not have a choice of hospitals
I do not need to choose a hospital or change hospitals at this time
The information provided is not specific to my personal health condition
Other factors are more important in my decision making
The information provided does not cover the specific hospital I want to know about
The information provided did not seem trustworthy
The information is confusing or difficult to understand
Other: **[free text]

**Page 7

75% complete

What would you like added or changed?

**Item 1

What additional information would make the Web site more useful? More information about:
(choose all that apply)
How well the hospital treats my specific medical condition
How well the hospital does my specific surgery or procedure
How much I would pay
Practical aspects of the hospital (for example, phone number, location)
Comments from people who have been patients at the hospital
Hospitals that are not currently on the Web site
Individual doctors within a hospital
No other information
Other: **[free text]

**Item 2

What would make the Web site easier for you to use?
(choose all that apply)
Provide a different way of searching the Web site
Provide a different way of sorting the results on the Web site
Make the information easier to understand (for example, fewer technical terms)
Make it easier to find the best hospital
Require fewer clicks to get information that I want
Other: **[free text]

**Item 3

Please use this box to add details about your choices in the prior two questions or comments about how to make the Web site more useful to you.
**[Free text box]

**Item 4

How likely are you to visit the Web site again?
Very likely
Likely
Unlikely
Very unlikely

**Page 8

85% complete

A few last questions about you

**Item 1

What is your age?
<18 years old
18 to 24
25 to 34
35 to 44
45 to 54
55 to 64
65 to 74
75 or older

**Item 2

Are you male or female?
Male
Female

**Item 3

Are you of Hispanic or Latino descent?
Yes, Hispanic or Latino
No, not Hispanic or Latino

**Item 4

What is your race?
White
Black or African American
Asian
Native Hawaiian or Other Pacific Islander
American Indian or Alaska Native
Other

**Item 5

What is the highest grade or level of school that you have completed?
8th grade or less
Some high school but did not graduate
High school graduate or GED
Some college or 2-year degree
4-year college graduate
More than 4 year-college degree

**Item 6

What type of health insurance do you have?
(choose only one)
Private insurance (i.e., from your employer or purchased by you)
Medicare
Medicaid
No insurance
I don't know
Other: **[free text]

Health Care Professional

**Page 9

40% complete

Purpose of your visit

**Item 1

What was the primary purpose of your visit to the Web site today? To:
(choose only one)
See how my hospital is performing
Compare my hospital's performance to other hospitals' performance
Choose a hospital to make a patient referral
Choose a hospital for myself **[branch to HEALTH CARE PROFESSIONAL (CHOOSE A HOSPITAL FOR MYSELF)]
Get practical information about a hospital (phone number, location)
Other: **[free text]

**Item 2

Were you able to accomplish the primary purpose of your visit?
Definitely
Mostly
Only partially
Not at all

**Item 3

Did you have other reasons (in addition to the primary reason above) for your visit today? To:
(choose all that apply)
See how my hospital is performing
Compare my hospital's performance to other hospitals' performance
Choose a hospital for the purposes of making a patient referral
Choose a hospital for myself
Get practical information about a hospital (phone number, location)
No, I had no other reason
Other: **[free text]

**Page 10

60% complete

What would you like added or changed?

**Item 1

What additional information would make the Web site more useful? More information about:
(choose all that apply)
Quality measures that are not currently included
Quality by inpatient service (for example, intensive care unit, pediatric unit)
Costs for patients (for example, cost of a procedure, cost of a hospital stay)
Methodology used to calculate performance measures (for example, risk adjustment methods)
Detailed results for each hospital (for example, sample size or 95% confidence intervals around their performance)
Hospitals that are not currently on the Web site
Individual doctors within a hospital
No other information
Other: **[free text]

**Item 2

**Item 3

Please use this box to add details about your choices in the prior two questions or comments about how to make the Web site more useful to you.
**[Free text box]

**Item 4

How likely are you to visit the Web site again?
Very likely
Likely
Unlikely
Very unlikely

**Page 11

80% complete

A few last questions about you

**Item 1

Are you a:
(choose all that apply)
Physician **[branch to page 35, for specialty question]
Nurse
Nurse practitioner **[branch to page 35, for specialty question]
Pharmacist
Social worker
Executive
Quality manager
Other: **[free text]

**Item 2

What is your age?
18 to 24
25 to 34
35 to 44
45 to 54
55 to 64
65 to 74
75 or older

**Item 3

**Item 4

What is the ZIP Code at your primary workplace?

