Hospital Performance Evaluation Template

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1. How knowledgeable was the staff at this hospital?
How knowledgeable was the staff at this hospital? Extremely knowledgeable
Very knowledgeable
Moderately knowledgeable
Slightly knowledgeable
Not at all knowledgeable
2. How professionally did the staff at this hospital behave?
How professionally did the staff at this hospital behave? Extremely professionally
Quite professionally
Moderately professionally
Slightly professionally
Not at all professionally
. How easy was it to talk to the staff at this hospital about your medical condition!s"?
How easy was it to talk to the staff at this hospital about your medial ondition!s"? Extremely easy
Quite easy
Moderately easy
Slightly easy
Not at all easy
#. How often did you receive conflicting information from the staff at this hospital?
How often did you reeive onfliting information from the staff at this hospital? Extremely often
Quite often
Moderately often
Slightly often
Not at all often
$. How responsive was the staff at this hospital to your %uestions?
How responsive was the staff at this hospital to your #uestions? Extremely responsive
Very responsive
Moderately responsive
Slightly responsive
Not at all responsive
&. How considerate of you were the staff at this hospital?
How onsiderate of you were the staff at this hospital? Extremely onsiderate
Quite onsiderate
Moderately onsiderate
Slightly onsiderate
Not at all onsiderate
'. How often did the staff at this hospital describe possible side effects before administering your medicine?
How often did the staff at this hospital desribe possible side effets before administering your mediine? $lways
Most of the time
$bout half of the time
%ne in a while
Never
(. How often did the staff at this hospital e)plain the purpose of your medicine before administering it to you?
How often did the staff at this hospital explain the purpose of your mediine before administering it to you? $lways
Most of the time
$bout half of the time
%ne in a while
Never
*. +uring this stay at this hospital, when you pressed the call button, how often did a staff member attend you
promptly?
&uring this stay at this hospital' when you pressed the all button' how often did a staff member attend you promptly? $lways
Most of the time
$bout half of the time
%ne in a while
Never
Not appliable
1-. +uring this stay at this hospital, how clean was your room kept?
&uring this stay at this hospital' how lean was your room kept? Extremely lean
Quite lean
Moderately lean
Slightly lean
Not at all lean
11. .verall, how hygienic do you feel this hospital is?
%verall' how hygieni do you feel this hospital is? Extremely hygieni
Quite hygieni
Moderately hygieni
Slightly hygieni
Not at all hygieni
12. How noisy was your room or sleeping space at this hospital?
How noisy was your room or sleeping spae at this hospital? Extremely noisy
Very noisy
Moderately noisy
Slightly noisy
Not at all noisy
1. +uring this stay at this hospital, how often did doctors e)plain things in a way you could understand?
&uring this stay at this hospital' how often did dotors explain things in a way you ould understand? $lways
Most of the time
$bout half of the time
%ne in a while
Never
1#. +uring this stay at this hospital, how respectfully did the doctors treat you?
&uring this stay at this hospital' how respetfully did the dotors treat you? Extremely respetfully
Quite respetfully
Moderately respetfully
Slightly respetfully
Not at all respetfully
1$. +uring this stay at this hospital, how well was your pain controlled?
&uring this stay at this hospital' how well was your pain ontrolled? Extremely well
Quite well
Moderately well
Slightly well
Not at all well
1&. +uring this stay at this hospital, how often did you feel confused about what was going on?
&uring this stay at this hospital' how often did you feel onfused about what was going on? $lways
Most of the time
$bout half of the time
%ne in a while
Never
1'. How well did the meals served at this hospital meet your dietary needs?
How well did the meals served at this hospital meet your dietary needs? Extremely well
Quite well
Moderately well
Slightly well
Not at all well
1(. +uring this stay at this hospital, how well did the nurses listen to you?
&uring this stay at this hospital' how well did the nurses listen to you? Extremely well
Quite well
Moderately well
Slightly well
Not at all well
1*. How respectful of your religious beliefs were the staff at this hospital?
How respetful of your religious beliefs were the staff at this hospital? Extremely respetful
Quite respetful
Moderately respetful
Slightly respetful
Not at all respetful
Not appliable
2-. .ver the course of your stay at this hospital, were you satisfied with the care you received dissatisfied with
the care you received, or neither satisfied nor dissatisfied with it?
