[name of office/clinic] patient experience survey
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[NAME OF OFFICE/CLINIC] PATIENT EXPERIENCE SURVEY You are being invited to take part in this survey because you have just had a visit at [NAME OF OFFICE/ CLINIC]. Your responses to the questions on this survey will help us improve the care we provide. There are seven sections of the survey and it will take approximately 10 minutes to complete. Participation in the survey is voluntary and all your responses to the survey questions will be kept confidential. A1. Are you completing this survey for yourself or are you completing it for another person? I am completing this survey for myself I am completing this survey for another person A2. If you are completing this survey for someone else, who are you completing it for? I am completing this for a family member or friend I am completing this for the patient or client Other (please specify): _____________________ www.hqontario.ca YOUR LOGO HERE Section 1: Contacting Us Q1.1. Thinking about the visit you just had, what was the reason for your visit? Check all that apply. □ Routine examination/ annual examination □ Follow-up of a health problem/ pregnancy follow-up □ New health problem □ An urgent but minor health problem □ Prescription renewal □ Many issues to discuss □ Other (please specify): __________________ Q1.2. How was the appointment for this visit made? I didn’t have an appointment – I was a walk-in (SKIP TO QUESTION Q1.3c) I called and set it up I set it up at my last visit You called me to set it up Other (please specify): __________________ Q1.3. Thinking about the visit you just had, on a scale of poor to excellent, how would you rate the following …? Good Very Good Excellent c. d. Fair b. The length of time it took between making your appointment and the visit you just had The options that are available for you to make an appointment with us (e.g., phone, online, etc.) The hours that we are open Your overall experience with contacting or accessing us Poor a. FEEDBACK (OPTIONAL) Q1.4. Please provide any comments, positive or negative, about contacting, accessing or making an appointment with us. Primary Care Patient Experience Survey (Full Pilot Test Version) Page 2 of 10 YOUR LOGO HERE Section 2: Arriving at the Office/Clinic For this section, still thinking about the visit you just had… Q2.1. How long did you wait in the reception area past your appointment time? Less than 5 minutes 5 to 10 minutes 11 to 20 minutes 21 to 30 minutes More than 30 minutes I did not make an appointment Q2.2. On a scale of poor to excellent, how would you rate the following …? Poor Fair Good Very Good Excellent a. The length of time you had to wait in the reception/ waiting area b. The comfort of the reception/waiting area c. The courtesy of the reception staff d. The ability of the reception staff to communicate in language you could understand e. The convenience of our location f. Your overall experience from when you arrived to when you were shown into an examination room FEEDBACK (OPTIONAL) Q2.3. Please provide any comments, positive or negative, about your experience from when you arrived to when you were shown into an examination room. Primary Care Patient Experience Survey (Full Pilot Test Version) Page 3 of 10 YOUR LOGO HERE Section 3: Your Appointment Still thinking about the visit you just had… Q3.1. How long did you wait in the examination room before you actually spoke with a doctor/ health care provider about the reason for your visit? [IF YOU SAW MORE THAN ONE PERSON, THIS APPLIES TO THE FIRST DOCTOR/ HEALTH CARE PROVIDER YOU SAW] Saw the doctor/ health care provider immediately Less than five minutes Five to 10 minutes 11 to 20 minutes 21 to 30 minutes More than 30 minutes Not applicable Q3.2. On a scale of poor to excellent, how would you rate the following …? Fair Good Very Good Excellent The cleanliness of the examination room The length of time you had to wait in the examination room before you spoke with the doctor/ health care provider about the reason for your visit Poor a. b. Q3.3a. Please identify the MAIN doctor/ health care provider you spoke with. Check ONE only. [PRACTICES TO CUSTOMIZE LIST BASED ON AVAILABILITY OF PROVIDERS AT THEIR PRACTICE. SUGGESTED LIST BELOW: □ My regular doctor □ Another doctor here □ A specialist □ A nurse □ A nurse practitioner □ A nutritionist or a dietitian □ A physiotherapist or an occupational therapist □ A psychologist or a social worker □ A complementary/ alternative person (for example, acupuncturist, chiropractor, registered massage therapist) (please specify):____________________ □ Other (please specify): _____________________] Primary Care Patient Experience Survey (Full Pilot Test Version) Page 4 of 10 YOUR LOGO HERE Q3.3b. Please identify ANY OTHER doctor/ health care provider(s) you spoke with during the visit you just had. Check ALL that apply. [PRACTICES TO CUSTOMIZE LIST BASED ON AVAILABILITY OF PROVIDERS AT THEIR PRACTICE. SUGGESTED LIST BELOW: □ My regular doctor □ Another doctor here □ A specialist □ A nurse □ A nurse practitioner □ A nutritionist or a dietitian □ A physiotherapist or an occupational therapist □ A psychologist or a social worker □ A complementary/ alternative person (for example, acupuncturist, chiropractor, registered massage therapist) (please specify):____________________ □ Other (please specify): _____________________] Q3.4. Thinking about the MAIN doctor/ health care provider you spoke with during the visit, on a scale of poor to excellent, how would you rate this person on the following …? Good Very Good Excellent Primary Care Patient Experience Survey (Full Pilot Test Version) Page 5 of 10 Fair Listened to your concerns Treated you with respect Spent enough time with you Communicated in language you could understand e. Explained things in a way that was easy to understand f. Was sensitive to your needs and preferences g. Involved you to the extent you wanted to be in decisions related to your care and treatment h. Encouraged you to ask questions i. Knew your medical history j. Gave you clear instructions about what you need to do after your visit is over k. Your overall experience speaking with the doctor/ health care provider about the reason for your visit Poor a. b. c. d. YOUR LOGO HERE FEEDBACK (OPTIONAL) Q3.5. Please provide any comments, positive or negative, about your experience speaking with the doctor/ health care provider about the reason for your visit. Section 4: After speaking with the doctor/ health care provider For this section, still thinking about the visit you just had… Q4.1. Did you speak with the reception staff about any of the following before you left? Check ALL that apply. □ Did not speak with reception staff before leaving (SKIP TO QUESTION Q4.3) □ Setting another appointment with us □ Scheduling tests/ further examinations □ Making an appointment/ referral to a specialist □ Ask a question □ Other (please specify): _________________________ Q4.2. On a scale of poor to excellent, how would you rate the following … ? Fair Good Very Good Excellent b. c. The clarity of information provided by the reception staff about what you need to do after your visit The helpfulness of the reception staff Your overall experience speaking with the reception staff after seeing your doctor/ health care provider Poor a. FEEDBACK (OPTIONAL) Q4.3. Please provide any comments, positive or negative, about the end of your visit with us. Primary Care Patient Experience Survey (Full Pilot Test Version) Page 6 of 10 YOUR LOGO HERE Section 5: Your Overall Experience with the Visit You Just Had Q5.1. Thinking about the visit you just had, on a scale of poor to excellent, how would you rate the following … ? Very Good Excellent d. Good c. Fair b. Your confidence in the doctor/ health care provider(s) you saw during the visit Your confidence that your health information was treated with the level of privacy/confidentiality you expect The usefulness of the information you received for managing your care and treatment Your overall experience with the visit you just had with us Poor a. FEEDBACK (OPTIONAL) Q5.2. Thinking of your overall experience with the visit you just had, what are …? a. Two things that were done particularly well: 1. _______________________________________________________________________ 2. _______________________________________________________________________ b. Two things that could be improved? 