Friend or Family Member

**Page 12

30% complete

**Item 1

I am looking for information for a:
(choose all that apply)
Family member
Non-family member
Child (under 18 years)
Non-senior adult (18-65 years)
Senior (65+)
Non-English speaker. Please specify language spoken: **[free text]

**Page 13

40% complete

Purpose of your visit

**Item 1

What was the primary purpose of your visit to the Web site today? To:
(choose only one)
Choose the best hospital or compare hospitals
See how good a specific hospital is
Prepare for a talk with a doctor
Learn about a particular disease
Get practical information about a hospital (phone number, location)
Find out how much one would have to pay at a hospital
Other: **[free text]

**Item 2

Were you able to accomplish the primary purpose of your visit?
Definitely
Mostly
Only partially
Not at all

**Item 3

Did you have other reasons (in addition to the primary reason above) for your visit today? To:
(choose all that apply)
Choose the best hospital or compare hospitals
See how good a specific hospital is
Prepare for a talk with a doctor
Learn about a particular disease
Get practical information about a hospital (phone number, location)
Find out how much one would have to pay at a hospital
No, I had no other reason
Other: **[free text]

**Page 14

50% complete

Topics of interest to you

**Item 1

**Item 2

**Item 3

What type of health insurance does your friend or family member have?
(choose one)
Private insurance (i.e., from his or her employer or that he or she purchased)
Medicare
Medicaid
No insurance
I don't know
Other: **[free text]

**Page 15

60% complete

Using information from the Web site

**Item 1

How likely are you to use the Web site information now to help your friend or family member to choose a hospital or change hospitals?
Very likely
Likely
Unlikely **[branch to page 16]
Very unlikely **[branch to page 16]

**Item 2

How likely are you or your friend or family member to use the Web site information to have a conversation with a doctor or other health care provider?
Very likely
Likely
Unlikely
Very unlikely

**Item 3

What do you like about the Web site?
(choose all that apply)
The number of hospitals included
The range of conditions and treatments included
Information provided about quality of care (for example, whether the right treatments were given)
Information about how to talk to a doctor
Information about how to choose a doctor
Nothing (I do not like anything about the Web site)
Other: **[free text]

**Item 4

**Page 16

65% complete

**Item 1

Why are you unlikely to use the information to help your friend or family member choose a hospital?
(choose all that apply)
My friend or family member does not have a choice of hospitals
He or she does not need to choose a hospital or change hospitals at this time
The information provided is not specific to his or her personal health condition
Other factors are more important in the decision making
The information provided does not cover the specific hospital he or she wants to know about
The information provided did not seem trustworthy
The information is confusing or difficult to understand
Other: **[free text]

**Page 17

80% complete

What would you like added or changed?

**Item 1

What additional information would make the Web site more useful? More information about:
(choose all that apply)
How well the hospital treats the specific medical condition my friend or family member has
How well the hospital does the specific surgery or procedure my friend or family member needs
How much my friend or family member would pay (for example, cost of a procedure or cost of a hospital stay)
Practical aspects of the hospital (for example, phone number, location)
Comments from people who have been patients at the hospital
Hospitals that are not currently on the Web site
Individual doctors within a hospital
No other information
Other: **[free text]

**Item 2

**Item 3

Please use this box to add details about your choices in the prior two questions or comments about how to make the Web site more useful to you.
**[Free text box]

**Item 4

How likely are you to visit the Web site again?
Very likely
Likely
Unlikely
Very unlikely

**Page 18

90% complete

A few last questions about YOU

**Item 1

What is your age?
<18 years old
18 to 24
25 to 34
35 to 44
45 to 54
55 to 64
65 to 74
75 or older

**Item 2

Are you male or female?
Male
Female

**Item 3

What is the highest grade or level of school that you have completed?
8th grade or less
Some high school but did not graduate
High school graduate or GED
Some college or 2-year degree
4-year college graduate
More than 4 year-college degree

Employer/Labor Union

**Page 19

40% complete

**Item 1

Are you a(n):
Employer **[show item 1 on page 20]
Labor Union Representative

**Page 20

50% complete

**Item 1 [only shown for Employers]

Where do you work in your company?
Human resources
Finance
Other senior management
Other: **[free text]

**Item 2

What was the primary purpose of your visit to the Web site today? To:
(choose only one)
Choose hospitals to include in the network for my employees or members
Learn about the quality of a hospital (or hospitals) for my employees or members
Learn about comparative costs of hospitals for my employees or members
Provide information to my employees or members
Get information for myself
Get information for family or friends
Get practical information about a hospital (phone number, location)
Other: **[free text]

**Item 3

Were you able to accomplish the primary purpose of your visit?
Definitely
Mostly
Only partially
Not at all

