Ots 24 > Oac43-45 > Annexure

Annexure 1: QUESTIONNAIRE FOR SURVEY Questionnaire for assessing the level of Patient Satisfaction of indoor and outdoor patients (to be administered to the inpatients who have been discharged from the hospital, before they leave the premises, and on outpatients after they have been treated at the OPDs.)

General Information: 1. Name of patient (and who is the respondent) 2. Age 3. Sex 4. Address 5. Date of interview 6. Since when has he been in the hospital (for inpatients) 7. Occupation a) Farmer b) Professional c) Businessman

  

8. Income level (per month) a) Less than 5000 b) 5000-10000 c) 10000 and above

  

9. Type of i. Patient ii. Treatment

a) Inpatient a) Medical

d) Government employee  e) Other (please specify)____________

b) Outpatient b) Surgical

 

 

10. Disease or problem __________________________________________ 11. Dept. visited 12. Doctor 13. Tests undertaken: a. Radio diagnosis b. Pathology

 

14. Type of Ward/ Room (for inpatients) a) General  b) Special 

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c) Semi-special  d) Deluxe  e) ICU i. MICU  ii. SICU  iii. SIMC  iv. PICU  v. NICU  (Specify which department the ward falls under) 15. Policy holder a) Krupa



b) Non-Krupa



16. Number of visits to Shree Krishna Hospital in the last 6 months__________ 17. Which was the first point of contact when you entered the hospital? a) Reception counter  b) Krupa desk  c) Security Personnel  d) Registration Counter  e) Social worker  f) Other (please specify)  18.Where did you get your case registered? a. General counter  b. Krupa counter  19. Did you avail of any freeship facilities provided by the hospital? a) Yes  b) No  If yes please specify what kind and how much__________________________ _______________________________________________________________ 20. Did you find any difficulty regarding the freeship? a) Yes  b) No



If yes, please indicate: a) Access to Freeship  b) Procedural details  (ease of obtaining it) c) Other (if any specify)_______________________________________ 21. Have you taken any mediclaim facilities? If yes specify which kind_________ __________________________________________________________________

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22. Rate the following factors on the scale in choosing a hospital. Extremely Important (5) Somewhat Important (4)

Very Important (4) Not Important (1)

Undecided (3)

1) Services Provided

5

4

3

2

1

2) Location

5

4

3

2

1

3) Expert Referrals

5

4

3

2

1

4) Word of mouth

5

4

3

2

1

5) Historical association

5

4

3

2

1

6) Reputation

5

4

3

2

1

7) Value for money

5

4

3

2

1

8) Infrastructure and medical facilities 5

4

3

2

1

9) Convenience

5

4

3

2

1

10) Skill profile of Doctors etc.

5

4

3

2

1

11) Efficacy of service provided

5

4

3

2

1

12) Advertisement

5

4

3

2

1

13) Discount/freeship

5

4

3

2

1

14) Support facilities

5

4

3

2

1

15) Aesthetics

5

4

3

2

1

16) Grievance redressal system

5

4

3

2

1

17) Others specify (if any) ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ________________________________________

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Please rate the following: Completely satisfied

(5)

Somewhat Dissatisfied (2)

Somewhat Satisfied

(4)

Undecided (3)

Completely Dissatisfied (1)

___________________________________________________________________________ 1. Information pertaining to patient’s rating of the hospital as a whole:

1. Location

5

4

3

2

1

2. Infrastructure

5

4

3

2

1

3. Facilities

5

4

3

2

1

4. Technology

5

4

3

2

1

5. Cleanliness of

a. Corridors

5

4

3

2

1

b. Bathrooms

5

4

3

2

1

5

4

3

2

4

3

2

1

c. Ward in general d. For inpatients: Bedsheets

5

1

(including regularity of changing)

6. Layout (Maternity –Pediatric,

5

4

3

2

1

location of testing depts., (ultrasound-bathroom etc)

7. Comfort of surroundings

5

4

3

2

1

8. Aesthetics (Trees, light, cramping or

5

4

3

2

1

5

4

3

2

1

5

4

3

2

1

spaciousness of wards/ rooms, colour of wards, rooms)

