Who accompanied the patient named on the cover letter

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Reference no: EM131671099

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.

Reference no: EM131671099

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Reviews

len1671099

10/7/2017 2:47:40 AM

I am writing my dissertation research trial and need to convert this survey in to an appendix (Appendix B to be exact) and have tried everything to make this happen and cannot do. This attachment is a part of my research trial and must be incorporated in to the paper? Is this possible to do? 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. Thank you for taking the time to complete this questionnaire! Your answers are greatly appreciated.

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