**Item 4

Any comments?
**[Free text box]

**Item 5

Did you have other reasons (in addition to the primary reason above) for your visit today? To:
(choose all that apply)
Choose hospitals to include in the network for my employees or members
Learn about the quality of a hospital (or hospitals) for my employees or members
Learn about comparative costs of hospitals for my employees or members
Provide information to my employees or members
Get information for myself
Get information for family or friends
Get practical information about a hospital (phone number, location)
No, I had no other reason
Other: **[free text]

**Item 6

How likely are you to visit the Web site again?
Very likely
Likely
Unlikely
Very unlikely

**Item 7

Any comments?
**[Free text box]

**Item 8

What would make the Web site more useful to you?
**[free text]

**Item 9

Insurer

**Page 21

35% complete

Purpose of your visit

**Item 1

What was the primary purpose of your visit to the Web site today? To:
(choose only one)
Choose hospitals to include in your network
Assess the quality performance of hospitals in your network
Assess the cost performance of hospitals in your network
Assess the quality of hospitals outside your network
Assess the cost of hospitals outside your network
Make decisions about pay for performance or other financial incentive programs
Provide information to your enrollees
Get information for yourself
Get information for a friend or family member
Other: **[free text]

**Item 2

Were you able to accomplish the primary purpose of your visit?
Definitely
Mostly
Only partially
Not at all

**Item 3

Did you have other reasons (in addition to the primary reason above) for your visit today? To:
(choose all that apply)
Choose hospitals to include in your network
Assess the quality performance of hospitals in your network
Assess the cost performance of hospitals in your network
Assess the quality of hospitals outside your network
Assess the cost of hospitals outside your network
Make decisions about pay for performance or other financial incentive programs
Provide information to your enrollees
Get information for yourself
Get information for a friend or family member
No, I had no other reason
Other: **[free text]

**Page 22

70% complete

What would you like added or changed?

**Item 1

What additional information would make the Web site more useful? More information about:
(choose all that apply)
Quality measures that are not currently included
Quality by service line (for example, intensive care unit, pediatric unit)
Costs for patients (for example, cost of a procedure, cost of a hospital stay)
Methodology used to calculate performance measures (for example, risk adjustment methods)
Detailed results for each hospital (for example, sample size or 95% confidence intervals around their performance)
Hospitals that are not currently on the Web site
Individual doctors within a hospital
No other information
Other: **[free text]

**Item 2

**Item 3

Please use this box to add details about your choices in the prior two questions or comments about how to make the Web site more useful to you.
**[Free text box]

**Item 4

How likely are you to visit the Web site again?
Very likely
Likely
Unlikely
Very unlikely

**Item 5

**Item 6

What is the ZIP Code at your primary workplace?

Other

**Page 23

35% complete

**Item 1

Are you a: **[branch from this question according to personae chosen below]
Member of the media (for example, TV, blog, print/online media) [branch to MEDIA]
Advocacy organization staff member [branch to ADVOCACY ORGANIZATION STAFF MEMBER]
Elected official or government worker [branch to ELECTED OFFICIAL OR GOVERNMENT WORKER]
Researcher [branch to RESEARCHER]
Foundation staff member [branch to FOUNDATION STAFF MEMBER]
Legal professional [branch to LEGAL PROFESSIONAL]
Other: **[free text]

Media

**Page 24

40% complete

**Item 1

What type of media do you work in?
TV
Print/online print
Blog
Radio
Other: **[free text]

**Item 2

What was the primary purpose of your visit to the Web site today? To:
(choose only one)
Compare hospitals
See how good a specific hospital is
Learn generally about the quality of the hospitals in a community
Learn generally about health care quality issues in a community
Look for an angle on a story
Create a synopsis of a quality report for my audience
Choose a hospital for myself
Choose a hospital for a friend or family member
Other: **[free text]

**Item 3

Were you able to accomplish the primary purpose of your visit?
Definitely
Mostly
Only partially
Not at all

**Item 4

Did you have other reasons (in addition to the primary reason above) for your visit today? To:
(choose all that apply)
Compare hospitals
See how good a specific hospital is
Learn generally about the quality of the hospitals in a community
Learn generally about health care quality issues in a community
Look for an angle on a story
Create a synopsis of a quality report for my audience
Choose a hospital for myself
Choose a hospital for a friend or family member
No, I had no other reason
Other: **[free text]

**Item 5

What would make the Web site more useful to you?
**[Free text box]

**Item 6

**Item 7

What is the ZIP Code of your primary workplace?