9. Skill profile of doctors and other healthcare professionals

10. Expenses (or costs)

Where do u find the cost high? If found high in which department or treatment? Any other comments if any pertaining to Hospital as a whole: __________________________________________________________________________________ ____________________________________________________________________

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2. Information pertaining to patient’s rating of the staff 1. Courtesy shown by:

a. Receptionists/ Registration counter 5

4

3

2

1

c. Nurses

5

4

3

2

1

d. Doctors

5

4

3

2

1

b. Personnel

e. Lab Technicians

5

4

3

2

1

f. Ward Boys

5

4

3

2

1

5

4

3

2

5

4

3

2

1

i. Any other staff that patient mentions5

4

3

2

1

g. Pharmacy staff h. Billing staff 2. Information provided by doctor or

5

4

3

2

1

1

nurse to the patient 3. Way in which information was provided to family or attendants of the patient

4. Attentiveness of nurses to calls from patients

5

4

3

2

1

5

4

3

2

1

5

4

3

2

1

for help or medical attention

5. Gentleness of nurses in administering medical treatment Any other comments pertaining to staff

__________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ _________________________________

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3. Information pertaining to patient’s rating of the services provided

1. Diagnosis by Doctor

5

4

3

2

1

2. Compassion and reassurance by doctor

5

4

3

2

1

3. Patience or attention by Doctor

5

4

3

2

1

4. Personal attention

5

4

3

2

1

5. Consultation with Doctor of choice

5

4

3

2

1

6. Privacy of Consultation

5

4

3

2

1

7. Duration for receiving test results

5

4

3

2

1

a) Timeliness

5

4

3

2

1

b) Cleanliness

5

4

3

2

1

c) As per Dietician instruction

5

4

3

2

1

9. No. of visits by Doctors (inpatient)

5

4

3

2

1

10. Regularity of ward staff

5

4

3

2

1

11. Availability of Medicine

5

4

3

2

1

12. Information dissemination to relatives

5

4

3

2

1

13. Efficacy of treatment

5

4

3

2

1

14. Facilities for persons accompanying patient

5

4

3

2

1

15. Procedure at the time of discharge

5

4

3

2

1

16. Emergency services (ambulance etc.)

5

4

3

2

1

8. Kitchen food (inpatients only)

at trauma center Any other comments pertaining to services provided __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________

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__________________________________________________________________________________ __________________________________________________________________________________ _________________________________

4. Information pertaining to procedural details

1. Easy location of the departments

5

4

3

2

1

a) Registration

5

4

3

2

1

b) Pharmacy

5

4

3

2

1

c) Cashier

5

4

3

2

1

receiving report on time)

5

4

3

2

1

e) Consultation with Doctor

5

4

3

2

1

3. Billing promptness

5

4

3

2

1

4. Clarity in showing expenses

5

4

3

2

1

5. No overcrowding

5

4

3

2

1

2. Time spent at

d) Test (Specified including

Any other grievance pertaining to procedural details

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5. Information pertaining to Krupa details

1. Initial information

5

4

3

2

1

2. Discount on medicine

5

4

3

2

1

3. Range of diseases or ailments covered

5

4

3

2

1

4. Price

5

4

3

2

1

5. Range of options

5

4

3

2

1

6. Media approach

5

4

3

2

1

7. Post registration tracking

5

4

3

2

1

8. Documentation

5

4

3

2

1

9. Treatment offered at hospital

5

4

3

2

1

10. Information provided in booklet

5

4

3

2

1

11. Clarification of doubts

5

4

3

2

1

12. Association with other hospitals

5

4

3

2

1

13. Other benefits (such as income tax exemption) 5

4

3

2

1

14. Hospitality shown by Krupa staff

4

3

2

1

5

Q. Would you like to suggest your friends/ relatives/ neighbours to become a member of Krupa? If yes, why? If no, why? __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ _______________________________________________ Any Other grievances in general:

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