%ver the ourse of your stay at this hospital' were you satisfied with the are you reeived dissatisfied with the are you reeived' or
neither satisfied nor dissatisfied with it? Extremely satisfied
Quite satisfied
Somewhat satisfied
Neither satisfied nor dissatisfied
Somewhat dissatisfied
Quite dissatisfied
Extremely dissatisfied
21. How likely are you to choose this hospital for your care again in the future?
How likely are you to hoose this hospital for your are again in the future? Extremely likely
Quite likely
Moderately likely
Slightly likely
Not at all likely
22. How likely are you to recommend this hospital to others?
How likely are you to reommend this hospital to others? Extremely likely
Quite likely
Moderately likely
Slightly likely
Not at all likely
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1. :3u;nto sabe el personal de este hospital?
o Extremadamente bien informado
o Muy bien informado
o Moderadamente bien informado
o (n poo onoedor
o No' en absoluto bien informado
2. :3<mo profesionalmente %u= el personal de este hospital se comportan?
o muy profesionalmente
o Moderadamente profesionalmente
o (n poo profesionalmente
o No' en absoluto profesionalmente
. :>ue f;cil para hablar con el personal de este hospital, acerca de su condici<n m=dica !s"?
o muy f)il
o Moderadamente f)il
o (n poo f)il
o No' en absoluto f)il
#. :3on %u= frecuencia recibe informaci<n contradictoria desde el personal de este hospital?
o muy a menudo
o Moderadamente menudo
o *igeramente a menudo
o No' en absoluto menudo
$. :3<mo fue el personal de respuesta en este hospital a sus preguntas?
o Muy sensible
o Moderadamente sensibles
o (n poo sensible
o No' en absoluto sensible
&. 3<mo considerado de su parte fue el personal de este hospital?
o Extremadamente atento
o muy atento
o Moderadamente onsiderado
o (n poo onsiderado
o No' en absoluto onsiderado
'. :3on %u= frecuencia el personal de este hospital se describen los posibles efectos secundarios antes de
administrar el medicamento?
o *a mayor+a de las vees
o $lrededor de la mitad de las vees
o &e ve, en uando
o nuna
(. :3on %u= frecuencia el personal de este hospital de e)plicar el prop<sito de su medicamento antes de
administrarlo a usted?
o *a mayor+a de las vees
o $lrededor de la mitad de las vees
o &e ve, en uando
o nuna
*. +urante esta estancia en este hospital, cuando puls< el bot<n de llamada, :con %u= frecuencia un miembro
del personal %ue asista con rapide??
o *a mayor+a de las vees
o $lrededor de la mitad de las vees
o &e ve, en uando
o nuna
o no apliable
1-. +urante esta estancia en este hospital, lo limpio se mantuvo a su habitaci<n?
o -astante limpio
o Moderadamente limpio
o (n poo limpio
o No' en absoluto limpio
11. En general, :c<mo te sientes higi=nica este hospital es?
o Extremadamente higi.nio
o muy higi.nio
o Moderadamente higi.nia
o (n poo higi.nia
o No' en absoluto higi.nia
12. :3<mo era ruidoso su habitaci<n o espacio para dormir en este hospital?
o Extremadamente ruidoso
o Muy ruidoso
o Moderadamente ruidoso
o (n poo ruidoso
o No es nada ruidoso
1. +urante esta estancia en el hospital, :con %u= frecuencia los m=dicos e)plican las cosas de una forma %ue
pudiera entender?
o siempre
o *a mayor+a de las vees
o $lrededor de la mitad de las vees
o &e ve, en uando
o nuna
1#. +urante esta estancia en el hospital, :c<mo respetuosamente %u= los doctores te tratan?
o Extremadamente respetuosamente
o muy respetuosamente
o Moderadamente respetuosamente
o (n poo respeto
o No' en absoluto respeto
1$. +urante esta estancia en este hospital, %ue tan bien se controla su dolor?
o muy bien
o muy bien
o Moderadamente bien
o (n poo as+
o Nada bien
1&. +urante esta estancia en el hospital, :con %u= frecuencia se siente confundido acerca de lo %ue estaba
pasando?
o siempre
o *a mayor+a de las vees
o $lrededor de la mitad de las vees
o &e ve, en uando
o nuna
1'. :@u= tan bien las comidas %ue se sirven en este hospital satisfacer sus necesidades diet=ticas?
o muy bien
o Moderadamente bien
o (n poo as+
o Nada bien
1(. +urante esta estancia en este hospital, lo bien %ue hicieron las enfermeras te escuchan?
o muy bien
o Moderadamente bien
o (n poo as+
o Nada bien
1*. :3<mo respetuoso de sus creencias religiosas eran el personal de este hospital?
o Extremadamente respetuoso
o muy respetuoso
o Moderadamente respetuosa
o (n poo de respeto
o No del todo respetuosa
o no apliable
2-. +urante el transcurso de su estancia en este hospital, estaba satisfecho con la atenci<n %ue recibi<
satisfecho con la atenci<n %ue recibi<, o ni satisfecho ni insatisfecho con ella?
o Extremadamente satisfeho
o -astante satisfeho
o algo satisfeho
o Ni satisfeho ni insatisfeho
o algo insatisfeho
o muy insatisfeho
o Extremadamente insatisfeho
21. :@u= tan probable es %ue eliAa este hospital para su atenci<n de nuevo en el futuro?
o muy posiblemente
o Es muy probable
o Moderadamente probable
o (n poo probable
o Nada probable
22. :@u= tan probable es %ue usted recomiende este hospital a otras personas?
o muy posiblemente
o Es muy probable
o Moderadamente probable
o (n poo probable
o Nada probable