Advocacy Organization Staff Member

**Page 25

40% complete

**Item 1

What was the primary purpose of your visit to the Web site today? To:
(choose only one)
Compare hospitals
See how good a specific hospital is
Learn generally about the quality of the hospitals in a community
Learn generally about health care quality issues
Learn about health care quality for the population I represent
Provide information to the population I represent
Choose a hospital for myself
Choose a hospital for a friend or family member
Other: **[free text]

**Item 2

Were you able to accomplish the primary purpose of your visit?
Definitely
Mostly
Only partially
Not at all

**Item 3

Did you have other reasons (in addition to the primary reason above) for your visit today? To:
(choose all that apply)
Compare hospitals
See how good a specific hospital is
Learn generally about the quality of the hospitals in a community
Learn generally about health care quality issues
Learn about health care quality for the population I represent
Provide information to the population I represent
Choose a hospital for myself
Choose a hospital for a friend or family member
No, I had no other reason
Other: **[free text]

**Item 4

What would make the Web site more useful to you?
**[Free text box]

**Item 5

**Item 6

What is the ZIP Code of your primary workplace?

Elected Official or Government Worker

**Page 26

40% complete

**Item 1

What was the primary purpose of your visit to the Web site today? To:
(choose only one)
Compare hospitals
See how good a specific hospital is
Learn generally about the quality of the hospitals in a community
Learn generally about health care quality issues
Learn about health care quality for the population I represent
Provide information to the population I represent
Choose a hospital for myself
Choose a hospital for a friend or family member
Other: **[free text]

**Item 2

Were you able to accomplish the primary purpose of your visit?
Definitely
Mostly
Only partially
Not at all

**Item 3

Did you have other reasons (in addition to the primary reason above) for your visit today? To:
(choose all that apply)
Compare hospitals
See how good a specific hospital is
Learn generally about the quality of the hospitals in a community
Learn generally about health care quality issues
Learn about health care quality for the population I represent
Provide information to the population I represent
Choose a hospital for myself
Choose a hospital for a friend or family member
No, I had no other reason
Other: **[free text]

**Item 4

What would make the Web site more useful to you?
**[Free text box]

**Item 5

**Item 6

What is the ZIP Code of your primary workplace?

Researcher

**Page 27

40% complete

**Item 1

What was the primary purpose of your visit to the Web site today? To:
(choose only one)
Compare hospitals
See how good a specific hospital is
Learn generally about the quality of the hospitals in a community
Learn generally about health care quality issues
Learn about the methodology used for the measures reported on the Web site (for example, risk adjustment methods)
Choose a hospital for myself
Choose a hospital for a friend or family member
Other: **[free text]

**Item 2

Were you able to accomplish the primary purpose of your visit?
Definitely
Mostly
Only partially
Not at all

**Item 3

Did you have other reasons (in addition to the primary reason above) for your visit today? To:
(choose all that apply)
Compare hospitals
See how good a specific hospital is
Learn generally about the quality of the hospitals in a community
Learn generally about health care quality issues
Learn about the methodology used for the measures reported on the Web site (for example, risk adjustment methods)
Choose a hospital for myself
Choose a hospital for a friend or family member
No, I had no other reason
Other: **[free text]

**Item 4

What would make the Web site more useful to you?
**[Free text box]

**Item 5

**Item 6

What is the ZIP Code of your primary workplace?

Foundation Staff Member

**Page 28

40% complete

**Item 1

What was the primary purpose of your visit to the Web site today? To:
(choose only one)
Compare hospitals
See how good a specific hospital is
Learn generally about the quality of the hospitals in a community
Learn generally about health care quality issues
Learn about health care quality for a specific population
Choose a hospital for myself
Choose a hospital for a friend or family member
Other: **[free text]

**Item 2

Were you able to accomplish the primary purpose of your visit?
Definitely
Mostly
Only partially
Not at all

**Item 3

Did you have other reasons (in addition to the primary reason above) for your visit today? To:
(choose all that apply)
Compare hospitals
See how good a specific hospital is
Learn generally about the quality of the hospitals in a community
Learn generally about health care quality issues
Learn about health care quality for a specific population
Choose a hospital for myself
Choose a hospital for a friend or family member
No, I had no other reason
Other: **[free text]

**Item 4

What would make the Web site more useful to you?
**[Free text box]

**Item 5

**Item 6

What is the ZIP Code of your primary workplace?