1. _______________________________________________________________________ 2. _______________________________________________________________________ Section 6: Your Experiences with Visits with us over the Last Year or So The first couple of questions below are similar to ones asked earlier. However, instead of thinking specifically about your recent visit, we’d like you to think more broadly…about your experiences with us OVER THE LAST YEAR OR SO. Q6.1. The last time you were sick or were concerned you had a health problem, how many days did it take from when you first tried to see your doctor or nurse practitioner to when you actually SAW him/her or someone else in their office? Same day Next day 2-19 days (enter number of days: _______) 20 or more days Not applicable (don’t know/ refused) Primary Care Patient Experience Survey (Full Pilot Test Version) Page 7 of 10 YOUR LOGO HERE Q6.2. When you see your doctor or nurse practitioner, how often do they or someone else in the office…? Sometimes Often Always c. Rarely b. Give you an opportunity to ask questions about recommended treatment Involve you as much as you want to be in decisions about your care and treatment Spend enough time with you Never a. Q6.3. Please identify the different doctors/ health care providers you have seen during your visits with us over the last year or so. Check ALL that apply. [PRACTICES TO CUSTOMIZE LIST BASED ON AVAILABILITY OF PROVIDERS AT THEIR PRACTICE. SUGGESTED LIST BELOW: □ My regular doctor □ Another doctor here □ A specialist □ A nurse □ A nurse practitioner □ A nutritionist or a dietitian □ A physiotherapist or an occupational therapist □ A psychologist or a social worker □ A complementary/ alternative person (for example, acupuncturist, chiropractor, registered massage therapist) (please specify):____________________ □ Other (please specify): _____________________ □ Did not see other doctors/ health care providers (SKIP to Q6.5)] Q6.4. You indicated that you have seen more than one doctor/ health care provider during your visits with us over the last year or so. Thinking of these people as a group, on a scale of never to always, how often …? Sometimes Often Always Primary Care Patient Experience Survey (Full Pilot Test Version) Page 8 of 10 Rarely c. Did they seem to know about your medical history Were they consistent in what they were telling you about your care and treatment Did they seem to work well together in caring for you Never a. b. YOUR LOGO HERE Q6.5. Have you seen any doctors/ health care providers OTHER THAN THOSE WHO WORK HERE over the last year or so? Check ALL that apply. □ Another doctor □ A specialist □ A nurse □ A nurse practitioner □ A nutritionist or a dietitian □ A physiotherapist or an occupational therapist □ A psychologist or a social worker □ A complementary/ alternative person (for example, acupuncturist, chiropractor, registered massage therapist) (please specify):____________________ □ Other (please specify): _____________________ □ Did not see other doctors/ health care providers (SKIP to Q6.7) Q6.6.Thinking about all the different doctor/ health care providers that you have seen at all the different places you have received care over the last year or so, how often…? Rarely Sometimes Often Always Did each seem to know your medical history Did each seem to have your recent tests or exam results Did they seem to work well together in caring for you Never a. b. c. Q6.7. On another issue, the last time when you needed medical care in the evening, on a weekend, or on a public holiday, how easy was it to get care without going to the emergency department? Not applicable/Never Somewhat Somewhat Very Difficult Very Easy tried to do this/never Difficult Easy needed care Primary Care Patient Experience Survey (Full Pilot Test Version) Page 9 of 10 YOUR LOGO HERE Section 7: Context/Demographics Q7.1. Do you have any of the following? Check ALL that apply. □ Chronic illness (long term conditions like diabetes, heart conditions, etc.) □ Mental illness □ Developmental disability □ Learning disability □ Physical disability □ Sensory disability (i.e. hearing loss or vision loss) □ Drug or alcohol dependence □ Other (please specify): _______________________ □ Prefer not to answer Q7.2. In general how would you rate your overall health? Poor Fair Good Very Good Excellent Q7.3. How long have you been visiting us for your health care? Less than six months Six months to less than one year One year to less than three years Three years to less than five years Five years, or longer Q7.4. About how many times did you visit us over the last year or so for your own medical care? One Two Three Four Five or more Q7.5. Would you recommend our services to friends or your family? Check ONE only. Definitely would Probably would Might Probably would not Definitely would not Thank you for completing our survey. 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