PATIENT EXPERIENCE SURVEY

Step 1 of 4

PATIENT EXPERIENCE SURVEY
You are being invited to take part in this survey because you have recently had a visit at Your responses to the questions on this survey will help us improve the care we provide.

There are six sections of the survey and it will take approximately 5 minutes to complete.

Participation in the survey is completely voluntary and all your responses to the survey questions will be kept confidential.
A. Are you completing this survey for yourself or for another person?*
- I am completing this survey for myself
- I am completing this survey for another person
B. 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 your relationship with the patient, not your name):
SECTION 1: CONTACTING US
Q1. How was the appointment for your most recent visit made?*
- I didn’t have an appointment – I just dropped-in
- I called and set it up
- I emailed and set it up
- I set it up at my last visit
- You called me to set it up
- Other
Please Specify
Q2. Thinking about your most recent visit, on a scale of poor to excellent, how would you rate the following …?*
Poor Fair Good Very Good Excellent
The length of time it took between making your appointment and the visit you just had
Your overall experience accessing the office/ clinic
SECTION 2: ARRIVING AND WAITING AT THE OFFICE/CLINIC
Still thinking about your most recent visit…

Q3. On a scale of poor to excellent, how would you rate the following …?*

	Poor	Fair	Good	Very Good	Excellent
The length of time you had to wait in the reception/ waiting area
Your overall experience with our reception staff
The length of time you had to wait in the examination room before you spoke with the health care provider about the reason for your visit

FEEDBACK (OPTIONAL)
Thinking of your overall experience with our office/clinic, what are …?
a. Two things done particularly well:*
b. Two things that could be improved:*
Is there any additional information or feedback you would like to share with us that could help us improve the way we provide care?*

	Poor	Fair	Good	Very Good	Excellent
They knew about your medical history
They listened to your concerns
They spoke using a language you could understand
They explained things in a way that was easy to understand
They were sensitive to your needs and preferences
They treated you with dignity and respect
They gave you clear instructions about what you need to do after your visit
Your overall experience speaking with the health care provider about the reason for your visit

	never	Rarely	Sometimes	Often	Always
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	Rarely	Sometimes	Often	Always
Did each seem to know your medical history
Did each seem to have your recent tests or exam results
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

Twin Bridges

Nurse Practitioner-Led Clinic

PATIENT EXPERIENCE SURVEY

Step 1 of 4

PATIENT EXPERIENCE SURVEY

SECTION 1: CONTACTING US

SECTION 2: ARRIVING AND WAITING AT THE OFFICE/CLINIC

SECTION 3: YOUR APPOINTMENT

SECTION 4: YOUR OVERALL EXPERIENCE WITH YOUR MOST RECENT VISIT

SECTION 5: YOUR EXPERIENCES VISITING WITH US OVER THE LAST YEAR OR SO

SECTION 6: CONTEXT/DEMOGRAPHICS

FEEDBACK (OPTIONAL)

	Poor	Fair	Good	Very Good	Excellent
The length of time it took between making your appointment and the visit you just had
Your overall experience accessing the office/ clinic

	Poor	Fair	Good	Very Good	Excellent
The overall cleanliness of the office/ clinic
The overall physical comfort of the office/ clinic
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 you expect
Your overall experience with the visit you had with us