SURVEY INSTRUCTIONS -
Please do not fill out this survey unless you are the parent or guardian who accompanied the patient named on the cover letter.
Please think about your child's Day Surgery experience on March 3, 2013 as you provide your best answer to each of the following questions.
Q1. Are you the parent or guardian of the child named on the cover letter?
1. Yes
2. No (STOP, please return the survey in the envelope provided)
Q2. Were you with your child during your child's visit to the outpatient surgical facility?
1. Yes
2. No (STOP, please return the survey in the envelope provided)
BEFORE YOUR CHILD'S PROCEDURE
Q3. Once you knew that your child needed surgery, was it easy for you to get a surgery date scheduled for your child's procedure?
1. No
2. Yes, somewhat
3. Yes, mostly
4. Yes, definitely
Q4. Once you knew that your child needed surgery, how long did you have to wait for your child to have the surgery?
1. 1 to 3 days
2. 4 to 7 days
3. 1 to 2 weeks
4. 2 to 3 weeks
5. 4 weeks or more
Q5. After you knew that your child needed surgery, was this facility able to perform your child's surgery on as soon a date as you wanted?
1. No
2. Yes, somewhat
3. Yes, mostly
4. Yes, definitely
Q6. Was the surgical staff informed about the procedure your child was scheduled to have?
1. No
2. Yes, somewhat
3. Yes, mostly
4. Yes, definitely
Q7. Did you get all the information you wanted about your child's surgery before the procedure began?
1. No
2. Yes, somewhat
3. Yes, mostly
4. Yes, definitely
Q8. Before your child's procedure, did someone from the hospital staff check his/her ID band or otherwise confirm your child's identity?
1. Yes
2. No
Q9. Did your child's procedure begin close to the scheduled time?
1. No
2. Yes, somewhat
3. Yes, mostly
4. Yes, definitely
YOUR EXPERIENCE WITH NURSES
Q10. How often did nurses treat you with courtesy and respect?
1. Never
2. Sometimes
3. Usually
4. Always
Q11. How often did nurses listen carefully to you?
1. Never
2. Sometimes
3. Usually
4. Always
Q12. How often did nurses explain things in a way you could understand?
1. Never
2. Sometimes
3. Usually
4. Always
Q13. How often were you able to discuss your worries or concerns with a nurse?
1. Never
2. Sometimes
3. Usually
4. Always
5. Did not have any worries or concerns
Q14. How often did you have confidence and trust in the nurses treating your child?
1. Never
2. Sometimes
3. Usually
4. Always
YOUR EXPERIENCE WITH DOCTORS
Q15. How often did doctors treat you with courtesy and respect?
1. Never
2. Sometimes
3. Usually
4. Always
Q16. How often did doctors listen carefully to you?
1. Never
2. Sometimes
3. Usually
4. Always
Q17. How often did doctors explain things in a way you could understand?
Never
Sometimes
Usually
Always
Q18. How often were you able to discuss your worries or concerns with a doctor?
Never
Sometimes
Usually
Always
Did not have any worries or concerns
Q19. How often did you have confidence and trust in the doctors treating your child?
1. Never
2. Sometimes
3. Usually
4. Always
YOUR OTHER EXPERIENCES IN THIS FACILITY
20. How often did areas around you appear clean?
1. Never
2. Sometimes
3. Usually
4. Always
Q21. How often did you or your child get help from nurses or other staff as soon as you wanted?
1. Never
2. Sometimes
3. Usually
4. Always
5. Did not need help
Q22. How often were the different doctors and nurses consistent with each other in providing you information about your child's care?
1. Never
2. Sometimes
3. Usually
4. Always
5. I did not notice
Q23. Did your child have any pain?
1. Yes
2. No (Go to #26)
Q24. How often was your child's pain well controlled?
1. Never
2. Sometimes
3. Usually
4. Always
Q25. How often did the staff do everything they could to help your child with his/her pain?
1. Never
2. Sometimes
3. Usually
4. Always
Q26. Was your child given any medicine?
1. Yes
2. No (Go to #31)
Q27. Before giving your child any medicine, how often did someone from the hospital staff check his/her ID band or otherwise confirm your child's identity?
