Healthcare Quality Questionnaire

HEALTHCARE QUALITY QUESTIONNAIRE

Purpose: This questionnaire collects patient-reported information about the quality, safety and coordination of care received. Responses will be used by the facility and its quality improvement staff to evaluate clinical processes, patient experience and safety events. Participation is voluntary. All responses will be treated as confidential in accordance with applicable privacy protections and used for internal quality improvement unless you authorize otherwise below.

Patient Information

Patient Name:    Date of Birth:

Male    Female    Other    Prefer not to say

Emergency Contact

Insurance Information

Medical History (Relevant to this visit)

Experience of Care — Please select one per question

Overall satisfaction with care received:

1 (Very Poor) 2 3 4 5 (Excellent)

Clarity of explanations from providers:

1 2 3 4 5

Timeliness of care (wait times, scheduling):

1 2 3 4 5

Staff professionalism and courtesy:

1 2 3 4 5

Care coordination between providers (tests, referrals, follow-up):

1 2 3 4 5

Patient Safety and Adverse Events

Did you experience any of the following during this episode of care? (check all that apply)

Medication error    Fall or injury    Suspected infection    Wrong procedure/site    Other (describe below)

Open Comments and Recommendations

Use of Responses & Follow-up Authorization

I acknowledge that the information provided on this questionnaire may be used for internal quality improvement, staff training and aggregate reporting. Identifiable health information will be handled in accordance with the facility's privacy practices and applicable law. I understand that declining to provide information will not affect my ability to obtain care.

I consent to the use of my de-identified information for quality improvement and training.

I authorize clinical quality staff to contact me for follow-up clarification about this questionnaire.

Phone    Email    Mail

Privacy Acknowledgment

By signing below I acknowledge that I have received and understand the facility's notice of privacy practices regarding the use and disclosure of my health information for treatment, payment and healthcare operations, including quality improvement activities described above.

I acknowledge receipt of the privacy notice and understand how my information may be used.

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