Legal Professional

**Page 29

40% complete

**Item 1

What was the primary purpose of your visit to the Web site today? To:
(choose only one)
Compare hospitals
See how good a specific hospital is
Learn generally about the quality of the hospitals in a community
Learn generally about health care quality issues
Learn about health care quality for a client
Provide information for a client
Choose a hospital for myself
Choose a hospital for a friend or family member
Other: **[free text]

**Item 2

Were you able to accomplish the primary purpose of your visit?
Definitely
Mostly
Only partially
Not at all

**Item 3

Did you have other reasons (in addition to the primary reason above) for your visit today? To:
(choose all that apply)
Compare hospitals
See how good a specific hospital is
Learn generally about the quality of the hospitals in a community
Learn generally about health care quality issues
Learn about health care quality for a client
Provide information for a client
Choose a hospital for myself
Choose a hospital for a friend or family member
No, I had no other reason
Other: **[free text]

**Item 4

What would make the Web site more useful to you?
**[Free text box]

**Item 5

If you searched using Google (or Yahoo, Bing, or other search engine) to get to the Web site, did you search for a:
Specific hospital (for example, "St. Francis Medical Center")
Web site comparing hospitals
Medical problem or treatment (for example,"heart failure" or "high blood sugar")
I did not use Google or another search engine
I do not know
Other: **[free text]

**Item 6

What is the ZIP Code of your primary workplace?

Health Care Professional Answering Primary Purpose as "Choosing a Hospital for Myself"

**Page 30

35% complete

Topics of interest to you

**Item 1

What medical conditions are you looking for information about today?
(choose all that apply)
Heart disease (for example, heart attacks or heart failure)
Surgery (for example, knee or hip replacement, or gallbladder surgery)
Obstetrics and gynecology (for example, having a baby)
Pediatric conditions
Cancer
Asthma
Pneumonia
None of the above
Other: **[free text]

**Item 2

**Page 31

50% complete

Using information from the Web site

**Item 1

How likely are you to use the Web site information now to choose a hospital or change hospitals?
Very likely
Likely
Unlikely
Very unlikely

**Item 2

How likely are you to use the Web site information to have a conversation with your doctor or other health care provider?
Very likely
Likely
Unlikely
Very unlikely

**Item 3

**Item 4

If you searched using Google (or Yahoo, Bing, or other search engine) to get to the Web site, did you search for a:
Specific hospital (for example, “St. Francis Medical Center”)
Web site comparing hospitals
Medical problem or treatment (for example, “heart failure” or “high blood sugar”)
I did not use Google or another search engine
I do not know
Other: **[free text]

**Page 32

55% complete

**Item 1

**Page 33

65% complete

What would you like added or changed?

**Item 1

**Item 2

**Item 3

Please use this box to add details about your choices in the prior two questions or comments about how to make the Web site more useful to you.
**[Free text box]

**Item 4

How likely are you to visit the Web site again?
Very likely
Likely
Unlikely
Very unlikely

**Page 34

75% complete

A few last questions about you

**Item 1

What is your age?
18 to 24
25 to 34
35 to 44
45 to 54
55 to 64
65 to 74
75 or older

**Item 2

Are you male or female?
Male
Female

**Item 3

Are you of Hispanic or Latino descent?
Yes, Hispanic or Latino
No, not Hispanic or Latino

**Item 4

What is your race?
White
Black or African American
Asian
Native Hawaiian or Other Pacific Islander
American Indian or Alaska Native
Other

**Item 5

**Item 6

What type of health care insurance do you have?
(choose one)
Private insurance (i.e., from your employer or purchased by you)
Medicare
Medicaid
No insurance
I don't know
Other: **[free text]

**Item 7

Are you a:
(choose all that apply)
Physician **[branch to page 35 for specialty question]
Nurse
Nurse practitioner **[branch to page 35 for specialty question]
Pharmacist
Social worker
Executive
Quality manager
Other: **[free text]

**Page 35
[this item appears if a Health Care Professional says that he or she is a Physician or Nurse Practitioner]

95% complete

**Item 1

What is your specialty?
Internal Medicine
Family Medicine/General Practice
Pediatrics
Surgery
Psychiatry
Obstetrics/Gynecology
Other: **[free text]

**Completion Event

Thank you for taking the survey!

Your participation will help us understand how to make the Web site better so that people can easily find information about how well hospitals take care of their patients.

If you have any questions about the survey, please contact us at: youremailhere@email.com

You may now return to [http://participatingwebsitehere.org] or simply close this window.

** Denotes survey directions—not visible in survey.

Current as of December 2011

Internet Citation: AHRQ Hospital-Public Report (H-PR) Survey: Version 1.0. December 2011. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/quality-patient-safety/quality-resources/value/hospitalwebsurvey/hospsurvey.html