Patient Outcome Survey (phone version)

Re-Engineered Discharge (RED) Toolkit

This survey available for download in two formats:

If contact sheet indicates patient needs an interpreter for phone communication, arrange for interpreter services before the call.

Overview

This phone interview script is provided to assist interviewers while attempting to reach the respondent. The script explains the purpose of the survey and confirms necessary information about the respondent. Interviewers must not conduct the survey with a proxy respondent.

General Interviewing Instructions

  • Survey is administered to patients beginning 30 days after the date of index hospital discharge.
  • Patients are called up to 60 days after the date of index hospital discharge.
  • All questions and all answer categories must be read exactly as they are worded.
  • No changes are permitted to the order of the answer categories.
  • All transitional statements must be read.

Index admission date: ___ ___ /___ ___ /___ ___ ___ ___

Index discharge date: ___ ___ /___ ___ /___ ___ ___ ___

Date initial call attempt: ___ ___ /___ ___ /___ ___ ___ ___

Caller records the call attempts and time talking with patient:
 

#1: Date(mo/day/yr): ____ /____ /____ Time of day ___:___ action taken/time with subject: ___________________________________________________________________________

 

#2: Date(mo/day/yr): ____ /____ /____ Time of day ___:___ action taken/time with subject: ___________________________________________________________________________

 

#3: Date(mo/day/yr): ____ /____ /____ Time of day ___:___ action taken/time with subject: ___________________________________________________________________________

 

#4: Date(mo/day/yr): ____ /____ /____ Time of day ___:___ action taken/time with subject: ___________________________________________________________________________

 

#5: Date(mo/day/yr): ____ /____ /____ Time of day ___:___ action taken/time with subject: ___________________________________________________________________________

 

#6: Date(mo/day/yr): ____ /____ /____ Time of day ___:___ action taken/time with subject: ___________________________________________________________________________

 

#7: Date(mo/day/yr): ____ /____ /____ Time of day ___:___ action taken/time with subject: ___________________________________________________________________________

 

#8: Date(mo/day/yr): ____ /____ /____ Time of day ___:___ action taken/time with subject: ___________________________________________________________________________

 

INTRODUCTION

Hello. may I please speak to [patient name]?

This is [name of caller] from [hospital name]. We are conducting a survey about the hospital discharge process. I am calling to talk to {patient name} about a recent health care experience.

Our records show that you were recently a patient at {name of hospital} and discharged on {date of discharge}. Because you had a recent hospital stay, we are asking for your help. This survey is part of an ongoing effort at {name of hospital} to improve the way they get patients ready to return home from the hospital. These results will help this hospital to understand if its improvements are helping patients.

Your participation is voluntary and will not affect your health benefits. You do not need to answer these questions. Your answers will only be shared with people who are trying to improve the hospital and the care that is given to patients.

If you have any questions about this survey, please call {hospital project manager name} at {project manager phone number}. Thank you for helping to improve health care for all patients.

This survey will take approximately 10 minutes. Are you willing to complete the survey now? With acknowledgment, caller continues.

..................................................

According to our records, you stayed in {hospital name} from {start date} to {discharge date}. Most of the questions on this survey are about this stay in the hospital.

Please tell me which response most closely matches your answer.

HOSPITAL USE

1.   Have you stayed in a hospital overnight since you left the hospital on {discharge date}? This means being admitted to a hospital floor (not just the emergency room).

1___ Yes   2___ No

If YES, please fill out the table below for each hospital visit. Ask for the hospital, date of arrival, and reason for each hospitalization.

HospitalDate You ArrivedReason
1.  
2.  
3.  
4.  
5.  

2.   Have you been to the emergency room since you left the hospital on {discharge date}? These would be emergency room visits that did not cause you to be admitted to the hospital (so you stayed in the emergency room the entire time and went home from the emergency room).

1___ Yes   2___ No

If YES, please fill out the table below for each emergency room visit. Ask for the hospital, date of arrival, and reason for each visit.

HospitalDate You ArrivedReason
1.  
2.  
3.  
4.  
5.  

APPOINTMENTS

These next questions are about any appointments you had after you left the hospital on {discharge date}.

3.   Do you have a particular doctor's office, clinic, health center, or other place that you usually go if you are sick or need advice about your health?

1___ Yes   2___ No

4.   Since you left the hospital on {discharge date}, have you seen your medical provider, sometimes called a primary care provider (or someone in their office)?

1___ Yes   2___ No

If YES, What date did you see this person? _______________________________________

DIAGNOSIS

5.   During your hospital stay, the doctors and nurses may have told you the name of your primary diagnosis or main problem. Do you know what your main problem was?

1___ Yes   2___ No   3___ N/A, reason: _________________________________________________

If YES, Can you please tell me the name of your primary diagnosis or main problem? ______

___________________________________________________________________________

These next questions ask about your visit at {hospital name} from {admit date} to {discharge date}.