1. Never
2. Sometimes
3. Usually
4. Always
Q28. Before giving your child any medicine, how often did someone from the staff tell you what the medicine was for?
1. Never
2. Sometimes
3. Usually
4. Always
Q29. Before giving your child any medicine, did someone from the staff ask about your child's allergies or other medications he/she may have been taking?
1. No
2. Yes, somewhat
3. Yes, mostly
4. Yes, definitely
5. No allergies/other meds
Q30. Before giving your child any medicine, how often did someone from the staff describe possible side effects in a way you could understand?
1. Never
2. Sometimes
3. Usually
4. Always
Q31. How often did the staff include you in discussions about your child's procedure?
1. Never
2. Sometimes
3. Usually
4. Always
32. How often were you able to talk to someone from the staff treating your child?
1. Never
2. Sometimes
3. Usually
4. Always
Q33. How often was there good communication between the different doctors and nurses treating your child?
1. Never
2. Sometimes
3. Usually
4. Always
Q34. How often did you have enough input or say in your child's care?
1. Never
2. Sometimes
3. Usually
4. Always
YOUR CHILD'S RECOVERY
Q35. While your child was recovering after his/her procedure, were you allowed to be with your child as much as you wanted?
1. No
2. Yes, somewhat
3. Yes, mostly
5. Yes, definitely
Q36. While your child was recovering after his/her procedure, did he/she have any nausea or discomfort?
1. Yes
2. No (Go to #38)
Q37. Did the staff do everything they could to help your child with his/her nausea or discomfort?
1. No
2. Yes, somewhat
3. Yes, mostly
4. Yes, definitely
Q38. Did someone from the staff tell you accurately how your child might feel after surgery?
1. No
2. Yes, somewhat
3. Yes, mostly
4. Yes, definitely
Q39. Do you think that your child had enough time to recover from his/her procedure before being released?
1. No
2. Yes, somewhat
3. Yes, mostly
4. Yes, definitely
GOING HOME FROM THIS FACILITY
Q40. Did someone on the staff talk with you about whether you or your child would have the help you needed after you left?
1. No
2. Yes, somewhat
3. Yes, mostly
4. Yes, definitely
Q41. Did you get information in writing about what symptoms or health problems to look out for in your child after you left?
1. No
2. Yes, somewhat
3. Yes, mostly
4. Yes, definitely
Q42. Did you know who to call if you needed help or information after you left?
1. No
2. Yes, somewhat
3. Yes, mostly
4. Yes, definitely
OVERALL IMPRESSIONS
Q43. How would you describe the outcome of your child's procedure?
1. A lot worse than I expected
2. A little worse than I expected
3. As good as I expected
4. Better than I expected
Q44. Using any number from 0 to 10, where 0 is the worst facility possible and 10 is the best facility possible, what number would you use to rate this outpatient surgical facility?
0. 0 Worst possible
1. 1
2. 2
3. 3
4. 4
5. 5
6. 6
7. 7
8. 8
9. 9
10. 10 Best possible
Q45. Would you recommend this outpatient surgical facility to your friends and family?
1. Definitely no
2. Probably no
3. Probably yes
4. Definitely yes
ANESTHESIOLOGISTS
Anesthesiologists are specialists who manage pain or consciousness before and/or during a medical procedure. Please answer the following questions about your child's care from an anesthesiologist during this hospital visit.
Q46. Did your child get treatment from an anesthesiologist?
1. Yes
2. No (Go to #55)
Q47. Did the anesthesiologist listen carefully to you?
1. No
2. Yes, somewhat
3. Yes, mostly
4. Yes, definitely
Q48. Did the anesthesiologist treat you with courtesy and respect?
1. No
2. Yes, somewhat
3. Yes, mostly
4. Yes, definitely
Q49. Did the anesthesiologist explain things in a way you could understand?
1. No
2. Yes, somewhat
3. Yes, mostly
4. Yes, definitely
Q50. Did the anesthesiologist treat your child with kindness and compassion?