YOUR HOSPITAL STAY

6.   During this hospital stay, how often did nurses treat you with courtesy and respect?

1___ Never
2___ Sometimes
3___ Usually
4___ Always

7.   During this hospital stay, how often did nurses listen carefully to you?

1___ Never
2___ Sometimes
3___ Usually
4___ Always

8.   During this hospital, stay, how often did nurses explain things in a way you could understand?

1___ Never
2___ Sometimes
3___ Usually
4___ Always

9.   During this hospital stay, how often did doctors treat you with courtesy and respect?

1___ Never
2___ Sometimes
3___ Usually
4___ Always

10.  During this hospital stay, how often did doctors listen carefully to you?

1___ Never
2___ Sometimes
3___ Usually
4___ Always

11.  During this hospital stay, how often did doctors explain things in a way you could understand?

1___ Never
2___ Sometimes
3___ Usually
4___ Always

12.  During this hospital stay, how often were your questions answered to your satisfaction?

1___ Never
2___ Sometimes
3___ Usually
4___ Always

13.  How often did hospital staff listen to you when they decided the plan for your care?

1___ Never
2___ Sometimes
3___ Usually
4___ Always

MEDICINES

14.  During this hospital stay, were you told to take any medicine after you left the hospital? Include prescription and nonprescription medicines as well as any medicines you were already taking before your hospital stay.

1___ Yes   2___ No → If No, Go to Question 21

15.  During this hospital stay, did hospital staff explain the purpose of each of the medicines you were to take at home?

1___ Yes   2___ No → If No, Go to Question 17

16.  Was the explanation of each medicine's purpose easy to understand?

1___ Never
2___ Sometimes
3___ Usually
4___ Always

17.  During this hospital stay, did hospital staff explain how much to take of each medicine and when to take it when you were at home?

1___ Yes   2___ No → If No, Go to Question 19

18.  How often was their explanation of how and when to take each medicine easy to understand?

1___ Never
2___ Sometimes
3___ Usually
4___ Always

19.  During this hospital stay, did hospital staff ask you to describe how much you would take of each medicine and when you would take it when you were at home?

1___ Yes   2___ No

20.  During this hospital stay, did hospital staff tell you whom to call after you left the hospital if you had questions about your medicines?

1___ Yes   2___ No

21.  During this hospital stay, did hospital staff talk with you about whether you would have the help you needed when you left the hospital?

1___ Yes   2___ No

22.  During this hospital stay, did you get information in writing about what symptoms or health problems to look out for after you left the hospital?

1___ Yes   2___ No → If No, Go to Question 24

23.  Were these written instructions easy to understand?

1___ Yes   2___ No

WHEN YOU LEFT THE HOSPITAL

24.  After you left the hospital, did you go directly to your own home, to someone else's home, or to another health facility?

1___ Own home
2___ Someone else's home
3___ Another health facility

25.  After you left the hospital, did someone from the hospital call you to check how you were doing?

1___ Yes   2___ No → If No, Go to Question 27

If YES, please tell me how much you agree with the following statement:

26.  After the call, all of my questions about my medical care were answered.

1___ Strongly disagree
2___ Disagree
3___ Agree
4___ Strongly Agree

OVERALL RATING OF HOSPITAL

27.  Using any number from 0 to 10, where 0 is the worst hospital possible and 10 is the best hospital possible, what number would you use to rate this hospital during your stay?

_________ (0-10)

28.  Would you recommend this hospital to your friends and family?

1___ Definitely no
2___ Probably no
3___ Probably yes
4___ Definitely yes

ABOUT YOU

There are only a few remaining items left.

29.  What is your age?

1___ 18-30 years
2___ 31-50 years
3___ 51-70 years
4___ 71-above years

30.  In general, how would you rate your overall health?

1___ Excellent
2___ Very good
3___ Good
4___ Fair
5___ Poor

31.  What is the highest grade or level of school that you have completed?

1___ Some elementary or high school but did not graduate
2___ High school graduate or GED
3___ Some college or 2-year degree
4___ 4-year college graduate

32.  Are you of Spanish, Hispanic, or Latino origin or descent?

1___ No, not Spanish/Hispanic/Latino
2___ Yes

33.  How would you describe your race? Please choose one or more.

1___ White
2___ Black or African American
3___ Asian
4___ Native Hawaiian or Other Pacific Islander
5___ American Indian or Alaska Native

34.  What language do you mainly speak at home?

1___ English
2___ Spanish
3___ Some other language (please print): ___________________________________________

Those are all the questions I have. Thank you for your time. Have a good (day/evening).

Current as of March 2013
Internet Citation: Patient Outcome Survey (phone version): Re-Engineered Discharge (RED) Toolkit. March 2013. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/systems/hospital/red/toolkit/ptoutcome-phone.html