1. No
2. Yes, somewhat
3. Yes, mostly
4. Yes, definitely
Q51. Did the anesthesiologist take time to explain things to your child in a way that he/she could understand?
1. No
2. Yes, somewhat
3. Yes, mostly
4. Yes, definitely
5. Not applicable
Q52. Did you have confidence and trust in the anesthesiologist who treated your child?
1. No
2. Yes, somewhat
3. Yes, mostly
4. Yes, definitely
Q53. Did you get all the information you wanted from the anesthesiologist about different options for managing your child's pain?
1. No
2. Yes, somewhat
3. Yes, mostly
4. Yes, definitely
Q54. Did the anesthesiologist effectively manage your child's pain during his/her procedure?
1. No
2. Yes, somewhat
3. Yes, mostly
4. Yes, definitely
INTERPRETER SERVICES
Q55. An interpreter is someone who helps you talk with others who do not speak your language. Interpreters can be facility staff or telephone interpreters. On this visit, did you need an interpreter to help you speak with staff?
1. Yes
2. No (Go to #60)
Q56. When you needed an interpreter to help you talk with providers, how often did you get one?
1. Never
2. Sometimes
3. Usually
4. Always
Q57. On this visit, was there ever a time when one or more of your child's providers could not easily talk with you in your preferred language?
1. Yes
2. No
Q58. On this visit, because a provider could not easily talk with you in your preferred language, how often did you have a problem getting help or information you or your child needed?
1. Never
2. Sometimes
3. Usually
4. Always
Q59. On this visit, because a provider could not easily talk with you in your preferred language, how often did you feel confused or unsure about your child's care?
1. Never
2. Sometimes
3. Usually
4. Always
OTHER QUESTIONS ABOUT YOUR CHILD'S VISIT
Q60. How often did staff introduce themselves and explain their role in your child's care?
1. Never
2. Sometimes
3. Usually
4. Always
Q61. How often were your family's cultural, spiritual and religious needs and beliefs respected?
1. Never
2. Sometimes
3. Usually
4. Always
5. Did not have any cultural, spiritual, or religious needs
Q62. How often did the staff work together as a team to care for your child?
1. Never
2. Sometimes
3. Usually
4. Always
Q63. How often did we partner with you to prevent and treat your child's pain?
1. Never
2. Sometimes
3. Usually
4. Always
5. Child did not have pain
Q64. Is there anything else you would like to say about the care your child received during this visit?
ABOUT THE CHILD
Q65. In general, how would you rate your child's overall health?
1. Excellent
2. Very Good
3. Good
4. Fair
5. Poor
Q66. Does your child have special needs?
1. Yes
2. No
Q67. Is your child of Spanish, Hispanic, or Latino origin or descent?
1. No, not Spanish/Hispanic/Latino
2. Yes, Puerto Rican
3. Yes, Mexican, Mexican American, Chicano
4. Yes, Cuban
5. Yes, other Spanish/Hispanic/Latino
Q68. What is your child's race? Please mark one or more.
1. White
2. Black or African-American
3. Asian
4. Native Hawaiian or other Pacific Islander
5. American Indian or Alaskan Indian or Alaskan Native
6. Other
ABOUT THE PARENT/GUARDIAN
Q69. What is your age?
1. Under 18
2. 18 to 24
3. 25 to 34
4. 35 to 44
5. 45 to 54
6. 55 to 64
7. 65 to 74
8. 75 or older
Q70. Are you male or female?
1. Male
2. Female
Q71. What is the highest grade or level of school that you have completed?
1. 8th grade or less
2. Some high school, but did not graduate
3. High school graduate or GED
4. Some college or 2-year degree
5. 4-year college graduate
6. More than 4-year college graduate
Q72. What language does your family mainly speak at home?
1. English
2. Spanish
3. Chinese
4. Russian
5. Vietnamese
6. Some other language (please print):
Q73. How are you related to the child?
1. Mother or father
2. Grandparent
3. Aunt or uncle
4. Older brother or sister
5. Other relative
6. Unrelated legal guardian
Thank you for taking the time to complete this questionnaire! Your answers are greatly appreciated.